Chapter 50: Pressure Injury

The nurse is discharging a patient with a wound. What dietary changes should the nurse suggest be increased to improve wound healing? Select all that apply.

-Protein -Zinc -Vitamin C -B Vitamins -Iron

What clients are at risk for pressure injury? Select all that apply. 1) Client with advanced age 2) Client with malnutrition 3) Client with insomnia 4) Client with urinary or fecal incontinence 5) Client with dehydration

1) Clients with advanced age 2) Clients with malnutrition 4) Clients with urinary or fecal incontinence 5) Clients with dehydration

The wound care nurse is educating a group of nursing students about the stages of a pressure injury. Which statement is correct when describing a stage III pressure injury? 1) There is full-thickness skin and tissue loss that can extend to the muscle, bone, or tendon. 2) A stage III pressure injury is when the skin is intact but does not blanch. 3) Stage III is full-thickness skin loss with exposure of the adipose tissue. 4) There is a partial-thickness loss of skin with exposed dermis.

3) Stage III is full-thickness skin loss with exposure of the adipose tissue.

The provider encourages Louanne to wear different shoes and return to the clinic in a week. When she returns, she has a low-grade fever and the heel has darkened in color. The red area now has a quarter-sized serum-filled blister. Louanne says "I tried some other shoes but they were not comfortable, so I went back to these." What stage pressure ulcer is now present?

Stage 2 pressure injury Stage 2 injuries have partial thickness loss of the dermis with a shallow open ulcer. The bed of the wound if red or pink, usually without sloughing. There may be an intact or ruptured serum-filled blister, or there may not.

The nurse is caring for a bedbound patient with a pressure injury of the coccyx and a Braden score of 9. Which nursing action is the priority?

Position the head of the bed less than 30°.

In which stage does a pressure injury show a partial loss in the thickness of the dermis?

stage II

Because Louanne has a fever, the provider performs lab work and finds that her white blood cell count is elevated. Louanne is admitted to the hospital for intravenous antibiotics. What should the nurse include in the plan of care? Select all that apply. 1) Wound care to the site 2) Functional assessment 3) Braden scale assessment 4) Positioning so that heal is not resting on the bed 5) Nutritional assessment

- wound care to the site - functional assessment - braden scale assessment - positioning so that heal is not resting on the bed - nutritional assessment The wound site care should include a dressing and prevention of further injury. Both a functional assessment and Braden skin assessment are important to see her level of mobility and risk for further skin injury. The nutritional assessment will determine if she has a balanced diet with adequate protein. Nutritional planning may also help to control her blood sugars.

The nurse is admitting a client with a stage III pressure injury. Which serum lab values would the nurse expect to be drawn on the client during the hospital stay? 1) B-type natriuretic peptide and lactic acid 2) Prothrombin time / international normalized ratio and partial thromboplastin time (PTT) 3) C-reactive protein and erythrocyte sedimentation rate 4) Hemoglobin and hematocrit

3) C-reactive protein and erythrocyte sedimentation rate

Upon admission, the nurse knows that all patients must be assessed using the Braden Scale to evaluate the patient's risk for skin breakdown. Which of the following areas are included when assessing the patient using the Braden Scale? Select all that apply.

-Activity -Nutrition -Mobility

The nurse is reviewing the admission laboratory results for Louanne. Which of these laboratory findings are indicative of inflammation or infection? Select All That Apply: 1) C-reactive protein (CRP) elevation 2) Erythrocyte sedimentation rate (ESR) elevation 3) White blood cell (WBC) elevation 4) Red blood cell (RBC) elevation 5) Platelet elevation

-C-reactive protein (CRP) elevation -Erythrocyte sedimentation rate (ESR) elevation -White blood cell (WBC) elevation CRP, ESR, and WBC elevation are all signs that may indicate inflammation or infection, but RBC and platelet elevation does not.

