20.2 Basic Concepts Related to Wounds
Open Resources for Nursing (Open RN)
Phases of Wound Healing
When skin is injured, there are four phases of wound healing that take place: hemostasis, inflammatory, proliferative, and maturation.[1] See Figure 20.1[2] for an illustration of the phases of wound healing.
To illustrate the phases of wound healing, imagine that you accidentally cut your finger with a knife as you were slicing an apple. Immediately after the injury occurs, blood vessels constrict, and clotting factors are activated. This is referred to as the hemostasis phase. Clotting factors form clots that stop the bleeding and act as a barrier to prevent bacterial contamination. Platelets release growth factors that alert various cells to start the repair process at the wound location. The hemostasis phase lasts up to 60 minutes, depending on the severity of the injury.[3],[4]
After the hemostasis phase, the inflammatory phase begins. Vasodilation occurs so that white blood cells in the bloodstream can move into the wound to start cleaning the wound bed. The inflammatory process appears to the observer as edema (swelling), erythema (redness), and exudate. Exudate is fluid that oozes out of a wound, also commonly called pus.[5],[6]
The proliferative phase begins within a few days after the injury and includes four important processes: epithelialization, angiogenesis, collagen formation, and contraction. Epithelialization refers to the development of new epidermis and granulation tissue. Granulation tissue is new connective tissue with new, fragile, thin-walled capillaries. Collagen is formed to provide strength and integrity to the wound. At the end of the proliferation phase, the wound begins to contract in size.[7],[8]
Capillaries begin to develop within the wound 24 hours after injury during a process called angiogenesis. These capillaries bring more oxygen and nutrients to the wound for healing. When performing dressing changes, it is essential for the nurse to protect this granulation tissue and the associated new capillaries. Healthy granulation tissue appears pink due to the new capillary formation. It is also moist, painless to the touch, and may appear “bumpy.” Conversely, unhealthy granulation tissue is dark red and painful. It bleeds easily with minimal contact and may be covered by shiny white or yellow fibrous tissue referred to as biofilm that must be removed because it impedes healing. Unhealthy granulation tissue is often caused by an infection, so wound cultures should be obtained when infection is suspected. The provider can then prescribe appropriate antibiotic treatment based on the culture results.[9]
During the maturation phase, collagen continues to be created to strengthen the wound. Collagen contributes strength to the wound to prevent it from reopening. A wound typically heals within 4-5 weeks and often leaves behind a scar. The scar tissue is initially firm, red, and slightly raised from the excess collagen deposition. Over time, the scar begins to soften, flatten, and become pale in about nine months.[10]
Types of Wound Healing
There are three types of wound healing: primary intention, secondary intention, and tertiary intention. Healing by primary intention means that the wound is sutured, stapled, glued, or otherwise closed so the wound heals beneath the closure. This type of healing occurs with clean-edged lacerations or surgical incisions, and the closed edges are referred to as approximated. See Figure 20.2[11] for an image of a surgical wound healing by primary intention.
Secondary intention occurs when the edges of a wound cannot be approximated (brought together), so the wound fills in from the bottom up by the production of granulation tissue. Examples of wounds that heal by secondary intention are pressure injuries and chainsaw injuries. Wounds that heal by secondary intention are at higher risk for infection and must be protected from contamination. See Figure 20.3[12] for an image of a wound healing by secondary intention.
Tertiary intention refers to a wound that has had to remain open or has been reopened, often due to severe infection. The wound is typically closed at a later date when infection has resolved. Wounds that heal by secondary and tertiary intention have delayed healing times and increased scar tissue.
Wound Closures
Lacerations and surgical wounds are typically closed with sutures, staples, or dermabond to facilitate healing by primary intention. See Figure 20.4[13] for an image of sutures, Figure 20.5[14] for an image of staples, and Figure 20.6[15] for an image of a wound closed with dermabond, a type of sterile surgical glue. Based on agency policy, the nurse may remove sutures and staples based on a provider order. See Figure 20.7[16] for an image of a disposable staple remover. See the checklists in the subsections later in this chapter for procedures related to surgical and staple removal.
Common Types of Wounds
There are several different types of wounds. It is important to understand different types of wounds when providing wound care because each type of wound has different characteristics and treatments. Additionally, treatments that may be helpful for one type of wound can be harmful for another type. Common types of wounds include skin tears, venous ulcers, arterial ulcers, diabetic foot wounds, and pressure injuries.[17]
Skin Tears
Skin tears are wounds caused by mechanical forces such as shear, friction, or blunt force. They typically occur in the fragile, nonelastic skin of older adults or in patients undergoing long-term corticosteroid therapy. Skin tears can be caused by the simple mechanical force used to remove an adhesive bandage or from friction as the skin brushes against a surface. Skin tears occur in the epidermis and dermis but do not extend through the subcutaneous layer. The wound bases of skin tears are typically fragile and bleed easily.[18]
Venous Ulcers
Venous ulcers are caused by lack of blood return to the heart causing pooling of fluid in the veins of the lower legs. The resulting elevated hydrostatic pressure in the veins causes fluid to seep out, macerate the skin, and cause venous ulcerations. Maceration refers to the softening and wasting away of skin due to excess fluid. Venous ulcers typically occur on the medial lower leg and have irregular edges due to the maceration. There is often a dark-colored discoloration of the lower legs, due to blood pooling and leakage of iron into the skin called hemosiderin staining. For venous ulcers to heal, compression dressings must be used, along with multilayer bandage systems, to control edema and absorb large amounts of drainage.[19] See Figure 20.8[20] for an image of a venous ulcer.
