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Questions and Answers
A nurse is educating a group of caregivers about the etiology of pressure injuries. Which statement by a caregiver indicates the need for further teaching?
A nurse is educating a group of caregivers about the etiology of pressure injuries. Which statement by a caregiver indicates the need for further teaching?
A patient presents with a pressure injury that involves full-thickness tissue loss, exposure of bone, and the presence of slough and eschar. How should the nurse document this finding?
A patient presents with a pressure injury that involves full-thickness tissue loss, exposure of bone, and the presence of slough and eschar. How should the nurse document this finding?
A patient with limited mobility has a Braden Scale score of 14 during an assessment. What should the nurse prioritize in the patient's care plan?
A patient with limited mobility has a Braden Scale score of 14 during an assessment. What should the nurse prioritize in the patient's care plan?
Which intervention is most effective in promoting wound healing in a patient with a sacral pressure injury?
Which intervention is most effective in promoting wound healing in a patient with a sacral pressure injury?
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A surgical wound with neatly approximated edges that undergoes a three-phase healing process is an example of which type of wound healing?
A surgical wound with neatly approximated edges that undergoes a three-phase healing process is an example of which type of wound healing?
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Which action should the nurse take first when managing a wound infection?
Which action should the nurse take first when managing a wound infection?
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A nurse is teaching a caregiver about pressure injury prevention. Which statement by the caregiver indicates effective learning?
A nurse is teaching a caregiver about pressure injury prevention. Which statement by the caregiver indicates effective learning?
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A nurse is educating a family member about the causes of pressure injuries. Which statement indicates the family member needs further teaching?
A nurse is educating a family member about the causes of pressure injuries. Which statement indicates the family member needs further teaching?
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A nurse assesses a patient's wound and notes partial-thickness skin loss involving the dermis and a pink wound bed. Which pressure injury stage does this describe?
A nurse assesses a patient's wound and notes partial-thickness skin loss involving the dermis and a pink wound bed. Which pressure injury stage does this describe?
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A patient has a Braden Scale score of 12 upon admission. What is the priority nursing intervention?
A patient has a Braden Scale score of 12 upon admission. What is the priority nursing intervention?
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A wound with wide, irregular margins and significant tissue loss is healing with granulation tissue and scar formation. This type of healing is classified as:
A wound with wide, irregular margins and significant tissue loss is healing with granulation tissue and scar formation. This type of healing is classified as:
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A patient presents with a pressure injury covered by slough and eschar. What is the most appropriate nursing action?
A patient presents with a pressure injury covered by slough and eschar. What is the most appropriate nursing action?
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Before administering antibiotics for a suspected wound infection, the nurse should:
Before administering antibiotics for a suspected wound infection, the nurse should:
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Which intervention is most effective in preventing pressure injuries in a bedridden patient?
Which intervention is most effective in preventing pressure injuries in a bedridden patient?
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A patient with a non-healing pressure injury has a dietary consult. Which intervention would most effectively promote healing?
A patient with a non-healing pressure injury has a dietary consult. Which intervention would most effectively promote healing?
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Study Notes
Pressure Injuries/Skin Integrity
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Question 1: Etiology of Pressure Injuries
- Pressure injuries occur when oxygen supply to the tissue is reduced.
- Shearing forces occur when skin sticks to the bed, and the body moves in the opposite direction.
- Excessive perspiration can contribute to moisture-related pressure injuries.
- Pressure injuries are caused by both external (friction, shearing) and internal (perfusion) factors.
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Question 2: Staging of Pressure Injuries
- A pressure injury involving full-thickness tissue loss, bone exposure, and presence of slough and eschar is classified as unstageable.
- National Pressure Injury Advisory Panel (NPIAP) guidelines dictate this classification.
- An assessment of the injury's depth is not possible due to the necrotic tissue.
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Question 3: Using the Braden Scale
- A Braden score of 14 indicates a high risk of pressure injury, requiring interventions like pressure-relief devices.
- Turning and repositioning every 4 hours is crucial for pressure injury prevention.
- Applying a pressure-relief mattress is a priority.
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Question 4: Nutrition and Wound Healing
- Adequate protein intake is crucial for tissue repair and wound healing.
- Increasing protein intake supports tissue repair.
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Question 5: Identifying Wound Healing Processes
- A surgical wound with neatly approximated edges undergoes three-phase healing—primary intention.
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Question 6: Managing Wound Infection
- Obtaining a wound culture is the initial step when managing wound infection before administering antibiotics.
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Question 7: Patient Education on Pressure Injury Prevention
- Proper repositioning every 4 hours is essential.
- Using a lift sheet aids in reducing friction and shearing forces.
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Continued: Question 1: Pressure Injury Etiology
- Prolonged pressure on the skin and underlying tissues lead to pressure injuries.
- Friction from moving the patient damages skin.
- Moisture (sweat/incontinence) causes skin breakdown.
- Adequate nutrition, especially protein, is crucial for preventing pressure injuries.
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Question 2: Staging Pressure Injuries
- Partial-thickness skin loss with a red/pink wound bed (without slough) constitutes Stage 2.
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Question 3: Pressure Injury Risk Assessment
- A Braden Score of 12 indicates a high risk of pressure injury.
- Frequent repositioning (every 1-2 hours) prevents skin breakdown.
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Question 4: Wound Healing by Intention
- Wounds with significant tissue loss and irregular margins heal through secondary intention (granulation tissue and scar formation).
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Question 5: Managing Unstageable Wounds
- Leave dry, stable eschar intact initially.
- Protective barriers should not be removed unless signs of infection are present.
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Question 6: Wound Care Techniques
- A wound culture using Levine's technique is necessary before initiating antibiotic therapy.
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Question 7: Prevention of Pressure Injuries
- Moisture barrier creams are vital for incontinent patients.
- Elevating the head of the bed to 45 degrees helps reduce pressure on bony prominences.
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Question 8: Nutrition and Healing
- Increased protein intake promotes tissue repair and wound healing.
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Description
This quiz explores the etiology, staging, and assessment of pressure injuries, focusing on skin integrity. It covers the impact of external and internal factors, as well as the use of the Braden Scale for risk assessment. Test your knowledge and understanding of key concepts in this important area of healthcare.
