Clinical Reasoning Questions

When collecting a wound culture with a swab, the nurse should culture the a. Wound drainage b. Healthy-appearing tissue c. Most necrotic-appearing tissue d. Very outer edges of the wound

b. Healthy-appearing tissue

Why is her mobility 1?

She only has bed mobility

need more frequent dressing changes and a secondary dressing.

alginate dressings

Can shear happen without friction?

no

During your assessment, you note that R.L. has very dry, thin, almost transparent skin. She has limited mobility from her stroke and is currently bedridden. There are several areas of ecchymosis on her upper extremities. She is alert and oriented to person only. You review the transfer summary from the long-term care facility and note she has a history of urinary and fecal incontinence. What is here activity level according to braden? (4-ambulant, 3-walk/help, 2-chair bound, 1-bedrest)

1

During your assessment, you note that R.L. has very dry, thin, almost transparent skin. She has limited mobility from her stroke and is currently bedridden. There are several areas of ecchymosis on her upper extremities. She is alert and oriented to person only. You review the transfer summary from the long-term care facility and note she has a history of urinary and fecal incontinence. What is here incontinence level according to braden? (4-not, 3-occasional, 2-usually/urine, 1-urinary and fecal)

1

What major factors increase risk for developing a pressure injury?

1. Immobility 2. poor nutritional state 3. incontinence 4. decreased sensory perception 5. Lowered mental awareness

Knowing that R.L. is frail, has right-sided weakness, and has a pressure injury, what consultations or referrals could you initiate? 1. _ assessment from the _ 2. _ _ assessment 3. _ _ or _ assessment for suggestions on managing pressure injury

1. Nutritional; dietician 2. specialty bed 3. wound nurse; team

Elevated skin temperature and perspiration increase risk for pressure injury. Write 4 specific measures to manage the microclimate. 1. Use _ _ and _ to wick incontinence moisture away from the skin versus trapping moisture against the skin, causing _ 2. Check for incontinence a minimum of every _ _ , and as needed. 3. Cleanse skin gently after each incontinent episode with _ or _-_ _ . Avoid excess _ and _, which can further traumatize skin. 4. Use_ _ _ on skin (e.g., creams, ointments, film-forming skin protectants) as needed to protect skin or to treat non-intact skin. 5. _ _ often for excess perspiration.

1. absorbent underpads; briefs; maceration 2. 2 hours 3. water; ph-balanced cleanser; avoid; friction; scrubbing 4. moisture barrier protectant 5. Change linen

Each health care setting should have a policy that outlines how to assess patients' risk for developing a pressure injury. What should be included in that assessment? 1. _ and _ level 2. _ condition of the _ 3. Presence of coexisting physical conditions, including _, _ instability, _ _ _ , and _ use 4. Nutritional status, including _, _, serum _ levels, and _ 5. _ and _ incontinence and general skin _ 6. _ and _ 7. Decreased perfusion to the _

1. activity; mobility 2. general; skin 3. diabetes; cardiovascular; low blood pressure; oxygen 4. hemoglobin; anemia; albumin; weight 5. fecal; urinary; moisture 6. friction; shear 7. legs

6 Interventions aimed at minimizing friction and shear: 1. Unless contraindicated, keep the head of the bed _ or _ _ degrees. 2. If the head of the bed is elevated,_ the _ time. Use the _ _ to help keep the torso from sliding down in the bed. 3. Use _ devices to lift the body off the bed/chair, such as mechanical lifts. 4. Keep skin well hydrated and _ with hypoallergenic lubricating oils, creams, or lotions that lower the _ _ on the skin and reduce _. 5. Use_ _ , _ dressings, or _ _ on bony prominences (such as elbows) to decrease _ 6. _ or _ _ before placing under the patient. _ patients to place the bedpan rather than pushing and pulling it in and out. 7. Protect skin from _. Excess moisture weakens _ _ and destroys the outer _ layer so that less force is needed to wound the skin.

1. at; below 30 2. limit; elevation; knee gatch 3. transfer 4. moisturized; surface tension; friction 5. transparent film; hydrocolloid; skin sealants; friction 6. Lubricate; powder bedpans; roll 7. moisture; skin integrity; lipid

What are the 3 best dressings?

