Tissue Integrity Pressure Injuries In Class Assignment
A nurse is conducting a training session with new staff members at a nursing home. One of the staff members asks why the facility's older adult clients are at elevated risk for pressure injuries. Which response is best? "Age-related changes in the veins and arteries put older adults at risk for diminished blood flow, which can contribute to impaired skin integrity." "Due to increased oil production, the skin of older adults tends to be moister than that of younger clients. Increased moistness increases the risk for impaired skin integrity." "As compared to younger clients, older adults have higher average body temperatures, and excess body heat is a risk factor for pressure injuries." "As people age, their epidermis becomes more elastic. This increased elasticity makes older adults' skin more susceptible to damage."
Correct! "Age-related changes in the veins and arteries put older adults at risk for diminished blood flow, which can contribute to impaired skin integrity." Several factors put older adults at increased risk for pressure injuries; these include loss of lean body mass; generalized thinning of the epidermis; decreased strength and reduced elasticity of the skin; and diminished venous and arterial flow due to aging vascular walls. Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands also increases the risk for impaired skin integrity in older adults. Although excess body heat is a risk factor for pressure injuries, older adults tend to have lower average body temperatures than younger clients.
A client requests a small inflated doughnut-style device to sit on to relieve pressure. Which response by the nurse is most appropriate? "I will need to get an order from the physician." "Using the doughnut can cause skin breakdown." "I will obtain the device for you." "You will need to wait until discharge and use this at home."
Correct! "Using the doughnut can cause skin breakdown." The use of a doughnut-style device applies pressure and results in tissue anoxia. The client may indeed feel that pressure is lessened, but this is due to the loss of sensation. The use of the device should be avoided whether at the hospital or at home.
The nurse is caring for a client who failed to meet the outcome of healing of a stage 2 pressure injury over the coccyx. Which should the nurse identify as a likely contributing factor? The client's serum albumin increased over the last month. The rubber doughnut pressure relief device was not delivered by central supply. Nurses did not document disinfection of the wound with alcohol at each dressing change. A right side-back-left side-back turning schedule was used.
Correct! A right side-back-left side-back turning schedule was used. Of the options listed, the only one that would result in poor healing is the right side-back-left side-back turning schedule. This schedule places the client on the back 50% of the time, which is where the ulcer is located. There are six possible body positions when preventing or treating a pressure ulcer, and these positions should be used equally. The nurse should be careful to minimize pressure on an already-formed pressure ulcer. A rubber doughnut-style device should not be used, so the fact that it was not delivered did not contribute to failure to meet the outcome. An increase in serum albumin is a good finding and would increase, not decrease, wound healing. Alcohol interrupts healing, so it is good that nurses did not use alcohol to disinfect the wound.
An 84-year-old client with poor skin turgor has slipped down in the hospital bed. Which action by the nurse is appropriate to safely reposition this client to prevent further skin breakdown? Lifting the client, using the client's legs and arms for assistance Placing the bed in reverse Trendelenburg position Using the bed sheet to slide the client up in bed Using the client's arms to pull the client up in bed
Correct! Lifting the client, using the client's legs and arms for assistance The client is of advanced age and has poor skin turgor. Both of these factors put the client at increased risk for alterations in skin integrity, including damage due to shearing forces. To prevent shearing of the client's skin, the nurse should lift the client up in bed, using the client's legs and arms for assistance. Pulling the client up in bed may cause skin shearing. Sliding the client on a bed sheet also has the potential to cause shearing because the skin may adhere to the sheet. Placing the bed in reverse Trendelenburg position will not facilitate appropriate positioning of the client in the bed.
The nurse is concerned that a client is at risk for pressure injuries. Which assessment data supports the nurse's concern? Select all that apply. Body temperature within normal limits Age 35 Low serum albumin level Continence of urine and stool Prescribed bedrest
Correct! Low serum albumin level Correct! Prescribed bedrest Risk factors for pressure ulcer development include immobility and inadequate nutrition. The client who is prescribed bedrest is at risk for immobility, and a low serum albumin level is evidence of inadequate nutrition. Continence of urine and stool would reduce the risk of pressure ulcer development. The age of 35 would not increase the client's risk for pressure ulcer development. A normal body temperature would reduce the client's risk for pressure ulcer development.
When planning care for a client at risk for developing pressure injuries, which intervention should be included? Select all that apply. Turn the client every 4 hours. Use inflatable doughnut-style devices to reduce pressure on the sacrum. Raise the heels off of the bed. Massage pressure areas with lotion every 4 hours. Initiate a frequent toileting schedule.
Correct! Raise the heels off of the bed. Correct! Initiate a frequent toileting schedule. Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and potential for skin breakdown. Raising the heels off of the bed should be done to remove pressure from this area of the client's body. The client should be turned at least every 2 hours. Massage of pressure areas can cause friction and damage to problem skin areas. Inflatable doughnut-style devices are contraindicated, as they increase pressure and reduce perfusion to affected areas.
What stage of pressure injury presents as a shallow open ulcer with a viable, moist wound bed that is red or pink? Stage 1 Stage 2 Stage 3 Stage 4
Correct! Stage 2 A stage 2 pressure injury is characterized by partial-thickness skin loss involving the dermis. It presents as a shallow open ulcer with a viable, moist wound bed that is red or pink. Granulation tissue, slough, and eschar are not present. A stage 2 injury may also present as an intact or open serum-filled blister.
A client has a pressure ulcer on the medial malleolus. The client's skin is intact with purple discoloration and a blood-filled blister. When documenting this finding, which terminology is appropriate for the nurse to use? Non-blanchable erythema Suspected deep tissue injury Full-thickness tissue loss Partial-thickness loss of dermis
Correct! Suspected deep tissue injury A suspected deep tissue injury manifests as intact skin with purple discoloration or a blood-filled blister. Non-blanchable erythema refers to a Stage I ulcer. Partial-thickness loss of dermis refers to a Stage II ulcer. Full-thickness tissue loss refers to Stage III, IV, and unstageable ulcers.
What is softening of the skin as a result of prolonged wetting or soaking? excoriation maceration debridement shearing
Correct! maceration Maceration involves softening of the skin due to prolonged wetting or soaking. Excoriation is loss of the superficial layers of the skin. Debridement is the removal of necrotic material from a wound. Shearing occurs when one layer of tissue slides over another.
A client's spouse reports the presence of a reddened area on the client's coccyx and wants to massage the area. Which response by the nurse is appropriate? "I will record these findings in the medical record." "I will need to obtain an order from the healthcare provider to perform a massage." "Massaging the area may actually cause more harm to a potentially compromised area of skin." "Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care."
Correct!"Massaging the area may actually cause more harm to a potentially compromised area of skin." The presence of redness may indicate the presence of a stage I pressure ulcer. Massage can cause a friction-like response to compromised skin and should be restricted when problems are noted. Massages, when therapeutic, do not require a healthcare provider's order.
