209 Exam 3 (Integumentary)

What is a pressure injury?

this is injury to the skin as a result of prolonged pressure, intense pressure of a short duration, or pressure in combination with shear

Tissue tolerance is affected by

moisture, incontinence, impaired nutrition, or impaired perfusion (blood flow)

Types of wounds: Puncture

needle/knife penetration

What is the name of the gel used for chemical debridement of a stage 4 pressure injury?

Autolytic gel

[How to tell if skin abnormality is benign or malignant]: Border

Benign: even edges all around Malignant: uneven edges

[How to tell if skin abnormality is benign or malignant]: Asymmetry

Benign: it will be symmetrical (round) Malignant: it will be asymmetrical

Types of wounds: Contaminated

open/traumatic wound with break in asepsis so theres high risk in infection

Stage 2 pressure injury

partial thickness loss this is a break through the epidermis and dermis you can see the wound base

Types of wounds: Clean

a closed surgical wound that did not enter the GI , resp, or GU systems

Purposes of wound dressings

To absorb drainage, prevent contamination, and provide moist environment

The nurse is caring for an older adult male patient who is bedridden. The patient is frail, thin, and incontinent of urine and stool. The patient refuses to eat because he is scared that he may soil the bed. Upon assessment, the nurse finds that the skin in the perineal area is macerated due to moisture and excoriation. The patient keeps sliding down to the foot of the bed and then digs his heels in to push upward. 1. Which patient circumstances increase his potential for impaired skin integrity? 2. Braden Score:_________ 3. What preventive interventions should the nurse perform to prevent maceration in the patient's skin?

1. Age [Older age so less sensation to pain], frail and thin [in adequate nutrition], incontinence [risk for skin breakdown], refuses to eat [also in adequate nutrition], keep sliding down on bed [friction/shear], patient digs heels into bed [pressure] 2. Activity: 1, sensory: 4, mobility: 3, nutrition: 2, friction and shear: 2, moisture: 1 TOTAL: 13 3. Footboard at the foot of the bed/reminding to switch positions/moisture barrier cream for macerated skin/ to help with incontinence you would increase fiber OR decrease caffeine or carbonated drinks

How often should a nurse aim to turn their patients?

2 hrs

[How to tell if skin abnormality is benign or malignant]: Color

Benign: one shade Malignant: 2 or more shades

Hemovac drainage device

A portable suction drainage system

Jackson-Pratt Drainage Device

A portable suction drainage system

Individual factors that affect wound healing

Age, obesity, smoking, medications

[How to tell if skin abnormality is benign or malignant]: Diameter

Benign: smaller than 6mm Malignant: bigger than 6mm

Is the following statement true or false? An application of a cold pack to the leg of a patient with peripheral vascular disease is much less likely to cause a complication than the application of a hot pack.

False. Cold application on peripheral vascular disease patients will cause further vasoconstriction

Local factors that affect wound healing

Nature of the injury, infection, and local wound environment

What scale is used for predicting pressure sore risk?

The Braden scale

Mucosal membrane pressure injury

This develops in mucosal membranes. Can be due to medical devices.

Penrose drainage

This is a port put in place to allow drainage to come out

What is a wheal?

This is a raised area that is red or itchy and can spread through the body

What type of dressing can be put over an IV site?

Transparent adhesive dressings

A Penrose drain typically exits a client's skin through a stab wound created by the surgeon. True False

True Explanation: A Penrose drain is an open drainage system that exits the skin through a stab wound. The purpose a Penrose drain is to provide a sinus tract for drainage.

Types of wounds: Acute

any type of injury that is healing within 6 months

Types of wounds: Laceration

cut in the skin & may be smooth or jagged

Stage 3 pressure injury

full thickness loss there is a break in the epidermis, dermis & subcutaneous tissue

Stages of wound healing

hemostasis, inflammation, proliferation, remodeling

Types of healing

primary intention secondary intention tertiary intention (purposely left open because of infection or drainage and is closed later on)

Erythema

redness of the skin due to increased blood flow to an area

Types of wound drainage

serous, purulent, serosanguineous, sanguineous

Types of wounds: Abrasions

skidding knee when falling off skateboard

The most common germs that cause dermatitis are

staphylococcus and streptococcus

Is the following statement true or false? Clean surgical incisions which have edges approximated heal by primary intention.

true

The nurse is teaching a client about healing of a minor surgical wound by first intention. What teaching will the nurse include? "Very little scar tissue will form." "This is a complex reparative process." "The margins of your wound are not in direct contact." "The surgeon will leave your wound open intentionally for a period of time."

