Test 2 nursing 1100
. The nurse has given the client instructions about crutch safety. Which statements indicate that the client understands the instructions? Select all that apply. 1. "I should not use someone else's crutches." 2. "I need to remove any scatter rugs at home." 3. "I can use crutch tips even when they are wet." 4. "I need to have spare crutches and tips available." 5. "When I'm using the crutches, my arms need to be completely straight."
1, 2, 4
Scores of the braden score
6-9 severe 10-12 high 13-14 moderate 15-18 mild 19-23 none
A nurse is education a 21-year old lifeguard about the risk of skin cancer and the need to wear sunscreen. which statement by the patient requires additional teaching?
A. I wear a hat and sit under the umbrella when not in the water B. I do not bother with sunscreen on over cast days C. I use a sunscreen the highest SPF number D. I wear a UV shirt and limit exposure to the sun by covering up ANSWER B: I do not bother with sunscreen on over cast days
A nurse is caring for a group of patients on the surgical unit. which of the patients has a higher risk of impaired tissue integrity?
A. a 35 year old patient with type 2 diabetes mellitis B. an 82 year old patient with limited mobility and incontience C. a 50 year old patient with a history of hypertension and stable angia D. a 68 year old patient who underwent knee surgery replacement a week ago
A nurse is providing care for a patient who has developed a stage 2 pressure ulcer on sacral area. what intervention should the nurse prioritize for the plan of care for this patient?
A. administering intravenous antibiotics B. applying moisture retentive dressing C. scheduling frequent turning and repositioning D. initiating wound debridement answer C
a nurse is caring for a patient with impaired tissue integrity. the patient has a wound with significant purulent drainage and sign of infection. what action would the nurse prioritize when caring for the patients wound?
A. applying a sterile occlusive dressing B. irrigating the wound hydrogen peroxide C. administering oral antibiotic medication D. Performing a wound culture to identify the causative organism
A client is admitted to the hospital after a motor vehicle accident and multiple abrasions and lacerations to the chest and all four extermeties. which food items would the nurse recommend the client to select for the upcoming meals?
A. meatloaf and tea B. meatloaf and strawberries C. chicken soup and a baked apple D. chicken soup and buttered bread ANSWER IS B because protein and vitamin C
the staff nurse reviews documentation in a clients chars and notes that the wound care nurse has documented the client as a stage 2 pressure injury in the sacral area. which finding would the nurse expect to note on the assessment of the clients sacral area?
A.intact skin B. full thickness skin loss C. exposed bone tendon or muscle D. partial thickness skin loss of dermis Answer is D. partial thickness skin loss of the dermis. the skin is not intact at this point and loss of dermis is occured
The nurse is reviewing dental care with a client who is edentulous and wears dentures. Which client statement indicates an understanding of proper dental care? 1. "Since I have no teeth, I do not need to brush my mouth." 2. "I need to use hot water when cleaning my dentures to kill bacteria." 3. "I will remove my dentures before bed and keep them in my labeled denture cup covered with water." 4. "When I am not wearing my dentures during the day, I can keep them in the denture cup with no water, as they should only be in water at night."
Answer: 3
mucosal membrane pressure injury
Found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue these ulcers cannot be staged.
unstageable pressure injury
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.
deep tissue injury
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Debride
Removal of dirt and dead tissue from a wound
the braden scale is an evidence based tool that predicts the risk for developing hospital or facility aquired pressure ulcer injury
TRUE
the braden scale scores from less than or equal to 9 to as high as 23
TRUE
a skin ulcer
a crater like open sore on the skin. roughly circular the center is open and raw can be caused by trauma, lack of circulation, long term pressure
puncture
a small hole made by a sharp object
pustule
elevation of skin containing pus
4 types of tissue
epithelial, connective, muscle, nervous
surgical incisions
external, internal, staples, sutures, dermabond - all types of closures you may see dehiscence and eviseration are a big deal.
