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Chapter 35 Potter &
Skin Integrity and Wound Care
| Question | Answer |
|---|---|
| ________________ is the term used to describe impaired skin integrity resulting form pressure. | pressure ulcer |
| A patient experiencing decreased mobility, inadequate nutrition, decreased sensory perception, or decreased activity is a risk for ________________ development. | pressure ulcer |
| ________________ occurs when capillary blood flow is obstructed, as in the case of pressure. | tissue ischemia |
| ________________ is an area of skin that appears red and warm and will turn lighter in color following fingertip palpation. | blanchable hyperemia |
| ________________ is redness that persists after palpation and indicates tissue damage. | nonblanchable hyperemia |
| ________________ is the force exerted against the skin while the skin remains stationary and the boy structures move. | shear |
| ________________ is an injury to the skin that has the appearance of an abrasion. | friction |
| ________________ on the skin increases the risk of ulcer formation. | moisture |
| Poor nutrition, specifically severe ________________, causes soft tissue to become susceptible to breakdown. | protein deficiency |
| Low ________________ cause edema or welling, which contributes to problems with oxygen transport and the transport of nutrients. | protein levels |
| In patients with ________________, hypoalbuminemia(serum albumin level below 3 g/100 mL) leads to a shift of fluid from the extracellular fluid volume to the tissues, resulting in edema. | severe protein loss |
| serum albumin level below 3 g/100 mL | hypoalbuminemia |
| total protein level below 5 g/100 mL | total protein |
| ________________ increases the affected tissue's risk for pressure ulcer formation. | edema |
| ________________ is generalized ill health and malnutrition, marked by weakness and emaciation. | cachexia |
| extreme thinness | emaciation |
| A patient with an ________________ usually has a fever. | infection |
| Infection and fever increase the ________________ of the body, making already hypoxic tissue more susceptible to ischemic injury. | metabolic needs |
| Skin structure changes with ________________, causing a loss of dermal thickness and an increase in the risk of skin tears. | age |
| ________________ are at highest risk for development of pressure ulcers. | older adults |
| 60% to 90% of all pressure ulcers occur in patients over ________________ years of age. | 65 |
| Pressure exerted against the skin surface causes ________________, usually a bone and the surface of the bed compress the skin. | pressure ulcers |
| When the intensity of the pressure exerted to the capillary exceeds ________________, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. | 12 to 32 mm Hg |
| The ulcer appears a s defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones the ulcer appears with persistent red, blue, or purple hues and the skin intact. | stage I |
| Partial-thickness skin loss involving epidermis, dermis, or both; the ulcer is superficial and presents as an abrasion, blister, or shallow crater (skin is broken). | stage II |
| Full-thickness skin loss involving damages to, or necrosis of, subcutaneous tissue that extends down to, but not through, underlying fascia; the ulcer presents as a deep crater with or without undermining of surrounding tissue. | stage III |
| Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. | stage IV |
| dead, dry tissue | eschar |
| A wound with little or no tissue loss, such as a clean surgical incision, heals by ________________. | primary intention |
| when skin edges are close together | approximate |
| A wound involving loss of tissue such as a severe laceration or a chronic wound such as a pressure ulcer heals by ________________. | secondary intention |
| The wound heals with a layer of ________________ at the edges and base, and several day s after the initial wounding the wound edges are brought together with sutures or adhesive closures. | granulation tissue |
| ________________ are the first response to a partial-thickness wound repair, bringing white blood cells to the site. | erythema and edema |
| The inflammatory response of a partial-thickness wound repair appears ________________. | red and swollen |
| During the inflammatory response of a partial-thickness wound repair, the ________________, or discharge, if allowed to dry, brings the white blood cells to the area and a scab will form. | exudate |
| The inflammatory response of a partial-thickness wound repair occurs for approximately ________________. | 24 hours |
| Peak epithelial proliferation occurs within ________________ after injury. | 24 to 72 hours |
| peak epithelial proliferation | epidermal cell migration across a wound |
| Wounds kept in a moist environment will heal in approximately ________________ (as opposed to 7 days when kept dry) b/c new epithelial cells migrate across a moist surface. | 4 days |