"Very little scar tissue will form." Explanation: Very little scar tissue is expected to form in a minor surgical wound.

Interigo

Fungal infections in the dark/warm areas and usually are found under breasts or skin folds

Adequate blood flow to the skin is necessary for healthy, viable tissue. Adequate skin perfusion requires four factors. Which is not one of these factors? Local capillary pressure must be lower than external pressure. The heart must be able to pump adequately. The volume of circulating blood must be sufficient. Arteries and veins must be patent and functioning well.

Local capillary pressure must be lower than external pressure. Explanation: Local capillary pressure must be higher than external pressure for adequate skin perfusion.

Systemic factors that affect wound healing

Nutrition, circulation & immunity of the host

What to types of patients are more prone to skin tears?

Older adults and people with rheumatoid issues

Tunneling and undermining

This means the wound is progressing farther into the tissue

Reasons for cold applications

To control bleeding or edema by causing vasoconstriction of blood vessels so this decreases blood flow to an area and thus, decreasing metabolic tissue demands. Also used for sprains, fractures, trauma

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider as an indication of infection? foul-smelling drainage that is grayish in color copious drainage that is blood-tinged large amounts of drainage that is clear and watery and has no smell small amount of drainage that appears to be mostly fresh blood

foul-smelling drainage that is grayish in color

Friction

when two surfaces rub together causing for skin abrasion. To prevent friction when moving a patient in bed, you move them on the SHEET, do not drag the patient themselves. To lift the feet while moving them, put on socks or heel pads

Precautions for hot or cold applications

Age: [older people have a hard time differentiating between hot and cold so they may be getting injured and not know]. Unconsciousness: [a patient who is unconscious mean not be able to differentiate between hot and cold]. Metallic implants: [pacemakers and joint replacements] -metal conducts heat so higher risk for burns Circulatory impairment: [peripheral vascular disease; diabetes]- cold application causes vasoconstriction of blood vessels which decreases circulation to an already compromised area Broken skin: Damaged tissue is more sensitive to temperature extremes. Fewer pain receptors are there to warn of possible tissue damage. (further explanation: patient can still have damage without knowing damage is happening)

A nurse is caring for a patient with a stage IV sacral pressure ulcer for which the provider has prescribed mechanical debridement. Which of the following should the nurse plan for this patient? Placing a transparent dressing over the ulcer Applying larvae to the wound bed Changing dressings using the wet-to-dry method Using a topical enzyme solution in the wound's base

Changing dressings using the wet-to-dry method A wet-to-dry saline dressing provides mechanical debridement when it is removed at the next dressing change. It is a common method of mechanical debridement.

Types of wounds: Open

open wounds have higher risk for infection

Pressure

Intensity and duration of pressure coupled with tissue damage can cause a pressure ulcer

Reasons for heat applications

It increases the supply of oxygen and leukocytes by dilating blood vessels. It's also used for muscle aches. Sitz baths are used for hemorrhoids or episiotomy (cut vagina curing labor to prevent tearing)

A nurse is documenting data about a deep necrotic wound on a patient's left buttock. The nurse observes a yellowish-tan, soft, stringy area of necrotic tissue formed in clumps and adhering firmly to the wound bed. The nurse should document this type of necrotic tissue as: Keloid Slough Gangrene Eschar

Slough Slough is stringy and whitish, yellowish, and/or tan necrotic tissue that is firmly attached to the wound bed. This is the correct term for the tissue the nurse has observed.

