ch 11 Wounds, Pressure Ulcers (Fund ch 48)

eschar

-black, brown, tan, or necrotic tissue -must be removed so wound can heal

stage IV pressure ulcer

-full thickness tissue loss -muscle or bone visible -often includes undermining and tunneling -slough or eschar may be present

stage III pressure ulcer

-full-thickness skin loss -subcutaneous fat may be visible (not bone or muscle) -may include undermining and tunneling -slough may be present but doesn't obscure depth of tissue loss

pressure ulcer risk factors

-immobility, impaired mobility -impaired sensory perception -decreased level of consciousness -malnutrition -obesity -incontinence, moisture -advanced age -infection -diabetes mellitus -elevated body temperature -anemia -impaired circulation

stage I pressure ulcer

-nonblanachable redness of intact skin -discoloration, warmth, edema, or pain may also be present

stage II pressure ulcer

-partial-thickness skin loss, abrasion -shallow, open ulcer with red-pink wound bed without slough -intact blister with serosanguinous fluid

primary intention

-primary union of the edges of a wound, progressing to complete scar formation without granulation -healing occurs quickly with minimal scar formation

granulation

-red, moist tissue composed of blood vessels -indicates progression toward healing

pressure ulcer prevention - friction and shear

-reposition pt using drawsheet or transfer board -provide trapeze to facilitate movement in bed -limit head elevation to 30 degrees

slough

-stringy substance attached to wound bed -soft yellow or white tissue -must be removed so wound can heal

purulent drainage

-thick -yellow, tan, brown -result of infection

sanguineous drainage

-thick, red, contains serum and blood cells -bright red indicates fresh bleeding

vitamins/nutrients that promote wound healing

-vitamin A -vitamin C -zinc -protein

secondary intention

-wound closure in which the edges are separated, granulation tissue develops to fill the gap -wound is left open until it becomes filled with scar tissue -it takes longer for a wound to heal by secondary intention -loss of tissue function is often permanent

Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes. 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel 6. Applying a moisture barrier ointment

1. Frequent position changes 4. Using an incontinence cleaner 6. Applying a moisture barrier ointment Fundamentals

A nurse is caring for an older client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to maintain the integrity of the client's skin? Select all that apply: 1. Keep the head of the bed elevated at 30 degrees 2. Massage the client's bony prominences frequently 3. Apply cornstarch liberally to the skin after bathing 4. Have the client sit on a gel cushion when in a chair 5. Reposition the client at least every 3 hr when in bed

1. Keep the head of the bed elevated at 30 degrees 4. Have the client sit on a gel cushion when in a chair (do not massage, reposition at least every 2 hr) ATI Fundamentals

Which of the following types of wounds heal by secondary intention? Select all that apply: 1. Stage III pressure ulcer 2. Sutured surgical incision 3. Casted bone fracture 4. Laceration sealed with adhesive 5. Open burn area

1. Stage III pressure ulcer 5. Open burn area ATI Fundamentals

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device, e.g. transfer board 2. Have head of bed elevated when transferring patient 3. Have head of bed flat when re positioning patients 4. Raise head of bed 60 degrees when patient positioned supine 5. Raise head of bed 30 degrees when patient positioned supine

1. Use a transfer device, e.g. transfer board 3. Have head of bed flat when re positioning patients 5. Raise head of bed 30 degrees when patient positioned supine Fundamentals

Braden Scale - 6 categories

1. sensory perception 2. moisture 3. activity 4. mobility 5. nutrition 6. friction and shear

3 major areas of nursing interventions to prevent pressure ulcers

1. skin care and management of incontinence 2. mechanical loading and support devices, which include proper positioning and therapeutic surfaces 3. education (Fundamentals)

What is the correct sequence of steps when performing a wound irrigation? 1. Use slow continuous pressure to irrigate wound. 2. Attach angio catheter to syringe 3. Fill syringe with irrigation fluid 4. Place water proof bag near bed 5. Position angio catheter over wound

4, 3, 2, 5, 1 1. Place water proof bag near bed 2. Fill syringe with irrigation fluid 3. Attach angio catheter to syringe 4. Position angio catheter over wound 5. Use slow continuous pressure to irrigate wound Fundamentals

A nurse is assigned to care for the following patients. Which of the patients is most at risk for developing skin problems and thus requiring thorough bathing and skin care? 1. A 44-year-old female who has had removal of a breast lesion and is having her menstrual period. 2. A 56-year-old male patient who is homeless and admitted to the emergency department with malnutrition and dehydration and who has an intravenous line. 3. A 60-year-old female who experienced a stroke with right-sided paralysis and has an orthopedic brace applied to the left leg. 4. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool.

4. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool. (the 70-year-old patient has reduced circulation, which increases risk for infection, is likely unaware of skin problems because of dementia, and presence of stool will irritate the skin) Fundamentals ch 40

The nurse evaluates which laboratory values to assess a patient's potential for wound healing? 1. Fluid status 2. Potassium 3. Lipids 4. Nitrogen balance

4. Nitrogen balance Fundamentals ch 45

The evening nurse reviews a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? 1. Intact skin 2. Full-thickness skin loss 3. Exposed bone, tendon, or muscle 4. Partial-thickness skin loss of the dermis

4. Partial-thickness skin loss of the dermis NCLEX ch 46

hydrocolloid dressing

a dressing that forms a gel that interacts with the wound surface

Which patient is most at risk for the development of a pressure ulcer? a. An older patient who is septic, bedridden, and incontinent b. An obese woman with leukemia who is receiving chemotherapy c. A middle-aged thin man in a halo cast after a motor vehicle accident d. An adult with type 1 diabetes mellitus admitted in diabetic ketoacidosis

a. An older patient who is septic, bedridden, and incontinent MS

What is the removal of devitalized tissue from a wound called? a. Debridement b. Pressure reduction c. Negative pressure wound therapy d. Sanitization

a. Debridement Fundamentals

After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should be included in the plan of care? a. Reposition every 2 hours. b. Measure the size of the reddened area. c. Massage the area to increase blood flow. d. Evaluate the area later to see if it is better.

a. Reposition every 2 hours. MS

What type of dressing will the nurse most likely use for the pt from the previous question? a. hydrocolloid b. transparent film c. absorptive dressing d. negative pressure wound therapy

a. hydrocolloid (a clean wound would be treated with hydrocolloid or hydrogel dressing because they provide a moist environment to encourage granulation) workbook

Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. a. stage I b. stage II c. stage III d. stage IV

a. stage I Fundamentals

how often to reposition pt in chair (pressure ulcer prevention)

at least every 1 hr

how often to reposition pt in bed (pressure ulcer prevention)

at least every 2 hrs

For a patient who has a muscle sprain, localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? a. Binder b. Ice bag c. Elastic bandage d. Absorptive dressing

b. Ice bag Fundamentals

Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage III pressure ulcer? a. Keep the pressure ulcer clean and dry. b. Maintain protein intake of at least 1.25 g/kg/day. c. Use a 10-mL syringe to irrigate the pressure ulcer. d. Irrigate the pressure ulcer with hydrogen peroxide.

b. Maintain protein intake of at least 1.25 g/kg/day. MS

A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? a. Serous b. Purulent c. Fibrinous d. Catarrhal

b. Purulent MS

What does the Braden Scale evaluate? a. Skin integrity at bony prominences, including any wounds b. Risk factors that place the patient at risk for skin breakdown c. The amount of repositioning that the patient can tolerate d. The factors that place the patient at risk for poor healing

b. Risk factors that place the patient at risk for skin breakdown Fundamentals

What is the most important nursing intervention for the prevention and treatment of pressure ulcers? a. using pressure-reduction devices b. repositioning the pt frequently c. massaging pressure areas with lotion d. using lift sheets and trapeze bars to facilitate pt movement

b. repositioning the pt frequently workbook

Partial thickness skin loss or intact blister with serosanginous fluid. a. stage I b. stage II c. stage III d. stage IV

b. stage II Fundamentals

serum albumin level below ___ increases risk for delayed wound healing and infection

below 3.5 g/dL indicates lack of protein

An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient? a. Dress it with an absorbent dressing for exudate. b. Handle the wound gently and let it dry out to heal. c. Debride the nonviable, eschar tissue to allow healing. d. Use negative-pressure wound (vacuum) therapy to facilitate healing.

c. Debride the nonviable, eschar tissue to allow healing. MS

Who is at the greatest risk for developing pressure ulcers? a. a 42-yr-old obese woman with type 2 diabetes b. a 78-yr-old man who is confused and malnourished c. a 30-yr-old man who is comatose following a head injury d. a 65-yr-old woman who has urge and stress incontinence

c. a 30-yr-old woman who is comatose following a head injury (the immobility, mental deterioration, and possible neurologic disorder of the comatose pt present the greatest risk for tissue damage related to pressure) workbook

