[Music] hi guys it's me professor d and welcome back to my channel if you haven't done so already you know what i'm about to say be sure to like comment and subscribe below on this video this is actually going to be part one out of a two-part series video on um skin integrity wound care okay why there's so many questions so many concepts that are covered i couldn't just cover it all in one video so this is going to be part one so let's just jump right into the questions first question pressure ulcers form primarily as a result of one nitrogen buildup in underlying tissues two prolonged illness or disease three tissue ischemia four poor nutrition and i'll give you a moment and the correct answer is number three the primary cause is tissue ischemia so let me explain to you because i know a lot of you guys wanted to choose choice number four poor nutrition poor nutrition is a risk factor okay but one of the primary causes is tissue ischemia okay there's a difference between a cause and a risk factor so let me explain this to you what happens is for whatever reason the patient has been on that portion of the skin which is usually a bony prominence but they've been on that uh pressure has been applied on that skin for too long okay whether it be due to that patient being emaciated and that's why they're on that bony prominence or the patient's obese and that's why there's so much pressure on that side or it could be that the patient is um incontinent right and so um the acidity of the urine or the wetness of feces the feces it starts to emaciate at the skin you know there could be a list of of things that places the patient at risk but the point is that patient has put pressure on that site when there's pressure on that site guess what's not excuse me guess what's not getting to that site blood and along with blood comes oxygen vitamins nutrients so what happens to that tissue it starts to die okay it starts to be suffocated of not getting enough oxygen and that's what that tissue ischemia is so that's a primary um result um of pressure ulcer tissue ischemia why because of all that pressure to the site when you have pressure you have decreased oxygen um you have when you have too much pressure you have decreased blood if you have decreased blood that means you're getting decreased oxygen to the site and along with decreased oxygen is decreased vitamins d decrease nutrients and minerals okay so don't be fooled you see for poor nutrition poor nutrition is a risk factor if that patient has poor nutrition you know they're not having in eating enough uh protein they're emaciated or they're obese it could be the opposite those can put that patient at risk pressure to go on the bony provinces decrease blood flow with the decreased blood flow decrease oxygen vitamin nutrients which lead to what tissue ischemia so i hope that makes sense for you guys number one and two is just wrong flat out so you should have been between number three and number four those should have been your two choices and between those two choices i hope i kind of explained it and made it clear to you why three was the correct answer and not number four but just for clarification poor nutrition being emaciated being obese being incontinent um having decreased level of consciousness such as a patient who sedated such as a patient who's in a coma all of those are risk factors for a patient um getting pressure ulcer okay next question the nurse notes uh excuse me the nurse knows a client's skin is reddened with a small abrasion and serious fluid present the nurse should classify this stage of ulcer formation as one stage one two stage two three stage three or four stage four and i'll give you a moment to think of your answer and the correct answer is stage two and here's the key guys that made you guys know the answer was stage two and not stage one in the question it told you that yes the skin's redden but look there's a small abrasion what's this there's a break in the skin it can't be a stage one anymore so a stage one is when that area is reddened it's non-blanchable right but guess what the skin is still intact you're at a one once that skin's no longer intact such as an opening or an abrasion okay you're now at skin too skin too you're now at stage two and that's where that um the ulcer comes down to the dermis or the epidermis then you have your stage three stage three is when it gets down to the sub-q layer the fatty tissue the sub-q layer and stage four is when it comes down to the bone okay so that's an easy way to remember your stages one redden non-blanchable but the skin's still intact two skins no longer attack intact the epidermis or the dermis is affected three it's gone down to the sub-q layer four it's gone down to the bone okay next question the client has rheumatoid arthritis is prone to skin breakdown and is also somewhat immobile because of arthritic discomfort which of the following is the best intervention for the client's skin integrity one having the client sit up in a chair for four hour intervals two keeping the head of the bed in high follows position to increase circulation three keeping a written schedule of turning and positioning the client four encouraging the client to perform pelvic muscle training exercises several times a day i'll give you a moment to think of your answer the correct answer guys is keeping a written schedule of turning and positioning why because when you keep that schedule you're making sure that that patient is turning and repositioning at least every two hours what does that mean that means that pressure is not being applied to any given site for more than a max of two hours at a time i want to go through these other choices with you one having the client sit up in a chair for four hour intervals well we have a problem with that number one in the question it tells us that the patient's prone to skin breakdown and they're somewhat immobile because of arthritic discomfort so if you're having that patient sitting