Deck 36: Skin Integrity Wound Healing

Question 1

Review the case of William Harmon (MeetYour Patient). What risks, if any, does William have for skin breakdown or delayed healing?
What additional information do you need to know to fully evaluate his risk?
What risks do you have for impaired skin integrity? What actions can you take to protect your skin?

Answer 1

Risks for skin breakdown as seen on the scenario "Meet Your Patient":
• Age
• His immobility from the surgery
• Undernourishment from being depressed
Additional information to further evaluate the patient in the scenario "Meet Your Patient":
Information to be added is that the patient has presence of discolored skin in the coccyx area and the soles of the feet. These are the signs of an impending pressure ulcer which should be immediately intervened to halt the progression.
Common risks for skin integrity:
• Dryness of the skin
• Under nourished individual
• Immobility
• Less intake of water
• Underlying medical conditions
Actions to do in taking care of the skin:
• To combat dryness, lotion should be applied to moisturize the skin.
• Eating the right kind of food to help wounds heal faster examples are protein rich foods like meat.
• Immobility often leads to skin breakdown on pressure point of the body sample is the coccyx.
• Have adequate amounts of fluids to help prevent dryness in addition to the increase of the skin's elasticity.
• Underlying medical situations like in diabetes mellitus, special type of skin care is needed since wound healing is a bit delayed because of uncontrolled blood sugar. Wearing of socks, closed type of shoe which is not that fit for the individual and proper nail trimming are some of the examples that could be brought up.

Question 2

Describe three types of wound drainage.

Answer 2

Types of wound drainage :
Serous Exudate
This is watery, consists of serum and has little amount of cellular matter. Clean wounds normally drain serous exudates.
Sanguineous Exudate
This is a bloody drainage from deep wounds that indicates damaged capillaries. Bright red blood indicates fresh bleeding while dark red-brown blood signifies older or dried blood.
Serosanguineous Exudate
This is commonly seen on fresh wounds. It is mixture of serous and sanguineous exudates.

Question 3

Accurately document assessment of a wound.

Answer 3

Assessment for all kinds of wounds :
Location
• Describe the area where the wound is located using anatomical terms.
Size
• Measure the width and length of a wound in centimeters.
• Gently insert a sterile cotton tip applicator to reach the deepest part of the wound and measure the applicator from the skin level to the tip.
• If possible, use photo documentation and indicate the dimensions on the photo. This can be useful to wounds having an irregular border.
Appearance
• Describe the kind of wound. (I.e. is it an open or closed wound)
• Sutured wounds must be examined to check for wound closure, proximity of wound edges, and stitches.
• Assess and note for the color of the wound.
• The wound bed condition must be described.
• Examine the affected area for any presence of slough, eschar, and necrosis.
Drainage
• Check if there is any exudate or drainage present.
• Weigh soaked dressing and note the quantity of wound drainage.
• Collect and measure the exudates if drain is present.
• Assess for any presence of unusual odor for the exudates. It may indicate presence of fistula.

Question 4

PATIENT SITUATION A 66-year-old obese man with diabetes and hypertension, Tio Santos, is being seen for a wound on his right foot that does not seem to be healing. He injured his foot when repairing drywall at home. He is otherwise relatively sedentary at home. The wound is oozing, swollen, tender, and warm to the touch. Mr. Santos is now running a low-grade fever of 100.4°F at home. He tells you his foot is very painful, especially with any weight bearing, and throbs when sitting or lying still. You measure the wound bed to be 6 an x 4 cm and note purulent exudate at the distil edge. He is referred to an outpatient wound care center for treatment.
THINKING
Critical Thinking (Considering Alternatives, Deciding What to Do):
a. To care for Mr. Santos' wound, should you use sterile gloves, dean nonsterile gloves, or no gloves? Explain your thinking.

Question 5

Describe the percentage and type of tissue found in Mr. Harmon's wounds.
What are the goals of treatment with both of Mr. Harmon's wounds?

Question 6

Demonstrate appropriate technique for irrigating a wound.

Question 7

• Identify the factors that affect skin integrity.
• What nutritional components are essential to maintain skin?

Question 8

• What stage pressure ulcer does Mr. Harmon (MeetYour Patient) have?
• What factors have contributed to its development?

Question 9

Describe care of a wound with a drain.

Question 10

Identify wound type based on accepted classification schemes.

Question 11

Review the major complications of wound healing.

Question 12

Differentiate the five forms of wound debridement.