The nurse is assigned to a patient who is preparing to go to surgery for wound debridement. The nurse explains to the patient the purpose of the wound debridement, including which of the following? Select all that apply.

-Facilitates healing -Removal of necrotic tissue -Reduces the risk of infection

The nurse is caring for a patient at risk for skin breakdown. Which nursing interventions are appropriate to implement to minimize the effects of injury? Select all that apply.

-Use a draw sheet when moving the patient. -Minimize the amount of time the patient is in one position.

Arrange the steps of obtaining a swab culture chronologically.

-evaluate the wound bed to locate the area. -prepare to use sterile technique to obtain the specimen -clean the entire wound bed using a nonasepic solution -moisten the swab with normal saline -rotate the swab with gentle pressure on the wound tissue -place the swab into sterile container and label it -send the specimen to the laboratory without delay

The nurse is caring for a client with a pressure injury. Which comorbidities could the nurse expect to treat? Select all that apply. 1) Anemia 2) Varicose veins 3) Peripheral vascular disease 4) Diabetes 5) Plantar fascilitis

1) Anemia 3) Peripheral vascular disease 4) Diabetes

The nurse is teaching a group of students about physical assessment of the integumentary system. Which statement made by the nursing student indicates the need for further teaching? Select all that apply.

-"I should perform a visual inspection to identify the abnormalities." -"I should perform the assessment in a well-lit area when the client is fully clothed."

Which point regarding surface swab culture for the identification and treatment of a wound infection indicates a need for better understanding?

"It is considered the gold standard in identifying wound pathogens."

The nurse is explaining to the student nurse the difference between undermining and tunneling. How should the nurse explain the two terms?

"Undermining is the destruction of tissue under the wound edges and tunneling is the development of a passageway under the skin's surface."

The nurse would implement which nursing interventions to decrease the chance of the client developing pressure injury? Select all that apply. 1) Keep the draw sheet and any other bedding material located under the client clean, dry, and without wrinkles. 2) Keep the client elevated to at least 45 degrees at all times 3) Develop and implement a turning schedule if the client is unable to turn independently. 4) Use a skin risk assessment tool such as the Braden Scale per facility policy. 5) Encourage client to sit in a chair for long periods of time

1) Keep the draw sheet and any other bedding material located under the client clean, dry, and without wrinkles. 3) Develop and implement a turning schedule if the client is unable to turn independently. 4) Use a skin risk assessment tool such as the Braden Scale per facility policy.

The nurse receives hand-off report on a group of patients. Which patient is the highest risk for developing pressure injury? Select all that apply. 1) A young adult who is a quadriplegic 2) An older adult who is bedridden and diaphoretic 3) A middle-aged adult with a body mass index (BMI) of 13.6 and incontinent of stool 4) A middle-aged adult with a Braden scale score of 7 5) A middle-aged adult wth controlled diabetes who is ambulating three times a day

1,2,3,4 1) A young adult who is a quadriplegic 2) An older adult who is bedridden and diaphoretic 3) A middle-aged adult with a body mass index (BMI) of 13.6 and incontinent of stool 4) A middle-aged adult with a Braden scale score of 7

The home care nurse assesses a stage I pressure injury on an older adult patient who has limited mobility from a stroke. What should the nurse include when educating the patient's daughter about her care? Select all that apply. 1) Deliver high protein shakes twice a day. 2) Exercise the extremities actively and pa1) Deliver high protein shakes twice a day. 3) Be sure she changes positions at least every 2 hours. 4) Keep the skin moist and layer the sacral area with extra sheet layers. 5) Use pillows to pad all bony prominences.

1,2,3,5 1) Deliver high protein shakes twice a day. 2) Exercise the extremities actively and passively every 4 hours. 3) Be sure she changes positions at least every 2 hours. 5) Use pillows to pad all bony prominences.

