ATI: chapters 56-58

Card Set Information

ATI: chapters 56-58
2011-04-15 21:56:51
ati flashcards

basic nursing care
Show Answers:

  1. What are the basic nutrients required by the body?
    • Carbohydrates
    • Fats
    • Proteins
    • Vitamins
    • Minerals
    • Water
  2. What nutrient provides most of the body's energy and fiber?
  3. What nutrient is used for energy and to provide vitamins for the body?
  4. What nutrient should be no more than 30% of the daily caloric intake?
  5. What nutrients need to be consumed daily and are necessary for metabolism?
  6. What nutrients are needed by the body to complete essential biochemical reactions in the body?
  7. What nutrient is needed to replace fluids lost through perspiration, elimination and respiration?
  8. What practices may guide a client's food preparation or choices?
    Religious practices
  9. How do finances affect nutrition?
    May prevent clients from buying foods that are higher in protein or vitamins and minerals
  10. What are some reasons appetite may decrease?
    • Illness
    • Medications
    • Pain
    • Depression
    • Unpleasant environmental stimuli
  11. How might a client's preferences for nutrition and hydration be influenced?
    • Bad experiences with certain foods
    • Familiarity of foods that the client has tried and liked before
  12. What can impact the functional ability of the client to prepare and eat food?
  13. How can medications affect the nutritional status of a client?
    • Can alter taste and appetite
    • Can interfere in the absorption of certain nutrients
  14. What factors can affect nutrition?
    • Age
    • Religious practices
    • Appetite
    • Preferences
    • Disease/illness
    • Medications
  15. What are the nutritional requirements for infants (birth to 1 year)?
    • Breast milk is preferred or formula
    • Needs to provide 108 kcal/kg of weight the first 6 months and 98 kcal/kg of weight the second 6 months
  16. What age should solid foods be introduced?
    4 to 6 months
  17. What are the nutritional requirements for toddlers and preschoolers?
    • Fewer calories per kg of weight than infants
    • Increased protein from sources other than milk
  18. What are the nutritional requirements for school-age children?
    • Adequate protein and vitamins C and A
    • Need to be monitored because they tend to eat too many foods high in carbohydrates, fats and salt
  19. What are the nutritional requirements for adolescents?
    • High metabolic demands which require more energy
    • Protein, calcium, iron, iodine, folic acid and B vitamin needs are high
    • 1/4 of dietary intake comes from snacks
    • Increased water consumption for active adolescents
  20. What are the nutritional requirements for young and middle adults?
    • Decreased need for most nutrients (except during pregnancy)
    • Calcium and iron consumption are important for women
  21. What are the nutritional requirements for older adults?
    • Slower metabolic rate requires fewer calories
    • Need the same amount of vitamins and minerals as younger adults
  22. What are three main types of eating disorders?
    • Anorexia nervosa
    • Bulimia
    • Obesity
  23. What are the clinical/psychological presentations of anorexia nervosa?
    • Body weight less than 85% of ideal
    • Fear of being fat
    • Feeling fat
    • In female clients - no menses for at least 3 consecutive months
  24. What is bulimia?
    Cycle of binge eating followed by purging
  25. What are some methods of purging used by bulimic individuals?
    • Vomiting
    • Using diuretics or laxatives
    • Exercise
    • Fasting
  26. What BMI is considered obese?
    30 or higher
  27. How is BMI determined?
    Dividing weight (in kg) by height (in meters2)
  28. What should the dietary history include?
    • Number of meals per day
    • Fluid intake
    • Food preferences and amounts
    • Food preparation/purchasing practices, access to food
    • Hx of indigestion, heartburn and/or gas
    • Allergies
    • Taste
    • Chewing and swallowing
    • Appetite
    • Elimination patterns
    • Use of any medications
  29. What clinical measures and labs need to be acquired during a nutrition assessment?
    • Height and weight for BMI and ideal body weight (IBW) calculations
    • Lab values of cholesterol, triglycerides, hemoglobin, electrolytes, and albumin levels
  30. Which clients require I&O monitoring?
    Any client with fluid or electrolyte alterations
  31. When should weights be taken and what should the client be wearing?
    Each day at the same time after the client voids and while wearing the same type of clothes
  32. If you are using a bed scale to weigh the client, what needs to be done?
    Use the same amount of linen each day and zero out the scale if possible
  33. What does clinical assessment of poor nutrition include?
    • Muscle tone flaccidity
    • Mental status changes
    • Loss of appetite
    • Change in bowel pattern
    • Spleen or liver enlargement
    • Dry, brittle hair
    • Loss of subcutaneous fat
    • Dry, scaly skin
    • Inflammation and bleeding of gums
    • Poor dental health
    • Dry, dull eyes
    • Enlarged thyroid
    • Prominent protrusions over bony areas
  34. What are some nursing diagnoses for nutritional status?
    • Constipation
    • Deficient/excess fluid volume
    • Imbalanced nutrition: less/more than body requirements
    • Feeding self-care deficit
  35. What are some nursing interventions for nutritional status of clients?
    • Assisting the client in advancing diet as disease allows
    • Education
    • Promoting appetite
    • Feeding assistance
    • Prevent aspiration
    • Therapeutic diets
    • Assessing and monitoring enteral/parental feedings
    • Maintaining fluid balance
  36. What are some interventions to promote appetite?
    • Good oral hygiene
    • Favorite foods
    • Decreasing environmental odors
  37. How does a nurse assess for and assist with preventing aspiration when eating?
    • Position client in Fowler's or in a chair
    • Support the upper back, neck and head
    • Have client tuck chin when swallowing
    • Observe for aspiration and/or pocketing of food in the cheeks or other areas of the mouth
    • Maintain client in semi-Fowler's position for at least 1 hour after meals
    • Provide oral hygiene after meals/snacks
  38. Match the diet with its liquids/foods:
    1. clear liquid
    2. full liquid
    3. pureed
    4. mechanical soft
    5. soft/low-residue
    6. High-fiber
    7. Low sodium
    8. Low cholesterol
    9. Diabetic
    10. Dysphagia
    11. Regular