1. foam 2. alginate 3. foam cavity fillers

Major Factors for developing a pressure injury: 1. _ 2. poor _ _ 3. _ _ a. She has a catheter to help with _ incontinence but we are still concerned about this type of incontinence 4. decreased _ _ 5. Lowered _ _ (_) 6. _ 7. _ skin

1. immobility 2. nutritional state 3. fecal incontinence 4. sensory perception 5. mental awareness; confusion 6. paresthesia 7. frail

During your assessment, you note that R.L. has very dry, thin, almost transparent skin. She has limited mobility from her stroke and is currently bedridden. There are several areas of ecchymosis on her upper extremities. She is alert and oriented to person only. You review the transfer summary from the long-term care facility and note she has a history of urinary and fecal incontinence. What is here mental condition according to braden? (4-alert, 3-apathetic, 2-confused, 1-stupor)

2

During your assessment, you note that R.L. has very dry, thin, almost transparent skin. She has limited mobility from her stroke and is currently bedridden. There are several areas of ecchymosis on her upper extremities. She is alert and oriented to person only. You review the transfer summary from the long-term care facility and note she has a history of urinary and fecal incontinence. What is here mobility level according to braden? (4-full, 3-slightly limited, 2-very limited, 1-immobile)

2

During your assessment, you note that R.L. has very dry, thin, almost transparent skin. She has limited mobility from her stroke and is currently bedridden. There are several areas of ecchymosis on her upper extremities. She is alert and oriented to person only. You review the transfer summary from the long-term care facility and note she has a history of urinary and fecal incontinence. What is here physical condition according to braden? (4-good, 3-fair, 2- poor, 1-very bad)

2

Which instructions will you give to the UAP helping you care for R.L.? Select all that apply. a. Assess R.L.'s skin status every shift b. Develop an every-2-hour turn schedule c. Use the appropriate sheets on the airflow bed d. Keep R.L.'s head of bed below a 30-degree angle e. Assist with hygiene measures when R.L. is incontinent f. Empty and measure output in the urine collection device

c. Use the appropriate sheets on the airflow bed d. Keep R.L.'s head of bed below a 30-degree angle e. Assist with hygiene measures when R.L. is incontinent f. Empty and measure output in the urine collection device

What solution is only for normal uninfected wounds?

chlorhexidine

What problems can be created by packing a wound too full? As wounds heal, they _. If a wound is packed too tightly, it creates a _ _ to the wound bed and causes a _ _ _ or further _

contract; pressure insult; secondary pressure injury; tunneling

How often should patients be reassessed for the risk of developing an injury? In most settings, a comprehensive skin assessment is done _, and on _ or _. In some settings, however, it may be done as often as_ _

daily; transfer; discharge; every shift

The nurse systematically assesses the injury and confirms the presence of a stage 3 wound with moderate yellow drainage. There is no tissue necrosis or debris. What does it mean to "stage" a wound? Staging involves noting the_ _ _ involved in the insult.

different tissue layers

a longer wear time (up to 7 days between dressing changes depending on amount of draining)

foam dressings

What do you feel would be the best choice for dressing R.L.'s wound? Because the wound bed is free of debris and necrotic tissue and there is moderate drainage, _ dressings, _ dressings, and _ _ _would help keep a moist environment, offer thermoregulation, provide absorbency for draining wounds, minimize pain, and improve comfort level. _ has a longer wear time (up to 7 days between dressing changes depending on amount of draining); _ need _ _ dressing changes and a _ dressing.

foam; alginate; foam cavity fillers; foam; alginates; more frequent; secondary

What risk factor does using a draw sheet prevent or minimize?

friction

occurs when the skin slides against a surface

friction

What would you expect a stage 3 pressure injury to look like? A stage 3 injury has __-_ tissue loss. _ fat tissue might be visible, but bone, tendon, and muscle are not exposed. _ can occur but will _obscure the depth of tissue loss. This is usually a _ _ with _ or _present.

full-thickness; Subcutaneous; slough; not; deep crater; undermining; tunneling

Culture the _appearing tissue in the _ of the wound.

healthiest; center

As part of R.L.'s admission assessment, you conduct a skin assessment. What areas of R.L.'s body will you pay particular attention to? The first area to assess is the_ _ to the right hip. You would then assess all other _ _ because they are vulnerable to pressure injuries. Examine in _ and the _ area for _. Examine the skin and take _ below the _ because she has a history of _ _ disease.