Arterial Ulcers
Arterial ulcers are caused by lack of blood flow and oxygenation to tissues. They typically occur in the distal areas of the body such as the feet, heels, and toes. Arterial ulcers have well-defined borders with a “punched out” appearance where there is a localized lack of blood flow. They are typically painful due to the lack of oxygenation to the area. The wound base may become necrotic (black) due to tissue death from ischemia. Wound dressings must maintain a moist environment, and treatment must include the removal of necrotic tissue. In severe arterial ulcers, vascular surgery may be required to reestablish blood supply to the area.[21] See Figure 20.9[22] for an image of an arterial ulcer on a patient’s foot.
Diabetic Ulcers
Diabetic ulcers are also called neuropathic ulcers because peripheral neuropathy is commonly present in patients with diabetes. Peripheral neuropathy is a medical condition that causes decreased sensation of pain and pressure, especially in the lower extremities. Diabetic ulcers typically develop on the plantar aspect of the feet and toes of a patient with diabetes due to lack of sensation of pressure or injury. See Figure 20.10[23] for an image of a diabetic ulcer. Wound healing is compromised in patients with diabetes due to the disease process. In addition, there is a higher risk of developing an infection that can reach the bone requiring amputation of the area. To prevent diabetic ulcers from occurring, it is vital for nurses to teach meticulous foot care to patients with diabetes and encourage the use of well-fitting shoes.[24]
Pressure Injuries
Pressure injuries are defined as “localized damage to the skin or underlying soft tissue, usually over a bony prominence, as a result of intense and prolonged pressure in combination with shear.”[25] Shear occurs when tissue layers move over the top of each other, causing blood vessels to stretch and break as they pass through the subcutaneous tissue. For example, when a patient slides down in bed, the outer skin remains immobile because it remains attached to the sheets due to friction, but deeper tissue attached to the bone moves as the patient slides down. This opposing movement of the outer layer of skin and the underlying tissues causes the capillaries to stretch and tear, which then impacts the blood flow and oxygenation of the surrounding tissues.
Braden Scale
Several factors place a patient at risk for developing pressure injuries, including nutrition, mobility, sensation, and moisture. The Braden Scale is a tool commonly used in health care to provide an objective assessment of a patient’s risk for developing pressure injuries. See Figure 20.11[26] for an image of a Braden Scale. The six risk factors included on the Braden Scale are sensory perception, moisture, activity, mobility, nutrition, and friction/shear, and these factors are rated on a scale from 1-4 with 1 being “completely limited” to 4 being “no impairment.” The scores from the six categories are added, and the total score indicates a patient’s risk for developing a pressure injury. A total score of 15-19 indicates mild risk, 13-14 indicates moderate risk, 10-12 indicates high risk, and less than or equal to 9 indicates severe risk. Nurses create care plans using these scores to plan interventions that prevent or treat pressure injuries.
For more information about using the Braden Scale, go to the “Integumentary” chapter of the Open RN Nursing Fundamentals textbook.
Staging
Pressure injuries commonly occur on the sacrum, heels, ischial tuberosity, and coccyx. The 2016 National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury Staging System now uses the term “pressure injury” instead of pressure ulcer because an injury can occur without an ulcer present. Pressure injuries are staged from 1 through 4 based on the extent of tissue damage. For example, Stage 1 pressure injuries have reddened but intact skin, and Stage 4 pressure injuries have deep, open ulcers affecting underlying tissue and structures such as muscles, ligaments, and tendons. See Figure 20.12[27] for an image of the four stages of pressure injuries.[28] The NPUAP’s definitions of the four stages of pressure injuries are described below:
- Stage 1 pressure injuries are intact skin with a localized area of nonblanchable erythema where prolonged pressure has occurred. Nonblanchable erythema is a medical term used to describe skin redness that does not turn white when pressed.
- Stage 2 pressure injuries are partial-thickness loss of skin with exposed dermis. The wound bed is viable and may appear like an intact or ruptured blister. Stage 2 pressure injuries heal by reepithelialization and not by granulation tissue formation.[29]
- Stage 3 pressure injuries are full-thickness tissue loss in which fat is visible, but cartilage, tendon, ligament, muscle, and bone are not exposed. The depth of tissue damage varies by anatomical location. Undermining and tunneling may occur in Stage 3 and 4 pressure injuries. Undermining occurs when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound’s edge. Tunneling refers to passageways underneath the surface of the skin that extend from a wound and can take twists and turns. Slough and eschar may also be present in Stage 3 and 4 pressure injuries. Slough is an inflammatory exudate that is usually light yellow, soft, and moist. Eschar is dark brown/black, dry, thick, and leathery dead tissue. See Figure 20.13 [30] for an image of eschar in the center of the wound. If slough or eschar obscures the wound so that tissue loss cannot be assessed, the pressure injury is referred to as unstageable.[31] In most wounds, slough and eschar must be removed by debridement for healing to occur.
