Pressure Injury (Ulcers)- NUR 1014

Serum protein

helps establish nutritional status.

The nurse is reviewing documentation on a client at risk for developing a pressure injury. Which note in the documentation should indicate to the nurse that the plan of care has been followed​ correctly?

"Client refusing meals. Nutritional consult prescribed." Rationale: Nutritional consults should be prescribed for clients with inadequate nutritional intake. Clients should be turned every 2 hours. Client comfort and pain should be assessed more often than daily. Nutritional supplements should be given to clients who eat​ 50% or less of their meals.

What does ESR (erythrocyte sedimentation rate) determine?

The presence of osteomyelitis.

Treatment: Pharmacologic

Topical and systemic antibiotics, topical products that promote healing, dressings: hydrocolloid and transparent film dressing, protect from friction and bacterial colonization.

What pharmacologic treatments are used for pressure ulcers?

Topical and systemic antibiotics, topical products that promote healing, dressings: hydrocolloid and transparent film dressing, protect from friction and bacterial colonization.

Identify categories of the Braden Scale.

Sensory perception: ability to respond meaningfully to pressure related discomfort. Moisture: degree to which skin is exposed to moisture. Activity: Degree of physical activity Mobility: Ability to change and control body position Nutrition: Usual food intake pattern Friction and sheer

The nurse is caring for a client with an open pressure injury with minimal necrotic tissue. Which dressing should the nurse identify as most appropriate for the​ client?

Wet-to- dry gauze dressing with sterile normal saline Rationale: Wet-to-dry gauze dressing with sterile normal saline will soften the necrotic tissue so it will adhere to the gauze and be debrided with the dressing change. Granulex is appropriate for intact skin. Transparent and hydrocolloid dressings help to prevent skin breakdown.

The charge nurse receives report for all clients on the unit. Which client should the nurse consider as being at risk for development of pressure injuries

Client who is 92- years- old, client with type 1 diabetes mellitus, client with a history of anorexia nervosa, client on bedrest Rationale: A client on bedrest is​ immobile, which increases the risk for developing pressure injuries. An older adult client is at risk because of the loss of lean body​ mass, epidermal​ thinning, decreased skin​ elasticity, and increased skin dryness. A client with type 1 diabetes mellitus is at risk because of compromised oxygen delivery to the tissues. A client with a history of anorexia nervosa is at risk because of inadequate​ nutrition, which leads to weight​ loss, muscle​ atrophy, and loss of subcutaneous tissue. A client admitted to an acute care unit is not usually at risk for developing a pressure injury.

Planning

Determine SMART goals for individuals with pressure ulcers

Ischemia

Inadequate blood supply to an organ or part of the body which causes tissue necrosis and eventual ulceration

What is the most serious complication of pressure ulcers?

Infection

Assessment: How does the nurse assess for pressure ulcers?

Inspect in good lighting Assess Cap refill or blanch response over boney prominences. Assess for abrasions or excoriations Palpate the temp of the skin over pressure areas Palpate over bony prominences for edema which feels spongy or boggy

What are the clinical signs of systemic infection?

fever, chills, elevated WBC

Stage 4 of pressure ulcer

full thickness skin loss with extensive tissue damage and necrosis, muscle tendon, and bone are exposed and directly palpable, risk of osteomyelitis is increased

Unstageable pressure ulcer

full thickness tissue loss with depth completely obscured by slough or eschar in the wound bed, stable eschar serves as a natural barrier and should not be removed

Stage 1 of pressure ulcer

nonblanchable erythema of intact skin, usually occurs on a localized area over a bony prominence, may be painful and a different temperature and consistency than surrounding skin

Stage 2 of pressure ulcer

partial thickness skin loss involving the dermis; presents as a shallow open ulcer without slough may also be present in an intact or open pus or blood filled blister or a shiny dry ulcer without slough

What are the clinical signs of infection at the site?

redness, warmth, swelling, pain, odor, exudate

Necrosis

the death of most or all of the cells in an organ or tissue due to disease, injury, or failure of the blood (dead tissue)

The nurse is assisting nursing assistive personnel​ (NAP) reposition a client who is immobile and has been lying on the left side. For which action by the NAP should the nurse​ intervene?

