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ATI Module
Tissue Integrity (Exam 3)
| Question | Answer |
|---|---|
| benchmarking | Comparing results and outcomes to other sources of similarly retrieved data. |
| blanchable erythema | An area of a reddened skin that temporarily turns white or pale when light pressure is applied. the skin then reddens when pressure is relieved. |
| cellulitis | An infection of the superficial layers of skin. |
| debridement | The process of surgically removing dead tissue and other debris that can cause infection. |
| deep tissue pressure injury (DTPI) | Persistent nonblanchable tissue injury of the skin appearing deep red, maroon, or purple color. |
| dehiscence | The complete or partial separation of the suture line and underlying tissues that occurs when a wound fails to heal properly. |
| dermatitis | A red skin irritation that develops when the skin is exposed to irritants such as feces, urine, stoma effluent, and wound exudates. This type of dermatitis is called an irritant dermatitis. |
| dermis | The layer under the epidermis that is composed mainly of connective tissue and provides strength and flexibility of the skin. |
| epidermis | The outer most layer of the skin, made of squamous epithelial cells, which provides a barrier against the external environment. |
| erythema | Redness of the skin due to dilation of blood vessels. |
| eschar | Hard nonviable black/brown tissue found in the wound bed. |
| evisceration | Protrusion of internal organs through a surgical wound which has dehisced or opened. |
| exudate | Fluid secreted by the body during the inflammatory stage of healing and is made of plasma. |
| friction | The force created when two objects rub together. |
| granulation tissue | New skin tissue that forms on the surface of the wound. |
| hemorrhage | Bleeding (may be internal or external). |
| hypoperfusion | Inadequate supply of blood circulation, which results in low oxygen levels in tissues. |
| hypoxia | Below the expected level of oxygen in body tissue. |
| keratinocytes | Cells formed in the basal layer of the skin that function to protect the skin from the external environment |
| lacerations | Any tearing of the skin, usually caused by blunt or sharp objects. |
| Langerhans cells | Cells found in the epidermis that play a role in cutaneous immune system reactions. |
| maceration | An irritation of the epidermis caused by moisture. |
| malnutrition | Imbalance in a client's intake, which can include deficiencies or excesses in nutrients, vitamins, or calories. |
| melanin | A pigment that determines the color of the hair, skin, and eyes. |
| melanocytes | Cells that are produced in the epidermis and produce melanin. |
| Merkel cells | Receptors cells in the epidermis that are specialized for detection of light touch. |
| moisture-associated skin damage (MASD) | A form of dermatitis; a skin irritation that forms when the skin is exposed to irritants such as feces, urine, stoma content, and wound exudates. |
| mucosal membrane pressure injury | Injury to a mucous membrane caused by the pressure related to the insertion or placement of a foreign device. |
| necrosis | Death of body tissue as a result of diminished blood flow. |
| nonblanchable erythema | Redness of the skin that does not go away when pressure is applied and indicates structural damage has occurred in the small vessels supplying blood to the underlying skin and tissues. |
| pressure injuries | Localized damage to the skin and/or the soft underlying tissue, which can be caused by prolonged contact with a firm surface that interferes with circulation to the area. |
| pressure injury | Localized damage to the skin and/or the soft underlying tissue, which can be caused from prolonged contact with a firm surface that interferes with circulation to the area. |
| purulent | Green/yellow wound drainage. |
| sanguineous | Bloody wound drainage. |
| serosanguineous | Thin, watery wound drainage mixed with blood. |
| serous | Thin, watery wound drainage. |
| shearing | A force parallel to the surface of the skin. |
| skin frailty | At-risk vulnerable skin. |
| skin tears | Loss of the top skin layer caused by mechanical forces. The severity of a skin tear is defined by the depth of the skin layer loss. |
| slough | Yellow or dark, stringy nonviable tissue found in the base of the wound. |
| tunneling | A narrow channel or passageway extending in any direction from the base of the wound |
| undermining | An open area extending under skin along the edge of the wound. |
| unstageable pressure injury | Obscured full-thickness skin and tissue loss injury. |
| vasoconstriction | The narrowing of the blood vessels due to acute blood loss, pain, and/or low body temperature. |
| wound | A wound is a disruption in the normal composition and performance of the skin and its underlying structures. |
