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Chapter 22

The document discusses skin care and prevention of wounds, emphasizing the importance of maintaining skin cleanliness and dryness to prevent pressure injuries. It outlines various strategies for preventing skin tears and highlights the significance of proper wound management, including the use of appropriate dressings and monitoring for signs of infection. Additionally, it provides guidance on handling clients with wounds, including the use of pain management and safe practices during care.

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chenjingyu1
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5 views10 pages

Chapter 22

The document discusses skin care and prevention of wounds, emphasizing the importance of maintaining skin cleanliness and dryness to prevent pressure injuries. It outlines various strategies for preventing skin tears and highlights the significance of proper wound management, including the use of appropriate dressings and monitoring for signs of infection. Additionally, it provides guidance on handling clients with wounds, including the use of pain management and safe practices during care.

Uploaded by

chenjingyu1
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF or read online on Scribd
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TL *Z sey a bs YaldVHD “Surssoxp appioisuow a8ueqp 01 uiBoq nok a10j0q papas aueurdinbo ype yoo nok ams ae AL Buyous auaaaid o1 a3ed Apoq aunua arp appa Pmoys ades aatsoupe ‘poydde wayyy XL -suouy 394 wo Burg 100 are Aowp amnsup 03 auoUTATOOUy ase wpa stuorp spaup Apuanboy asm nok ‘soumfuy amssosd quod OL dL ‘Aysnoro8ys qn -moy Arona 3y8}9m sPaTp YRYs 02 popuywsay 9q Pinoys sreyp e uy Suns s1usyT) Ag ‘Besseur yorq e BuIA wy, AL Ep ap Surdsp 10 Suryreq wy, AL" a 1 -asgnf anf apauza 20 ones 4af J, 22429 astv4 yO ANdL spunom jo UOMUSAAd PUL a1eD UPS 10 15. 16. 17. 18. 20. a1. CHAPTER 22 1 F In obese clients, pressure injuries can develop where skin surfaces press against each other, causing a decrease in blood flow. Heel protectors reduce pressure on the heels by lowering them. AA flotation pad or cushion is placed in a pillowcase so the pad does not touch the skin, You should check with the nurse before using soap on a client who is at risk for pressure injuries because soap can moisturize the skin. Skin should be kept clean and dry and free of moisture from urine, stool, perspiration, and wound drainage. ‘When very small amounts of drainage are expected, a drain is applied to enable the drainage to Teave the wound. Scabs and scars are complications of wound healing that are surgical emergencies. Skin Care and Prevention of Wounds MU! LTIPLE RESPONSE From the list below choose all of the correct answers. 22. 23. Strategies for preventing skin tears include: ‘Ac Keeping the skin dry and avoiding all moisturizers or skin softeners Offering fluids Dressing and undressing the client carefully Dressing the client in soft clothing with long sleeves and long pants Keeping your fingernails short and smoothly filed Keeping the client's fingernails short and smoothly filed ‘Not wearing rings with raised or large stones Following safety guidelines when lifting and transferring clients Preventing friction and shearing during lifting, moving, transferring, and repositioning (e.g., using a transfer sheet or pad) ‘Avoiding the use of pillows to support arms and legs Being patient and calm when