Skin Integrity and Wound Care: Answers To Case Study

Chapter 37
Skin integrity and wound care

Answers to Case Study
Mr Wickham, a 54-year-old, became paraplegic following an accident. Prior to
the accident, he had lived an active and independent life with no known health
problems. After his initial hospitalisation, Mr Wickham spent 3 months in a
residential community rehabilitation centre, and then was discharged back to his
home after appropriate modifications were made. Two weeks post discharge
from this facility, a pre-planned home visit from the community health nurse
(whose caseload includes care of Mr Wickham) took place.
On the nurse’s arrival in the afternoon, the nurse found Mr Wickham still
dressed in his night clothes, unshaven and smelling of alcohol. His house
was considered very untidy, littered with beer bottles and take-away food
packaging. Mr Wickham made very minimal eye contact and spoke in a
barely audible monotone. While the community nurse was assisting Mr
Wickham, she noticed a small lesion on his scarum and a larger superficial
lesion on his left buttock. Mr Wickham was transferred to an acute care
facility where surgical debridement took place, identifying a stage 4 pressure
ulcer on his sacrum.
1. People who sustain injuries of the type similar to Mr Wickham are

predisposed to pressure area concerns. Why might this be and what
would be a recommendation for care?
Solution: Mr Wickham’s decreased activity and mobility, his decreased

sensation, his incontinence and his nutritional status (thin for his height) suggest
that he is vulnerable. In fact, he has evidence of a stage 4 pressure ulcer on his
sacrum.
NMBA standards
2.4 – RN practice is based on purposefully engaging in effective therapeutic and
professional relationships. This includes collegial generosity in the context of
mutual trust and respect in professional relationships. The registered nurse
provides support and directs people to resources to optimise health-related
decisions.
4.3 – RNs accurately conduct comprehensive and systematic assessments. They
analyse information and data and communicate outcomes as the basis for
practice. The registered nurse works in partnership to determine factors that
Copyright © 2018 Pearson Australia (a division of Pearson Australia Group Pty Ltd) – 9781488613654/Kozier
and Erb’s Fundamentals of Nursing 4e
affect, or potentially affect, the health and wellbeing of people and populations
to determine priorities for action and/ or for referral.
2. What other allied health professionals would you incorporate into

your care of Mr Wickham and, based on these interventions, what
are the recommendations for care outcomes? What other allied
health professionals would you incorporate into your care of Mr
Wickham and, based on these interventions, what are the
recommendations for care outcomes?
Solution: Allied health workers that could be involved in the care of Mr Wickham
could include a social worker, community nurse, the GP, a dietician and a
psychologist. The recommendations for care outcomes would include a holistic
approach to ensure Mr Wickham has all his physical and emotional needs met.
NMBA standards
2.4 – RN practice is based on purposefully engaging in effective therapeutic and
professional relationships. This includes collegial generosity in the context of
mutual trust and respect in professional relationships. The registered nurse
provides support and directs people to resources to optimise health-related
decisions.
3. Does it appear that Mr Wickham may experience other co-

morbidities? If so, what are your recommendations for his care?
Solution: Other co-morbidities may include depression and lack of, or poor,
nutritional status. The suggestion of a counsellor may be of benefit to Mr
Wickham, as well as a social worker to ascertain his financial status. Isolation
and lack of support network may be a contributing factor as to why he is in this
state to begin with, and the signs of self-neglect may be contributing factors to
look at.
NMBA standards
practice. The registered nurse uses a range of assessment techniques to
systematically collect relevant and accurate information and data to inform
practice.
4. A person undergoing surgical debridement resulting in a stage 4

pressure ulcer will require a specialised wound dressing regime. Can
you describe what this involves and the expected outcomes?
Solution: A dressing suited to a stage 4 pressure ulcer would be of the

hydrocolloid variety. This dressing could be a wafer designed to be worn for up to
seven days. These dressings absorb exudates and form a layer of hydrated gel
over the wound and occlusive seal. The purpose would be to absorb exudate from
the wound and produce a moist environment that facilitates healing; does not
macerate surrounding skin; prevents shearing and protects the wound from
contamination. The dressing should remain intact for up to seven days, and the
expected outcomes would be a wound that demonstrates signs of new tissue and
no infection.
NMBA standard
practice.
5. Mr Wickham expresses concern to you, ‘Nurse, I am very worried