Types of wounds: Clean/contaminated

a surgical wound that enters the GI , resp, or GU systems so theres risk for infection

Shear

bone tissue rubbing against muscle, fat, skin. This can cause blood vessels to stretch and tear

Types of wounds: Closed

closed skin but may be purple color (ex: deep tissue pressure injury)

Characteristics of normal skin

color-consistent with ethnicity temperature (if an area is very warm that means inflammation or (erythema)) moisture (should be dry but excessive sweating means diapheresis texture and thickness odor

Upon responding to the client's call bell, the nurse discovers the client's wound has dehisced. Initial nursing management includes calling the health care provider and: covering the wound area with sterile towels moistened with sterile 0.9% saline. closing the wound area with reinforced adhesive skin closures. pouring sterile hydrogen peroxide into the abdominal cavity and packing it with gauze. holding the wound together until the health care provider arrives.

covering the wound area with sterile towels moistened with sterile 0.9% saline. Explanation: If dehiscence occurs, the nurse should cover the wound area with sterile towels moistened with sterile 0.9% saline. The nurse should also place the client in the low Fowler position and cover the exposed abdominal contents with sterile saline, not hydrogen peroxide. The nurse notifies the health care provider immediately, because this is a medical emergency. The nurse should not leave the client alone but does not need to hold the wound together until the health care provider arrives.

A nurse is assessing a pressure injury on a client's coccyx area. The wound size is 2 cm × 5 cm. Approximately 30% of the wound bed is covered in yellow slough. There is an area of undermining to the right side of the wound, 2 cm deep. Subcutaneous fat is visible. Which stage should the nurse assign to this client's wound? stage II stage IV stage I stage III

stage III Explanation: Stage III wounds have full-thickness tissue loss. Subcutaneous tissue may be visible, but no bone, tendon, or muscle should be seen. Stage I involves intact skin with nonblanchable redness. Stage II involves a partial tissue loss, such as a blister. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.

The nurse is caring for a client with an ankle sprain. Which client statement regarding an ice pack indicates that nursing teaching has been effective? "I should keep this on my ankle until it is numb." "I must wait 15 minutes between applications of cold therapy." "I will put a layer of cloth between my skin and the ice pack." "I can let this stay on my ankle an hour at a time."

"I will put a layer of cloth between my skin and the ice pack." Explanation: Teaching has been effective when the client understands that a layer of cloth is needed between the ice pack and skin to preserve skin integrity. The ice pack should be removed if the skin becomes mottled or numb; this indicates that the cold therapy is too cold. The ice pack can be in place for no more than 20-30 minutes at a time, and a minimum of 30 minutes should go by before it is reapplied.

A nurse is caring for a patient who has a heavily draining wound that continues to show evidence of bleeding. Which of the following types of dressings should the nurse select to help promote hemostasis? Transparent Hydrofiber Alginate Biologic

Alginate Alginate dressings help establish hemostasis while providing a moist environment for healing and good absorption of exudate. They do not adhere to the wound; therefore, removal is unlikely to cause further bleeding.

Prep U A pediatric nurse is familiar with specific characteristics of skin across the life span. Which statement accurately describes skin characteristics? An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thicker and stronger than in adults. A child's skin becomes less resistant to injury and infection as the child grows. An individual's skin changes little over the life span.

An infant's skin and mucous membranes are easily injured and at risk for infection. Explanation: An infant's skin and mucous membranes are easily injured and at risk for infection. In children younger than 2 years, the skin is thinner and weaker than in adults. The structure of the skin changes as a person ages. A child's skin becomes more resistant to injury and infection as the child grows.

Which statement accurately describes a developmental consideration when assessing skin integrity of clients? In children younger than 2 years, the skin is thicker and stronger than it is in adults. An infant's skin and mucous membranes are injured easily and are subject to infection. A child's skin becomes increasingly at risk for injury and infection. In the older adult, circulation and collagen formation are increased.

An infant's skin and mucous membranes are injured easily and are subject to infection. Explanation: In children younger than 2 years, the skin is thinner and weaker than it is in adults. An infant's skin and mucous membranes are injured easily and are subject to infection. Careful handling of infants is required to prevent injury to, and infection of, the skin and mucous membranes. A child's skin becomes increasingly resistant to injury and infection. The structure of the skin changes as a person ages. The maturation of epidermal cells is prolonged, leading to thin, easily-damaged skin. Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure.

