NMNC 4335 - Tissue Integrity / Wound Care

what are the advantages of wound vacuum assisted closure? (wound VAC)

× Uses negative pressure × Removes drainage × Increases circulation × Decreases edema

Dehiscence

- partial or total separation of wound layers - watch for increased drainage from incision

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A stage 3 pressure injury needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

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

An 82year-old man is being cared for at home by his family. A pressure injury on his right buttock measures 1 × 2 × 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4

c. Stage 3

what is involved in a skin assessment?

color moisture texture turgor temperature

what are some indications for wound vac?

- Chronic open wounds (diabetic ulcers & Stages III, IV) - Acute/traumatic wounds - Dehisced wound

What score on the Braden scale indicates severe risk for pressure sore?

9 and below

indurated

hard

what are some examples of wound healing complications?

infection (EX) osteomyelitis delayed healing scarring contractures evisceration dehiscence

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and pieces of small bowel are noted at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the health care provider. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound. 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.

1. Notify the health care provider. 4. Cover the area with sterile, saline-soaked towels immediately.

What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure distribution 3. Negative-pressure wound therapy 4. Sanitization

1. Debridement

When is the application of a warm compress to an ankle muscle sprain indicated? (Select all that apply.) 1. To relieve edema 2. To reduce shivering 3. To improve blood flow to an injured part 4. To protect bony prominences from pressure injuries 5. To immobilize area

1. To relieve edema 3. To improve blood flow to an injured part

What score on the Braden scale indicates high risk for pressure sore?

10-12

how do you assess a wound?

location etiology shape size / depth color peri-wound appearance exudate (drainage) dressing

how does a stage 4 pressure injury present?

× Full thickness tissue loss with exposed bone, tendon or muscle × Slough or eschar may be present on some parts of the wound bed × Undermining and tunneling are often present × Increases risk of osteomyelitis

What does wound irrigation do?

× Gentle debridement × Clear exudate × Clean wound bed

Which of the following describes a hydrocolloid dressing? 1. A seaweed derivative that is highly absorptive 2. Premoistened gauze placed over a granulating wound 3. A debriding enzyme that is used to remove necrotic tissue 4. A dressing that forms a gel that interacts with the wound surface

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

Which patient has the greatest risk for experiencing delayed wound healing? a. A 65-yr-old woman with stress incontinence b. A 52-yr-old obese woman with type 2 diabetes c. A 78-yr-old man who has a history of hypertension d. A 30-yr-old man who drinks 2 alcoholic beverages per day

b. A 52-yr-old obese woman with type 2 diabetes

A patient in the unit has a 103.7°F temperature. Which intervention would be most effective in restoring normal body temperature? a. Using a cooling blanket while the patient is febrile b. Giving antipyretics on an around-the-clock schedule c. Providing increased fluids and have the UAP give sponge baths d. Giving prescribed antibiotics and placing warm blankets for comfort

b. Giving antipyretics on an around-the-clock schedule

The nurse assessing a patient with a chronic leg wound finds local signs of erythema, and the patient reports pain at the wound site. What would the nurse expect to be ordered to assess the patient's systemic response? a. Serum protein analysis b. WBC count and differential c. Punch biopsy of center of wound d. Culture and sensitivity of the wound

b. WBC count and differential

eschar

black, hard, non viable tissue

ecchymosis

bruising

osteomyelitis

infection of the bone

what are some risk factors for skin breakdown?

nutrition hydration mental status mobility incontinence diabetes heart disease obesity Hx of skin breakdown

how does autolytic debridement work? which dressing do you use?

