305 Wound Care Case Studies

Front 1

When caring for a pressure ulcer, the nurse should document specific information. What information should be documented?

Back 1

Documentation includes: risk assessment, inspection of wound during the dressing changes such as the presence of pain, appearance, size, drainage, swelling, and status of drains or tubes.

Front 2

Several clients have pressure ulcers over bony prominences. What are some risk factors that contribute to the development of pressure ulcers?

Back 2

Immobility, incontinence, nutrition, and level of consciousness

Front 3

While providing instructions to the family of one of the clients being discharged from the facility, the nurse reviews ways to reduce the formation of pressure ulcers. What should these instructions include?

Back 3

Discuss adequate nutrition and hydration, wound assessment and mechanisms to document findings, establish a turning and repositioning schedule, demonstrate application of appropriate skin protection agents and devices, identify potential sources of skin trauma and means of avoidance.

Front 4

The nurse is going to be applying a binder to one client. What are the purposes of using a binder?

Back 4

The purpose of a binder is to support large areas of the body, such as abdomen, arm, or chest.

Front 5

Which of the following actions would place a client at the greatest risk for a shearing force injury to the skin?

Back 5

Sitting in Fowler's position