Skin Integrity and Wound Care

1.An elderly patient is admitted to the hospital for a bowel obstruction. The patient is immobile and the nurse notices that there is a reddened area on the right heel. When the nurse presses on the area it does not turn lighter in color. How should the nurse document the tissue condition?

a.
Reactive hyperemia
b.
Blanchable hyperemia
c.
Nonblanchable hyperemia
d.
Tissue ischemia

ANS: C

Nonblanchable hyperemia is redness that persists after palpation and indicates tissue damage. When you press a finger against the red or purple area, it does not turn lighter in color. Deep tissue damage is present and is commonly the first stage of pressure ulcer development. Reactive hyperemia is a redness of the skin resulting from dilation of the superficial capillaries. Reactive hyperemia blanches. In blanchable hyperemia, the area that appears red and warm will blanch (turn lighter in color) following fingertip palpation. Tissue ischemia, decreased blood flow to tissue, usually results in tissue death and occurs when capillary blood flow is obstructed, as in the case of pressure.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 1062 OBJ: Describe risk factors for pressure ulcer development.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

2.The student nurse asks a nursing assistive personnel (NAP) to help move a patient up in bed. The student nurse instructs the NAP to position the patient in bed to avoid which of the following factors that would contribute to pressure ulcer formation?

a.
Friction
b.
Shear
c.
Moisture
d.
Tunneling

ANS: B

Shear is the force exerted against the skin while the skin remains stationary and the bony structures move. For example, when the head of the bed is elevated, gravity causes the bony skeleton to pull toward the foot of the bed, while the skin remains against the sheets. Friction is surface damage caused by the skin rubbing against another surface that often results in an abrasion. Friction would result if the patient is dragged across the sheets. Skin moisture increases the risk for ulcer formation as moisture softens the skin and reduces its resistance to other physical factors such as pressure or shear. Moisture comes from many sources such as wound drainage, perspiration, and/or fecal and urinary incontinence. With continuous pressure over the area, deep tissue destruction continues, which often results in larger pockets of necrotic tissue beneath the opening of the main wound that resemble a tunnel; this is referred to as tunneling.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 1062 | 1063 OBJ: Describe risk factors for pressure ulcer development.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

3.An elderly patient has been admitted to the hospital for pneumonia. Which factor could put this patient at risk for a pressure ulcer?

a.
A diet low in protein
b.
Braden Scale results of 22
c.
Primary health care provider orders that read “activity as tolerated”
d.
Being repositioned every 2 hours

ANS: A

Poor nutrition, specifically severe protein deficiency, causes soft tissue to become susceptible to breakdown. Low protein levels cause edema or swelling, which contributes to problems with the transportation of oxygen and nutrients. A hospitalized adult with a score of 16 or below and an older adult at 18 or below are at risk for pressure ulcer development; a score of 22 does not place the patient at risk. A patient with decreased mobility, inadequate nutrition, excessive skin moisture, decreased sensory perception, or decreased activity is at risk for pressure ulcer development. Repositioning a patient every 2 hours will help prevent pressure ulcers. Activity as tolerated will help prevent pressure ulcers.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1063 OBJ: Describe risk factors for pressure ulcer development.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

4.A patient is admitted to the hospital with a pressure ulcer on the sacrum. The wound is open with exposed bone. The nurse should document this pressure ulcer at what stage?

a.
Stage I
b.
Stage II
c.
Stage III
d.
Stage IV

ANS: D

Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling

Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence

Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister

Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1063

OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

5.A preschool paraplegic patient with cerebral palsy is admitted to the hospital with complications from the H1N1 virus. The admitting nurse notes that an area of redness on the right malleolus is nonblanchable. The nurse correctly identifies this pressure ulcer at what stage?

