Chapter 48 & 26 Flashcards
What is the purpose of SBAR format in shift reports?
To provide a structured communication framework for patient handoffs
SBAR stands for Situation, Background, Assessment, and Recommendations.
What information is included in the ‘Situation’ section of an SBAR report?
Patient Name, Room Number, Admission Date, Physician(s)
This section provides a quick overview of the patient’s identity and current status.
What details are covered in the ‘Background’ section of an SBAR report?
Admission Diagnosis, Past medical history, Allergies, Code Status, Procedures done in previous 24 hours
This section gives context to the patient’s current condition.
What are the key components of the ‘Assessment’ section in an SBAR report?
Biophysical assessment, Abnormal vital signs, Dressing condition, NG/Drain output, IV fluids/drips/site, Current pain score, Rhythm
This section summarizes the current clinical findings.
What should be included in the ‘Recommendations’ section of an SBAR report?
Change in plan of care, Concerns, Discharge planning, Pending labs/x-rays, Requests for changes, Consults needed, Contact with physician
This section outlines the next steps and any additional needs for the patient.
Fill in the blank: We need to request a change in ________.
[diet, activity, medications]
This indicates areas where adjustments may be needed in patient care.
What types of professionals might be consulted according to the recommendations section?
PT, ST, OT, dietician, diabetes nurse, social worker, wound care nurse
These professionals can provide specialized care and support.
True or False: The ‘Assessment’ section includes the patient’s dressing condition.
True
Dressing condition is an important aspect of the patient’s current assessment.
What does ‘Code Status’ refer to in the background section?
Any advance directives, DNR orders
This information is crucial for making decisions in emergencies.
What should be done regarding pain management according to the assessment?
Current pain score and what has been done to manage pain
This ensures that pain control measures are documented and evaluated.
What does ‘Rhythm’ refer to in the assessment section?
If the patient is on telemetry
Monitoring cardiac rhythm is essential for patients with cardiac conditions.
What is Stage 1 in pressure injury classification?
Non-blanchable erythema of intact skin
Intact skin with a localized area of non-blanchable erythema; may appear differently in darkly pigmented skin.
What are the characteristics of Stage 2 pressure injury?
Partial-thickness skin loss with exposed dermis
Wound bed is viable, pink or red, moist; may present as intact or ruptured serum-filled blister.
What should not be described as Stage 2 pressure injury?
Moisture associated skin damage (MASD)
Includes incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds.
What defines Stage 3 pressure injury?
Full-thickness skin loss
Adipose is visible, granulation tissue and epibole may be present; depth varies by anatomical location.
What occurs in Stage 4 pressure injury?
Full-thickness skin and tissue loss
Exposed fascia, muscle, tendon, ligament, cartilage, or bone; slough and/or eschar may be visible.
What is an Unstageable pressure injury?
Obscured full-thickness skin and tissue loss
Extent of tissue damage cannot be confirmed due to slough or eschar obscuring it.
What characterizes a Deep Tissue Pressure Injury?
Persistent non-blanchable deep red, maroon, or purple discoloration
May reveal a dark wound bed or blood-filled blister; results from intense and/or prolonged pressure.
What is the significance of stable eschar in pressure injuries?
Should not be removed if dry, adherent, intact without erythema or fluctuance
Particularly important on ischemic limbs or heels.
True or False: Stage 1 pressure injury can have purple or maroon discoloration.
False
These colors indicate deep tissue pressure injury.
Fill in the blank: Stage 3 pressure injuries may present with _______.
granulation tissue
Other features include slough and/or eschar.
What does undermining and tunneling indicate in pressure injuries?
Potential depth and extent of tissue loss
Commonly observed in Stage 3 and Stage 4 injuries.
Identify all stages of pressure injury
What does pallor indicate in clinical assessment?
Vasoconstriction present
Pallor is characterized by a white hue in light-skinned individuals, indicating reduced blood flow.
What is the appearance of erythema in skin assessment?
Skin is red
Erythema is associated with inflammation and increased blood flow to the skin.
What does cyanosis indicate?
Hypoxia of tissue
Cyanosis presents as a bluish tinge in the skin, particularly in areas like earlobes and lips.
What color changes are observed in a light-skinned person with ecchymosis?
Purple-blue to yellow-green to yellow
Ecchymosis occurs when deoxygenated blood seeps into subcutaneous tissue.