| What must a nurse document in the client’s medical record following suture or staple removal? | Documentation should include the date and time of removal, description of the procedure, wound characteristics, signs of infection, client tolerance, unexpected outcomes, and education provided. |
| Why does the skin play a critical role in thermoregulation? | The skin plays a critical role in thermoregulation by utilizing sweat glands for heat dissipation, blood vessels to adjust heat loss, and the insulating properties of the subcutaneous adipose layer to retain body heat. |
| What is the purpose of surgical debridement in the management of chronic wounds? | The purpose of surgical debridement is to remove nonviable tissue, such as necrotic tissue, slough, biofilm, and foreign material, to create a clean wound environment that promotes healing, reduces infection risk, and allows healthy tissue to regenerate. |
| What client preparation steps must be completed before collecting a wound culture? | The nurse should provide privacy, introduce themselves, perform hand hygiene, apply PPE, identify the client using two identifiers, check for allergies or contraindications, and educate the client about the procedure. |
| Why is it important to count the foam pieces removed during an NPWT dressing change? | Counting the foam pieces ensures that no pieces are left behind in the wound, which can prevent infection and complications from foreign material remaining in the wound bed. |
| Which factors can delay wound healing and must be addressed in a care plan? | Factors include diabetes (which impairs sensation and circulation), infection, presence of a foreign body, use of corticosteroids, malnutrition, tissue necrosis, hypoxia, and the presence of multiple wounds competing for healing resources. |
| What factors make bony prominences common sites for pressure injury development? | Bony prominences are more prone to pressure injuries because these areas experience concentrated pressure due to their proximity to the surface of the skin, reducing blood flow and increasing the risk of tissue damage. |
| What tissue type is commonly removed to properly stage an unstageable pressure injury? | Eschar, a hard nonviable black or brown tissue, or slough, a yellow or grey stringy nonviable tissue, must be removed to accurately determine whether the injury is a stage 3 or stage 4 pressure injury |
| What factors place a client at higher risk for developing pressure injuries? | Factors include malnutrition, immobility, decreased sensory perception, altered circulation, general health disorders, incontinence, and advanced age. These factors contribute to reduced skin integrity and an increased likelihood of tissue breakdown |
| Which nutritional interventions should be prioritized for a client with delayed wound healing and poor dietary intake? | Nutritional interventions include offering high-calorie, high-protein supplements, ensuring adequate intake of vitamins A and C, including omega-3 and omega-6 fatty acids, monitoring weight and oral intake regularly, and consulting a dietitian |
| What items must be included in the documentation following a wound culture specimen collection? | Documentation should include the date and time of collection, collection method, description of the wound and drainage, and any wound dressing changes performed. |
| Which type of dressing is recommended for wounds with moderate to high exudate, and why? | Alginate dressings are recommended for wounds with moderate to high exudate because they have high absorptive abilities, provide hemostasis, and can remain in place for several days, reducing dressing change frequency. |
| What is the rationale for performing hand hygiene and applying PPE during sterile wound irrigation? | Performing hand hygiene minimizes infection risk, and PPE prevents exposure to blood or body fluids, protecting both the nurse and the client while maintaining sterile technique. |
| When is it appropriate to use hydrocolloid dressings on a pressure injury wound? | Hydrocolloid dressings are suitable for wounds with low to moderate exudate but should not be used in cases of infection, tunneling, or undermining, as they are not designed for these conditions. |
| How can a nurse ensure the newly applied dressing is secure? | The nurse can secure the dressing using appropriate medical tape or adhesive methods ensuring proper placement based on the wound type, location, and size. |
| What client teaching should a nurse provide before applying or changing an NPWT dressing? | The nurse should explain the procedure to decrease client anxiety, answer questions, verify understanding, and address any concerns the client may have about the process. |
| What is the role of the Five Rights of Delegation during sterile wound irrigation? | The Five Rights of Delegation ensure tasks are delegated appropriately based on the right task, right circumstance, right person, providing correct directions and communication, and conducting proper supervision and evaluation. |
