Fundamentals of Nursing Chapter 48

Questions and Answers

What is the appropriate position for a patient during repositioning to prevent risk for shearing and friction injuries?

30-degree lateral position

What stage of pressure ulcer does not require a dressing?

III

I (correct)

What should the nurse do to decrease a patient's anxiety when changing a dressing?

Explain the procedure (correct)

Ask the family to leave the room

Tell the patient to close his eyes

Turn on the television

Which intervention should be included while cleansing a wound site?

Cleansing in a direction from the least contaminated area Signup and view all the answers

What is the best explanation for using an abdominal binder after an open abdominal aortic aneurysm repair?

The binder supports the abdomen Signup and view all the answers

Which intervention should the nurse implement for pain management following a postoperative medial meniscus repair?

Elevate right knee and apply ice Signup and view all the answers

What score on the Braden scale indicates decreasing risk for skin breakdown?

23 Signup and view all the answers

Which consults should always be included for a patient with a stage II pressure ulcer?

Physical therapist Signup and view all the answers

Which factors influence wound healing by tertiary intention?

Tissue perfusion Signup and view all the answers

Which nursing assessment questions should be included in a skin integrity assessment?

How often do you need to use the toilet? Signup and view all the answers

Which components should the nurse include in a skin assessment for potential skin breakdown?

Blanching Signup and view all the answers

What should the nurse do before applying a large abdominal bandage and binder?

Assess condition of current dressings Signup and view all the answers

Which outcomes indicate progression toward goals for a patient with a stage III pressure ulcer?

Reduce injury to the underlying tissues Signup and view all the answers

Which risk factor predisposes a patient to pressure ulcer development?

Alteration in level of consciousness Signup and view all the answers

What is the major element involved in the development of a decubitus ulcer?

Pressure Signup and view all the answers

Which nursing observation indicates a patient is at risk for pressure ulcer formation?

The patient has fecal incontinence Signup and view all the answers

How would the nurse stage a healing stage III pressure ulcer?

Healing stage III pressure ulcer Signup and view all the answers

What stage is a shallow open ulcer without slough on the right heel?

Stage II Signup and view all the answers

Which assessment would be used first to assist in staging an ulcer on a patient with darkly pigmented skin?

Halogen light Signup and view all the answers

What type of wound healing occurs for a stage IV pressure ulcer?

Full-thickness wound repair Signup and view all the answers

If a wound is kept moist, it can resurface in how many days?

4 Signup and view all the answers

What should the nurse expect to see in a full-thickness repair?

Granulation Signup and view all the answers

A laparoscopic appendectomy wound heals by which intention?

Primary intention Signup and view all the answers

A burn wound heals by which intention?

Secondary intention Signup and view all the answers

What indicates a wound healed by secondary intention?

Scarring can be severe Signup and view all the answers

What nursing observation indicates a complication of wound healing after a total hysterectomy?

The incision has a mass, bluish in color Signup and view all the answers

Which finding in a postoperative patient should the nurse associate with dehiscence?

Complaint by patient that something has given way Signup and view all the answers

What laboratory data is important to gather for a patient with a decubitus ulcer?

Serum albumin Signup and view all the answers

What is the most important piece of assessment data for wound healing?

Pulse oximetry assessment Signup and view all the answers

What should the nurse do when noticing signs of infection in a healing stage III pressure ulcer?

Complete the head-to-toe assessment and gather vital signs. Signup and view all the answers

What is the nurse's assessment related to a patient's psychological response to a wound?

The patient's psychological response to any wound is part of the nurse's assessment. Signup and view all the answers

After determining that a patient is stable, what is the next best step for a laceration?

Inspect the wound for bleeding Signup and view all the answers

When caring for a patient with a wound that needs changing, what should the nurse do first?

Provide analgesic medications as ordered Signup and view all the answers

What is the next best step if a drainage collection device shows a sudden decrease in drainage?

Call the physician Signup and view all the answers

Which specialty bed is most appropriate for a patient with a stage IV pressure ulcer?

Low-air-loss therapy unit Signup and view all the answers

What is the next step in caring for a patient with a black pressure ulcer?

Débridement of the wound Signup and view all the answers

What order should the nurse question for a patient with a clean stage III pressure ulcer?

Irrigate with hydrogen peroxide Signup and view all the answers

Which assessment is essential when evaluating a patient's skin integrity?

Pressure points Signup and view all the answers

What would be the Braden scale total score for a patient with specific risk factors?

