Pressure Ulcers
Hardened black/brown tissue covering wounds.
Eschar
What factors influence healing
Adequate nutrition & hydration, sensory perception, ability to change positions independently, age
A wound with necrotic tissue needs debriding, you would use what method
Wet-to-dry
An action by the nurse that is most appropriate when evisceration occurs
Cover the wound with saline soaked gauze and notify the surgeon immediately
Full thickness loss with exposed muscle or bone.
Stage 4
Soft yellow/tan tissue made of dead cells in a wound bed
Slough
Which patient is at highest risk for delayed wound healing?
A 25 year old with a clean surgical incision
A 76 year old with diabetes and poor nutrition
A 58 year old with good perfusion at a healthy weight
A 7 year old with a small laceration
A 76 year old with diabetes and poor nutrition
This type of solution would be used for a wet-to-dry dressing
normal saline
A patient who recently had abdominal surgery suddenly feels a pop after straining to cough. What would the nurse suspect happened and what interventions would they do?
Dehiscence, keep head of bed elevated slightly, provide binder if necessary, notify the provider immediately
Depth unknown due to slough/eschar.
Unstageable Ulcers
What does a low Braden scale score mean?
High risk for pressure ulcers
A burn wound heals by
Secondary intention
Packing the wound too tightly can lead to
tissue damage
The nurse is taking care of a patient and suspects an internal hemorrhage. Upon assessment what signs would the nurse expect to see
Decrease in BP, Increase in HR, swelling around area
Partial thickness loss or clear-fluid blister.
Stage 2
What steps must a nurse take with a suspected pressure injury?
Immediately remove pressure, inspect, palpate, CLEAN WOUND then stage, measure size and depth of wound, protect/cover wound, notify provider, document findings and interventions. Rotate patient every 2 hours to prevent further injury.
Which outcome would the nurse see that the wound has entered the proliferative phase of healing?
Bleeding and clot formation
Inflammation and redness
Development of granulation tissue
Scar maturation and remodeling
Development of granulation tissue
A dressing that is too saturated can lead to
maceration
A nurse is assessing an 81 year old who recently had a hip surgery. She is unable to roll over in bed on her own, incontinent and has had little interest in eating. Which nursing diagnosis is appropriate based on these findings?
Risk for impaired skin integrity
Imbalanced nutrition: less than body requirements
Infection related to impaired skin integrity
Risk for impaired tissue integrity
Risk for impaired skin integrity
Full thickness loss with visible fat.
Stage 3
Locations most at risk for developing pressure ulcer in bed bound individual?
Scapula, sacrum, trochanter, elbows, ankles, knees, and back of the head
This phase of wound healing is when the clotting mechanism occurs
Hemostasis
You must do this before reapplying a dressing
reassess wound
Upon assessment the nurse notices their patient's temperature is 101.2, purulent drainage, redness and heat coming from their incision site. What would the nurse suspect is happening
Infection
Intact skin with non-blanchable redness.
Stage 1