Skin Integrity Management

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Questions and Answers

Which of the following is NOT recommended when managing pressure injuries?

Consulting a dietitian for nutritional input

Massaging the area of the pressure injury (correct)

Using pressure-reducing devices as needed

Monitoring albumin and prealbumin levels

What type of food is specifically recommended for increasing zinc levels in a patient's diet?

High-protein foods (correct)

Citrus fruits

Sweet potatoes

Dark green leafy vegetables

When performing a moist compress, which step is essential for maintaining temperature?

Change the compress every hour

Soak the gauze in cold water

Apply the compress directly without any covering

Cover with towels or a waterproof pad (correct)

What is the recommended action for a moist soak to ensure proper care?

Maintain temperature by covering the container and extremity Signup and view all the answers

Which of the following assessments is primarily used to evaluate risk for pressure injuries?

Braden Scale Signup and view all the answers

Which of the following is an appropriate method for using heat and cold therapy with noncommercial ice bags?

Remove air before sealing Signup and view all the answers

What type of foods should be encouraged for their high vitamin A content?

Carrots and dark yellow vegetables Signup and view all the answers

What is an essential consideration when obtaining and using an aquathermia pad?

Only distilled water should be used in the pad channels Signup and view all the answers

What is the most effective method to clean a wound without damaging healing cells?

Normal saline 0.9% Signup and view all the answers

When wrapping an injured limb, which technique should be employed to secure the bandage?

Perform two circular wraps to secure Signup and view all the answers

In managing a malignant wound, what is the primary action regarding dressings?

Keep dressings dry and intact Signup and view all the answers

Which method should NOT be used to clean wounds due to potential harm to healing tissue?

Acetic acid Signup and view all the answers

What is the recommended technique for securing a bandage on a joint?

Figure 8 wrap Signup and view all the answers

What action is essential before wrapping an injured limb?

Keep the limb elevated for 15 to 30 minutes Signup and view all the answers

What is the proper way to clean around a wound drain?

Clean in a circular motion from close to the drain outward Signup and view all the answers

What is the recommended coverage method when applying a dressing?

Cover half of the previous wrap Signup and view all the answers

Which of the following is a critical step when managing negative pressure wounds?

Document wound assessment and patient response Signup and view all the answers

For a burn wound, what initial action should be taken?

Pat dry the surrounding skin and apply a barrier Signup and view all the answers

What is the primary purpose of the Salem Sump tube's secondary lumen?

To serve as an air vent preventing mucosal suction Signup and view all the answers

What is the recommended type of water for flushing devices and preparing medications for immunocompromised patients?

Purified or sterile water Signup and view all the answers

In which circumstance should a nurse avoid repositioning the NG tube?

If the patient has undergone gastric surgery Signup and view all the answers

Which tube is generally preferred for enteral feeding if a patient cannot take food safely by mouth?

Small-bore feeding tube Signup and view all the answers

For effective stomach decompression, which intervention should be avoided with a Salem Sump tube?

Clamping the air vent Signup and view all the answers

Which nursing intervention is essential for maintaining the integrity of an NG tube?

Provide oral care to minimize dryness of the mucosa Signup and view all the answers

What is a potential risk associated with using contaminated tap water for patient procedures?

Infections outbreaks Signup and view all the answers

What is the main function of the Levin tube in gastric decompression?

It drains stomach secretions into a drainage bag. Signup and view all the answers

Which factor should influence the choice of tube for gastric procedures?

The patient’s comfort level Signup and view all the answers

What should be done if the NG tube becomes dislodged or changes position?

Notify the physician and reassess the tube position Signup and view all the answers

What is the primary purpose of a pressure dressing applied with elastic bandages?

To promote hemostasis by applying localized downward pressure Signup and view all the answers

Which dressing technique should be utilized for a necrotic wound requiring debridement?

Moist-to-dry dressing technique Signup and view all the answers

What is a critical consideration when using pressure dressings?

They should be assessed to ensure they do not interfere with circulation Signup and view all the answers

How should the periwound area be managed to prevent skin breakdown?

Apply a protective barrier and keep it clean and dry Signup and view all the answers

What characteristic of absorbent dressings allows them to manage excess drainage effectively?

The wicking action of woven gauze dressings Signup and view all the answers

What is the recommended method for cleaning contaminated skin to promote skin integrity?

Use warm water and a mild pH-neutral soap. Signup and view all the answers

How should the head of the bed be positioned to minimize shear effects in a patient at risk for pressure ulcers?

At 30 degrees or less. Signup and view all the answers

What dietary components are critical for wound healing in patients with skin integrity issues?

Adequate calories, protein, and vitamin C. Signup and view all the answers

What is the correct interval for repositioning a patient to prevent pressure injuries?

Every 2 hours. Signup and view all the answers

Which of the following actions helps to prevent pressure on bony prominences when a patient is side-lying?

Position the patient laterally at 30 degrees. Signup and view all the answers

What is a primary characteristic of pressure-reducing mattresses?

They accommodate all types of patients, including obese individuals. Signup and view all the answers

How often should wet or soiled gowns and sheets be changed to maintain skin integrity?

Frequently as needed. Signup and view all the answers

What type of cushioning can be beneficial for patients who cannot change positions independently when seated?

Pressure-redistribution cushions. Signup and view all the answers

What should be done to the heels of a patient to remove pressure while they are lying in bed?

