Comprehensive Skin and Wound Care: Definitions, Types, and Healing Phases

patient has a break in the skin after a fall. Which concern explains why the nurse should assess and protect the area?

Disruption of the body's first line of defense against invading organisms.

During a skin assessment, the nurse explains why intact skin matters. What primary function should be emphasized?

Protection of underlying structures from microorganisms.

A patient has damaged skin and asks why wound care matters. What is the nurse's best explanation?

A break in skin integrity can lead to dangerous, potentially life-threatening complications.

A nursing care plan addresses wound assessment, complications, interventions, and coping. What approach does this demonstrate?

An individualized nursing-process approach to wound care.

A nurse identifies the body's outermost skin layer. Which layer is it?

Epidermis.

A wound involves tissue beneath the dermis. Which layer has been reached?

Subcutaneous tissue, also called the hypodermis.

Which functions of intact skin should the nurse recognize when assessing skin integrity?

Protection, temperature regulation, sensation, vitamin D production, immune activity, psychosocial function, adsorption, and elimination.

An older patient has multiple comorbidities and little underlying tissue. How does this affect skin care priorities?

These factors reduce resistance to skin injury and call for careful assessment and protection.

A patient with poor nutritional intake has fragile skin. What relationship guides the nurse's care?

Adequately nourished and hydrated cells better resist injury and disease.

A patient has inadequate tissue perfusion. Why is impaired circulation a threat to skin integrity?

Cells receive insufficient nourishment and remove metabolic wastes less efficiently.

The nurse observes a straight, clean wound with well-aligned edges after surgery. How should this wound be classified?

Incision.

A patient was struck by a blunt object and has bruising without broken skin. Which injury is most likely?

Contusion.

A patient scraped the knee against pavement, removing the top skin layers. What wound type should be documented?

Abrasion.

Why does a contaminated abrasion deserve careful wound assessment?

Scraped epidermal layers can contain dirt and microorganisms and may become infected.

The nurse observes torn tissue with irregular wound edges and loose skin flaps. Which injury does this describe?

Laceration.

A patient stepped on a sharp object that pierced the sole of the foot. What type of wound occurred?

Puncture wound.

When judging infection potential after a puncture injury, what characteristic should be considered?

The object that penetrated the skin.

Imaging shows a foreign fragment lodged under the skin after trauma. Which wound type is described?

Penetrating wound.

A traumatic injury tears tissue from its usual anatomic position. How should the nurse classify it?

Avulsion.

In an avulsion injury, which additional structures may be damaged?

Blood vessels, nerves, and other underlying structures.

The nurse assesses tissue injury following exposure to an acid. Which wound category applies?

Chemical injury.

A patient sustained tissue damage from extreme heat or cold. Which injury category applies?

Thermal injury.

A patient has skin breakdown after radiation exposure. Which mechanism is relevant?

Irradiation can produce wet or dry desquamation.

A lower-leg ulcer is associated with poor venous return and substantial drainage. Which type of ulcer is most likely?

Venous ulcer.

Which treatment principle is essential for a venous ulcer after adequate arterial flow has been verified?

Compression.

A lower-extremity ulcer results from ischemia due to poor arterial supply. Which ulcer type is likely?

Arterial ulcer.

An arterial ulcer has black eschar and impaired perfusion. Which treatment goal is essential?

Improving blood flow to the affected tissue.

A patient with diabetes has a wound below the ankle caused by neuropathy and arterial disease. What ulcer type should be considered?

Diabetic ulcer.

A nurse orders the wound-healing phases for a care-plan discussion. What is the correct sequence?

Hemostasis, inflammation, proliferation, maturation.

A newly injured patient begins clot formation. Which phase of wound healing is occurring?

Hemostasis.

The wound-healing process has advanced beyond initial hemostasis. Which phase follows?

Inflammation.

The wound is developing new tissue after inflammation. Which healing phase is this?

Proliferation.

A healing wound has entered the final remodeling period. Which phase is this?

Maturation.

A patient has pressure, edema, and maceration surrounding a wound. How are these healing factors classified?

