[Music] hi guys it's me professor d and welcome back to my channel if you haven't done so already please be sure to press that like and subscribe button below please comment if there's any content that you'd like to see me cover on this video i will be doing part two of the skin and wound care video that i did last week this week will be the completion of it so let's just jump right into it the first question which of the following statements shows the greatest understanding of wound staging one an ulcer must involve broken skin in order to be staged two a wound that contains love is difficult to stage three this wound can't be staged until it's debrided or four the healthcare provider will need to stage the ulcer and i'll give you a moment to think of your answer and guys the correct answer is three this one can't be staged until it's debrided why because it's not until that wound is debrided you can actually see how deep that wound goes and remember the deepness that's what lets you know what stage that wound is remember in part one of the skin and wound care video i taught you the difference of stage one verse two verses three verse four make sure you go back and watch if you don't know what that is but you won't be able to stage a wound until you actually debride it and see how deep it goes now i want to go over these other choices with you once said an ulcer must involve broken skin in order for uh in order to be staged well we know that's incorrect right what's stage one right stage one is when that um skin is non-blanchable it's red in and when you press on it it's supposed to blanch but it doesn't right that's your stage one so let's look at choice number two so we know one was wrong choice number two a wound that contains sloth is difficult to stage that's wrong a wound that contains love is impossible to stage why because like i said you have to be able to see clearly you have to be able to see how deep that wound goes in order to stage it that's why you have to debride the wound and your last choice for was the healthcare provider will need to stage the ulcer in what world that's what you do as a registered nurse okay you can stage that ulcer not the health care provider the health care provider doesn't have to do that that's the rn's responsibility okay next question granulated tissue is best described as one soft yellow and stringy two black hard and necrotic three red moist and vascular rich for yellow spongy and sinewy i have no idea what that works annoying means but i'll give you more to think of your answer and the correct answer is three red moist and vascular rich when you see that word vascular i want you to think of vessels i want you to think of bloody i want you to think of what um circulation so that's good when it looks like that what number three's showing it shows that the wounds healing there's circulation it's red it's moist and it's vascular our other choices choice number one says soft yellow and stringy that's what sloth looks like right remember that's what we have to actually remove to see what that wound actually looks like in order to stage the wound okay so not one that's what sloth looks like you need to remove that to be able to even stage the wound then you have two black heart and necrotic that's what's known as the e-scar um that also has to be removed in order to stage a wound to really see how deep it goes okay and number four yellow spongy and sinewy i don't have no idea what's in it i've never seen that word before i need to look it up so one of you guys i know you remind me remind me in the comment section i'll look that up and i'll let you know i've never even seen that word before but the correct answer is three red moist and vascular that's what the wound is supposed to look like it lets you know that that wound is healing it's getting blood and remember blood is what's carrying the oxygen of vitamins and nutrients for that wound to heal next question a cognitively impaired client spends hours a day involuntarily ringing her hands which of the client's interventions is most therapeutic as a means of minimizing the client's risk for friction damage to her hands one placing thin cotton mitts on her hands two frequently distracting her with conversation three regularly reminding her to stop bringing her hands four getting a prescription to minimize the compulsive behavior and i'll give you a moment to think of your answer the correct answer is one giving them uh mitten now i know some many of you guys haven't done psych yet so i'll just kind of explain this to you these patients that have um these compulsive disorders they're driven to do whatever the disorder is for this patient it's constantly ringing their hands they constantly have to do it they feel driven to do it so guess what you're not going to be able to distract them okay but let's i want to go back to the question and look at what the question said it says what intervention is going to be most therapeutic to minimize the risk for friction okay you are not going to be able to distract that patient enough that patient's gonna be ringing their hands so what can you do to protect their hands from all that friction so the skin doesn't break down put mittens on their hands so guess what they're gonna keep doing this they're not gonna stop but when they're doing this they're not having friction on their hands it's friction against what the mittens okay so you're you're able to keep that patient's um dermatologic integrity right while later you know we can deal with those um compulsions that the patient has but to keep that uh skin from breaking down you're gonna put the mittens on their hands let's look at the other choices you have two well we went over two um two already we know why two's wrong three regularly reminding the patient to stop no that's not going to work i'm telling you right now when they have those compulsions they are driven to do what those compulsions are and then you have choice for getting a prescription to minimize the compulsive behavior no no um what you're going to do you're going to give them mittens and while they have mittens and they're doing their compulsions they're going to go to therapy and they're going to work on those compulsions so they can understand why they have those compulsions which is usually due to what anxiety which is usually um usually fear you know i'll talk about the other stuff when we get the site but the point is while they're constantly doing this and they have the mittens on they'll be getting therapy for it okay so just meds and diversion trying to distract them that's not going to work you're trying to protect their skin integrity and that's how you're going to do it okay next question when changing the soiled linen on the bed of a client who's comatose the nurse notices a redden blanchable area