Place pillows so that the heels 'float' off the mattress. Signup and view all the answers

What should nurses avoid using when cleaning skin to prevent drying?

Antibacterial soap. Signup and view all the answers

Study Notes

Skin Integrity

Turning and repositioning: Turn patients at least every 2 hours to prevent pressure injuries, elevate the head of the bed no more than 30 degrees to decrease shear effects, position the patient laterally at 30 degrees when side-lying to avoid direct pressure on bony prominences, place pillows between the knees for side-lying, position legs with pillows so that heels "float" off the mattress, limit chair use to 2 hours or less, and provide assistance to patients who are unable to change positions independently.
Pressure-reducing mattresses: Use support surfaces like overlays, replacement mattresses, and specialty beds to redistribute the body's weight.
Cleaning and drying: Keep skin dry from urine, stool, wound drainage, and moisture, apply skin barrier as needed, and change wet/soiled gowns and sheets frequently.
Wound dressings: Choose dressings according to the wound type and healing goals, moisten gauze dressings with saline before removal to prevent trauma, use moist-to-dry dressings for debridement, and apply pressure dressings for bleeding wounds.

Heat and Cold Therapy Actions

Moist Compress Application: Soak sterile gauze or linen in a sterile solution, place over the wound/injury, and cover with towels or a waterproof pad to maintain warmth or cold for the prescribed time.
Moist Soak Application: Place the extremity completely in the solution, maintain the temperature of the solution by covering the container and extremity, and keep the solution warm or cold by changing the solution or adding to it as needed (about every 10 minutes). Dry the extremity completely.
Sitz Bath Application: Soak the perineum/pelvic area for 20 minutes, adjust the temperature according to facility protocol, and use a chair, tub, or toilet attachment. Monitor the perineal area for complications.
Aquathermia Application: Obtain pad and control unit, place pad around the extremity, and turn on the control unit.
Hot/Cold Pack Application: Follow manufacturer instructions for commercial packs, fill noncommercial ice bags with water or crushed ice, remove air before closing, and do not place heat or cold pack directly on the skin, placing a small washcloth between the skin and pack.

Wound Cleansing and Irrigation

Cleaning agent selection: Use a cleaning agent that balances cleaning and trauma to the wound bed, avoid Dakin's solution, povidone-iodine, acetic acid, and hydrogen peroxide because they can damage healing cells, and use normal saline 0.9% for wound cleaning.
Wound Drain Cleaning: Clean the drain in a circular motion from close to the drain outward using a new cleansing gauze for each movement, place a specially prepared 4" x 4" dressing around the drain, and apply ABD pads and tape.

Negative Pressure Wound Therapy (NPWT)

Application: Clean and pat dry wound and surrounding skin, apply skin barrier protectant, cut foam to fit the wound, apply a transparent occlusive dressing over foam and extend 2 inches out, cut a hole in the dressing if there is not a precut center hole, place suction tubing in the center hole without the tubing touching the wound bed, apply another transparent dressing over both the tubing and the first dressing, apply the suction tubing to the canister, discard gloves and wash hands, and turn on the unit.
Documentation: Document wound assessment, characteristics of drainage, dressing type, pressure setting, and patient response to NPWT

Malignant, Traumatic, and Surgical Wounds

Dressing Care: Keep dressing dry and intact, assess and change dressings as needed or in accordance with healthcare provider instructions or facility policies, and assess and measure the wound inspecting the skin for abrasions, edema, discoloration, or exposed wound edges prior to applying bandages or binders.
Drainage Care: Assess drainage characteristics and monitor and clean drains as needed.

Nasogastric (NG) Tube Management

Tube Selection: Choose the smallest lumen tube effective for intended use, and select a Levin or Salem Sump tube for stomach decompression or enteral feedings.
Tube Insertion and Care: Insert using clean technique, lubricate the naris, provide frequent mouth care, and change soiled tape or securement devices.
Positioning: Do not reposition the NG tube if the patient has undergone gastric surgery to avoid disrupting the suture line.
Water Use: Use purified or sterile water for flushing and medication preparation, and use sterile water for reconstituting powdered formula and for all procedures involving immunocompromised patients.

Nutrition

High-Protein Foods: Offer foods high in protein, including meat, milk, eggs, cheese, beans, nuts, and seeds.
Vitamins C and A: Provide foods high in vitamins C and A, such as oranges, citrus fruit, strawberries, kiwi, broccoli, peppers, tomatoes, carrots, apricots, sweet potatoes, and dark yellow or orange vegetables.
Zinc and Copper: Offer food high in zinc and copper, like high-protein foods and molasses.
Fluids: Encourage fluid intake to increase fluid consumption.
Patient Input: Ask for the patient's input on favorite foods and completion of diet requests.
Consultations: Consult with a dietitian/nutritionist as needed.
Monitoring: Monitor albumin and prealbumin levels.

Pressure Injuries

Prevention: Use Braden Scale or Norton Scale to assess risk for pressure injuries, do not massage pressure injuries, and suggest fluid intake.

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Description

This quiz covers essential practices for maintaining skin integrity, including turning and repositioning techniques, the use of pressure-reducing mattresses, and proper cleaning and dressing of wounds. Understanding these principles is crucial for preventing pressure injuries and promoting healing in patients with compromised skin conditions.