Despite the nurse's attempts to keep Louanne's heels away from the pressure of the mattress, she continues to kick the pillow out from under her legs. She tells the nurse "It doesn't hurt me, I don't see what the big deal is." How should the nurse respond? 1) "It's your decision since they're your feet." 2) "When your heels rest on the mattress, the continued pressure to the site creates injury." 3) "I'm glad it doesn't hurt, it looks like it would." 4) "We'll have to ask your provider if we can get rid of the pillow, since she ordered it to be there." 5) "Did you know you could end up with an amputation?"

2) "When your heels rest on the mattress, the continued pressure to the site creates injury." The response by the nurse should provide education as to why the pillow is necessary, since Louanne may not understand. B is the most direct response to the issue of concern.

The nurse is caring for a client with a stage IV pressure injury on the coccyx. The nurse advises the client to increase which types of foods in the diet to assist in the healing process? 1) Bread and starches (Carbohydrates) 2) Meat and dairy (Protein) 3) Fats 4) Fruits and Vegetables

2) Meat and dairy (protein)

Louanne struggles to maintain a nutritious diet. What should the nurse encourage during the hospital stay for better wound healing? 1) Carbohydrates 2) Protein 3) Fats 4) Fruits 5) Vegetables

2) Protein The client should increase protein intake to assist in wound healing. The nurse should include this information in client education, along with examples of nutritious, protein-rich foods. Baseline lab work would be ordered during hospitalization to assess the client's protein status. A dietitian could be consulted per facility policy.

The nurse is caring for a patient with a pressure injury that is a shallow, open ulcer with a red-pink wound bed, without slough. How should the nurse document the finding? 1) Stage 1 2) Stage 2 3) Stage 3 4) Stage 4

2) Stage 2

Which skin condition should the nurse document as pressure injury stage II?

4

A few days later, the nurse performs a focused assessment and identifies that Louanne's pressure injury is now full thickness. There is some bone showing. There is eschar on the edges of the site along with some tunneling. What stage injury should the nurse document? 1) Stage 1 2) Stage 2 3) Stage 3 4) Stage 4 5) Unstagable

4) Stage 4 pressure injury Stage 4 injury includes full thickness tissue sloughs with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often undermining and tunneling are present.

Louanne's Braden Scale score is an 11. What conclusions can the nurse make? 1) Since she is ambulatory with assistance the skin score is insignificant 2) Today she's an 11, but it may be different tomorrow 3) The risk is minimal and not a concern 4) The risk is moderate so some interventions are important including a special mattress 5) The risk is high and referrals are needed for therapy services and wound care

5) The risk is high and referrals are needed for therapy services and wound care. The Braden scale score: Mild risk - 15 to 18 Moderate risk - 13 to 14 High risk - 10 to 12 Very high risk - 9 or below

Louanne is 70 years old and lives with her husband of 52 years in a small rural community. Louanne was diagnosed with diabetes 5 years ago and the disease is poorly controlled. She presented to the office today with a deep red bruise on the heel of her foot that doesn't seem to be healing. She tells the provider that "I think something bit me." The provider removes Louanne's shoe and sees an area the size of a half dollar on the heel of her foot that is bright read and does not blanch. The provider notes that the shoes Louanne is wearing are very tight and too small for her foot. What type of injury is Louanne demonstrating?

Stage 1 pressure injury Stage 1 pressure injuries have intact skin with non-blanching redness to a localized area, usually on a bony prominence.

The nurse is caring for a bedbound patient with a pressure injury of the coccyx and a Braden score of 6 out of 23. What does this indicate?

The patient is at a high risk for alteration in skin integrity.

A nurse is assessing a patient's skin and notes a 1 cm shallow crater on the coccyx. The site is painful to palpation. How should the nurse document the stage of this wound?

stage II

The nurse is assessing a pressure ulcer with full thickness tissue loss, visible subcutaneous fat with no bone, muscle, or tendons exposed. Slough is present, but does not obscure the depth of tissue loss. There is some undermining and tunneling. What stage is this pressure ulcer?

stage III