| With ________________ , the epidermis thickens, anchors to adjacent cells, and resumes normal function and looks pink, dry, and fragile. | dermal repair |
| During full-thickness wound repair, the first event of ________________ is hemostasis. | inflammatory phase |
| ________________ cause coagulation and vasoconstriction within inflammatory phase during full-thickness wound repair. | platelets |
| The ________________ during full-thickness wound repair lasts approximately 3 days in an acute clean wound, such as a surgical incision. | inflammatory phase |
| The key events in the ________________ of full-thickness wound repair are production of new tissue, epithelialization, and contraction. | proliferative phase |
| The ________________ of full-thickness wound repair, which lasts up to 1 year, reorganizes the collagen to produce a more elastic, stronger collagen for the scar tissue. | remodeling phase |
| The tensile strength of the scar tissue during the remodeling phase of full-thickness wound repair is never more than ________________ of the tensile strength in non-wounded tissue. | 80% |
| Bleeding from an acute wound is normal during and immediately after initial trauma, but ________________ usually occurs within several minutes. | hemostasis |
| hemostasis | cessation of bleeding by vasoconstriction and coagulation |
| collection of clotted blood | hematoma |
| ________________ prevents healing by increasing tissue damage and altering the healing process. | bacterial wound infection |
| A contaminated or traumatic wound infection develops within ________________. | 2 to 3 days |
| A surgical wound infection develops within ________________. | 4 to 5 days |
| ________________ of a wound infection include fever, general malaise, and an elevated white blood cell count. | systemic signs |
| ________________ is the partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly. | dehiscence |
| ________________ have a high risk for dehiscence because of constant strain on their wounds and the poor vascularity of fatty tissue. | obese patients |
| Dehiscence occurs most often in ________________ after a sudden strain such as coughing, vomiting, or sitting up in bed. | abdominal surgical wounds |
| When ________________ drainage increases from a wound, be alert for dehiscence. | serosanguineous |
| ________________ occurs when wound layers separate below the fascial layer, and visceral organs protrude through the wound opening. | evisceration |
| A ________________ is an abnormal opening between two organs or between an organ and the skin. | fistula |
| ________________ increase the risks of infection, fluid and electrolyte imbalances, and skin breakdown fro chronic drainage. | fistulas |
| In the ________________, some patients require well-though-out modifications of wound care techniques. | immediate postoperative period |
| Skin assessment for the patient with intact darkly pigmented skin: appears ________________ than surrounding skin--purplish, bluish, eggplant. | darker |
| Skin assessment for the patient with intact darkly pigmented skin: use ________________ light versus fluorescent lamps. | natural or halogen |
| Skin assessment for the patient with intact darkly pigmented skin: ________________ is taut, shiny, or indurated (edema occurs w/more than 15 mm dia.) | tissue consistency |
| Skin assessment for the patient with intact darkly pigmented skin: assess for for firm or ________________ feel. | boggy |
| Skin assessment for the patient with intact darkly pigmented skin: skin may feel initially ________________, but subsequently may feel ________________. | warmer; cooler |
| Use ________________ such as creams, ointments, pastes, and film forming skin protectants as needed to protect and maintain intact skin. | incontinence skin barriers |
| Use ________________ to transfer patients in bed. | lift sheets |
| Maintain head of bed at , or below ________________ or at the lowest level of elevation consistent with the patient's medical condition. | 30 degrees |
| Avoid ________________ over bony prominences. | vigorous massage |
| When you notice ________________, document location, size, and color, and reassess the area after 1 hour. | hyperemia |
| Turning time - arrhythmia time = | next turning time |
| If you suspect ________________, outlining the affected area with a marker makes reassessment easier. | nonblancable hyperemia |
| Nonblanchable hyperemia is an early indicator of ________________, but damage to the underlying tissue is sometimes more progressive. | impaired skin integrity |
| ________________ is associated with overall morbidity and mortality. | malnutrition |
| Inadequate caloric intake causes ________________ and a decrease in subcutaneous tissue, allowing bony prominences to compress and restrict circulation. | weight loss |