What does jaundice indicate in skin assessment?
Accumulated bilirubin in tissues
Jaundice typically presents with yellow skin, mucous membranes, and sclera of the eyes.
What are petechiae?
Round, pinpoint purplish red spots on skin
Petechiae indicate dermal or submucosal bleeding.
How does skin appear in a dark-skinned person when assessing for pallor?
Ashen gray
In dark-skinned individuals, the loss of red tones indicates pallor.
What areas should be observed for color changes in dark-skinned individuals?
Mucous membranes, lips, and nailbeds
These areas may show paleness or grayish tones indicating changes in skin color.
What is the significance of palpating the skin during assessment?
Increased warmth, edema, tightness, or induration
Palpation helps identify underlying conditions affecting the skin.
What does the presence of yellow discoloration in sclera, oral mucosa, and palms indicate?
Jaundice
Yellow discoloration is a key indicator of bilirubin accumulation.
Fill in the blank: Skin changes from purple-blue to ______ to yellow in cases of ecchymosis.
yellow-green
This sequence of color changes helps in assessing the healing process of bruises.
True or False: In cyanosis, tissue color returns quickly when pressure is applied.
False
In cyanosis, the return of color is slow, spreading from the periphery to the center.
What should be noted when assessing for trauma and discomfort in skin assessment?
Swelling and induration
Observing these signs can indicate underlying issues requiring further investigation.
What are pressure injuries (PIs)?
Pressure injuries (PIs) are wounds caused by prolonged pressure on the skin, often occurring in patients with limited mobility.
What are other names for pressure injuries?
Pressure injuries are also known as pressure ulcers, decubitus ulcers, or bedsores.
What is the annual incidence of pressure injuries in hospital patients?
2.5 million hospital patients develop a pressure injury each year.
How many deaths are attributed to pressure injuries annually?
Approximately 60,000 patients die each year due to pressure injuries.
Why are pressure injuries a significant concern in healthcare?
Pressure injuries are costly, cause pain, extend hospital stays, and can lead to premature death.
What is the range of costs associated with pressure injury care?
The cost of pressure injury care can range from $620 to $1,200.
What can pressure injuries present as?
Pressure injuries can present as intact skin or an open sore.
What is the gold standard in wound documentation?
Digital imaging is considered the gold standard in wound documentation.
It reduces subjectivity in assessments and provides comprehensive documentation.
How accurate is measuring wounds with rulers?
Measuring wounds with rulers is only 40% accurate and subject to significant variabilities.
What is one benefit of digital imaging in wound care?
Digital imaging speeds workflow by enabling clinicians to capture and document wound images quickly and easily.
How much charting time can Tissue Analytics’ imaging solution save daily?
It can save a minimum of 2.5 hours of charting time daily.
What is the average cost of pressure injuries per patient?
The average cost of pressure injuries per patient ranges from $20,900 to $151,700.
What advantage does the Net Health/Tissue Analytics system provide?
It allows for quick retrieval of wound images to ensure accurate reporting and staging of pressure injuries.
What challenges do clinicians face when caring for patients with pressure injuries today?
Clinicians face increased demands due to comorbidities that contribute to the chronicity of pressure injuries.
Why is timely and accurate assessment important in pressure injury management?
Timely and accurate assessment is essential for managing pressure injuries and ensuring patients receive the care they deserve.
What is the significance of skin integrity?
The skin serves as the body’s primary defense against environmental hazards. Maintaining its integrity is vital to prevent infections and other complications.
What are the layers of the skin?
- Epidermis: Outermost layer providing a barrier against pathogens.
- Dermis: Middle layer containing blood vessels, nerves, and connective tissues.
- Subcutaneous Tissue: Innermost layer composed of fat and connective tissue, offering insulation and cushioning.
What are the functions of the skin?
Protection, sensation, temperature regulation, and excretion.
What are intrinsic factors affecting skin integrity?
- Age: Elderly individuals may have thinner, less elastic skin.
- Chronic Illnesses: Conditions like diabetes can impair healing.
What are extrinsic factors affecting skin integrity?
- Moisture: Prolonged exposure can lead to maceration.
- Friction and Shear: Can cause skin tears or pressure ulcers.
What are the classifications of wounds by onset and duration?
- Acute Wounds: Such as surgical incisions, typically heal promptly.
- Chronic Wounds: Like pressure ulcers, persist over time.