that this might happen again.’ What does your discharge education
involve for Mr Wickham?
Solution: Suggestion of follow-up with a social worker to ensure his mental

state is not affecting his ability to care for himself. Regular visits from a
community nurse will ensure his health is being maintained effectively. Regular
visits to the GP will ensure that his mental health is not a concern.
A care plan regime is needed for Mr Wickham to follow to ensure he is making
regular turns and preventing further pressure areas. Ongoing skin assessment
and evaluation of the effectiveness of his overall treatment plan are also
essential. Discuss the benefit of each of these measures. Consider their cost and
the amount of caregiver time required. Prioritise the measures and include
rationales.
NMBA standards
3.2 – RNs, as regulated health professionals, are responsible and accountable for
ensuring they are safe, and have the capability for practice. This includes
ongoing self-management and responding when there is concern about other
health professionals’ capability for practice. RNs are responsible for their
professional development and contribute to the development of others. They are
also responsible for providing information and education to enable people to
make decisions and take action in relation to their health. The registered nurse
provides the information and education required to enhance people’s control
over health.
practice.
Answers to Concept Check

1. The person that you have assessed has a Braden Scale score of 17.
The appropriate nursing action is:
1. Assess the person again in 24 hours; the score is within normal
limits.
2. Implement a turning schedule; the person is at increased risk of
skin breakdown.
3. Apply a transparent wound barrier to major pressure sites; the
person is at moderate risk of skin breakdown.
4. Request an order for a special low-air-loss bed; the person is at
very high risk of skin breakdown.
Solution: 2. Implement a turning schedule; the person is at increased risk of skin

breakdown.
A score ranging from 15 to 18 is considered at risk, and a turning schedule is
appropriate.
Option 1 requires a score above 18 (normal and ongoing assessment is
indicated).
Option 3, moderate risk, for which a transparent barrier would be appropriate, is
applied to persons with scores of 13 to 14.
Option 4, very high risk, is assigned for those with a score of nine or less.
NMBA standards
practice.
2. Proper technique for performing a wound culture includes which of

the following?
1. Cleansing the wound prior to obtaining the specimen.
2. Swabbing for the specimen in the area with the largest collection
of drainage.
3. Removing crusts or scabs with sterile forceps and then culturing
the site beneath.
4. Waiting 8 hours following a dose of antibiotic to obtain the
specimen.
Solution: 1. Cleansing the wound prior to obtaining the specimen.

Wound culture specimens should be obtained from a cleaned area of the
wound. Microbes responsible for the infection are more likely to be found in
viable tissue. Collected drainage contains old and mixed organisms. An
appropriate specimen can be obtained without causing the client the
discomfort of debriding. The nurse does not generally debride the wound to
obtain a specimen. Once systemic antibiotics have been commenced, the
interval following a dose will not significantly affect the concentration of wound
organisms.
NMBA standards
practice.
3. An individual has a pressure ulcer with a shallow, partial skin

thickness, eroded area but no necrotic areas. The nurse would treat
the area with which of the following dressings?
1. Alginate.
2. Dry gauze.
3. Hydrocolloid.
4. No dressing is indicated.
Solution: 3. Hydrocolloid.
Hydrocolloid dressings protect shallow ulcers and maintain an appropriate
healing environment.
Alginates (option 1) are used for wounds with significant drainage;
dry gauze (option 2) will stick to new granulation tissue, causing more damage.
A dressing is needed to protect the wound and enhance healing.
NMBA standards
practice.
4. Thirty (30) minutes after application is initiated, the person requests

