SKILLS - Ch. 39 - Pressure Injury Prevention
A patient who is completely immobile scores low on the activity, mobility, and friction/shear Braden subscales. A red, intact, warm area is noted over the sacrum. Which interventions would be appropriate for the care of this patient? (Select all that apply.) 1. Use a moisture-barrier ointment at least three times per day. 2. Consult with the wound clinical nurse specialist about the most appropriate bed surface to redistribute pressure. 3. Develop and implement a turning schedule to commiserate with the patient's condition. 4. Use a dressing to protect the sacrum and promote healing. 5. Use safe patient handling to help reposition frequently 6. Massage the red area at each position change.
2. Consult with the wound clinical nurse specialist about the most appropriate bed surface to redistribute pressure. 3. Develop and implement a turning schedule to commiserate with the patient's condition. 4. Use a dressing to protect the sacrum and promote healing. 5. Use safe patient handling to help reposition frequently Since the patient's pressure injury risk assessment noted impairment in activity, mobility, and friction/shear, the plan of care should address how to provide changes in position and the best support surface. The sacral injury is shallow and requires a healing environment that will protect the area from friction and shear forces. Massaging the skin can cause further tissue injury.
A patient in intensive care has an endotracheal tube (ET) inserted through the mouth for ventilation, an intravenous (IV) line in place, an abdominal incision that is dry and intact, and pillows under both calves. The patient weighs 145.45 kg (320 lbs.) and is difficult to turn. Which locations are at high risk for developing a pressure injury? (Select all that apply) 1. Heels 2. Posterior bony prominences 3. Nose 4. Mouth 5. IV site.
2. Posterior bony prominences 4. Mouth The patient is at high risk for device-related pressure injury at mouth or lips because of the endotracheal tube location. All patients are at risk fro pressure injury over bony prominences, but the risk is greatest posteriorly in this patient because of obesity and difficulty turning. The pillows remove the risk of heel injury, and the IV site is not subject to a pressure injury; however, if the patient lies on the tubing, and injury could result.
What are the correct steps in assessing a pressure injury and changing the pressure injury dressing? (Place in the correct order) 1. Remove the old dressing; assess the amount , color, and character of the drainage if present. 2. Measure the wound diameter (length, width, and depth) 3. Assess the periwound skin. 4. Ask the patient about his or her pain level at previous dressing changes and medicate as indicated. 5. Clean the wound base and the surrounding skin with prescribed solution. 6. Bring wound dressings to bedside. 7. Describe the wound base and stage. 8. Replace the dressing.
4. Ask the patient about his or her pain level at previous dressing changes and medicate as indicated. 6. Bring wound dressings to bedside. 1. Remove the old dressing; assess the amount , color, and character of the drainage if present. 5. Clean the wound base and the surrounding skin with prescribed solution. 2. Measure the wound diameter (length, width, and depth) 7. Describe the wound base and stage. 3. Assess the periwound skin. 8. Replace the dressing. Determine if the patient will need pain medication before the dressing change and medicate if necessary. Have all of the items for the wound dressing change at the bedside to avoid leaving the patient as the dressing change is done. The dressing should be assessed for type, volume, and character (including odor) after removal to determine if the dressing choice is appropriate. The wound should be measured to determine movement toward healing; the type of tissue and condition of the periwound skin will contribute to this assessment.
An elderly patient who spends most of his waking hours in a chair is at risk for skin breakdown on his buttocks. What is the most appropriate action that the nurse should initiate with this patient? A. Set a timer to ring at 15- to 20-minute intervals to remind the patient to change position. B. Teach the patient to change position with every television commercial. C. Assess the outcomes of skin-focused interventions every 2 to 3 days. D. To relieve pressure, place an inflatable ring on his chair.
A. Set a timer to ring at 15- to 20-minute intervals to remind the patient to change position. A timer provides an audible cue to change position. An elderly person may forget, may doze off, or may be distracted by involvement in an activity, causing him to lose track of time. There are many commercials on television, and telling the patient to move with every television commercial could be quite taxing. Outcomes of interventions should be assessed every shift or more frequently, and placement of an inflatable ring may cause pressure ulcers on other areas not already affected.
The nurse is checking for discoloration on a patient who has darkly pigmented skin. The nurse would be administering appropriate care if which technique was used? A. The nurse uses a gloved hand to feel for warmth or change in tissue texture. B. The nurse uses a fluorescent light for the skin assessment. C. The nurse places the patient in a 30-degree lateral position for the assessment. D. The nurse checks for discoloration an hour after the patient is turned.