- Stage 4 pressure injuries are full-thickness tissue loss like Stage 3 pressure injuries, but also have exposed cartilage, tendon, ligament, muscle, or bone. Osteomyelitis (bone infection) may be present.[32]
View a supplementary YouTube video on Pressure Injuries[33]
Factors Affecting Wound Healing
Multiple factors affect a wound’s ability to heal and are referred to as local and systemic factors. Local factors refer to factors that directly affect the wound, whereas systemic factors refer to the overall health of the patient and their ability to heal. Local factors include localized blood flow and oxygenation of the tissue, the presence of infection or a foreign body, and venous sufficiency. Venous insufficiency is a medical condition where the veins in the legs do not adequately send blood back to the heart, resulting in a pooling of fluids in the legs.[34]
Systemic factors that affect a patient’s ability to heal include nutrition, mobility, stress, diabetes, age, obesity, medications, alcohol use, and smoking.[35] When a nurse is caring for a patient with a wound that is not healing as anticipated, it is important to further assess for the potential impact of these factors:
- Nutrition. Nutritional deficiencies can have a profound impact on healing and must be addressed for chronic wounds to heal. Protein is one of the most important nutritional factors affecting wound healing. For example, in patients with pressure injuries, 30 to 35 kcal/kg of calorie intake with 1.25 to 1.5g/kg of protein and micronutrients supplementation is recommended daily.[36] In addition, vitamin C and zinc deficiency have many roles in wound healing. It is important to collaborate with a dietician to identify and manage nutritional deficiencies when a patient is experiencing poor wound healing.[37]
- Stress. Stress causes an impaired immune response that results in delayed wound healing. Although a patient cannot necessarily control the amount of stress in their life, it is possible to control one’s reaction to stress with healthy coping mechanisms. The nurse can help educate the patient about healthy coping strategies.
- Diabetes. Diabetes causes delayed wound healing due to many factors such as neuropathy, atherosclerosis (a buildup of plaque that obstructs blood flow in the arteries resulting in decreased oxygenation of tissues), a decreased host immune resistance, and increased risk for infection.[38] Read more about neuropathy and diabetic ulcers under the “Common Types of Wounds” subsection. Nurses provide vital patient education to patients with diabetes to effectively manage the disease process for improved wound healing.
- Age. Older adults have an altered inflammatory response that can impair wound healing. Nurses can educate patients about the importance of exercise for improved wound healing in older adults.[39]
- Obesity. Obese individuals frequently have wound complications, including infection, dehiscence, hematoma formation, pressure injuries, and venous injuries. Nurses can educate patients about healthy lifestyle choices to reduce obesity in patients with chronic wounds.[40]
- Medications. Medications such as corticosteroids impair wound healing due to reduced formation of granulation tissue.[41] When assessing a chronic wound that is not healing as expected, it is important to consider the side effects of the patient’s medications.
- Alcohol consumption. Research shows that exposure to alcohol impairs wound healing and increases the incidence of infection.[42] Patients with impaired healing of chronic wounds should be educated to avoid alcohol consumption.
- Smoking. Smoking impacts the inflammatory phase of the wound healing process, resulting in poor wound healing and an increased risk of infection.[43] Patients who smoke should be encouraged to stop smoking.
Lab Values Affecting Wound Healing
When a chronic wound is not healing as expected, laboratory test results may provide additional clues regarding the causes of the delayed healing. See Table 20.2 for lab results that offer clues to systemic issues causing delayed wound healing.[44]
Table 20.2 Lab Values Associated with Delayed Wound Healing[45]
| Abnormal Lab Value | Rationale |
|---|---|
| Low hemoglobin | Low hemoglobin indicates less oxygen is transported to the wound site. |
| Elevated white blood cells (WBC) | Increased WBC indicates infection is occurring. |
| Low platelets | Platelets are important during the proliferative phase in the creation of granulation tissue and angiogenesis.[46] |
| Low albumin | Low albumin indicates decreased protein levels. Protein is required for effective wound healing. |
| Elevated blood glucose or hemoglobin A1C | Elevated blood glucose and hemoglobin A1C levels indicate poor management of diabetes mellitus, a disease that impacts wound healing. |
| Elevated serum BUN and creatinine | BUN and creatinine levels are indicators of kidney function, with elevated levels indicating worsening kidney function. Elevated BUN (blood urea nitrogen) levels impact wound healing. |
| Positive wound culture | Positive wound cultures indicate an infection is present and provide additional information, including the type and number of bacteria present, as well as identifying antibiotics to which the bacteria is susceptible. The nurse reviews this information when administering antibiotics to ensure the prescribed therapy is effective for the type of bacteria present. |
Wound Complications
In addition to delayed wound healing, several other complications can occur. Three common complications are the development of a hematoma, infection, or dehiscence. These complications should be immediately reported to the health care provider.