| The ________________ is less tolerant to pressure, friction, and shear b/c of decreased elasticity from normal aging. | older adult's skin |
| The major change in aging skin is dryness, which affects as many as ________________ of patients over the age of 64. | 59% to 85% |
| The thinning of the dermis and flattening of the dermal-epidermal junction that occur in aging predispose the older adult's skin to ________________. | tearing |
| abrasion | loss of dermis |
| An ________________ is usually superficial with little bleeding but some weeping. | abrasion |
| plasma leakage from damaged capillaries | abrasion |
| A ________________ is damage to the dermis and epidermis and is a torn, jagged wound. | laceration |
| The depth and location of the ________________ affect the extent of bleeding, with serous bleeding possible in lacerations greater than 5 cm (2 inches) long or 2.5 cm (1 inch) deep. | laceration |
| ________________ bleed in relation to the depth and size of the wound. | puncture wounds |
| Internal bleeding and infection are the ________________ of puncture wounds. | primary dangers |
| 3 steps of assessing a puncture wound: 1. inspect the wound for ________________. | contaminant material |
| 3 steps of assessing a puncture wound: 2. assess the ________________ of the wound and the need for suturing or surface protection. | size |
| 3 steps of assessing a puncture wound: 3. If from a dirty penetrating object, ascertain if patient has had a ________________ injection within the last year. | tetanus toxoid |
| ________________ provide an excellent environment for bacterial growth. | saturated dressing |
| When you plan a dressing change, give the patient an analgesic at least ________________ before exposing a wound. | 30 minutes |
| Risk for malnutrition: age: < ________________ years or > ________________ years. | 18; 64 |
| Risk for malnutrition: age: weight ________________ loss in 1 to 6 month. | 5 to 10% |
| Risk for malnutrition: albumin: < ________________ mg/dl | 3.0 |
| Risk for malnutrition: total protein ________________ mg/dl | 5.0 |
| ecchymosis | superficial bleeding under the skin or a mucous membrane; a bruise |
| A simple method for estimating the volume of ________________ is to report the number and type of dressings used and saturated over an interval of time. | wound drainage |
| Types of wound drainage: serous | clear, watery plasma |
| Types of wound drainage: sanguineous | fresh bleeding |
| Types of wound drainage: serosanguineous | pale, more watery, a combination of plasma and red cells, may be blood-streaked |
| Types of wound drainage: purulent | thick, yellow, green, brown, indicating the presence of dead or living organisms and white blood cells |
| Note the character and amount of drainage if there is a ________________. | collecting device |
| Notify the ________________ of any sudden decrease that indicates a blocked drain or an increase indication bleeding or infection. | physician or health care provider |
| When a wound exhibits swelling, separtion of its edges, or redness in the periwound area, it is important to evaluate for the presence of ________________. | cellulitis |
| Use ________________ to detect localized areas of tenderness or collection of drainage. | light palpation |
| Pain assessment is an important component of ________________ for detecting complications and planning for future wound care. | wound assessment |
| Never collect a wound culture sample from ________________, b/c resident colonies of bacteria grow in exudate. | old drainage |
| To collect an ________________, wipe a sterile swab from a culturette tube onto clean, healthy-looking tissue, return the swab to the culturette tube, cap the tube, and crush the inner ampule so that the medium for organism growth coats the swab tip. | aerobic specimen |
| Nursing diagnoses relevant to wound care: risk for ________________ | infection |
| Nursing diagnoses relevant to wound care: impaired ________________ | physical mobility |
| Nursing diagnoses relevant to wound care: ________________ bed mobility | impaired |
| Nursing diagnoses relevant to wound care: imbalanced nutrition: ________________ | less than body requirements |
| Nursing diagnoses relevant to wound care: ________________ pain | acute |
| Nursing diagnoses relevant to wound care: ________________ pain | chronic |
| Nursing diagnoses relevant to wound care: situational low ________________ | self-esteem |
| Nursing diagnoses relevant to wound care: impaired ________________ | skin integrity |
| Nursing diagnoses relevant to wound care: risk for impaired ________________ | skin integrity |
| Nursing diagnoses relevant to wound care: ineffective ________________ | tissue perfusion |
| ________________ for predicting pressure sore risk | Braden Scale |
| A score of ________________ on the Braden Scale indicates at risk for pressure sores. | 16 |
| A score of ________________ on the Braden Scale indicates at high risk for pressure sores. | <=9 |