20 Signup and view all the answers

What intervention is most important to decrease the risk of pressure ulcers for an immobile patient?

Provide analgesic medication as ordered Signup and view all the answers

What nursing diagnosis is appropriate for a patient with a stage IV pressure ulcer?

Impaired skin integrity Signup and view all the answers

What nursing diagnosis should be assigned for a patient with a reddened area on the heel that does not blanch?

Ineffective tissue perfusion Signup and view all the answers

What is the most important intervention for a patient with a stage II pressure ulcer at risk for infection?

Encourage thorough handwashing Signup and view all the answers

Which professional should the nurse consult for optimal nutrition to promote wound healing?

Registered dietitian Signup and view all the answers

What is the best goal for an unconscious and bedridden patient with a stage II pressure ulcer?

The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound Signup and view all the answers

What risk does a postpartum patient with an episiotomy face when heat treatment is applied incorrectly?

Trauma Signup and view all the answers

Which intervention assists in managing expenses associated with long-term wound care?

Clean dressings and no touch technique Signup and view all the answers

What initial intervention should the nurse select to decrease skin impairment for a patient with mobility problems?

Gentle cleaners and thorough drying of the skin Signup and view all the answers

How long should a patient be scheduled to sit in a chair to prevent skin impairment?

Less than 2 hours Signup and view all the answers

What is the best method for repositioning a patient at risk for skin impairment?

Obtain assistance and use the drawsheet Signup and view all the answers

Study Notes

Risk Factors for Pressure Ulcers

Confusion or disorientation prevents patients from recognizing and relieving pressure, increasing ulcer risk.
Key additional predisposing factors: impaired sensory perception, impaired mobility, shear, friction, and moisture.
Diet low in calories and fat, muscular pain, and shortness of breath are not recognized risk factors.

Primary Causes of Decubitus Ulcers

Pressure remains the primary cause, with intensity, duration, and tissue tolerance critical in ulcer development.
Ischemic injury can occur when pressure exceeds 12 to 32 mm Hg on capillaries.
Skin breakdown may arise from both high pressure over a short period and low pressure over longer durations.

Indicators of Pressure Ulcer Risk

Fecal incontinence significantly heightens the risk due to prolonged moisture on the skin.
Other observations, such as food intake or mild skin irritations, do not indicate imminent risk for pressure ulcers.

Staging of Pressure Ulcers

A healing pressure ulcer retains its stage designation (e.g., a stage III ulcer that is healing is termed a "healing stage III pressure ulcer").
Stage II ulcers exhibit partial-thickness skin loss without slough, presenting as abrasions or blisters.

Importance of Lighting in Skin Assessment

Halogen or natural light is essential for accurate skin assessments, especially on patients with darkly pigmented skin.
Incorrect lighting can distort assessment findings, preventing proper identification of skin issues.

Types of Wound Healing

Pressure ulcers are examples of full-thickness wounds healing by scar formation.
Wounds healing primarily through tissue regeneration involve minimal tissue loss and include procedures like laparoscopic surgeries.

Resurfacing of Wounds

Wounds that are kept moist can resurface within 4 days, while those exposed to air may take up to 6-7 days.
The timeframe for epithelial proliferation varies based on the type of wound care provided.

Healing Characteristics

Granulation tissue indicates positive healing progression in full-thickness wounds.
Presence of eschar, slough, or purulent drainage signifies complications such as infection or improper healing.

Complications in Wound Healing

A hematoma, characterized by bluish discoloration and swelling, indicates possible complications and requires careful monitoring.
Dehiscence is signaled by patient complaints of a sensation of something "giving way."

Nutritional Support for Wound Healing

Protein is crucial for effective wound healing; it supports physiological processes involved in tissue repair.
Vitamins A and C, along with zinc and copper, are also essential for optimal healing, while fats and carbohydrates do not require special increases.

Psychological Impact of Wounds

Patients' concerns about appearance and odor from wounds can affect self-concept, indicating psychological distress.
Responses to wound conditions can reveal underlying feelings about body image and healing progress.

Emergency Care for Lacerations

Initial action should focus on inspecting the wound for bleeding.
Subsequent assessments should include checking for foreign bodies and assessing the need for tetanus prophylaxis.