Hematoma
A hematoma is an area of blood that collects outside of the larger blood vessels. A hematoma is more severe than ecchymosis (bruising) that occurs when small veins and capillaries under the skin break. The development of a hematoma at a surgical site can lead to infection and incisional dehiscence.[47] See Figure 20.14[48] for an image of a hematoma.
Infection
A break in the skin allows bacteria to enter and begin to multiply. Microbial contamination of wounds can progress from localized infection to systemic infection, sepsis, and subsequent life- and limb-threatening infection. Signs of a localized wound infection include redness, warmth, and tenderness around the wound. Purulent or malodorous drainage may also be present. Signs that a systemic infection is developing and requires urgent medical management include the following[49]:
- Fever over 101 F (38 C)
- Overall malaise (lack of energy and not feeling well)
- Change in level of consciousness/increased confusion
- Increasing or continual pain in the wound
- Expanding redness or swelling around the wound
- Loss of movement or function of the wounded area
Dehiscence
Dehiscence refers to the separation of the edges of a surgical wound. A dehisced wound can appear fully open where the tissue underneath is visible, or it can be partial where just a portion of the wound has torn open. Wound dehiscence is always a risk in a surgical wound, but the risk increases if the patient is obese, smokes, or has other health conditions, such as diabetes, that impact wound healing. Additionally, the location of the wound and the amount of physical activity in that area also increase the chances of wound dehiscence.[50] See Figure 20.15[51] for an image of dehiscence in an abdominal surgical wound in a 50-year-old obese female with a history of smoking and malnutrition.
Wound dehiscence can occur suddenly, especially in abdominal wounds when the patient is coughing or straining. Evisceration is a rare but severe surgical complication when dehiscence occurs, and the abdominal organs protrude out of the incision. Signs of impending dehiscence include redness around the wound margins and increasing drainage from the incision. The wound will also likely become increasingly painful. Suture breakage can be a sign that the wound has minor dehiscence or is about to dehisce.[52]
To prevent wound dehiscence, surgical patients must follow all post-op instructions carefully. The patient must move carefully and protect the skin from being pulled around the wound site. They should also avoid tensing the muscles surrounding the wound and avoid heavy lifting as advised.[53]
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 ↵
- “417 Tissue Repair.jpg” by OpenStax College is licensed under CC BY 3.0. Access for free at https://openstax.org/books/anatomy-and-physiology/pages/1-introduction ↵
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 ↵
- This work is a derivative of StatPearls by Grubbs and Mannah and is licensed under CC BY 4.0 ↵
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 ↵
- This work is a derivative of StatPearls by Grubbs and Mannah and is licensed under CC BY 4.0 ↵
- This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 ↵
- This work is a derivative of StatPearls by Grubbs and Mannah and is licensed under CC BY 4.0 ↵
- This work is a derivative of StatPearls by Alhajj, Bansal, and Goyal and is licensed under CC BY 4.0 ↵
- This work is a derivative of StatPearls by Grubbs and Mannah and is licensed under CC BY 4.0 ↵
- “Ventriculoperitoneal shunt - surgical wound healing - belly - day 12.jpg” by Hansmuller is licensed under CC BY-SA 4.0 ↵
- “Atrophied skin.png” by sansea2 is licensed under CC BY-SA 3.0 ↵
- “Wound closed with surgical sutures.jpg” by Wikip2011 is licensed under CC BY-SA 3.0 ↵
- “Surgical staples1.jpg” by Llywrch is licensed under CC BY-SA 2.5 ↵
- “Incision wound on child's arm, closed with Dermabond.jpg” by ragesoss is licensed under CC BY-SA 3.0 ↵
- “Not quite scissors - TROML - 1366” by Clint Budd is licensed under CC BY 2.0 ↵
- Cox, J. (2019). Wound care 101. Nursing, 49(10). https://doi.org/10.1097/01.nurse.0000580632.58318.08 ↵
- Cox, J. (2019). Wound care 101. Nursing, 49(10). https://doi.org/10.1097/01.nurse.0000580632.58318.08 ↵
- Cox, J. (2019). Wound care 101. Nursing, 49(10). https://doi.org/10.1097/01.nurse.0000580632.58318.08 ↵
- “Úlceras_antes_da_cirurgia.JPG” by Nini00 is licensed under CC BY-SA 3.0 ↵
- Cox, J. (2019). Wound care 101. Nursing, 49(10). https://doi.org/10.1097/01.nurse.0000580632.58318.08 ↵
- “Arterial ulcer peripheral vascular disease.jpg” by Jonathan Moore is licensed under CC BY 3.0 ↵
- “Diabetic Planta ulcer.jpg” by Dr. Lorimer is licensed under CC BY-SA 4.0 ↵
- Cox, J. (2019). Wound care 101. Nursing, 49(10). https://doi.org/10.1097/01.nurse.0000580632.58318.08 ↵
- Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing: Official Publication of The Wound, Ostomy and Continence Nurses Society, 43(6), 585–597. https://journals.lww.com/jwocnonline/Fulltext/2016/11000/Revised_National_Pressure_Ulcer_Advisory_Panel.3.aspx ↵
- The Braden Scale, from Prevention Plus, is included on the basis of Fair Use. ↵
- “Wound stage.jpg” by Babagolzadeh is licensed under CC BY-SA 3.0 ↵
- Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing: Official Publication of The Wound, Ostomy and Continence Nurses Society, 43(6), 585–597. https://doi.org/10.1097/WON.0000000000000281 ↵
- Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing: Official Publication of The Wound, Ostomy and Continence Nurses Society, 43(6), 585–597. https://doi.org/10.1097/WON.0000000000000281 ↵
- "Inoculation_eschar_Rickettsia_sibirica_mongolitimonae_infection.jpg" by José M. Ramos, Isabel Jado, Sergio Padilla, Mar Masiá, Pedro Anda, and Félix Gutiérrez is licensed under CC0 ↵
- Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing: Official Publication of The Wound, Ostomy and Continence Nurses Society, 43(6), 585–597. https://doi.org/10.1097/WON.0000000000000281 ↵
- Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing: Official Publication of The Wound, Ostomy and Continence Nurses Society, 43(6), 585–597. https://doi.org/10.1097/WON.0000000000000281 ↵
- RegisteredNurseRN. (2018, March 7). Pressure ulcers (injuries) stages, prevention, assessment | Stage 1, 2, 3, 4 unstageable NCLEX [Video]. YouTube. All rights reserved. Video used with permission. https://youtu.be/MDtPik1UE6k ↵
- Guo, S., & Dipietro, L. A. (2010). Factors affecting wound healing. Journal of Dental Research, 89(3), 219–229. https://doi.org/10.1177/0022034509359125 ↵
- Guo, S., & Dipietro, L. A. (2010). Factors affecting wound healing. Journal of Dental Research, 89(3), 219–229. https://doi.org/10.1177/0022034509359125 ↵
- Cox, J. (2019). Wound care 101. Nursing, 49(10). https://doi.org/10.1097/01.nurse.0000580632.58318.08 ↵
- Guo, S., & Dipietro, L. A. (2010). Factors affecting wound healing. Journal of Dental Research, 89(3), 219–229. https://doi.org/10.1177/0022034509359125 ↵
- Guo, S., & Dipietro, L. A. (2010). Factors affecting wound healing. Journal of Dental Research, 89(3), 219–229. https://doi.org/10.1177/0022034509359125 ↵
- Guo, S., & Dipietro, L. A. (2010). Factors affecting wound healing. Journal of Dental Research, 89(3), 219–229. https://doi.org/10.1177/0022034509359125 ↵
- Guo, S., & Dipietro, L. A. (2010). Factors affecting wound healing. Journal of Dental Research, 89(3), 219–229. https://doi.org/10.1177/0022034509359125 ↵
- Guo, S., & Dipietro, L. A. (2010). Factors affecting wound healing. Journal of Dental Research, 89(3), 219–229. https://doi.org/10.1177/0022034509359125 ↵
- Guo, S., & Dipietro, L. A. (2010). Factors affecting wound healing. Journal of Dental Research, 89(3), 219–229. https://doi.org/10.1177/0022034509359125 ↵
- Guo, S., & Dipietro, L. A. (2010). Factors affecting wound healing. Journal of Dental Research, 89(3), 219–229. https://doi.org/10.1177/0022034509359125 ↵
- Grey, J. E., Enoch, S., & Harding, K. G. (2006). Wound assessment. BMJ (Clinical research ed.), 332(7536), 285–288. https://doi.org/10.1136/bmj.332.7536.285 ↵
- Grey, J. E., Enoch, S., & Harding, K. G. (2006). Wound assessment. BMJ (Clinical research ed.), 332(7536), 285–288. https://doi.org/10.1136/bmj.332.7536.285 ↵
- This work is a derivative of StatPearls by Grubbs and Mannah is licensed under CC BY 4.0 ↵
- Edsberg, L. E., Black, J. M., Goldberg, M., McNichol, L., Moore, L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised pressure injury staging system. Journal of Wound, Ostomy, and Continence Nursing: Official Publication of The Wound, Ostomy and Continence Nurses Society, 43(6), 585–597. https://doi.org/10.1097/won.0000000000000281 ↵
- “Ankle swell and internal bleeding” by Glen Bowman is licensed under CC BY-SA 2.0 ↵
- WoundSource. (2016, October 19). 8 signs of wound infection. https://www.woundsource.com/blog/8-signs-wound-infection ↵
- WoundSource. (2018, March 28). Complications in chronic wound healing and associated interventions. https://www.woundsource.com/blog/complications-in-chronic-wound-healing-and-associated-interventions ↵
- “Bogota bag.png” by Suarez-Grau, J. M., Guadalajara Jurado, J. F., Gómez Menchero, J., Bellido Luque, J. A. is licensed under CC BY 4.0 ↵
- WoundSource. (2018, March 28). Complications in chronic wound healing and associated interventions. https://www.woundsource.com/blog/complications-in-chronic-wound-healing-and-associated-interventions ↵
- WoundSource. (2018, March 28). Complications in chronic wound healing and associated interventions. https://www.woundsource.com/blog/complications-in-chronic-wound-healing-and-associated-interventions ↵
The very thin, top layer of the skin that contains openings of the sweat gland ducts and the visible part of hair known as the hair shaft.