known injury; bony prominences; skinfolds; perianal; candidiasis; pulses; knees; peripheral vascular

Compare friction and shear. Both are _ injuries. _ occurs when the skin slides against a surface; shear is a force applied _ to the plane of the _ in the _ direction to the force being applied. Shear is the result of _. For example, the head of the bed is elevated, and the patient slowly slides toward the foot of the bed. The skin of the sacrum meets the resistance of the bed surface while gravity pulls the patient's body toward the foot of the bed. This means the skin and the bones are going in _ directions, thereby pulling and stretching tissue and distorting vessels within the area, causing destruction of both. _ can happen without _, but _ always begins with _

mechanical; friction; parallel; skin; opposite; gravity; opposite; Friction; shear; shear; friction

What would we clean the pressure ulcer with?

normal saline

Why is a specialty mattress used for immobile or compromised patients? Specialty mattresses "_-_" _ points by redistributing pressure over a _ _ . There are several classifications, each with general guidelines for placement based on a patient's _, _, _, and _.

off-load; pressure; larger surface; condition; weight; height; risks

What intervention can you initiate to protect R.L.'s heels? Place a _, _ wedge, or device under the length of her _ _ and calf to suspend, or "_," the heels. The heels need to be elevated only high enough to slip a _ _ _ under easily.

pillow; foam; lower leg; calf; float; piece of paper

Why are patients placed on specialty mattresses still at risk for skin breakdown? Although they reduce _, or _-_ _ _ , there is no such thing as complete pressure relief. A specialty mattress _ _ replace the need to _ the patient at regular intervals and manage _

pressure; off-load pressure points; does not; reposition; moisture

Why do the heels have the greatest incidence of breakdown, even when the patient is on a specialty mattress? It is difficult to_ _ when the body part is _. _ _ _ can exceed_ _ _ quickly, even on a specialty mattress.

redistribute pressure; small; Heel interface pressure; capillary closing pressure

For example, the head of the bed is elevated, and the patient slowly slides toward the foot of the bed.

shear

a force applied parallel to the plane of the skin in the opposite direction to the force being applied

shear

is the result of gravity.

shear

involves noting the different tissue layers involved in the insult.

staging

Tunneling wounds have channels or passageways that extend from a wound into and through the surrounding _ _ or muscle. They often are _ to treat and might persist for _ periods. They often are associated with _, _ injury, _ wounds, or _ _ wounds, including dressed with materials that _ wounds or were packed with _ _ or_ _ packing

subcutaneous tissue; muscle; difficult; long; infections; pressure; nonhealing; improperly dressed; dehydrate; too much; too little

What are the advantages of using a validated risk assessment tool to document her skin condition on admission? These tools give a _ approach for assessment. Many facilities have a policy requiring the use of a scale, such as the _ or _, when a patient is admitted to identify those at risk for developing a pressure injury. The results guide the treatment of _ injuries and the implementation of appropriate interventions to _ _ .

systematic; braden; norton; existing; prevent injuries

have channels or passageways that extend from a wound into and through the surrounding subcutaneous tissue or muscle

tunneling

Describe the technique for packing a tunneled wound. To pack a tunneled wound: Open or _ the material that will be placed in the wound bed. _ the gauze. Pour prescribed solution over gauze to moisten it. _ out excess fluid. Lay moistened material over wound surface with _ until all surfaces are in contact with the moistened material and the wound is _ filled. _ _ allow the material to touch the _ _ . Fill the wound, making sure _ _ _ from sinus tracts, undermining, or tunneling is loosely packed with the material. Leave a _ to assist with removing the gauze. Avoid packing the wound too tightly or having the material extend beyond the top of the wound.

unfold; fluff; Wring; forceps; loosely; do not; surrounding skin; all dead space; tail

What factors influence the choice of a wound dressing? Wound dressings are chosen based on the characteristics of the _ _ . The choice of a dressing depends on the type of wound tissue in the base of the wound, the amount and type of _, the presence of _, the _ of the wound, the _ of the wound, undermining, tunneling, edema, _-effectiveness, and _ of the patient.

wound bed; drainage; infection; location; size; cost; comfort

Can friction happen without shear?

yes

Is friction a mechanical injury?

yes

Is shear a mechanical injury?

yes