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What is a primary focus of nursing care for patients with skin integrity issues?
Conducting a skin inspection at least once a day is recommended for all patients.
True
What should be avoided when cleaning the skin of patients with impaired skin integrity?
Hot water
Systematic and routine skin care may decrease _____ injury incidence.
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Match the intervention with its purpose:
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What is a key factor in determining the nursing implementation for skin integrity?
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Cleaning the skin with hot water is recommended for patients with impaired skin integrity.
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What should be done to skin when soiling occurs?
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Systematic skin care may decrease pressure _____ incidence.
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Match the interventions with their focuses:
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What is the impact of low humidity on skin hydration?
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Massaging over bony prominences is recommended to avoid deep tissue trauma.
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What should be used when moisture from incontinence cannot be controlled?
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Moisture alone can increase the susceptibility of the skin to _____
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Match the following moisture sources with their management strategies:
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What is a primary strategy to reduce friction injuries when moving a patient?
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Proper positioning can completely eliminate shear injuries.
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What is the recommended frequency for repositioning at-risk patients?
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Shear injury occurs when the skin remains stationary while the underlying tissue ______.
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Match the following interventions with their purposes:
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What is the most common method to relieve pressure on the heels of an immobile patient?
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Doughnut-type devices are recommended for patients at risk of pressure injury.
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What body area should not be directly placed on the bony prominence when positioning a patient?
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Maintaining the head of the bed at the lowest degree of elevation can help reduce the risk for pressure injury to the _____.
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Match the pressure relief methods with their purposes:
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What is the primary purpose of using assistive devices like a trapeze or draw sheet?
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Patients who are chair-bound should not be repositioned every hour.
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What should patients who are able to shift their weight do, and at what frequency?
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Nurses collaborate with _______ when caring for patients at risk for pressure injuries in hospitals.
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Match the following areas of teaching with the corresponding topics:
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Study Notes
Nursing Implementations for Skin Integrity
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Patient-centered approach: Nursing interventions are tailored to the specific needs of each patient, considering their mobility, pressure injury risk, and current ulcer stage.
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Focus on prevention: Nursing care aims to prevent ulcers and infections, maintaining skin integrity.
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Systematic Skin Inspection:
- Conduct a thorough skin inspection at least once daily, paying close attention to bony prominences.
- This provides valuable data for identifying risk factors and designing interventions.
- The data collected is then used to evaluate the effectiveness of interventions.
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Routine Skin Care:
- Systematic, comprehensive, and routine skin care may reduce pressure injury incidence, although the exact mechanism is not fully understood.
- Clean the skin promptly when soiled and at regular intervals based on the patient's needs and preferences.
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Gentle Skin Cleansing:
- Avoid using hot water, opt for mild cleansing agents, and perform gentle cleansing with minimal force and friction.
- This approach minimizes irritation and skin damage.
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Preventing Skin Irritation:
- Metabolic waste and environmental contaminants accumulate on the skin.
- Remove these substances frequently to prevent skin irritation.
- Feces and urine can cause chemical irritation and should be removed as soon as possible.
Nursing Implementations for Skin Integrity
- Nursing implementations depend on the patient's mobility, risk factors for pressure injuries, and existing ulcer staging.
- Nursing care focuses on ulcer and infection prevention.
- Interventions for patients with or at risk for impaired skin integrity include:
- Daily systematic skin inspection, focusing on bony prominences.
- Routine, comprehensive skin care may decrease pressure injury incidence, although the exact role is unknown.
- Skin inspection provides data for nursing interventions to reduce risk and evaluate outcomes.
- Clean the skin when soiled and at regular intervals based on patient need or preference.
- Use mild cleanser and avoid hot water.
- Clean gently with minimal force and friction.
- Metabolic wastes and environmental contaminants on the skin can irritate and should be removed frequently.
- Feces and urine cause chemical irritation and should be removed promptly.
Skin Hydration and Environmental Factors
- Ambient air temperature affects skin hydration, especially with low humidity.
- Low humidity and cold exposure increase the risk of skin dryness.
- Well-hydrated skin is more resistant to mechanical trauma.
Skin Dryness and Pressure Injury
- Dry skin is less pliable, increasing the risk of fissuring and cracking of the stratum corneum.
- Avoid massage over bony prominences in at-risk patients, as it may contribute to deep tissue trauma and pressure injury development.
Managing Moisture and Skin Irritation
- Moisture from incontinence, perspiration, or wound drainage can irritate the skin and increase its susceptibility to injury.
- Use absorbent underpads or briefs to manage moisture and provide a quick-drying surface for the skin.
- Change underpads and briefs frequently to prevent moisture buildup.
- Avoid placing plastic directly against the skin, as it can trap moisture and further irritate the skin.
Friction and Shearing Forces
- Friction injuries occur when the skin moves across a rough surface.
- Shear injuries occur when skin remains stationary, but the underlying tissue shifts.
- These injuries can lead to ischemia and tissue damage.
Minimizing Friction and Shear Injuries
- Use proper positioning, transferring, and turning techniques.
- Avoid dragging the patient's skin across bed linens.
- Use positioning devices like pillows and foam wedges to protect bony prominences.
Preventing Skin Injuries in Immobile Patients
- Reposition immobile patients at least every 2 hours, using a systematic schedule.
- This helps prevent pressure injuries and optimize circulation.
Pressure Relief for Immobile Patients
- Use devices to relieve pressure on the heels of immobile patients.
- Raising the heels off the bed is a common method for pressure relief.
- Avoid using doughnut-type devices as they can increase pressure and damage tissue.
- Patients needing prolonged time laying down require pressure reduction devices to prevent pressure injuries.
- Avoid placing patients directly on their trochanter in side-lying position, as this can increase the risk of pressure injury.
- Keep the head of the bed at the lowest elevation possible while considering medical conditions and restrictions.
- Limit the duration of head of bed elevation to decrease pressure injury risk on bony prominences like the sacrum.
Using Assistive Devices for Transfers
- Utilize assistive devices like trapezes or draw sheets when moving patients who can't assist.
- This minimizes shear and friction injuries.
Chair-Bound Patient Positioning
- Utilize pressure-reducing devices for chair-bound patients.
- Consider postural alignment, weight distribution, and pressure relief when positioning.
- Prevent uninterrupted sitting in chairs or wheelchairs.
- Reposition patients hourly.
- Teach patients who can to shift weight every 15 minutes.
- Utilize a written plan for positioning, movement, and device use.
Collaboration for Pressure Injury Care
- Nurses often collaborate with physical therapists in hospitals, rehabilitation centers, and long-term care facilities.
- When caring for home-bound patients, nurses collaborate with primary caregivers.
- Nurses provide education to caregivers on:
- General information about pressure injuries.
- Risk factors for pressure injuries.
- Skin care and pressure injury prevention.
- Diet and nutrition.
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Description
This quiz covers key nursing interventions aimed at maintaining skin integrity in patients. You will learn about patient-centered approaches, systematic skin inspections, and effective routine skin care practices. Understanding these principles is essential for preventing pressure injuries and promoting overall patient health.