What are the classifications of wounds by depth?
- Partial-Thickness: Involves the epidermis and possibly part of the dermis.
- Full-Thickness: Extends through the dermis into deeper tissues.
What is a pressure ulcer?
Localized damage to the skin and underlying tissue, usually over a bony prominence, due to prolonged pressure.
What are the risk factors for pressure ulcers?
- Impaired mobility
- Decreased sensory perception
- Moisture from incontinence
- Poor nutrition
What are the stages of pressure ulcers?
- Stage I: Non-blanchable erythema of intact skin.
- Stage II: Partial-thickness skin loss with exposed dermis.
- Stage III: Full-thickness skin loss, possibly exposing fat.
- Stage IV: Full-thickness tissue loss with exposed bone, muscle, or tendon.
- Unstageable: Obscured full-thickness skin and tissue loss.
- Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon, or purple discoloration.
What are the phases of the wound healing process?
- Hemostasis: Immediate response to injury, involving blood clotting.
- Inflammatory Phase: Body’s natural response to injury, characterized by redness and swelling.
- Proliferative Phase: Formation of new tissue, including collagen deposition.
- Maturation (Remodeling) Phase: Strengthening of the wound site over time.
What factors influence wound healing?
- Nutrition
- Oxygenation
- Infection
- Age
What are the techniques for assessing skin and wounds?
Visual inspection and palpation, assessing for color, temperature, moisture, and integrity.
What are the wound assessment parameters?
- Size (length, width, depth)
- Appearance (e.g., presence of granulation tissue)
- Exudate (type and amount)
- Condition of surrounding skin
What assessment tool is used for predicting pressure ulcer risk?
Braden Scale.
What are some preventive measures for skin care?
- Keep skin clean and moisturized.
- Regularly reposition patients to alleviate pressure.
- Use specialized mattresses or cushions.
- Ensure adequate protein and calorie intake.
What are some wound care techniques?
- Cleaning: Use appropriate solutions to prevent infection.
- Debridement: Removal of non-viable tissue to promote healing.
- Dressing Selection: Choose based on wound type and exudate level.
- Adjunctive Therapies: Such as negative pressure wound therapy.
What are the pain management strategies in wound care?
- Administer analgesics as needed.
- Employ non-pharmacological methods like relaxation techniques.
What should be included in patient and caregiver education?
- Teach proper wound care techniques.
- Discuss signs of infection to watch for.
What should be documented in wound care?
Record detailed assessment findings and note interventions performed and patient responses.
What is involved in the evaluation of wound healing?
Regularly assess wound healing progress.
What are the purposes of documentation in nursing?
- Communication: Vital for conveying patient information among healthcare team members.
- Legal Documentation: A confidential and permanent legal document recording relevant healthcare information.
- Financial Billing: Essential for appropriate billing and reimbursement for healthcare services.
- Education and Research: Provides valuable data for educational purposes and clinical research.
What are the guidelines for quality documentation?
- Factual: Include only objective and factual information.
- Accurate: Ensure all entries are precise with exact measurements.
- Complete: Capture all relevant aspects of patient care comprehensively.
- Current: Document care promptly to reflect real-time interventions.
- Organized: Present information logically for ease of understanding.
What are the methods of documentation in nursing?
- Narrative Documentation: Chronological account of patient status and interventions.
- Problem-Oriented Medical Record (POMR): Organizes information based on identified patient problems.
- Charting by Exception (CBE): Documents deviations from established norms.
- PIE Charting: Structured format: Problem, Intervention, Evaluation.
- SOAP/SOAPIE/SOAPIER: Structured formats encompassing Subjective, Objective, Assessment, Plan, Intervention, Evaluation, Revision.
What are the legal guidelines for documentation?
- Confidentiality: Adhere to regulations like HIPAA to protect patient privacy.
- Accuracy and Completeness: Provide precise and thorough documentation.
- Timeliness: Complete documentation promptly.
- Legibility and Permanence: Use clear handwriting and ensure secure electronic entries.
What is informatics in nursing?
The integration of nursing science with information and communication technologies to enhance healthcare delivery.
What are Electronic Health Records (EHRs)?
Digital versions of patients’ paper charts, providing real-time, patient-centered records accessible to authorized users.
What are the advantages of EHRs?
- Improved Accessibility: Records can be accessed from multiple locations.