a.
Stage I
b.
Stage II
c.
Stage III
d.
Stage IV

ANS: A

Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence

Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister

Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling

Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1063

OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

6.An older adult patient with diabetes recently moved into an assisted living apartment to have assistance with bathing and housework. During a bath, the assistive nursing personnel noticed that there was a large blister on the patient’s right heel. The patient denies knowledge of having injured self. It was reported to the nurse who correctly documented it as what stage of a pressure ulcer?

a.
Stage I
b.
Stage II
c.
Stage III
d.
Stage IV

ANS: B

Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister

Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence

Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling

Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1063

OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

7.A middle-age adult paraplegic patient has been admitted for follow-up from a traumatic brain injury received while serving in Afghanistan. The admitting diagnosis is failure-to-thrive. On admission, the patient was found to have a wound on the right scapula. The nurse noted full-thickness tissue loss with tunneling, but did not note any bone, tendon, or muscle. This was correctly identified as what stage of a pressure ulcer?

a.
Stage I
b.
Stage II
c.
Stage III
d.
Stage IV

ANS: C

Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling

Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence

Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister

Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1063

OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

8.A patient is being seen in the Emergency Department for a puncture wound on the foot. The patient was walking in a construction site, but is unsure what caused the injury. During the initial assessment the nurse determines if the patient has received a tetanus toxoid injection within which time frame?

a.
Within the past year
b.
Within the last 3 years
c.
Within the last 5 years
d.
Within the last 10 years

ANS: D

When an injury results from trauma from a dirty penetrating object, determine if the patient has received a tetanus toxoid injection within the last 10 years. Within the past year, 3 years, or 5 years is too early.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1072 OBJ: Discuss common complications of wound healing.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

9.An elderly patient who resides in a nursing home is suffering from a respiratory infection. During the illness, the patient has become incontinent of both urine and stool. The nursing staff used a special cleanser on the perineum, put a moisture barrier on the exposed area, and used absorbent briefs to prevent the skin from becoming soft because of the moisture. What was the staff trying to prevent?

a.
Maceration
b.
Dehiscence
c.
Evisceration
d.
Debridement

ANS: A

The staff is preventing maceration. For a patient who is incontinent of stool or urine, use a specialized incontinence cleanser. To protect the skin you apply a moisture barrier product (generally petrolatum or dimethicone based) liberally to the exposed area. Select underpads, diapers, or briefs that are absorbent to wick incontinence moisture away from the skin versus trapping the moisture against the skin, which causes maceration (softening of the skin because of moisture). To maintain a stable environment it is important to control infection and promote cleansing, debride (remove) necrotic tissue, provide exudate management, control dead space, and provide wound protection. Dehiscence is the partial or total separation of layers of skin and tissue above the fascia in a wound that is not healing properly. Evisceration occurs when wound layers separate below the fascial layer, and visceral organs protrude through the wound opening.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 1066 | 1077 OBJ: Describe risk factors for pressure ulcer development.

TOP:Nursing Process: Assessment

MSC: Client Needs: Safe and Effective Care Environment

10.The nurse is caring for a patient with a necrotic hip wound. Which dressing would be the bestchoice for the nurse to use on this type of wound to help with debridement?

a.
Dry gauze
b.
Transparent film
c.
Hydrogel
d.
Hydrocolloid

ANS: C

Hydrogel dressings are available in sheets or in a gel in a tube (amorphous). They contain a high percentage of water and are indicated for wounds that require moisture, either a wound with granulation (maintaining the moist wound environment needed for healing) or a wound that has a high percentage of necrotic tissue (the hydrogel facilitates debridement by softening the dead tissue). Gauze dressings are best for wounds with moderate drainage, deep wounds, undermining, and tunnels. Transparent film dressings are used as a primary dressing in wounds with minimal tissue loss that have very little wound drainage. Hydrocolloid dressings are used for stage I, II, and III pressure ulcers.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 1077 OBJ: Describe the mechanism of action of wound care dressings.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

11.The nurse is preparing to change a large wound dressing on the patient’s buttock. Which intervention should the nurse address first?

a.
Inspect the dressing for drainage.
b.
Medicate appropriately before performing the dressing change.
c.
Observe wound edges and if staples or sutures are intact.
d.
Assess the insertion site of the drain(s).