    A. clear and full liquids, plus pureed meats and fruits, and scrambled eggs
    B. pureed food and thickened liquids
    C. leave little residue (clear fruit juices, gelatin broth)
    D. clear and full liquids, plus foods that are diced or ground
    E. clear liquids, plus liquid dairy products, all juice, pureed vegetables
    F. no restrictions
    G. balanced intake of protein, fats, and carbohydrates with a total caloric intake of about 1800 calories
    H. whole grains, raw and dried fruits
    I. no added salt or 1 to 2 g of sodium
    J. foods that are low in fiber and easy to digest
    K. no more than 300 mg/day of dietary cholesterol
    • 1 - C
    • 2 - E
    • 3 - A
    • 4 - D
    • 5 - J
    • 6 - H
    • 7 - I
    • 8 - K
    • 9 - G
    • 10 - B
    • 11 - F
  39. What types of nutrients are given parenterally?
    • Lipids
    • Electrolytes
    • Minerals
    • Vitamins
    • Dextrose
    • Amino acids
  40. How is placement confirmed for parenteral nutrition?
  41. How is the rate of parenteral nutrition infusion determined?
    Gradually increasing the rate until the desired rate is achieved
  42. How often are parenteral nutrition tubes supposed to be changed?
    • Lipids - every 24 hours
    • Other solutions - every 48 hours
  43. How is fluid balance maintained?
    • Administering IV fluids
    • Restricting oral fluid intake
    • Encouraging oral intake of fluid
    • (it all depends on the client)
  44. What are ways in which restricting oral fluid intake can be implemented?
    • Removing the water pitcher from the bedside
    • Communicating with the dietary staff about the amount of fluid to be served with each meal tray
    • Communicating with each shift about the amount of fluid the client is allowed besides what is served with each meal
  45. How can you encourage your client in increase their oral intake of fluids?
    • Provide fresh drinking water
    • Ask the client about beverage preferences
  46. When conducting a nursing assessment on a family with a low income, the nurse discovers that the family is deficient in protein. Which of the following would be the best choice for increasing protein intake for this family?
    A. peas and beans
    B. red meat and fish
    C. potatoes and rice
    D. beans and rice
    D. beans and rice
    (this multiple choice question has been scrambled)
  47. A client is diagnosed as being high risk for aspiration. Which of the following is an appropriate nursing intervention?
    A. give the client thin liquids
    B. instruct the client to tuck chin when swallowing
    C. encourage the client to lie down and rest after meals
    D. have the client use a straw
    B. instruct the client to tuck chin when swallowing
    (this multiple choice question has been scrambled)
  48. Which nutrient is the body's preferred energy source?
    A. protein
    B. vitamins
    C. carbohydrates
    D. fat
    C. carbohydrates
    (this multiple choice question has been scrambled)
  49. Which of the following is most appropriate for a client on a low-reside diet?
    A. fruits and vegetables
    B. nuts and legumes
    C. dairy products
    D. whole grains
    C. dairy products
    (this multiple choice question has been scrambled)
  50. School-age children tend to have a dietary deficiency in which of the following if their diet is not adequately supervised?
    A. vitamins
    B. fats
    C. carbohydrates
    D. minerals
    A. vitamins
    (this multiple choice question has been scrambled)
  51. What are the stages of wound healing?
    • Inflammatory
    • Proliferative
    • Maturation or remodeling
  52. When and how long is the inflammatory stage of healing?
    First 3 days after the initial trauma
  53. What is happening during the inflammatory stage of healing?
    The body attempts to control bleeding with clot formation and attempts to deliver oxygen, white blood cells and nutrition to the area via the blood supply
  54. How long does the proliferative stage last?
    3 to 24 days
  55. What happens to the wound during the proliferative stage?
    • Lost tissue is replaced with connective or granulated tissue
    • Contracting of the wound
    • Resurfacing of new epithelial cells
  56. What happens during the maturation or remodeling stage of wound healing?
    Strengthening of the collagen scar and the resumption of a more normal appearance
  57. How long does the maturation/remodeling stage of wound healing last?
    It can take more than 1 year to complete - depends on the original wound
  58. What are the three types of healing?
    • Primary intention
    • Secondary intention
    • Tertiary intention
  59. Which type of healing occurs in a wound with little or no tissue loss, with edges that are approximated?
    Primary intention
  60. Which type of healing of a wound will heal rapidly, has a low risk of infection, and will have no or minimal scarring?
    Primary intention
  61. Which type of healing occurs in a wound with loss of tissue, and with wound edges that are widely separated?
    Secondary intention
  62. Which type of healing of a wound will have a longer healing time, increased risk of infection and scarring?
    Secondary intention
  63. Which type of healing occurs in a wound that is widely separated, deep, may be a spontaneous opening of a previously closed wound, and has a possible presence of infection?
    Tertiary intention
  64. Which type of healing occurs in a wound likely to have extensive drainage and tissue debris, will be closed later and has a long healing time?
    Tertiary intention
  65. What are the 11 factors that affect wound healing?
    • Increased age
    • Overall client wellness
    • Immune function
    • Medications
    • Nutrition
    • Tissue perfusion
    • Obesity
    • Chronic diseases
    • Chronic stress
    • Smoking
    • Wound stress
  66. Why does increased age affect wound healing?
    • Loss of skin turgor
    • Skin fragility
    • Decreased peripheral circulation and oxygenation
    • Slower tissue regeneration
    • Decreased absorption of nutrients
    • Decreased collagen
    • Impaired function of the immune system
  67. Why is nutrition important in wound healing?
    Provides elements required for wound healing and energy requirements
  68. Why is adequate tissue perfusion important in wound healing?
    Provides circulation needed to deliver the required elements for tissue repair and infection control
  69. How does obesity effect wound healing?
    Fatty tissue lacks blood supply
  70. How does smoking impair wound healing?
    Impairs oxygenation and clotting
  71. How would vomiting or coughing disrupt the wound healing process?
    Stresses the suture line
  72. What is a wound?
    Disruption of the skin
  73. A localized protective response brought on by injury or destruction of tissue
  74. How can wounds become infected?
    By the invasion of a pathogenic microorganism
  75. What are the principles of wound care?
    • Assessment
    • Cleansing
    • Protection
  76. What nursing responsibility has a high impact on wound healing?
    Wound care
  77. When collecting assessment data on the appearance of a wound, what should the nurse be looking for?
    • The color of open wounds
    • Skin edges of closed wounds should be well-approximated
  78. What does the color red indicate in an open wound?
    Healthy regeneration of tissue
  79. What does the color yellow indicate in an open wound?
    Presence of purulent drainage and slough
  80. What does the color black indicate in an open wound?
    Presence of eschar that hinders healing and must be removed
  81. When does drainage, a normal result of the healing process, occur?
    During the inflammatory and proliferative phases
  82. What things are important to note about drainage?
    • The amount of drainage from a drain or on a dressing
    • Skin around the drain - irritation and breakdown
    • Character of the drainage (serous, sanguinous, etc...)
    • Wound closure
    • Pain
  83. Match the drainage type with its description
    1. serous
    2. sanguinous
    3. serosanguinous
    4. purulent

