Sherpath week 6
A patient who was recently diagnosed with diabetes mellitus asks the student nurse why diabetes mellitus affects skin integrity and healing. Which response by the student nurse indicates effective learning?
"Diabetes mellitus causes changes to the micro-vascular and macro-vascular systems." Diabetes mellitus causes changes to the micro-vascular and macro-vascular systems, which decreases blood flow to the wound. Decreased blood flow decreases the supply of nutrients and oxygen to the wound, thereby affecting skin healing.
The registered nurse is teaching the student nurse about delayed wound healing. Which statement made by the student nurse indicates a need for further teaching?
"Wounds should be kept wet and moist to prevent skin tissue from tightening" is a statement that indicates the need for further teaching. Excessive moisture can complicate the wound healing process by inviting bacteria into the wound.
The nurse is classifying a wound in her chart. The nurse understands that which documentation would be a standard classification that other health care workers would be able to comprehend?
An open knife wound with contamination is documentation that others would comprehend, as wounds are classified by cause (in this case a knife), as well as whether they are contaminated.
A patient with diabetes is being seen in the emergency department for blood sugar issues. What is the most appropriate nursing action in this scenario?
Checking the patient's feet Checking the patient's feet indicates proper assessment of this patient. Patients with diabetes are at high risk for wounds to their feet, due to impaired microvasculature. Therefore, checking the patient's feet for wounds should be part of the assessment process.
The student nurse is learning how to classify burn wounds. Which statement made by the student nurse reflects a misunderstanding?
I can classify burn wounds according to the depth and width of the lesion." Burn wounds are not classified according to how wide the lesion is, so this statement shows a misunderstanding on the part of the student nurse.
A student nurse understands that some patients are more prone to developing pressure ulcers than others. Which statement made by the student nurse indicates teaching has been effective?
Patients with a low BMI are at risk for pressure ulcers." "Patients with a low BMI are at risk for pressure ulcers" is a statement that indicates effective teaching. When patients are of a low weight or have a low BMI, they risk being malnourished. Nutritional deficits can adversely affect wound healing. The body requires additional energy to recover and heal from any injury because overall caloric needs increase. "Patients with zinc deficiencies are at risk for pressure ulcers." "Patients with zinc deficiencies are at risk for pressure ulcers" is a statement that indicates effective teaching. A zinc deficiency is a type of malnutrition. Nutritional deficits can adversely affect wound healing. The body requires additional energy to recover and heal from any injury because overall caloric needs increase.
A patient has a post-operative follow-up appointment with the nurse. During the appointment, the nurse removes the patient's dressing and observes that the wound appears infected. Which action by the nurse demonstrates proper knowledge of wound healing and skin integrity?
Reviewing the patient's medications Reviewing the patient's medications is the appropriate action. Some medications, such as steroids, suppress cellular wound responses and may increase the risk of infection in a wound. Given that the patient just had surgery, it is most likely that the patient is taking medications that could interfere with the wound healing process.