Asks for help pulling client back up to the head of the bed Rationale: Clients should not be pulled up in​ bed, as shearing forces and friction can break down skin tissue. Clients should be lifted instead of being pulled. It is appropriate for the foam wedge to be placed under the​ client's left side. The skin over bony prominences on the left side should be inspected when the client is turned. It is appropriate to use pillows to keep the​ client's heels off the bed.

How do pressure ulcers develop?

External pressure compress blood vessels: when pressure is applied to the skin over a bony prominence for 2 hours, the ischemia occurs and hypoxia causes irreversible damage Friction from shearing: forces that tear and injure vessels; results when 1 tissue layer slides over the other, the stretching and bending of the blood vessels cause shearing forces when the HOB is elevated and the torso slides down, or pulling the client up in bed can cause this as well

A client with a deep tissue injury and white exudate develops a fever. Which test should the nurse anticipate being prescribed by the healthcare provider?

Culture and sensitivity of the wound bed Rationale: The wound bed can be cultured to determine the organism causing the infection.

Implementation

How does the nurse implement a plan of care to treat and prevent pressure ulcers.

What are the factors that contribute to pressure ulcers?

Immobility, inadequate nutrition, edema, fecal and urinary incontinence, decreased mental status, diminished sensation, excessive body heat, advanced age, chronic medical conditions, poor lifting and transferring techniques, incorrect positioning, hard surfaces, and incorrect positioning, hard surfaces, and incorrect application of pressure relieving devices

Nursing Problem/Diagnosis: Identify common nursing problems/nursing diagnoses for individuals with pressure ulcers.

Impaired skin integrity, infection, imbalanced nutrition, risk for compromised dignity, low self esteem.

The nurse manager observes a new nurse talk with a client with a stroke and decreased mobility about ways to prevent pressure injures. For which statement should the nurse manager​ intervene?

"Due to decreased mental status, you will need to be turned every 2 hours." Rationale: There is no indication the client has decreased mental status. The client should be turned and repositioned every 2 hours. Keeping the skin​ clean, dry, and moisturized will help prevent tissue damage. A diet with adequate​ calories, protein,​ vitamins, and iron will help to prevent skin breakdown. The client can be encouraged to participate by helping to move the left side every​ 15-30 minutes. Even small adjustments of​ 10-20 degrees can prevent tissue injury.

A client asks what effect nutrition has on skin integrity. Which response should the nurse make that explains the relationship of nutrition to pressure injury development?

"Poor dietary intake kilocalories, protein, and iron can increase the risk of pressure injuries." Rationale: Poor dietary intake of​ kilocalories, protein, and iron has been associated with the development of pressure injuries. An association between minerals and risk of pressure injury development is unknown. Increased intake of protein will not cause pressure injuries to develop.

A client is suspected of having a deep tissue injury. Which intervention should the nurse include in the plan of care?

Application of a moisturizing barrier cream, application of nonadhesive protective dressing, consideration of appropriate support surfaces and other measures to remove all pressure Rationale: To treat a client with a suspected deep tissue​ injury, the nurse should apply a moisturizing barrier​ cream, a nonadhesive protective​ dressing, and consider support surfaces that will remove all pressure from the area. Debridement of wound bed and edges and​ wet-to-damp dressing changes are not appropriate for deep tissue injuries.

How does the nurse prevent nutritional imbalance?

Assess factors involved in inadequate dietary intake of protein or nutrients Offer nutritional supplements and support during meal time as necessary Consult with a dietician

How does the nurse support human dignity and self-esteem?

At each exam, notice signs of neglect or abuse Develop a caring trusting relationship with the client Refer to counseling as appropriate Teach family members and caregivers about repositioning every two hours, skin hygiene, and positioning Assist the family to obtain supportive devices to maintain appropriate positioning of the client.

The nurse identifies that a client is at risk for impaired skin integrity. Which intervention should the nurse add to this client's plan of care?

Avoid massaging bony prominences, use positioning devices, Inspect the skin every day Rationale: Using positioning devices such as pillows or foam wedges to protect bony​ prominences, not massaging bony​ prominences, and inspecting the skin daily help prevent skin breakdown. A​ side-lying position or keeping the head of bed elevated more than 30 degrees can put pressure on specific body areas.

How does the nurse maintain skin integrity for an individual with a pressure ulcer?

