Chapter 31 Skin Integrity and Wound Care Study guide exam questions with solutions guaranteed success graded a+.

The nurse is changing the dressing on a Pt's incision. This type of wound is commonly known as a(n) --- wound. - correct answer intentional The nurse notes swelling and pain occurring form an incision. These symptoms are most likely caused by an accumulation of.. - correct answer exudate A patient's wound is in the inflammatory cellular phase, meaning that -- or -- cells arrive first to ingest bacteria and cellular debris. - correct answer neutrophils, polymorphonuclear New tissue found in a wound that is highly vascular, bleeds easily, and is formed in the proliferative phase is known as -- tissue. - correct answer granulation The nurse is measuring the depth of a Pt's wound and discovers an abnormal passage from an internal organ to the skin. This wound condition is known as a(n) -- - correct answer fistula When cleaning a wound, the nurse might choose sterile 90% -- as the cleansing solution. - correct answer sodium chloride solution The nurse anchors a bandage by wrapping it around the Pt's body part with complete overlapping of the previous bandage turn. This procedure is the -- method of bandage wrapping. - correct answer circular turn A nurse assessing a Pt's wound documents a localized area of tissue necrosis. this type of would is known as a(n) - correct answer pressure ulcer Dehiscence - correct answer The partial or total distal or total disruption of wound layers Ischemia - correct answer Eschar - correct answer necrotic tissue Wound - correct answer a disruption in the normal integrity of the skin Exudate - correct answer composed of fluid and cells that escape from the blood vessels and are deposited in or on tissue surfaces. Granulation tissue - correct answer new tissue pink-red in color, composed of fibroblasts and small blood vessels that fill an open wound when it starts to heal Epithelialization - correct answer Natural act of healing of dermal and epidermal tissue in which a protective membrane forms over a wound. Scar - correct answer avascular collagen tissue that does not sweat, grow har, or tan in sunlight Hemorrhage - correct answer may occur from a slipped suture, a dislodged clot from stress at the suture line, infection, or the erosion of blood vessel by a foreign body (such as a drain) Evisceration - correct answer the protrusion of viscera through the incisional area. serous wound drainage - correct answer wound drainage that is composed of the clear, serous portion of the blood and drainage from serous membranes. Sanguineous wound drainage - correct answer wound drainage that consists of large numbers of red blood cells and looks like blood Purulent wound drainage - correct answer wound drainage that is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. red wounds - correct answer wounds in the proliferative stage of healing that are the color of granulation tissue yellow wounds - correct answer wounds that are characterized by oozing from the tissue covering the wound, often accompanied by purulent drainage Black wounds - correct answer wounds that are covered with thick eschar, which is usually black but may be brown, gray, or tan dressing - correct answer Telfa - correct answer a special gauze that covers the incision line and allows drainage to pass through and be absorbed by the center absorbent layer Gauze dressing - correct answer commonly used to cover wounds: they come in various sizes and are commercially packaged as single units or in packs Sof-wick - correct answer precut halfway to fit around drains or tubes ABDs, Surgipads - correct answer Placed over the smaller gauze to absorb drainage and protect the wound from contamination or injury Transparent dressing - correct answer The type of dressing often used over intravenous sites, subclavian catheter insertion sites, and non-infected healing wounds. Bandages - correct answer They may be made of cloth (flannel or muslin) or an elasticized material that fastens together with Velcro. Binders - correct answer wraps designed for a specific body part Roller bandages - correct answer List six major functions of the skin; - correct answer protect the body regulate body temperature sense stimuli from the environment and transmit these sensation excrete waste products help maintain water and electrolyte balance produce and absorb Vitamin D Describe how the following mechanisms contribute to pressure ulcer development. - correct answer External pressure: Compresses blood vessels and causes friction Friction and shearing forces: Tear and injure blood vessels Give an example of how the following factors affect the likelihood that a Pt will develop a pressure ulcer. - correct answer Nutrition: Poorly nourished cells are easily damaged (vit C deficiency causes capillaries to become fragile, and poor circulation to he area results when they break) Hydration: dehydration can interfere with circulation and subsequent cell nourishment Moisture on the skin: moisture associated with urinary incontinence increase the risk for skin damage more than chemical irritation from the ammonia in urine Mental status: the more alert a Pt is, the more likely it is that he or she will relieve pressure periodically and mange adequate skin hygiene Age: older people are good candidates for pressure ulcers because their skin is susceptible to injury Immobility: Causes prolonged pressure on body area When visiting a Pt recovering from a stroke in her home, you notice a pressure ulcer developing on her coccyx. Develop a nursing care plan for this Pt that involves the family in the treatment of the ulcer. - correct answer Provide the caregivers with a