- body's own enzymes & WBC loosen & liquefy necrotic tissue - hydrocolloid - occlusive dressings keep contaminants out

The nurse instructs a client about safety measures and precautions when taking care of a pressure ulcer. During a follow-up visit, the nurse finds increased tissue necrosis with damaged capillary beds. Which actions by the client would the nurse expect are the reason for the client's condition? SATA 1. Massaging the reddened skin areas 2. Placing pillows between two bony surfaces 3. Using donut-shaped pillows for pressure relief 4. Keeping the head of the bed below 30 degrees 5. Using a bed pillow under the ankles to keep the heels off the bed surface

1. Massaging the reddened skin areas 3. Using donut-shaped pillows for pressure relief

When providing care for a client with quadriplegia, which nursing intervention assists in decreasing the potential occurrence of pressure ulcers? 1 Avoid massaging the client's legs. 2 Frequently reposition the client on a scheduled basis. 3 Increase the fiber content in the client's food. 4 Encourage the client to participate in weight-bearing exercises.

2 Frequently reposition the client on a scheduled basis

Which age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? 1. Atrophy of the sweat glands 2. Decreased subcutaneous fat 3. Stiffening of the collagen fibers 4. Degeneration of the elastic fibers

2. Decreased subcutaneous fat In older adults, a decrease in subcutaneous fat leads to skin shearing, which may lead to pressure ulcers. Atrophy of the sweat glands will cause dry skin and decreased body odor. Stiffening of the collagen fibers and degeneration of the elastic fibers will result in the development of wrinkles.

Which intervention would be included in the plan of care for the prevention of a pressure injury? 1. Positioning a client directly on the trochanter 2. Keeping the client's skin directly off plastic surfaces 3. Keeping the head of the bed elevated above 30 degrees 4. Placing a rubber ring or donut under the client's sacral area

2. Keeping the client's skin directly off plastic surfaces For the prevention of a pressure ulcer, the client's skin should be kept directly off plastic surfaces. While the client is positioned on his or her side, direct positioning on the trochanter should be avoided. The head of the bed should not be kept elevated above 30 degrees. This is to prevent shearing. A rubber ring or donut under the client's sacral area should be avoided.

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Providing support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2. Providing support to abdominal tissues when coughing or walking 4. Reduction of stress on the abdominal incision

Which findings are expected when assessing the skin of an older adult? SATA 1. Scaly skin 2. Tenting of skin 3. Transparent skin 4. Increased wrinkles 5. Pigmented lesions

2. Tenting of skin 3. Transparent skin 4. Increased wrinkles 5. Pigmented lesions Decreased subcutaneous fat with degeneration of elastic fibers allows tenting of the skin and increased wrinkles. Decreased dermal thickness results in paper-thin, transparent skin. Pigmented lesions (liver spots, solar lentigines) increase in number, size, and distribution with aging. Scaling of the skin is more commonly associated with psoriasis than aging.

how do bulb suction drains work? (AKA) JP drains brand name "Jackson Pratt," Blake drains, davol drains

× Compression based bulb drains × Assess - insertion site, periinsertion site, drainage characteristics, tube patency, bulb suction function × Bulbs can be replaced × Often long-term drains

how do you apply gauze dressings?

× Unfold to make contact c wound bed × Moisten c saline or other solution × Lightly pack to fill all dead space Secure

Why and how do you maintain a moist environment? What type of dressing?

× Why - moist environment supports movement of epithelial cells & facilitates wound closure × How - hydrocolloid dressing - Colloid + adhesive - Occlusive, adhesive, mold to the wound - Wound contact layer forms a gel as wound exudate is absorbed & maintains moist healing enviro - Support healing in clean granulating wounds & autolyticallly debride necrotic wounds - Variety of sizes & shapes - Absorbs drainage, maintains moisture, slowly liquefies necrotic debris - 3-5 days - Impermeable to bacteria + contaminants - Act as preventive dressing for high-risk friction areas - Shallow to moderately deep dermal injuries - Cannot absorb drainage from heavily draining wounds - Contra - full-thickness & infected wounds - Leave a residue that's easy to confuse c purulent discharge × How - composite film × How - hydrogel - Gauze / sheet dressings impregnated c water / glycerin-based amphorous gel - Partial thickness + full thickness wounds, deep wounds w some exudate, necrotic wounds, burns, radiation-damaged skin

How does a Penrose drain work?

