Fundamentals
of
Nursing
Chapter
48:
Skin
Integrity
and
Wound
Care
Practice
questions
1.
The
nurse
is
working
on
a
medical-surgical
unit
that
has
been
participating
in
a
research
project
associated
with
pressure
ulcers.
The
nurse
recognizes
that
the
risk
factors
that
predispose
a
patient
to
pressure
ulcer
development
include
a.
A
diet
low
in
calories
and
fat.
b.
Alteration
in
level
of
consciousness.
c.
Shortness
of
breath.
d.
Muscular
pain.
-
ANSANS:
B
Patients
who
are
confused
or
disoriented
or
who
have
changing
levels
of
consciousness
are
unable
to
protect
themselves.
The
patient
may
feel
the
pressure
but
may
not
understand
what
to
do
to
relieve
the
discomfort
or
to
communicate
that
he
or
she
is
feeling
discomfort.
Impaired
sensory
perception,
impaired
mobility,
shear,
friction,
and
moisture
are
other
predisposing
factors.
Shortness
of
breath,
muscular
pain,
and
a
diet
low
in
calories
and
fat
are
not
included
among
the
predisposing
factors.
2.
The
nurse
is
caring
for
a
patient
who
was
involved
in
an
automobile
accident
2
weeks
ago.
The
patient
sustained
a
head
injury
and
is
unconscious.
The
nurse
is
able
to
identify
that
the
major
element
involved
in
the
development
of
a
decubitus
ulcer
is
a.
Pressure.
b.
Resistance.
c.
Stress.
d.
Weight.
-
ANSANS:
A
Pressure
is
the
main
element
that
causes
pressure
ulcers.
Three
pressure-related
factors
contribute
to
pressure
ulcer
development:
pressure
intensity,
pressure
duration,
and
tissue
tolerance.
When
the
intensity
of
the
pressure
exerted
on
the
capillary
exceeds
12
to
32
mm
Hg,
this
occludes
the
vessel,
causing
ischemic
injury
to
the
tissues
it
normally
feeds.
High
pressure
over
a
short
time
and
low
pressure
over
a
long
time
cause
skin
breakdown.
Resistance
(the
ability
to
remain
unaltered
by
the
damaging
effect
of
something),
stress
(worry
or
anxiety),
and
weight
(individuals
of
all
sizes,
shapes,
and
ages
acquire
skin
breakdown)
are
not
major
causes
of
pressure
ulcers.
3.
Which
nursing
observation
would
indicate
that
the
patient
was
at
risk
for
pressure
ulcer
formation?
a.
The
patient
ate
two
thirds
of
breakfast.
b.
The
patient
has
fecal
incontinence.
c.
The
patient
has
a
raised
red
rash
on
the
right
shin.
d.
The
patient's
capillary
refill
is
less
than
2
seconds.
-
ANSANS:
B
The
presence
and
duration
of
moisture
on
the
skin
increase
the
risk
of
ulcer
formation
by
making
it
susceptible
to
injury.
Moisture
can
originate
from
wound
drainage,
excessive perspiration,
and
fecal
or
urinary
incontinence.
Bacteria
and
enzymes
in
the
stool
can
enhance
the
opportunity
for
skin
breakdown
because
the
skin
is
moistened
and
softened,
causing
maceration.
Eating
a
balanced
diet
is
important
for
nutrition,
but
eating
just
two
thirds
of
the
meal
does
not
indicate
that
the
individual
is
at
risk.
A
raised
red
rash
on
the
leg
again
is
a
concern
and
can
affect
the
integrity
of
the
skin,
but
it
is
located
on
the
shin,
which
is
not
a
high-risk
area
for
skin
breakdown.
Pressure
can
influence
capillary
refill,
leading
to
skin
breakdown,
but
this
capillary
response
is
within
normal
limits.
4.
The
wound
care
nurse
visits
a
patient
in
the
long-term
care
unit.
The
nurse
is
monitoring
a
patient
with
a
stage
III
pressure
ulcer.
The
wound
seems
to
be
healing,
and
healthy
tissue
is
observed.
How
would
the
nurse
stage
this
ulcer?
a.
Stage
I
pressure
ulcer
b.
Healing
stage
II
pressure
ulcer
c.
Healing
stage
III
pressure
ulcer
d.
Stage
III
pressure
ulcer
-
ANSANS:
C
When
a
pressure
ulcer
has
been
staged
and
is
beginning
to
heal,
the
ulcer
keeps
the
same
stage
and
is
labeled
with
the
words
"healing
stage."
Once
an
ulcer
has
been
staged,
the
stage
endures
even
as
the
ulcer
heals.
This
ulcer
was
labeled
a
stage
III,
it
cannot
return
to
a
previous
stage
such
as
stage
I
or
II.
This
ulcer
is
healing,
so
it
is
no
longer
labeled
a
stage
III.
5.
The
nurse
is
admitting
an
older
patient
from
a
nursing
home.
During
the
assessment,
the
nurse
notes
a
shallow
open
ulcer
without
slough
on
the
right
heel
of
the
patient.
This
pressure
ulcer
would
be
staged
as
stage
a.
I.
b.
II.
c.