simple, easy-to-understand list of instructions about caring for the pressure ulcer; address the causative factor for the pressure ulcer before proceeding with the plan of care; consult frequently with the MD about the progress of wound healing and products being used, used clean dressing tech caregivers food hand washing technique, review signs of infection with caregivers and encourage them to contact a MD or home health nurse about any problems Briefly describe the phases of wound healing - correct answer hemostasis: occurs immediately after the initial injury. Involved blood vessels constrict and blood clotting begins through platelet activation and clustering. After only a brief period of constriction, these same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured, forming a liquid called exudate. inflammatory phase: follows hemostasis and last about 4 to 6 days, WBC, predominantly leukocytes and macrophages, move to the wound, about 24 hours after the injury, macrophages enter the wound area and remain for an extended period. Macrophages are essential to the healing process. They not only ingest debris, but also release growth factors that are necessary for the growth of epithelial cells and new blood vessels. These growth factors also attract fibroblast that help to fill in the wound, which is necessary for the next stage of healing. Acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury. proliferative phase: begins about day 2 or 4 up to 2 to 3 weeks. new tissue is built to fill the wound space (action of fibroblasts) Capillaries grow across the wound, fibroblast form fibrin that stretches through the clot, a thin layer of epithelial cells forms across the wound, and blood flow is reinstituted. Granulation tissue forms the foundation for scar tissue. maturation phase: Begins about 3 weeks after injury up to 6 months if wound is large. Collagen is remodeled, new collagen is deposited, and avascular collagen tissue becomes a flat, white line. list three goals for Pt two are at risk for impaired skin integrity. - correct answer The Pt will participate in the prescribed Tx regimen to promote wound healing. The Pt will remain free of infection at the site of the pressure ulcer. The Pt will demonstrate self-care measures necessary to prevent the development of a pressure ulcer. Give two examples of interview questions that could be asked to assess a Pt's skin integrity in the following areas. - correct answer Overall appearance of the skin: Are there any areas on your body where you skin feels paper thin? How does you skin feel in relation to moisture, dry, clammy, oily? Recent changes in skin condition: Have you noticed any sores anywhere on your body? Do you ever notice any redness over a bony area when you stay I none position for a while? Activity/mobility: Do you need assistance to walk to the bathroom? Can you change your position freely and painlessly? Nutrition: Have you lost weight lately? Do you eat well-balanced meals? Pain: Do you have any painful sores on your body? Do you take any medication for pain? Elimination: Do you have any problems with incontinence? Have you ever used any briefs or pads for incontinence problems? Describe how you would assess the following aspects of wound healing: - correct answer Appearance: assess for the approximation of wound edges, color of the wound and surrounding areas drain or tubes, sutures and signs of dehiscence or evisceration. Wound drainage: Assess the amount, color, odor, and consistency of wound drainage. Drainage can be assessed on the wound, dressing, in drainage bottles or reservoirs, or under the Pt. Pain: Assess whether the pain has increased or is constant, pain may indicate delayed healing or an infection. Sutures and staples: Assess the type of suture and whether enough tensile strength has developed to hold the wounds edges together during healing List the purposes for wound dressings - correct answer provide physical, psychological, and aesthetic comfort; removed necrotic tissue; prevent, eliminate, or control infection; absorb drainage, maintain and moist wound environment; protect the wound from further injury and protect the skin surrounding the wound. Descibe the RYB color classification and care of open wounds - correct answer R=red=protect: Red wounds are in the proliferative stage of healing and are the color of normal granulation. They need protection by gentle cleansing, using moist dressing, applying a transparent or hydrocolloid dressing, and changing the dressing only when necessary. Y=yellow=cleanse: Yellow wounds are characterized by oozing from the tissue covering the wound, often accompanied by purulent drainage. They need to be cleansed using irrigation; wet-to-moist dressings, using non-adherent, hydrogel, or other absorptive dressing; and topical antimicrobial medication. b=black=debride: Black wounds are covered with thick eschar, which is usually black but may also be brown, gray, or tan. The eschar must be debrided before the wound can heal by using sharp, mechanical, chemical or autolytic debridement. briefly describe the use of the following methods of applying heat and any advantages or disadvantages. - correct answer Hot water bags or bottles: relatively inexpensive and easy to use; may leak, burn, or make the Pt uncomfortable from their weight. Electric heating pad: Can by used to apply dry heat locally; it is easy to apply and relatively safe and provides constant and even heat. Improper use can result in injury. Aquathermia pad: commonly used in health care agencies for various problems including back pain, muscle spasms, thrombophlebitis, and mild inflammation. Safer than a heating pad but sill must be checked carefully.