- hollow soft flat plastic tubes left in patient, with a small opening - usually sutured in place - drains freely, surrounded by 4x4 to catch exudate - assess wound, periwound skin, drainage characteristics

how does chemical debridement work? which dressing do you use?

- must have an order - lightly pack wound c gauze moistened c prescribed solution

The nurse is teaching a client about sleeping positions to follow to prevent pressure ulcers. Which statement made by the client indicates effective learning? SATA 1. "I should use pressure-relieving pads." 2. "I should place a rubber ring under the sacral area." 3. "I should place pillows between two bony surfaces." 4. "I should keep the head of the bed elevated above 30 degrees." 5. "I should keep my heels off the bed surface using a bed pillow under the ankles."

1. "I should use pressure-relieving pads." 3. "I should place pillows between two bony surfaces." 5. "I should keep my heels off the bed surface using a bed pillow under the ankles." The client should use pressure-relieving pads to prevent pressure ulcers. Place a pillow between two bony surfaces to prevent pressure. Keeping the heels off the bed surface using a bed pillow under ankles gives uniform positioning and reduces pressure. The rubber ring should not be placed under the sacral area because it may increase pressure. The head of the bed should not be elevated above 30 degrees because it prevents shearing.

how does mechanical debridement work? which dressing do you use?

Wound irrigation Use dressing that keeps wound bed moist

macerated

pruney, soggy

granulation

red/pink new cell growth

how does an unstageable pressure injury present?

× Full thickness tissue loss in which wound bed covered by slough/eschar × CANNOT determine stage and depth until wound bed is exposed × Stable eschar on heels serves as the body's natural cover and should not be removed

how does a stage 1 pressure injury present?

× Intact skin with non-blanchable redness, usually over a bony prominence × Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area × The area may be painful, firm, soft, warmer/cooler than adjacent tissue

what are wet to dry dressings? why are they harmful?

× Outdated × Not evidence based × Moisten gauze dressing c saline, pack wound with it, cover c another dry gauze, let packing dry. Next shift, remove dry gauze out of wound bed - along w any new epithelial cells. "Debrided wound bed" but also debrided healthy tissue!!

what are hydrogel dressings? what are their benefits?

× Saline in gel form for extra dry wound beds × Non-adhesive × Sheets / gel × Apply gel to gauze or wound bed itself × Stays moist for longer than regular saline solution

what is tegaderm? how do you use it?

× Use only for IVs × transparent dressing × If you use them on wounds (esp fragile skin) you will tear skin

Why and how do you manage exudate? What type of dressing?

× Why - excessive exudate ruins environment & jeopardizes wound healing - Supports bac growth - Macerates periwound skin - Slows healing process × How - calcium alginate - Used c significant exudate - Must cover c secondary dressing - Manufactured from seaweed & come in sheet/rope form - Forms soft gel when it contacts wound fluid - Highly absorbent - Do not cause trauma when removed from wound - Contra - dry wounds × How - foam dressings - Wounds c large amt of exudate & those that need packing - Used around drainage tubes to absorb drainage

what volume of syringe and gauge of angiocath do you use to irrigate a wound at high pressure?

20 ml syringe 18 gauge angiocath

How does a wound vac work?

- creates a negative pressure environment - removes drainage, increases circulation, decreases edema - stimulates mitosis + angiogenesis of granulation tissue - as the wound heals, the sponge gets smaller

why are surgical drains important? what are some examples of the different drains?

- drain excess body secretions from surgical sites & wounds - excess fluid suppurating in wounds is harmful (EX) Penrose, hemovac, bulb suction drains

What are alginate dressings?

(EX) calcium alginate × Seaweed polymer × Hemostatic × Highly absorbent × Use for heavy exudate × Use in tunneling wounds × 3-5 days (EX) silver alginate × Sustained microbial activity × 7 days

what are hydrocolloid dressings? what are their benefits?

(EX) duoderm × Occlusive × Impermeable × Autolysis (self-debridement) × Use for low to moderate exudate × 7 days

what are foam dressings? what are their benefits?