- Enhanced Coordination: Promotes better collaboration among healthcare team members.
- Decision Support: Offers tools and reminders to aid clinical decisions.
What are the roles in nursing informatics?
- System Implementation Specialist: Assists in deploying new healthcare technologies.
- Data Analyst: Interprets healthcare data to identify trends.
- Educator: Trains healthcare staff on informatics tools.
What are confidentiality and security measures in nursing?
- Access Controls: Implement passwords and authentication methods.
- Encryption: Protect data during transmission.
- Audit Trails: Maintain logs of access and modifications.
- Proper Disposal: Securely dispose of printed patient information.
How should printed and electronic information be disposed of?
- Printed Information: Dispose of securely to prevent unauthorized access.
- Electronic Information: Ensure proper deletion of files to prevent data retrieval.
What are nurses obligated to keep confidential?
All patient information
This obligation is both legal and ethical.
What responsibility do nurses have regarding patient records?
Protecting records from unauthorized readers
This includes ensuring that only authorized personnel have access.
What does HIPAA require regarding the disclosure of health information?
Limited to the minimum necessary
This regulation aims to protect patient privacy.
What are the legal risks associated with electronic documentation?
Legal risks include potential breaches of privacy and confidentiality.
What is PHI?
PHI stands for Private Health Information.
Name one method to protect PHI from being viewed by unauthorized individuals.
Use screen covers.
Where should computers be physically located to enhance security?
At the nurses’ station.
What should you do when leaving your workspace to ensure security?
Log out.
True or False: Professional conversations about patient information can occur freely without consideration for privacy.
False.
What should be done with fax communications, notes, and report sheets to ensure safe disposal?
They should be disposed of safely.
What should be documented for telephone calls made to a provider?
Document every call.
What are the types of orders that need to be documented?
Telephone orders (TOs) and verbal orders (VOs).
What is the purpose of incident or occurrence reports?
Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient.
What should be followed when documenting events?
Follow agency policy.
What should be documented for telephone calls made to a provider?
Document every call.
What are the types of orders that need to be documented?
Telephone orders (TOs) and verbal orders (VOs).
What is the purpose of incident or occurrence reports?
Used to document any event that is not consistent with the routine operation of a health care unit or the routine care of a patient.
What should be followed when documenting events?
Follow agency policy.
What is the purpose of Nursing Clinical Information Systems?
Allows nurses to access computerized information at the patient’s bedside.
How does Nursing Clinical Information Systems benefit patient care?
Enables the nurse to share care plan immediately with the patient.
What can nurses check using Nursing Clinical Information Systems?
Can check on laboratory results.
What are the designs associated with Nursing Clinical Information Systems?
Nursing process, Protocol or critical pathway.
What are some advantages of Nursing Clinical Information Systems?
Helpful Handouts: Stream, Courses, Calendar.
What is the purpose of documentation in the health care setting?
To provide a record of the events that occurred during the patient’s visit.
How does good documentation benefit health care encounters?
It helps to provide a detailed record of the health care encounter.
What role does clear documentation play in legal matters?
It helps protect against litigation when an error occurs.
Why is documentation important for reimbursement?
It serves as quality control and justification for reimbursement from Medicare, Medicaid, or private insurance.
What must nurses document to ensure health care institutions receive reimbursement?
Nurses need to document all their services.
What is the impact of proper documentation on community services?
It allows health care institutions to offer needed services to the community.
What is the purpose of a health record in nursing practice?
A health record is a vital aspect of nursing practice and serves as a valuable source of data for all members of the healthcare team.
Name the different methods for record keeping.
- Paper-based records
- Electronic health records
- Electronic medical records
- Personal health records
What is the significance of documentation in healthcare?
Documentation facilitates inter-professional communication, justifies financial billing and reimbursement, and serves as a source for education and research.
What are the legal guidelines for documentation?
- Do not document retaliatory or critical comments
- Record all the facts and correct errors promptly
- Document discussions with providers that you initiate
- Document only for yourself
- Protect patient PHI and follow HIPAA protocols
Fill in the blank: Nursing documentation systems should reflect current standards of nursing practice and should minimize the risk of _______.
[errors]
What should each entry in a patient’s medical record begin and end with?
Begin with date and time, and end with signature and credentials.
What are the five quality guidelines for documentation and reporting?
