CHAPTER 2?
Skin Care and
of Wounds
TRUE OR FALSE When changing a dressing, you
should make sure that the client
Circle T for true, or circle F for false. looks at his or her wound.
4. T F When giving a back massage, 3. When changing a dressing, you
massage the bony areas need to wear gloves only if there is
thoroughly. drainage.
2. T F Clients sitting in a chair should be 9. You should never apply lotion to a
reminded to shift their weight every Bree
hour.
10. A venous ulcer is caused by poor
3. T F When bathing or drying the client, blood return through the veins.
rub vigorously.
11; A skin tear is a very deep cut in the
4. T F To prevent pressure injuries, you een
must frequently check clients who
are incontinent to ensure they are 12. Skin tears commonly occur in the
not lying on wet linens. head and chest.
5. TF When applied, adhesive tape should 13: When oxygen and nutrients get into
circle the entire body part to prevent the cells, skin, and tissues, pressure
swelling. ulcers will occur.
6. T F Make sure you collect all equipment 14. When a client slides down in a bed
needed before you begin to change a or chair, shearing occurs. Blood
nonsterile dressing. vessels and tissues are damaged.
110 CHAPTER 22 Skin Care and Prevention of Wounds
Tbe 71 F In obese clients, pressure injuries can MULTIPLE RESPONSE
. er) . e
develop where skin surfaces press
From the list below, choose all of the correct
against each other, causing a decrease
in blood flow. answers.
16. T F Heel protectors reduce pressure on 22. Strategies for preventing skin tears include:
the heels by lowering them. A. Keeping the skin dry and avoiding all
moisturizers or skin softeners
LAs 8 A flotation pad or cushion is placed B. . Offering fluids
in a pillowcase so the pad does not C. Dressing and undressing the client
touch the skin. carefully
D. Dressing the client in soft clothing with
18. T F You should check with the nurse long sleeves and long pants
before using soap on a client who is E. Keeping your fingernails short and
at risk for pressure injuries because smoothly filed
soap can moisturize the skin. es Keeping the client’s fingernails short
and smoothly filed
jie ad eo Skin should be kept clean and dry Not wearing rings with raised or large
and free of moisture from urine, stones
stool, perspiration, and wound coFollowing safety guidelines when lifting
drainage. and transferring clients
— Preventing friction and shearing during
20. -T F When very small amounts of lifting, moving, transferring, and
drainage are expected, a drain is repositioning (e.g., using a transfer
applied to enable the drainage to sheet or pad)
leave the wound. J. Avoiding the use of pillows to support
arms and legs
Py odNe Scabs and scars are complications
K. Being patient and calm when the client
of wound healing that are surgical
resists care
emergencies.
L. Padding bed rails and wheelchair arms,
footrests, and leg supports
M. Providing good lighting to help prevent
the client from bumping into furniture
or walls
23. What are common causes of skin breakdown
and pressure injuries?
A. Pressure
B. Age
C. Friction
D. Shearing
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CHAPTER 22 Skin Care and Prevention of Wounds 111
24. You can prevent shearing and friction by: 29. What are the risk factors for the development
A. Using proper lifting, positioning, and of arterial ulcers?
transferring procedures A. High blood pressure
B. Applying a thin layer of powder to the B. Diabetes
bottom sheets C. Poor diet
C. Never raising the head of the bed more D. Aging
than 30 degrees E. Smoking
D. Use a turning pad (or sheet) to move F Osteoporosis
and turn the client in bed
30. When observing a wound’s appearance, what
ZS; Clients at risk for pressure injuries are those should you continue to monitor?
who: A. Ifthe wound is red and swollen
A. Are confined to a bed or chair B. If the area around the wound is warm
B. Require moderate to complete help in to the touch
moving G If sutures, staples, or clips are intact or
Have loss of bowel or bladder control broken
Have fair to good nutrition ID: If wound edges are closed or separated,
Have altered mental awareness’ or if the wound has broken open
Have problems sensing pain or pressure lee If the client has complained of the
Have circulatory problems wound getting itchy at times
Are younger
moO
“TO
Are obese or very thin 31. What are the functions of wound dressings?
A. ‘They protect wounds from injury and
26. Why are pillows and blankets used to prevent microbes.
pressure injuries? B. ‘They absorb drainage.
A. To prevent skin from being in contact C. ‘They remove dead tissue.
with skin D. ‘They promote comfort.
B. To reduce moisture and friction E. They keep the wound warm.
between skin surfaces FE They cover unsightly wounds.