Learning Activities
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activities are provided as immediate feedback.)
Ethical Application & Reflection Activity
Case A
Filmmaker Lulu Wang first shared a story about her grandmother on This American Life podcast and later turned it into the 2019 movie The Farewell starring Awkwafina. Both share the challenges of a Chinese-born but U.S.-raised woman returning to China and a family who has chosen to not disclose that the grandmother has been given a Stage IV lung cancer diagnosis and three months to live. Listen to the podcast and then answer the following questions:
585: In Defense of Ignorance Act One: What You Don't Know
1. Reflect on the similarities and differences of your family culture with that of the Billi family. Consider things such as what family gatherings, formal and informal, look like and spoken and unspoken rules related to communication and behavior.
2. The idea of “good” lies and “bad” lies is introduced in the podcast. Nai Nai’s family supports the decision to not tell her about her Stage IV lung cancer, stage a wedding as the excuse to visit and say their goodbyes, and even alter a medical report as good lies necessary to support her mental health, well-being, and happiness. Is the family applying deontological or utilitarian ethics to the situation? Defend your response.
3. Define the following ethical principles and identify examples from this story:
- Autonomy
- Beneficence
- Nonmaleficence
- Paternalism
4. Imagine this story is happening in the United States rather than China and you are the nurse admitting Nai Nai to an inpatient oncology unit. Using the ethical problem-solving model of your choice, identify and support your solution to the ethical dilemma posed when her family requests that Nai Nai not be told that she has cancer.
Ethical Application & Reflection Activity
Case B
You are caring for a 32-year-old client who has been in a persistent vegetative state for many years. There is an outdated advanced directive that is confusing on the issue of food and fluids, though clear about not wanting to be on a ventilator if she were in a coma. Her husband wants the feeding tube removed but is unable to say that it would have been the client’s wish. He says that it is his decision for her. Her two adult siblings and parents reject this as a possibility because they say that “human life is sacred” and that the daughter believed this. They say their daughter is alive and should receive nursing care, including feeding. The health care team does not know what to do ethically and fear being sued by either the husband, siblings, or the parents. What do you need to know about this clinical situation? What are the values and obligations at stake in this case? What values or obligations should be affirmed and why? How might that be done?
1. Define the problem.
2. List what facts/information you have.
3. What are the stakeholders' positions?
- Patient:
- Spouse:
- Family:
- Health Care Team:
- Facility:
- Community:
4. How might the stakeholders' values differ?
5. What are your values in this situation?
6. Do your values conflict with those of the patient? Describe.
Test your knowledge using this NCLEX Next Generation-style Case Study. You may reset and resubmit your answers to this question an unlimited number of times.[1]
Sample Documentation of Expected Findings
Mrs. Smith is a 65-year-old patient who appears her stated age. Calm, cooperative, alert, and oriented x 3. Well-groomed with clean clothing and appropriate for weather. Speech is clear, understandable, and follows instructions appropriately. Moves all extremities equally bilaterally with good posture. Gait is smooth and maintains balance without assistance. Skin warm and mucous membranes moist. 5’4” and weighs 143 pounds with BMI of 24 in normal weight category. Vital signs: BP 120/70, pulse 74 and regular, respiratory rate 14, temperature 36.8 Celsius, SpO2 98% on room air.
Sample Documentation of Unexpected Findings
Mrs. Smith is a 65-year-old patient with older appearance than stated age. Slightly agitated during the interview. Oriented to person only and denies pain. Wearing a heavy winter coat on a warm summer day and unclean body odor. Slow to respond to questions and does not follow commands. Neglect noted of right arm. Gait shuffling with stooped posture with no assistive device. 5’4” and weighs 102 pounds with BMI of 17.5 in the underweight category. Vital signs: BP 186/55, pulse 102 and irregular, respiratory rate 22, temperature 38.1 Celsius, and SpO2 88% on room air.
Sample Documentation of Expected Findings
Mrs. Smith is a 65-year-old patient who appears her stated age. Calm, cooperative, alert, and oriented x 3. Well-groomed with clean clothing and appropriate for weather. Speech is clear, understandable, and follows instructions appropriately. Moves all extremities equally bilaterally with good posture. Gait is smooth and maintains balance without assistance. Skin warm and mucous membranes moist. 5’4” and weighs 143 pounds with BMI of 24 in normal weight category. Vital signs: BP 120/70, pulse 74 and regular, respiratory rate 14, temperature 36.8 Celsius, SpO2 98% on room air.