ANS: B

When you plan a dressing change, consider giving the patient an analgesic at least 30 minutes before exposing a wound. Then assess the appearance of the wound. Next, assess the character of wound drainage by noting the amount, color, odor, and consistency. Then assess the drains. Drains lie within tissue, extend from the skin, and are connected to a drainage bag or suction apparatus or allowed to drain into a dressing. Most drains attach to a collection device. First, observe the security of the drain and its location with respect to the wound. Next, note the character and amount of drainage if there is a collecting device. In the case of a surgical wound, inspect the staples, sutures, or wound closures for irritation, and note whether the wound edges are intact.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1073

OBJ: Describe the purposes of and precautions taken with applying dressings and binders.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

12.Which therapy should the nurse choose that will improve a patient’s circulation, relieve edema, and promote concentration of pus and drainage?

a.
Warm soaks
b.
Warm moist compresses
c.
Sitz baths
d.
Cold moist compresses

ANS: B

A warm moist compress improves circulation, relieves edema, and promotes concentration of pus and drainage. Warm soaks involve the immersion of a body part in a warmed solution that promotes circulation, lessens edema, increases muscle relaxation, and allows application of medicated solution. The patient who has had rectal surgery or an episiotomy during childbirth or who has painful hemorrhoids or vaginal inflammation will benefit from a sitz bath, a bath in which only the pelvic area is immersed in warm fluid. Cold moist compresses are used to relieve inflammation and swelling.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1090 | 1091

OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

13.A patient who has undergone a colectomy is demonstrating wound healing. The nurse correctly identifies the wound phase characterized by synthesis of collagen fibers as which of the following?

a.
Proliferative phase
b.
Inflammation phase
c.
Hemostasis phase
d.
Secondary intention phase

ANS: A

The proliferative phase, in wound healing by primary intention, causes new capillary networks to form that provide oxygen and nutrients for new tissue and contribute to the synthesis of collagen. In the inflammation phase the goal is to establish a clean wound bed and obtain bacterial balance. If exudate brings white blood cells to the area, a scab will form. When wounds involve loss of tissue, such as a severe laceration or chronic wound, these heal by secondary intention. Hemostasis phase controls bleeding.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1066

OBJ: Discuss the response of the body during each phase of the wound healing process.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

14.A surgical wound requires a hydrogel dressing. What is the primary advantage of a hydrogel dressing?

a.
It provides an absorbent to collect wound drainage.
b.
It provides a negative pressure to promote healing.
c.
It provides protection from the external environment.
d.
It provides moisture needed for wound healing.

ANS: D

Hydrogels maintain moisture in some wounds for 1 to 3 days. Hydrogel dressings are available in sheets or in a gel in a tube (amorphous). They contain a high percentage of water and are indicated for wounds that require moisture, either a wound with granulation (maintaining the moist wound environment needed for healing) or a wound that has a high percentage of necrotic tissue (the hydrogel facilitates debridement by softening the dead tissue). Negative pressure wound therapy (NPWT) uses negative pressure to assist wound healing. Negative pressure wound therapy supports wound healing by evacuating wound fluids, stimulating granulation tissue formation, reducing the bacterial burden of a wound, and maintaining a moist wound environment. Gauze dressings are best for wounds with moderate drainage, deep wounds, undermining, and tunnels. You apply gauze either moist or dry. The moistened gauze increases the absorptive ability of the dressing to collect exudate. A transparent or hydrocolloid dressing protects against the external environment.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1083 OBJ: Describe the mechanism of action of wound care dressings.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

15.A patient is wearing an abdominal binder after abdominal surgery. What does the nurse need to assess and document about the patient?

a.
Neurological response
b.
Respiratory status
c.
Lymphatic status
d.
Genitourinary response

