DSM: Pressure Ulcers

A patient who is prescribed larval therapy for a chronic pressure injury asks why this treatment is being used. Which response should the nurse make to this patient?

"Your ulcer has bacterial growth, and the maggots will decrease the amount of bacteria" Maggots secrete and excrete potent antimicrobial compounds which reduce bacterial growth on pressure ulcers, and secrete enzymes that break down necrotic tissue, while keeping healthy tissue intact. The maggots used in larval therapy do not help an ulcer to drain and are not the fastest method of treating a pressure injury. Larval enzymes to not affect pain level.

The nurse reviews with a new graduate nurse the care of a patient on an active low-air-loss bed. Which statement by the graduate nurse indicates correct understanding of this patient's care?

"Despite the use of the special mattress, the patient needs to be repositioned every 2 hours."

A patient at risk for a pressure injury responds to verbal commands, has no sensory deficits, has moist skin, ambulates occasionally, makes slight position changes, and eats approximately 50% of each meal. Which Braden scale score should the nurse identify for this patient?

16. The patient's Braden score would be: sensory perception: no impairment (4); moisture: moist (2); activity: walks occasionally (3); mobility: slightly limited (3); nutrition: probably inadequate (2); friction and shear: potential problem (2). The total score would be 16.

The nurse is reviewing medical records for assigned patients. Which patient should the nurse identify as being at the greatest risk for developing a pressure injury?

A patient who is unable to transfer into and out of a wheelchair without assistance

A patient on bedrest is experiencing frequent episodes of watery diarrhea. Which action should the nurse take to prevent skin breakdown?

Apply a dimethicone-based cream to prevent moisture from collecting on the skin. A dimethicone-based cream or alcohol-free barrier film should be applied to prevent moisture from collecting on the skin. Petroleum-based lotions or ointments should be avoided.

The nurse is reviewing a list of patients who are all at risk for a pressure injury. Which patient should the nurse identify that would benefit the most from a kinetic bed?

Bedridden patient with limited mobility

A patient with a stage 3 pressure injury reports pain at the site which has developed a yellow-white exudate on the wound bed. Which laboratory test should the nurse anticipate being prescribed?

Complete blood count. An elevated white blood cell (WBC) count indicates a possible infection, and when infection is suspected, WBC count (included in a CBC) can be used to indicate the degree of inflammation or invasive infection. Diagnostic tests for pressure injuries include: WBC count to indicate degree of inflammation or invasive infection; *Assess nutritional status: Albumin; Prealbumin; Transferrin; Serum protein **As indicated by specific patient situation:Urinalysis; Stool sample; Blood cultures; Biopsy or culture of wound tissue.

The nurse is teaching a patient and the family about nutritional interventions to decrease the risk of developing pressure injuries. Which dietary instruction should the nurse include in the teaching?

Ensure adequate intake of carbohydrates, fluids, and vitamin C. Inadequate intake of protein, carbohydrates, fluids, zinc, and vitamin C are associated with increased risk of pressure injuries. Carbohydrates may not need to be decreased, but they should be maintained at an adequate level. It is fine to include nutritious snacks in the patient's meal plan. Adequate amounts of protein are necessary. **Dietary interventions to reduce the risk of pressure injuries include: maintaining adequate intake of protein, carbohydrates, fluids, iron, zinc, and vitamin C assessing factors related to poor dietary intake offering nutritional supplements providing support as necessary during mealtimes consulting with dietitian as needed.

Which data is the least important for the nurse to document after re-evaluating an existing pressure injury?

Level of mobility. The mobility level of a patient is important to note but is the least relevant for evaluation of an existing pressure injury. When assessing an existing pressure injury, the nurse should note the location in relation to bony prominences, color of the wound bed, and signs of infection. Pressure injury assessment includes: inspecting pressure areas for discoloration, abrasion, & excoriation; palpating the surface temperature of the skin over the pressure area; palpating the skin over bony prominences.

The nurse preceptor is observing a new graduate nurse who is caring for a patient with limited mobility and fecal incontinence. For which action by the graduate nurse should the preceptor intervene?

Petroleum-based ointment applied to the skin

The nurse notes that a patient has shearing tissue damage on the skin over their back. Which reason should the nurse consider as the cause of the injury?

Shearing forces as a result of the patient sliding down in the bed and being pulled back up. Shearing forces, a result of a pt sliding down and being pulled back up in bed, cause stretching and bending of blood vessels that result in injury and thrombosis. External pressure applied over bony prominences for more than 2 hours will result in tissue ischemia and hypoxia.

