Positioning and Skin Care

Question 1

what is the first nursing priority for clients upon admission to a health care facility related to skin condition?

Answer 1

using clinical judgement and the use of a structured, valid and reliable assessment tool, such as the braden scale for predicting pressure ulcer risk. braden uses: sensory preception, moisture, activity, mobility, nutrition, and friction and shear to determine risk.

Question 2

What is the Braden Scale used for and what are the assessment categories?

Answer 2

Used to predict pressure ulcer risk
categories include:
sensory perception, moisture, activity, mobility, nutrition and friction and shear. Score up to 23 points, scores below 18 indicate a risk.

Question 3

What is interRAI PURS? What are the categories of this tool?

Answer 3

interRAI PURS is a pressure ulcer risk scale. it is a minimum data set based scale used to identify various levels of risk to plan prevention of ulcers.
categories include: impaired bed mobility, impaired walking, bowel incontinence, weight loss, history of resolved pressure ulcers, daily pain and shortness of breath.

Question 4

What is NSRAS?

Answer 4

Neonatal Skin Condition Score for the pediatric population

Question 5

what is SCIPUS?

Answer 5

Spinal Cord Injury Prssure Ulcer Scale

Question 6

Performance Palliation Scale?

Answer 6

Ulcer risk assessment for palliative care population?

Question 7

why is important to assess mobility when considering risk factors for pressure ulcers?

Answer 7

paralysis, extreme weakness, immobility, or any cause of decreased activity can prevent or limit a persons ability to adjust position independently when uncomfortable

Question 8

Why is nutrition assessment integral for gathering baseline data for risk assessment for pressure ulcers? What nursing measures can insure better nutrition?

Answer 8

prolonged inadequate nutrition leads to weight loss, muscle atrophy and the loss of subcutaneous tissue.This is directly related to padding. between skin and bone and increases the risk of pressure ulcers. Hypoproteinemia, caused by inadequate intake or abnormal loss, predisposes to edema. Edema increases the distance between the capillaries and the cells, decreasing oxygen levels to the tissue and removal of metabolites away from the cells.

Question 9

Why does fluid increase the risk for skin breakdown? What nursing measures can be taken to decrease skin breakdown?

Answer 9

moisture promotes skin maceration (tissue softened by prolonged wetting or soaking) and causes the epidermis to be more easily eroded and susceptible to injury. This makes skin prone to breakdown and infection. Keep the skin dry.

Question 10

What are the causes of pressure ulcers?

Answer 10

result from ischemia, a deficiency in the blood supply to the tissue. external pressure that exceeds capillary closing pressure causes occlusion of blood vessels, decreased tissue perfusion and possibly tissue necrosis.

Question 11

name some positioning devices used to maintain body alignment in bed or when sitting.

Answer 11

Pillows and wedges (foam, gel, air, fluid) available to support positioning and prevent bone on bone when lying down. Pressure reducing devices such as pillows can be used in bed, in chair. Protect the heal independently using heel protectors (including sheepskin boots, padded splints, off-loading inflatable boots and foam block that can raise or “float the heal” off the surface) or air or foam mattress overlays, foam wedges and pillows.

Question 12

In the supported Fowler’s position the head of the bed is elevated 45o - 60o degrees. Why would you not elevate the bed higher than this? What must you consider regarding the sacrum and the heels?

Answer 12

It a position higher than 60 degrees the knees may or may not be flexed. It is not the position of choice for patients at risk for pressure ulcers. As it increases the pressure on the sacrum and heels.

Question 13

In the supine position, the body is positioned in the same manner as standing in good body alignment. Why would pillows, footboards and hand rolls be beneficial?

Answer 13

The neck is at risk for hyperextension – correct with a suitable thickness pillow
The lumbar curvature is unsupported – place a small pillow or roll under the curvature
External rotation of the legs – roll or sandbags placed laterally to trochanter of femur
Hyperextension of knees – small pillow under the thigh to flex knee slightly
Feet suffer from plantar flexion – a footboard or rolled pillow to support feet in dorsal flexion
Pressure on heels – place a pillow under the calfs

Question 14

The use of the lateral or side-lying position removes the most pressure from bony prominences. What measures are taken to maintain correct alignment in the side-lying position?

Answer 14

Lateral flexion and fatigue of sternocleidomastoid muscles – place a pillow under head and neck to provide good alignment
Internal rotation and adduction of shoulder and subsequent limited function – impaired chest functioning – pillow under upper arm to place it in good alignment; lower arm should be flexed comfortably
Internal rotation and adduction of femur; twisting of spine – pillow under the leg and thigh to place them in good alignment – hip and shoulder should be aligned.

Question 15

How does the Sim’s position differ from the side-lying position and when would it be used?

Answer 15

Sims is different only in the added support of sandbagging to support the feet in dorsal flexion

Question 16

YOur client has a Braden Scale score of 17. What is the appropriate nursing action?

a. assess the client again in 24 hours; the score is within normal limits.
b. Implement a turning schedule; the client is at an increased risk of skin breakdown.
c. apply transparent wound barrier to major pressure sites.
d. request a prescription for a special low-air-loss bedd

Answer 16

b. implement a turning schedule. they are at risk.

Question 17

Proper technique for preforming a wound culture includes which of the following?

a. cleansing the wound before obtaining the specimen
b. swabbing for the specimen in the area with the largest collection of drainage
c. removing crusts or scabs with sterile forceps and then culturing the site beneath
d. waiting 8 hours following a dose of antibiotic to obtain the specimen

Answer 17

a. cleansing the wound before obtaining the specimen. microbes responsible for the infection are more likely to be found in viable tissue.