| Do not ________________ reddened areas b/c reddened areas indicate tissue injury. | massage |
| When cleansing the skin, use a ________________ agent. | mild cleansing |
| A ________________ will provide skin protection form the irritating effects of stool or urine and will allow you to clean the next incontinent episode easily. | moisture barrier |
| Most underpads and briefs have a ________________ that holds moisture against skin. | plastic outer lining |
| Diapers and underpads will ________________ the skin if left under patients for prolonged periods of time. | irritate |
| A standard turning interval of ________________ will not prevent pressure sore development in some patients such as an immobilized patient. | 1 to 2 hours |
| The WOCN recommends reducing ________________ by keeping the patient's head of bed below the 30-degree angle, using assistive devices when turning or transferring patients, using the bed gatch or footboard, and using the 30-degree lateral position. | shear |
| When the patient is able to sit int he chair, reposition the patient every ________________. | hour |
| Assist or teach patients with the ability to shift weight every ________________. | 15 minutes |
| ________________ decrease teh amount of pressure exerted over bony prominences by maximizing contact (allowing the body to touch the entire surface) and thereby redistributing weight over a large area. | support surfaces |
| When using a ________________, make sure there are minimal layers of bed linens between the patient and the surface. | support surface |
| Place ________________ on a pressure reduction/relief surface and not on an ordinary hospital mattress. | at-risk individuals |
| Avoid using foam rings, donuts, and sheepskin for ________________. | pressure reduction |
| ________________ concentrate the pressure to the surrounding tissue. | foam rings and donuts |
| The patient must receive ________________ to achieve wound healing. | systemic support |
| ________________ is necessary to support new blood vessels and collagen synthesis. | protein intake |
| Certain medications and medical conditions influence ________________. | wound healing |
| B/c ________________ causes problems with wound healing, blood glucose control is essential. | hyperglycemia |
| A ________________ environment is necessary to promote healing. | stable wound |
| To maintain a ________________ it is important to control infection and promote cleansing, debridement, exudate management, control of dead space, and wound protection. | stable environment |
| Assess the patient with a ________________ for signs and symptoms of a wound infection: redness, warmth of surrounding tissue, odor, and the presence of exudate. | pressure ulcer |
| Cleanse pressure ulcers at each ________________ to promote removal of wound debris and bacteria from the wound surface. | dressing change |
| ________________ slows wound healing b/c it becomes a source for infection and a barrier for epithelialization. | necrotic tissue |
| Cleanse dirty wounds with ________________. | irrigation |
| Clean wounds require only gentle flushing with ________________. | normal saline solution |
| A ________________ supports wound healing. | moist wound environment |
| Excessive ________________ will macerate the wound edges and interfere with wound healing. | wound moisture |
| Allow a ________________ to bleed to remove dirt and other contaminants. | puncture wound |
| If a ________________ is in a patient's body, do not remove the object. | penetrating object |
| Gentle ________________ of a wound removes contaminants that serve a sources of infection. | cleansing |
| ________________ causes bleeding or further injury. | vigorous cleaning |
| Ideally a ________________ provides a moist environment to promote normal epidermal cell migration. | dressing |
| The proper dressing will absorb ________________ to prevent polling of exudate that promotes bacterial growth. | drainage |
| The proper dressing prevents ________________ from coming into contact with intact skin. | wound drainage |
| A dressing ________________ wound exposure to microorganisms. | discourages |
| If a wound has minimal drainage, the natural formation of a ________________ eliminates the need for a dressing. | fibrin seal |
| A pressure dressing promotes ________________ by exerting localized, downward pressure over an actual or potential bleeding site. | hemostasis |
| A pressure dressing fosters ________________ by eliminating dead space in underlying tissues. | normal healing |
| Assess skin color, pulses in distal extremities, patient comfort, and any changes in sensation to ensure pressure dressings do not interfere with ________________. | circulation |
| A ________________ promotes healing by allowing the wound to heal by primary intention and absorbing minimal oozing of wound drainage. | dry dressing |
