Skin integrity and wound care Practice test
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Show Potter & Perry: Fundamentals of Nursing, 7th Edition Test Bank Chapter 48: Skin Integrity and Wound Care MULTIPLE CHOICE 1.The nurse determines that the client’s wound may be infected. To perform an aerobic wound culture, the nurse should: 1.Collect the superficial drainage 2. Collect the culture before cleansing the wound 3.Obtain a culturette tube and use sterile technique 4.Use the same technique as for collecting an anaerobic culture ANS:3 The nurse uses different methods of specimen collection for aerobic or anaerobic organisms. To collect an aerobic wound culture, the nurse uses a sterile swab from a culturette tube and sterile technique. The nurse never collects a wound culture sample from old or superficial drainage. Resident colonies of bacteria from the skin grow in superficial drainage and may not be the true causative organisms of a wound infection. The nurse should clean a wound first with normal saline to remove skin flora before obtaining the culture. DIF:AREF:1299OBJ:Comprehension TOP: Nursing Process: Planning MSC:NCLEX® test plan designation: Potential for Risk Reduction/Potential for Alter- ations in Body Systems 2.Pressure ulcers form primarily as a result of: 1.Nitrogen buildup in the underlying tissues 2.Prolonged illness or disease 3.Tissue ischemia 4.Poor nutrition ANS:3 Pressure is the major cause of pressure ulcer formation. Prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ischemia and ultimately tissue death. Prolonged illness or disease and poor nutrition may place a client at risk for pressure ulcer development. DIF:AREF:1280OBJ:Comprehension TOP:Nursing Process: Assessment
largest organ of body Dermal-Epithelial Junction Separates the Dermis and Epidermis Top layer of skin Inner layer of skin pressure sore, decubitus sore, bed sore. Factors for Pressure Ulcer/Bed sores pressure intensity: How much weight/gravity is put on skin Risk Factors for Pressure Ulcer Development Impaired sensory perception:clients dont know they need to move to shift pressure Stage 1 Pressure Ulcer Formation 1: intact skin, NONBLANCHABLE, erythema stage 2 Pressure Ulcer Formation partial-thickness skin loss INVOLVES EPIDERMIS, DERMIS OR BOTH full thickness skin loss: involving damage or necrosis to SUBCUTANEOUS TISSUES full thickness skin loss with tissue necrosis or damage to MUSCLE,BONE OR SUPPORTING STRUCTURES Wound Classification: acute and chronic acute: timely and orderly healing: wound edges are clean and intact: surgery and trauma Phases of wound healing (4) 1. Hemostasis phase control of bleeding, clots form, injured blood vessels constrict, platelets accumulate acute= 3-4 days, chronic= longer 1. Hemostasis phase HIPR: Hot Italians Practice Religion Tell-tale signs of inflammatory phase erythema, edema, pain, warmth WEPE Proliferative phase: develops? produces? 4-21 days; collagen produced; development of tensile strength and scar tissue; granulation tissue formation; epithelialization (new skin); new blood vessels form Remodeling/ Maturation Phase: 3-4 weeks; fibroblasts leave wound, can last for over a year. new and remodeled collagen is deposited; tightens and reduces scar size; tensile strength increases (regains 80% strength)---> scar Primary, Secondary and Tertiary Primary wound healing tissue surfaces closed Secondary wound healing extensive tissue loss Tertiary wound healing intentionally left open to drain Hemorrhage greatest in first 48 hours after surgery. bleeding from wound bed or site. infection change in wound color,pain or drainage, fever, elevated WBC dehiscence partial or total rupturing of a sutured wound. occurs before collagen production( 3-11 days after injury) Evisceration MEDICAL EMERGENCY abnormal tube-like passageway that forms between two organs or from one organ to outside the body serous,purulent,serosanguineous,sanguineous mostly serum thick,yellow,green,tan or brown pale,red,watery: mixture of clear and red fluid bright red; indicates active bleeding physical and mental condition,activity, mobility, and continence sensory perception, moisture, activity, mobility, nutrition and friction/shear nursing process: assessment assess areas of bony prominences at risk for skin breakdown. assessment data: inspection and palpation skin color distribution, skin turgor, presence of edema, characteristics of skin lesions, assessment data: untreated wounds location, extent of tissue damage, wound length,width, and depth. bleeding, foreign bodies, associated injuries assessment data: treated wounds appearance,size,drainage,presence of swelling, pain, status of drains/tubes minimize direct pressure, schedule and record position changes (every 2 hours), never use alcohol and hydrogen peroxide, obtain culture and sensitivity if infectied, clean and dress the ulcer _____ ______ is a good cleanser 30 degrees at head of bed color guide for wound care Red: protect--granulation tissue retains dressings on wounds, bandage hands and feet provide pressure to an area supports large areas of body protects wound from surface contamination maintains a moist surface to support healing uses negative pressure to support healing if it's wet, ___it sharp hollow rubber tube placed directly or near the incision placed near the incision or where drainage is expected; suction is maintained through compression of the spring like mechanism place near incision or where drainage is expected; gentle suction is maintained by compression of the bulb heat: vasodilated Mr. Thomas What are 4 components of a wound assessment?Tissue Loss. Clinical appearance of the wound bed and stage of healing. Measurement and dimensions. Wound edge.
What are five 5 wound characteristics you would identify when assessing a wound?Wound report
Characteristics of the wound bed, such as necrotic tissue, granulation tissue and infection. Odour and exudate (none, low, moderate, high) Condition of the surrounding skin (normal, oedematous, white, shiny, warm, red, dry, scaling, thin)
What are the 9 parameters included in doing a wound assessment?Wound assessment should include the following components:. Anatomic location.. Type of wound (if known). Degree of tissue damage.. Wound bed.. Wound size.. Wound edges and periwound skin.. Signs of infection.. What are the 6 key principles of wound assessment?The basic principles for the management of a wound or laceration are:. Haemostasis.. Cleaning the wound.. Analgesia.. Skin closure.. Dressing and follow-up advice.. |