which skin care measures are used to manage a patient who is experiencing fecal and/ urinary incontience
frequent position changes using a contience cleaner applying barrier ointment 1, 4, 5
stage 3 pressure ulcer
full thickness skin loss adipose fat is visible slough and eschar may be present
stage 4 pressure ulcer
full thickness skin tissue loss with exposed or directly papable fascia, muscle, tendon, ligament cartilage or bone
Fungal infection-
fungi that cause superficial infections live on dead skin cells of the epidermis. Candidia Albicians and other Candida species thrive in warm, moist areas of the skin and mucous membranes. (mouth, vagina, skin folds)
deep dermal structures
hair follicles, sweat glands, do not regenerate. partial dermal loss heats by regeneration while total dermal loss heals scar formation
Primary prevention
hygiene nutrition sun exposure burn prevention pressure injury and dermal ulcer prevention
subcutaneous tissue
hypodermis. contains adipose, connective tissue, blood vessels, lymphatics and nerve endings
wound
injury that results in a disruption in the normal continuity of a body tissue
stage 1 pressure injury
intact skin localized area and firm light pink
trauma/injury **
intentional or unintentional damage, surgery can be superficial abrasion or a deep wound - intentional -unintentional -simple -complex
partial thickness
is just loss of the first two layers of skin
Infestations
lice, scabies, bed bugs, maggots
fissure
linear crack of skin extending into dermis
induration
localized firmness, soft tissue usually bc inflammation accumulation of blood/pus
factors that affect wound healing
long inflammation phase pressure, moisture, ischemia, edema, vascular diabetes nutritional status medications aging tobacco use obesity diabetes
slough
lose, stringy, nonviable tissue yellow or brown
inmflamatory phase also called hemostasis
manifests after injury and presents itself as erythema, edema, pain and warmth usually lasts 3 DAYS phase 1
subcutaneous tissue,
muscle fascia do not regenerate when there is tissue death, heal by scar formation
abcess
nodule containing pus >0.5cm
stage 2 pressure injury
partial thickness skin lossed exposed dermis slough and eschar are not present
Interrelated concepts tissue integrity
perfusion, gas exchange, elimination, thermoregulation, fluid and electrolytes, infection, pain, sensory perception, mobility, nutrition
Infants have thinner,
permeable skin less subcutaneous fat than older children and adults
profilerative phase
provides formation of granulation tissue very distinctive appearance appearing as thin, silvery layer of new epithelial cells phase 2
epidermis and most dermal structures are capable of
regeneration
maturation phase
remodeling phase. continuity of skin surface tissue strength has been established to meet normal activity levels
bone
traumatic injuries regenerate while necrotic processes usually require resection
fascia and muscle
very well vascularized and is the most sensitive to ischemia
secondary intention
would left open to heal through process of granulation
purulent
yellow or foul smelling drainage is bad. caused by infection
Wound Identification
-Skin layers involved -Appearance -Location -Etiology and causative factors -Differential diagnosis
proliferation can begin as early as 4 days if wound bed is kept nice and moist or as late as
24 days
secondary prevention
ABCDE and screening
The nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath? 1. "Do you have any allergies?" 2. "Will you be able to wash your own hair?" 3. "Are there any areas you want us to spend more time bathing?" 4. "Do you have any preferences regarding how we help you bathe?"
Answer: 1
The nurse is teaching a client with right-sided weakness related to a stroke about how to properly ambulate with a cane. Which client action would indicate a need for further teaching? 1. The client holds the cane on the right side of the body. 2. The client moves the weaker leg toward the cane first. 3. The client holds the cane 6 inches laterally from the foot. 4. The client keeps two points of support on the floor at all times.
