Skin and Wound Care Lecture (Part 2)

Wound Staging

Key Question

• Question: Which of the following statements shows the greatest understanding of wound staging?
• Answer: The correct answer is: This wound can’t be staged until it’s debrided
  • Explanation: You can't stage a wound until it's debrided and the depth can be assessed.
  • *Incorrect Answers:
    • Ulcer must involve broken skin in order to be staged.
    • Wound with sloth is difficult to stage --> Impossible to stage, not just difficult,
    • Healthcare provider must stage the ulcer --> Registered nurses are responsible for this.

Granulated Tissue Description

• Question: What best describes granulated tissue?
• Answer: The correct answer is: Red, moist, and vascular rich

Cognitively Imparied Client and Friction Damage

Key Question

• Question: What intervention is most therapeutic to minimize risk for friction damage?
• Answer: The correct answer is: Place thin cotton mitts on her hands
  • Explanation: Protective mittens reduce direct friction on skin.
  • *Incorrect Answers:
    • Distracting with conversation --> Ineffective long-term.
    • Remind her to stop --> Compulsions can't be overcome this simply.
    • Get a prescription --> Meds and diversion alone are insufficient.

Skin Breakdown Intervention

Key Question

• Question: Initial intervention when noticing a red, blanchable area?
• Answer: The correct answer is: Position client on the right side
  • Explanation: Relieves pressure immediately.
  • *Incorrect Answers:
    • Provide fresh dry linen --> Important but not first priority.
    • Include turning schedule --> Needed but not initial step.
    • Measure the area to describe it in notes --> Important but less urgent.

Managing Pressure Ulcer Risk Factors

Key Question

• Question: Statement showing greatest insight into managing pressure ulcer risks?
• Answer: The correct answer is: Decrease the time spent with weight on the body resting on hip
  • Explanation: Reducing pressure on bony prominences is most important.
  • *Incorrect Answers:
    • Including more protein in diet --> Good for wound healing, not pressure ulcers.
    • Move more gently --> Important but secondary.
    • Addressing incontinency --> Important but not primary concern.

Pressure Ulcer Risks in Older Adults

Key Question

• Question: Primary reason older adults are more prone to pressure ulcers on elbows?
• Answer: The correct answer is: Less subcutaneous padding on the elbows
  • Explanation: Older adults have less cushioning protecting bony prominences.

Reducing Pressure Points

Key Question

• Question: What action reduces pressure points leading to ulcers?
• Answer: The correct answer is: Elevate the head of the bed as little as possible
  • Explanation: Minimizes sliding and friction.
  • *Incorrect Answers:
    • Position on trochanter --> Direct pressure on bony prominence.
    • Use donut device when sitting --> Decreases blood supply.
    • Massage over bony prominences --> Increases pressure and risk.

External Hemorrhaging Assessment

Key Question

• Question: Initial assessment for external hemorrhaging?
• Answer: The correct answer is: Monitor wound dressing for bloody drainage
  • Explanation: Immediate visual inspection gathers crucial information.
  • *Incorrect Answers:
    • Assess blood pressure --> Secondary step.
    • Monitor heart rate --> Secondary step.
    • Redress the wound --> Protective but not assessment.

Skin Assessment in Dark-Skinned Clients

Key Question

• Question: Source of light to avoid for dark-skinned clients?
• Answer: The correct answer is: Fluorescent light
  • Explanation: Fluorescent light casts a bluish hue making assessment harder.

Risk Factors for Pressure Ulcers

Key Question

• Question: Who is at greatest risk for pressure ulcers?
• Answer: The correct answer is: Comatose patient
  • Explanation: Inability to move increases constant pressure on body parts.

Summary

• This lecture covered important aspects of wound staging, recognizing granulated tissue, managing skin friction in cognitively impaired clients, initial interventions for skin breakdown, and strategies to manage and prevent pressure ulcers, especially in the most vulnerable populations like older adults and comatose patients.

Reminder: Next review session is on August 29th-30th. More information available on the website Nexus Nursing Institute.