C. To keep the client well hydrated G. They provide a moist environment for
wound healing.
27. Signs that a pressure injury is beginning and H. When bleeding is a problem, pressure
that therefore should be reported include: dressings help control bleeding.
A. Shivering and a drop in body
temperature 32. How should tape be applied to secure a
B. An increase in blood pressure dressing?
C. Pale skin A. Apply tape to the top, middle, and
D. A warm, reddened area bottom of the dressing.
B. Extend the tape several centimetres
28. Common sites for venous ulcers are: beyond each side of the dressing.
A. Lower legs C. Place one piece of adhesive tape across
B. Upper arms the iniddle of the dressing.
me beet
D. Face and neck 33. What types of tape do not cause allergic
reactions?
A. Paper tape
B. Plastic tape
Copyright © 2022 Elsevier Inc. All rights reserved.
112 CHAPTER 22. Skin Care and Prevention of Wounds
34. If a client has a draining wound, you can 38. Which of the following practices are
help improve the client’s appetite by: intended to prevent skin tears in clients?
A. Covering the wound with an airtight A. Taking daily baths
dressing B. Keeping your fingernails short and
Using room deodorizers as directed smoothly filed
Keeping drainage containers out of the C. Wearing jewellery with large stones
client’s sight D. Wearing a clean uniform daily
OF
U Offering foods that are strongly scented
to mask any odour of wound drainage 39. To prevent pressure injuries, the health care
ee Removing soiled dressings promptly team may place the client on a surface such
from the room as:
A. A firm mattress
3D: How should you remove tape and old B. A foam, air, alternating air, or gel
dressings from a wound? mattress
A. Hold the skin down and gently pull C. Plastic or rubber material
the tape toward the wound. Remove D. Abed board
adhesive from the skin.
B. Lift the dressing very gently, and keep 40. Which of the following measures is helpful
the soiled side of the dressing out of the in preventing pressure injuries?
client’s sight. Position the client at a 45-degree angle.
C. Pull the dressing off as quickly as you B. Reposition the client every 6 hours.
can. C. Massage around bony and reddened
areas.
36. You can assist a client with a wound by: D. Keep the client’s heels on the bed.
A. Allowing pain medications to take effect
before giving care 41. Which of the following measures would help
B. Ensuring the client stays on complete to prevent venous ulcers?
bed rest until the wound is fully healed A. Making sure the client’s clothing fits
C. Carefully observing the wound and tightly
reporting any signs or symptoms of B. Having the client wear elastic stockings
infection immediately as ordered by the doctor
D. Implementing Standard Practices C. Massaging any reddened area over
during all client care pressure points
D. Having the client trim his own toenails
weekly
MULTIPLE CHOICE
Circle the correct answer. 42. Why may pain medication be given before a
dressing change?
OF. Which of the following is a cause of skin To reduce discomfort during the
breakdown? dressing change
A. Good nutrition and hydration B. To prevent the client from looking at
B. Decreased mobility the wound
—C. Increased circulation C. To prevent the client from seeing your
D. A regular exercise program nonverbal responses
D. ‘To prevent contamination of the wound
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CHAPTER 22. Skin Care and Prevention of Wounds 113
43. When you are removing an old dressing, it 46. Clients who are in pain are at greater risk for
should be: developing pressure injuries because:
A. Shown to the client They may be more likely to eat and
B. Removed quickly from the wound with drink well
a quick pull B. ‘They cry more and require more
C. Removed so that the soiled side is emotional support
turned away from the client’s sight C. They are less likely to require pain
D. Placed in the client’s garbage can medication
D. They are less likely to move and
44. Movement and ambulation can contribute to reposition themselves
wound healing by:
A. Ensuring the wound dressing stays in 47. Clients with infected and draining wounds
place will require more of which two nutrients?
B. Keeping the client’s skin clean and dry A. Calcium and iron
C. Encouraging better oxygenation of B. Protein and vitamin C
tissue cells C. Potassium and phosphorus
D. Preventing discoloration of the wound D. Vitamins A and D
scar :
45. Which practice is intended to prevent
pressure injuries in the client’s coccyx area?
A. Never trimming the client’s toenails if
the client has diabetes
sm
B. Brushing the client's teeth, flossing
gently, and inspecting the mouth for
food particles
Washing bony prominences with gentle
soap, rinsing, and drying well
Encouraging deep breathing and
helping the client to cough up phlegm
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114 CHAPTER 22. Skin Care and Prevention of Wounds
ee inn anna an ARN NOAA A ADD
MATCHING
Match the type of wound with the correct description.