A nurse is caring for a patient who is admitted with multiple wounds sustained in a motor-vehicle crash. Understanding the patient's specific needs during this initial stage of wound healing, the nurse should incorporate which of the following into the patient's plan of care to prevent a prolongation of this phase? Leave nonbleeding wounds open to the air. Administer 325 mg aspirin PO as needed for pain. Initiate mechanical debridement. Apply oxygen at 2 L/min via nasal cannula.

Apply oxygen at 2 L/min via nasal cannula. Following an acute injury, the body responds by increasing perfusion to the location of the injury during the inflammatory phase of wound healing. The purpose of this increased blood supply to the wounds is to transport the oxygen and nutrients essential for healing. It is common to see a delay in the resolution of the inflammatory phase of chronic wounds in patients who have a lack of oxygen or poor perfusion

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to be intact, reddened, and nonblanchable. What is the best way to document the nurse's assessment finding? As a stage I pressure injury As a stage II pressure injury As a stage III pressure injury As a stage IV pressure injury

As a stage I pressure injury Explanation: Stage I pressure injuries are characterized by intact but reddened skin that is nonblanchable. Therefore, the nurse categorizes and documents this pressure injury as stage I. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue. Stage IV exposes muscle and bone. Therefore, the nurse does not categorize this pressure injury as stage II, III, or IV.

An obese patient slid down to the bottom of the hospital bed and was assisted back up by several unit staff members. The most likely type of mechanical force that might cause injury to the skin in this case is: A. Pressure B. Friction C. Shear D. Gravity

C. Shear It's shear because the staff is moving him. So his bone is sliding against other tissues. If he was moving himself it would be friction.

A nurse is cleaning the wound of a client who has been injured by a gunshot. Which guideline is recommended for this procedure? Clean the wound from the top to the bottom and from the center to outside. Once the wound is cleaned, gently dry the wound bed with an absorbent cloth. Clean the wound in a circular pattern, beginning on the perimeter of the wound. Use clean technique to clean the wound.

Clean the wound from the top to the bottom and from the center to outside. Explanation: Using sterile technique, clean the wound from the top to the bottom and from the center to the outside.

A nurse is caring for a patient who has multiple sclerosis and has a chronic nonhealing wound. The nurse should recognize that which of the following types of medications is known to delay wound healing? Tricyclic antidepressants Corticosteroids Beta blockers Anticholinergics

Corticosteroids Corticosteroids suppress the immune system and therefore can delay wound healing.

Hydro gel is used for stage ____ , ______ , and _____ wounds

Hydro gel is used for stage 2, 3 , and 4 wounds

Hydrocolloid dressing are used for Stage ____ or Stage ___ wounds

Hydrocolloid dressing are used for Stage 1 or Stage 2 wounds

A patient who has a full-thickness wound continues to experience considerable pain during dressing changes, despite administration of the prescribed analgesic prior to wound care. Which of the following types of dressings should the nurse select to help minimize the pain of dressing changes? Wet-to-dry Antimicrobial Gauze Hydrogel

Hydrogel In general, keeping some moisture within a wound reduces pain. Hydrogel dressings work by maintaining a moist wound environment, so they are a good choice for helping to reduce the pain associated with dressing changes.

A 77-year-old client has experienced an ischemic stroke and is now dependent for all activities of daily living. What components of nursing care will the nurse initiate to prevent skin breakdown? Implement a 2-hour repositioning schedule Perform passive range-of-motion exercises Massage skin surfaces daily, especially areas under pressure and bony prominences Frequently orient client to place and situation

Implement a 2-hour repositioning schedule Explanation: The nurse must regularly turn and reposition the client who is immobile to prevent ischemia and consequent skin breakdown.

Deep tissue injury

Skin is intact but there is purpleish/maroon color underneath and you can't tell how far the wound extends

A nurse assessing client wounds would document which wounds as healing normally without complications? Select all that apply. The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. a wound that takes approximately 2 weeks for the edges to appear approximated and heal together a wound with increased swelling and drainage that may occur during the first 5 days of wound healing a wound that does not feel hot and tender upon palpation a wound that forms exudate due to the inflammatory response incisional pain during the wound healing, which is most severe for the first 3 to 5 days, and then progressively diminishes

The edges of a healing surgical wound appear clean and well approximated, with a crust along the edges. a wound that does not feel hot and tender upon palpation a wound that forms exudate due to the inflammatory response

Which nursing interventions reflect the accurate use of heat or cold during wound care? Select all that apply. The nurse makes more frequent checks of the skin of an older adult using a heating pad. The nurse places a heating pad on a sprained wrist that is in the acute stage. The nurse instructs the client to lean or lie directly on the heating device. The nurse fills an ice bag with small pieces of ice to about two-thirds full. The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm. The nurse applies moist cold to a client's eye for 40 minutes every 2 hours.

