EAQ 48 Pressure Ulcers

Arrange the steps in order that the nurse follows while irrigating a wound.

1.Pour sterile solution into sterile irrigation containers 2. Place waterproof pad under the patient 3. Allow the solution to gently flow over wound Correct 4. Apply gauze pads over surrounding skin Correct 5. Remove the gloves

The nurse is evaluating the outcome of a patient provided with negative-pressure wound therapy (NPWT) for pressure ulcers. Which nursing action is appropriate for determining the patient's level of comfort while providing the treatment?

Asking the patient to rate the pain using a scale of 0 to 10

During assessment, the nurse notes a foul-smelling drainage from the wound with deep tunneling. Which actions of the nurse indicate the need for further teaching? Select all that apply.

Covering the entire wound with the gauze Correct 2 Placing the dripping wet gauze into the tunnel

While caring for a patient who has a chronic wound, the nurse observes exudates in the periwound area. Which nursing intervention is appropriate in this scenario? Select all that apply

Increase the frequency of dressing change Use of petrolatum-based skin protectant Use of dressing material that has more absorbing capacit

The nurse determines the patient's risk of developing ulcers using the Braden Scale and finds the score to be 16. Which nursing interventions are appropriate for the patient to decrease the risk of skin breakdown? Select all that apply.

Protecting the patient's heels Correct 2 Turning the patient frequently Correct 3 Providing pressure-redistribution surfaces A patient with a score of 16 on the Braden scale indicates that the patient is at risk for pressure ulcers. The patient in this condition should be provided with interventions that protect the heels, because this site is more susceptible to ulcer formation. The patient should frequently be turned to prevent the risk of pressure ulcer development. The patient should also be provided with pressure-redistribution surfaces to prevent ulcer formation. Foam wedges should be provided for the 30-degree lateral position, not the 40-degree lateral position. Application of moisturizer should be avoided in the patient, because it increases the risk of ulcer formation.

After receiving negative suction wound therapy for pressure ulcers, the patient complains of severe pain. What should be the immediate nursing action?

Reduce the suction

Which intervention can be performed by nursing assistive personnel (NAP) while caring for a patient who has a chronic wound?

Reporting changes in the skin integrity to the registered nurse immediately

While caring for a patient who has pressure ulcers, the nurse finds that the skin surrounding the ulcer has become macerated. Which nursing intervention would be most appropriate to manage the patient's condition? Select all that apply.

Reporting to the primary health care provider Correct 3 Applying liquid skin barrier on the periwound skin Reducing the exposure of wound to topical agents

Which task can be delegated to nursing assistive personnel (NAP)?

Securing the dressing using special tapes

The registered nurse is teaching a nursing student about the instructions to be followed while dressing any type of wound. Which statement made by the nurse indicates effective learning? Select all that apply.

Select the dressing that controls the exudate Use the dressing that provides a moist environment to the ulcer bed

While changing the wet-to-dry dressing, the nurse notes a dime-sized ulcer under the adhesive tape. What should be applied to secure the wound? Select all that apply.

Solid skin barrier Correct 5 Montgomery ties

While caring for a patient who had hip replacement surgery and developed pressure ulcers, the nurse applies debriding enzymes on the ulcer region. After few hours, the patient complains of burning sensation in the wound area. Which nursing action is responsible for the patient's condition?

The nurse applied ointment to the surrounding skin.

During a follow-up visit, the patient complains of irritation in the periwound tissue where the wound is dressed. Which nursing action could have caused this patient condition?

The nurse cut the gauze to fit the wound The nurse should not cut the gauze to fit around the drain or the wound, because the cut edges may fray and enter the wound, causing irritation at the wound site. Black foam is used for dressing a granulating wound, because it provides wound contraction, but it is not used for a draining wound. A wound with drainage should be dressed with precut split gauze to provide absorption of the drainage from the wound. Barrier film helps to provide an airtight seal needed for negative-pressure wound therapy (NPWT) and protects the periwound from maceration.

While applying gauze dressing to a wound, the patient complains of severe pain. What could be the reason for the pain?

The nurse did not remove the gauze dressings one at a time

The nurse is assisting the primary health care provider in applying moist dressing for a patient who has pressure ulcers. The nurse reviews the orders for the dressing change procedure. What is the rationale behind this nursing action?

To learn the type of dressing that is to be used

Which patients are at risk of developing pressure ulcers? Select all that apply.

A patient who has urinary incontinence Correct 2 A patient who has had hip replacement surgery Correct 3 A patient who walks with the help of an assistant

While dressing a patient's wound, the nurse irrigates the wound until there is a clear flow of the solution. What is the rationale behind this nursing action?

To remove the debris from the wound

What is the rationale behind cleaning the wound with normal saline using an irrigating syringe?

To remove wound debris

Which type of dressing is used for stage I pressure ulcers?

Transparent film dressings

Arrange the steps in the order to be followed by a nurse who is caring for a patient who has a pressure ulcer.

1. Explain the procedure to the patient and family 2. Select the appropriate dressing and tape 3. Clean the ulcer with normal saline 4. Apply topical agents 5. Reposition the patient comfortably off of the pressure area

Arrange in order the steps that the nurse follows while treating pressure ulcers in a patient.

1.Determine if the patient has allergies to topical agents 2.Determine if the patient needs pain medication 3.Position the patient for access to dressing removal 4.Remove the dressing and place it in a plastic bag 5.Measure the length and width of the pressure ulcer

While assessing a patient with the Braden Scale, the nurse suspects that the patient is at very high risk of pressure ulcer development. What might be the patient's score?

8

Which topical agents are used to clean highly colonized wounds? Select all that apply.

