Podcast
Questions and Answers
Which tasks are appropriate to delegate to family members? (Select all that apply)
Which tasks are appropriate to delegate to family members? (Select all that apply)
What collaborative opportunities can the nurse pursue for this patient? (Select all that apply)
What collaborative opportunities can the nurse pursue for this patient? (Select all that apply)
Based on the initial assessment, what is the most appropriate goal for the patient?
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?
What is the most appropriate outcome for the 87-year-old patient?
Signup and view all the answers
Which statement reflects a misunderstanding on the part of the patient? (Select all that apply)
Which statement reflects a misunderstanding on the part of the patient? (Select all that apply)
Signup and view all the answers
Common nursing diagnoses related to skin integrity and wound care often involve?
Common nursing diagnoses related to skin integrity and wound care often involve?
Signup and view all the answers
Which nursing diagnoses are appropriate for a patient with a wound? (Select all that apply)
Which nursing diagnoses are appropriate for a patient with a wound? (Select all that apply)
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)
What objective data can the nurse collect about an older adult patient with an unhealed pressure ulcer? (Select all that apply)
Signup and view all the answers
Which is a nursing diagnostic statement related to skin integrity and wound care?
Which is a nursing diagnostic statement related to skin integrity and wound care?
Signup and view all the answers
Once nursing diagnoses are selected, a plan of care is developed based on?
Once nursing diagnoses are selected, a plan of care is developed based on?
Signup and view all the answers
What is the nurse's primary responsibility in patient care planning?
What is the nurse's primary responsibility in patient care planning?
Signup and view all the answers
Tasks are delegated depending on the?
Tasks are delegated depending on the?
Signup and view all the answers
After collaboration with the patient and other members of the health care team, what is formulated?
After collaboration with the patient and other members of the health care team, what is formulated?
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.
Interventions are deemed effective when skin integrity and wound care goals are ____. However, if goals are ____, the treatment plan and interventions are revised accordingly.
Signup and view all the answers
Which nursing action is an example of collaboration?
Which nursing action is an example of collaboration?
Signup and view all the answers
Which tasks can UAP perform regarding skin integrity and wound care? (Select all that apply)
Which tasks can UAP perform regarding skin integrity and wound care? (Select all that apply)
Signup and view all the answers
Which tasks can be delegated to a family member regarding skin integrity and wound care?
Which tasks can be delegated to a family member regarding skin integrity and wound care?
Signup and view all the answers
Which goals are examples of goals related to skin integrity and wound care? (Select all that apply)
Which goals are examples of goals related to skin integrity and wound care? (Select all that apply)
Signup and view all the answers
Which goal is an example of a long-term goal related to skin integrity and wound care?
Which goal is an example of a long-term goal related to skin integrity and wound care?
Signup and view all the answers
What is an appropriate diagnostic label related to an older adult female with a wound on her heel?
What is an appropriate diagnostic label related to an older adult female with a wound on her heel?
Signup and view all the answers
Which diagnostic label would be a priority for a patient who has lost weight and has a wound?
Which diagnostic label would be a priority for a patient who has lost weight and has a wound?
Signup and view all the answers
What are two appropriate diagnostic labels for a wheelchair-bound patient with wounds? (Select all that apply)
What are two appropriate diagnostic labels for a wheelchair-bound patient with wounds? (Select all that apply)
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)
What objective data can be collected for an older adult patient with a pressure ulcer? (Select all that apply)
Signup and view all the answers
What is the most appropriate nursing diagnostic statement for a patient with a pressure ulcer?
What is the most appropriate nursing diagnostic statement for a patient with a pressure ulcer?
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)
Which plan of care components promote skin integrity and wound healing for a patient being discharged? (Select all that apply)
Signup and view all the answers
Which actions are examples of proper task delegation by a nurse? (Select all that apply)
Which actions are examples of proper task delegation by a nurse? (Select all that apply)
Signup and view all the answers
Which actions are examples of a UAP collaborating with a nurse? (Select all that apply)
Which actions are examples of a UAP collaborating with a nurse? (Select all that apply)
Signup and view all the answers
Which task is a UAP unable to perform regarding skin integrity and wound care?
Which task is a UAP unable to perform regarding skin integrity and wound care?
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)
Which collaboration specialists would the nurse consult for a patient with a stage III pressure ulcer? (Select all that apply)
Signup and view all the answers
Study Notes
Nursing Diagnoses Related to Skin Integrity and Wound Care
- 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.
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
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.