Question 18

A client has a pressure ulcer with a shallow partial-skin-thickness eroded area but no necrotic areas. The nurse would treat the area with which of the following dressings?

a. Alginate
b. Dry gauze
c. Hydrocolloid
d. No dressing is indicated

Answer 18

c. Hydrocolloid - dressings protect shallow ulcers and provide hydration thus maintaining a healing environment.

Question 19

Thirty minutes after the application of a heating pad is initiated, the client requests that the nurse leave it in place. What should the nurse explain to the client.

a. Heat application for longer than 30 minutes can actually cause the opposite effect (constriction) of the one desired (dilation)
b. It will be acceptable to leave the pad in place if the temperature is reduced
c. It will be acceptable to leave the pad in place for another 30 minutes if the site appears satisfactory when assessed.
d. It will be acceptable to leave the pad in place as long as it is moist heat.

Answer 19

a. heat applications for more than 30 minutes actually have the opposite effect. It causes constriction of the vessels.

Question 20

Which statement, if made by the client or family member, would indicate the need for further teaching?

a. If a skin area gets red and the red does not go away after turning, I should report it to the nurse.
b. Putting foam pads under the heels or other bony areas can help decresae pressure.
c. If a person cannot turn himself or herself in bed, someone should help the person change position every 4 hours.
d. The skin should be washed with only warm water (not hot) and lotion put on while the skin is still a little wet.

Answer 20

c. If a person cannot turn himself or herself in bed …

immobile and dependent persons should be repositioned at least every 2 hours not 4.

Question 21

Your client has a pressure ulcer on his heel. It is 3 cm deep and 2 cm wide, and is covered with black eschar. According to the National Pressure Ulcer Advisory Panel staging system, how would this wound be classified?

a. Stage III
b. Stage IV
c. Suspected deep tissue injury
d. Unstageable

Answer 21

d. Unstagable. the black eschar must be removed to determine the extend of damage.

Question 22

Which of the following is an appropriate nursing diagnosis for a a client with large areas of skin excoriation resulting from scratching an allergic rash?

a. risk for impaired skin integrity
b. impaired skin integrity
c. impaired tissue integrity
d. social isolation

Answer 22

b. impaired skin integrity - the damage is at skin level.

Question 23

Mr. Boyle, 55 years old, smoked a pack of cigarettes each day. Two weeks ago, he experienced a cerebrovascular accident. Mr. Boyle has left hemiplegia and will be transferred to a rehab hospital within the week. How would the nurse BEST prevent the development of a pressure ulcer?

a. encourage mr. boyle to re-position himself as necessary
b. turn mr. boyle every 1-2 or as neccessary
c. massage bony prominences with moisturizing cream
d. place mr. boyle in a semi-fowler’s position.

Answer 23

b.turn every 1-2 hrs as necessary

Question 24

Which of the following items are used to perform wound irrigation?

a. Unsterile drape
b. sterile gloves
c. refrigerated irrigating solution
d. 5 mL syringe

Answer 24

b. sterile gloves

Question 25

Which of the following indicates proper use of a triangle arm sling?

a. elbow is kept flexed at 90 degrees or more
b. the knot is places on either side of the vertebrae of the neck
c. the sling extends to just proximal of the hand
d. the sling is removed every 2 hours to check for circulation and skin integrity

Answer 25

b. the knot is place on either side of the vertebrae of the neck.

Question 26

List the important observations to make about a client’s skin? Please make a comment on implications for dark-skinned clients.

Answer 26

Abrasions – superficial layers of skin scraped or rubbed away
Excessive dryness – flaky and rough
Ammonia Dermatitis – skin bacteria reacting with urea in the urine (diaper rash)
Acne – inflammatory condition with papules and pustules
Erythema – redness caused by various conditions (Rashes, sun, increased temperature)
Hirsutism – excess hair on body or face
With dark skin things like abrasions and erythema are more difficult to notice. Extra care must be taken.

Question 27

perineal-genital care. What can the nurse do to reduce the client anxiety with such personal care?

Answer 27

The nurse can reduce the clients anxiety by asking them if they are able to clean their privates. If so hand them a clean washcloth and towel.
If the client Is unable to the nurse need to provide perineal care efficiently and in a matter-of-fact manner. Nurses should wear gloves to protect both themselves and the client.

Question 28

Perinatal care - What is the most important principle to remember with females?

Answer 28

Female:
• Clean the labia majora and then spread the majora and clean the minora as secretions that collect around the labia minora facilitate bacterial growth.
• Use separate quarters of the washcloth for each stroke and wipe from the pubis to the rectum. For menstruating clients with indwelling catheters use a fresh wipe for each stroke. Using different areas or a new cloth for each stroke prevents the transmission of microorganisms from one area to another. and from pubis to rectum is least contaminated to greatest.
• Rinse and dry thoroughly paying particular attention to the folds between the labia. Moisture promotes the growth of many microorganisms.
Both:
• Note areas of inflammation, excoriation or swelling between the labia for female and scrotal folds for male.
• Note any excessive discharge or secretions from orifices and the presence of odours.

Question 29

Perinatal care - What is the most important principle to remember with males?

Answer 29

Male:
• retract the foreskin to expose the penis for cleaning to remove the smegma. Smegma facilitates bacterial growth. Be sure to replace the foreskin to prevent constriction of the penis preventing edema.
• Wash and dry the scrotum which is usually more soiled than the penis due to proximity to the rectum. Clean it after the penis.
• inspect orifices for intactness especially if a catheter is inserted which can cause excoriation around the urethra
Note areas of inflammation, excoriation or swelling between the labia for female and scrotal folds for male.
• Note any excessive discharge or secretions from orifices and the presence of odours.