up in a chair for four hour intervals that's four hours that you have them putting pressure on bony areas such as their coccyx does that make any sense absolutely not so we're going to throw that one out then you have choice number two keeping the head of the bed in high fat is positioned to increase circulation you want to know what happens when you put that patient in high follis position you put that head in high followers right so you're putting that bed in high followers guess what that patient keeps doing sliding down the bed sliding down the bed sliding down the bed and every time they slide down that bed that's producing shearing forces between the sheet and that patient's skin okay which allows for what skin breakdown so absolutely not patients who are prone to having ulcers patients who are prone to having skin breakdown we don't want the head of that bed high we want it low because we don't want that shearing force that's going to happen if you have the head of the bed high choice number four encouraging the client to perform pelvic muscle training exercises several times a day that help does helps nothing with pressure pelvic training exercises does nothing for pressure and that's the problem that the patient has we want to keep pressure off of them so the best in this situation is having that schedule and making sure that that patient is turning that that patient being repositioned at least every two hours for the next question okay when turning a client the nurse notices a reddened area on the coccyx what skin intervention should the nurse use on this area one clean the area with mild soap dry and add a protective moisturizer two apply a dilute hydrogen peroxide and water mixture and use a heat lamp to the area three soak the area in normal saline four wash the area with astringent and paint paint it with povadine iodine also known as betadine i'll give you a moment to think of your answer i didn't mean to laugh okay so the correct answer is one you want to clean the area with mild not harsh soaps right it says mild soap dry and then you want to add a protective barrier look at our other choices two dilute apply dilute hydrogen peroxide no let's stop right there that hydrogen peroxide is going to cause skin breakdown we don't want that choice number three soak stop right there you don't ever want to soak because what does that soaking do it's gonna cause skin breakdown it causes uh maceration of the skin that's why we always want that skin to be dry that's why i remember i think i told you just in the last question or maybe two questions ago i don't recall but patients who are at risk for skin breakdown are patients who are what incontinent because the urine the feces that sits there on the skin will cause skin breakdown so you don't want to soak the patient's skin at all because that moisture will add to skin breakdown and then you have four wash the area with astringent excuse me absolutely not that is harsh and it's going to cause excessive drying okay so your only correct answer here is the mild mild soap and then you want to dry it you want to make sure that skin's dry and then put a protective barrier on the skin next question a client comes to the er department following an injury the nurse implements appropriate first aid for the client when one removing any penetrating objects two elevating an effective an affected part that's bleeding three vigorously cleaning areas of abrasion or laceration four keeping any puncture wounds from bleeding and i'll give you a moment to think of your answer the correct answer is too you want to elevate the affected part that is bleeding okay so guys you want to apply pressure to the site and you want to elevate it to decrease the bleeding let's look at our other choices you have one removing any penetrating objects look at me in my eyeball when i tell you this you do not pull out any penetrating objects do you hear me because that penetrating object may be what's keeping that patient from hemorrhaging out the minute you pull it out that patient's blood is flirting all over the place okay you leave that to the surgeon when that patient's in surgery but you're not pulling anything out of that patient okay that penetrating object may be what's stabilizing that patient hemodynamically speaking okay so never ever ever in the history of your nursing career are you going to pull out any penetrating object are we clear good choice number three vigorously stop pop the brakes you know what vigorously means that means harshly that means you to do something in the hard way that means to do something roughly do we do anything vigorously in nursing no vigorously cleaning areas of abrasion or laceration absolutely not you may cause more harm and damage than good okay you're not gonna vigorously clean anything you're gonna do it delicately okay and choice four keeping any puncture wound um from bleeding if something um if the patient has a puncturing wound how are you gonna keep it from bleeding by doing number two putting pressure on the side and l of uh pressure on the side if you can if there's um uh um uh if putting pressure on the actual site and not what's puncturing the patient okay so applying pressure and doing what elevating that affected extremity that's how you decrease the bleeding okay and you see this question the answer of two elevating the affected part that's bleeding that is an umbrella answer and we love umbrella answers guys remember i taught you guys about umbrella answers on my video um 11 tips on passing nclex this is a perfect example why because number two covers number four which says keeping the puncture wounds from bleeding and that's what you guys want to do next question the nurse is concerned that the client's midsternal wound is at risk for dehiscence which of the following is the best intervention to prevent this complication one administering antibiotics to prevent infection two using appropriate sterile technique when changing the dressing three