| Why must the nurse apply sterile gloves before inserting packing material into the wound | Sterile gloves prevent contamination, protect the wound from infections, and ensure safe placement of sterile packing material into tunneling or undermined areas. |
| What is the primary benefit of using foam dressings for pressure injury prevention, and where are they applied? | Foam dressings provide a protective barrier, reducing and preventing pressure injuries. They are applied to areas of high pressure, such as the sacrum or heels, within 24 hours of admission. |
| What characteristics of the drainage should a nurse note and document after emptying a closed wound drainage system | The nurse should document the amount, color, consistency, and odor of the drainage, as these characteristics provide critical information about the client’s healing status. |
| What is the correct procedure for removing vertical mattress sutures while minimizing stress on the wound? | The nurse should use forceps and suture-removal scissors to cut the two ends of the suture on the opposite side of the knot, remove the suture, and pull subsequent sutures toward the knot using consistent tension control. |
| What factors should be assessed during inspection of the wound and skin around the drain insertion site? | The nurse should assess for signs of infection such as increased redness, odor, or purulent drainage and inspect the skin for breakdown or irritation. |
| Which supplies are essential to gather before emptying a closed wound drainage system? | Essential supplies include a waterproof pad, a graduated measuring container, and a facility-approved antiseptic for cleaning the drainage port. |
| What is the significance of ensuring that the foam collapses after turning on the NPWT vacuum | Foam collapse indicates that compression has occurred and the negative pressure is being effectively delivered to the wound, ensuring the therapy is functioning correctly. |
| What interventions can reduce friction and shear in clients at risk for pressure injuries while repositioning in bed? | Interventions include using draw sheets to lift rather than drag the client, maintaining the head of the bed below 30° to prevent sliding, placing pillows or pads under vulnerable areas, and minimizing the extent of friction during repositioning. |
| How do keratinocytes in the epidermis contribute to skin integrity? | Keratinocytes, formed in the basal layer of the epidermis, help protect the skin from water loss, pathogens, and injury. They migrate to the superficial layers, die, and are shed, maintaining a constant protective barrier. |
| What equipment is required to perform a negative pressure wound dressing change? | Equipment needed includes a waterproof absorbent pad, adhesive remover, barrier film, NPWT drainage canister, NPWT tubing, foam dressing, transparent dressing, irrigation supplies, and sterile gauze. |
| How can the nurse ensure infection control when preparing to perform a dressing change for a pressure injury? | The nurse can ensure infection control by performing hand hygiene, using appropriate PPE (such as gloves and gowns), and following standard precautions to prevent contact with blood or body fluids. |
| What considerations should guide the nurse in selecting the appropriate dressing after wound irrigation? | The nurse should consider factors such as the wound condition, prescribed treatment, absorption capacity, moisture maintenance, and prevention of infection or skin irritation. |
| How does the subcutaneous layer protect the body and maintain tissue integrity? | The subcutaneous layer insulates the body to prevent heat loss, absorbs shock to protect internal structures, and pads the organs against physical trauma. It also houses blood vessels and nerves for thermoregulation and sensation. |
| When removing a continuous suture, why is it essential to pull the suture out toward the knot? | Pulling the suture toward the knot prevents drawing the external portion into the tissue, avoiding contamination and minimizing trauma to the wound. |
| What unique assessment challenges might nurses face when evaluating pressure injuries in clients with darker skin tones? | Pressure injury assessment in clients with darker skin tones may be difficult. Skin temperature, moisture, tautness, shininess, or induration should be assessed, along with palpating for localized pain or edema changes. |
| When preparing the wound bed for a new NPWT dressing, what steps should the nurse take before applying the foam dressing? | The nurse should irrigate the wound bed, clean adhesive residue from the surrounding skin, apply a barrier film around the wound (if needed), and ensure the skin is dry and prepared for the new dressing. |
