Pressure Ulcers

Which documented description is best for this wound?

"Oval-shaped wound bed that is pink and moist, approximately 6 cm x 4 cm with undermining noted at the 12 o'clock to 1 o'clock position."

A client asks what effect nutrition has on skin integrity. Which response provided by the nurse is most accurate?​

"Poor dietary intake of​ kilocalories, protein, and iron can increase the risk of pressure​ injuries."

​Jan (pronouns: she, her) was admitted to the hospital from a residential care facility. Her history includes a stroke with residual musculoskeletal and neurological deficits on her right side. Which nursing action would be most helpful in preventing Jan from developing a pressure ulcer?​

Assist Jan to reposition every 2 hours.

The nurse is preparing to change Jan's wound dressing. Which items should the nurse collect for use? Select all that apply.​

All except warm lactated ringer solution

How will the nurse best assess the client for a suspected deep tissue injury if they have darker skin tones?

Assess the area for changes in temperature or consistency.

​Which description is discussing a Stage II pressure ulcer?

Partial thickness loss of dermis, shallow open ulcer with a red-pink wound bed without slough.

Jan is at the highest risk of developing _______ and _____

pneumonia sepsis

1. Stage 1 2. Stage 2 3. Stage 3 4 Stage 4

1. Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. 2. Partial-thickness loss of dermis, shallow open ulcer with a red-pink wound bed without slough. 3. Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. 4. Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present. Exposed bone or muscle is visible or directly palpable.

Based on this information, complete the form to calculate Jan's Braden Scale score.

3 2 2 2 1 1

Which are common risk factors associated with pressure ulcer development? Select all that apply.

Incontinence Obesity Increased temperature​

For each potential nursing action, click to specify if the intervention is indicated, nonessential, or contraindicated when caring for Jan.​

Indicated 1. Applying a moisture barrier to the perianal area​ 2. Turning the client at least every 2 hours​​ 3. Encouraging oral fluid intake​ Nonessential​ 1. Changing bed linens six times per day​ Contraindicated​ 1.Massaging the reddened skin​ 2. Restricting caloric intake to 800 Kcal per day​

Which factors play a role in delaying wound healing? Select all that apply.

Obesity Smoking Diabetes mellitus

Which statements made by Jan's daughter indicate an understanding of the steps to take to reduce the risk of future pressure ulcers? Select all that apply​.

Request a pressure relieving mattress. Reposition Jan while in bed frequently and get her up to the chair. Assist Jan to the bathroom every 2 hours instead of utilizing adult briefs.

What are common locations for pressure ulcers or sores? Select all that apply.

Select All

Which outcomes are appropriate for a bedfast client with a duodenal feeding tube admitted with a pressure ulcer? Select all that apply.​

The intact skin will remain intact until discharge. The signs of healing will increase in the current wound.

Select all the findings that require follow-up by the nurse.

thick, yellow-tan, foul-smelling drainage