(EX) mepilex × Insulates × Absorbs × Cushions × Preventative / Txt × Made from sticky silicone that's easy to reapply × Easy to check skin underneath and stick back

what are non-cytotoxic wound cleansers? examples?

- Does not kill or damage fibroblasts - For non- infected and granulating wounds (EX) normal saline, commercial wound cleansers like Saf-Clens

what do you look for when assessing a wound vac?

- Foam should look raisin like - Assess peri wound skin - Assess character of drainage in tubing, not canister - Keep plugged in - Troubleshooting & dressing patching is within your scope - Remove dressing & replace c moist saline gauze after 2hr of no suction - 15 minutes if skin graft & CALL PROVIDER!!

what are cytotoxic wound cleansers? examples?

- For infected wounds - Dakins - dilute bleach - Acetic Acid - component of vinegar - Sulfamylon (Mafenide) - sulfa abx

how does a deep tissue injury present?

- Purple or maroon bruised area - Skin is INTACT - Can be a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear - Feels boggy or mushy - Continual evolution

what are contraindications for wound vac?

- Unexplored fistulas - Necrotic tissue c eschar present - Untreated osteomyelitis - Malignancy in wound - Exposed blood vessels & organs

Which statement is correct regarding negative pressure wound therapy? SATA 1. A suction pump is used. 2. Necrotizing infections are treated. 3. Oxygen is administered under high pressure. 4. A low-voltage current is applied to a wound area. 5. Chronic ulcers are reduced by removing fluids from the wound.

1. A suction pump is used. 5. Chronic ulcers are reduced by removing fluids from the wound. In negative pressure wound therapy, a suction pump is used to treat the wounds. This therapy can reduce chronic ulcers by removing fluids from the wound. Necrotizing infections are treated by hyperbaric oxygen therapy. Hyperbaric oxygen therapy is the administration of oxygen under high pressure. Electrical stimulation is the application of a low-voltage current to a wound area.

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. Applying a moisture barrier ointment

1. Frequent position changes 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment

Which key feature is associated with a stage 2 pressure ulcer? 1. Presence of nonintact skin 2. Development of sinus tracts 3. Damage to the subcutaneous tissues 4. Appearance of a reddened area over a bony prominence

1. Presence of nonintact skin

The registered nurse is teaching a student nurse about the use of a suction pump in negative-pressure wound therapy. Which statement by the student nurse indicates the need for further teaching? 1. "The wound site should be monitored at least every 2 hours." 2. "This treatment is used mostly for areas of skin cancer." 3. "The foam dressing should be changed every 48 to 72 hours." 4. "A continuous low-negative pressure should be maintained."

2. "This treatment is used mostly for areas of skin cancer." A suction pump is used in negative-pressure wound therapy to reduce chronic ulcers by removing the fluids from the wounds and to enhance granulation. A suction pump should not be used in the areas of skin cancer because it may cause serious bleeding and may lead to death. The wound site should be monitored at least every 2 hours. The suction pump is covered by a sponge, and the foaming dressing should be changed every 48 to 72 hours. While using the suction pump, a continuous low-negative pressure should be maintained.

The nurse uses the same pair of gloves to remove a soiled dressing and to apply a new sterile dressing. Another nurse is observing the dressing change procedure. Which initial action would the observing nurse take? 1. File an incident report. 2. Discuss the incident with the nurse. 3. Offer to demonstrate the proper technique. 4. Report the individual to the nursing supervisor.

2. Discuss the incident with the nurse.

Which condition would the nurse question using a negative-pressure wound treatment device? 1. Chronic ulcer 2. Upper thigh wound 3. Hip wound with slight bleeding 4. Treated osteomyelitis within the vicinity of the wound

3. Hip wound with slight bleeding The nurse would question using this treatment option for a client with a bleeding wound with the primary health care provider because bleeding indicates exposed blood vessels and negative-pressure wound treatment is contraindicated. A negative-pressure wound treatment can close chronic ulcers and upper thigh wounds by removing fluids or infectious material, enhancing granulation. A negative-pressure wound treatment device can be used with treated osteomyelitis.

