Sherpath: Skin Integrity and Wound Care: Analyze Cues and Prioritize Hypotheses; Plan and Generate Solutions

Place the patients in the order in which the nurse would prioritize their care from highest priority to lowest priority. 1. Patient who is experiencing shock from a profusely bleeding wound 2. Patient with a stage 4 pressure injury 3. Patient who just had an incision eviscerate

Answer: 1,3,2 The patient experiencing shock from a profusely bleeding wound is seen first because this is life-threatening, and the wound is bleeding (ABCs). Next is the patient with an evisceration; although still a medical emergency, it is not as critical as active bleeding. The patient with a stage 4 pressure injury is seen last because it is a chronic condition.

The nurse would use which organization's guidelines to direct care for a patient's back wound? A. Agency for Healthcare Research and Quality (AHRQ) B. National Council of State Boards of Nursing (NCSBN) C. International Confederation of Dietetic Associations (ICDA) D. The Joint Commission (TJC)

Answer: A AHRQ provides evidence-based practice for wound care guidelines, and the nurse would use its guidelines. Although NCSBN is important for nurses, it does not provide guidelines for patients' wound care. While diet is important for wound healing, the ICDA does not provide guidelines for wound care. It provides dietary guidelines. TJC provides accreditation for health care organizations but does not provide guidelines for wound care.

Which hypothesis would the nurse develop for an immobile patient who has intact skin? A. Risk for Impaired Skin Integrity B. Traumatic Wound C. Risk for Impaired Tissue Integrity D. Pressure Ulcer/Injury

Answer: A Because the patient is immobile but still has intact skin, the hypothesis is a Risk for Impaired Skin Integrity. Traumatic Wound is inappropriate because the patient has intact skin; there is no evidence of a wound. Although Risk for Impaired Tissue Integrity is a "risk for" hypothesis, the patient would have altered skin integrity before altered tissue integrity. Pressure Ulcer/Injury is inappropriate because the patient still has intact skin. The appropriate hypothesis is a "risk for" hypothesis.

Which patient would the nurse see first after receiving report? A. A patient with a profusely bleeding wound B. A patient with a wound dehiscence C. A patient with an early wound infection D. A patient experiencing a wound from a surgical incision

Answer: A The nurse would see the patient with a profusely bleeding wound first because it is life-threatening. The nurse would see the patient with an eviscerated wound immediately, but not a patient with a wound dehiscence. A wound dehiscence is not as severe as an evisceration. Although the patient with an early wound infection is important, it is not life-threatening, and this patient does not need to be seen first. There is another patient who is more immediate. A wound from a surgical incision is not life-threatening, so this patient does not need to be seen first. There is another patient with a more serious condition.

Which hypothesis would the nurse select for a patient with a breakdown in the dermis from external forces? A. Impaired Skin Integrity B. Risk for Impaired Skin Integrity C. Impaired Tissue Integrity D. Burn Wound

Answer: A The nurse would select Impaired Skin Integrity because the dermis (skin) has a break in the integrity. There is an actual break; therefore a hypothesis with the words "risk for" is inappropriate for this patient. The dermis is affected, which is skin, not tissue. Subcutaneous tissue, bone, and tendon are tissue. The patient did not experience a burn wound; thus, the hypothesis of Burn Wound would be inappropriate for this patient. A burn is from an accident or traumatic event, not a breakdown in the dermis from external forces.

Which primary areas, if injured in the patient, would prompt the nurse to develop the hypothesis Impaired Tissue Integrity? Select all that apply. A. Bone B. Tendon C. Muscle D. Dermis E. Epidermis

Answer: A,B,C Bone is tissue and it would be damaged. The hypothesis Impaired Tissue Integrity would be appropriate. Tendon is tissue and it would be damaged. The hypothesis Impaired Tissue Integrity would be appropriate. Muscle is tissue and it would be damaged. The hypothesis Impaired Tissue Integrity would be appropriate. Dermis is skin, and it would not be a primary area that would be damaged. Dermis is damaged in Impaired Skin Integrity, not Impaired Tissue Integrity. Epidermis is skin, and it would not be a primary area that would be damaged. Epidermis is damaged in Impaired Skin Integrity, not Impaired Tissue Integrity.

Which multidisciplinary team members would the nurse consult for a thin, homeless patient who has a stage 2 pressure injury on the sacrum? Select all that apply. A. Wound, ostomy, and continence nurse (WOCN) B. Social worker C. Surgeon D. Nutritionist E. X-ray technician

Answer: A,B,D A WOCN would be consulted in this situation to ensure proper healing of the pressure injury. A social worker would be part of the collaboration team in this situation to ensure the homeless patient has access to community resources and finances. A surgeon does not need to be consulted yet, as wounds are only in stage 2. A nutritionist should be consulted because the patient is thin. Although the x-ray technician is an employee, the technician is not a multidisciplinary team member.

