Pressure Ulcers Sherpath

The charge nurse is leading a unit discussion on pressure ulcers. Which statements should the nurse include? "They result from a break in the skin" "The risk is influenced by nutrition and activity" "People with an inability to communicate are at high risk" "They can be prevented by relieving pressure on the effected area" "They only occur over bones surfaces, where the skin tends to rub against bone"

"The risk is influenced by nutrition and activity." - A person's activity level and nutrition status places a person at risk for pressure ulcer formation. "People with an inability to communicate are at high risk." - A person who cannot communicate their needs to change position increases their risk for pressure ulcer formation. "They can be prevented by relieving pressure on the affected areas." - Relieving pressure by moving or repositioning can prevent the formation of pressure ulcers.

The nurse is caring for a patient with a pressure ulcer determined to be unstageable. What characteristics would the nurse expect? Skin is intact Ulcer is superficial Muscle is exposed Eschar is covering wound bed

Eschar is covering wound bed - When eschar covers the wound bed, the nurse cannot determine the true depth of the wound. This wound would be considered unstageable.

Which information about pressure ulcer formation should be provided by the nurse to a patient with decreased mobility? "Ambulate to the restroom frequently." "Have someone bring your meals to your recliner." "Place pillows between your legs when sleeping." "Shift your weight every 60 minutes while sitting down." "Sleep in the same position throughout the night for comfort."

"Ambulate to the restroom frequently." - Instructing the patient to ambulate to the restroom frequently decreases two risk factors. It encourages mobility and it decreases the likelihood of incontinence episodes by establishing a toileting schedule. "Place pillows between your legs when sleeping." - Placing pillows between the legs when sleeping offloads pressure and decreases the risk of pressure ulcer formation. "Shift your weight every 60 minutes while sitting down." - When a person is sitting down, weight should be shifted every hour to relieve pressure.

The wound care nurse assesses a group of patients on the unit. Which patient is at risk of developing a pressure ulcer? A patient with a spinal cord injury A patient experiencing infectious diarrhea A patient with peripheral vascular disease A patient that ambulates with the assistance of one person

A patient with a spinal cord injury - A spinal cord injury results in the inability to sense pain along with immobility. These patients are at very high risk for pressure ulcers.

The nurse is evaluating a patient's risk for developing a pressure ulcer. Which patient characteristics does the nurse consider? Age Activity Food Choices Family History General Health

Age - Older adults are at a higher risk for developing a pressure ulcer due to age-related skin and cognitive changes. Activity - A patient who is less active and has decreased mobility is at an increased risk for pressure ulcer formation. General Health - A patient's overall general health should be assessed to determine the presence of risk factors for developing a pressure ulcer. These include mobility, continence, and comorbidities.

The nurse assesses a patient with diabetes mellitus who has a pressure ulcer on the heel. Which intervention should the nurse question while the patient is on bedrest? Administering pain medication as needed Maintaining head of bed at 30 to 45 degrees Leaving the blankets loose at the bottom of the bed Application of bilateral knee-high compression socks

Application of bilateral knee-high compression socks - Placing knee-high compression socks on a patient with diabetes mellitus who has a pressure ulcer may further impede the patient's circulation by applying compression from the knee down. This intervention would not help heal the pressure ulcer and should be question.

The nurse is caring for patient with paraplegia. Which nursing action is important for preventing pressure ulcer formation in this patient? Inspect the patient's skin weekly Evaluate the patient's pain rating Ensure the bed is elevated to 90 degrees Ask patient to participate in repositioning whenever possible

Ask patient to participate in repositioning whenever possible - If the patient can participate in repositioning, the likelihood of friction and shearing of skin decreases. When the patient needs to be pulled up in bed by others, this can cause friction and shearing.

The patient on anticoagulant therapy has a pressure ulcer on the right foot that has a foul odor to the drainage. The patient has good peripheral pulses. The nurse anticipates the health care provider will prescribe which interventions? Obtain a wound drainage specimen for culture and sensitivity Cushion foot to prevent contact between the ulcer and the bed Consult wound care specialist to use a negative-pressure device Have a dietitian evaluate nutrition needs and create a new diet plan

Obtain a wound drainage specimen for culture and sensitivity - The nurse should anticipate the health care provider to obtain a specimen of the drainage for culture and sensitivity to assess for infection and determine the appropriate antibiotic to use. Cushion foot to prevent contact between the ulcer and the bed - Placing a cushion between the foot ulcer and the bed will alleviate pressure placed on the ulcer and provide a good blood supply to the wound. This will promote healing. Have a dietitian evaluate nutrition needs and create a new diet plan - It is important for a dietitian to assess the patient's nutritional needs and to possibly change the patient's diet to a high-protein/high-calorie diet to help promote wound healing.

The nurse is caring for an immobile older adult who is at high risk for pressure ulcer formation. Which measure is important to prevent pressure ulcer formation in this patient? Obtain a swab culture Use of The Braden Scale Reposition patient every 4 hours Provide foam material for the patient's heels

Provide foam material for the patient's heels - The nurse should ensure the patient's heels are properly supported to prevent pressure ulcer formation. Foam material placed under the ankles can help lift the patient's heels off the bed and relieve pressure. Pressure on the bony prominences of the heels can lead to pressure ulcer formation.

A nurse is reviewing the electronic medical record of a patient with a stage 2 pressure ulcer to the iliac crest and notices the following entry: "Wound bed is pink with noticeable slough. It measures 2 cm * 2 cm. Packed with normal saline wet-to-damp dressing and covered with dry sterile dressing." Which data is missing from the documentation entry? Measurements Type of drainage Condition of tissue Intervention provided

Type of drainage - The nurse did not document any wound drainage. The wound drainage is an essential aspect of wound documentation.