Sample Documentation of Unexpected Findings
Mrs. Smith is a 65-year-old patient with older appearance than stated age. Slightly agitated during the interview. Oriented to person only and denies pain. Wearing a heavy winter coat on a warm summer day and unclean body odor. Slow to respond to questions and does not follow commands. Neglect noted of right arm. Gait shuffling with stooped posture with no assistive device. 5’4” and weighs 102 pounds with BMI of 17.5 in the underweight category. Vital signs: BP 186/55, pulse 102 and irregular, respiratory rate 22, temperature 38.1 Celsius, and SpO2 88% on room air.
Learning Activities
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
Maria is working on a medical surgical unit and receives a direct admission from the internal medicine clinic. She arrives at the patient’s room to complete the initial admission assessment. All of the following conditions are found. Of these conditions, which of the following should be reported immediately to the health care provider.
- Patient ambulates with assistance of wheeled walker.
- Patient’s BMI is outside of the normal range.
- Patient appears unkempt and has strong body odor.
- Patient is experiencing increased difficulty breathing.
"Vital Signs Case Study” by Susan Jepsen for Lansing Community College is licensed under CC BY 4.0
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 1.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 2.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 3.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 4.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 5.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 6.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 7.
Learning Activities
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)
Maria is working on a medical surgical unit and receives a direct admission from the internal medicine clinic. She arrives at the patient’s room to complete the initial admission assessment. All of the following conditions are found. Of these conditions, which of the following should be reported immediately to the health care provider.
- Patient ambulates with assistance of wheeled walker.
- Patient’s BMI is outside of the normal range.
- Patient appears unkempt and has strong body odor.
- Patient is experiencing increased difficulty breathing.
"Vital Signs Case Study” by Susan Jepsen for Lansing Community College is licensed under CC BY 4.0
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 1.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 2.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 3.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 4.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 5.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 6.
Test your clinical judgment with an NCLEX Next Generation-style question: Chapter 1, Assignment 7.
Learning Activities
(Answers to "Learning Activities" can be found in the "Answer Key" at the end of the book. Answers to interactive activities are provided as immediate feedback.)
- The nurse is conducting an assessment on a 70-year-old male client who was admitted with atrial fibrillation. The client has a history of hypertension and Stage 2 chronic kidney disease. The nurse begins the head-to-toe assessment and notes the patient is having difficulty breathing and is complaining about chest discomfort. The client states, “It feels as if my heart is going to pound out of my chest and I feel dizzy.” The nurse begins the head-to-toe assessment and documents the findings. Client assessment findings are presented in the table below. Select the assessment findings requiring immediate follow-up by the nurse.
Vital Signs
| Temperature | 98.9 °F (37.2°C) |
|---|---|
| Heart Rate | 182 beats/min |
| Respirations | 36 breaths/min |
| Blood Pressure | 152/90 mm Hg |
| Oxygen Saturation | 88% on room air |
| Capillary Refill Time | >3 |
| Pain | 9/10 chest discomfort |
| Physical Assessment Findings | |
|---|---|
| Glasgow Coma Scale Score | 14 |
| Level of Consciousness | Alert |
| Heart Sounds | Irregularly regular |
| Lung Sounds | Clear bilaterally anterior/posterior |
| Pulses-Radial | Rapid/bounding |
| Pulses-Pedal | Weak |
| Bowel Sounds | Present and active x 4 |
| Edema | Trace bilateral lower extremities |
| Skin | Cool, clammy |
2. The following nursing actions may or may not be required at this time based on the assessment findings. Indicate whether the actions are "Indicated" (i.e., appropriate or necessary), "Contraindicated" (i.e., could be harmful), or "Nonessential" (i.e., makes no difference or are not necessary).
| Nursing Action | Indicated | Contraindicated | Nonessential |
|---|---|---|---|
| Apply oxygen at 2 liters per nasal cannula. | |||
| Call imaging for a STAT lung CT. | |||
| Perform the National Institutes of Health (NIH) Stroke Scale Neurologic Exam. | |||
| Obtain a comprehensive metabolic panel (CMP). | |||
| Obtain a STAT EKG. | |||
| Raise the head-of-bed to less than 10 degrees. | |||
| Establish patent IV access. | |||
| Administer potassium 20 mEq IV push STAT. |
3. The CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to help guide prioritization based on identifying the differences among Critical needs, Urgent needs, Routine needs, and Extras.
You are the nurse caring for the patients in the following table. For each patient, indicate if this is a "critical," "urgent," "routine," or "extra" need.
<td">
| Critical | Urgent | Routine | Extra | |
|---|---|---|---|---|
| Patient exhibits new left-sided facial droop | ||||
| Patient reports 9/10 acute pain and requests PRN pain medication | ||||
| Patient with BP 120/80 and regular heart rate of 68 has scheduled dose of oral amlodipine | ||||
| Patient with insomnia requests a back rub before bedtime | ||||
| Patient has a scheduled dressing change for a pressure ulcer on their coccyx |
||||
| Patient is exhibiting new shortness of breath and altered mental status | ||||
| Patient with fall risk precautions ringing call light for assistance to the restroom for a bowel movement |
Test your knowledge using this NCLEX Next Generation-style Case Study. You may reset and resubmit your answers to this question an unlimited number of times.[2]
Advocacy: The act or process of pleading for, supporting, or recommending a cause or course of action. Advocacy may be for persons (whether an individual, group, population, or society) or for an issue, such as potable water or global health.[3]
Autonomy: The capacity to determine one’s own actions through independent choice, including demonstration of competence.[4]
Beneficence: The bioethical principle of benefiting others by preventing harm, removing harmful conditions, or affirmatively acting to benefit another or others, often going beyond what is required by law.[5]
Code of ethics: A set of ethical principles established by a profession that is designed to govern decision-making and assist individuals to distinguish right from wrong.
