Sherpath 48: Skin Integrity and Wound Care

Question 1

what is essential to skin assessments?

Answer 1

Establishing a baseline skin assessment is essential because skin assessments are conducted regularly

Question 2

IPPA: what is used on skin?

Answer 2

-inspection and palpation
-Auscultation is not performed on a skin assessment, and percussion is rarely performed by the nurse

Question 3

if the patient develops pressure injuries while at the facility, as a pressure injury is considered a

Answer 3

“never” event

Question 4

Braden Scale

Answer 4

-The Braden Scale ranks a patient’s risk for the following: sensory perception, moisture, activity, mobility, nutrition, friction, and shear.

A lower score indicates higher risk:
19–23, no risk
15–18, mild risk
13–14, moderate risk
10–12, high risk
9 or below, severe risk

If the patient scores particularly low in one or more categories, preventive strategies can be directed more precisely at those specific areas to decrease overall risk

Question 5

Norton Scale

Answer 5

-The Norton Scale ranks risk based on the following parameters: patient’s physical condition, mental state, activity, mobility, and continence.

A lower score indicates higher risk:
16–20, low risk
11–15, moderate risk
10 or below, high risk

Understanding definitions of different categories is essential for arriving at a risk score that is reflective of actual risk

Question 6

wound assessment includes

Answer 6

-Close inspection of the wound to determine possible etiology of the wound, unless it is already known (e.g., surgical incision)
-Thorough patient history (e.g., incident that produced the wound)
-Head-to-toe physical examination (e.g., for the presence of other wounds/lesions)
-Focused wound assessment: see the table for more information

Question 7

what to look for when assessing

Answer 7

-location
-size
-presence of undermining or tunneling
-drainage
-wound edges and surrounding tissues
-wound bed
-patient response

Question 8

why is measuring the wound important?

Answer 8

Measurement of wound size is an important nursing assessment because wound size changes over time and indicates healing or negative progression

Question 9

steps involved in wound measurements

Answer 9

dimensions: At the widest open wound area, measure width laterally from the left to right sides.
From the top to the bottom, or head to toe, or at the widest open area of the wound, measure length vertically.

depth: deepest. part of wound

undermining: depth of edges of wound. At the widest undermining gapping section, laterally insert applicator tip as far as possible (do not force; go slowly)

documentation

Question 10

Pressure Ulcer Scale for Healing (PUSH)

Answer 10

assigns a numerical score to pressure injuries according to three characteristics:
-Surface area of the wound
-Wound exudate
-Type of wound tissue

-Pressure
-Ulcer
-Scale for
-Healing

Question 11

differences and causes between pressure injuries vs wounds

Answer 11

-pressure injuries: Damage to the skin from pressure produces pressure injuries
-causes: Tissue ischemia leads to decreased perfusion, which leads to decreases in oxygen and nutrients, which cause the skin to break down

-wounds: Wounds are disruptions in the skin’s surface; they interfere with the skin’s normal functions
-causes: Injuries, surgeries, burns, accidents, trauma, and cancer can lead to open and closed wounds.

Question 12

stages of pressure ulcers

Answer 12

Stage 1: intact skin with nonblanchable erythema

Stage 2: exposed dermis from loss of partial-thickness tissue

Stage 3: loss of full-thickness skin but no loss of underlying tissue

Stage 4: full-thickness skin loss with exposed muscle, bone, tendons, and/or cartilage (includes loss of tissue)