What is the correct sequence of steps when performing wound irrigation to a large open wound? 1. Use slow, continuous pressure to irrigate wound. 2. Attach 19-gauge angiocatheter to syringe. 3. Fill syringe with irrigation fluid. 4. Place biohazard bag near bed. 5. Position angiocatheter over wound.

4, 3, 2, 5, 1

When teaching an older adult client about skincare to prevent pressure ulcers, which client statement indicates a misunderstanding? 1. "I should gently pat my skin." 2. "I should use mild, heavily fatted soap." 3. "I should wash my skin with tepid, rather than hot water." 4. "I should apply powders or talc on a perineum wound."

4. "I should apply powders or talc on a perineum wound." A client should not use powders or talc on the perineum wound, and the nurse needs to follow up to correct this misconception. All the other statements are correct and need no follow-up intervention. The client should gently pat the skin rather than rub. The client should use mild, heavily fatted soap. The client should use tepid rather than hot water.

Which nursing action would be included in the plan of care to promote the nutritional status of a client during the acute phase of treatment after extensive burns? 1. Provide a diet high in sodium. 2. Limit caloric intake to decrease the work of the body. 3. Reduce protein intake to avoid overtaxing the kidneys. 4. Administer the prescribed intravenous fluid with the added vitamin C.

4. Administer the prescribed intravenous fluid with the added vitamin C.

A nurse caring for a client with quadriplegia notices ulcers on the sacrum, hips, and ankles. Arrange the order of the pathophysiology involved in the development of these ulcers. 1. Development of pressure ulcers 2. Local tissue compression 3. Restriction of blood flow 4. Local cell death 5. Reduced tissue perfusion

Quadriplegic clients are bedridden or wheelchair bound and incapable of changing position without assistance; therefore they have more chances of developing pressure ulcers. Tissue compression from pressure restricts blood flow to the skin resulting in reduced tissue perfusion and oxygenation and, eventually, leading to cell death and the development of pressure ulcers. 1. Local tissue compression 2. Restriction of blood flow 3. Reduced tissue perfusion 4. Local cell death 5. Development of pressure ulcers

contractures

shortening & hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints

petechiae

small purplish pinpoint hemorrhages little bruises

STSG

split thickness skin graft

evisceration

wound separation & displacement of organs outside of the body

slough

yellow/brown/white non-viable tissue

what are the wound care principles?

× CLEAN - Prevent & treat infection - Debride non- viable tissue × MOIST - Manage exudate - Keep moist × COVERED - Protect from foreign material - Cushion wound - Immobilize dressing in wound bed

How do you clean a wound? Describe wound irrigation and the preferred cleaning agent.

× Clean from least contaminated area (EX) from incision out to surrounding skin × Use gentle frxn when applying solutions locally to skin × When irrigating, allow solution to flow from least to most contaminated area × Use irrigation syringe to flush wound c constant low-pressure flow of solution - cleanses wound from exudate + debris × Irrigation - Deep wounds - Wounds involving inaccessible body part (EX ear canal) - Sensitive body parts - conjunctival lining of eye × Solution for irrigation - normal saline, noncytotoxic solutions

Why and how do we prevent and manage infection?

× Why - wound infxn prolongs inflammatory phase, delays collagen synth, prevents epithelialization, increases proinflammatory cytokine prdxn (leads to additional tissue dstrxn) × How - nutrition - Zinc - host defenses - Vitamin A - wound closure, inflammatory response, angiogenesis, collagen formation - Vitamin C - collagen synthesis, capillary wall integrity, fibroblast fxn, immunological fxn, antioxidant - Protein - fibroplasia, angiogenesis, collagen formation, wound remodeling, immune fxn - Fluid - essential fluid enviro for all cell fxn (P&P 1240) × How - wound cultures - detect a pathogen before infection gets worse - Needle aspiration procedure (anaerobic organisms) - Quantitative swab procedure (aerobic organisms) × How - wound care - Irrigate & cleanse wounds - Pack open areas c gauze moistened c abx solution as ordered

What are the principles of maintaining a healthy wound environment?