The nurse is caring for a postoperative pt who develops a wound dehiscence. Which of the following will the nurse do when this occurs? a. approximate the wound edges with tape b. irrigate the wound with sterile saline c. cover the wound with sterile, moist saline dressings d. hold the abdominal contents in place with a sterile, gloved hand

c. cover the wound with sterile, moist saline dressings Leadership and Management

A pt's documentation indicates he has a stage III pressure ulcer on his right hip. What should the nurse expect to find on assessment of the pt's right hip? a. exposed bone, tendon, or muscle b. an abrasion, blister, or shallow crater c. deep crater through subcutaneous tissue to fascia d. persistent redness (or bluish color in darker skin tones)

c. deep crater through subcutaneous tissue to fascia -exposed bone, tendon, muscle = stage IV -abrasion, blister, shallow crater = stage II -persistent redness = stage I workbook

The pt is admitted from home with a clean stage II pressure ulcer. What does the nurse expect to observe when she does her wound assessment? a. adherent gray necrotic tissue b. clean, moist granulating tissue c. red-pink wound bed, without slough d. creamy ivory to yellow-green exudate

c. red-pink wound bed, without slough workbook

Full thickness skin loss, subcutaneous fat may be visible. May include undermining. a. stage I b. stage II c. stage III d. stage IV

c. stage III Fundamentals

The pt's wound is not healing, so the HCP is going to send the pt home with negative pressure wound therapy. What will the caregiver need to understand about the use of this device? a. the wound must be cleaned daily b. the pt will be placed in a hyperbaric chamber c. the occlusive dressing must be sealed tightly to the skin d. the diet will not be as important with this sort of treatment

c. the occlusive dressing must be sealed tightly to the skin -the wound is cleaned weekly or when the dressing is replaced -for the negative pressure therapy to work, a vacuum is created between the device and wound so the excess fluid, bacteria, and debris are removed from the wound workbook

On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer? a. stage II b. stage IV c. unstageable d. suspected deep tissue damage

c. unstageable (since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined) Fundamentals

Which of the following describes a hydrocolloid dressing? a. A seaweed derivative that is highly absorptive b. Premoistened gauze placed over a granulating wound c. A debriding enzyme that is used to remove necrotic tissue d. A dressing that forms a gel that interacts with the wound surface

d. A dressing that forms a gel that interacts with the wound surface Fundamentals

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? a. A local skin infection requiring antibiotics b. Sensitive skin that requires special bed linen c. A stage III pressure ulcer needing the appropriate dressing d. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode.

d. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode. Fundamentals

When obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? a. Necrotic tissue b. Wound drainage c. Wound circumference d. Cleansed wound

d. Cleansed wound Fundamentals

Which nursing interventions for a pt with a stage IV sacral pressure ulcer are most appropriate to delegate to a LPN/LVN? (Select all that apply) a. assess and document wound appearance b. teach the pt pressure ulcer risk factors c. choose the type of dressing to apply to the ulcer d. measure the size (width, length, depth) of the ulcer e. assist the pt to change positions at frequent intervals

d. measure the size (width, length, depth) of the ulcer e. assist the pt to change positions at frequent intervals (other interventions relate to assessment, judgement, and teaching) workbook

The pt is transferring from another facility with the description of a sore on her sacrum that is deep enough to see the muscle. What stage of pressure ulcer does the nurse expect to see on admission? a. stage I b. stage II c. stage III d. stage IV

d. stage IV (full-thickness tissue loss with muscle, tendon, or bone exposed) workbook

Full thickness tissue loss, muscle and bone visible. May include undermining. a. stage I b. stage II c. stage III d. stage IV

d. stage IV Fundamentals

Braden Scale

evaluates risk factors that place the patient at risk for skin breakdown, 23 total points

pressure ulcer prevention - moisture

following each incontinent episode clean area with perineal clean and protect skin with moisture-barrier ointment

unstageable pressure ulcer

full-thickness tissue loss, depth of ulcer is obscured by slough or eschar

serosanguineous drainage

pale, pink, watery, contains both serum and blood, appears blood-streaked or blood-tinged

types of wounds that heal by secondary intention

wounds involving loss of tissue: -pressure ulcers -burns -severe lacerations