Wound assessment is very important point in the preparation and treatment of wound. The entire person need to be assessed,life history, such as smoking,hypertension and diabetes.
And for pressure ulcer to be treated effectively, a team approach is required. This involves the patients, families,healthcare providers and caregivers.
Medical Diagnosis of
: Pressure ulcer is usually pressure areas.
Arterial is usually distal ,small in size,round in shape, the dept is usually shallow, smooth margins and surrounding tissues are pale.
Venous is above malleolus, size can be small or large.Burns,dermatitis, abcess,necrotizing fasciitis,and Diabetic ulcers is on pressure areas of the foot.
Nursing Diagnosis:
Impaired skin integrity related to non healing wound.
(1) Partial thickness wound can be classified as:
(A )Stage IV
(B )Stage 111.
(C )Stage 11.
(D)Wound covered with escher and some sloughs
Correct answer C.
The partial thickness wound involves loss of dermis.It presents itself filled blisters or as an open shallow ulcer that has no sloughs.
(2) Full thickness wound without exposed exposed bony areas, tendon,or slough should be classified as :
( A)Stage 11.
(B) Unstagable.
(C)Stage 1V.
(D)Stage 111
Correct answer D.
(3)What is most important factors in delayed of chronic wound healing is known as:
(A)Prolonged inflammation.
(B)High mitogenic activity.
(C) Face mask.
(D) All of the above.
Correct Answer A.
(4)The most common method of wound measurement includes
(A)Linear measurements.
(B) Fluid distribution.
(C) Surface Tracing.
( D)All of the above.
Correct Answer:A.
(5) What is pressure ulcer ?.
(A )Pressure ulcer is defined as a localized injury to the skin or underlying tissue usually are found over a bony prominence due to pressure .It can also be a combination of pressure and shear.
(B )All wounds are pressure ulcer.
(C )It is blanchable and nonblanchable.
(D )All of the above.
Correct answer A.
(6)What are the stages of pressure ulcer?.
(A)There are two stages of pressure ulcer.Stage 11 and stage IV.
(B )There are four stage Stage1,stage11,(partial thickness) stage111(Full thickness)stage IV (Full thickness tissue loss with exposed bone tendons and muscle),Unstagable, Suspected (Deep is unknown)Deep tissue injury.
C Depth unknown and full thickness.
D All of the above.
Correct answer B.
(7) Arterial insufficiency. What is it?.Who are more vulnerable?.
(8) Give examples of diabetic neuropathy.
(9) What is Venous insufficiency?.
(10)The major function of neutrophils in the wound is to:
(A) Destroy bacteria by the process of phagocytosis.
( B) No function.
(C) Manufacture of white blood cells.
( D)A and C.
Correct answer : A.
(11) Bedridden patient position should be changed. While in bed – – – and while in in a wheelchair – ——-.
(12) When do we remove foot pump or SCD?.
(A)Whenever a patient ask for its removal.
(B)The patient does not need it.
(C)As needed.
(D)During the patient’s initial skin assessment in your shift.
Correct answer D.
Plan for Skin integrity.
Wound care dressing, using the right type of dressing on the right wound. Wound care Consultation done.
Documentation. Accurate documentation of wound care wound location in the body, color,etiology of the wound.
Drainage Care.
Jackson pratt,
Hemovac,
T tube,
biliary drainage system,
and wound vac system.
Reposition of patient frequently for comfort and pressure redistribution every two hours while in bed and every one hour while in the wheelchair.
Nutrition consult, increase in protein intake unless it is contraindicated.
Hydration intravenously or by po.
Special Equipments to help manage care for the patient with the wound for example assistive devices such Accu care mattress.
Pain management.
Keep patient comfortable. Medicate as ordered by the doctor.
Assessment for signs and symptoms of infection. Checking for wound color, edema, temperature and wound drainage.
The goal is to possibly return wound to the baseline skin integrity .
QUESTIONS AND ANSWERS ON BURNS.
Mrs Maggy Cuban 59years female is brought to the hospital after she sustains burns when her oven blew up on her face.Her burns had second and third degree covering her face,neck,upper chest,upper arms,forearms and hands.So she is admitted to the burn unit.
Nurses You Move Me 