Which patient cues, when analyzed together, would prompt the nurse to select the hypothesis Impaired Skin Integrity? Select all that apply. A. Low prealbumin levels B. Immobility C. Inexperience with wound care D. Stage 2 pressure injury E. Stage 4 pressure injury

Answer: A,B,D Low prealbumin level is a cue for Impaired Skin Integrity because it can affect healing. Immobility is a cue for Impaired Skin Integrity because it can lead to prolonged pressure. Inexperience with wound care is a cue for inadequate knowledge of wound care, not Impaired Skin Integrity. A stage 2 pressure injury is a cue for Impaired Skin Integrity because it affects the epidermal and dermal layers of the skin. A stage 4 pressure injury is a cue for Impaired Tissue Integrity, not Impaired Skin Integrity, because it affects subcutaneous tissue and underlying tissue of bone, tendon, muscle, and cartilage

Which components to promote skin integrity and wound healing would the nurse include when caring for a patient with a leg wound who will be discharged in several days? Select all that apply. A. Therapies consistent with guidelines for treatment of wounds B. Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN) C. Ability of the patient to maintain a pain rating of 8/10 during activities of daily living D. Agreement of the patient with the treatment plan E. Capability of the patient to purchase supplies for home care as required

Answer: A,B,D,E Therapies consistent with guidelines for treatment of wounds and pressure injuries are an appropriate component to include. Recommendations from collaborating health care professionals, such as a WOCN, are appropriate components to include. Ability of the patient to maintain a pain rating of 8/10 during activities of daily living is inappropriate. The patient would be in too much pain to complete activities of daily living. The patient should agree with the established treatment plan to encourage compliance, and this agreement would be included.Capability of the patient to purchase supplies for home care is an appropriate component of care to include.

For which patient hypotheses would the nurse select turning and positioning as a solution? Select all that apply. A. Impaired Skin Integrity B. Risk for Pressure Ulcer/Injury C. Malignant Wound D. Impaired Tissue Integrity E. Risk for Impaired Skin Integrity

Answer: A,B,D,E Turning and positioning is not a solution for Malignant Wound; specific wound care is needed.

Which categories can the nurse use to organize and link the patient's skin integrity cues? Select all that apply. A. Type of wound B. Type of wound bed tissue C. Type of infection D. Unexpected assessment findings E. Unexpected laboratory findings

Answer: A,B,D,E Type of wound is a category the nurse can use to link cues for skin integrity and determine the correct hypothesis. Type of wound bed tissue is a category the nurse can use to link cues for skin integrity and determine the correct hypothesis. While infection may be a cue, it is not a category the nurse can use to link cues for skin integrity and determine the correct hypothesis. Unexpected assessment findings is a category the nurse can use to link cues for skin integrity and determine the correct hypothesis. Unexpected laboratory findings is a category the nurse can use to link cues for skin integrity and determine the correct hypothesis.

Which tasks related to skin integrity and wound care would the nurse likely delegate to an unlicensed assistive personnel (UAP) who is caring for a patient with a wound? Select all that apply. A. Repositioning the patient B. Administering medication for wound pain C. Assessing and evaluating a patient's skin and wounds D. Reporting any changes in patient's skin integrity or condition E. Applying a nonsterile dressing for chronic wounds with an established treatment plan

Answer: A,D,E Repositioning the patient is a task the UAP can perform for a patient with a wound. The UAP cannot administer medications for pain; this is a nursing responsibility. Assessing and evaluating a patient's skin and wounds are nursing responsibilities; they cannot be delegated. The UAP can report any changes in the patient's skin condition or integrity to the nurse. Application of nonsterile dressings for chronic wounds with an established treatment plan is a task the UAP can perform.

Which components are likely damaged when the nurse chooses the hypothesis Impaired Skin Integrity for a patient? Select all that apply. A. Dermis B. Bone C. Muscle D. Tendon E. Epidermis F. Subcutaneous tissue

Answer: A,E The dermis would be damaged if Impaired Skin Integrity is the hypothesis. Skin layers are affected. Bone would be damaged if the hypothesis is Impaired Tissue Integrity, not Impaired Skin Integrity. Bone is tissue, not skin. Muscle would be damaged if Impaired Tissue Integrity (not Impaired Skin Integrity) is the hypothesis. Muscle is tissue, not skin. A tendon would be damaged if the hypothesis is Impaired Tissue Integrity, not Impaired Skin Integrity. Tendon is tissue, not skin. The epidermis would be damaged if Impaired Skin Integrity is the hypothesis, indicating skin layers are affected.Subcutaneous tissue would be damaged if Impaired Tissue Integrity (not Impaired Skin Integrity) is the hypothesis. Subcutaneous tissue is tissue, rather than skin.