| Why is it important to place an absorbent pad beneath the wound area during a dressing change? | Placing an absorbent pad prevents the bed linens from being soiled by drainage and ensures cleanliness throughout the dressing change procedure. |
| What considerations should be made when labeling a new wound dressing? | The nurse should label the dressing with date, time, and their initials per facility policy, ensuring accurate information for caregivers to monitor wound care history. |
| How should a nurse remove a simple interrupted suture to avoid damaging the skin | The nurse should grasp the end of the suture with forceps and gently raise it to just above skin level before cutting it close to the skin with suture-removal scissors. |
| How can a nurse differentiate a deep tissue pressure injury from other types of pressure injuries? | A deep tissue pressure injury presents with localized, nonblanchable deep red, maroon, or purple discoloration of the skin. The skin may be intact or broken, and the discoloration is due to intense and/or persistent pressure and shearing forces. |
| Why is it essential to irrigate the wound before collecting a culture sample? | Irrigating the wound helps remove necrotic tissue and debris, exposing clean tissue for accurate sample collection. |
| Why is it important to distinguish between blanchable and nonblanchable erythema during a skin assessment? | Blanchable erythema indicates temporary dilation of blood vessels that resolves with pressure, whereas nonblanchable erythema suggests structural damage to small blood vessels and indicates the early stages of a pressure injury. |
| What is the role of antimicrobial agents like silver or honey in wound dressings? | Silver and honey in wound dressings function as antimicrobials. Silver is effective on moist wounds with infection, while honey reduces wound infection, odor, and inflammation with its antimicrobial properties. |
| What factors should a nurse examine when inspecting the wound during a dressing change? | The nurse should assess the wound for exudate, redness, maceration, malodor, changes in size or depth, signs of systemic infection, necrosis, and the condition of surrounding skin. |
| Why is it important to position the drainage reservoir below the level of the wound after emptying? | Positioning the drainage reservoir below the wound level uses gravity to promote effective drainage and prevents backflow that could lead to infection. |
| Which crucial step should be performed first when collecting a wound culture using a sterile cotton applicator? | The nurse should clean the wound with 0.9% sodium chloride solution to prevent contamination from surrounding tissues or exudate. |
| What is the significance of assessing skin temperature during a skin integrity evaluation? | Assessing skin temperature helps identify areas of inflammation, which present as increased warmth, or areas of decreased blood flow, which feel cool to the touch. |
| How should a nurse remove an adhered dry dressing from a wound bed? | If a dry dressing is adhered to the wound bed, the nurse should use 0.9% sodium chloride to loosen the dressing gently to avoid pulling on healthy granulation tissue or dried exudate. |
| What essential nursing actions promote skin integrity and prevent alterations in clients at risk for pressure injuries? | skin assessment within 24 hours of admission, using risk assessment tools( Braden Scale) Q2 turn, maintaining hygiene with pH-balanced cleansers, encouraging adequate nutrition and hydration, and addressing incontinence promptly. |
| Which steps are necessary for cleaning the wound before suture or staple removal? | The nurse should clean the wound using a facility-approved antiseptic solution to remove crust or debris and ensure the area is free of potential contaminants. |
| How does repositioning a client help in preventing pressure injuries? | Repositioning reduces prolonged pressure on specific body areas, thereby improving blood circulation and decreasing the chances of skin breakdown over vulnerable areas such as bony prominences. |
| What nursing measures should be taken for a bed-bound client to prevent pressure ulcers on bony prominences? | Q 2 turns, using supportive surfaces such as special mattresses, placing pillows or foam wedges under bony prominences, keeping the head of the bed below 30°, flexing knees to prevent sliding, and documenting repositioning schedules accurately. |
| Why are clients with obesity at higher risk for skin integrity issues? | Clients with obesity face increased risk due to elevated skin moisture (maceration), higher skin temperatures, and reduced blood and lymphatic flow, leading to conditions like pressure injuries, skin-fold rashes, and bacterial infections. |
| What distinguishes an unstageable pressure injury from other types of pressure injuries? | obscured full-thickness skin and tissue loss due to the presence of slough, which is yellow or grey, stringy nonviable tissue, or eschar, which is hard, nonviable black or brown tissue, covering the wound bed. |