Consequentialism: An ethical theory used to determine whether or not an action is right by the consequences of the action. For example, most people agree that lying is wrong, but if telling a lie would help save a person’s life, consequentialism says it’s the right thing to do.
Cultural humility: A humble and respectful attitude towards individuals of other cultures and an approach to learning about other cultures as a lifelong goal and process.
Deontology: An ethical theory based on rules that distinguish right from wrong.
Ethical dilemma: Conflict resulting from competing values that requires a decision to be made from equally desirable or undesirable options.
Ethical principles: Principles used to define nurses’ moral duties and aid in ethical analysis and decision-making.[6] Foundational ethical principles include autonomy (self-determination), beneficence (do good), nonmaleficence (do no harm), justice (fairness), and veracity (tell the truth).
Ethics: The formal study of morality from a wide range of perspectives.[7]
Ethics committee: A formal committee established by a health care organization to problem-solve ethical dilemmas.
Fidelity: An ethical principle meaning keeping promises.
Institutional Review Board (IRB): A group that has been formally designated to review and monitor biomedical research involving human subjects.
Justice: A moral obligation to act on the basis of equality and equity and a standard linked to fairness for all in society.[8]
Moral conflict: Feelings occurring when an individual is uncertain about what values or principles should be applied to an ethical issue.[9]
Moral courage: The willingness of an individual to speak out and do what is right in the face of forces that would lead us to act in some other way.[10]
Moral distress: Feelings occurring when correct ethical action is identified but the individual feels constrained by competing values of an organization or other individuals.[11]
Moral injury: The distressing psychological, behavioral, social, and sometimes spiritual aftermath of exposure to events that contradict deeply held moral beliefs and expectations.
Morality: Personal values, character, or conduct of individuals or groups within communities and societies.[12]
Moral outrage: Feelings occurring when an individual witnesses immoral acts or practices they feel powerless to change.[13]
Morals: The prevailing standards of behavior of a society that enable people to live cooperatively in groups.[14]
Nonmaleficence: The bioethical principle that specifies a duty to do no harm and balances avoidable harm with benefits of good achieved.[15]
Paternalism: The interference by the state or an individual with another person, defended by the claim that the person interfered with will be better off or protected from harm.[16]
Utilitarianism: A type of consequentialism that determines whether or not actions are right based on their consequences, with the standard being achieving the greatest good for the greatest number of people.
Values: Individual beliefs that motivate people to act one way or another and serve as a guide for behavior.[17]
Veracity: An ethical principle meaning telling the truth.
Affect: Outward display of one’s emotional state. A “flat” affect with little display of emotion is associated with depression.
AIDET: Mnemonic for introducing oneself in health care that includes Acknowledge, Introduce, Duration, Explanation, and Thank You.[18]
Auscultation: Listening to sounds, such as heart, lung, and bowel sounds, created by organs using a stethoscope.
BMI: A standardized reference range to gauge a patient’s weight status.
Cultural safety: The creation of safe spaces for patients to interact with health professionals without judgment, racial reductionism, racialization, or discrimination.
Developmental stages: A person’s life span can be classified into nine categories of development, including Prenatal Development, Infancy and Toddlerhood, Early Childhood, Middle Childhood, Adolescence, Early Adulthood, Middle Adulthood, Late Adulthood, and Death and Dying.
Family dynamics: Patterns of interactions between family members that influence family structure, hierarchy, roles, values, and behaviors.
General survey assessment: A component of a patient assessment that observes the entire patient as a whole. Observation includes using all five senses to gather cues that provide a guideline for additional focused assessments in areas of concern.
Inspection: The observation of a patient’s anatomical structures.
Medical asepsis: Measures to prevent the spread of infection in health care agencies.
Objective data: Information observed through your sense of hearing, sight, smell, and touch while assessing the patient.
Older adults: People over the age of 65.
Percussion: An advanced physical examination technique where body parts are tapped with fingers to determine their size and if fluid is present.
Personal Protective Equipment (PPE): Includes gloves, gowns, goggles, face shields, and masks, along with environmental controls, to prevent the transmission of infection for patients who are diagnosed or suspected of having an infectious disease.
Physical examination: A systematic data collection method of the body that uses the techniques of inspection, auscultation, palpation, and percussion.
Primary data: Information provided directly by the patient.
Primary survey: A brief observation at the start of a shift or visit to verify the patient is stable by assessing mental status, airway, breathing, and circulation.
Secondary data: Information collected from a family member, chart, or other sources.
Subjective data: Information obtained from the patient and/or family members that offers important cues from their perspectives.
