Tissue Integrity

You are assigned five patients in your nursing unit. Which patient is at the most risk for pressure ulcers? A. A 72-YEAR-OLD FEMALE WEIGHING 82 LBS WITH STRESS INCONTINENCE AND DEMENTIA. B. A 90-YEAR-OLD MALE WITH CONGESTIVE HEART FAILURE WHO HAS 3+ PITTING EDEMA IN LOWER EXTREMITIES. C. A 6-MONTH-OLD WITH THE FLU. D. ANAMBULATORY 88-YEAR-OLD WITH DEMENTIA WHO IS ADMITTED WITH SHINGLES.

Correct Answer - A

While performing a skin assessment on a patient who is immobile, you note a purplish black area on the patient's left heel. The skin is intact. On palpation the site feels heavy and spongy. You suspect this may be? A. STAGE 1 PRESSURE INJURY B. DEEP-TISSUE INJURY STAGE 4 C. PRESSURE INJURY D. STAGE 2 PRESSURE INJURY

Correct Answer - B DEEP-TISSUE INJURIES PRESENT AS PURPLISH OR BLACKISH AREAS OVER SKIN THAT IS INTACT. THE FATTY TISSUE BELOW IS INJURED. ALSO, THEY MAY LOOK LIKE A BLACK BLISTERED AREA AND MAY FEEL HEAVY OR SQUISHY.

During a full body admission assessment, you note the patient has a stage III pressure ulcer. How would you document the appearance of the wound? A. AREA IS RED AND DOES NOT BLANCH. B. FULL-THICKNESS SKIN LOSS TO DERMIS AND SUBCUTANEOUS TISSUES. C. PARTIAL THICKNESS OF DERMIS WITH SHALLOW OPEN ULCER. D. FULL THICKNESS WITH BONE AND TENDON VISIBLE.

Correct Answer - B THIS QUESTION ASKS FOR THE CHARACTERISTICS OF A STAGE 3 PRESSURE ULCER. STAGE 3 PRESSURES ARE FULL-THICKNESS SKIN LOSS TO DERMIS AND SUBCUTANEOUS TISSUES.

During a full body admission assessment, you note the patient has a stage III pressure ulcer. How would you document the appearance of the wound? A. AREA IS RED AND DOES NOT BLANCH. B. FULL-THICKNESS SKIN LOSS TO DERMIS AND SUBCUTANEOUS TISSUES. C. PARTIAL THICKNESS OF DERMIS WITH SHALLOW OPEN ULCER. D. FULL THICKNESS WITH BONE AND TENDON VISIBLE.

Correct Answer - B THIS QUESTION ASKS FOR THE CHARACTERISTICS OF A STAGE 3 PRESSURE ULCER. STAGE 3 PRESSURES ARE FULL-THICKNESS SKIN LOSS TO DERMIS AND SUBCUTANEOUS TISSUES.

The nurse is caring for the immobile client who is at risk for development of pressure ulcers. Which food should the nurse recommend? A. ASSORTED FOOD SALAD B. OATMEAL WITH RAISINS C. BAKED CHICKEN BREAST D. LETTUCE AND TOMATO SALAD

Correct Answer - C CHICKEN IS A HIGH PROTEIN FOOD. PROTEINS ARE NEEDED TO HELP MEET THE BODY'S NEEDS FOR TISSUE REPAIR AND TO MAINTAIN TISSUE INTEGRITY

The nurse is caring for the client with the pressure ulcer illustrated. Which stage should the nurse document? A. STAGE I B. STAGE II C.STAGE III D. STAGE IV

Correct Answer - C STAGE 3 PRESSURE ULCER IS FULL THICKNESS SKIN LOSS THAT EXTENDS TO THE SUBCUTANEOUS FAT, BUT NOT FASCIA, BONE, TENDON, AND MUSCLE ARE NOT VISIBLE.

You are educating a group of nursing students about the different stages of a pressure injury. Which statement is correct about a stage 3 pressure injury? A. THERE IS FULL LOSS OF SKIN TISSUE THAT CAN EXTEND TO THE MUSCLE, BONE, OR TENDON. B. A HALLMARK OF A STAGE 3 PRESSURE INJURY IS THAT THE SKIN WILL BE INTACT BUT IT NOT BLANCH. C. THE SKIN WILL NOT BE INTACT, AND THERE WILL BE A FULL LOSS OF SKIN TISSUE THAT CAN EXTEND TO THE SUBCUTANEOUS TISSUE. D. THE WOUND EDGES WILL NEVER ROLL AWAY, AS WITH A STAGE 2 PRESSURE INJURY.

Correct Answer - C THIS IS THE ONLY CORRECT STATEMENT ABOUT A STAGE 3 PRESSURE INJURY.

As a home care nurse, you are providing care to a 63 year old male who suffered a massive stroke. He has paralysis on upper and lower extremities. He has a PEG tube with tubing feedings. The patient's daughter provides care to the patient. You notice the patient has a stage I pressure ulcer on the sacral area. What would you NOT include when educating the daughter on preventing further breakdown of the current pressure ulcer and how to prevent other ones from forming? A. EXERCISE THE EXTREMITIES ACTIVELY AND PASSIVELY. B. TURN AND RE-POSITION THE PATIENT EVERY 2 HOURS. C. KEEP THE SKIN MOIST AND LAYER THE SACRAL AREA WITH EXTRA SHEET LA YERS. D. USE PILLOWS TO ELEVATED BONY PROMINENCES.

