Pressure Ulcers and Wound Care Nursing

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Questions and Answers

What is a significant risk associated with keeping patients in a sitting position in bed?

Higher risk of pressure sores on the coccyx (correct)

Reduced circulation to the extremities

Increased dehydration due to sweating

More difficulty in breathing

What is the primary purpose of the epidermis layer of the skin?

To protect against external factors (correct)

To serve as a connection to nerves

To store fat and larger blood vessels

To provide nutrients and oxygen to the dermis

What can be considered a sentinel event in healthcare?

A client dying from a medication error (correct)

A patient refusing treatment

A patient experiencing a minor fall

A patient developing a mild rash

Why is it recommended to use grab bars for patients with joint impairments?

To encourage independence in bathing and toileting Signup and view all the answers

Which of the following statements about perspiration is accurate?

It leads to dehydration without fluid replacement. Signup and view all the answers

What is an appropriate action if a patient's mental status suddenly changes?

Assess for potential harm and use protective devices Signup and view all the answers

What is a potential consequence of excessive daytime napping?

Restlessness and difficulty sleeping at night Signup and view all the answers

What is an appropriate intervention for a patient with diabetes to prevent burns due to impaired circulation?

Use extra blankets and bed socks Signup and view all the answers

What is the primary benefit of placing patients at risk for falls near the nurses' station?

It allows for frequent monitoring by the nurse. Signup and view all the answers

What must healthcare workers obtain before using physical restraints?

An order from a healthcare provider. Signup and view all the answers

Which of the following strategies is suggested as an alternative to the use of protective devices?

Supervising patients with family members or friends. Signup and view all the answers

What is a critical action a nurse should take when managing a confused or unsteady patient?

Checking if a family member can stay with the patient. Signup and view all the answers

What should a Safety Data Sheet (SDS) provide information about?

Guidelines for handling biohazard substances. Signup and view all the answers

What is alarm fatigue, and why is it a concern in nursing?

Desensitization to alarms causing delays in response. Signup and view all the answers

What precautions should nurses take regarding medical alarms at the beginning of their shift?

Ensure alarms are checked for functionality and volume. Signup and view all the answers

Which of the following statements is true concerning the use of protective devices on patients?

They require a healthcare provider's order and cannot be used for punishment. Signup and view all the answers

What is the purpose of responding promptly to alarm beeps?

To ensure timely healthcare interventions and prevent adverse outcomes. Signup and view all the answers

What does the acronym PASS stand for in relation to using a fire extinguisher?

Pull, Aim, Squeeze, Sweep. Signup and view all the answers

How does low humidity affect patients with respiratory conditions?

It dries out their respiratory passages. Signup and view all the answers

What is the first step the nurse should take before repositioning a patient?

Ensure the bed is waist high. Signup and view all the answers

What technique should a nurse use to transfer a patient who can stand?

Use a transfer belt for pivoting and transferring. Signup and view all the answers

What position is recommended to relieve pressure from the sacral area in semiconscious patients?

Prone position. Signup and view all the answers

What is the benefit of using high-top sneakers or a footboard for immobile patients?

To prevent footdrop and maintain dorsiflexion. Signup and view all the answers

What is a common misconception about the use of a wheelchair for semiconscious patients?

It is not effective for semiconscious patients. Signup and view all the answers

What position is considered a High Fowler's position?

60 to 90 degrees elevation Signup and view all the answers

Which muscle group should be utilized to lift heavy objects from the floor?

Leg muscles Signup and view all the answers

For a patient requiring transfer assistance, what is the best method to reduce gravitational pull?

Place the patient on her back Signup and view all the answers

What is the most appropriate position for a patient undergoing a rectal examination?

Lithotomy position Signup and view all the answers

What is a common risk factor for falls in the elderly?

Poor lighting Signup and view all the answers

What benefit does using a cane provide to an individual?

Provides extra stability Signup and view all the answers

What is the maximum angle for a semi-Fowler's position?

60 degrees Signup and view all the answers

How many people are typically needed to move a patient with increased weight and inability to move up in bed?

Two people Signup and view all the answers

What should a nurse assess before transferring a patient to a chair or ambulating?

