"Let me check your bum" (assessment)
Name at least 4 signs of a wound infection that you would document & report to the MD if you newly assessed in your patient.
foul smell, redness, hot-to-touch, drainage (green, tan, purulent), increased pain, swelling, fevers/malaise.
Name a cream you would use on an open (stage II - partial thickness loss of dermis) pressure injury?
Triad
Name the dark area of this photo
Eschar
To be considered present on admission (POA) pressure injury, what is the max timeframe of which a wound must be documented?
24 hours after admission
True or False: You need the doctor to place an order for a low air loss mattress.
False. The RN can order it as a nursing intervention.
Indications
A. Skin breakdown resulting from excessive moisture i.e. incontinence or drainage. B. Pressure Injuries on more than one turning surface and the patient is unable, unwilling, or restricted from being positioned off of the injury. C. Pain management.
When should a skin assessment be completed? (4 instances)
1. admission
2. transfer
3. daily
4. discharge
Which cream would you need an order for?
1. Thick Moisture Barrier Paste (Citric Acid Skin Paste)
2. Clear Moisture Barrier Cream (Citric Acid Clear)
3. Clear Moisture Barrier Cream with Antifungal (Citric Acid Clear - AF)
4. Triad Cream
3. Clear Moisture Barrier Cream with Antifungal (Citric Acid Clear - AF)
Pressure injury or wound? (photo)
Pressure Injury - Deep Tissue Injury (DTI)
Your patient has limited ability to feel or communicate pain or discomfort. What would you document as part of the S-K-I-N bundle?
True or false: PCTs can apply or change any dressings as long as the nurse validates the dressing change was complete.
False: PCTs can only change simple dry dressings, and the nurse should be validating/reviewing any task that is delegated to a PCT.
Your newly admitted patient states they have been having a wound care RN come to assess, pack & dress a deep calf ulcer. The wound is currently dressed and the patient states their wound care nurse saw them this morning. What are your next steps?
Take the dressing down, assess the wound with the patient's skin assessment, document, and consult ET
Name 3 of the 5 appropriate wound cleansers.
Soap and water, normal saline, sterile water, dermal wound cleanser, Vashe
How would you chart this wound (name and description of photo).
Doucment as new "Skin Tear"
bloody drainage, partial flap loss
Wound, Ostomy, Continence (WOC) Nursing form; found in the forms section of the patient's chart.
True.
The dressing should be promptly removed. Assess the wound and apply a normal saline wet to dry dressing. Send the home V.A.C. machine home with family for safe keeping. Notify the MD that a V.A.C was in place as a new wound VAC order will need to be placed.
A patient was admitted 2 days ago and is complaining of soreness behind his ears. He wears glasses and uses oxygen at home intermittently but has been wearing a nasal cannula since admission. The patient has non-blanchable red marks behind his ears. Nothing is documented in his chart about skin issues. What is this injury called & what are your next steps?
Hospital acquired pressure injury - stage I (stage will be determined by ET)
Consult ET for new pressure injury & staging, protect wound from further injury
Interdry and Nystatin powder are both ordered for your patient. You should apply them together in your patient's skin folds. True or False (rationale)
False. These interventions should be used separately from one another.
Your patient was just admitted from a SNF. During her skin check, you assess this on her buttocks region. Name this wound (photo)
Incontinence-associated (moisture-associated) dermatitis
When charting your S-K-I-N assessment, what does the “K” stand for and what qualifies a patient for charting this?
“K” stands for limited mobility, and the patient qualifies for this specific charting if patient is unable, unwilling, or restricted to independently walk and/or adjust position, and/or is unable to prevent sliding while in bed or chair
Any medication/treatment for wounds that is dispensed by pharmacy requires what?
a physician order
A new patient was just admitted to your unit. Describe your initial skin assessment.
Full skin check of bony prominences, documentation of presenting pressure injuries – including locations, size, characteristics, and nursing interventions, consult ET/wound care
Name the steps and order or products for a weeping/edematous leg wounds with an ulcer on the calf (no ET order yet).
Clean with wound cleanser first.
Non-adherent layer (adaptic, petroleum gauze, xeroform or medihoney on ulcer).
absorbent layer (ABD or gauze).
Wrap (ACE or Kerlex)
Tape & Label (initial, date, time).
Name this wound category (photo)
venous (stasis) ulcers
When charting your S-K-I-N assessment, what qualifies a patient for the “N” category?
Qualifications for inadequate nutrition includes: Less than or equal to 50% decrease in PO intake, OR NPO/CL greater than or equal to 3 days, OR Tube feed not at goal rate or held intermittently for several days
If a wound vac stops working and is unable to be fixed within ____ (timeframe), then I must inform the physician and ________(nursing intervention).
Timeframe - 2 hours
Nursing Intervention - a wet-to-dry dressing must be applied
The wound vac must be intact and running at least 22 out of 24 hours. (reference: POLICY: NP 1907)