ANS: B

Evaluate the patient’s ability to ventilate properly, including deep breathing and coughing. An abdominal binder supports a large incision that is vulnerable to stress when a patient moves or coughs. Neurological, lymphatic, and genitourinary responses are not affected by the abdominal binder.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1087

OBJ: Describe the purposes of and precautions taken with applying dressings and binders.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

16.A patient’s draining wound is pale and watery with a combination of plasma and red cells. How should the nurse document this finding?

a.
Serous drainage
b.
Purulent drainage
c.
Sanguineous drainage
d.
Serosanguineous drainage

ANS: D

Serosanguineous is pale, more watery, and a combination of plasma and red cells, which may be blood streaked. Serous is clear, watery plasma. Purulent is thick, yellow, green, or brown, indicating the presence of dead or living organisms and white blood cells. Sanguineous is fresh bleeding.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1073

OBJ: Describe wound assessment criteria: anatomical location, size, type, and percentage of wound tissue, volume and color of wound drainage, and condition of surrounding skin.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

17.A postoperative patient visits the ambulatory care clinic complaining of just “not feeling well.” The patient has an elevated temperature. Which assessment finding should indicate to the nurse that the wound has become infected?

a.
Negative culture
b.
No odor
c.
Presence of fluid around the edges
d.
Purulent drainage coming from the incision area

ANS: D

Purulent drainage indicates an infection as it contains dead or living organisms and white blood cells and is often yellow, green, or brown. If the drainage has a pungent or strong odor, an infection is likely. No odor indicates normal healing. When an infection develops, the wound edges are usually brightly inflamed, warm, tender, and swollen. Culture results would come back positive for bacteria if an infection is present; a negative culture indicates no infection is present.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1073 OBJ: Discuss common complications of wound healing.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

18.Which patient is best suited for heat therapy?

a.
A patient with low back pain
b.
A patient with suspected appendicitis
c.
A patient with first-degree burn
d.
A patient with active bleeding

ANS: A

Low back pain treatment of heat is used to promote muscle relaxation, and reduces pain from spasm or stiffness. Do not apply heat over an active area of bleeding (risk for continued bleeding) or an acute localized inflammation such as appendicitis (risk for rupture). Cold therapy, not heat, is indicated for a first-degree burn.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1088 | 1089 OBJ: Describe the differences in therapeutic effects of heat and cold

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

19.The primary health care provider has ordered the patient to wear an elastic bandage to the left ankle owing to a severe strain. The nurse has instructed the patient on proper application of the elastic bandage. Which statement indicates the patient needs more teaching?

a.
“I need to wrap the bandage toward my toes.”
b.
“I need to make sure the bandage is smooth.”
c.
“I need to watch my toes for swelling and feeling cold.”
d.
“I need to take the bandage off and call the physician if I experience increased pain.”

ANS: A

The response: “I need to wrap the bandage toward my toes” is the correct answer because the patient is wrapping the bandage from the proximal boundary to the distal boundary. Proper application of the bandage is from distal point toward proximal boundary, stretching the dressing slightly, using a variety of bandage turns to cover various body shapes. Prevent uneven dressing tension or circulatory impairment by overlapping turns by one-half to two-thirds width of dressing roll. Be sure the bandage is smooth (without creases). Evaluate circulation to dressing area every 4 hours by palpating distal pulse, palpating skin, noting temperature and observing skin color. Saying, “make sure the bandage is smooth,” “watch my toes for swelling and feeling cold,” and “call the physician if I experience increased pain” are all correct and require no teaching.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1088

OBJ: Describe the purposes of and precautions taken with applying dressings and binders.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

20.Assistive personnel ask the nurse the differences between wound healing by primary and secondary intention. The nurse’s best response is that healing by primary intention occurs when the skin edges:

a.
are approximated.
b.
overlap each other.
c.
appear slightly red and moist.
d.
cannot come together.