Acetic acid Hydrogen peroxide Correct 5 Sodium hypochlorite

What purpose does the dry gauze dressing serve in wound healing? Select all that apply.

Aids in hemostasis Provides debridement Prevents microbial contamination

What are the advantages of using hydrogel dressing? Select all that apply.

Allows for easy removal Debrides necrotic tissue Provides a moist environment

Which task can be delegated to nursing assistive personnel (NAP) in caring for a patient who has pressure ulcers?

Applying an elastic bandage

Which type of gauze should be used for dressing a wound on the palm?

Elastic net

Which fluids if exposed to the skin pose the highest risk for skin breakdown?

Gastric secretions

A patient developed a pressure ulcer that was deep with the presence of exudates. Which type of dressing is provided to the patient?

Hydrogel

Which type of dressing is preferred for dry wounds?

Hydrogel

Which statement is true regarding nonblanchable erythema?

It indicates potential damage to blood vessels

A nurse finds that a patient who has urinary incontinence scores 11 on the Braden Scale. Which nursing action is most appropriate to prevent this patient from developing pressure ulcers?

Managing moisture

A patient is diagnosed with moderate deep dermal ulcers. Why would the nurse provide a hydrocolloid dressing to this patient? Select all that apply.

Minimizes skin trauma Provides moist environment Correct 5 Slowly liquefies necrotic debris

Which equipment is used by the primary health care provider while applying moist dressing to a patient who has pressure ulcers?

Montgomery ties

A patient developed a pressure ulcer after knee surgery due to restriction to bed. Which irrigating fluid should the nurse use to clean the ulcer?

Normal saline

Which nursing interventions are appropriate when a patient complains of sensation under the dressing? Select all that apply.

Observe the wound for increased drainage Correct 4 Report to the primary health care provider immediately Correct 5 Cover the wound with a sterile moist dressing if underlying organs protrude

The registered nurse is applying dressings to four patients. Which dressing is appropriate for the suggested wound care?

Patient D

The nurse notes a quarter-sized area of blanchable erythema over the patient's sacral area. The nurse knows this finding is likely due to what? 1 Friction

Pressure

The health care provider prescribes a dressing that will facilitate autolytic debridement. Which action made by the nurse indicates effective nursing?

Using hydrocolloid dressings to remove the dead tissue

The nurse reviews the primary health care provider's orders for the amount of negative pressure to be applied while providing negative-pressure wound therapy (NPWT) to a patient. Which step of the nursing process is involved in this situation?

Assessment

While treating a patient with negative-pressure wound therapy (NWPT) for radiation-damaged skin on the forearm, the nurse observes pressure ulcers on the elbow. Which nursing action is responsible for the patient's condition?

The nurse placed the tubing over the elbow.

The nurse observes that a patient with pressure ulcers has a score on the Braden Scale of 11. What would the nurse suspect from this observation?

The patient is at high risk of development of pressure ulcers. The Braden Scale provides a baseline for comparing increased or decreased risk for development of pressure ulcers that helps plan for interventions. If the score is 10 to 12, then the patient is at high risk of developing pressure ulcers; therefore, this patient is considered at a high risk of pressure ulcer development. If the score is 13 to 14, then the patient is at moderate risk of developing pressure ulcers. If the score is lower than 9, it indicates severe complication and the patient should be taken to the intensive care unit immediately. If the score is high, it indicates low risk, and the condition can be managed in a few days with minimal interventions.

The nurse observes that a patient's ulcer is very slow to heal. Which action made by the nurse can help facilitate faster healing of the patient's wound?

Assessing the ulcer during each dressing

The nurse observes increased wound drainage in a patient provided with a moist-to-dry dressing for pressure ulcers. What should be the immediate nursing intervention?

Change the dressing

A patient provided with polyurethane foam for negative-pressure wound therapy (NPWT) complains of severe pain. Which intervention would be most appropriate to manage the patient's condition in this situation?

Change the wound filler

After the nurse dresses a patient's wound, which nursing intervention would help prevent the contamination of that previously cleaned wound?

Cleaning the wound from the center to the surrounding skin

What are the functions of black polyurethane foam in wound healing? Select all that apply.

Contracts the wound Correct 2 Absorbs fluids from the wound

Which type of gauze should a nurse use when a patient has a necrotic ulcer?

Dry gauze

The registered nurse is teaching a nursing student about home care considerations to prevent the risk of pressure ulcers. Which statements made by the nursing student indicate effective learning? Select all that apply.

I should educate the patient about the signs of wound infection." Correct 2 "I should discuss reactive surfaces that may increase pressure to the wound." The nurse should educate the patient and the family caregiver about the signs of wound infection, so that early detection of the wound can be made and appropriate intervention provided. The nurse should discuss the home associated pressure and the methods of pressure redistribution to prevent ulcer development. The soiled dressings at home should be disposed in a manner consistent with the local regulations for contaminated wastes and not by incineration. The healing process should not be evaluated by the use of a pressure ulcer staging system; this is a system to determine the depth of the wound. Healing takes 2 to 4 weeks. If the patient does not observe any healing beyond 4 weeks, then the patient should be advised to report to the health care provider or the registered nurse.

What does the nonblanchable erythema indicate about the skin?

The tissue is damaged.

Which statement is true regarding hydrogel dressings?

They enhance autolytic debridement.

The nurse uses an elastic net as additional dressing in a patient's leg region. What is the rationale behind this nursing action?

To prevent the dressing from slipping

Which topical solutions can be used to clean a granulating wound? Select all that apply.

Water Normal saline

The registered nurse is providing dietary instructions to a patient who has pressure ulcers. Which statements by the nurse are true? Select all that apply.

You should consume 1.25 g of protein per kg body weight each day." Correct 5 "You should avoid eating foods that contain high amounts of zinc."