Correct Answer - C YOU WILL KEEP THE PRESSURE ULCER DRY AND CLEAN AND AVOID EXTRA SHEETS (THIS COULD INCREASE THE RISK FOR MOISTURE AND FORM WRINKLES AND FRICTION ONTO THE SKIN. ALL THE OTHER OPTIONS ARE CORRECT EDUCATION MATERIAL.

As a home care nurse, you are providing care to a 63 year old male who suffered a massive stroke. He has paralysis on upper and lower extremities. He has a PEG tube with tubing feedings. The patient's daughter provides care to the patient. You notice the patient has a stage I pressure ulcer on the sacral area. What would you NOT include when educating the daughter on preventing further breakdown of the current pressure ulcer and how to prevent other ones from forming? A. EXERCISE THE EXTREMITIES ACTIVELY AND PASSIVELY. B. TURN AND RE-POSITION THE PATIENT EVERY 2 HOURS. C. KEEP THE SKIN MOIST AND LAYER THE SACRAL AREA WITH EXTRA SHEET LAYERS. D. USE PILLOWS TO ELEVATED BONY PROMINENCES.

Correct Answer - C YOU WILL KEEP THE PRESSURE ULCER DRY AND CLEAN AND AVOID EXTRA SHEETS (THIS COULD INCREASE THE RISK FOR MOISTURE AND FORM WRINKLES AND FRICTION ONTO THE SKIN. ALL THE OTHER OPTIONS ARE CORRECT EDUCATION MATERIAL.

You are working on a medical-surgical floor. You have the following patients below. Select all the patients below that are at risk for a pressure injury. A. A 19-YEAR-OLD FEMALE WHO IS A QUADRIPLEGIC. B. A 35-YEAR-OLD MALE WITH A BMI OF 13.6 THAT IS INCONTINENT OF STOOL AND HAS A RIGHT LEG SPLINT. C. A 55-YEAR-OLD FEMALE WHO HAS CONTROLLED DIABETES AND IS AMBULATING THREE TIMES A DAY. D. A 76-YEAR-OLD MALE WITH AN ELEVATED AMMONIA LEVEL AND IS EXCESSIVELY SWEATY. E. A 45-YEAR-OLD WITH A BRADEN SCALE SCORE OF 7.

Correct Answers - A, B, D, E THE ONLY PATIENT NOT AT RISK FOR A PRESSURE INJURY IS THE PATIENT IN OPTION C. REMEMBER ALTERED SENSORY PERCEPTION, ANY TYPE OF MOISTURE ISSUE (INCONTINENCE, SWEATING ETC.), IMMOBILITY, POOR NUTRITION, ALTERED MENTAL STATUS (HIGH AMMONIA LEVEL CAN CAUSE CONFUSION AND DROWSINESS), BRADEN SCALE SCORE LESS THAN 9 ARE ALL RISK FACTORS FOR A PRESSURE INJURY.

The nurse is planning care for the client with a Stage II pressure ulcer on the ball of the right foot. Which interventions should the nurse include in the client's care? Select all that apply. A. OBTAIN CULTURES OF THE WOUND DAILY B. CLEAN VIGOROUSLY TO REMOVE DEAD TISSUE C. COVER WITH PROTECTIVE DRESSING D. REPOSITION AT LEAST EVERY TWO HOURS E. ELEVATE THE RIGHT HEEL COMPLETELY OFF THE BED

Correct Answers C, D, E DAILY WOUND CULTURES ARE UNNECESSARY, AS ALL WOUNDS HAVE BACTERIA THE WOUND SHOULD BE CLEANSED GENTLY TO PREVENT FURTHER TISSUE TRAUMA

You're developing a plan of care for a patient who is at risk for pressure injury development. The patient is 75 years old and weighs 95 lbs. The patient is confused and has right and left leg contractures. In addition, the patient has a urinary tract infection and is incontinent of urine. The patient is on aspiration precautions and is ordered a honey thick liquid diet with pureed foods. Select all the nursing intervention you will include in the patient's plan of care to prevent a pressure injury. A. WHEN FEEDING THE PATIENT KEEP THE HEAD OF BED ELEVATED AT 45' DEGREE AND AVOID ELEVATING THE FOOT OF THE BED. B. APPLY BARRIER CREAM AS NEEDED TO THE SKIN DAILY. C. TURN THE PATIENT EVERY 4 HOURS. D. KEEP LINENS AND GOWNS DRY AND WRINKLE FREE. E. USE A WEDGE PILLOW FOR THE RIGHT AND LEFT LEGS.

Correct Answers- B, D, E OPTION A IS WRONG BECAUSE WHEN THE PATIENT IS SITTING UP YOU WANT TO PREVENT THEM FROM SLIDING DOWN IN THE BED. THIS CAN CAUSE FRICTION AND SHEAR, WHICH CAN LEAD TO A PRESSURE INJURY. RAISING THE FOOT OF THE BED WHEN THE HOB IS ELEVATED WILL HELP PREVENT THE PATIENT FROM SLIDING DOWN. OPTION C IS WRONG BECAUSE YOU WILL NEED TO TURN THE PATIENT EVERY 2 HOURS NOT EVERY 4 HOURS. OPTION E IS BENEFICIAL FOR THE LEG CONTRACTURES TO PREVENT A PRESSURE INJURY TO THE KNEES AND ANKLES.