The patient's response to position change Signup and view all the answers

What can occur if a patient is pulled up in bed without being lifted first?

Shearing force application leading to pressure ulcers Signup and view all the answers

Which statement is true regarding passive range of motion (ROM) exercises?

They improve circulation in the limbs. Signup and view all the answers

What is the correct method for lowering a patient to the floor to prevent injury during a fall?

Step behind the patient and slide them down gently. Signup and view all the answers

How should a nurse position their hand while assisting a patient with an unsteady gait?

From the bottom under the gait belt at the middle of the back Signup and view all the answers

What technique can help ease the effort required when moving a patient up in bed?

Using a rocking motion while fixing feet in place Signup and view all the answers

What is an important consideration for the tightness of a gait belt?

It should be tight enough to secure the patient but still allow the nurse's hand to pass. Signup and view all the answers

What is a potential consequence of immobility when a patient first attempts to sit or stand?

Dizziness or drop in blood pressure Signup and view all the answers

Study Notes

Pressure Ulcers and Care

Sitting position in bed can lead to increased pressure on the coccyx and bottom, contributing to pressure sores.
Symptoms of pressure ulcers include redness, swelling, and unhealed areas of skin.
Staging of pressure ulcers is crucial for proper assessment and treatment.

Body Temperature Regulation

Diaphoresis (sweating) helps the body cool down; replenishing lost fluids prevents dehydration.

Skin Layers and Protection

The dermis is the inner skin layer with blood vessels, nerves, and glands, while the epidermis is the outer layer.
Subcutaneous tissue contains fat and larger blood vessels to support the dermis with nutrients and oxygen.

Safety and Restraint

Protective devices are essential when patient behavior changes mid-treatment to prevent harm.
A sentinel event refers to a patient death or serious injury caused by an incident in healthcare.
Local and federal laws regulate the use of restraints; alternatives such as family supervision are encouraged.

Patient Mobility and Falls

Moving partially immobile patients to a supine position ensures safety; bed rails should be used.
Reducing noise on the unit aids patient rest; encourage staff to speak softly in hallways.
Grab bars and well-lit areas decrease fall risks for patients with mobility issues.

Patient Comfort and Temperature

Extra blankets and bed socks can help warm patients, particularly those with diabetes or circulation issues.

Patient Monitoring

Placing at-risk fall patients near the nurse's station enables frequent checks.
Bed and chair alarms are essential as per the 2019 National Patient Safety Goals to enhance patient monitoring.

Fire Safety

The PASS technique (Pull, Aim, Squeeze, Sweep) is critical for effectively using a fire extinguisher.

Humidity and Breathing

Low humidity can dry respiratory passages; vaporizers or humidifiers may be ordered for patients with respiratory conditions.

Patient Transfers

To safely transfer patients to wheelchairs, they should first sit at the bed's edge with feet on the floor.
A transfer belt can assist patients who can stand, promoting safety and active exercise.

Patient Positions

The prone position alleviates pressure on the sacrum for semiconscious or bed-bound patients.
Waist-high bed height is optimal for nurses to prevent back injuries during patient repositioning.

Orthostatic Hypotension

Assess immobile patients for dizziness or blood pressure drops when transitioning to sitting or standing.

Preventing Pressure Ulcers

Avoid shearing forces on bony prominences during patient repositioning to reduce pressure ulcer risk.
Passive range of motion exercises aid in circulation and prevent contractures for bedfast patients.

Fall Prevention Tactics

Lower patients threatening to fall to the floor gently to avoid injury.
Proper use of gait belts and body mechanics is essential for patient stability during transfers.

Examination Positions

Prone position is used for spinal assessments; supine is for examining the abdomen.
Fowler's position is beneficial for shortness of breath management and certain procedures.

Handling Heavier Patients

Moving patients with increased weight requires at least two caregivers and a lift sheet to reduce strain.
Mechanical lifts aid in patient transfer but are not suitable for adjusting position within the bed.

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Description

This quiz explores the symptoms and staging of pressure ulcers, also known as pressure sores. It focuses on the impact of positioning and the importance of wound care nursing. Review your knowledge on effective prevention and treatment strategies.