Interventions to prevent compromised human dignity and risk for and situational low self-esteem include:

assessing for indicators of abuse or neglect developing caring, trusting relationship providing essential teaching to reduce risk of pressure injury development and promote patient self-esteem assisting patients and family members to obtain supportive devices for appropriate positioning.

Risk factors for developing a pressure injury include:

immobility; inadequate nutrition; fecal and urinary incontinence; decreased mental status; diminished sensation; excessive body heat; advanced age chronic medical conditions; poor lifting and transferring techniques; incorrect positioning; hard support surfaces incorrect application of pressure-relieving devices.

Documentation of a pressure injury includes:

location of injury as related to a bony prominence size of ulcer in cm; pressure of undermining or sinus tracts (assessed as a face on a clock where the patient's head is 12 o'clock); stage of injury; color of wound bed and location of necrosis or eschar; condition of wound margins; integrity of surrounding skin; presence of clinical signs of infection; patient complaints or pain or discomfort at the wound site; presence of systematic signs of infection.

Older adults may be at an increased risk for the development of pressure injuries due to one or more of the following:

weakness and/or immobility'; diminished appetite leading to inadequate nutrition; decreased mental status due to dementia; fecal and/or urinary incontinence; diminished sensation, especially diminished pain perception, and diminished sensation of pressure and light touch; changes in the structure of the skin and its support; loss of lean body massgeneralized thinning of the epidermisdecreased strength and elasticity of the skindiminished venous and arterial flow due to aging vascular walls; increased dryness due to decreased oil production by sebaceous glands; chronic medical conditions

The nurse plans care to reduce a patient's risk for pressure injuries. Which factor should the nurse recall that contributes to the increase in the cell's need for oxygen?

Excessive body heat. Excessive body heat increases the metabolic rate and the cell's need for oxygen. Immobility, diminished sensation, and inadequate nutrition contribute to the formation of pressure injuries, but they do not increase the cells' need for oxygen.

The nurse is caring for a patient with a stage 1 pressure injury to the sacrum. Which product should the nurse suggest to help increase the blood supply to the skin of this pressure injury?

Granulex. ranulex is a product that increases blood supply to the intact skin of a stage 1 pressure injury. Granulex toughens intact skin, adds moisture, and contains trypsin to aid in removal of necrotic tissue

A patient with pressure injuries has dementia, limited mobility, and lives with an adult daughter. Which should the nurse suggest to the patient's daughter to help reduce the patient's risk for pressure injuries?

Place a memory foam pad on the chair. A memory foam pad can be placed on the chair to reduce pressure on the patient's buttocks. Other devices to reduce pressure on body parts include gel flotation pads and pillows and wedges made of foam, gel, air, or fluid.

A patient being treated for a stage 1 pressure injury asks why Granulex is being used. Which statement should the nurse say in response?

"Granulex will increase blood supply to the skin." Granulex is a product that increases blood supply to the intact skin of a stage 1 pressure injury. Granulex toughens intact skin, adds moisture, and contains trypsin to aid in removal of necrotic tissue. Vacuum-assisted closure creates a negative pressure to help reduce edema.

The nurse reviews with new nursing staff the importance of supporting human dignity for home care patients who are bedridden. Which statement indicates the review was successful?

"We should teach the family how to conduct skin hygiene for the patient."

The nurse reviews with new nursing staff the importance of supporting human dignity for home care patients who are bedridden. Which statement indicates the review was successful

"We should teach the family how to conduct skin hygiene for the patient." Pt's family should be instructed on how to conduct skin hygiene for pt so that pt's human dignity is not compromised. Encouraging the family to speak to the patient more often or to bring the patient to the hcp more often will not improve the patient's skin hygiene. The patient is bedridden and depends on family for care, so teaching the patient to be self-reliant in skin hygiene is not the most effective or practical way to address the problem.

The nurse caring for an older patient who is becoming increasing immobile teaches the family caregiver how about preventing pressure injuries. Which statement from the family members should indicate to the nurse that teaching was effective?

"We will monitor the diet to ensure adequate daily intake of proteins and calories" Inadequate intake of calories, protein, vitamins, and iron are risk factors for the development of pressure injuries. The patient should move when feeling uncomfortable or at least every 2 hours. Alcohol-based cleansers are drying to the skin. The skin should be kept clean, dry, and moisturized. Bony prominences should not be massaged.

