- Study guides, Class notes & Summaries

Skin & Wound Care questions and answers assessment for pressure ulcers skin bony prominences & pressure injury sites predictive measurs mobility nutrition status body fluids pain who is at high risk for skin breakdown people with moisture from urine, stool, bile, wound drainage or gastric fluid what predictive measures to assess braden scale mobility nutrition body fluids comfort leels who is at the higher risk for pressure injuries

Skin & Wound Care questions and answers After completing a scheduled every-2-hour turn by turning the client to the left side, the nurse notices a reddened area over the coccyx. The area blanches when the nurse compresses it with thumb pressure. One hour later, the nurse reassesses the area and finds the redness has disappeared. How should the nurse document this area? 1. Reactive hyperemia 2. Stage I pressure ulcer 3. Stage II pressure ulcer 4. Stage III pressure ulcer - Correct...

Skin & Wound Care questions and answers Acute wounds - •trauma •surgical Chronic wounds - •diabetics are most at risk for arterial ulcers Pressure ulcers - •decubitus ulcer (bedsores) •impaired skin integrity •prolonged pressure in combo w/ shear or friction •Localized, over bony prominence Stage I Pressure Ulcer - •*NON*blanchable erythema •skin remains intact Stage II Pressure Ulcer - •partial-thickness skin loss

Skin & Wound Care questions and answers Intrinsic (patient) risks - Factors such as ↓ Sensation/level of consciousness, ↓ Activity/Mobility, Poor nutrition/hydration, and Moisture that contribute to pressure-injury formation. Extrinsic (care/environment) risks - Factors such as Pressure + friction + shear, Prolonged chair time without micro-shifts, and Lack of pressure-redistributing surfaces/supportive devices that contribute to pressure-injury formation.

Skin & Wound Care questions and answers Pressure ulcers form primarily as a result of: - tissue ischemia Patient has been on that portion of the skin (bony prominence) for too long. Incontinent pts are at risk for pressure ulcers. - Too much pressure on that site - Decreased blood flow - Decreased oxygen - Leads to tissue ischemia The nurse notes a client's skin is reddened with a small abrasion and serous fluid present. The nurse should classify this stage of ulcer formation as: -...

Skin & Wound Care Vocab questions and answers Abrasion Scrape, little bleeding, superficial, partial thickness Approximated Wound edges are closed & fit together Blanchable hyperemia pressing finger on affected area, blanches (turns white), erythema returns when you remove your finger. able to overcome ischemic episode Blanching Skin turns white when pressed & returns to normal color

Skin/wound care questions and answers Integumentary System changes in the older adult -Maturation of epidermal cells is delayed leading to thin & easily damaged skin -Poor turgor -Circulation and collagen formation are impaired, decreased elasticity and increased risk for tissue damage from pressure -Drier skin (sweat glands decrease) -Skin may become unevenly pigmented Wound Classifications Intentional Unintentional Open Closed Acute Chronic Intentional Wound Planned disru...

Skin/wound care questions and answers stage 1 wound - persistent red, blue, or purple hues, no skin break (firm or boggy) stage 1 wound drainage - no drainage stage 2 partial thickness - skin is broken, shallow, intact or ruptured blister stage 2 partial thickness drainage - small to heavy drainage stage 3, 4, and full thickness - skin is broken, deep crater w/ or w/o undermining stage 3, 4, and full thickness drainage - low exudate or moderate to heavy exudate stage 1 wound cleani...

Skin/wound care questions and answers What are priority assessments for clients with impaired skin integrity? - - Inspect bony prominences for any redness and moisture that could lead to skin breakdown/shearing - Ensure to check behind commonly missed places (ex. Behind the ear) Discuss safe transfers/repositioning techniques for clients with skin impairments - - Turn client q2h - Use trapeze bar when assisting with transfer - Elevate the HOB to reduce shearing - Limit chair time to 2 h...

Skin/wound care questions and answers What is important with skin care ? - Pt must be repositioned at least Q2H to prevent pressure ulcers What are pressure ulcers - Injury to skin and underyling tissue d/t prolonged pressure What is shearing - Loss of skin integrity due to forces being applied that cause skin to move in opposite direction