Nursing Diagnoses on Skin Integrity and Wound Care

Questions and Answers

Which tasks are appropriate to delegate to family members? (Select all that apply)

Assisting with oral hygiene (correct)

Providing skin hygiene (correct)

Taking care of wounds/pressure ulcers

Assisting with turning or repositioning, as deemed safe by the nurse (correct)

Taking vital signs

What collaborative opportunities can the nurse pursue for this patient? (Select all that apply)

Wound specialist (correct)

Nutritionist (correct)

Family (correct)

Social services (correct)

Surgeon

Based on the initial assessment, what is the most appropriate goal for the patient?

Show signs of wound healing, as evidenced by presence of granulation tissue in the wound within 1 week.

What is the most appropriate outcome for the 87-year-old patient?

Patient will show acceptance of the change in body image by helping with dressing change within 1 week. Signup and view all the answers

Which statement reflects a misunderstanding on the part of the patient? (Select all that apply)

I will be infection free by the time I go home. Signup and view all the answers

Common nursing diagnoses related to skin integrity and wound care often involve?

Nutritional status, pressure ulcers, immobility, pain, and other factors that alter skin integrity or impair wound healing. Signup and view all the answers

Which nursing diagnoses are appropriate for a patient with a wound? (Select all that apply)

Knowledge Deficit Signup and view all the answers

What objective data can the nurse collect about an older adult patient with an unhealed pressure ulcer? (Select all that apply)

History of Type II diabetes Signup and view all the answers

Which is a nursing diagnostic statement related to skin integrity and wound care?

Impaired Physical Mobility related to pain during position changes Signup and view all the answers

Once nursing diagnoses are selected, a plan of care is developed based on?

Patient needs and abilities. Signup and view all the answers

What is the nurse's primary responsibility in patient care planning?

Collaboration and delegation. Signup and view all the answers

Tasks are delegated depending on the?

Delegated person's scope of practice and ability to perform those tasks. Signup and view all the answers

After collaboration with the patient and other members of the health care team, what is formulated?

Desired goals and outcomes. Signup and view all the answers

Interventions are deemed effective when skin integrity and wound care goals are . However, if goals are , the treatment plan and interventions are revised accordingly.

met, unmet Signup and view all the answers

Which nursing action is an example of collaboration?

Making a decision as to when to call a wound care specialist Signup and view all the answers

Which tasks can UAP perform regarding skin integrity and wound care? (Select all that apply)

Reporting changes in patient skin condition Signup and view all the answers

Which tasks can be delegated to a family member regarding skin integrity and wound care?

Assisting with hair care Signup and view all the answers

Which goals are examples of goals related to skin integrity and wound care? (Select all that apply)

Patient will show acceptance by helping with dressing change within 48 hours Signup and view all the answers

Which goal is an example of a long-term goal related to skin integrity and wound care?

Patient will implement a nutritional meal program Signup and view all the answers

What is an appropriate diagnostic label related to an older adult female with a wound on her heel?

Impaired Skin Integrity related to compromised nutritional status Signup and view all the answers

Which diagnostic label would be a priority for a patient who has lost weight and has a wound?

Imbalanced Nutrition: Less Than Body Requirement Signup and view all the answers

What are two appropriate diagnostic labels for a wheelchair-bound patient with wounds? (Select all that apply)

Impaired Tissue Integrity related to pressure ulcer Signup and view all the answers

What objective data can be collected for an older adult patient with a pressure ulcer? (Select all that apply)

History of Type II diabetes Signup and view all the answers

What is the most appropriate nursing diagnostic statement for a patient with a pressure ulcer?

Impaired Skin Integrity related to compromised nutritional status Signup and view all the answers

Which plan of care components promote skin integrity and wound healing for a patient being discharged? (Select all that apply)

Ability of the patient to purchase supplies for home care Signup and view all the answers

Which actions are examples of proper task delegation by a nurse? (Select all that apply)

Supervising UAP Signup and view all the answers

Which actions are examples of a UAP collaborating with a nurse? (Select all that apply)

Reporting changes in patient skin condition Signup and view all the answers

Which task is a UAP unable to perform regarding skin integrity and wound care?