Conduct assessment daily Clean skin at time of soiling, routine intervals, avoid hot water, use gentle cleansers Minimize environmental factors that lead to skin drying: treat dry skin with moisturizers, provide humidity to room. Avoid massage over bony prominences. This has been shown to lead to deep tissue trauma in clients at risk for or beginning to show sings of a pressure ulcer. Minimize exposure to moisture due to incontinence, perspiration, or wound drainage. Proper positioning, transferring, and turning. Use lubricants, protective films, dressings, and padding to reduce friction. Reposition immobile clients at least every two hours, use positioning devices such as pillows or foam wedges to protect bony prominences. Use devices to totally relieve pressure from the heels for the totally immobile client. Avoid placing the client in the side lying position directly on the trochanter Maintain the head of the bed at the lowest degree of elevation limit the amount of time that the head of the bed is in high fowlers. Use assistive devices to move the client in bed who cannot assist during transfers or position changes. Place the at risk client on a pressure reducing device, such as foam, static air, alternating air, gel, or water mattress. Use pressure reducing devices when the client is in the chair.

A client with poor nutritional intake is at high risk for developing pressure injuries. Which device should the nurse identify as appropriate for this client?

Foam wedges and pillows, Static low-air- loss bed, Memory foam chair pad while client is in chair, gel flotation pads Rationale: Gel flotation pads can be used to protect bony prominences and are filled with a substance similar to fat. A static​ low-air-loss bed is made up of many​ air-filled cushions that can be reduced under bony prominences and inflated to provide support in other areas. Foam wedges and blocks can be used to prevent​ bone-on-bone contact and support positioning. Memory foam chair pads distribute weight more evenly over the surface of the seat and can mold to the body. Foam​ blocks, not rolled​ blankets, are used to protect heels from shearing and limit pressure.

Stage 3 of pressure ulcer

Full thickness skin loss involving damage or necrosis of subQ tissue bone, tendon, and muscle are not exposed, the ulcer presents clinically as a deep crater with or without adipose tissue, may be very shallow

Eschar

Hard, leathery crust that covers a burn wound and harbors necrotic tissue.

A client in high- Fowler position to facilitate breathing. Which body pressure are should the nurse be most concerned about?

Heels Rationale: A client in Fowler position has pressure on the​ heels, pelvis,​ sacrum, and vertebrae. A client in the lateral position has pressure on the knee and ilium. A client in the prone position has pressure on the zygomatic bone.

The nurse is caring for a client with incontinence of urine and sudden onset of watery diarrhea. Which action should be included in the plan of care to maintain skin​ integrity?

Increase the humidity in the room and limit exposure to cold, apply a moisturizing barrier cream to the skin at greatest risk of breakdown, clean skin immediately at the time of soiling and routinely, assess skin systematically at least once a day Rationale: To maintain skin integrity of a client with incontinence of urine and​ stool, the nurse should assess skin systematically at least once a​ day, clean skin immediately upon soiling and​ routinely, increase the humidity in the room and limit exposure to​ cold, and apply a barrier cream to the skin at the greatest risk of breakdown. Bony prominences should not be massaged.

When a pressure ulcer is present, what does the nurse notice and record?

Location related to the bony prominence Size of the ulcer in cm (length, width, depth) Presence of undermining or sinus tracts (assess as on the face of a clock, where the 12 oclock is the patients head) Stage of ulcer Color of the wound bed and location of necrosis or eschar Condition of the wound margins Integrity of the surrounding skin Clinical signs of infection at the site Client complaints of pain or discomfort at the wound site Clinicals signs of systemic infection

How does the nurse prevent Infection of Pressure ulcers?

Maintain skin hygiene, maintain appropriate nutrition and hydration, recognize early stages of a pressure ulcer, contact HCP at early appearance of pressure ulcer, maintain and improve activity level.

A client has a follow- up appointment for treatment of a pressure injury. Which client outcome should indicate to the nurse that treatment goals have been met?

The client and family demonstrate an understanding of preventative care measures, the client has enrolled in a smoking cessation program, and the wound has decreased in size Rationale: The client and family demonstrate an understanding of wound​ care, the wound has decreased in​ size, and the client has enrolled in a smoking cessation program indicate that nursing interventions and education have been effective. Greenish exudate indicates a possible infection. The​ client's decrease in weight indicates that nutrition may not be adequate for optimal wound healing and maintenance of proper weight.

