Module 8 - Multidimensional Care I

Nurse Melinda is caring for an elderly bedridden adult. To prevent pressure ulcers, which intervention should the nurse include in the plan of care? A. Turn and reposition the client at least once every 8 hours. B. Vigorously massage lotion into bony prominences. C. Post a turning schedule at the client's bedside. D. Slide the client, rather than lifting, when turning.

C. Post a turning schedule at the client's bedside.

Nurse Catherine is changing a dressing and providing wound care. Which activity should she perform first? A. Assess the drainage in the dressing. B. Slowly remove the soiled dressing C. Wash hands thoroughly. D. Put on latex gloves.

C. Wash hands thoroughly

Adequate Nutrition Intake

Calories Protein Vitamins Minerals Water

The staff nurse reviews the nursing documentation in a client's chart and notes that the wound care nurse has documented that the client has a stage II pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? A. Intact skin B. Full thickness skin loss C. Exposed bone, tendon, or muscle D. Partial thickness skin loss of dermis

D. Partial thickness skin loss of the dermis

The nurse is assessing the skin of a caucasian client who is diagnosed with psoriasis. Which of the following characteristics is associated with this skin disorder? A. Clear, thin nail beds. B. Red-purplish scaly lesions. C. Oily skin and no episodes of puritis. D. Silvery-white scaly patches of the scalp, elbow, knees, and sacral regions.

D. Silvery-White scaly patches of the scalp, elbow, knees, and sacral regions.

Good Skin Habits

Exercise regularly Good nutrition No smoking Avoid tattoos Drink water

Hemostasis Phase

Immediate blood clotting -vasoconstriction -platelet aggregation -coagulation cascade activation -fibrinous clot

Shearing

Opposing motion of tissue -i.e. pulling patient up in bed

Blanching

Press down on red area, turns white, then turns red again -i.e. sunburn

Purulent

Pus

Puritis

itching

Dehisence

seperation of layers of surgical wounds

Pressure Injuries

injuries or wounds that result from skin deterioration and shearing results in: -decreased tissue perfusion -hypoxemia -tissue ischemia -cellular death

Skin Infection

-Bacteria -Virus -Fungus

Non-Surgical Interventions Pressure Injuries

-Change dressings as needed -Measure wound weekly -Compare measurements -Assess & document healing & exudate for infection -Document condition of surrounding skin -Maintain pressure devices -Change position every 2 hours -Check for s/sx of infection

Skin Traumatic Injuries

-Incisional -Laceration: skin tear -Abrasion: road rash -Puncture: Stab wound -Penetration: GSW -Contusion: fall, bruising -Hematoma: swelling of clotted blood; bruise

Inflammatory phase

-cleans -removes bacteria and cellular debris -vasodilation -chemoattractants *promotes WBC to affected area

Proliferation phase

-granualtion -angiogenesis *regeneration of injured/broken blood vessels

Maturation/Remodeling Phase

-scar -3 weeks to a year -strengthens scar tissue up to 80% repaired

Pre-Existing PI Assessment

1. Assess for contributing factors 2. Identify reason for impaired skin integrity 3. Assess the wound -location -size -color -extent of tissue involvement -wound base & margins -exudate -surrounding tissue condition 4. Presence of foreign bodies 5. Pain level 6. Nutritional status

Wound Drainage Assessment

1. Color 2. Odor 3. Consistency 4. Amount

Assessment of Wound Complications

1. Hemorrhage 2. Infection 3. Dehiscense 4. Evisceration 5. Fistula

Wound healing phases

1. Hemostasis 2. Inflammatory 3. Proliferative 4. Maturation/Remodeling

PI Prevention Assessment

1. Mobility 2. Impaired sensation 3. Impaired communication -comatose patient 4. Mechanical forces -keep bed at 30 degrees or below 5. Moisture leads to maceration (skin softening) 6. Impaired nutritional status 7. Past history of PI

Types of Wound Healing

1. Primary Intention -Surgical/Clean cut -Wound edges can be connected 2. Second Intention -Wound edges cannot be connected -infected and extensive tissue loss 3. Third Intention -stays open to heal from the inside out to prevent infection -surgically closed once ready

Pressure Injury Stages

1. Redness top layer 2. Dermis - blistering 3. Subcutaneous - fat layer 4. Bone, tendon, ligament visibility 5. Unstageable -eschar/dead black tissue

Which nursing intervention can help a client maintain healthy skin? A. Keep the client well hydrated. B. Avoid bathing the client with mild soap. C. Remove adhesive tape quickly from the skin. D. Recommend wearing tight fitting clothes in hot weather.

A. Keep the client well hydrated

Fistula

Abnormal connection between two cavities

The nurse prepares to care for a male client with acute cellulitus (infection of skin) of the lower leg. The nurse anticipates which of the following will be prescribed for the client? A. Cold compress to the affected area. B. Warm compress to the affected area. C. Intermittent heat lamp treatments four times daily. D. Alternating hot and cold compresses continuously.

B. Warm compress to the affected area helps with pain

Friction

Skin against sheets

Dressing Care

Wet wound = Dry dressing Dry wound = Wet dressing - ALWAYS offer pain medications

Urticaria (hives)

acute allergic reaction in which red, round wheals develop on the skin

Sanguineous

bloody

Serosanguineous

bloody and serous

Psoriasis

chronic skin condition producing red lesions covered with silvery scales -genetic -autoimmune -inflammatory

Serous

clear, watery plasma; typically clean wounds

Non-Blanching

does not lose color with pressure -sign of tissue death

Evisceration

wound separation with protrusion of organs