approximately two centers in diameter on her left buttocks the nurse's initial skin breakdown intervention is to one position a client on the right side two finish providing fresh dry linen to the client's bed three include a two hour turning schedule in the clients care plan four measure the area in order to describe it in the nurses notes and i'll give you a moment to think of your answer and the correct answer is one the very first thing you want to do is turn that patient remember the reason that they're having that reddened area is because of all that pressure that is on the area so the first thing you want to do is relieve that pressure right it kind of keeps that same concept i told you something's offending the patient so for example if a patient's getting an iv infusion and it's harming them the first thing you want to do is what stop the infusion whatever is harming the patient you want to stop that first before you do anything else okay so the first thing you're going to want to do is turn the patient on the other side get the pressure off of that patient you see all the other choices all the other choices are wonderful and yes you do want to do that for the patient but the very first priority is to stop what's offending the patient so yes you want to give them dry linen because we know one of the reasons patients have skin breakdown is because of maceration due to moisture so yes you want to give them dry linen yes we want to keep them at least turning every two hours and yes we want to measure the area so we can describe it remember it's always patient before paperwork okay so if you ever have to choose two choices between documenting and doing something for the patients don't be doing something for the patient okay so first thing you want to do is stop what's offending the patient in this instance it's the pressure off the area you want to take the pressure pressure off of that area and then choices two three and four you want to do wonderful but your priority is stop what is offending that patient next question which of the following statements made by the nurse shows the greatest insight into the need to manage risk factors that contribute to the formation of a pressure ulcer one her diet needs to include more protein and less sugary foods two she needs to be moved more gently and with attention to her skin three we need to decrease the time she spends with the weight on her body resting on her hip four the urinary incontinency makes the risk for developing a pressure ulcer so much greater for her and i'll give you a moment to think of your answer and guys i hope you chose three three's the best answer i just talked to you guys about that we need to decrease the time she spends with weight on her body resting on her hip why you want to take pressure off of those bony prominences such as the hip such as a coccyx such as the heels okay you want to take pressure off now let's talk about the other good choices two's a good choice she needs to be moved more gently and with more attention to her skin absolutely and that is a nursing intervention for um patients with pressure ulcers but the number one thing to do to reduce um the the risk factor for pressure ulcer is to make sure that there's no pressure on that side right so two is a good choice but not as good as three let's look at choice number four urinary incontinency makes the risk for developing pressure ulcer so much greater for her that's true that's a good answer but it's not as good as number three and i talked about this in depth in my first video about skin and wound care right the number one thing is what keeping pressure off the site so even choice even though choice two and three are great choices three um excuse me even though two and four are great choices choice three is the best because that's the one that talks about keeping pressure off the site number one you should have gotten rid of immediately number one her diet needs to include more protein and less sugary foods that answer choice is great for um uh wound healing if the patient has a wound and does have to even be a pressure ulcer that that type of wound any type of when the patient has right protein vitamin c is good for wound healing right and you want to decrease the sugar because what loves sugary environments bacteria so choice number one is a great answer for wounds but not pressure ulcers which is what we were talking about in this question next question the primary reason an older adult client is more likely to develop a pressure ulcer on the elbow as compared to a middle adult client middle age client is one a reduced skin elasticity is common in the older adult two the attachment between the epidermis and dermis is weaker three the older client has less sub-cute padding on the elbows or four older adults have a poor diet that increases the risk for ulcers and i'll give you a moment to think of your answer and the correct answer three the older adult has a less sub-cute padding on the elbows i just talked to you guys about this we want to keep pressure outside especially what the bony prominences and patients who are elderly they tend to be more frail okay so their um their bony prominences tend to be more why because they don't have enough not enough but they don't have as much fat subcutaneous fat also known as padding they don't have enough padding as much padding i should say as a regular middle-aged adult does right i'm a regular aged middle-aged adult i got plenty of planning pack i have plenty of padding here here everywhere right but the older adult they lose their sense of thirst they really don't drink as much they really don't eat as much um so their sub-q fat becomes a lot less so they have a lot more bony prominences so imagine an older adult with way more bony prominences with pressure on the site they're going to be more addressed to get a pressure ulcer than somebody else who has more cushion next question to reduce pressure points that may lead to pressure ulcers the nurse should one position the client directly on the trochanter when sidelined two use a donut device for the client when sitting up three elevate the head of the bed as little as possible massage over the bony prominences and i'll give you a moment to think of your answer and the correct answer three elevate the head of the bed as little as possible i talked about this in the first video the reason you want the head of the bed elevated as little as possible because when the head of the belt bed is elevated high you have a 90 degree angle or even slightly lower what happens that patient just keeps sliding down and that friction does what it can open up the skin right and before you know the patient got as um ulcer um they might have a pressure one so that's your correct answer i want to go over the other choices number one position the