The nurse caring for an older patient who is becoming increasing immobile teaches the family caregiver how about preventing pressure injuries. Which statement from the family members should indicate to the nurse that teaching was effective

"We will monitor the diet to ensure adequate daily intake of proteins and calories." Although the role nutrition plays in development & healing of pressure injuries is not well understood, poor dietary intake of kilocalories, protein, & iron have been associated c development of pressure injuries. nurse should assess factors related to dietary intake, offer nutritional supps & provide support as necessary during mealtimes to ensure adequate dietary intake. If barriers to adequate nutrition are found on assessment, nurse should find solutions c pt to reduce or eliminate these barriers. If, after interventions and support, pt's dietary intake remains inadequate, nurse should consult c a dietitian for strategies to improve nutritional status.

Stages

*Stage 1: nonblanchable erythema of intact skin, heralding lesion of skin ulceration. usually occur in localized area over bony prominence. Identification may be difficult in pts c dark skin. Affected areas may be painful and have a different temp and consistency than surrounding skin. *Stage 2: partial-thickness skin loss involving dermis. present as shallow, open ulcers c a viable pink or red moist wound bed. Granulation tissue, slough, & eschar are not present. These injuries may also present as intact or open serum-filled blisters. *Stage 3: full-thickness skin loss involving damage or necrosis of subcut tissue; adipose tissue is visible within ulcer. Granulation & rolled wound edges are often present. Bone, tendon, & muscle are not exposed. ulcer presents clinically as a deep crater with or without undermining and tunneling of adjacent tissue. Slough and/or eschar may be present. *Stage 4: full-thickness skin loss c extensive tissue damage & necrosis. Fascia, muscle, ligament, cartilage, tendon, and/or bone are exposed & directly palpable; slough or eschar may be present. Undermining & tunneling, and rolled wound edges are usually present. *Unstageable: full-thickness tissue loss with depth completely obscured by slough or eschar in wound bed. Depth of wound cannot be determined until slough or eschar is removed; once it is removed, the injury will be classified as stage 3 or 4.

The nurse is caring for multiple patients with mobility issues. Which patient should the nurse identify that is most at risk for a pressure injury?

A 96-year-old female who is dependent on staff to move into and out of a wheelchair. An older adult patient who is dependent upon staff to get into and out of a wheelchair has extreme weakness and immobility issues that increase the risk for developing pressure injuries. The patient may also be at risk for fecal and urinary incontinence related to immobility, which adds to the risk for this type of injury.

A patient has a pressure injury with deep exudate. Which dressing should the nurse use because it forms a gel when in contact with wound exudate?

Alginate. Alginate dressings form a gel when in contact with wound exudate from pressure injuries. Nonpharm interventions for pressure injuries include: repositioning at least every 2 hours cleaning wound with every dressing change cleaning and dressing the wound using surgical asepsis testing exudate for sensitivity to antibiotic agents teaching the patient how to move to alleviate pressure providing ROM exercises and mobility out of bed.

The nurse identifies that a patient with decreased mental status is at risk for a pressure injury. Which action should the nurse take to maintain skin hygiene and prevent a pressure injury?

Applying lotion to moist skin after bathing. Moisturizing lotions applied directly to moist skin after bathing help maintain skin hygiene and prevent pressure injuries. kin assessment is done on admission and then daily. Interventions to prevent infection of pressure injuries include: keeping skin clean, dry, & moisturized maintaining appropriate nutrition & hydration recognizing early stages of pressure injuries reporting to the HCP at earliest appearance of a change in tissue integrity & maintaining & improving patient activity levels.

A patient has an area of eschar within a healing wound. Which type of debridement should the nurse expect to be ordered because it does not damage healthy and healing tissue within a pressure injury?

Autolytic. Autolytic debridement is most selective type of debridement & causes least damage to healthy & healing tissue surrounding a pressure injury. Sharp, mechanical & chemical debridement take less time than autolytic debridement but cause more damage & are not as selective. Necrotic tissue that remains despite phagocytic action retards healing and prolongs inflammation. To prevent this from happening, the necrotic tissue must be removed by one of three methods: *Surgical debridement (cutting away of necrotic tissue) *Mechanical debridement (removal of dead tissue via applying & removing dressings, hydrotherapy, irrigation, scissors/tweezers (sharp debridement), gauze dressings = simplest method but cause pain & damage granulation tissue *Enzymatic debridement (topical agent to dissolve & remove necrotic tissue & lift eschar)

A patient who is confined to bed is at risk for developing a pressure injury. Which support surface should the nurse request for this patient?