The nurse makes more frequent checks of the skin of an older adult using a heating pad. The nurse fills an ice bag with small pieces of ice to about two-thirds full. The nurse covers a cold pack with a cotton sleeve to keep it in place on an arm.

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? May vary from brown or black to cherry red or pearly white; bullae may be present Superficial, which may be pinkish or red with no blistering Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown A superficial partial-thickness burn, which can appear dry and leathery

Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Explanation: Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.

A nurse is caring for a patient who has developed a stage I pressure ulcer in the area of the right ischial tuberosity. Which of the following should the nurse plan to apply to the ulcer? Zinc oxide Nystatin Papain-urea Polymyxin B

Zinc oxide Barrier creams and ointments are used for patients prone to skin breakdown from pressure, shear, or incontinence. They are intended for prevention and for resolving new-onset problems, such as a stage I pressure ulcer.

Types of wounds: Contusions

a blunt trauma (getting hit in the head/falling down stairs)

A client is brought to a health care facility for treatment of a bleeding cut. The client was injured by a sharp knife. How can the nurse describe the client's wound? a clean separation of skin and tissue with smooth, even edges a shallow crater in which skin or mucous membrane is missing a wound in which the surface layers of the skin are scraped away a separation of skin and tissue in which the edges are torn and irregular

a clean separation of skin and tissue with smooth, even edges Explanation: The nurse can describe a wound caused by a sharp knife as an incision wound with clean separation of skin and tissue with smooth, even edges. Ulceration is a shallow crater in which skin or mucous membrane is missing. An abrasion is a wound in which the surface layers of the skin have been scraped away. A laceration is the separation of skin and tissue in which the edges are torn and irregular.

The nurse is preparing to measure the depth of a client's tunneled wound. Which implement should the nurse use to measure the depth accurately? a sterile, flexible applicator moistened with saline a small plastic ruler a sterile tongue blade lubricated with water soluble gel an otic curette

a sterile, flexible applicator moistened with saline Explanation: A sterile, flexible applicator is the safest implement to use. A small plastic ruler is not sterile. A sterile tongue blade lubricated with water soluble gel is too large to use in a wound bed. An otic curette is a surgical instrument designed for scraping or debriding biological tissue or debris in a biopsy, excision, or cleaning procedure and not flexible.

The nurse is assessing the wounds of clients in a burn unit. Which wound would most likely heal by primary intention? a surgical incision with sutured approximated edges a large wound with considerable tissue loss allowed to heal naturally a wound left open for several days to allow edema to subside a wound healing naturally that becomes infected.

a surgical incision with sutured approximated edges Explanation: Wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention. Wounds healed by secondary intention have edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention.

A nurse is caring for a client who is 2 days postoperative after abdominal surgery. What nursing intervention would be important to promote wound healing at this time? administering pain medications on a PRN and regular basis assisting the client in moving to prevent strain on the suture line telling the client that a mild fever is a normal response preventing scar formation so it does not limit joint movement

assisting the client in moving to prevent strain on the suture line Explanation: The proliferative phase of wound healing begins within 2 to 3 days of the injury. Collagen synthesis and accumulation continue, peaking in 5 to 7 days. During this time, adequate nutrition, oxygenation, and prevention of strain on the suture line are important client care considerations. Pain medication assists with the pain and not with the wound healing process. Fever is not a normal response. A scar will occur later in the wound healing process and usually does not limit the joint movement.

