Chapter 29. Skin intergrity and would care: analyze cues and prioritize hypotheses; plan and generate solutions

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

"My wound will look beefy red within 1 week."

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

A patient with a profusely bleeding wound

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

Agency for Healthcare Research and Quality (AHRQ)

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

Bone Tendon Muscle

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

Dermis Epidermis

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? Ingest 25% of each meal during hospitalization. Report that pain management regimen lowers pain level to 6/10 or lower within the shift. Show acceptance of the change in body image by continuing to have the nurse change the dressing after 1 week. Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week.

Exhibit signs of healing as evidenced by presence of granulation tissue in the wound within 1 week.

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. Wound, ostomy, and continence nurse (WOCN) Social worker Surgeon Nutritionist X-ray technician

Wound, ostomy, and continence nurse (WOCN) Social worker Nutritionist

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

Impaired Skin Integrity

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

Impaired Skin Integrity Risk for Pressure Ulcer/Injury Impaired Tissue Integrity Risk for Impaired Skin Integrity

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

Low prealbumin levels Immobility Stage 2 pressure injury

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

Patient who is experiencing shock from a profusely bleeding wound Patient who just had an incision eviscerate Patient with a stage 4 pressure injury

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. Patient will be infection-free. Patient will eat a high-protein diet at every meal. Patient will help with transfers within 24 hours Patient will be infection-free. Patient's wound will heal normally. Patient's incision will have proper healing.

Patient will eat a high-protein diet at every meal. Patient will help with transfers within 24 hours

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

Patient's Braden Scale score will stay the same or increase within 72 hours.

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? Patient's pressure injury will decrease at least 1 to 2 cm in size per week. Patient's wound will exhibit granulation tissue in the wound by 1 week. Patient will demonstrate wound care after receiving teaching. Patient will have intact skin throughout hospital stay.

Patient's wound will exhibit granulation tissue in the wound by 1 week.

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

Promote complete healing of wound.

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. Repositioning the patient Administering medication for wound pain Assessing and evaluating a patient's skin and wounds Reporting any changes in patient's skin integrity or condition Applying a nonsterile dressing for chronic wounds with an established treatment plan

Repositioning the patient Reporting any changes in patient's skin integrity or condition Applying a nonsterile dressing for chronic wounds with an established treatment plan

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

Risk for Impaired Skin Integrity

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. Therapies consistent with guidelines for treatment of wounds Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN) Ability of the patient to maintain a pain rating of 8/10 during activities of daily living Agreement of the patient with the treatmen

Therapies consistent with guidelines for treatment of wounds Recommendations from collaborating health care professionals, such as a wound, ostomy, and continence nurse (WOCN) Agreement of the patient with the treatment plan Capability of the patient to purchase supplies for home care as required

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

Type of wound Type of wound bed tissue Unexpected assessment findings Unexpected laboratory findings