the client resists care Padding bed tails and wheelchair arms, footrests, and leg supports |. Providing good lighting to help prevent the client from bumping into furniture or walls 9 OF ad = K. Le M. ‘What are common causes of skin breakdown and pressure injuries? Pressure Age Friction / Shearing Ware Copyright © 2022 Elsevier Inc. llrightsreserved admonseig “g ade dey -y suonotor orSioype asne rou op adeajo soda rey, “Eg -Buysoup 2up Jo oppprer amp ssoroe aden anisoype jo 20014 2u0 298] “D -Suyssoup oyp Jo apis ypra puoaq sonoumpuzo feraaos ade amp pussy “ef “Bujssoup oqp Jo won0q pure ‘oppprar ‘don arp on aden Addy oy" Supssarp vamnoas 01 paydde aq aden pmnoys Mo] “ze -Suppaayg jonuos dipy sSuyssoup amssoud ‘wioiqoad v st Sumpooyq u3y A Suypeay punom Jo} usuTMONAUD Is}our ¥ aprAoud A>, “spunoa Ajryfisun 19400 A>uy, “wea puniom axp dooy 44, “uoyutos arowrord Aoyy, -anssn peap aaouras Aa. -sSeuresp quosqe ayy, ‘sagonoqut pue Amnfuy wo spunom xoaord Aayy, aUAnnU < sBuissoxp punom jo suonouny aqp a7e et), sown 3e Aypa} Sum98 punow ayp jo pourejduos sey warp 2mp J ado uayorq sey punom aqp jt 10 2ppau puie a2e, 304 sure odd) sB9] 1aMOT 2add to4e S199 N sNOUDA Joy saa1s UOUTUFOD voxe pauappas “uneasy Ups ea amssaud pooyg ur aseaiour uy amesaduraa Apoq 1 dosp & pue Sunaaryg ada Vv :apnpsuy parrodar aq pjnoys azoyazatp 2e4p pur Suruuioq st Aanfuy amnssard v rexp suBig porespy yjam auaypp axp daay oy, sooppIMS UNs UDDAKIIg ‘uono1y pur aimasious 2onpar oy, Ups (piss peo. Wy Suppq Woy UpPAs yudAard OF, 3. a sounfuy amsssud qusaaad 03 pasn sioxury pure saroppid axe Au unp Aran 10 asoqo ary sofunod ary, swigigord Azorejnon> ancy ainssoud 10 ured Susuas surajqord aarp ssouareave [ELUDU Pa1Oy]e SALE] ‘uopuanu poo8 or sey 2aeyy Jonuod sappEyq 10 amog Jo sso] 2AeFy Suysou uy dipq 212{du109 01 arerapour arnboyy _eqp 30 poq ¥ 03 pouyuos ary OCRH GTS a ty soy asoup are saymfuy amssord 10 ys 3 UDI) “¢z pag uy quay ayp wma pue ‘aout 0 (a90ys 10) ped Supuama v 257) soaiBap o¢ wey ‘40ur poq atp Jo peay xp Supsyes 1919} saaoys wromog 2qp 01 Jopatod jo rae] untp v Sukyddy sompapord Supsnaystres) pur ujuonysod ‘Sunyy sadord Busy) ‘a °O a ¥ 4 id 19% :Aq wonony pue Supeoys wusasid we> noK “pz 12 34. If: CHAPTER 22. Skin Care and Prevention of Wounds ‘a client has a draining wound, you can help improve the client’s appetite by: ‘A. Covering the wound with an airtight 9 OF me dressing Using room deodorizers as directed Keeping drainage containers out of the client’ sight Offering foods that are strongly scented to mask any odour of wound drainage Removing soiled dressings promptly from the room 35. How should you remove tape and old dressings from a wound? A B. a Hold the skin down and gently pull the tape toward the wound. Remove adhesive from the skin. Lift the dressing very gently, and keep the soiled side of the dressing out of the lent’ sight. Pull the dressing off as quickly as you can. 36. You can assist a client with a wound by: A. Allowing pain medications to take effect B. before giving care Ensuring the client stays on complete bed rest until the wound is fully healed C. Carefully observing the wound and reporting any signs or symptoms of infection immediately D. Implementing Standard Practices during all client care MULTIPLE CHOICE Circle the correct answer. 37. Which of the following is a cause of skin breakdown? A. B. ey D. Good nutrition and hydration Decreased mobility Increased circulation A regular exercise program 38, 39. 