keeping sterile towels and extra dressing supplies near the client's bed four placing a pillow over the incision site when the client is deep breathing or coughing and i'll give you a moment the correct answer is for having the client use a pillow over the incision site when they're coughing or deep breathing why that keeps those sutures from busting wide open also known as dehiscence okay so when they use a pillow what does that pillow act as a splint and you want a patient to splint the area when they're coughing when they're deep breathing in order not to cause any dehiscence to the wound site next question following a head injury the client has thin drainage coming from the left ear the nurse describes this drainage as one cirrus two purulent three ceros cerebrospinal fluid or four cereal sanguiness and i'll give you a moment to think of your answer and the correct answer is one serous fluid serous fluid guys it looks um clear watery and let's go back to the question that says following a head injury the client has thin drainage it's coming from the left ear how would you describe it let's look at our other choices so you have two which is purulent when you see that word purulent that means something that looks or appears to be infectious so with purely drainage you would expect it to be thick yellow or green you'd expect it to be malodorous right you have um choice three cerebral spinal fluid now guys cerebral spinal fluid you're not going to know unless you test it okay but i'll give you some indicators if you see that the leakage is clear but you see a yellow ring around it most likely cerebral spinal fluid or you test it with the dipstick in a test positive for glucose cerebral spinal fluid but you have to test it you can't just say cerebral spinal fluid from looking at it okay like you would be able to look at serous fluid and say okay this is serious because you know it's clear it's watery and then you have your cherries four which is a cereal sandwiches fluid that's when it's like pale reddish color when it's a pale reddish color and it could be mixed with clear red it might maybe give you a pink tinge that's your one that's cereal sanguines okay so that's the difference between those four descriptions next question the nurse recognizes that skin integrity can be compromised by being exposed to body fluids the greatest risk exists for the client who has exposure to one urine two purulent exodus three pancreatic fluids or four cereal sandwiches drainage and i'll give you a moment so the correct answer is three pancreatic fluids now i'm gonna do this a little bit backwards i'm gonna explain to you go over the other choices first then i'm gonna go over the correct choice so you see one and two a urine and pure lit exodus those place they do they place the patient at risk for um [Music] decreased skin integrity but not number one risk so those are risk factors i want to make it sure that that's clear those are risk factors but it's not on top of the list okay let me tell you why pancreatic fluids is on top of the list if you guys can recall on one of the first videos i ever did actually diabetes is so important i did a couple of videos on diabetes but anyway i talked to you guys and i explained about the endocrine and exogenous functions of the pancreas right and one of the things that i explained to you that the pancreas does is that it releases pancreatic enzymes all right so every time you eat something you put food in your mouth the pancreas is supposed to shoot out these pancreatic pancreatic enzymes so when the food goes from your stomach to your small intestine those pancreatic enzymes break down the food so that you can digest the food okay so guess what those pancreatic enzymes do what break things down so if you get pancreatic enzymes on the skin what do you think is going to do to your skin break your skin down that's how harsh pancreatic enzymes do that's how harsh pancreatic enzymes are that's its function it breaks things down so when you have to compare pancreatic enzymes to the urine or feces or vomit or any other bodily fluids yes any bodily fluids put patients at risk for skin breakdown but nothing like pancreatic enzymes do because pancreatic pancreatic enzymes work a lot faster they will break that skin down a lot faster and a lot harsher okay than the other bodily fluids that i just mentioned so that's why the correct answer is number three next question when cleaning a wound the nurse should one wash over the wound twice and discard that swab two move from the outer region of the wound to the center three start at the drainage site and move out in circular motions or four start an antiseptic solution followed by normal saline rinse and i'll give you a moment to think of your answer and the correct answer is three you want to start at the drainage site and move out with circular motions okay you wanna you wanna um clea uh start at cleanest and move out okay not at the dirtiest and move in because if you start outwards and you move in you're pushing it all where in the center absolutely not okay you guys learned this in first semester of nursing program in the nursing program you want to start in the center where the drainage is and move your way out okay one says wash over the wound twice and discard um that swab no once and discard okay you want to keep sterility and i explained to you why two is a wrong answer what's for use an antiseptic solution followed by normal say they know opposite you're going to clean it out first you're going to use the normal saline then you're going to use the antiseptic solution if order okay so the only correct answer in this choice is three starting the drainage at the drainage site and moving outwards in circular motion just like i taught you or just like i showed you i should say the nurse is aware that application of cold is indicated for the client with one menstrual cramping two an infected wound three a fractured ankle or four degenerative joint disease and