that the nurse leave the heating pad in place. The nurse explains to
the person that:
1. Heat application for longer than 30 minutes can actually cause
the opposite effect (constriction) to the one desired (dilation).
2. It will be acceptable to leave the pad in place if the temperature
is reduced.
3. It will be acceptable to leave the pad in place for another 30
minutes if the site appears satisfactory when assessed.
4. It will be acceptable to leave the pad in place as long as it is
moist heat.
Solution: 1. Heat application for longer than 30 minutes can actually cause the
opposite effect (constriction) to the one desired (dilation).
The heating pad needs to be removed. After 30 minutes of heat application, the
blood vessels in the area will begin to exhibit the rebound effect, resulting in
vasoconstriction. Lowering the temperature, but still delivering heat—dry or
moist—will not prevent the rebound effect.
The visual appearance of the site on inspection (option 3) does not indicate if
rebound is occurring.
NMBA standard
over health.
5. Which statement, if made by the individual or family member, would

indicate the need for further teaching?
1. If a skin area gets red but then the red goes away after turning, I
should report it to the nurse.
2. Putting foam pads under the heels or other bony areas can help
decrease pressure.
3. If a person cannot turn himself or herself in bed, someone should
help the person change position every 4 hours.
4. The skin should be washed with only warm water (not hot) and
lotion put on while it is still a little wet.
Solution: 3. If a person cannot turn himself or herself in bed, someone should

help the person change position every 4 hours.
Immobile and dependent persons should be repositioned at least every two
hours, not every four, so this client or family member requires further teaching.
Warm water and moisturising damp skin are correct techniques for skin care.
Red areas that do not return to normal skin colour should be reported. It would
also be correct to use a foam pad to help relieve pressure.
NMBA standard
over health.
6. The individual that you are caring for is only comfortable lying on the
right or left side (not on the back or stomach). List four potential
sites of pressure ulcers you must assess.
1.
2.
3.
4.
Solution: Potential pressure ulcer sites for side-lying clients include ankles,
knees, trochanters, ilia, shoulders and ears.
NMBA standards
practice.
7. An appropriate nursing diagnosis for a person with large areas of

skin excoriation resulting from scratching an allergic rash is:
1. Risk for impaired skin integrity.
2. Impaired skin integrity.
3. Impaired tissue integrity.
4. Risk for infection.
Solution: 2. Impaired skin integrity.

This client has an actual impairment of the integrity of the skin due to the rash
and the scratching so is no longer ‘at risk’.
Because the damage is at the skin level, it is not impaired tissue integrity (option
3) since that would involve deeper tissues. Surface excoriation is also not prone
to becoming infected.
NMBA standard
practice.
8. Which of the following are primary risk factors for pressure ulcers?
Select all that apply.
1. Low-protein diet.
2. Insomnia.
3. Lengthy surgical procedures.
4. Fever.
5. Sleeping on a waterbed.
Solution: Options 1, 3 & 4.

1. Low-protein diet.
3. Lengthy surgical procedures.
4. Fever.
Risk factors for pressure ulcers include a low-protein diet, lengthy surgical
procedures, and fever. Protein is needed for adequate skin health and healing.
During surgery, the client is on a hard surface and may not be well protected
from pressure on bony prominences. Fever increases skin moisture, which can lead
to skin breakdown, and the stress on the body from the cause of the fever could
impair circulation and skin integrity.
Insomnia (option 2) would generally involve restless sleeping, which transfers
pressure to different parts of the body and would reduce the chances of skin
breakdown.
A waterbed (option 5) distributes pressure more evenly than a regular mattress
and thus actually reduces the chances of skin breakdown.
NMBA standard
practice.
9. Which of the following items are used to perform wound irrigation?

Select all that apply.
1. Clean gloves.
2. Sterile gloves.
3. Refrigerated irrigating solution.
4. 60 mL syringe.
Solution: Options 1, 2 & 4.

1. Clean gloves.
2. Sterile gloves.
4. 60 mL syringe.
To irrigate a wound, the nurse uses clean gloves to remove the old dressing and
to hold the basin collecting the irrigating fluid, plus sterile gloves to apply the
new dressing. A 60-mL syringe is the correct size to hold the volume of irrigating
solution and deliver safe irrigating pressure. The irrigation fluid should be room
or body temperature—certainly not refrigerated.
NMBA standard
identifies and promotes the integral role of nursing practice and the profession in
influencing better health outcomes for people.
10.Which of the following indicates proper use of a triangle arm sling?