× Wound - disruption of the integrity & function of tissues in the body × Tissue perfusion - O2 fuels cellular fxns essential to healing process - Ability to perfuse tissue w adequate amt of oxygenated blood is critical to wound healing - Pt w DM & peripheral vasc disease are at r/f poor tissue perfusion bc of poor circulation × Infection - infection slower healing process × Age - Older - decrease in functioning macrophages · Delayed inflammatory response · Delayed collagen synth · Slower epithelialization × Psychosocial impact - body image changes impose stress on pts' adaptive mechanisms × Manage pain × Protect wound from further injury (EX) splinting coughs for abd wounds

how does a hemovac work?

- manual compression of chamber creates negative pressure to promote healing - foam sponge in wound, apply suction c an air tight seal to bring together edges of skin - compression drain - mainly for ortho + neurosurgery - abundant sanguineous drainage - assess - insertion site, periinsertion site, drainage characteristics, tube patency, reservoir suction function

how does low pressure wound irrigation work?

- pour solution over wound - always direct solution from top to bottom & clean to dirty

Sterile warm saline soaks three times a day are prescribed for a client with cellulitis from a puncture wound. The primary nurse places a clean basin, washcloth, and protective pad at the bedside in preparation for the soak but is unable to continue the procedure. Which step would the new nurse assigned to complete the soak do? 1. Continue the procedure as started. 2. Collect new supplies before starting. 3. Discuss the type of soak with the primary health care provider. 4. Report the primary nurse to the unit's nurse manager

2. Collect new supplies before starting. The supplies at the bedside are not sterile, and the primary health care provider prescribed sterile soaks; new supplies must be gathered. Continuing the procedure as started is unsafe; a clean basin and washcloth are not sterile. It is unnecessary to discuss the type of soak with the primary health care provider; the primary health care provider has already indicated the type of soak desired. Reporting the primary nurse to the unit's nurse manager is not the priority; client safety is the priority at this time.

Which dressing technique promotes autolysis in the spontaneous separation of necrotic tissue? 1. Continuous wet gauze 2. Moisture-retentive covering 3. Topical enzyme preparations 4. Wet-to-dry damp saline moistened gauze

2. Moisture-retentive covering A moisture-retentive dressing is used to promote autolysis in the spontaneous separation of necrotic tissue in wound debridement. Continuous wet gauze is used in promoting dilution of viscous exudate and softening the dry scar. Topical enzyme preparation shows proteolytic action on thick, adherent eschar, causing the breakdown of denatured protein and a more rapid separation of necrotic tissue. In wet-to-dry damp saline-moistened gauze, necrotic debris is mechanically removed but with less trauma to healing tissue.

A home health nurse teaches a family member to cleanse a client's wound and apply a sterile dressing. Which action by the family member during a return demonstration indicates the need for additional teaching? 1. Placing the old dressing in a plastic bag 2. Changing the dressing without wearing a mask 3. Donning nonsterile gloves for removing the old dressing 4. Using a back-and-forth motion with the same gauze while cleaning the wound

4. Using a back-and-forth motion with the same gauze while cleaning the wound After each swipe, sterile gauze should be discarded, and a new sterile gauze should be used for the next swipe. The other options are correct. Placing the old dressing in a plastic bag confines the soiled dressing to a leak-proof bag and prevents contamination of the environment or others. A mask is not necessary. Nonsterile gloves are acceptable for dressing removal because the dressing is contaminated; sterile gloves may be required for dressing application.