Local factors affecting wound healing.

A patient has necrotic tissue, infection, and a wound biofilm. What do these conditions have in common?

They are local factors that can interfere with wound healing.

The nurse identifies advanced age, impaired oxygenation, and poor nutrition. What category of healing factors do these represent?

Systemic factors affecting wound healing.

A patient's medications and immunosuppression slow healing. Which category of factors explains this?

Systemic factors.

A patient regularly skips prescribed wound care. Which systemic influence on healing is involved?

Adherence to the treatment plan.

Which wound complications should the nurse monitor for during ongoing assessment?

Infection, hemorrhage, dehiscence, evisceration, and fistula formation.

After abdominal surgery, the incision separates and abdominal contents protrude. How should the nurse classify the complication?

Dehiscence with evisceration, a medical emergency.

A nurse discovers exposed bowel through an abdominal incision. What should the nurse do immediately to protect the tissue?

Cover it with sterile saline-soaked bandages to keep the exposed contents moist.

Which position should be used for a patient with abdominal evisceration?

Low Fowler's position.

A patient experiences dehiscence with evisceration. What must the nurse avoid doing?

Leaving the patient alone.

Who must be notified immediately after abdominal wound evisceration is identified?

The healthcare provider or surgeon, while obtaining immediate assistance.

Why does dehiscence with evisceration require urgent escalation?

It is an emergency requiring prompt surgical repair.

An abnormal passage has formed between an internal organ and the body's exterior. Which wound complication is present?

Fistula.

An ulcer develops over the sacrum after prolonged pressure. What is the underlying mechanism?

Compromised circulation from pressure, possibly combined with friction or shear.

A nurse assesses intact skin with localized nonblanchable redness over a bony prominence. What pressure-injury stage is present?

Stage 1.

A nurse observes a pressure-related blister with partial-thickness skin loss. What pressure-injury stage is present?

Stage 2.

A pressure injury has full-thickness skin loss with visible adipose tissue. How should it be staged?

Stage 3.

A pressure injury extends to muscle, tendon, ligament, or bone. How should it be staged?

Stage 4.

A pressure-injury wound bed is covered by slough or eschar, concealing its depth. How should it be classified?

Unstageable pressure injury.

The skin has persistent nonblanchable purple or maroon discoloration. Which pressure injury should be suspected?

Deep tissue pressure injury.

A nurse cannot see the full extent of a pressure injury because eschar covers the base. Why should a numbered stage not be assigned?

The obscured wound bed prevents determination of the depth of tissue loss.

A bedbound older adult has poor intake and altered mental status. Which pressure-injury risks are present?

Immobility, poor nutrition or hydration, altered mental status, and age.

Which patient is at higher risk for pressure injury: one who ambulates independently or one who cannot reposition?

The patient unable to reposition independently.

A patient remains in one position for an extended period. Which mechanical factors can injure the skin?

External pressure and friction or shear.

Which anatomical areas deserve attention when checking a supine patient for pressure injury?

Bony prominences, including the occiput, scapulae, vertebrae, sacrum, coccyx, and heels.

A patient uses a wheelchair throughout the day. Which pressure areas should the nurse inspect?

Areas under sustained pressure, including the sacrum and ischial regions.

How can microclimate affect the development of pressure injuries?

It influences tissue tolerance to pressure and shear.

The nurse admits a patient at risk for skin breakdown. What assessment approach should be used?

Systematic head-to-toe skin inspection, including bony prominences.

When should an at-risk patient in acute care receive follow-up skin assessments?

Every shift and whenever the condition changes.

How often does the lecture recommend skin reassessment during home-health visits?

On admission and at every visit.

What reassessment schedule does the lecture recommend for long-term care residents?

On admission, weekly for four weeks, then quarterly and whenever the condition changes.

A wound produces clear, watery exudate. How should the nurse document the drainage?

Serous drainage.

A wound has bright-red drainage that resembles blood. What does this indicate?

Sanguineous drainage associated with fresh bleeding.

A surgical dressing has darker bloody drainage. What does this suggest about the bleeding?

