Incorrect application of pressure-relieving devices
The picture below is an example of what stage pressure ulcer.
Stage 1 ulcer
Factors that affect wound healing include:
Age
Nutritional status
Lifestyle
Medications
The treatments for pressure ulcer:
Minimize direct pressure
Schedule and record position changes
Provide devices to reduce pressure areas
Clean and dress the ulcer using surgical asepsis
Never use alcohol or hydrogen peroxide
Obtain C&S, if infected
Teach the client
Provide ROM exercise
What can promote healing & prevent pressure ulcer complications?
Fluid intake
Protein, vitamin, and zinc intake
Dietary consult
Nutritional supplements
Monitor weight/lab values
Prevent entry of microorganisms
Prevent transmission of pathogens
True or False.
Any client experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition is at risk for pressure ulcer development.
True
______ the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface.
Shear
The force of two surfaces moving across one another, such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens is called ____.
Friction
True or False.
Moisture reduces the skin's resistance to other physical factors such as pressure and/or shear force.
True
Identify the stage pressure ulcer being described based on the information given below: Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Stage II pressure ulcer
Partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. This is a _____ pressure ulcer.
Stage III
A wound involving loss of tissue, such as a burn, pressure ulcer, or severe laceration, heals by ______.
Secondary intention
Wounds that are contaminated and require observation for signs of inflammation heal by______.
Tertiary intention
_____ is a localized collection of blood underneath the tissues.
A hematoma
What type of wound drainage is seen below and give some characteristics of it:
This is a purulent type of wound drainage. Typically purulent wound drainage is thick, yellow, green, tan, or brown in appearance.
A score of 14 or less on the Norton scale indicates ______.
Risk of pressure sore development
A low score on the Braden scale indicates ____.
A high risk for pressure sore development
When repositioning an immobile client, the nurse notices redness over a bony prominence. When the area is assessed, the red spot blanches with fingertip touch, indicating:
1.A local skin infection requiring antibiotics
2.This client has sensitive skin and requires special bed linen
3.A stage III pressure ulcer needing the appropriate dressing
4.Reactive hyperemia, a reaction that causes the blood vessels to dilate in the injured area
The correct is #
This type of pressure ulcer has an observable pressure-related alteration of intact skin whose indicators, compared with an adjacent or opposite area on the body, may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or beefy feel), and/or sensation (pain, itching).
1.Stage I
2.Stage II
3.Stage III
4.Stage IV
The correct answer is # 1
Postoperatively the client with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open and pieces of small bowel are noted at the bottom of the now opened wound. The correct intervention would be to:
1. Allow the area to be exposed to air until all drainage has stopped
2. Place several cold packs over the areas, protecting the skin around the wound
3. Cover the areas with sterile saline-soaked towels and immediately notify the surgical team; this is likely to indicate a wound evisceration
4. Cover the area with sterile gauze, place a tight binder over the areas, and ask the client to remain in bed for 30 minutes because this is a minor opening in the surgical wound and should reseal quickly
The correct answer is #
Serous drainage from a wound is defined as:
1.Fresh bleeding
2.Thick and yellow
3.Clear, watery plasma
4.Beige to brown and foul smelling