    A. drainage contains both serum and blood; watery and appears blood-streaked or blood tinged
    B. watery and clear or slightly yellow in appearance
    C. result of infection; composed of white blood cells, tissue debris and bacteria; may have a foul odor, is thick and appears colored by the specific type of organism present
    D. contains serum and red blood cells; thick and appears reddish
    • 1 - B
    • 2 - D
    • 3 - A
    • 4 - C
  84. What are some nursing diagnoses for wounds?
    • Pain
    • Risk for infection
    • Impaired skin integrity
    • Impaired tissue integrity
    • Disturbed body image
    • Imbalanced nutrition
  85. How much fluid should a client with a wound be encouraged to drink?
    2,000 to 3,000 mL of water/day if not contraindicated
  86. What dietary education should be given to a client with a wound?
    Education on high sources of protein
  87. What are some foods with high protein content?
    • Meat
    • Fish
    • Poultry
    • Eggs
    • Dairy products
    • Beans
    • Nuts
    • Whole grains
  88. What serum ablumin level indicates a need for increased protein intake?
    <3.5 g/dL
  89. Cleanse a wound in a direction from ______ contaminated to ______ contaminated
    least; most
  90. What amount of friction is used when cleansing or applying solutions to the skin when performing wound cleansing?
    Gentle friction
  91. Why is it important only use gentle friction when cleansing a wound?
    To avoid bleeding or further injury to the wound
  92. What type of solution (hypotonic, isotonic, or hypertonic) is the preferred cleansing agent for wounds?
  93. True or false: Use the same gauze to clean across an incision or wound, until the gauze pad is completely soiled
    False - never us the same gauze more than once
  94. How high above the wound should a solution-filled irrigation syringe be?
    1 inch
  95. Match the wound dressing with its description
    1. woven gauge (sponge)
    2. nonadherent
    3. self adhesive, transparent film
    4. hydrocolloid
    5. hydrogel (Aquasorb)

