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Questions and Answers
An ______ can occur when skin is rubbed against a sheet.
abrasion
Excoriations result from prolonged skin contact with body ______ or excretions.
secretions
The temperature of the skin over pressure areas should be the same as that of the ______ skin.
surrounding
An increase in temperature might indicate ______ or blood trapped in the area.
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If there is an open or visibly ______ area of the pressure injury, the nurse should wear gloves during the examination.
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What is the first step in measuring the size of a pressure ulcer?
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The presence of eschar in a wound indicates healthy tissue.
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What should the nurse assess regarding the condition of the wound margins?
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Complaints of __________ at the wound site may indicate infection or discomfort.
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Match the clinical signs of infection with their descriptions:
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What is used to assess the presence of undermining or sinus tracts in a pressure injury?
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Clinical signs of infection include warmth, swelling, and pain.
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What does the nurse need to document regarding the patient's pressure injury?
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The __________ of a pressure injury should be assessed by observing the color and presence of necrosis or eschar.
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Match the aspects of a pressure injury assessment with their descriptions:
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Study Notes
Pressure Area Inspection
- Inspect pressure areas for abrasions and excoriations.
- Abrasions can occur when skin is rubbed against a sheet.
- Excoriations result from prolonged skin contact with body secretions or excretions or with dampness in skinfolds.
Pressure Area Palpation
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Palpate the surface temperature of the skin over the pressure areas using warm hands.
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A normal temperature is the same as the surrounding skin.
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An increase in temperature may indicate inflammation or trapped blood.
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Palpate over bony prominences and dependent body areas to identify the presence of edema.
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Edema will feel spongy or boggy.
Pressure Injury Examination
- Use gloves when examining open or visibly infected pressure injuries.
Pressure Injury Assessment
- Location: Note the injury's location relative to a bony prominence.
- Size: Measure the ulcer's length (head to toe), width (side to side), and depth using a sterile applicator swab.
- Undermining & Sinus Tracts: Assess for undermining or sinus tracts, using a clock face analogy with 12 o'clock representing the patient's head.
- Stage: Determine the stage of the injury using a staging system.
- Wound Bed: Note the wound bed's color, presence of necrosis or eschar, and its location.
- Wound Margins: Assess the condition of the wound margins.
- Surrounding Skin: Evaluate the integrity of the skin surrounding the wound.
- Infection Signs: Look for signs of infection, including erythema, warmth, swelling, pain, odor, exudate (note exudate color), fever, chills, and elevated white blood cell (WBC) count.
- Patient Complaints: Document any pain or discomfort reported by the patient at the wound site.
- Documentation: Record the status of the patient's skin and wounds on the standard agency form.
Pressure Injury Assessment
- The location of the injury should be noted in relation to a bony prominence.
- Measure the size of the ulcer in centimeters, starting with length (head to toe), then width (side to side), and finally depth.
- Depth is measured by inserting a sterile applicator swab into the deepest part of the wound and measuring the swab against a guide.
- Assess the presence of undermining or sinus tracts using a clock face analogy, where 12 o'clock represents the patient's head.
- Determine the stage of the injury based on established guidelines.
- Note the color of the wound bed and presence of necrosis or eschar.
- Document the condition of the wound margins and the integrity of the surrounding skin.
- Observe for clinical signs of infection, including erythema, warmth, swelling, pain, odor, and exudate, noting the color of any exudate.
- Record any complaints of pain or discomfort at the wound site.
- Monitor for symptoms of infection, such as fever, chills, or elevated white blood cell count.
- The status of the patient's skin and wounds should be documented on the agency's standard form.
- Track changes in the wound over time to monitor progress and potential complications.
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Description
Test your knowledge on inspecting and palpating pressure areas. This quiz covers key concepts such as identifying abrasions, excoriations, and assessing skin temperature. Additionally, learn about examining pressure injuries effectively and safely using gloves.