Priorities in Wound Care

Before changing dressings or managing drainage, it’s vital to gather all necessary supplies to ensure an efficient and organized approach to wound care.### Wound Care and Pressure Ulcer Management
Administer analgesics 30 minutes prior to dressing changes to minimize pain associated with removal.
Sudden decrease in wound drainage requires assessment for blockage; notify the physician if suspected.
Low-air-loss therapy units are effective for patients with stage IV pressure ulcers to prevent skin breakdown.
Débridement is essential for necrotic tissue to promote healing and prevent infection in pressure ulcers.
Use noncytotoxic cleansers like normal saline for clean granulating wounds to avoid harming healing tissue.

Skin Integrity Assessment

Regularly assess skin for signs of ulcer development; monitor pressure points and bony prominences.
Braden scale scores assist in assessing a patient's risk for skin breakdown based on sensory perception and mobility.
Nursing diagnoses related to skin include "Impaired skin integrity" for patients with stage IV pressure ulcers and "Ineffective tissue perfusion" for areas with redness that does not blanch.

Infection Risk and Prevention

Hand hygiene is the primary intervention to prevent infection in patients with pressure ulcers.
Consult a registered dietitian to optimize the diet for wound healing.
Educate families about infection signs and wound care, particularly for unconscious or bedridden patients.

Patient Mobility and Repositioning

Encourage adequate pain control to increase patient comfort and mobility, thus reducing pressure ulcer risk.
Limit chair sitting time to 2 hours, using cushions to alleviate pressure.
When repositioning, utilize safe methods like a transfer sliding board to avoid shearing forces.

Dressing Changes and Patient Comfort

Explain dressing change procedures to alleviate patient anxiety and involve them in their care.
Clean wounds in a direction from least to most contaminated to minimize infection risk.
Abdominal binders support large incisions post-surgery, particularly during movement and coughing.

General Care Strategies

Employ clean techniques for dressing changes in home care to manage costs and reduce infection risk.
Position patients appropriately to reduce pressure and improve comfort, adjusting care based on individual capabilities and needs.### Postoperative Care for Medial Meniscus Repair
Pain management post-surgery includes elevating the knee and applying ice to minimize edema and control bleeding.
Brace application is supportive but does not directly manage pain.
Vital signs monitoring is routine but not a direct pain intervention.
Pulses should be checked to ensure circulation, not specifically for pain management.

Braden Scale Assessment

Braden scale scores range from 6 (high risk) to 23 (low risk); a score of 18 indicates pressure ulcer risk.
A score of 23 signifies optimal skin integrity and a decreasing risk for skin breakdown after interventions.

Multi-disciplinary Approach for Pressure Ulcers

Consults for patients with stage II pressure ulcers should include:
- Registered dietitian for nutritional support.
- Wound care nurse specializing in wound management.
- Physical therapist to enhance mobility and minimize risk.
- Case management for arranging outside care.
Spiritual or medication needs are generally secondary and not core consults unless necessary.

Factors Influencing Wound Healing

Key influencing factors include:
- Nutrition: Essential for repair.
- Tissue perfusion: Adequate oxygen significantly aids healing.
- Infection: Delays healing and increases tissue damage.
- Age: Older patients experience delayed healing.
Evisceration and hemorrhage are complications but not direct influences on the healing process.

Skin Integrity Assessment Questions

Important questions during skin integrity assessment include:
- Ability to change positions to reduce pressure.
- Sensitivity to temperature for self-protection.
- Frequency of toileting to assess incontinence risk.
- Pain during movement indicating mobility issues.

Components of Skin Assessment

Skin assessment involves evaluating:
- Hyperemia: Observing abnormal reactions post blood flow obstruction.
- Induration: Detecting hard areas on the skin.
- Blanching: Testing reddened areas for circulation recovery.
- Skin temperature: Monitoring for blood flow changes.
Mobility and nutritional status are crucial but are overall assessment aspects rather than direct skin assessment components.

Responsibilities Before Applying Bandages

Inspect for abrasions, edema, and skin integrity.
Cover exposed wounds with sterile dressings.
Assess current dressing conditions for needed changes.
Evaluate the skin beneath the bandage for circulatory integrity.

Outcomes Indicating Progress in Pressure Ulcer Care

Positive outcomes toward improving skin integrity include:
- Preventing injury to skin and tissues.
- Reducing various levels of skin and tissue injury.
- Restoring skin integrity.
Patient expectations and perceptions provide useful feedback but are not direct measurable outcomes.

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Description

Test your knowledge on skin integrity and wound care with these practice questions. This quiz focuses on key concepts and risk factors related to pressure ulcers as discussed in Chapter 48 of the Fundamentals of Nursing. Improve your understanding and readiness for the clinical application of wound care principles.