    A. occlusive dressing that swells in the presence of exudate
    B. does not adhere to the wound bed
    C. may be used on infected, deep wounds and it provides a moist wound bed
    D. temporary second skin that is ideal for small, superficial wounds
    E. absorbs exudate from the wound
    • 1 - E
    • 2 - B
    • 3 - D
    • 4 - A
    • 5 - C
  96. Which type of wound dressing is used to maintain a granulating wound bed and may be left in place up to 5 days?
  97. What is done to remove dead wound tissue that prevents wound healing?
  98. What are common forms of debridement?
    • Wet-to-dry dressing
    • Surgical intervention
    • Proteolytic enzyme
  99. How does a wound VAC work?
    Uses negative pressure to remove drainage from a wound
  100. True or false: staples/sutures may be removed without a doctor's order
  101. What needs to be documented about a wound?
    • Location
    • Type of wound/incision
    • Status of wound
    • Type of drainage
    • Type of dressings and materials used
    • Client teaching provided
    • How the client tolerated the procedure
  102. The partial or total rupture of a sutured wound usually with separation of underlying skin layers
  103. A type of dehiscence that involves the protrusion of visceral organs through the surgical incision
  104. What typically causes an evisceration?
    Increased flow of serosanguineous fluid occurring approximately 3-11 days post-op
  105. What are the following signs and symptoms of?
    - Appreciable increase in the flow of serosanguineous fluid on the wound dressings
    - Immediate history of sudden straining
    - Client stats "something just happened to my stomach"
    - Visualization of visceral organs
  106. What are the risk factors for dehiscence?
    • Chronic disease
    • Advanced age
    • Obesity
    • Invasive abdominal cancer
    • Vomiting
    • Dehydration/malnutrition
    • Ineffective suturing
    • Abdominal surgery
  107. What should be done when evisceration is found?
    • Call for help
    • Stay with the client
    • Cover the wound and any protruding organs with sterile towels or dressing that have been soaked in saline solution
    • Position the client supine with hips and knees bent
    • Observe the client for signs of shock
    • Maintain a calm environment
  108. True or false: Do not attempt to reinsert eviscerated organs
  109. What are the risk factors for infection?
    • Extremes in age
    • Impaired circulation and oxygenation
    • Wound condition/nature
    • Impaired/suppressed immune system
    • Malnutrition
    • Alcoholism
    • Chronic disease
    • Poor wound care
  110. what are the signs and symptoms of infection pertaining to wounds?
    • Purulent drainage
    • Pain
    • Redness and edema - in and around wound
    • Fever
    • Chills
    • Increased pulse and respiratory rate
    • Increase in white blood cell count
  111. When do signs and symptoms of infection typically present after injury/surgery?
    2 to 7 days
  112. How can infection of wounds be prevented?
    • Using appropriate aseptic technique when performing dressing changes
    • Promoting good nutrition
    • Providing for adequate rest to promote healing
  113. How can infections of wounds be treated?
    • Antibiotic therapy per physician's orders
    • Good nutrition
    • Adequate rest
    • Aseptic technique
  114. Scenario: An adolescent client with diabetes is recovering from an appendectomy. This is the third post-op day. The client has been ordered a regular diet and is tolerating it well. He has ambulated successfully around the unit with the help of his parents and is requesting pain medication every 6 to 8 hours while reporting pain at a 2 on a scale of 0 to 10 after medication is given. His incision is approximated and free of redness with scant serous drainage noted on the dressing.