8. Which patients are at most risk for pressure injuries? Select all that apply. a. A patient with right sided-paralysis and fecal incontinence b. An older adult who is alert and needs assistance to ambulate c. A young adult patient with paraplegia after a gunshot wound d. A morbidly obese patient who has an open abdominal wound e. An ambulatory patient who has occasional stress incontinence f. A young adult with a tibial fracture from a motor vehicle accident

a. A patient with right sided-paralysis and fecal incontinence c. A young adult patient with paraplegia after a gunshot wound d. A morbidly obese patient who has an open abdominal wound

An 85-yr-old patient has a score of 16 on the Braden Scale. What should the nurse include in the plan of care? a. Implementing a 1-hour turning schedule with skin assessment. b. Elevating the head of bed to 90 degrees when the patient is supine. c. Continuing with weekly skin assessments with no special precautions. d. Placing a silicone foam dressing on the patient's sacrum to prevent breakdown.

a. Implementing a 1-hour turning schedule with skin assessment.

A patient 1 day postoperative after abdominal surgery has incisional pain, 99.5°F temperature, slight erythema at the incision margins, and 30 mL serosanguinous drainage in the Jackson-Pratt drain. Based on this assessment, what conclusion would the nurse make? a. The patient has a normal inflammatory response. b. The abdominal incision shows signs of an infection. c. The abdominal incision shows signs of impending dehiscence. d. The patient's health care provider must be notified about her condition.

a. The patient has a normal inflammatory response.

Which order should a nurse question in the plan of care for an older adult, immobile stroke patient with a pink, clean stage 3 pressure injury? a. Pack the wound with foam dressing. b. Turn and position the patient every hour. c. Clean the wound every shift with Dakin's solution. d. Assess for pain and medicate before dressing change.

c. Clean the wound every shift with Dakin's solution.

A nurse is caring for a patient who has a pressure injury that is treated with debridement, irrigations, and moist gauze dressings. How would the nurse expect healing to occur? a. Cell regeneration b. Tertiary intention c. Secondary intention d. Remodeling of tissues

c. Secondary intention

How is non-viable tissue removed?

× Debridement - removal of nonviable, necrotic tissue - Mechanical - will remove viable + nonviable tissue · Wet-to-dry · Pulsatile lavage · Wound irrigation - Autolytic - removal of dead tissue via lysis of necrotic tissue by WBC & natural enzymes of the body · Use dressings that support moisture @ wound surface · If wound base is dry, use dressing that adds moisture · For excessive exudate, use dressing that absorbs excessive moisture, while maintaining moisture at the wound bed · (EX) transparent film, hydrocolloid - Chemical · Topical enzyme preparation - induce changes in the substrate, resulting in breakdown of necrotic tissue, preparation either dissolves or digests the tissue · Dakin's solution - breaks down & loosens dead tissue in a wound, apply solution to gauze & apply gauze to wound · Sterile maggots - through to ingest dead tissue - Sharp/surgical (physicians/NP/PA) - removal of devitalized tissue c scalpel / scissors / sharp instrument

what are some interventions to minimize wound healing complications?

× Excellent assessment × Excellent wound care × Supportive multidisciplinary care × Teach pt how to care for wounds × PT to prevent contractures × DM educator to control BS × Nursing team to prevent skin breakdown

how does a stage 3 pressure injury present?

× Full thickness tissue loss × SQ fat may be visible but bone, tendon or muscle are NOT exposed × Slough may be present but does not obscure the depth of tissue loss × May include undermining and tunneling

What are the types of solutions for wound cleaning?

× NS - abrasion, minor laceration, small puncture wound - Physiological neutral - Doesn't harm tissue - Keeps wound surface moist to promote dev & migration of epithelial tissue × Noncytotoxic solutions - c sterile gauze or by irrigation

how does a stage 2 pressure injury present?

× Partial thickness with loss of dermis × Shallow open injury with a red pink wound bed without slough × Can be a serous filled blister, or ruptured blister × NOT skin tears, tape burns, perineal dermatitis, maceration or excoriation

How do you irrigate a wound?

