Inflammation, Wounds, and Pressure Ulcers part 7

Question 1

What is the assessment for pressure injuries?

Answer 1

• past med history
• meds
• surgery/treatments
• functional health patterns
• assessment findings: integumentary and diagnostic findings

Question 2

Acute care pressure injuries care

Answer 2

• relieve pressure
• do not turn patient onto unblanchable skin
• do not massage
• lift versus sliding when repositioning

Question 3

What area of the body do you not debride?

Answer 3

heels

Question 4

Explain nursing care of pressure injuries

Answer 4

keep wound bed moist 
-do not disrupt new granulation tissue
-avoid cytotoxic cleaning 
-nutrition support 
-

Question 5

What labs would make a pt nutritionally at risk?

Answer 5

-albumin <3.2
-prealbumin <15
lymphocyte <1,000
Hgb-A1c > 6.5%
glucose >126

Question 6

How do you document a wound?

Answer 6

location - specifically

• stage
• size: length (head to toe), width (hip to hip), depth (deepest point)
• measure in cm
• tunneling: measure using a clock
• edges: approximation (edges meet), rolled, jagged, undermining
• wound base: granulation, epithelialization, necrotic tissue (slough, eschar, adherence)
• tunneling
• undermining
• drainage: serous, sanguineous, sero-sangineous, purulent, odor, amount
• surrounding tissue
• pain
• wound progress

Question 7

Who performs the first dressing change 24-48 hours after surgery?

Answer 7

the surgeon

Question 8

What are the types of debridement?

Answer 8

• autolytic: dressing (clear) and bodys own mechanisms
• enzymatic: commercially prepared enzymes
• mechanical: physical force (dry and wet dressing to remove
• surgical/sharp: using an instrument

Question 9

What are the 3 basic tyes of dressings?

Answer 9

maintain mositure
absorb mositure
add mositure
-keep wound tissue moist and surrounding skin dry

Question 10

Dressings: 
remain for 4-7 days
-use for stage 1 pressure injuries 
-minimal drainage 
-facilitate autolytic debridement

Answer 10

transparent

Question 11

Dressings:

• use for stage 2 and 3
• use for high riskfriction areas
• wounds with necrosis or slough
• not for infected wounds

Answer 11

hydrocolloid EX duoderm

Question 12

Dressings:

• use for 3-5 days
• use for stage 2-4
• absorb light to heavy
• surgical wounds

Answer 12

Foams EX: Mepilex

Question 13

↓bacteria
Removes excess fluid
Promotes moist wound environment
Used for:  
Stage 3 of 4 PI
Arterial, venous, and diabetic ulcers
Dehisced surgical wounds
Infected wounds, skin graft sites
Full thickness burns

Answer 13

negative pressure wound vac

Question 14

What vitamins are good for nutrition therapy for wound healing?

Answer 14

C and B

Question 15

increases amount of oxygen dissolved in plasma

Answer 15

HBOT

Question 16

Promotes cell proliferation and healing,
Increases wound metabolism,
Promotes an increased response to growth factors, stimulates development of blood vessels,
antibacterial and antioxidant effects, improve immune function

Answer 16

HBOT

Question 17

What are some nursing interventions for the immobile older adult?

Answer 17

exercise
increase protein, calcium, and D 
pace activities
assistive devices 
reduce risk of falls

Question 18

What does immobility do to the cardiovascular system?

Answer 18

• increases workload of the heart
• increases risk of orthostatic hypotension
• increases risk for venous thrombosis

Question 19

What does immobility do to the respiratory system?

Answer 19

• decreases depth of resp
• decreases rate of resp
• pooling of secretions
• impaired gas exchange

Question 20

What does immobility do to the GI system?

Answer 20

• disturbance in appetite
• altered protein metabolism
• altered digestion and utilization of nutrients
• decreased peristalsis

Question 21

What does immobility do to the urinary system?

Answer 21

• increased urinary stasis
• increases risk of renal calculi (stones)
• decreases bladder muscle tone

Question 22

What does immobility do to the musculoskeletal system?

Answer 22

• decreases muscle size, tone, strength
• decreases joint mobility and flexability
• bone demineralization
• decreased endurance and stability
• increased risk for contracture formation

Question 23

What does immobility do to the metabolic system?

Answer 23

• increased risk for electrolyte imbalance

- altered exchange of nutrients and gases

Question 24

What does immobility do to the integumentary system?

Answer 24

increases risk for skin breakdown and formation of pressure injuries

Question 25

What does immobility do to psychological well-being?

Answer 25

• increased sense of powerlessness, depression
• decreased self concept, social interaction, sensory stimulation
• altered sleep-wake pattern
• risk for learned helplessness