client directly on the trucanto and sideline if i have talked to you guys about anything in this video it's been what no pressure on bony prominences so you are not going to put this patient to lie down directly on the trochanter which is what a bony prominence absolutely not so we're gonna get rid of that choice two use a donut device for the client when sitting up no why that's gonna decrease the blood supply to that area so you're absolutely not going to do that so we throw that out as a choice and then you have four massage you do not massage over bony promises ever ever ever ever what do you think that massage is that massage is what pressure so that you massaging that bony promise is the same thing as applying pressure on that bony promise which is something you never want to do okay so the correct answer is elevate the head of the bed as little as possible i feel like i did this question with you guys already i'm going to put this on the side next question the initial nursing intervention for the assessment of external hemorrhaging is one close monitoring of the wound dressing for bloody drainage two frequent assessment of the client's blood pressure three monitoring the client's heart rate or four redressing of the wound and i'll give you a moment to think of your answer i hope you guys all chose one close monitoring of the wound dressing for bloody drainage let's go back to the question it said what is initial what is the first intervention for assessment of external hemorrhage so what is the first thing you're going to do when you're assessing a patient that you suspect is bleeding out remember assessment is anything that gathers um information whether it's doing a physical exam on a patient whether it's asking a patient or family questions whether it's going into the chart anything that gives you information is a form of assessment so if you suspect that a patient's bleeding out externally if you suspect that they're bleeding out what is the first thing you're going to do as assessment look eyeball the patient the answer is one close monitoring of the wound dressing for bloody drainage easy peasy look at that wound do you see blood dripping out look at the other choices two frequent assessment of the client's uh blood pressure that's a wonderful answer you're gonna do frequent assessments of their blood pressure because guess what if a patient's bleeding out that blood pressure is gonna go down right but the first thing you want to do why would you overlook just looking at the wound and take the patient's blood pressure so number one is the correct answer we're going to get rid of number two by the way taking their blood pressure that's also not only external that lets you know if the patient's bleeding internally as well number three monitor their heart rate yes you want to do that because when the patient's bleeding out the blood pressure goes down and the heart rate does what go up because the heart's trying to compensate for that blood loss so yeah you want to check their heart rate but the first thing you're going to do is what look look at the patient remember we go from least invasive to most invasive and the fourth choice redressing of the wound redressing of the wound is great you put pressure on it you can help control the bleeding but that's not assessment it's not going to give you any information you want to look and so the correct answer is number one next question the nurse is assessing a 78 year old female african-american client with dark skin when assessing the skin the nurse knows to avoid which source of light because it can cast a bluish hue on the skin making the assessment difficult one natural sunlight two halogen light three fluorescent light four incandescent and i can never say this word incandescent light i think i said that right so i'll give you guys a moment to think of your answer i'll give you a hint it's not four excuse me so the correct answer guys is three and so you do need to know this for patients who have darker skin um they've got a little bit more melanin right we want to stay away from the fluorescent light because it just kind of gives them um a bluish bluish hue and kind of make makes it more hard to assess all right so um the natural light we like the halogen light is fine the incandescent light i gotta look down i don't even know what that is i know one and two are fine but three the fluorescent light you definitely want to stay away from because it gives a bluish hue so we really it's hard for you to tell on that patient is the bluish shoe coming from the light or are they really um not getting enough oxygen and they have that bluish look to them next question which of the following clients is most at risk for developing a pressure ulcer one a three-year-old in bucks traction two a 33 year old comatose patient three 76 year old who had a mouth stroke or four a 38 year old infant in an oxygen hood and i'll give you a moment to think of your answer and i expect you all to get this one right so the correct answer is to the comatose patient because remember if they're comatose they can't what move right so you have pressure that's constantly on their body right the three-year-old that's in bucks traction bus traction that's the type of skin traction so the three so they're able to move a little bit right this is contraction they got on right it's not skeletal traction then choice three is a 76 year old who had a mild stroke it was a mouth stroke it didn't say that the patient was completely debilitated that they couldn't move but we know if a comatose patient patients chromatos they're debilitated they're not moving at all and then we have choice four the infant in an oxygen hood it doesn't say anything about the infant being debilitated so they're still able to move the correct answer is the comatose patient why any patient that is unable to move and take pressure off of different sites of their body are at high risk for pressure ulcers and guys i think that was about maybe about 13 questions over the last questions i had to cover for skin and wound integrity um i hope you guys found it helpful i saw a couple comments asking me for more questions so here are your questions if that's not enough please let me know in the comments and i'll try to find some more wound care questions to cover for you guys thank you so much um for spending this time with me and practicing these questions i hope that i was helpful to you if there are any questions that you have or any content that you want to me to cover please be sure to leave a comment please don't forget my next review is going to be august 29th through the 30th information for that can be found on my website at www.nexusnursinginstitute.com and of course please do not forget to like and subscribe below thank you for joining me and i'll see you next time you