Pallor

decreased blood flow to an area

What are two conditions that make dermatitis worse?

diabetes and peripheral vascular disease

Factors that influence integumentary function

flaking, dryness in skin which indicates poor nutrition incontinence (can cause dermatitis) allergies (poison ivy)

Types of wounds: Chronic

healing that takes more than 6 months OR wound that become further infected

The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing? maturation phase hemostasis phase inflammatory phase proliferation phase

hemostasis phase Explanation: Hemostasis is the initial phase after an injury. Hemostasis stimulates other cells to come to the wound to begin other phases of wound healing. The inflammatory phase follows hemostasis; white blood cells move into the wound to remove debris and release growth factors. The proliferation phase is the regenerative phase, in which granulation tissue is formed. The maturation phase involves collagen remodeling.

What is an unstageable pressure injury?

injuries that cannot be staged due to presence of a scar or slough

Vesicle/Bulla/Pustule

just think "pimple"

The health care provider uses sutures during the surgery on a client at a health care facility. What are sutures? knotted ties that hold an incision together a bridge that holds two wound margins together a strip or roll of cloth wrapped around a body part tubes that provide a pathway for drainage

knotted ties that hold an incision together Explanation: Sutures are knotted ties that hold an incision together. Sutures generally are constructed from silk or synthetic materials such as nylon. Staples are wide metal clips that form a bridge to hold two wound margins together. A bandage is a strip or roll of cloth wrapped around a body part. Open drains are tubes that provide pathways for drainage toward the dressing.

In order to use a hydrocolloid dressing the wound has to be

non-infected

During a dressing change, the nurse assesses protrusion of intestines through an opened wound. What would the nurse do after covering the wound with towels moistened with sterile 0.9% sodium chloride solution? document the assessments and intervention reinforce the dressing with additional layers administer pain medications intramuscularly notify the physician and prepare for surgery

notify the physician and prepare for surgery Explanation: Protrusion of the intestines through an opened wound is evisceration. After covering the wound with towels soaked in sterile normal saline, the nurse should immediately notify the physician. Immediate surgical repair is required. Pain medication and documentation are also important. If necessary, the nurse should reinforce the dressing while waiting for surgery.

A nurse is documenting data about a healing wound on a patient's lower leg. The predominant exudate in the wound is watery in consistency and light red in color. The nurse should document this exudate as: serosanguineous. sanguineous. serous. purulent.

serosanguineous. This exudate is serosanguineous, which is thin and watery in consistency and pink to light red in color.

When clients are pulled up in bed rather than lifted, they are at increased risk for the development of decubitus ulcers. What is the name given to the factor responsible for this risk? friction necrosis of tissue ischemia shearing force

shearing force Explanation: A shearing force results when one layer of tissue slides over another layer. Clients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces.

A nurse assessing a pressure ulcer over a patient's right heel area observes a deep crater with no eschar or slough and no exposed muscle or bone. The nurse should document that this patient has a pressure ulcer that is... unstageable. a suspected deep tissue injury. stage IV. stage III.

stage III. A stage III pressure ulcer has full-thickness tissue loss appearing as a deep crater, without exposed muscle or bone. There may or may not be slough. This patient's wound fits this description.

Stage 4 pressure injury

there is a breakdown in muscle/bone

Stage 1 pressure injury

there is no break in skin integrity

Medical device related pressure injury

these injuries are caused from medical devices such as oxygen tubes, Foleys, bed pans etc.

A nurse is caring for a client with dehydration at the health care facility. The client is receiving glucose intravenously. What type of dressing should the nurse use to cover the IV insertion site? gauze transparent hydrocolloid bandage

transparent Explanation: The nurse should use a transparent dressing to cover the IV insertion site, because such dressings allow the nurse to assess a wound without removing the dressing. In addition, they are less bulky than gauze dressings and do not require tape, since they consist of a single sheet of adhesive material. Gauze dressing is ideal for covering fresh wounds that are likely to bleed or wounds that exude drainage. A hydrocolloid dressing helps keep the wound moist. A bandage is a strip or roll of cloth wrapped around a body part to help support the area around the wound.

What type of dressing is used for stage 4 pressure injuries?

wet to dry dressings (wet gauze is packed into the wound and removed the next day)

Types of wounds: Infected

wound site with pathogens present so its definitely infected

What kind of dressing would you use on a Stage 2 pressure injury?

you can use a hydrocolloid dressing or a dry gauze

What kind of dressing would you use on a Stage 1 pressure injury?

you would do a hydrocolloid dressing to provide a "cushion layer"