- Stick to the facts
- Write in short and simple sentences
- Use simple short words
- Avoid jargon and abbreviations
- Ensure timely entries that are current and complete
True or False: Personal opinions should be documented in a patient’s health record.
False
What is the purpose of a hand-off report?
To ensure continuity of care during transitions and reduce errors while maintaining patient safety.
What framework is used for structured communication in healthcare?
SBAR Framework: Situation, Background, Assessment, Recommendation.
List the content included in a hand-off report.
- Patient ID: Name, age, location
- Current Status: Diagnosis, condition, vital signs
- Medical History: Relevant past conditions
- Medications/Treatments: Current therapies and schedules
- Procedures/Tests: Recent or upcoming with results
- Safety Concerns: Allergies, fall risk, infection control
- Care Plan/Goals: Current plan and discharge considerations
- Pending Tasks: Labs, treatments, or actions needed
- Family/Psychosocial Info: Communication preferences or concerns
What does the PIE acronym stand for in nursing documentation?
- P - Nursing problem or diagnosis
- I - Interventions used to address the problem
- E - Evaluation
What does the DAR acronym stand for in nursing documentation?
- D - Data
- A - Action
- R - Response
Who is authorized to receive and record telephone and verbal orders?
Only authorized staff
This includes healthcare professionals designated by the facility’s policies.
What patient information must be clearly identified when taking telephone orders?
- Patient’s name
- Date of Birth (DOB)
- Room number
- Diagnosis
This information is crucial for accurate order processing.
What should be done to avoid misunderstandings during telephone orders?
Use clarification questions and ask the provider to repeat a word or phrase when needed
This ensures clear communication.
What should be documented when taking a telephone or verbal order?
- Date and time
- Name of patient
- Complete order
- Name and credentials of HCP giving orders
- Your name and credentials as the nurse taking the order
Accurate documentation is essential for legal and clinical reasons.
What does TORB stand for?
Telephone Orders Read Back
This indicates that the nurse has read back the order to the healthcare provider.
What must be done after taking a telephone order?
Read back all orders prescribed to the HCP who gave them
This is a safety measure to confirm accuracy.
What is a requirement for verbal orders (VO) and telephone orders (TO) according to agency policies?
Some require two nurses to review VO and TO
This is a double-check system to enhance patient safety.
Within what timeframe must the healthcare provider co-sign verbal and telephone orders?
Within 24 hours
Timely co-signing is necessary for compliance with healthcare regulations.
What is the first nursing intervention for a patient with impaired skin integrity?
Comprehensive Assessment: Regularly evaluate the affected and surrounding areas for signs of infection, changes in color, temperature, moisture, and integrity.
This helps in early identification of potential complications.
What does maintaining skin hygiene involve for patients with impaired skin integrity?
Gently cleanse the skin using pH-balanced products to remove contaminants without causing irritation.
pH-balanced products help maintain the skin’s natural barrier.
What is a critical aspect of moisture management for skin integrity?
Keep the skin dry and address excessive moisture from perspiration, wound exudate, or incontinence to prevent maceration.
Maceration can lead to further skin breakdown.
Why is nutritional support important for patients with impaired skin integrity?
Encourage a balanced diet rich in proteins, vitamins, and minerals to support tissue repair and overall skin health.
Adequate nutrition is essential for healing and skin maintenance.
What is pressure redistribution and why is it important?
Implement regular repositioning schedules and use support surfaces like specialized mattresses or cushions to alleviate pressure.
This is crucial for patients with limited mobility to prevent pressure ulcers.
What protective measures can be taken for skin integrity?
Apply barrier creams or films to shield the skin from irritants and use appropriate dressings to protect wounds and periwound areas.
Barrier creams can prevent further skin damage.
What role does patient education play in skin integrity management?
Inform patients and caregivers about proper skin care techniques, the importance of nutrition, and strategies to prevent further skin damage.
Education empowers patients to take an active role in their care.
Who should be included in collaborative care for patients with impaired skin integrity?
A multidisciplinary team, including dietitians, physical therapists, and wound care specialists, to develop a comprehensive care plan tailored to the patient’s needs.
Collaboration ensures holistic care addressing all aspects of the patient’s condition.
What are the risk factors that contribute to pressure ulcer formation?
Risk factors include:
* Age-related factors (reduced skin elasticity, decreased collagen, thinning of tissues)
* Existing medical conditions
* Polypharmacy
* Diminished inflammatory response
* Moisture on the skin
* Older adults, trauma victims, individuals with spinal cord injury, and patients in critical care.