ANS: A

A wound with little or no tissue loss, such as a clean surgical incision, heals by primary intention. The skin edges approximate, or close together (not overlapping), and the risk for infection is minimal. In contrast, 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 skin edges cannot come together because of the extensive tissue loss, and healing occurs gradually. A layer of granulation tissue, which is red, moist tissue consisting of blood vessels and connective tissue, covers the wound base in secondary intention.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 1064 OBJ: Differentiate healing by primary and secondary intention.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

21.When a patient has full-thickness loss but the depth is unknown, how should the nurse classify this pressure ulcer?

a.
Stage/Category III
b.
Unstageable
c.
Suspected deep tissue injury
d.
Stage/Category IV

ANS: B

Unstageable: Full-thickness tissue loss-depth unknown.

Stage/Category III: Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Suspected Deep Tissue Injury—Depth Unknown: Purple or maroon localized area of discolored intact skin or blood-filled blister owing to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared with adjacent tissue.

Stage/Category IV: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Often includes undermining and tunneling.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1063

OBJ: List the National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer stages.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

22.A patient’s full-thickness wound is establishing a clean wound bed and obtaining bacterial balance. This patient is in which phase of wound healing?

a.
Hemostasis phase
b.
Proliferative phase
c.
Inflammation phase
d.
Remodeling phase

ANS: C

Inflammation Phase: The goal of this phase is to establish a clean wound bed and obtain bacterial balance.

Hemostasis Phase: A full-thickness wound healing by primary intention first goes through the hemostasis phase, which controls bleeding.

Proliferative Phase: The key events are production of new tissue, epithelialization, and contraction.

Remodeling Phase: This phase may last up to 1 year, and reorganizes the collagen to produce a more elastic, stronger collagen for the scar tissue.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1066

OBJ: Discuss the response of the body during each phase of the wound healing process.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

MULTIPLE RESPONSE

1.On admission a patient is noted to have an alteration in skin integrity on the right heel. The nurse uses the Braden Scale. Which areas will the nurse assess when using this scale? (Select all that apply.)

a.
Mobility
b.
Nutrition
c.
Infection
d.
Friction and shear
e.
Sensory perception

ANS: A, B, D, E

The Braden Scale is a highly reliable scale that uses six subscales to identify patients at greatest risk for pressure ulcers: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Infection is not an area that is assessed on the Braden Scale.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1067

OBJ:Complete an assessment for a patient with impaired skin integrity.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2.A pre-teen quadriplegic patient was admitted with pressure ulcers to both ankles. The nurse should assess which parameters for a wound assessment? (Select all that apply.)

a.
Size
b.
Viable versus nonviable tissue
c.
Tissue type involvement
d.
Preventive measures
e.
Anatomical location

ANS: A, B, C, E

Wound assessment (regardless of cause) includes the following parameters: anatomical location, extent of tissue involvement (full or partial thickness loss), size (dimensions and depth of wound), tissue type (viable or nonviable) and percentage of wound tissue (e.g., viable vs. nonviable), volume and color of wound exudate, and condition of surrounding skin.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1064

OBJ: Describe wound assessment criteria: anatomical location, size, type, and percentage of wound tissue, volume and color of wound drainage, and condition of surrounding skin.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

3.A postoperative abdominal surgery patient has been admitted to the surgical floor. The nurse is aware that wound healing is delayed owing to complications. Which conditions would prevent normal wound healing at the surgical site? (Select all that apply.)

a.
Dehiscence
b.
Evisceration
c.
Erythema and edema at the suture site
d.
Hemostasis
e.
Hemorrhage

ANS: A, B, E

Complications of wound healing include any of the following: hemorrhage, hematoma, infection, dehiscence, and evisceration. Hemostasis is a normal response to healing, not a complication. Erythema and edema at the suture site is a normal response that occurs in the inflammation phase; it is not a complication.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1066 OBJ: Discuss common complications of wound healing.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity