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Terms in this set (58)vitamins/nutrients that promote wound healing -vitamin A purulent drainage -thick serosanguineous drainage pale, pink, watery, contains both serum and blood, appears blood-streaked or blood-tinged sanguineous drainage -thick, red, contains serum and blood cells slough -stringy substance attached to wound bed eschar -black, brown, tan, or necrotic tissue granulation -red, moist tissue composed of blood vessels primary intention -primary union
of the edges of a wound, progressing to complete scar formation without granulation secondary intention -wound closure in which the edges are separated, granulation tissue develops to fill the gap types of wounds that heal by secondary intention wounds involving loss of tissue: serum albumin level below ___ increases risk for delayed wound healing and infection below 3.5 g/dL indicates lack of protein stage I pressure ulcer -nonblanachable redness of intact skin stage II pressure ulcer -partial-thickness skin loss, abrasion stage III pressure ulcer -full-thickness skin loss stage IV pressure ulcer -full thickness tissue loss unstageable pressure ulcer full-thickness tissue loss, depth of ulcer is obscured by slough or eschar pressure ulcer risk factors -immobility, impaired mobility Braden Scale evaluates risk factors that place the patient at risk for skin breakdown, 23 total points Braden Scale - 6 categories 1. sensory perception pressure ulcer prevention - moisture following each incontinent episode clean area with perineal clean and protect skin with moisture-barrier ointment pressure ulcer prevention - friction and shear -reposition pt using drawsheet or transfer board how often to reposition pt in bed (pressure ulcer prevention) at least every 2 hrs how often to reposition pt in chair (pressure ulcer prevention) at least every 1 hr 3 major areas of nursing interventions to prevent pressure ulcers 1. skin care and management of incontinence (Fundamentals) hydrocolloid dressing a dressing that forms a gel that interacts with the wound surface On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the
correct category/stage for this patient's pressure ulcer? c. unstageable (since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined) Fundamentals When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area
blanches on fingertip touch? d. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode. Fundamentals When
obtaining a wound culture to determine the presence of a wound infection, from where should the specimen be taken? d. Cleansed wound Fundamentals What is the correct sequence of steps when performing a wound irrigation? 4, 3, 2, 5, 1 1. Place water proof bag near bed Fundamentals For a patient who has a muscle sprain,
localized hemorrhage, or hematoma, which wound care product helps prevent edema formation, control bleeding, and anesthetize the body part? b. Ice bag Fundamentals What is the removal of devitalized tissue from a wound called? a. Debridement Fundamentals What does the Braden Scale evaluate? b. Risk factors that place the patient at risk for skin breakdown Fundamentals Which skin care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes Fundamentals Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device, e.g. transfer board Fundamentals Which of the following describes a hydrocolloid
dressing? d. A dressing that forms a gel that interacts with the wound surface Fundamentals Partial thickness skin loss or intact blister with serosanginous
fluid. b. stage II Fundamentals Full thickness skin loss, subcutaneous fat may be visible. May include undermining. c. stage III Fundamentals Nonblanchable redness of intact skin. Discoloration,
warmth, edema, or pain may also be present. a. stage I Fundamentals Full thickness tissue loss, muscle and bone visible. May include undermining. d. stage IV Fundamentals The nurse is caring for a
postoperative pt who develops a wound dehiscence. Which of the following will the nurse do when this occurs? c. cover the wound with sterile, moist saline dressings Leadership and Management A
nurse is assigned to care for the following patients. Which of the patients is most at risk for developing skin problems and thus requiring thorough bathing and skin care? 4. A 70-year-old patient who has diabetes and dementia and has been incontinent of stool. (the 70-year-old patient has reduced circulation, which increases risk for infection, is likely unaware of skin problems because of dementia, and presence of stool will irritate the skin) Fundamentals ch 40 The nurse evaluates which laboratory values to assess a patient's potential for wound healing? 4. Nitrogen balance Fundamentals ch 45 A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the