What is the normal process of wound healing?
Wound healing involves integrated physiological processes and is determined by the extent of tissue loss:
* Partial thickness wounds involve partial loss of skin layers
* Full thickness wounds involve total loss of skin layers.
What is the difference between healing by primary and secondary intention?
Primary intention:
* Edges are approximated
* Low risk of infection
* Quick healing with minimal scarring.
Secondary intention:
* Wound is left open
* Higher risk of infection
* Longer healing time with potential for significant scarring.
What factors promote wound healing?
Factors that promote wound healing include:
* Adequate blood flow
* Proper nutrition
* Moist wound environment
* Effective infection control
* Optimal wound care
* Good hydration.
What factors impede wound healing?
Factors that impede wound healing include:
* Poor circulation
* Infection
* Chronic diseases
* Poor nutrition
* Smoking
* Medications
* Excessive pressure or trauma
* Age
* Dehydration.
What is the focus of assessment for acute wounds?
The focus is on:
* Wound size
* Depth
* Tissue damage
* Risk of infection.
What is the focus of assessment for chronic wounds?
A more comprehensive assessment including:
* Wound history
* Underlying causes
* Tissue viability
* Biofilm presence
* Nutritional and vascular status.
What are the treatment goals for acute wounds?
The primary goal is:
* Rapid wound closure
* Minimal scarring
* Prevention of infection.
What are the treatment goals for chronic wounds?
The goals include:
* Identifying and managing underlying conditions
* Reducing bioburden
* Promoting granulation tissue
* Preventing recurrence.
True or False: Infection risk for acute wounds is lower if proper aseptic techniques are used.
True
What does patient education for acute wounds focus on?
Education focuses on:
* Short-term wound care
* Signs of infection
* Promoting healing.
What does patient education for chronic wounds involve?
Education involves:
* Extensive wound management
* Lifestyle changes (diet, smoking cessation)
* Strategies to prevent recurrence.
Who primarily manages acute wounds?
Managed primarily by nurses and physicians.
What type of team is often required for chronic wound management?
A multidisciplinary team including:
* Wound care specialists
* Dietitians
* Physical therapists
* Surgeons.
Which term is used to describe deteriorated skin condition related to prolonged, unrelieved pressure on a body part? Select all that apply. One, some, or all responses may be correct.
Some correct answers were not selected
Skin tag
Bedsore
Skin wound
Pressure sore
Pressure ulcer
Decubitus ulcer
Bedsore, Pressure sore, Pressure ulcer, Decubitus ulcer
Which role does vitamin A play in wound healing?
• Quickens fibroplasia
• Acts as an antioxidant.
. Promotes wound closure
• Acts as immune function
Promotes wound closure
Which type of dressing is used for a stage 3 pressure ulcer?
Adherent film
• Composite film
• Calcium alginate
• Transparent dressing
Calcium alginate
Which patient may require a pulsatile high-pressure lavage for wound irrigation?
A patient who has graft sites
• The person who has a necrotic wound
• One who has exposed blood vessels
• The individual who has exposed muscle, tendons, or bone
The person who has a necrotic wound
Which statement is true regarding hydrogel dressings?
• They enhance autolytic debridement.
• They do not require secondary dressing.
• They are not used for painful wounds.
• They are impregnated with saline solution.
They enhance autolytic debridement by keeping the wound moist which promotes granulation tissue
Which pressure injury is expected to heal through granulation and reepithelialization?
Stage 1
Stage 2
• Stage 4
• Unstageable
Stage 4
Which vitamins promote wound healing?
A and c
Arrange the phases of wound healing in the correct order.
- Inflammatory phase
- Proliferative phase
- Remodeling
- Hemostasis
4, 1, 2, 3
What suture this?
Retention.
How many mg of vitamin c is needed for promoting wound healing?
1,000 mg a day
COCA
Consistency, odor, color, amount of
RICE
Rest, ice, compress , elevate
Which amount of zinc is recommended for wound healing?
15-30 mg
20-25 mg
30-40 mg
15-30
Which stage of pressure injury can be dressed with a transparent or hydrocolloid dressing?
1,2,3 or 4
1
Which type of dressing would be most appropriate for a patient with a partial-thickness, necrotic pressure ulcer with moderate drainage?
