NUR 300 Sherpath Review: Skin Integrity and Wound Care - Analyze Cues and Prioritize Hypotheses; Plan and Generate Solutions

Which hypothesis would ensure the nurse develop for an immobile patient who had intact skin?

risk for impaired skin integrity rationale: patient is immobile but has intact skin, so there is risk for impaired skin integrity

Which patient statement alerts the nurse that teaching was successful about the goals of treatment for a healing arm wound?

"My wound will look beefy red within 1 week" rationale: if the wound looks beefy red within 1 week, that indicates granulation tissue is forming and the wound is healing, which is normal. This indicates successful teaching

Which primary areas, if injured in the patient, would prompt the nurse to develop the hypothesis Impaired Tissue Integrity?

- bone - tendon - muscle rationale: Bone, tendon, and muscle relate to tissue integrity. side note: The dermis and epidermis would be impaired skin integrity, not tissue.

For which patient hypotheses would the nurse select turning and positioning as a solution?

- 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?

- low pre-albumin levels - immobility - stage 2 pressure injury rationale: low pre-albumin is a cue because it can affect healing, immobility is a cue because it can lead to prolonged pressure, and a stage 2 pressure injury is a cue because it affects the epidermal and dermal layers of the skin

Which SMART outcomes would the nurse develop for the patient who is recovering from a small abdominal incision with a hypothesis of Surgical Wound?

- patient will eat a high-protein diet at every meal - patient will help with transfers within 24 hours rationale: diet is a specific, measurable, achievable and relevant outcome. It also has a time frame (at every meal). Patient will help with transfers is a SMART outcome because it is specific, measurable, achievable, and relevant (help with transfers). It must also have a time frame (within 24 hours) side note: "patients wound will heal normally" and "Patients incision will have proper healing" are not measurable and there is no time frame and no way to measure the healing. Healing is different person to person.

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?

- repositioning the patient - reporting any changes in patient skin integrity or condition - applying a non-sterile dressing for chronic wounds with an established treatment plan

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

- therapies consistent with guidelines for treatment of wounds - recommendations from collaborating health care professionals, such as 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 rationale: first two are appropriate for obvious reasons :) the patient agreeing with the treatment plan is compliance, and this agreement would be included. Capability of the patient to purchase supplies for home care is important to ensure healing can continue after discharge.

Which multidisciplinary team members would the nurse consult for a thin, homeless patient who has a stage 2 pressure injury on the sacrum?

- wound, ostomy, and continence nurse (WOCN) - social worker - nutritionist rationale: WOCN to ensure proper healing of pressure injury, social worker to ensure the homeless patient has access to community resources and finances, and nutritionist because the patient is thin, and malnutrition affects skin integrity and the healing process

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 who just had an incision eviscerate 3. Patient with stage four pressure injury rationale: shock is an immediate emergency because it is life threatening (ABCs), the patient with an evisceration is still a medical emergency, but it is not as critical as active bleeding. Stage 4 pressure injury seen last because it is a chronic condition.

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?

Patients wound will exhibit granulation tissue in the wound by 1 week rationale: a break in the skin from an external force, such as trauma or an accident, indicates a wound; thus, this goal would directly relate to the break in skin from external forces side note: "patient will demonstrate wound care after receiving teaching" is appropriate for a patient to demonstrate teach back, this goal does not directly relate to a break in the skin from external forces; it relates to inadequate knowledge

Which outcome is appropriate for the patient recovering from abdominal surgery who reports not wanting to loos at the incision and not wanting to eat?

exhibits signs of healing as evidence by presence of granulation tissue in the wound within 1 week rationale: because the overall outcome is healing of the wound, this outcome demonstrates progressive healing of wound