| What observations should be documented when a dressing is removed? | The nurse should document the presence, amount, color, and odor of any drainage and place the old dressing in a biohazard receptacle for proper disposal. |
| How are mucosal membrane pressure injuries different from other types of pressure injuries? | Mucosal membrane pressure injuries occur in mucosal tissues due to medical devices like respiratory equipment or feeding tubes. These injuries cannot be staged as mucosal tissues lack the same layers as skin. |
| How does conducting a comprehensive skin assessment contribute to preventing pressure injuries? | identify vulnerable areas, document previous pressure injury sites, and detect early signs of skin issues like erythema, maceration, or rashes. This ensures timely intervention |
| Why is the syringe tip held at least 2.5 cm (1 inch) away from the wound during irrigation? | Holding the syringe tip at least 2.5 cm away prevents tissue damage, ensures even irrigation, avoids contaminating the wound, and prevents debris from being pushed deeper into the tissue. |
| Why is measuring the size and depth of a pressure injury wound important during treatment? | Measuring size and depth allows the nurse to monitor wound healing progress, evaluate the effectiveness of interventions, and detect any changes requiring adjustments to the care plan. |
| How do hydrocolloid dressings contribute to wound healing, and what are potential disadvantages? | Hydrocolloid dressings maintain a moist wound bed, have bacteriostatic properties, and stimulate growth of granulation tissue. However, they can cause contact dermatitis, maceration, and produce a foul-smelling film due to trapped bacteria. |
| Why is labeling the dressing with date, time, and initials essential? | Labeling the dressing provides information about when the dressing was last changed and by whom, ensuring proper continuity of care and adherence to facility policy. |
| What clinical signs might indicate a localized infection in a wound? | Signs of localized infection include cellulitis, redness around the wound, skin that is warm to touch, exudate, and foul odor. |
| How does a negative pressure wound therapy (NPWT) device promote wound healing? | An NPWT device promotes wound healing by decreasing edema, increasing vascularization of the wound bed, removing exudate, and promoting the proliferation of granulation tissue formation. |
| How should a nurse handle the reservoir when draining its contents to reduce splashing? | The nurse should carefully compress the sides of the reservoir while tilting the drainage port toward the graduated container to minimize splashing. |
| How does obesity affect the skin's risk of pressure injury formation | Obesity increases risk due to additional pressure placed on skin folds, making them prone to pressure injuries and moisture-associated skin damage. These areas should be assessed regularly for breakdown or infections. |
| Why is verifying prescriptions and orders essential during wound drainage system care? | Verifying prescriptions ensures that the correct procedure is performed, aligning care with the provider's orders and safeguarding client safety. |
| How does melanin contribute to the skin's protection against sunlight? | Melanin, produced by melanocytes in the epidermis, absorbs ultraviolet (UV) rays from sunlight. This helps prevent DNA damage and protects the skin from harmful effects caused by prolonged sun exposure. |
| Why is it essential to count the number of sutures or staples removed during the procedure? | Counting ensures that all sutures or staples have been removed, and missed sutures or staples can be promptly reported to the provider to avoid complications. |
| What functions do Langerhans cells perform in protecting tissue integrity? | Langerhans cells in the epidermis ingest and package foreign antigens, presenting them to lymphocytes. This activates the immune system, providing a defense mechanism against invading pathogens. |
| What steps are necessary before removing the old dressing during sterile wound irrigation? | Before removing the old dressing, the nurse should perform hand hygiene, apply PPE, identify the client using two identifiers, verify allergies or contraindications, and provide client education. |
| What factors contribute to the development of device-related pressure injuries? | Device-related pressure injuries are caused by prolonged pressure from medical devices, such as oxygen delivery devices, tubes, braces, or electrodes, and result in injuries that conform to the shape of the device. |
| What role do fibroblasts in the dermis play in wound healing? | Fibroblasts release hyaluronic acid and fibronectin in the dermis, which are essential for promoting tissue repair and supporting the wound-healing process. |