• Dry gauze
• • Hydrocolloid dressing
• Calcium alginate dressing
Transparent film dressing
Hydrocolloid dressing
Which nursing intervention is appropriate for a patient who is at risk of skin breakdown because of decreased sensory perception?
* • Keep the skin dry and free of maceration.
Provide a pressure-redistribution surface.
• Consult a dietitian for nutritional assessment.
Provide a trapeze to facilitate movement in bed.
Provide a pressure redistribution surface
For which pressure injury would the nurse include education related to both granulation and reepithelialization? Select all that apply. One, some, or all responses may be correct.
Stage 1
Stage 2
Stage 3
Stage 4
Unstageable
Stage 3 and 4
For which pressure injury would the nurse include education related to just reepithelialization? Select all that apply. One, some, or all responses may be correct.
Stage 1
Stage 2
Stage 3
Stage 4
Unstageable
2
A patient has a stage 2 pressure injury. Which dressing might the nurse use for the patient?
Select all that apply. One, some, or all responses may be correct.
Some correct answers were not selected
Hydrogel
Hydrocolloid
Adherent film
Composite film
Transparent
Hydrogel hydrocolloid and composite film
Which type of dressing is provided to the patient that developed a deep pressure injury that has the presence of exudates?
Film
Foam
• Hydrogel
Calcium alginate
Hydrogel
Which topical agent is used to clean highly colonized wounds? Select all that apply. One, some, or all responses may be correct.
Water
Acetic acid
Saline solution
Hydrogen peroxide
Sodium hypochlorite
Acetic acid
Hydrogen peroxide
Sodium hypochlorite
Which advantage does hydrogel dressing provide? Select all that apply. One, some, or all responses may be correct.
Some correct answers were not selected
• Allows for easy removal
Minimizes skin trauma
• Debrides necrotic tissue
• Permits viewing of wound
• Provides a moist environment
Debrides necrotic tissue
Allows for easy removal
Provides a moist environment
Which purpose does dry gauze dressing serve in wound healing? Select all that apply.
Aids in hemostasis
Keeps the wound dry
Provides debridement
Keeps the periwound skin moist
Prevents microbial contamination
Aids in hemostasis
Provides debridement
Prevents microbial contamination
What is maceration ?
Excessive moisture can cause maceration of tissue surrounding a wound; therefore, the nurse can prevent this by drying the edges of the wound with gauze.
What needs to be assessed before placing an abdominal binder?
Affective coughing and deep breathing
Which stage of pressure injury would use Composite film, hydrocolloid, and hydrogel dressings?
1,2,3,4
2
What is a Stage 4 pressure wound injury?
A Stage 4 pressure wound injury exhibits muscle, subcutaneous fat, and bone.
What is undermining in a pressure wound?
Undermining refers to hollowed areas underneath the wound edges.
What is slough in the context of a pressure injury?
Slough is composed of dead skin cells found in a Stage 4 pressure injury.
What is tunneling in a pressure wound?
Tunneling consists of tunnels made deep into the wound between tissue structures.
Is blanching present in a Stage 4 pressure injury?
No, blanching is not seen in a Stage 4 injury; it is associated with Stage 1 injuries.
What is the typical pain level for a Stage 4 pressure injury?
Pain is not typical of a Stage 4 injury due to its depth.
Does a Stage 4 pressure injury have a foul drainage odor?
No, a Stage 4 pressure injury does not normally have a foul drainage odor.
Are sutures present in a Stage 4 pressure injury?
No, sutures are for surgical wounds, not for Stage 4 pressure injuries.
What does nonblanchable erythema indicate about the skin tissue?
Damage
Nonblanchable erythema indicates that the tissue was under pressure that caused inflammation, leading to tissue damage.
What signifies that tissue is infected?
Drainage from the wound or sutures at the surgical site
Infection is indicated by the presence of drainage or unusual signs at the surgical site.
What appearance does tissue under hypoxia exhibit?
Mottled or pallor
Tissue under hypoxia shows a mottled appearance or exhibits pallor due to inadequate blood flow.
What is an early indication of pressure to the tissue?
Erythema
Erythema is an early sign indicating that pressure is being applied to the tissue.
True or False: Nonblanchable erythema can be a sign of infection.
False
Nonblanchable erythema specifically indicates tissue damage due to pressure, not infection.
Describe types of sutures