nurse document this drainage? b. Purulent MS After the unlicensed assistive personnel (UAP) bathed the patient, she then told the nurse about a reddened area on the patient's coccyx. After assessing the area, what should be included in the plan of care? a. Reposition every 2 hours. MS An older adult patient is transferred from the nursing home with a black wound on her heel. What immediate wound therapy does the nurse anticipate providing to this patient? c. Debride the nonviable, eschar tissue to allow healing. MS Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage III pressure ulcer? b. Maintain protein intake of at least 1.25 g/kg/day. MS Which patient is most at risk for the development of a pressure ulcer? a. An older patient who is septic, bedridden, and incontinent MS The pt is admitted from home with a clean stage II pressure ulcer. What does the nurse expect to observe when she does her wound assessment? c. red-pink wound bed, without slough workbook What type of dressing will the nurse most likely use for the pt from the previous question? a. hydrocolloid (a clean wound would be treated with hydrocolloid or hydrogel dressing because they provide a moist environment to encourage granulation) workbook The pt's wound is not healing, so the HCP is going to send the pt home with negative pressure wound therapy. What will the caregiver need to understand about the use of this device? c. the occlusive dressing must be sealed tightly to the skin -the wound is cleaned weekly or when the dressing is replaced workbook Who is at
the greatest risk for developing pressure ulcers? c. a 30-yr-old woman who is comatose following a head injury (the immobility, mental deterioration, and possible neurologic disorder of the comatose pt present the greatest risk for tissue damage related to pressure) workbook What is the most important nursing intervention for the prevention and treatment of pressure ulcers? b. repositioning the pt frequently workbook The pt is transferring from another facility with the description of a sore on her sacrum that is deep enough to see the muscle. What stage of pressure ulcer does the nurse expect to see on admission? d. stage IV (full-thickness tissue loss with muscle, tendon, or bone exposed) workbook A pt's documentation
indicates he has a stage III pressure ulcer on his right hip. What should the nurse expect to find on assessment of the pt's right hip? c. deep crater through subcutaneous tissue to fascia -exposed bone, tendon, muscle = stage IV workbook Which nursing interventions for a pt with a stage IV sacral pressure ulcer are most appropriate to delegate to a LPN/LVN? (Select all that apply) d. measure the size (width, length, depth) of the ulcer (other interventions relate to assessment, judgement, and teaching) workbook A nurse is caring for an older client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to maintain the integrity
of the client's skin? Select all that apply: 1. Keep the head of the bed elevated at 30 degrees (do not massage, reposition at least every 2 hr) ATI Fundamentals Which of the following types of wounds heal by secondary intention? Select all that apply: 1. Stage III pressure ulcer ATI Fundamentals The
evening nurse reviews a client's chart and notes that the day nurse has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the nurse expect to note on assessment of the client's sacral area? 4. Partial-thickness skin loss of the dermis NCLEX ch 46 Sets with similar termsPotter & Perry Chapter 48: Skin Integrity & Wound…15 terms allisonpeirce1845 Chapter. 48: Skin Integrity and Wound Care Review…15 terms MikieG Skin Integrity and Wound Healing Nclex13 terms thefloridastategirl Chapter 3725 terms toxicoxide Sets found in the same folderExam 3 Revised144 terms matt209109 Exam 492 terms matt209109 Ch. 35 Elimination Prep U13 terms kendylau Fundamentals of Nursing Chapter 48: Skin Integrity…50 terms brent_roddyPLUS Other sets by this creatorShadowHealth Musculoskeletal Tina Jones22 terms Natacha625 Wk 13, Adv. Assess, Goolsby, Male Reproductive Sys…45 terms Natacha625 NURS550: Advanced Health Assessment and Diagnostic…55 terms Natacha625 AHA exam 1130 terms Natacha625 Other Quizlet setsa midsummer night's dream (Quotes) Act 111 terms Libbyvaldez17 bio ch 27 Bacteria Archaea38 terms erica_mcglone Chapter 1143 terms jenniehiro APES - Unit 6223 terms JasmineChen88 Which of the following interventions is the most important in preventing pressure ulcers?Regularly changing a person's lying or sitting position is the best way to prevent pressure ulcers. Special mattresses and other aids can help to relieve pressure on at-risk areas of skin. Most pressure ulcers (bedsores) arise from sitting or lying in the same position for a long time without moving.
Which intervention is most appropriate for a patient with a pressure ulcer?Wound cleansing, preferably with normal saline and appropriate dressings, is a mainstay of treatment for clean ulcers and after debridement. Bacterial load can be managed with cleansing. Topical antibiotics should be considered if there is no improvement in healing after 14 days.
What nursing interventions are used to prevent pressure injuries?The review identified four broad categories of interventions that are the most effective for preventing pressure injuries: (a) PI prevention bundles, (b) repositioning and the use of surface support, (c) prevention of medical device-related pressure injuries and (d) access to expertise.
What is the most important care task to prevent pressure injuries to the skin?Tips to prevent pressure injuries include: Keeping the skin clean and clear of bodily fluids. Moving and repositioning the body frequently to avoid constant pressure on bony parts of the body. Using foam wedges and pillows to help relieve pressure on bony parts of the body when turned in bed.
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What is the most important nursing intervention for the prevention and treatment of pressure ulcers quizlet?
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