A. The nurse uses a gloved hand to feel for warmth or change in tissue texture. Because of the darker skin tones, the nurse must feel for warmth in the suspected area or a change in texture because a change in color may not be visible. A fluorescent light is not appropriate. The lateral position is not indicated, and any assessment for discoloration would be done as soon as a patient is changed from one position to another.
An obese patient is at risk for skin breakdown and subsequent pressure ulcers. Which strategies should the nurse who is caring for this patient include in his care? A. Using a liftsheet and maintaining the head of the bed no higher than 30 degrees B. Decreasing dietary protein intake and increasing his fluid intake to 2000 mL per day C. Turning the patient every 4 hours and increasing caloric intake to maintain normal tissue status D. Increasing the patient's vitamin and mineral intake and keeping the patient in high Fowler's position
A. Using a liftsheet and maintaining the head of the bed no higher than 30 degrees Use of a lift sheet will reduce friction on the patient's skin when repositioning him. By keeping the head of the bed no higher than 30 degrees, you prevent the patient from sliding down and exerting a shearing force on his coccyx, which could lead to a pressure ulcer. Dietary protein would be increased, not decreased, and increased fluids would be recommended. The patient should be turned every 2, not 4, hours. However, caloric increase would not be provided for an already obese patient. Vitamins and minerals are important, but the patient would not be placed in high Fowler's position.
A patient has nonreactive hyperemia. What would be expected to be included in the patient's immediate care? A. An ordered increase in the amount of protein consumed B. Use of the Braden Scale C. Immediate transfer to a special pressure mattress D. Padding around the area susceptible to breakdown
B. Use of the Braden Scale The patient's tissue does not return to a pinkish color after compression; this indicates that the patient is at risk for skin breakdown. Use of the Braden Scale to perform a comprehensive evaluation would be recommended. Assessment is the priority. Additional protein would not be ordered at this time. Placing the patient on a special mattress or padding the area is not appropriate at this time. The patient needs to be assessed before appropriate interventions can be determined.
A patient has a pressure ulcer that contains necrotic tissue. Nursing care for this patient would be correct if which measure was taken to remove dead tissue from the wound bed? A. Use of a wick to remove moisture from the decayed tissue B. Use of hydrogen peroxide to loosen the necrotic tissue C. Vigorous sterile scrubbing of the wound bed D. A gentle topical method that removes dead tissue
D. A gentle topical method that removes dead tissue Care needs to be taken to avoid injuring the wound bed, so gentle cleaning is indicated. A wick is not indicated. Peroxide is known to cause tissue damage, and scrubbing could injure the wound's capillary bed.
3. The nurse knows that which of the following factors contribute to the development of pressure ulcers? (Select all that apply.) a. Friction and shear b. Immobility c. Poor nutrition d. Moisture and ammonia e. Uncontrolled pain
a. Friction and shear b. Immobility c. Poor nutrition d. Moisture and ammonia Factors such as incontinence, friction and shear, immobility, loss of sensory perception, reduced level of activity, and poor nutrition contribute to pressure ulcer formation. Moisture and ammonia from incontinence soften the skin, allowing the skin to become susceptible to breakdown. Uncontrolled pain does not contribute to the development of pressure ulcers.
3. The nurse is caring for four patients during a shift. Which of the following patients is at greatest risk for developing a pressure ulcer? a. The patient who is bedridden, but who turns himself randomly b. The patient whose Braden Scale score is 8 c. The patient who can ambulate to the bathroom independently d. The patient whose Braden Scale score is 18
b. The patient whose Braden Scale score is 8 Given the overall score on the Braden Scale, the patient will fall within one of these categories: mild risk, 16 to 18; moderate risk, 13 to 14; or high risk, 9 or less. Use these risk scores to plan care by looking at the individual risk factors that place the patient at risk and developing a care plan to decrease or eliminate the identified risk factors. Immobility often restricts the patient's ability to change and control body position, thus increasing pressure over bony prominences. Patients who can turn themselves are at less risk than those who cannot.
1. The nurse is aware that pressure ulcers can occur: (Select all that apply.) a. from any position that causes soft tissue compression. b. because of lack of blood flow (ischemia). c. only in bed bound patients. d. in as little as 90 minutes.
a. from any position that causes soft tissue compression. b. because of lack of blood flow (ischemia). d. in as little as 90 minutes. Pressure ulcers occur from any position that causes soft tissue compression. Compression of soft tissue interferes with blood flow to the tissue; if this compression continues for a prolonged time, the tissue dies from lack of blood flow, also known as ischemia. This pressure, if not relieved, can cause irreversible tissue damage in as little as 90 minutes. It is quite possible for an individual to develop a pressure ulcer even if not confined to bed.
