pressure injury

The nurse is screening clients for those at risk for developing a pressure injury. At highest risk for developing a pressure injury is the client

• a. who had an open cholecystectomy and has a closed-wound drainage device

• b. who has a long leg cast and a decreased serum albumin level

• c. with dementia, peripheral artery disease, and constipation

• d. with quadriplegia, moist skin, and an elevated temperature

Answer explanation

Pressure injuries develop from external pressure compressing capillaries and underlying soft tissue, or from friction and shearing forces.  The nurse should assess every client's risk for pressure injuries using a standardized assessment tool (eg, Braden scale) on admission and at least once daily during hospitalization.

Risk factors for pressure injuries include immobility, impaired sensation (eg, quadriplegia), increased skin moisture, and fever (ie, elevated temperature) or infection.  This client has four risk factors and therefore is at highest risk for developing a pressure injury (Option 4).

(Option 1)  This client has one risk factor: major surgical procedure (eg, open cholecystectomy).  Lines and drains (eg, closed-wound drainage device) may place the client at risk for falls, not for pressure injuries.

(Option 2)  This client has two risk factors: an orthopedic device (eg, long leg cast) and nutritional deficit (eg, decreased serum albumin level).

(Option 3)  This client has two risk factors: cognitive impairment (eg, dementia) and impaired sensation (eg, peripheral vascular disease).  Incontinence, not constipation, is a risk factor for pressure injuries.

The supervising nurse watches a newly hired nurse take care of a client who is at risk of developing a pressure ulcer. Which of the following interventions by the newly hired nurse requires follow-up?

Select all that apply.

• a. Applies zinc oxide to the client’s perineal skin.

• b. Provides a donut pillow while the client is sitting in the chair.

• c. Maintain the head of the client’s bed at 90 degrees.

• d. Encourages the client to consume foods rich in carbohydrates.

• e. Uses a pillow to float the client’s heels.

Answer explanation

Choices B, C, and D are correct. If the newly hired nurse provides a donut pillow while the client is sitting in the chair, this will require follow-up because this pillow creates pressure and damages capillary beds. Maintaining the client’s position at 90 degrees would require follow-up because this contributes to the client sliding, therefore creating shearing. It is recommended that they be kept at 30 degrees (if not medically contraindicated). A diet rich in carbohydrates is unhelpful to a client at risk for a pressure ulcer. A diet dense in protein is recommended to maintain skin integrity and mitigate any edema.

Choices A and E are incorrect. Applying zinc oxide to the client's skin is recommended. This product is a common ingredient in topical creams because it repels moisture. Floating the client’s heels is essential as it helps with offloading pressure. This can be done using a device comprised of foam or a pillow.

The nurse is planning to perform a dressing change for a client with a stage three pressure ulcer. The nurse should initially perform which action? 

• A. Gather all the necessary equipment

• B. Use non-sterile gloves to remove the old dressing.

• C. Documenting the characteristics of the wound

• D. Administer prescribed oral pain medication

Answer explanation

Choice D is correct. Pain associated with pressure ulcers should be appropriately addressed, specifically with dressing changes. The nurse must provide adequate pain medications to the client before the dressing changes. Oral pain medication may take 45 minutes to provide relief. Therefore, the nurse should administer the medication initially because while gathering supplies and explaining the procedure, the medication will exert benefit.

Choice A is incorrect. While gathering necessary equipment is essential in preparing for a dressing change, it should not be the first action in this scenario. To perform the dressing change while maintaining client comfort, oral pain medication should be administered initially so that when the dressing change is being performed, it has time to exert its effect.

Choice B is incorrect. Using non-sterile gloves to remove the old dressing is not the first action that should be taken. The nurse's initial priority should be assessing and addressing the client's pain management to ensure comfort during the dressing change.

Choice C is incorrect. Documenting the dressing change and characteristics of the wound should occur after the dressing change has been completed.

A newly licensed registered nurse is tasked by a nurse educator to perform a wet-to-dry dressing change on a client with a stage 3 pressure ulcer. Which action would indicate to the nurse educator that the registered nurse is following proper technique?

• A. The registered nurse cleans the ulcer from the outside, rotating into the inside of the ulcer.

• B. The registered nurse packs the incision with sterile gauze, then pours sterile normal saline over the dressing.

• C. The registered nurse packs wet gauze into the ulcer without overlapping it onto the skin.

Answer explanation

Choice C is correct. The wet dressing should not touch the intact skin as this may cause skin breakdown and potentially introduce additional pathogens into the wound.

Choice A is incorrect. The registered nurse should clean in a circular motion, beginning from the inside and rotating outward. Once the nurse reaches the edge of the wound, the nurse should change gloves and equipment.

Choice B is incorrect. When a wet-to-dry dressing is ordered, dressings are to be soaked before application to the client's tissue. The dressing is then allowed to dry while on the client, therefore allowing the removal of that dressing to essentially debride a small portion (i.e., existing debris and necrotic tissue if applicable) of the wound before the replacement dressing is applied.

Choice D is incorrect. Saturating the existing dressing prior to removal would defeat the purpose of having the dressing removed dry. Dry removal allows debris and necrotic tissue to be removed with the dressing.

An intensive care unit nurse is caring for a client with left-sided heart failure experiencing pulmonary edema as a complication. The nurse identifies a nursing diagnosis of "impaired gas exchange related to ineffective breathing patterns." Which nursing intervention would be the lowest priority based on the nursing diagnosis?

• A. Administer oxygen and monitor for drying of the nasal mucus membranes.

• B. Place the client in a semi-Fowler's position.

• C. Provide a pressure-reducing mattress.

• D. Encourage the client to turn, deep breathe, cough, and use the incentive spirometer.

Answer explanation

Choice C is correct. Pressure-reduction mattresses and beds are available to decrease the pressure on the client's pressure points when the client is in bed. More specifically, these support surfaces are used to prevent (or treat) pressure ulcers by attempting to redistribute pressure beneath the skin of the client's body to increase blood flow to tissues and relieve skin and soft tissue distortion. However, implementing measures to ease the stress on the pressure points is the lowest priority when managing a client experiencing acute pulmonary edema.

Choice A is incorrect. One of the mainstays of treatment for clients with pulmonary edema is the administration of oxygen therapy to improve oxygenation and profusion of the tissues while helping to reduce the client's dyspnea. Typically, 100% oxygen is administered via a non-rebreather mask, although each case is evaluated on a case-by-case basis, and some health care providers (HCPs) have personal preferences. Continuous oxygen administration can dry the client's mucus membranes.

Choice B is incorrect. Here, the client's acute pulmonary edema is attributable to the client's left-sided heart failure, resulting in the need for intensive care. In pulmonary edema, pulmonary venous hypertension and alveolar flooding are present. Symptoms include severe dyspnea, diaphoresis, wheezing, and, for some clients, blood-tinged frothy sputum. The nursing diagnosis of "impaired gas exchange related to ineffective breathing patterns" reflects the client's severe dyspnea. Placing a client in a semi-Fowler's position often enhances tissue oxygenation by promoting diaphragm expansion and optimizing lung expansion to facilitate breathing, leading to improved gas exchange.

Choice D is incorrect. A nursing intervention that would be promoted would be to encourage the client to turn, deep breathe, cough, and use the incentive spirometer to help clear the client's airway and facilitate oxygen delivery.