- draw up sterile NS in syringe (usually 20cc) - spray directly into the wound - repeat until it runs clear - pad dry with sterile gauze - too little pressure - won't adequately remove surface bacteria - too much pressure - forces vac into wound bed & damage delicate granulation tissue

how does sharp/surgical debridement work? which dressing do you use?

- only providers do this - devitalized tissue removed c scalpel / scissors / sharp instrument - use dressing that keeps wound bed moist

how does high pressure wound irrigation work?

- spray solution using syringe + angiocath (plastic part from IV) - for wounds with heavy exudate or necrotic tissue - small hole shaped wounds (EX) gunshot - don't put blunt/sharp needle on the end of the syringe - adding needle adds pressure

The nurse is assessing four clients for risk factors for developing a pressure injury. List in order of priority the client with the greatest risk for developing a pressure injury to the client with the smallest risk. 1. 78-year-old woman, admitted to the hospital for knee replacement surgery, no sensory impairment, continent, and ambulatory 2. 70-year-old man, admitted with metastatic bone cancer, weighing 80 lbs (36.36 kg), dehydrated, and bed bound 3. 62-year-old woman, admitted because of a cerebrovascular accident (CVA), left hemiplegia, incontinent of urine and stool, and transfers to a chair via a mechanical lift 4. 25-year-old man, diagnosed with sepsis, average height and weight, developmentally disabled, unable to communicate except with grunts, incontinent of urine, and ambulatory

1. 70-year-old man, admitted with metastatic bone cancer, weighing 80 lbs (36.36 kg), dehydrated, and bed bound 2. 62-year-old woman, admitted because of a cerebrovascular accident (CVA), left hemiplegia, incontinent of urine and stool, and transfers to a chair via a mechanical lift 3. 25-year-old man, diagnosed with sepsis, average height and weight, developmentally disabled, unable to communicate except with grunts, incontinent of urine, and ambulatory 4. 78-year-old woman, admitted to the hospital for knee replacement surgery, no sensory impairment, continent, and ambulatory Risk factors for pressure injuries include inadequate nutrition, dehydration, pain, decreased subcutaneous fat, and confinement to bed, making the 70-year-old man at greatest risk. An inability to sense or move the left side will inhibit changing positions without assistance, making the 62-year-old woman who had the CVA next at risk. Urine and fecal incontinence may result in skin breakdown in the perineal and sacral areas. The 25-year-old man is at some risk by not being able to communicate verbally and having urinary incontinence. The 78-year-old woman's nutritional status is acceptable, and she is able to move. This client has minimal risk factors. Because she is scheduled for a knee replacement, which is an elective procedure, it can be assumed that her general health is within acceptable limits. Also, she is continent and ambulatory.

Which type of debridement would the health care provider schedule for a client who requires removal of large amounts nonviable tissue, quickly? 1. Surgical debridement 2. Autolytic debridement 3. Enzymatic debridement 4. Mechanical debridement

1. Surgical debridement Surgical debridement removes large amounts of nonviable tissue in a quick manner. Autolytic debridement is a semiocclusive or occlusive dressing used to soften dry eschar via autolysis. Enzymatic debridement topically dissolves necrotic tissue, and involves placement of a moist dressing over the necrotic tissues. Mechanical debridement includes three methods: wet-to-dry dressings, wound irrigation, and whirlpool. The process occurs over time.

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 repositioning patient 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 repositioning patient 5. Raise head of bed 30 degrees when patient positioned supine

Which technology would the nurse use to reduce chronic ulcers by removing fluids from the wound? 1. Electrical stimulation 2. Topical growth factors 3. Hyperbaric oxygen therapy 4. Negative pressure wound therapy

4. Negative pressure wound therapy Negative pressure wound therapy is a new technology used to reduce chronic ulcers by removing fluids from the wound and enhancing granulation. Electrical stimulation is done by the application of low-voltage current to a wound area to increase blood vessel growth and promote granulation. Topical growth factors are the normal body substances that stimulate cell movement and growth. Hyperbaric oxygen therapy is the administration of oxygen under pressure, raising the tissue oxygen concentration.