7. The patient with a nasogastric (NG) tube in place may experience skin breakdown: a. in the nose. b. on the tongue. c. behind the ears. d. around the lips.
a. in the nose. NG and oxygen cannulas can cause pressure on the nares, leading to pressure ulcers. Skin breakdown around the lips and tongue may result from oral airways or endotracheal (ET) tubes. Skin breakdown behind the ears may result from pressure from the oxygen cannula or the patient's pillow.
2. In a patient with a stage II pressure ulcer, the nurse describes the wound as: a. superficial blistering. b. nonblanchable redness. c. loss of skin without bone exposure. d. loss of skin with exposed muscle.
a. superficial blistering. A stage II pressure ulcer is defined by partial-thickness loss presenting as a shallow open ulcer with a red to pink wound bed, without slough. It also may present as an intact or open/ruptured serum-filled blister. It usually presents as a shiny or dry shallow ulcer without sloughing or bruising. The hallmarks of a stage I pressure ulcer are intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, and warmer or cooler as compared with adjacent tissue. Stage III pressure ulcers involve full-thickness skin loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present in some parts of the wound bed.
4. The nurse is planning care for her patient who has a stage II pressure ulcer. Care should include which of the following? (Select all that apply.) a. A heat lamp to dry the wound b. Application of topical antibiotics c. Nutritional assessment d. Maintaining moisture in the wound
b. Application of topical antibiotics c. Nutritional assessment d. Maintaining moisture in the wound The treatment plan for a patient with a pressure ulcer must include elimination or reduction of the factors that have caused the pressure ulcer. A moist wound environment supports the growth of new tissue. If the wound is not free of necrotic tissue, you need to choose topical wound care that will cleanse the wound bed of devitalized tissue. Treat infection both systematically and topically. Wound healing in a patient with a pressure ulcer progresses if the patient has adequate nutritional status as well as control over preexisting conditions such as diabetes and cardiovascular and pulmonary disease.
4. Aggressive prevention measures should be implemented for a patient in the general population with a pressure ulcer risk on the Braden Scale of less than or equal to: a. 16. b. 18. c. 20. d. 24.
a. 16. Less than or equal to 16 is the risk cut score for the general population when the Braden Scale is used. Less than or equal to 18 is the risk cut score for older adults and black or Latino patients when the Braden Scale is used.
2. Patients are at risk for developing pressure ulcers on which areas of the body? (Select all that apply.) a. Coccyx b. Nares c. Ears d. Genitalia
a. Coccyx b. Nares c. Ears d. Genitalia The most common sites of pressure ulcers are the sacrum, coccyx, ischial tuberosities, greater trochanters, elbows, heels, scapulas, iliac crests, and lateral and medial malleoli (Pieper, 2007). Pressure ulcers can occur on any area of skin subjected to pressure. Nonbony locations in which pressure ulcers can occur include the nares, usually related to pressure caused by nasogastric (NG) tubes or oxygen cannulas; the ears, resulting from an oxygen cannula; and the genitalia, with ulcers resulting from Foley catheter tension.
12. After teaching a home caregiver how to manage a pressure ulcer, the nurse realizes that further education is needed when the caregiver says: a. "I will be sure to reposition her frequently and keep her off of the pressure ulcer." b. "I will wash the pressure ulcer with saline and report any changes in the drainage." c. "I know that a thick, black covering will protect the pressure ulcer from getting worse." d. "I will let you know if the pressure ulcer starts to smell rotten."
c. "I know that a thick, black covering will protect the pressure ulcer from getting worse." Black tissue in a pressure ulcer is eschar, a necrotic tissue that covers a section of the ulcer and prevents effective assessment. If the caregiver makes this statement additional education is needed. The other statements indicate that the caregiver understands how to care for pressure ulcers.
8. The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2 hours. While turning the patient, to what should the nurse who is performing the assessment pay particular attention? a. Edema in the sacrum b. Skin texture c. Skin temperature d. Pallor or mottling of the skin
c. Skin temperature Darkly pigmented skin does not always have visible blanching. Its color differs from that of surrounding skin. Skin temperature changes may be an important early indicator of a stage I pressure ulcer. Edema is not an initial indication of a pressure ulcer. Do not massage any reddened or discolored pressure points. Areas of nonblanchable erythema or discolored areas may indicate that deeper tissue damage is present. Massage in this area may worsen the inflammation by further damaging underlying damaged blood vessels. Pallor or mottling will be difficult or impossible to see in a patient with darkly pigmented skin.