    1. What type of healing process would the nurse expect this wound to be undergoing?

    2. Which of the following risk factors does this client possess? (select all that apply)
    - Extremes in age
    - Impaired circulation
    - Impaired/suppressed immune system
    - Malnutrition
    - Poor wound care such as breaches in sterile technique

    3. What is the single most important nursing intervention to protect this client from developing a post-op infection?
    • 1. Primary intention
    • 2. Impaired circulation and impaired/suppressed immune system
    • 3. Proper wound care
  115. An entry in a client's chart states the wound drainage is "sanguineous." That means it is
    A. foul-smelling
    B. bright red
    C. watery in appearance
    D. green-tinged or yellow
    B. bright red
    (this multiple choice question has been scrambled)
  116. Which of the following is an example of a wound or injury healing by secondary intention?
    A. a sutured surgical incision
    B. sprained ankle
    C. a bone fracture that is casted
    D. an open burn area
    D. an open burn area
    (this multiple choice question has been scrambled)
  117. Scenario: An older adult woman has undergone surgery for a bowel obstruction 6 days ago. Prior to surgery, she experienced nausea and vomiting for 3 days. During the last 24 hours, she has reported nausea, and she has vomited small amounts of clear liquid three times in the last 8 hours. Her vital signs are stable. The client weighs 81.6 kg and is 5 ft 2 in tall and smokes two packs of cigarettes a day. Currently, her incision is well approximated and free of redness, tenderness, or swelling.