Kinetic bed. For pts who are confined to bed, the support surface should be a kinetic bed that provides oscillation therapy. Gel flotation pads, a memory foam mattress, and an alternating pressure mattress help to reduce pressure on specific body parts but are not the recommended support surface

The nurse is providing teaching to the family caregiver of an older patient who has become increasingly immobile at home. Which instruction should the nurse provide to reduce the patient's risk of developing a pressure injury?

Monitor the diet to ensure adequate intake of proteins and calories

A patient has a pressure injury over the sacrum. Which assessment finding should indicate to the nurse indicates that this injury is in stage 3?

Necrosis of subcutaneous tissue

The nurse is caring for an older adult patient with poor dietary intake and decreased mobility. Which action is least effective in diminishing the risk of pressure injuries?

Offer the patient water before each meal. Pts c decreased kilocalorie, protein, & iron intake are at a higher risk for developing pressure injuries. Offering water prior to meals will not increase intake of kilocalories, protein, or iron. Offering supps high in calories, protein, & iron & sitting c pt to encourage eating during mealtimes are effective interventions. Assessing pt's ability to swallow may reveal the cause of decreased nutritional intake. *Interventions to prevent nutritional imbalance include: assessing factors related to dietary intake; offering nutritional suppls; providing support as necessary during mealtimes; working with patient to eliminate barriers to dietary intake; consulting with a dietitian as necessary.

The nurse is caring for a patient with limited mobility. Which action should the nurse take to prevent a skin injury caused by friction?

Placing the patient in the prone position. To prevent a skin injury caused by friction, the patient should be turned every 2 hours using six different body positions, including prone position. Elevating the head of the bed to a 60-degree angle, not using a draw sheet, and using baby powder may cause injury to the skin as a result of friction. Interventions to minimize skin injury from friction & shearing forces include: proper positioning, transferring, & turning techniques ensuring skin is never dragged across bed linens use of assistive device to reduce or eliminate friction between skin & bed linens.

A patient develops paraplegia (paralysis low lower legs/body) after a motor vehicle crash. Which information should the nurse include when teaching the patient to prevent pressure injuries?

Slight weight shifts of only 10 to 15 degrees every 15-30 minutes can help promote circulation. Even if a special mattress is used, patients should be repositioned at least every 2 hours.

Manifestations of pressure injuries include

Stage 1:Pressure injuries with nonblanchable erythemaIntact skin with localized redness; does not blanch when pressed Stage 2:Pressure injuries with partial-thickness loss of dermis; shallow open wound or blister; no slough Stage 3:Pressure injuries with full-thickness tissue loss; deep, open wound bed; necrosis of subcutaneous tissue; possible exposure of underlying bone, muscle, and support structure; slough or eschar present Stage 4:Suspected deep tissue injuryIntact skin with localized purple discoloration; possible quick development of a thin blister or eschar

A patient with type 1 diabetes mellitus has a blister on the left heel caused by ill-fitting shoes. Which stage should the nurse document this injury to be?

Stage 2. A stage 2 pressure injury is considered to be superficial & appears as a blister or shallow open wound. Stage 1 injuries have intact skin that doesn't blanch when pressed. Stage 3 pressure injuries are deep, open wounds with necrosis of subcutaneous tissue. Stage 4 pressure injuries have full-thickness skin loss with extensive tissue damage and necrosis.

A patient with a pressure injury on the sacrum has obvious necrosis of subcutaneous tissue. For which pressure stage should the nurse plan care for this patient?

Stage 3. In a stage 3 pressure injury, necrosis extends down to but not through the underlying fascia. Exposed muscle and bone occurs with a stage 4 pressure injury. An area of nonblanchable erythema of intact skin is associated with a stage 1 pressure injury. Skin loss to the dermis indicates a stage 2 pressure injury.

The nurse is reviewing options for preventing pressure injuries with a patient at high risk for skin breakdown. Which support surface should the nurse instruct the patient to avoid?

Supportive backboard. A supportive backboard is a firm surface that increases pressure on bony prominences. A foam mattress, high-air-loss bed, and kinetic bed are three types of support surfaces that can be used to relieve pressure. **Support surfaces to relieve pressure with a lower risk of skin breakdown includes: foam or gel mattress overlay specialty beds: high-air-loss beds & low-air-loss beds kinetic beds: continuous passive motion & oscillation therapy.