Question 13

Fernandez, R., Griffiths, R. (2010, March 14).Water for wound cleansing. Cochrane Database of Systematic Reviews, Issue I.Art.No.:CD00386 I. D01:10.1002/14651858. CDO 0386 I.pub2. Retrieved November 11,2011, from http:// onlinelibrary.wiley.congdoi/10.1002114651858.CD003861.pub31 abstractjsessionid=94E5F79 C171A97 5I6 C84A39 DA9082.
Use of saline versus tap water for cleansing wounds is debated. Normal saline is traditionally preferred because it cleanses without interfering with the normal healing process.Yet, tap water is used commonly in the community for cleaning wounds and for care of chronic wounds because it is generally free of pathogens, yet easily accessible and inexpensive. Researchers wanted to know if rates of infection and healing differ depending on whether tap water or normal sterile saline is used to clean acute and chronic wounds.They analyzed findings from 24 clinical studies. Results showed no differences in the rates of infections among acute and chronic wounds in adults and children cleansed with tap water as compared to those washed with saline.
If study findings indicate little difference in wound infection when tap water is used for cleansing, then what would you recommend to those using tap water in the community?

Question 14

What would be the best method to secure dressings for Mr. Harmon (MeetYour Patient)?

Question 15

Discuss the different kinds of tissue found in wounds.

Question 16

Recall the case of Mr. Harmon (MeetYour Patient).What form of wound healing (primary, secondary, or tertiary) is he undergoing? How long would you expect it to take before his wounds heal?

Question 17

• What should be included in a wound assessment?
• What is the preferred method of wound culture that may be performed by a registered nurse?
• Identify three types of laboratory data that may be associated with a delay in wound healing.

Question 18

Discuss when and how to use absorbent, alginate, collagen, gauze dressings, transparent films, hydrocolloids, hydrogels, and foam and antimicrobial dressings.

Question 19

PATIENT SITUATION A 66-year-old obese man with diabetes and hypertension, Tio Santos, is being seen for a wound on his right foot that does not seem to be healing. He injured his foot when repairing drywall at home. He is otherwise relatively sedentary at home. The wound is oozing, swollen, tender, and warm to the touch. Mr. Santos is now running a low-grade fever of 100.4°F at home. He tells you his foot is very painful, especially with any weight bearing, and throbs when sitting or lying still. You measure the wound bed to be 6 an x 4 cm and note purulent exudate at the distil edge. He is referred to an outpatient wound care center for treatment.
DOING
Practical Knowledge (Assessment):
a. What symptoms of infection does Mr. Santos have?
b. To be certain the wound is infected, what would you need to know or do?

Question 20

Explain the factors involved in the development of pressure ulcers.

Question 21

Describe guidelines to follow when applying heat or cold therapy.

Question 22

• Explain the difference between an acute and a chronic wound.
• Describe the wound categorization system based on the level of contamination
• How does wound depth affect healing?

Question 23

• Identify the major interventions for preventing pressure ulcers.
• What nursing diagnosis is most appropriate for a patient at risk for pressure ulcer development?

Question 24

Demonstrate bandage and binder application.

Question 25

Describe the three phases of wound healing.

Question 26

Use the Braden scale to assess risk for pressure ulcers.

Question 27

Fernandez, R., Griffiths, R. (2010, March 14).Water for wound cleansing. Cochrane Database of Systematic Reviews, Issue I.Art.No.:CD00386 I. D01:10.1002/14651858. CDO 0386 I.pub2. Retrieved November 11,2011, from http:// onlinelibrary.wiley.congdoi/10.1002114651858.CD003861.pub31 abstractjsessionid=94E5F79 C171A97 5I6 C84A39 DA9082.
Use of saline versus tap water for cleansing wounds is debated. Normal saline is traditionally preferred because it cleanses without interfering with the normal healing process.Yet, tap water is used commonly in the community for cleaning wounds and for care of chronic wounds because it is generally free of pathogens, yet easily accessible and inexpensive. Researchers wanted to know if rates of infection and healing differ depending on whether tap water or normal sterile saline is used to clean acute and chronic wounds.They analyzed findings from 24 clinical studies. Results showed no differences in the rates of infections among acute and chronic wounds in adults and children cleansed with tap water as compared to those washed with saline.
What implications does using tap water for cleaning wounds have when sending patients home after surgery?

Question 28

• Identify goals for wound care before applying a dressing to a wound.
• What solutions are used to cleanse a wound?
• How can you control the amount of force applied for wound irrigation?
• Identify three nursing responsibilities when caring for a client with a wound drain.

Question 29

Based on your knowledge of the factors that have contributed to Mr. Harmon's pressure ulcer development, what actions may lead to healing of the pressure ulcer? Note: To answer this question, you do not need to know about wound care (e.g., irrigation) for a pressure ulcer.