    1. What assessment findings would indicate development of a wound infection?

    2. What risk factors for poor healing does this client exhibit?

    3. Later that day, the client becomes confused and pulls of her surgical dressing. The nurse enters the room and finds the client with an extensive dehiscence. Which of the following nursing interventions are appropriate? (select all that apply)
    - repack the wound
    - call for help
    - assist the client to a chair
    - cover the wound with a sterile dressing moistened with normal saline
    - stay with the client

    4. What placed this client at risk for a wound dehiscence/evisceration?
    • 1. purulent drainage, pain, redness and edema, fever, shills, increased pulse/respirations, increased WBCs
    • 2. obesity, dehydration, smoker
    • 3. call for help, cover the wound with a sterile dressing moistened with normal saline, stay with the client
    • 4. age, obesity, abdominal surgery 6 days ago, recent vomiting
  118. What do pressure ulcers range from?
    Blanchable tissue redness to full thickness skin loss with damage to underlying muscle and bone
  119. What is the primary factor in the prevention of pressure ulcers?
    Excellent nursing care
  120. What is the primary focus of prevention and treatment of pressure ulcers?
    Relieve the pressure and provide for good nutrition and hydration
  121. What must all clients be assessed and evaluated for?
    • Skin-integrity status
    • Risk factors for impaired skin integrity
  122. What are a significant source of morbidity and mortality among older adults and presons of any age who suffer mobility limitations?
    Pressure ulcers
  123. What are risk factors for development of pressure ulcers?
    • Skin changes related to aging
    • Immobility
    • Incontinence or excessive moisture
    • Skin friction and shearing
    • Vascular disorders
    • Obesity
    • Inadequate nutrition and/or hydration
    • Anemia
    • Fever
    • Impaired circulation
    • Edema
    • Sensory deficits
    • Impaired cognitive functioning, neurological disorders
    • Chronic diseases
    • Sedation that impairs spontaneous repositioning
  124. What stage would this ulcer be in?
    Epidermal involvement only
    Lightly pigmented skin = redness; darker skin tones = red, blue or purple in tone
    Reversible if pressure is relieved
    Skin intact
    Stage 1
  125. What stage would this ulcer be in?
    Partial-thickness skin loss involving the epidermis and/or dermis
    Lesion presenting as an abrasion, shallow crater or blister
    May appear swollen and may be painful
    Takes several weeks to heal when pressure is relieved
    Stage II
  126. What stage would this ulcer be in?
    Full-thickness skin loss, including sub-q tissue and underlying fascia
    Lesion presenting as a deep crater with or without undermining of adjacent tissue
    May have foul-smelling, purulent drainage if locally infected
    Yellow slough and/or necrotic tissue in wound bed
    May require months to heal after pressure is relieved
    Shallow to deep
    Stage III
  127. What stage would this ulcer be in?
    Extensive damage to underlying structures including tendons, muscles, and bones
    Lesion appearing small on the surface but can have extensive tunneling out of sight beneath superficial tissue
    Local infection easily spread, which can cause sepsis
    May take months or years to heal after pressure is relieved
    Stage IV
  128. Why can some ulcers not be staged?
    Because they are covered with eschar and the wound bed cannot be visualized
  129. What are some nursing diagnoses related to pressure ulcers?
    • Pain
    • Impaired skin integrity
    • Impaired tissue integrity
    • Ineffective tissue perfusion
  130. How are pressure ulcers prevented?
    • Maintaining clean, dry skin and wrinkle-free linens
    • Repositioning the client
    • Providing adequate hydration and meeting protein and caloric needs
  131. How can a nurse maintain clean, dry skin and wrinkle-free linens?
    • Appropriately use pressure-reducing surfaces and pressure-relieving devices
    • Inspect skin frequently and document risk using a tool such as the Braden Scale
    • Clean and dry skin immediately following urinary or stool incontinence
    • Apply moisture barrier creams to the skin of clients who are incontinent
    • Use tepid water, minimal scrubbing and pat skin dry
  132. How often should a client be repositioned in bed? In a chair?
    every 2 hours; every 1 hour
  133. Where should pillows be placed to relieve pressure?
    Between bony surfaces
  134. To relieve pressure on sacrum, buttocks and heels, what angle should the HOB be maintained at, if not contraindicated?
    30 degrees or less
  135. Why should the client be prevented from sliding down in bed?
    To decrease shearing forces that pull tissue layers apart and cause damage
  136. Why should you lift rather than pull a client up in bed or in a chair?
    Because pulling creates friction that can damage the client's outer layer of skin
  137. When should a client be ambulated?
    As soon as possible and as often as possible
  138. What should be implemented for immobile clients to prevent pressure ulcers?
    Active/passive ROM exercises
  139. True or false: Massaging bony prominences relieves pressure
    False - do not massage bony prominences
  140. What are interventions to treat stage I pressure ulcers?
    • Relieve pressure
    • Encourage frequent turning/repositioning
    • Use pressure-relieving devices
    • Implement pressure-reduction surfaces
    • Keep the client dry, clean, well-nourished and hydrated
  141. What are interventions to treat stage II pressure ulcers?
    • Maintain a moist healing environment
    • Promote natural healing while preventing formation of scar tissue
    • Provide nutritional supplements as needed
    • Administer analgesics as needed
  142. What are interventions to treat stage III pressure ulcers?
    • Clean and/or debride
    • Provide nutritional supplements as needed
    • Administer analgesics as needed
    • Administer antimicrobials
  143. What are interventions to treat stage IV pressure ulcers?
    • Perform nonadherent dressing change every 12 hours
    • Treatment may require skin grafts
    • Provide nutritional supplements as needed
    • Administer analgesics as needed
    • Administer antimicrobials
  144. What are some complications of pressure ulcers?
    • Deterioration to a higher stage ulceration and/or infection
    • Systemic infection
  145. When deterioration of a pressure ulcer occurs, what does the nurse assess/monitor?
    • Frequently assess/monitor the ulcer and report increases in the size or depth of the lesion, changes in granulation tissues, and changes in exudates
    • Follow protocol for ulcer treatment
  146. What should be assessed/monitored for in a systemic infection?
    Signs of sepsis
  147. What are signs of sepsis?
    • Changes in level of consciousness
    • Persistent recurrent fever
    • Tachycardia
    • Tachypnea
    • Hypotension
    • Oliguria
    • Increased WBC
  148. Scenario: An older adult client with diabetes mellitus and Alzheimer's disease must now use a wheelchair after a CVA 2 years ago that affected her right side. She does not respond to verbal commands or pain on the right side of her body. Her fluid and food intake is good, but she does require help with eating. She is continent for stool but is frequently incontinent for urine.