III.
d.
IV.
-
ANSANS:
B
This
would
be
a
stage
II
pressure
ulcer
because
it
presents
as
partial-thickness
skin
loss
involving
epidermis,
dermis,
or
both.
The
ulcer
is
superficial
and
presents
clinically
as
an
abrasion,
blister,
or
shallow
crater.
Stage
I
is
intact
skin
with
nonblanchable
redness
over
a
bony
prominence.
With
a
Stage
III
pressure
ulcer,
subcutaneous
fat
may
be
visible,
but
bone,
tendon,
and
muscles
are
not
exposed.
Stage
IV
involves
full-thickness
tissue
loss
with
exposed
bone,
tendon,
or
muscle.
6.
The
nurse
is
completing
a
skin
assessment
on
a
patient
with
darkly
pigmented
skin.
Which
of
the
following
would
be
used
first
to
assist
in
staging
an
ulcer
on
this
patient?
a.
Cotton-tipped
applicator
b.
Disposable
measuring
tape
c.
Sterile
gloves
d.
Halogen
light
-
ANSANS:
D
When
assessing
a
patient
with
darkly
pigmented
skin,
proper
lighting
is
essential
to
accurately
complete
the
first
step
in
assessment—inspection—and
the
whole
assessment
process.
Natural
light
or
a
halogen
light
is
recommended.
Fluorescent
light
sources
can
produce
blue
tones
on
darkly
pigmented
skin
and
can
interfere
with
an
accurate
assessment.
Other
items
that
could
possibly
be
used
during
the
assessment
include
gloves
for
infection
control,
a
disposable
measuring
device
to
measure
the
size
of
the
wound,
and
a cotton-tipped
applicator
to
measure
the
depth
of
the
wound,
but
these
items
not
the
first
item
used.
7.
The
nurse
is
caring
for
a
patient
with
a
stage
IV
pressure
ulcer.
The
nurse
recalls
that
a
pressure
ulcer
takes
time
to
heal
and
is
an
example
of
a.
Primary
intention.
b.
Partial-thickness
wound
repair.
c.
Full-thickness
wound
repair.
d.
Tertiary
intention.
-
ANSANS:
C
Pressure
ulcers
are
full-thickness
wounds
that
extend
into
the
dermis
and
heal
by
scar
formation
because
the
deeper
structures
do
not
regenerate,
hence
the
need
for
full-thickness
repair.
The
full-thickness
repair
has
three
phases:
inflammatory,
proliferative,
and
remodeling.
A
wound
heals
by
primary
intention
when
wounds
such
as
surgical
wounds
have
little
tissue
loss;
the
skin
edges
are
approximated
or
closed,
and
the
risk
for
infection
is
low.
Partial-thickness
repairs
are
done
on
partial-thickness
wounds
that
are
shallow,
involving
loss
of
the
epidermis
and
maybe
partial
loss
of
the
dermis.
These
wounds
heal
by
regeneration
because
the
epidermis
regenerates.
Tertiary
intention
is
seen
when
a
wound
is
left
open
for
several
days,
and
then
the
wound
edges
approximated.
Wound
closure
is
delayed
until
risk
of
infection
is
resolved.
8.
The
nurse
is
caring
for
a
patient
with
a
large
abrasion
from
a
motorcycle
accident.
The
nurse
recalls
that
if
the
wound
is
kept
moist,
it
can
resurface
in
_____
day(s).
a.
4
b.
2
c.
1
d.
7
-
ANSANS:
A
A
partial-thickness
wound
repair
has
three
compartments:
the
inflammatory
response,
epithelial
proliferation
and
migration,
and
re-establishment
of
the
epidermal
layers.
Epithelial
proliferation
and
migration
start
at
all
edges
of
the
wound,
allowing
for
quick
resurfacing.
Epithelial
cells
begin
to
migrate
across
the
wound
bed
soon
after
the
wound
occurs.
A
wound
left
open
to
air
resurfaces
within
6
to
7
days,
whereas
a
wound
that
is
kept
moist
can
resurface
in
4
days.
One
or
2
days
is
too
soon
for
this
process
to
occur,
moist
or
dry.
9.
The
nurse
is
caring
for
a
patient
who
is
experiencing
a
full-thickness
repair.
The
nurse
would
expect
to
see
which
of
the
following
in
this
type
of
repair?
a.
Eschar
b.
Slough
c.
Granulation
d.
Purulent
drainage
-
ANSANS:
C
Granulation
tissue
is
red,
moist
tissue
composed
of
new
blood
vessels,
the
presence
of
which
indicates
progression
toward
healing.
Soft
yellow
or
white
tissue
is
characteristic
of
slough—a
substance
that
needs
to
be
removed
for
the
wound
to
heal.
Black
or
brown
necrotic
tissue
is
called
eschar,
which
also
needs
to
be
removed
for
a
wound
to
heal.
Purulent
drainage
is
indicative
of
an
infection
and
will
need
to
be
resolved
for
the
wound
to
heal.
10.
The
nurse
is
caring
for
a
patient
who
has
experienced
a
laparoscopic
appendectomy.
The
nurse
recalls
that
this
type
of
wound
heals
by