Assessing and evaluating a patient's skin Signup and view all the answers

Which collaboration specialists would the nurse consult for a patient with a stage III pressure ulcer? (Select all that apply)

Incontinent specialist Signup and view all the answers

Study Notes

Common nursing diagnoses include Impaired Skin Integrity, Imbalanced Nutrition, Disturbed Body Image, and Knowledge Deficit.
Pressure ulcers, immobility, pain, and nutritional status are critical factors affecting skin integrity and wound healing.

Appropriate Nursing Diagnoses for Wound Patients

Impaired Skin Integrity due to compromised nutrition and immobility can be evidenced by pressure ulcers.
Imbalanced Nutrition relates to increased demand for healing wounds, often resulting in weight loss.
Disturbed Body Image may arise from surgical changes, affecting the patient's willingness to acknowledge their condition.
Knowledge Deficit highlights the patient's unawareness or inexperience with wound care procedures.

Assessment Data Collection

Objective data for assessment can include the presence of wounds, the history of diabetes, and observable healing of other surgical sites.
Subjective symptoms like depression or loneliness can influence but are not strictly objective data.

Nursing Diagnostic Statements

Correctly identifying diagnostic statements is essential; for instance, recognizing impaired mobility due to pain or acute issues like Stevens Johnson Syndrome.
Statements should reflect accurate conditions and observable evidence.

Care Planning and Collaboration

Develop care plans based on individual patient needs and abilities, involving collaboration with healthcare teams.
Include the patient’s input and agreement to enhance compliance and success.

Goals for Skin Integrity and Wound Care

Goals should be measurable and time-bound, focusing on patient participation in care activities, signs of wound healing, and infection prevention.
Long-term goals may include substantial lifestyle changes, such as implementing nutritional meal plans.

Delegation and Collaboration

Tasks should be delegated based on the individual’s scope of practice; UAP can report changes in skin conditions or apply non-sterile dressings.
Appropriate collaboration with healthcare specialists, such as wound care or nutritionists, is vital for optimizing patient outcomes.

Family and UAP Involvement

Families can assist with tasks like skin hygiene and turning the patient, provided these tasks are within their capabilities.
UAP should focus on reporting changes in skin integrity and performing limited dressing changes.

Collaboration for Comprehensive Care

Consult wound care specialists for proper management of pressure ulcers and involve social workers for community resources.
Nutritionists can assist in dietary management to address weight concerns linked to wound healing.

Evaluating and Adjusting Care Plans

Regular reassessment of treatment effectiveness is necessary; adjust care plans if goals are unmet.
Continuous communication among healthcare providers, UAP, and family members ensures comprehensive care and recovery.### Wound Healing and Patient Assessment
Presence of granulation tissue in the wound is a positive indicator of wound healing within 1 week.
Effective pain management should reduce pain levels to 8 out of 10 or lower during the shift.
The patient's acceptance of body image changes can be measured by participation in dressing changes within 1 week.

Assessing Older Adult Post-Surgery

An 87-year-old female recovering from open heart surgery expresses reluctance to see her reflection and lack of appetite.
The most appropriate outcome for her post-surgery recovery is helping with dressing changes, indicating acceptance of her changed body image.

Patient Understanding and Miscommunication

The following statements indicate misunderstandings related to skin integrity and wound care:
- "I will be infection by the time I go home" reflects a lack of understanding; the goal should be to be infection-free.
- Other statements relate to necessary patient participation in care and realistic expectations for healing and nutrition.
Clear communication of goals for recovery, including infection management and nutritional intake, is essential for effective patient care.

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Description

This quiz focuses on common nursing diagnoses related to skin integrity and wound care. It covers important factors that affect skin health, including nutritional status and immobility. Test your knowledge on appropriate diagnoses for patients with wounds.