| The purpose of a ________________ dressing is to act as a sponge, absorbing excessive wound drainage, while providing a moist environment. | moist gauze |
| ________________ is the most common dressing type. | gauze |
| ________________ does not interact with wound tissues and thus causes little wound irritation. | gauze |
| ________________ are useful in debriding wounds. | wet-to-dry or moist-to-dry |
| The process of softening a solid by steeping in a fluid. | maceration |
| ________________ dressings are clear sheets coated on one side with an adhesive. | transparent film |
| Transparent film dressings are used as a ________________ in wounds with minimal tissue loss that have very little wound draingage. | primary dressing |
| You change a transparent film dressing when the seal is ________________. | broken |
| ________________ dressings are made of gelling agents and have an adhesive wound surface. | hydrocolloid |
| ________________ form a gel as they interact with the wound surface. | hydrocolloids |
| ________________ dressings are available in sheets or in a gel in a tube (amorphous). | hydrogel |
| Hydrogels maintain moisture in some wounds for ________________. | 1 to 3 days |
| A new treatment for chronic wounds is the wound ________________. | vacuum assisted closure |
| Wound closure applies ________________ to the wound to promote and accelerate healing. | negative pressure |
| add dressings w/o removing existing ones as needed | reinforce dressing prn |
| An order to "reinforce dressing prn" is common immediately after ________________, when the physician or health car provider does not want accidental disruption of the suture line or loss of hemostasis. | surgery |
| Use tape, ties, or bandages and cloth binders to secure a ________________ over a wound site. | dressing |
| To avoid repeated removal of tape from sensitive skin, secure dressings with reusable ________________. | Montgomery ties |
| Whenever cleansing a wound, clean from the ________________ contaminated area to the ________________ contaminated. | least; most |
| Do not use povidone-iodine (Betadine0, hydrogen peroxide, and acetic acid (vinegar) to irrigate a ________________. They kill ________________, a key component in wound healing. | clean, granular wound; fibroblasts |
| When ________________, allow the solution to flow from the least contaminated to the most contaminated area. | irrigating |
| Administer the prescribed solution at ________________ to enhance comfort and provide local cleansing application. | body temperature |
| When irrigating clean wounds, use sterile technique and an irrigation system with a safe pressure (________________) to prevent trauma to the newly formed granulation tissue. | 4 to 15 psi |
| An example of a safe wound cleansing and irrigation system is a 35-mL syringe and a 19-gauge needle, which has a ________________. | psi of 8 |
| ________________ are threads or wires made of silk, steel, cotton, nylon, and polyester (Dacron) and are used to sew body tissues together. | sutures |
| ________________ are convenient, portable units that connect to tubular drains within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage. | drainage evacuators |
| Before applying a bandage or binder, perform the following steps: 1. Inspect the ________________ for abrasions, edema, discoloration, or exposed wound edges. | skin |
| Before applying a bandage or binder, perform the following steps: 2. Cover exposed wounds or open abrasion with a ________________. | sterile dressing |
| Before applying a bandage or binder, perform the following steps: 3. Assess the condition of ________________, and change if they are soiled. | underlying dressings |
| Before applying a bandage or binder, perform following steps: 4. Assess skin of ________________ & parts that will be distal to bandage for signs of circulatory impairment to provide a means for comparing changes in circulation after bandage application. | underlying body parts |
| ________________ impair chest expansion. | breast binder |
| The local application of ________________ to an injured body part provides therapeutic benefits. | heat and cold |
| Systemic responses occur through ________________ (sweating or vasodilation) or mechanisms promoting heat conservation (vasocontriction or piloerection) and heat production (shivering). | heat loss mechanisms |
| ________________ generally is therapeutic. | heat |
| If ________________ is applied for 1 hour or more, a reflex vasoconstriction reduces blood flow as the body attempts to control heat loss from the area. | heat |
| Continuous exposure to ________________ damages epithelial cells, causing redness, localized tenderness, and even blistering of the skin. | heat |
| Prolonged exposure of the skin to ________________ results in a reflex vasodilation. | cold |
| Factors influencing heat & cold tolerance: 1. duration of application - a person is better able to tolerate ________________ to any temperature extremes. | short exposures |