6. In a long-term care agency, how often should the nurse reassess a patient for risk of a pressure ulcer? a. Every 1 to 2 days b. Every time the nurse sees the patient c. Weekly for the first few weeks of stay d. Monthly for the first 4 months of stay
c. Weekly for the first few weeks of stay In a long-term care agency, the patient is assessed every week for 4 weeks and then quarterly, or whenever the patient's condition changes. An assessment schedule of every 1 to 2 days would be more appropriate for acute care than in the long-term care setting. The patient is not reassessed for risk in the long-term setting every time the nurse sees the patient. The new patient in long-term care is reassessed weekly rather than monthly after he is admitted.
9. The patient is admitted with an open pressure ulcer with necrotic tissue around the base of the wound. How would the nurse classify this ulcer? a. Stage III pressure ulcer b. Stage IV pressure ulcer c. Wound that cannot be staged d. Stage II pressure ulcer
c. Wound that cannot be staged To correctly stage a pressure ulcer, the nurse must be able to see the base of the wound. Therefore, pressure ulcers that are covered with necrotic tissue cannot be staged until the eschar has been debrided and the base of the wound is visible. Until debridement occurs, the ulcer should be documented as unstageable.
11. When evaluating a patient, the nurse observes an unexpected outcome of treatment when the surrounding skin of an ulcer becomes macerated. The nurse should: a. obtain a wound culture. b. apply pressure-reducing devices. c. use dressings with increased moisture absorption. d. monitor the patient for systemic signs and symptoms.
c. use dressings with increased moisture absorption. Select a dressing that has increased moisture-absorbing capacity. Dressings that increase moisture absorption will result in dryer skin that is less macerated. A wound culture is not indicated for macerated skin unless an increase in drainage or development of necrotic tissue occurs. Pressure-reducing devices are not indicated for macerated skin. Macerated skin is a local reaction; the patient would not need systemic monitoring unless the pressure ulcer extended beyond the original margins.
5. A patient with anemia is at risk for developing pressure ulcers as a result of which of the following? a. Increased sedation b. Edematous tissues c. Reduced tensile strength d. Diminished oxygen to the tissues
d. Diminished oxygen to the tissues Decreased hemoglobin reduces the oxygen-carrying capacity of the blood and the amount of oxygen available to the tissues, thus increasing the risk for pressure ulcers. Anemia does not cause increased sedation, edematous tissue, or reduced tensile strength.
10. A nurse classifies a pressure ulcer according to the type of tissue in the wound bed. What does it indicate if the wound bed has granulation in it? a. Wound needs debridement b. The presence of significant infection c. Colonization by bacteria d. Movement toward healing
d. Movement toward healing The presence of granulation tissue signifies a movement toward wound healing. Black tissue is necrotic tissue. A wound with a high percentage of black tissue will require debridement. Yellow tissue or slough tissue indicates the presence of infection or colonization.
END OF CHAPTER QUESTIONS
END OF CHAPTER QUESTIONS
EVOLVE ONLINE QUESTIONS
EVOLVE ONLINE QUESTIONS
1. The nurse is turning a patient when she notices an area with nonblanchable redness over the patient's coccyx. The patient complains of pain at the site, and the site feels cooler than the areas immediately around the site. The nurse recognizes that this patient has developed: a. a stage I pressure ulcer. b. a stage II pressure ulcer. c. an unstageable pressure ulcer. d. deep tissue injury.
a. a stage I pressure ulcer. The hallmarks of a stage I pressure ulcer are intact skin with nonblanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, and warmer or cooler as compared with adjacent tissue. Stage II pressure ulcers are defined by partial-thickness loss that presents as a shallow open ulcer with a red or pink wound bed, without slough. They also may present as intact or open/ruptured serum-filled blisters. They usually present as shiny or dry shallow ulcers without sloughing or bruising. Unstageable pressure ulcers are characterized by full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore the stage, cannot be determined. Deep tissue injury usually is characterized by purple or maroon localized areas of discolored intact skin or blood-filled blisters caused by damage to underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, and warmer or cooler as compared with adjacent tissue. The wound may further evolve and become covered by thin eschar.
