Podcast
Questions and Answers
Which technique is crucial when preparing for a sterile dressing change?
Which technique is crucial when preparing for a sterile dressing change?
- Wearing jewelry during the procedure
- Using a non-sterile field for all items
- Performing hand hygiene before and after patient contact (correct)
- Rushing to complete the dressing change
What is the primary purpose of debridement in wound care?
What is the primary purpose of debridement in wound care?
- To enhance the color of the wound
- To cover the wound with a dressing
- To promote the growth of necrotic tissue
- To remove dead or infected tissue (correct)
How is the Braden Scale primarily utilized in a clinical setting?
How is the Braden Scale primarily utilized in a clinical setting?
- To determine the type of drainage from a wound
- To measure the size of a wound
- To evaluate a patient's risk of developing pressure ulcers (correct)
- To assess the level of pain a patient is experiencing
What does serosanguineous drainage indicate during the healing process?
What does serosanguineous drainage indicate during the healing process?
Which sign should be assessed during the palpation of a wound during evaluation?
Which sign should be assessed during the palpation of a wound during evaluation?
What indicates purulent drainage in a wound assessment?
What indicates purulent drainage in a wound assessment?
What action should be avoided to maintain sterile technique during dressing changes?
What action should be avoided to maintain sterile technique during dressing changes?
Which of the following is a characteristic of sanguineous drainage?
Which of the following is a characteristic of sanguineous drainage?
What is the primary purpose of debridement in wound care?
What is the primary purpose of debridement in wound care?
Which of the following criteria is NOT part of the Braden Scale?
Which of the following criteria is NOT part of the Braden Scale?
Which step is crucial when performing a sterile dressing change?
Which step is crucial when performing a sterile dressing change?
Which of the following terms refers to a bruise caused by trauma?
Which of the following terms refers to a bruise caused by trauma?
What is the proper order for a bed bath starting from the face?
What is the proper order for a bed bath starting from the face?
During a sterile dressing change, what should be done after removing the old dressing?
During a sterile dressing change, what should be done after removing the old dressing?
Which of the following is a key benefit of using the Braden Scale?
Which of the following is a key benefit of using the Braden Scale?
What aspect is NOT assessed when evaluating moisture on the Braden Scale?
What aspect is NOT assessed when evaluating moisture on the Braden Scale?
Which of the following factors is NOT considered a promoting factor for wound healing?
Which of the following factors is NOT considered a promoting factor for wound healing?
What is the primary goal of the Braden Scale in patient care?
What is the primary goal of the Braden Scale in patient care?
Which stage of pressure injury includes full-thickness skin loss with possible involvement of subcutaneous tissue?
Which stage of pressure injury includes full-thickness skin loss with possible involvement of subcutaneous tissue?
In the context of wound care, which type of drainage would indicate the presence of infection?
In the context of wound care, which type of drainage would indicate the presence of infection?
What is the recommended frequency for repositioning patients to relieve pressure and prevent injuries?
What is the recommended frequency for repositioning patients to relieve pressure and prevent injuries?
During a wound assessment, which characteristic should be documented for an accurate evaluation?
During a wound assessment, which characteristic should be documented for an accurate evaluation?
Which procedure involves the removal of necrotic tissue to enhance wound healing?
Which procedure involves the removal of necrotic tissue to enhance wound healing?
What aspect of a wound assessment helps identify the risk for further tissue damage?
What aspect of a wound assessment helps identify the risk for further tissue damage?
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Study Notes
Skin Integrity and Wound Care
- Risk factors for pressure injury formation: Elderly, Immobility, Palliative care, Diabetes.
- Key factors to consider regarding pressure injuries: Pressure intensity, Pressure duration, Tissue tolerance.
- Factors that promote wound healing: Good Nutrition, Moisture balance, Blood supply.
- Factors that impede wound healing: Infection, Necrotic tissue, Chronic illnesses.
- Nursing care plan for Impaired Skin Integrity: Regular skin assessments, documenting wound size, stage, and drainage. Nursing interventions include repositioning, hygiene, nutritional support, and patient education.
- Critical Thinking in Patient Care: Identify risk factors, Prioritize care based on mobility, skin condition, and nutrition. Collaboration with interdisciplinary teams for comprehensive care.
- Conditions at risk for Impaired Skin Integrity: Medical Conditions: Diabetes, vascular disease, obesity. Neurological Conditions: Impaired sensation affects pressure awareness. Incontinence: Increases moisture and risk of breakdown.
- Pressure Injury Staging: Stage I: Non-blanchable redness. Stage II: Partial loss of skin thickness. Stage III: Full-thickness skin loss; may involve subcutaneous tissue. Stage IV: Extensive damage; muscle and bone may be exposed. Unstageable: Full thickness obscured by slough or eschar.
- Assessment Techniques: Wound measurement (length, width, depth), signs of infection (redness, swelling, odor).
- Documentation: Include location, size, stage, drainage characteristics, and pain assessment.
- The Braden Scale: Assesses a patient's risk for developing pressure injuries based on six criteria: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
- Purpose of Braden scale: Identify patients at high risk for pressure injuries, enabling early intervention.
- Prevention using the Braden Scale: Regular skin assessments, repositioning, nutritional support, and the use of pressure-relieving devices.
- Wound and Injury Terminology: Laceration: A tear or a cut in the skin or tissue. Abrasion: A scrape or rub on the skin. Contusion: A bruise caused by trauma. Incision: A clean cut, typically from surgery. Fistula: An abnormal connection between two body parts.
- Debridement: The process of removing dead, damaged, or infected tissue from a wound.
- Purpose of Debridement: Promotes healing by removing barriers to healing, Reduces the risk of infection, Prepares the wound bed for effective closure or healing.
- Appropriate Hygiene Techniques (Bed Baths): Gather supplies (bathing basin, soap, towels, clean linens) and ensure privacy. Begin with the face and work downward, cleaning each body part with a fresh cloth. Pay attention to skin folds and areas that may be prone to irritation. Rinse and dry thoroughly, applying moisturizer as needed.
- Sterile Dressing Change: Gather sterile supplies and perform hand hygiene. Remove the old dressing carefully, assess the wound, and discard appropriately. Clean the wound as per protocol and apply a new sterile dressing.
- Central Line Dressing Change: Use sterile gloves, clean the catheter site with an antiseptic solution, and apply a sterile dressing. Ensure that the dressing is secure but not too tight to restrict blood flow.
Wound Drainage
- Serous Drainage: Clear or straw-colored fluid; normal in healing but excessive may indicate issues.
- Sanguineous Drainage: Red, bloody drainage; indicates active bleeding.
- Serosanguineous Drainage: Pink drainage; a mix of blood and serum; typically expected in the early stages of healing.
- Purulent Drainage: Thick, yellow, green, or brown; indicates infection and requires assessment and intervention.
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