| Factors influencing heat & cold tolerance: 2. Body part - The neck, inner aspect of the wrist and forearm, and perineal regions are ________________ sensitive to temperature variations. The foot & the palm of the hand are ________________ sensitive. | more; less |
| Factors influencing heat & cold tolerance: 3. Damage to body surface - Exposed skin layers are ________________ sensitive to temperature variations. | more |
| Factors influencing heat & cold tolerance: 4. Prior skin temperature - The ________________ responds best to minor temperature adjustments. | body |
| Factors influencing heat & cold tolerance: 5. Body surface area - A person is ________________ of temperature changes over a large area of the body. | less tolerant |
| Factors influencing heat & cold tolerance: 6. Age & physical condition - The very young and old are ________________ sensitive to heat & cold. | most |
| If the patient has ________________, it is unwise to apply heat to large portions of the body b/c massive vasodilation will disrupt blood supply to vital organs. | cardiovascular problems |
| Cold is ________________ if the site of injury is edematous or the patient has impaired circulation or is shivering (may intensify shivering and reduce blood flow). | contraindicated |
| The patient who has had rectal surgery or an episiotomy during childbirth or who has painful hemorrhoids or vaginal inflammation will benefit from a ________________, a bath in which only the pelvic area is immersed in warm fluid. | sitz bath |
| heat therapy: vasodilation | improves blood flow to injury body part; example: arthritis or degenerative joint disease |
| heat therapy: reduced blood viscosity | promotes delivery of nutrients and removal of wastes; example: localized joint pain or muscle strains |
| heat therapy: reduced muscle tension | promotes muscle relaxation; example: menstrual cramping |
| heat therapy: increased tissue metabolism | provides local warmth; example: hemorrhoidal, perianal, and vaginal inflammation |
| heat therapy: increased capillary permeability | promotes movement of waste products and nutrients; example: local abscesses |
| cold therapy: vasoconstriction | reduces blood flow to injured site, preventing edema formation; example: immediately after direct trauma (e.g., sprains, strains, fractures, muscle spasms) |
| cold therapy: local anesthesia | reduces localized pain; example: superficial laceration or puncture wound |
| cold therapy: reduced cell metabolism | reduces oxygen needs of tissues; example: minor burn |
| cold therapy: increased blood viscosity | promotes blood coagulation at injury site; example: after injections |
| cold therapy: decreased muscle tension | relieves pain; example: arthritis or joint trauma |
| Conditions that increase risk of injury from heat and cold application: very young; older adults | thinner skin layers increase risk of burns; ________________ have reduced sensitivity to pain |
| Conditions that increase risk of injury from heat and cold application: open wounds, broken skin | subcutaneous tissue is more sensitive to temperature variations |
| Conditions that increase risk of injury from heat and cold application: areas of edema or scar formation | there is reduced sensation to temp. & pain stimuli b/c of scar formation |
| Conditions that increase risk of injury from heat and cold application: peripheral vascular disease (e.g., diabetes, arteriosclerosis) | body's extremities are less sensitive to temp. & pain stimuli b/c of circulatory impairment & local tissue injury; cold application further compromises blood flow |
| Conditions that increase risk of injury from heat and cold application: confusion or unconsciousness | there is reduced perception of sensory or painful stimuli |
| Conditions that increase risk of injury from heat and cold application: spinal cord injury | alterations in nerve pathways prevent reception of sensory or painful stimuli |
| high pressure over short time; low pressure over long time | same results - potential pressure ulcers |
| A ________________ occurs when problems with sensory reception pr perception exist. | sensory deficit |
| ________________ occurs when inadequate quality or quantity of stimuli impairs perception. | sensory deprivation |
| When a person receives multiple sensory stimuli, the brain has difficulty distinguishing the stimuli that causes a ________________ to occur. | sensory overload |
| a common progressive hearing disorder in older adults | presbycusis |
| gradual decline in ability of the lens to accommodate or to focus on close objects; reduces ability to see near objects clearly | presbyopia |
| examples of medications reported to cause ototoxicity | antibiotics, diuretics, analgesics/NSAIDs, antineoplastic agents |
| gustatory | taste |
| proprioception | position and movement in space |
| olfactory | smell |
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