Answer: 1
A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds, knowing that which would most likely result from this improper crutch measurement? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates
Answer: 2
The nurse is preparing to provide wound care to a client with a stage 1 pressure injury. Which dressing would the nurse expect to be prescribed in the treatment of this wound? 1. Hydrogel dressing 2. Transparent dressing 3. Antimicrobial dressing 4. Calcium alginate dressing
Answer: 2
The nurse is performing a skin assessment on a client and notes an area of full-thickness loss of skin on the sacrum. Adipose tissue and granulation tissue are present with no visible muscle, tendon, ligament, cartilage, or bone. How would the nurse classify this pressure injury? 1. Stage 1 pressure injury 2. Stage 2 pressure injury 3. Stage 3 pressure injury 4. Stage 4 pressure injury
Answer: 3
. The nurse is preparing a list of client care activities to be done during the shift. For which clients would the nurse instruct the assistive personnel (AP) to use an electric razor for shaving? Select all that apply. 1.A client with leukocytosis 2.A client with thrombocytosis 3.A client with thrombocytopenia 4.A client receiving an antiplatelet medication 5.A client receiving acetaminophen as needed for mild pain
Answer: 3, 4
The nurse in a long-term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nursing student would indicate a need for further teaching? 1. The nursing student tells the client to avoid soaking the feet. 2. The nursing student dries the feet thoroughly, including in between the toes. 3. The nursing student advises the client to consult the physician or a podiatrist regarding nail trimming. 4. The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes.
Answer: 4
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 2 pressure injury in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? 1. Intact skin 2. Full-thickness skin loss 3. Exposed bone, tendon, or muscle 4. Partial-thickness skin loss with exposed dermis
Answer: 4
macule (lesion)
Flat, pigmented, circumscribed area Ex: Freckle, flat mole
papule (lesion)
Solid, elevated Ex: wart, pimple, ringworm
plaque (lesion)
a little yellow
loss of perfusion**
all tissue requires continuous supply of O2 blood skin relatively tolerant of poor circulation compared to all other organs EXAMPLES OF IMPAIRED TISSUE INTEGRITY PERFUSION- ULCERATIONS, NECROSIS, LOSS OF DIGITS
Diabetic foot ulcer
an open wound on the foot caused by complications from diabetes
a nurse is caring for a patient who has a sustained deep laceration on the forearm due to a household event. the would is actively bleeding. there are visible debris in the wound. what is the initial priority when managing the laceration?
apply a sterile dressing and control the bleeding
Tunneling
area of tissue loss extending in any direction from edge of wound
Bacterial infection-
bacteria normally present on the skin generally cause no harm. Pathogenic bacteria cause harm. Small abrasions or lesions can provide a portal for opportunistic pathogenic infections
fluctunant
boggy, mushy, feeling fluid under their skin
primary intention
closed surgically, require only small amount of granulation tissue, epithelial resurfacing
appearance of full thickness wounds
crater, formation, undermining tunneling may slough or eschar surgical, trauma, pressure, disease
what is the removal of devitalized tissue from a wound called?
debridement
ulcer
deeper lesion extending into dermis or below
teritary intention
delay between injury. surgical closure, begin healing by secondary intention then surgically closed
erythna
generalized redness
crust
scab composed of dried exudate of body fluid, blood or pus
Viral infections-
several viruses disruptions of skin integrity. Common form of skin virus is the verruca or wart. Warts mostly appear on skin of the hands and feet. They can also be found on the genitalia. Herpes, chicken pox, shingles are viral.
Older-
skin becomes thin, growth slows down. Tattoos can mask alterations in tissue integrity, also causes damage to sweat glands so you sweat less.
petechiae
small, pinpoint hemorrhages
dermal ulcer
sore that develops on the skin followed by destruction of the tissue surrounding it.
full thickness
the loss of all layers of skin including underlying tissue and bone
sterile dressing change
the nurse places the sterile package with the top flap opening away from her
thermal-
thermal injuries 1st degree, 2nd degree, 3rd degree, radiation. Sunburn occurs after the epidermis has been exposed to UV radiation. It appears red and imflammation occurs.
eschar
thick, leathery necrotic tissue
undermining
tissue destruction underlying intact skin along wound margins
full thickness wounds identification
total loss of epidermis and dermis extends into subcutaneous tissue, may extend into muscle or bone
alterations
trauma/injury loss of perfusion immunologic reaction infection and infestation thermal or radiation injury lesions