Which nursing-derived outcome relates directly to a patient who has a break in the skin from an external force, such as trauma or an accident? A. Patient's pressure injury will decrease at least 1 to 2 cm in size per week. B. Patient's wound will exhibit granulation tissue in the wound by 1 week. C. Patient will demonstrate wound care after receiving teaching. D. Patient will have intact skin throughout hospital stay.

Answer: B Pressure injuries are a result of prolonged pressure and tissue ischemia, not trauma or accidents; thus, this goal would not directly relate to a break in the skin from external forces. A break in the skin from external forces, such as trauma or an accident, indicates a wound; thus, this goal would directly relate to the break in skin from external forces. While it is appropriate for a patient to demonstrate wound care after receiving teaching, this goal does not relate directly to a break in the skin from external forces; it relates to inadequate knowledge. The patient cannot have intact skin because there is already a break in the patient's skin from external forces; thus, this outcome would not directly relate to the break in skin from external forces.

Which SMART outcomes would the nurse develop for the patient who is recovering from a small abdominal incision with a hypothesis of Surgical Wound? Select all that apply. A. Patient will be infection-free. B. Patient will eat a high-protein diet at every meal. C. Patient will help with transfers within 24 hours. D. Patient's wound will heal normally. Patient's incision will have proper healing.

Answer: B,C A SMART outcome has a time parameter; this outcome of being infection-free has no time parameter. A SMART outcome is specific, measurable, achievable, and relevant (high-protein diet). It also must have a time frame (at every meal). A SMART outcome is specific, measurable, achievable, and relevant (help with transfers). It also must have a time frame (within 24 hours). "Normally" is not measurable, making it an invalid SMART outcome. Also, there is no time frame and no way to measure the healing. "Proper healing" is not measurable, making it an invalid SMART outcome. Also, there is no time frame and no way to measure the healing.

Which overall goal would the nurse develop for a patient with a leg incision? A. Encourage participation in position changes within 48 hours. B. Reduce pain level to a 5/10 after treatment. C. Promote complete healing of wound. D. Enhance generation of solutions.

Answer: C Encouraging participation in position changes within 48 hours is more of an expected outcome. It is specific and uses the SMART (specific, measurable, assignable, relevant, time-based) method, unlike an overall goal, which is broader in scope. The pain level should decrease to a 3/10 or less after treatment. The overall goal for a patient with a wound is to promote complete healing of the wound. Solutions are developed after goals; enhancing generation of solutions is not an overall goal for wounds.

Which expected outcome would the nurse select for a patient who has a hypothesis of Pressure Ulcer/Injury? A. Patient will demonstrate wound care after receiving teaching. B. Patient will have intact skin throughout hospital stay. C. Patient's diet will be low in protein for each meal. D. Patient's Braden Scale score will stay the same or increase within 72 hours.

Answer: D Demonstrating wound care is a goal for the hypothesis of inadequate knowledge of wound care, not for Pressure Ulcer/Injury. Maintaining intact skin throughout hospital stay is for the hypothesis Risk for Impaired Skin Integrity, not for Pressure Ulcer/Injury. A patient with a Pressure Ulcer/Injury needs a high-protein diet, not a low-protein diet. A Braden Scale score that stays the same or increases is an expected outcome for Pressure Ulcer/Injury. It is a measurable outcome that is related to the hypothesis.

Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to look at the incision and not wanting to eat? A. Ingest 25% of each meal during hospitalization. B. Report that pain management regimen lowers pain level to 6/10 or lower within the shift. C. Show acceptance of the change in body image by continuing to have the nurse change the dressing after 1 week. D. Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week.

Answer: D It is not sufficient for a patient who is not hungry to ingest 25% of meals. The percent should be higher (at least 50% or more). Reporting that pain management regimen reduces pain to 3/10 or lower (not 6/10 or lower) within the shift is a more appropriate outcome. To show acceptance of change in body image, the patient should be helping with dressing changes within 1 week. Because the overall outcome is healing of the wound, this outcome demonstrates progressive healing of wound.

Which patient statement alerts the nurse that teaching was successful about the goals of treatment for a healing arm wound? A. "My participation is not needed for position changes." B. "I will be infection-free by the time I go home." C. "I will need to meet with the mental health professional before discharge." D. "My wound will look beefy red within 1 week."

Answer: D The patient's participation is needed for position changes; this statement does not indicate successful teaching. The wound is healing and should not become infected while the patient is in the hospital. The wound should be infection-free the entire time the patient is in the hospital. There is no indication that the patient is experiencing emotional issues related to the wound; thus, this requirement is unnecessary. If the wound looks beefy red within 1 week, that indicates granulation tissue is forming and the wound is healing, which is normal. This statement indicates successful teaching.