    1. What risk factors does this client have for developing pressure ulcers?

    2. What usual risk factor(s) does this client NOT have?

    3. What can the nurse do to prevent skin breakdown?
    • 1. wheelchair confinement (immobile), right-side immobility, decreased sensations on right side, impaired mental status, incontinence of urine, advanced age
    • 2. poor nutrition and dehydration
    • 3. encourage repositioning, keep client clean and dry, perform thorough daily assessments, provide good, frequent skin care, implement pressure-reducing devices, encourage and facilitate good nutrition
  149. Scenario: A client has developed a red area approximately 1 cm x 1 cm on his elbow. It does not blanch.

    1. To which stage has the client's skin lesion progressed, and which layer(s) of the skin are most likely damaged?

    2. The primary focus of prevention and treatment of pressure ulcers is ________, _________, and _________
    • 1. Stage I; epidermal damage
    • 2. relieving pressure, providing good nutrition, providing good hydration
  150. Which of the following statements best describes a stage III pressure ulcer?
    A. the skin is reddened and does not blanch with pressure
    B. the bone is exposed at the center of the ulcer
    C. the ulcer extends past the subcutaneous tissue to the muscle
    D. the ulcer is an abrasion or blister
    C. the ulcer extends past the subcutaneous tissue to the muscle
    (this multiple choice question has been scrambled)