Question 30

Assess and categorize pressure ulcers based on the pressure ulcer staging system.

Question 31

PATIENT SITUATION A 66-year-old obese man with diabetes and hypertension, Tio Santos, is being seen for a wound on his right foot that does not seem to be healing. He injured his foot when repairing drywall at home. He is otherwise relatively sedentary at home. The wound is oozing, swollen, tender, and warm to the touch. Mr. Santos is now running a low-grade fever of 100.4°F at home. He tells you his foot is very painful, especially with any weight bearing, and throbs when sitting or lying still. You measure the wound bed to be 6 an x 4 cm and note purulent exudate at the distil edge. He is referred to an outpatient wound care center for treatment.
CARING
Self-Knowledge: Imagine you have had a wound on your foot for 6 weeks. It has not healed and you have all Mr. Santos' symptoms and, in fact, are in his situation. What would be the most troublesome symptom in your daily life? What would worry you the most?

Question 32

• What should you consider when choosing a dressing?
• Describe the five types of wound debridement.
• Identify the purposes of a wound dressing.

Question 33

PATIENT SITUATION A 66-year-old obese man with diabetes and hypertension, Tio Santos, is being seen for a wound on his right foot that does not seem to be healing. He injured his foot when repairing drywall at home. He is otherwise relatively sedentary at home. The wound is oozing, swollen, tender, and warm to the touch. Mr. Santos is now running a low-grade fever of 100.4°F at home. He tells you his foot is very painful, especially with any weight bearing, and throbs when sitting or lying still. You measure the wound bed to be 6 an x 4 cm and note purulent exudate at the distil edge. He is referred to an outpatient wound care center for treatment.
THINKING
Theoretical Knowledge:
a. What is the Braden Scale and why might it be used for Mr. Santos?
b. What risk factors for delayed wound healing does Mr. Santos have?

Question 34

Identify the type of wound healing (primary, secondary, or tertiary intention):
• A wound that heals from inner layer to the surface
• A wound with approximated edges
• A wound that heals by approximating two surfaces of granulation tissue
• A wound that is sutured and has minimal or no tissue loss

Question 35

Provide nursing care that limits the risk of pressure ulcer development.

Question 36

• Identify the major functions of the skin.
• What is the function of the stratum corneum, the outermost layer of the skin?
• What is the function of the subcutaneous layer?
• What effect does aging have on skin?
• What effect does immobility have on skin?

Question 37

Distinguish primary intention healing, secondary intention healing,and tertiary intention healing.

Question 38

• Differentiate among the different categories of dressings.
• What types of dressings may be used for wounds with a large amount of exudate?
• What form of dressing is appropriate for a wound with an eschar that needs to be eliminated?

Question 39

Discuss the factors that affect skin integrity.

Question 40

Review the Braden scale.Apply this risk assessment scale to Mr. Harmon (MeetYour Patient).
What additional information, if any, do you need to complete these assessments?
Calculate a Braden score based on Mr. Harmon's risk factors, if he had also been incontinent of urine twice that day.

Question 41

Differentiate the kinds of chronic wounds.

Question 42

Fernandez, R., Griffiths, R. (2010, March 14).Water for wound cleansing. Cochrane Database of Systematic Reviews, Issue I.Art.No.:CD00386 I. D01:10.1002/14651858. CDO 0386 I.pub2. Retrieved November 11,2011, from http:// onlinelibrary.wiley.congdoi/10.1002114651858.CD003861.pub31 abstractjsessionid=94E5F79 C171A97 5I6 C84A39 DA9082.
Use of saline versus tap water for cleansing wounds is debated. Normal saline is traditionally preferred because it cleanses without interfering with the normal healing process.Yet, tap water is used commonly in the community for cleaning wounds and for care of chronic wounds because it is generally free of pathogens, yet easily accessible and inexpensive. Researchers wanted to know if rates of infection and healing differ depending on whether tap water or normal sterile saline is used to clean acute and chronic wounds.They analyzed findings from 24 clinical studies. Results showed no differences in the rates of infections among acute and chronic wounds in adults and children cleansed with tap water as compared to those washed with saline.
What trend in the research about cleansing wounds do you see as compared to previous times?

Question 43

• Describe four types of wound closures.
• Identify five types of wound complications.
• Describe three signs of internal hemorrhage.
• Differentiate between dehiscence and evisceration.

Question 44

• What is the effect of adding moisture to heat or cold treatments?
• For how long should heat or cold be applied to an area?
• What precautions should you take before using heat or cold therapy?