While assessing the skin of a client who has undergone​ surgery, the nurse observes erythema to the left scapulae. Which action should the nurse take before reassessing the skin to determine if the erythema is a pressure​ injury?

Reposition the client Rationale: The nurse should reposition the client to remove pressure from the scapulae and then reassess for redness in​ one-half or​ three-fourths the time it took to create the reddened area. If the reddened area does not​ clear, the client has a stage 1 pressure injury. Massaging the scapulae with​ lotion, applying a warm​ blanket, or covering the area with a dressing are not the most appropriate actions to take before reassessing the client.

The nurse reviews alginate dressings with a new nurse. For which type of pressure injury should the nurse identify this dressing is​ used?

Stage 2, 3, and 4 without eschar Rationale: Alginate dressing should be used for stage​ 2, 3, and 4 without eschar pressure​ injuries, but not for stage 4 with eschar pressure injuries. An alginate dressing is not used for stage 1 pressure injuries.

A client has a pressure injury on the right elbow that is covered with eschar and extensive tissue damage. Which stage should the nurse document this ulcer to be?

Stage 4 Rationale: A stage 4 pressure injury may be covered with eschar. Eschar is not present in stage 1 or stage 2. Stage 3 pressure injuries may have eschar​ present, but tissue damage is limited to the subcutaneous tissue.

The nurse is caring for a client admitted with a pressure injury. Which data should the nurse document when assessing the pressure​ injury?

Stage of the ulcer, Integrity of the surrounding tissue, signs of infection, and color of the wound bed Rationale: Documenting the stage of the pressure​ injury, color of the wound​ bed, integrity of the surrounding​ tissue, and signs of infection are of utmost importance. Assessment of home management does not need to be documented.

A client with deep tissue damage develops eschar. Which procedure should the nurse anticipate being prescribed?

Surgical debridement Rationale: When eschar has​ formed, surgical debridement and removal of necrotic material is necessary. Application of a barrier cream is appropriate for intact skin. Use of petroleum ointment is not appropriate. Application of a​ moisture-retaining protective dressing is appropriate for a pressure injury without eschar or after the eschar has been surgically removed.

A client who has been sedated and on mechanical ventilation for several days is on a low- air- loss bed; however, the client has a localized purple area of discoloration over the coccyx that does not blanch. Which pressure injury should the nurse suspect for this client?

Suspected deep tissue injury Rationale: Deep tissue injury is suspected when intact skin has a localized purple discoloration and does not blanch when pressed. A thin blister or eschar can develop very quickly. The assessment does not describe bruising. A stage 1 pressure injury has intact skin with localized redness that does not blanch when pressed. A stage 2 pressure injury has a shallow open wound or blister without sloughing.

The nurse is caring for a client at risk for a pressure injury. Which action should the nurse use to maintain the skin​ integrity?

Treating dry skin with moisturizing lotions directly applied to moist skin after bathing, assessing the skin upon admission and then daily using the same screening tool, Cleaning the skin immediately if exposed to urine or feces Rationale: To maintain skin integrity for clients at risk for pressure​ injuries, assess the skin upon admission and then​ daily, using the same screening​ tool; treat dry skin with moisturizing lotions directly applied to moist skin after​ bathing; and immediately clean the skin if exposed to urine or feces. Do not scrub the​ client's skin when​ bathing; instead, minimize the force and friction applied to the skin to prevent injury. Avoid exposing the client to cold and low humidity.

Debridement

the process of removing painful or necrotic material, including all loose tissue, wound debris, and dead tissue, from a wound.

Treatment: Autolytic debridement

dressing that contain wound moisture, such as hydrocolloid and clear absorbent acrylic dressings, trap the wound drainage against the eschar; this allows the body's own enzymes in the drainage to break down the necrotic tissue, this type causes the least damage to healthy surrounding tissue.

Suspected deep tissue injury

intact skin with purple discoloration or blood filled blister indicated damage of underlying soft tissue from shear or pressure

Pressure ulcer

ischemic lesions of the skin and underlying tissue caused by external pressure that impairs the flow of blood and lymph.

Urine culture and sensitivity

will determine the presence of a urinary tract infection​ (UTI)