The blood is older rather than fresh.

A wound produces light-pink, blood-tinged fluid. How should drainage be documented?

Serosanguineous drainage.

A wound drains thick green material with a foul smell. How should the drainage be documented?

Purulent drainage.

What is the typical composition of purulent drainage?

White blood cells, liquefied dead tissue, and live or dead bacteria.

The nurse cleans an incision with approximated edges. In what direction should each wipe proceed?

Top to bottom and outward from the incision toward less clean areas.

During cleansing of an approximated incision, when should the nurse use a new sterile swab or gauze?

For every downward cleansing stroke.

The nurse cleans a wound with open, unapproximated edges. Where should cleansing begin?

At the center, moving outward in full or half circles.

During cleaning of an unapproximated wound, how often should the gauze be changed?

Use a new swab or gauze for each circle.

When cleaning an unapproximated wound before a new dressing, how far beyond the new dressing should the nurse clean?

At least 1 inch beyond the end of the new dressing.

When cleaning an unapproximated wound that will not be dressed, how far beyond the wound margins should the nurse clean?

At least 2 inches beyond the wound margins.

A nurse secures a dressing and supports an injured area using rolled gauze. What is being applied?

Bandage.

A patient needs a device shaped to support the abdomen after surgery. Which wound-support product applies?

Abdominal binder.

Why may a wound left completely open to air heal more slowly?

Drying causes a scab or eschar that can delay healing and expose delicate cells if dislodged.

A wound produces a substantial amount of drainage. Which dressing goal should guide the nurse?

Absorb exudate while maintaining wound moisture balance and protecting surrounding skin.

A dressing is selected to protect the wound and nearby skin. Which wound-care goals does it address?

Prevention of further injury and protection from environmental exposure.

A wound contains damaged or necrotic tissue. Which wound-management intervention may be appropriate when indicated?

Debridement, the removal of damaged or dead tissue.

A patient receives prescribed local heat for muscle tightness. Which physiologic effect should the nurse anticipate?

Vasodilation, increased local blood flow, decreased muscle tension, and pain relief.

A patient receives local heat therapy. What change occurs in tissue metabolism and capillary permeability?

Both increase.

A patient requires local cold therapy after a sprain. Which effects support the treatment?

Vasoconstriction, decreased edema and inflammation, reduced muscle spasm, and pain relief.

Which thermal intervention reduces local blood flow and assists in controlling bleeding?

Cold therapy.

What maximum duration does the lecture specify for prescribed heat or cold application?

No longer than 30 minutes.

What details should be included in a prescription for heat or cold therapy?

Type of application, body area, frequency, and duration.

Before applying prescribed heat or cold, what should the nurse explain to the patient?

The purpose, steps, and sensations expected during treatment.

What equipment should be accessible during thermal therapy in the hospital?

A timer or clock and the call bell.

A new nurse wants the correct order for solving patient problems. What sequence should guide care?

Assessment, analysis or diagnosis, planning, implementation, evaluation.

A nurse is obtaining a history, examining the patient, and reviewing records. Which nursing-process phase is occurring?

Assessment.

A nurse organizes several findings into a pattern suggesting a patient problem. Which nursing-process phase is this?

Analysis or diagnosis.

A nurse writes measurable outcomes and selects interventions to address identified problems. Which phase is occurring?

Planning.

The nurse carries out the selected interventions for a patient's care. Which phase is occurring?

Implementation.

The nurse compares actual patient progress against planned outcomes. Which phase is occurring?

Evaluation.

Why must nursing care plans be reevaluated as patient conditions change?

The nursing process is dynamic and cyclical, not a one-time linear activity.

A nurse includes the patient and family while developing care goals. Which nursing-process characteristic is demonstrated?

Client-centered and collaborative care.

A new nurse requests guidance instead of guessing about unfamiliar care. Which critical-thinking principle is demonstrated?

Recognition of personal limits and use of helpful resources.

What does clinical reasoning mean in patient care?

Thinking through how to determine, prevent, and manage patient problems.