| What should a nurse note during the wound assessment after irrigation? | The nurse should document the wound’s appearance, including color, exudate, granulation tissue, bleeding, and any signs of infection or systemic reactions observed during irrigation. |
| What are the three primary layers of the skin, and what functions does each serve? | the epidermis- barrier against external harm such as water loss and pathogens the dermis, which provides strength and elasticity through collagen and elastin fibers; the subcutaneous- insulates the body, absorbs shock, and protects internal organs. |
| What steps should be taken to address unexpected cessation of drainage from the closed wound drainage system? | Inspect for tubing kinks or clamping, manipulate the tubing gently to relieve blockages, and evaluate the wound and dressing for signs of drainage overflow or blockage. |
| What are potential risk factors that may delay wound healing in a client? | Risk factors include infection, decreased blood supply, decreased oxygen perfusion, long-term steroid use, aging, chronic conditions such as diabetes mellitus, and malnutrition. |
| What are the potential complications a nurse should monitor for when using a negative pressure wound therapy (NPWT) device? | The nurse should monitor for complications such as hemorrhage, infection, and signs of hemorrhagic shock (e.g., low blood pressure, tachycardia). |
| What should the nurse do immediately after verifying client identification and before beginning suture or staple removal? | The nurse should determine any allergies or contraindications to ensure client safety and prevent adverse reactions. |
| Which components of the dermis are responsible for its strength and elasticity, and how do these change with aging? | The collagen and elastin fibers in the dermis provide strength and elasticity. With aging, these fibers degrade, which reduces the skin’s ability to maintain integrity and makes it more prone to tears and injuries. |
| Why is it essential to document the wound care procedure immediately after sterile wound irrigation? | Documentation provides an accurate record of the wound condition, interventions performed, client response, and any prescribed treatments, ensuring continuity of care and legal accountability. |
| Which type of solution is most commonly used for wound irrigation, and what does it achieve? | A 0.9% sodium chloride solution is most commonly used for wound irrigation. It helps remove surface materials from the wound and reduces bacterial levels. |
| What steps should a nurse take when removing an old NPWT dressing? | The nurse should drain fluid into the collection canister, clamp the tubing, turn off the vacuum, apply light pressure on the skin, and loosen the dressing by stretching the outer edges while preventing tissue injury. |
| What is the purpose of positioning the drain and tubing below the level of the wound? | Positioning the drain and tubing below the wound level uses gravity to promote effective drainage while reducing the risk of fluid accumulation and ensuring the tubing remains secure. |
| What steps should a nurse take immediately before emptying a closed wound drainage system to ensure client safety and infection control? | The nurse should perform hand hygiene, apply PPE if necessary, identify the client using two unique identifiers, and determine any allergies or contraindications. |
| What are the key differences in identifying erythema in clients with light versus dark skin tones | In light skin tones, erythema appears as redness. In dark skin tones, it may be more difficult to detect and requires palpation for warmth or texture changes to identify inflammation. |
| What technique should be used to clean a wound during a dry dressing change? | The nurse should use a prescribed solution to clean the wound from top to bottom, or from the center outward, using a new sterile gauze or cotton-tipped applicator for each wipe. |
| Why is proper hydration critical for wound healing, and how can nurses ensure adequate fluid intake? | Hydration supports nutrient delivery and waste removal, which are vital for wound healing. monitoring fluid intake, offering fluids frequently, encouraging foods high in water content, assessing skin turgor and urine output, and considering comorbidities |
| What is the purpose of irrigating a wound during a pressure injury dressing change? | Irrigation cleans the wound by removing debris, exudate, and bacteria, which allows for better visualization of healing tissues and improves the effectiveness of applied medications. |
| What key documentation should a nurse include when assessing pressure injuries? | location, stage, size of the pressure injury, tissue description, wound bed color, surrounding tissue condition, appearance of wound edges, presence of undermining and tunneling, exudate characteristics, any foul odor, and client-reported pain. |
| What distinguishes biological debridement from surgical debridement, and why might it be used? | Biological debridement uses medical-grade maggots to break down nonviable tissue by secreting enzymes that liquefy necrotic tissue. alternative when surgical debridement is not an option and can stimulate healing with minimal harm to healthy tissue. |
| Why is it important to check areas of existing breakdown for signs of further pressure injury development during an assessment? | Inspecting areas of existing breakdown can help identify if the injury is worsening. If new tissue damage is noted, immediate interventions can be implemented, such as repositioning or wound care, to prevent further complications. |
| What steps should the nurse follow to ensure proper client identification before starting care for a pressure injury? | The nurse should identify the client using two unique identifiers, such as the client's full name and date of birth, and confirm the provided information matches medical records and facility protocol. |
| Why is it necessary to label the dressing according to facility policy? | Labeling includes the date, time, and initials, which helps ensure proper record-keeping and provides information on dressing changes for continuity of care. |
| What are common risk factors for developing impaired skin integrity in older adults? | thinning skin, decreased collagen and elasticity, reduced hydration, lower blood supply, and loss of subcutaneous tissue, all of which make the skin more prone to tears, dryness, and pressure injuries. |
| Which steps should be followed to ensure the sterility of the culture swab during specimen collection? | The swab should be removed from the tube without touching any surfaces and handled using sterile technique to avoid contamination. |
| What is the purpose of a closed wound drainage system in client care? | A closed wound drainage system prevents the accumulation of fluids in the wound, reducing pressure on the wound bed to facilitate healing. |
| What is the purpose of assessing high-risk bony prominences in a client’s skin assessment? | Assessing bony prominences, such as the heels, elbows, and sacrum, helps identify areas at risk for pressure injuries because these weight-bearing points often sustain prolonged pressure |
| What is the purpose of collecting a wound culture from a client? | A wound culture is collected to identify the organism causing the infection so that appropriate treatment can be administered. |
| Which steps should a nurse take to ensure client safety before beginning a pressure injury assessment | The nurse should gather supplies, identify the client using two identifiers, determine any allergies or contraindications, explain the procedure to the client, and provide the necessary privacy to maintain client dignity and comfort. |
| How does negative pressure wound therapy (NPWT) assist in wound healing? | NPWT assists in wound healing by reducing edema around the wound, increasing granulation tissue formation, and promoting wound closure through constant or intermittent suction applied to a foam dressing. |
| Which factors should be included in a holistic skin assessment for clients at risk of skin integrity issues? | A holistic skin assessment includes reviewing medical history, evaluating risk factors (such as immobility or malnutrition), and examining the skin for abrasions, rashes, moisture, edema, texture, and temperature changes. |
| Why might sterile technique be replaced with clean technique 48 hours after surgery during dressing changes? | Sterile technique is replaced with clean technique after 48 hours because wounds are considered to be colonized by the client’s environment, rather than remaining sterile. |
| Pallor: Light Skin Tones | Loss of red undertones |
| Pallor: Dark Skin Tones | Ashen-gray discoloration is noticeable in the mucous membranes. Can use halogen or ambient lighting to assist with detection. |
| Cyanosis: Light Skin Tones | Bluish discoloration |
| Cyanosis :Dark Skin Tones | Evaluate the palms of the hands, soles of the feet, conjunctiva, nail beds, lips, and oral mucosa for color changes suggestive of cyanosis, which may appear gray, white, or blue. |
| Jaundice: Light Skin Tones | Yellow to orange discoloration |
| Jaundice: Dark Skin Tones | Check the hard palate and mucous membranes for yellowish discoloration. Check the sclera, palms, and soles for yellow discoloration. |
| Erythema: Light Skin Tones | Redness |
| Erythema: Dark Skin Tones | Maybe difficult to detect. Check the surrounding area and palpate the area for warmth. |
| Ecchymoses: Light Skin Tones | Reddish or bluish |
| Ecchymoses: Dark Skin Tones | A dark area of skin compared to the adjacent skin area. Tenderness when palpated. |
| Inflammation: Light Skin Tones | Reddish areas |
| Inflammation: Dark Skin Tones | A dark skin area compared to a nonaffected area of skin. Check for warmth, changes in texture, tautness, and swelling. |
