Skin Integrity and Wound Care Quiz
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Questions and Answers

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?

  • 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?

  • 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?

    <p>Normal healing process typically expected</p> Signup and view all the answers

    Which sign should be assessed during the palpation of a wound during evaluation?

    <p>Moisture and temperature changes</p> Signup and view all the answers

    What indicates purulent drainage in a wound assessment?

    <p>Thick, yellow, green, or brown fluid</p> Signup and view all the answers

    What action should be avoided to maintain sterile technique during dressing changes?

    <p>Reaching over the sterile field</p> Signup and view all the answers

    Which of the following is a characteristic of sanguineous drainage?

    <p>Red, bloody fluid indicating active bleeding</p> Signup and view all the answers

    What is the primary purpose of debridement in wound care?

    <p>To promote healing by removing barriers to healing</p> Signup and view all the answers

    Which of the following criteria is NOT part of the Braden Scale?

    <p>Hair loss</p> Signup and view all the answers

    Which step is crucial when performing a sterile dressing change?

    <p>Perform hand hygiene</p> Signup and view all the answers

    Which of the following terms refers to a bruise caused by trauma?

    <p>Contusion</p> Signup and view all the answers

    What is the proper order for a bed bath starting from the face?

    <p>Face, arms, torso, legs, feet</p> Signup and view all the answers

    During a sterile dressing change, what should be done after removing the old dressing?

    <p>Clean the wound using sterile saline and assess it</p> Signup and view all the answers

    Which of the following is a key benefit of using the Braden Scale?

    <p>It identifies patients at high risk for pressure injuries</p> Signup and view all the answers

    What aspect is NOT assessed when evaluating moisture on the Braden Scale?

    <p>Patient's preference for moisture levels</p> Signup and view all the answers

    Which of the following factors is NOT considered a promoting factor for wound healing?

    <p>Chronic Illnesses</p> Signup and view all the answers

    What is the primary goal of the Braden Scale in patient care?

    <p>To evaluate risk factors for pressure injury formation.</p> Signup and view all the answers

    Which stage of pressure injury includes full-thickness skin loss with possible involvement of subcutaneous tissue?

    <p>Stage III</p> Signup and view all the answers

    In the context of wound care, which type of drainage would indicate the presence of infection?

    <p>Purulent drainage</p> Signup and view all the answers

    What is the recommended frequency for repositioning patients to relieve pressure and prevent injuries?

    <p>Every 1-2 hours</p> Signup and view all the answers

    During a wound assessment, which characteristic should be documented for an accurate evaluation?

    <p>Location, size, and stage of the wound</p> Signup and view all the answers

    Which procedure involves the removal of necrotic tissue to enhance wound healing?

    <p>Debridement</p> Signup and view all the answers

    What aspect of a wound assessment helps identify the risk for further tissue damage?

    <p>Assessment of mobility and sensation</p> Signup and view all the answers

    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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    Description

    Test your knowledge on skin integrity and wound care principles, focusing on risk factors for pressure injuries and factors that promote or impede wound healing. This quiz also covers nursing care plans and critical thinking strategies in patient care. Perfect for nursing students and professionals looking to enhance their wound care expertise.

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