48. Wound containing large amounts of bacteria A. Chronic wound
49. Wound that does not heal easily B. Clean wound
50. Wound created for therapy C. Clean-contaminated wound
ST. Wound resulting from trauma D. Closed wound
aye Wound occurring from surgical entry of the urinary, E. Contaminated wound
reproductive, respiratory, or gastro-intestinal system
53. Wound that is not infected; microbes have not entered FE Dirty (infected) wound
wound
54. Wound in which dermis, epidermis, and subcutaneous G. Full-thickness wound
tissue are penetrated; muscle and bone may be involved
55. Wound with high risk of infection H. Intentional wound
56. Wound in which tissues are injured, but the skin isnot I. Open wound
broken
573 Wound in which skin or mucous membrane is broken ‘J. ~_—Partial-thickness wound
58. Wound in which dermis and epidermis of the skin are | K. Unintentional wound
broken
Match the type of wound drainage with the correct description.
59. Thin, watery drainage that is blood tinged A. Purulent drainage
60. Thick green, yellow, or brown drainage B. Sanguineous drainage
61. Bloody drainage C. Serosanguineous drainage
62. Clear, watery fluid D. Serous drainage
Match the stage of a pressure injury with the correct description.
63. The skin is gone, and underlying tissues are exposed. A. Stage l
64. The skin cracks, blisters, and peels. B. Stage 2
65. Drainage is likely. Ge Stages
66. The colour does not return to the skin when pressure is D. Stage 4
relieved.
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CHAPTER 22. Skin Care and Prevention of Wounds 115
Match the stage of a pressure injury with the correct description.
67. Muscle and bone are exposed and damaged. Ae Stage |
68. ‘The skin is red. Bawstage 2
69. There may be a shallow crater. CS Stage3
70. The exposed tissue is damaged. D. Stage 4
Match the phase of wound healing with the correct statement.
a1. Tissue cells multiply to repair the wound. A. Inflammatory phase
2. The scar eventually becomes thin and pale. B. Proliferative phase
a3. Blood supply to the wound increases. C. Maturation phase
FILL IN THE BLANKS
74. What is the purpose of heel elevators?
75. What is the purpose of a drain placed in a wound?
76. Why should you be careful to control nonverbal communication when changing a dressing?
77. How can you assist a person with a wound with the following concerns?
a. Pain and discomfort
b. Nutrition
c. Infection
Copyright © 2022 Elsevier Inc. All rights reserved.
116 CHAPTER 22 Skin Care and Prevention of Wounds.
LABELLING ° 81. Place an X on four areas where pressure
injuries may form on a person in the sitting
position.
78. Place an X on six areas where pressure
injuries may form on a person lying in the
lateral position.
79. Place an X on six areas where pressure
injuries may form on a person lying in the
prone position.
80. Place an X on three areas where pressure
injuries may form on a person lying in the
Fowler’s position.
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CHAPTER 22. Skin Care and Prevention of Wounds 117
82. Identify the stages of pressure injuries by writing the letter beside each stage number in the correct
order. Describe the tissue damage in each one.
(Courtesy Laurel Wiersma-Bryant, RN, MSN, Clinical Nurse Specialist, Barnes-Jewish Hospital, St. Louis.)
aaeotace,
Deocave mee aoe
x Sets
ab Seow
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118 CHAPTER 22 Skin Care and Prevention of Wounds
CROSSWORD PUZZLE
ea
Aeee ie
Aes
ae
el is) ace
ual
|
eB
I 2)
ale
coe
thee
PR hase
a
ee |Tees
Across Down
DB: Pressure injury, bedsore (2 words) 1. Open wound with torn tissues and jagged edges
7s Thick green, yellow, or brown discharge 2 Partial-thickness wound caused by scraping
away or rubbing of the skin
8. Clear, watery drainage
Open wound caused by poor blood return to
3; Disorder that results when there is not the heart from the legs and feet (2 words)
enough blood supply to organs and tissues . Excessive loss of blood in a short period of time
11. Disorder in which there is death of tissue . Separation of wound layers
We Thin, blood-tinged, watery drainage Break in the skin or mucous membranes
Closed wound caused by blow to the body
14. Accident or violent act that injures the skin,
mucous membranes, bones, and internal - Open wound with clean, straight edges;
organs usually intentionally produced with a sharp
instrument
16. Separation of wound along with protrusion
of abdominal organs 13. Break or rip in skin that separates the epidermis
from the underlying tissues (2 words)
15. Collection of blood under the skin and tissues
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