| Deep tissue pressure injuries: Light Skin Tones | Assess for persistent, nonblanchable deep red, maroon, or purple discoloration of intact skin, or the presence of a dark wound bed or blood-filled blister. |
| Deep tissue pressure injuries: Dark Skin Tones | Check the area for changes. Palpate for pain and temperature |
| The Braden Scale rates a client’s risk for alterations in tissue integrity using six categories: | sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The lowest overall score the client can receive is 6, and the maximum score is 23. |
| Hospital-Acquired Pressure Injury (HAPI) | pressure injuries that occur during hospitalization. They are considered a hospital-acquired conditon |
| Drains are used to | decrease accumulation of fluid, reduce accumulation of air, and collect wound drainage for testing and identification. |
| Wound drains are classified as either | passive or active based on their mechanism of action |
| Passive drains, such as Penrose drains, rely on | gravity to remove accumulated fluid from a body cavity or wound. |
| Active or aspiration drains, such as | portable wound bulb suction devices, use negative pressure to suction drainage from wounds or body cavities. |
| Drains may also be classified as either | open or closed. |
| Open drains remove | fluids to the air, while closed drains send fluids to a closed containment system. |
| Closed systems require | smaller incisions and are less likely to become contaminated with bacteria. |
| The type of drain selected depends on | the anatomic location of the surgery, the wound type, the client’s individual needs, and the expected volume of drainage. Drains are usually removed when the wound drainage is minimal. |
| complications of drains include | clot formation at the insertion site, small tissue fragments that obstruct the tubing and prevent the outflow of drainage, and accidental removal of the drainage tube. |
| A portable wound bulb suction device, or bulb suction drain, is an | active, closed system drain that uses negative suction to drain fluid from the wound. |
| Dehiscence is a | complication that occurs when the suture line and surrounding tissue become separated. |
| A hematoma refers to | an accumulation of blood under the skin, which can be swollen. |
| Manifestations of surgical site infection include | fever, purulent drainage, redness, swelling, and pain. |
| Evisceration is a | medical emergency that occurs when there is organ protrusion, typically of abdominal organs, through the surgical incision. |
| NPWT uses suction over a semi-porous dressing to | remove drainage, reduce edema and help granulation tissue form to promote wound healing. |
| prevents the client from sliding down in bed, which can cause shearing of the skin, while also relieving pressure to the client's hip. | tilt the client on their side at 20° to 30° |
| Hydrofiber dressings are used for | moderate and highly exudative wounds. Hydrofiber dressings provide high absorbency and can stay in the wound for several days |
| Alginate dressings are made from | algae and are recommended for moderate to high exudative wounds. They provide hemostasis and can remain in a wound for several days, thus requiring less frequent dressing changes. |
| Hydrogel can be successfully used for | debridement of wounds with necrotized tissue and eschars, and causes minimal trauma to the healing wound bed. |
| Hydrogels work differently than other dressings in that | they can provide moisture to or draw moisture away from the wound dependent upon the needs of the wound. |
| self-adhesive transparent dressings are used for | covering superficial wounds that have minimal exudate. Due to their reduced ability to absorb moisture |
| The incision site that is in postoperative days 1 through 4 may appear | red with a small to moderate amount of exudate. |
| By the seventh postoperative day, the incision site should appear | bright pink and drainage should have subsided |
| postoperative day, From day 15 through 1 year | the incision site becomes pale pink. |
| Incision sites that are healed with scar tissue will appear | white to silver in clients who have lighter skin tones and darker than the surrounding tissue in clients who have darker skin tones. |
| Disadvantages of hydrocolloid dressings | include their potential to cause contact dermatitis and the foul-smelling, yellow, gelatinous film that develops as bacteria is trapped on the underside of the dressing |
| An alginate dressing is not | self-adhesive and needs a secondary dressing for reinforcement. |
| The bulb of the portable wound bulb suction device should be emptied at | least every 8 hr or when it is more than half full. |
| Wet dressings are | moistened in normal saline and used for wound packing when continuous debridement is needed |
| A hydrogel dressing is used for | debridement of wounds with necrotized tissue and eschars. |
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