General Info
To ensure privacy for a patient, the nurse should...
This wound often appears as a "bruise" and may go deep into the skin/
What is a deep tissue injury?
Nurses shouldn't do this when caring for a client with a stage 1 pressure wound on a bony prominence.
What is "massage the area."
This type of wound drainage is considered infectious.
What is purulent drainage?
This type of drainage is often light to medium pink in color.
What is serosanguinous?
An order that is often present post-op to help with inflammation and swelling.
What is apply ice packs or cool compresses?
This Pressure wound extends into the muscle and bone.
What is Stage 4 pressure wounds?
Three areas to skin breakdown prevention...
What is Skin Mucous Membrane Protection, Pressure-Reducing Techniques, Pressure-Reducing Devices
Name signs of a wound infection:
What is redness, edema, pain, fever, purulent drainage, increased WBCs?
A client who is unresponsive should be ____________ when providing oral care...
Turned to their side and given full oral care at least every 4 hours.
This diet is helpful to prevent skin breakdown:
What is high protein, hydration, Vitamin D and Vitamin C and a well- balanced diet?
A wound with Eschar would be noted as.
What is unstageable?
This intervention to prevent pressure wounds is especially effective for patients who are on bedrest.
What is reposition every 2 hours?
Wounds described as:
rubbing off of the skin’s surface [e.g., a skinned knee]; stab wound; wound with torn, ragged edges, a wound with clean edges
What is an: Abrasion, Puncture Wound, Laceration and Surgical Incision?
Before letting a patient stand up the nurse should...
What is "have the patient sit on the side of the bed and assess for dizziness."
For this procedure, you cut close to and one end of the know and pull straight up.
What is suture removal?
A non-blanchable would should be treated with...
What is a transparent dressing?
The Braden Scale addressed these areas for risk for skin breakdown.
What is moisture, sensory perception, activity, mobility, nutrition, shear and friction?
To monitor for infection for a client who has a pressure wound, the nurse should review this lab value...
What is WBC?
Patients with diabetes should be taught ___________ about foot care?
What is:
Do not soak your feet
Check your feet everyday for injury
Wear well fitting socks and shoes
This type of wound closure occurs when the wound is left to heal from the "inside out."
What is secondary intention?
This wound extends into the subQ fat tissue.
What is a Stage 3 pressure wound?
This wound complication refers to one or more channels within or underlying an open wound.
What is tunneling
A post surgery client feels a "pop" at her incision site, the nurses next step is...
What is: assess for dehiscence or evisceration and if present, cover over a dressing soaked in a sterile normal saline solution and call the surgeon.
When asked why a patient can't leave their dentures in for surgery, the nurse should respond...
What is "aspiration risk or damage to the dentures."