i'll give you a moment the correct answer is a fractured ankle remember guys when you have fracture you have sprain you have uh um a strain you want to do rice r-i-c-e okay r is for rest you want to rest that affected area you have i is for ice why are you putting ice ice um anything that's cold causes constriction and of course if there's a fracture you can expect a lot of what swelling so you're going to put ice to cause constriction to decrease the swelling to that area c is for compression of course e elevation and the elevation does the same thing it helps decrease the swelling let's look at our other choices one menstrual cramping actual from menstrual cramping you want to use heat warmth because warmth causes what vasodilation okay so warmth relaxes smooth muscles and it causes vasodilation which will help with the pain look at choice two infected wound you don't put cold on an infected wound because cold causes what constriction and it decreases blood flow where there's an infection you want blood flow because remember that blood flow is bringing what oxygen vitamins nutrients so you're not going to put cold on the wound however you don't put heat either either because heat causes what just like causes vasoconstriction and it decreases blood's flow heat causes vasodilation and yes vasodilation increases blood flow but guess what vasodilation will also spread the infection so you're not putting heat or cold on an infection you're cleaning out that infection so the answer can't be number two and degenerative joint disease for a patient to have degeneration degenerative joint disease you want warmth you want to bring warmth to the side it's going to cause muscle relaxation and it's going to be soothing to the patient so the correct only correct answer for this question when it comes to patient that had a fracture it's going um excuse me of the patient that you're going to put cold on is going to be that patient that had a fracture r-i-c-e rest ice compression and elevation the client requires support and an abdominal binder is ordered the nurse correctly implements the use of a binder by one using it as a replacement for underlying dressings two keeping it loose for client comfort three having the client sit or stand when it is applied four making sure the client has adequate ventilatory capacity and i'll give you a moment to think of your answer the correct answer is four you want to make sure that the client can breathe okay that's the correct answer let's look at our other choices one using it as a replacement for underlying dressing absolutely not okay that binder goes over any dressings that the patient has it doesn't replace the dressing it goes on top of the dressing okay choice number two keeping it loose for con comfort no it needs to be snug notice i didn't say tight that patient has to be able to breathe but it needs to be snug okay otherwise it's not going to be effective three having the client sit or stand when it's applied know when you're playing it on the patient they should be lying down and then you have the correct answer making sure the client has adequate ventilatory capacity you want to make sure that they can breathe with it on okay and our last question to reduce pressure points that may lead to pressure ulcers the nurse should one position the client directly on the trochanter when side lying two use a doughnut device for the client when sitting up three elevate the head of bed as little as possible or four massage over bony prominences and i'll give you a moment although i i gave you the answer to this question a couple questions ago so let's see if you're paying attention the correct answer three elevate the head as little as possible remember i explained to you we don't want the shearing forces when you elevate the head of the bed what happens the patient keeps sliding down they keep sliding down so you don't want that to happen you don't want that to cause skin breakdown so you're going to elevate the head of bed as at least as little as possible let's look at our other choices you have number one it says position the client directly on the trochanter stop did i not tell you in order to avoid pressure also you have to make sure that you keep that patient off of bony prominences so why would you have them lying down on the trochanter so you know that can't be right so we're getting rid of that choice number two use a donut device for the client when they're sitting up no why that donut device you put it on that client while they're sitting up what does that do it decreases the blood supply which decreases blood oxygen vitamins nutrients they're supposed to go to that area so throw that out that's not the answer and then number four massage over bony prominences never guess what you when you're massaging over that bony prominences when you're giving somebody a massage what are you doing you're applying what pressure what causes an ulcer pressure over a bony promises over bony prominence so why would you give a patient a massage over that same bony prominence that you don't want to put pressure over does that make any sense so guys the correct answer is having that head of the bed as low as possible i hope you guys don't mind me yelling at you from what my students have told me they say professor d you know when i was taking my nclex when i was taking my test i remember you yelling at me about such and such or i'm going to tell you guys a secret my students i choke them sometimes i do if they say something crazy i'll come up behind and just squeeze their neck and they'll say to me they'll say professor d i remember you doing that and i chose the right answer so i hope you guys can get offended if i was yelling at you too much i hope you guys enjoyed this video if you haven't done so already please make sure you like comment and subscribe below like i said guys this was part one of the two part video so please watch out for part two thank you so much for joining me and i'll see you next time