1. The elbow is kept flexed at 90 degrees or more.
2. The knot is placed on either side of the vertebrae of the neck.
3. The sling extends to just proximal of the hand.
4. Remove the sling every 2 hours to check for circulation and skin
integrity.
Solution: 2. The knot is placed on either side of the vertebrae of the neck.
The knot of the triangle sling must be kept off the spinal processes, as this would
be uncomfortable and put unnecessary pressure on the vertebrae.
The elbow should be flexed slightly less than 80 degrees (not >90 as in option
1), so the hand is above the elbow to prevent dependent swelling. The sling must
extend past the wrist in order to support the hand.
Although the sling must be removed to check for circulation and skin integrity,
every two hours (option 4) is unnecessarily frequent and impractical.
NMBA standard
Answers to Focus on Critical Thinking
1. You are caring for an Indigenous person who spends a considerable
amount of time each day resting in bed. What challenges does this
pose for the nurse conducting a skin assessment?
Solution: An Indigenous client who spends all day in bed does pose problems
for nurses, as their beliefs may allow them to do so. However, it is the nurse’s
responsibility to discuss the issues with the client and highlight the impact of
what may happen to the skin if they don’t move around enough. The nurse
should be respectful of customs. However, if the client wants to maintain good
health and not be admitted several times for the same reason, then the client
needs to follow the guidelines in order to get better sooner and avoid
hospitalisation again.
NMBA standards
1.3 – RNs use a variety of thinking strategies and the best available evidence in
making decisions and providing safe, quality nursing practice within person-
centred and evidence-based frameworks. The registered nurse respects all
cultures and experiences, which includes responding to the role of family and
community that underpin the health of Aboriginal and Torres Strait Islander
peoples and people of other cultures.
2. What factors do you take into account in terms of selecting an

appropriate dressing product for a given wound type?
Solution: There are many types of wound dressings. The nurse must investigate
what type of dressing suits each particular type of wound and what benefits
there are to each type of wound. Also, the nurse must be aware that some
clients are allergic to types of skin dressings. Therefore, allergies must be
documented. Documentation is important to ensure the particular wound
dressing is achieving the best results.
NMBA standard
practice.
3. You are providing discharge education for an individual who is going

home with a wound. What features of health promotion do you
discuss that promote wound healing within a community setting?
Solution: The patient should have full documentation provided to them

regarding all the appropriate requirements for maintaining a healthy lifestyle,
including adequate hygiene, adequate nutrition and environmental issues, such
as tidiness and cleanliness of the hands and the keeping of pets in the house
which may be impacting on their cleanliness.
NMBA standards
over health.
practice.

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Chapter 37

Skin integrity and wound care

1. People who sustain injuries of the type similar to Mr Wickham are

Solution: Mr Wickham’s decreased activity and mobility, his decreased

2. What other allied health professionals would you incorporate into

3. Does it appear that Mr Wickham may experience other co-

4. A person undergoing surgical debridement resulting in a stage 4

Solution: A dressing suited to a stage 4 pressure ulcer would be of the

5. Mr Wickham expresses concern to you, ‘Nurse, I am very worried

Solution: Suggestion of follow-up with a social worker to ensure his mental

Answers to Concept Check

Solution: 2. Implement a turning schedule; the person is at increased risk of skin

2. Proper technique for performing a wound culture includes which of

Solution: 1. Cleansing the wound prior to obtaining the specimen.

3. An individual has a pressure ulcer with a shallow, partial skin

4. Thirty (30) minutes after application is initiated, the person requests

5. Which statement, if made by the individual or family member, would

Solution: 3. If a person cannot turn himself or herself in bed, someone should

7. An appropriate nursing diagnosis for a person with large areas of

Solution: 2. Impaired skin integrity.

Solution: Options 1, 3 & 4.

9. Which of the following items are used to perform wound irrigation?

Solution: Options 1, 2 & 4.

10.Which of the following indicates proper use of a triangle arm sling?

2. What factors do you take into account in terms of selecting an

3. You are providing discharge education for an individual who is going

Solution: The patient should have full documentation provided to them

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