40. a1. 42. ‘Which of the following practices are intended to prevent skin tears in clients? A. Taking daily baths B. Keeping your fingernails short and smoothly filed CC. Wearing jewellery with large stones D. Wearing a clean uniform daily “To prevent pressure injuries, the health car team may place the client on a surface suc! as: A. A firm mattress By A foam, air, alternating air, or gel mattress C. Plastic or rubber material D. Abed board Which of the following measures is helpfi in preventing pressure injuries? Position the client at a 45-degree ang B. Reposition the client every 6 hours. CC. Massage around bony and reddened areas. D. Keep the client’ heels on the bed. ‘Which of the following measures would h to prevent venous ulcers? ‘A. Making sure the client's clothing fits tightly By Having the client wear elastic stocki as ordered by the doctor CC. Massaging any reddened area over pressure points D. Having the client trim his own toen weekly ‘Why may pain medication be given befor pening change? "T reduce discomfore during che dressing change B. To prevent the client from looking the wound C.. To prevent the client from seeing yc nonverbal responses D. To prevent contamination of the we ‘Copyright © 2022 Elsevier In. All sights “pansosa suf iy Su s949sy zz02 @ 3BUKdo> woqyd dn ynoo on awayp arp Suydpy pur Sunprarq daop Suidemooug pm 3ui4ap pur Susu “deos pus yas soouourwuord Auog SUTysE, soppred poo 30y nour ay Supsodsur pure ‘Kpuss Buissoy ‘ypoen sauarp arp Surysng so1oqetp sey 1usIp ay {gy sjreuon sauoyp aqp Suyururyn sox ‘d Vv jeame xdo009 SaUDIp axp Ur sopmnfur aumssord auagand 01 popuarur sj 2onze1d yr AA ses pur y surety“ punom aya jo uoneiojoos1p Supuanag “q snroydsoyd pue umisseiog “ yp anssn ‘2D wurena pure uoig “gf go woneua84x0 soneq Suemoouy “3D vor pur ump -y Aap pue ura upjs sauatp axp Suidooy - “g gsquounNU osN YpRysA Jo aso suMbas | sud spunom 3ururesp pur porooyuy ym SIUEHS) “Zp ur sdeas Surssaxp punom ap Suunsug -y 24q Sueay punom soapswusyp wopisodas (01 anqunuos ues UOAEINquIE pue waTIAAC|y Pur aout o2 Afar] sso] axe Loy], “cr uopesrpour uv aBeqneS sauarp ayp wr pasr|q “Cd ured aumbor o1 Appyyy ssaj are ayy,“ ayBis sauayp axp woy Aeawe pousma auoddns jeuonours SI 9pIs pojios ayp 3etp os parourry “3 a10w asmbar pure arour 59 Ay, “gh Ind spmb e Ips 3UEp wpm Punos a1p wroy Ap parowry “ pue 19 01 Ajay arour aq Kew Aoyy, “Y aUaIp ap 02 UMoYS “y :asneoaq sopinfuy aunssoxd Surdopsasp :3q pnoys Joy 3st 1oneas8 ae ose ured UY are OYA SUE “gp 3y Buyssoup pjo we Sursouras aze nok way, ELT spunoy, Jo uonuanaig pue aie) urjs Zz Y3LdVHO “sy “bby “eb 114 CHAPTER 22 Skin Care and Prevention of Wounds MATCHING Match the type of wound with the correct description. 48. ‘Wound containing large amounts of bacteria 49, _1 Wound that does not heal easily 50. ___\__ Wound created for therapy 51. ‘Wound resulting from trauma 52. ‘Wound occurring from surgical entry of the urinary, reproductive, respiratory, or gastro-intestinal system 53. Wound that is not infected; microbes have not entered. wound 54, Wound in which dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved. 55. Wound with high risk of infection 56. ‘Wound in which tissues are injured, but the skin is not broken 57. ‘Wound in which skin or mucous membrane is broken 58. ‘Wound in which dermis and epidermis of the skin are broken Match the type of wound drainage with the correct description. 59. Thin, watery drainage that is blood tinged. 60, __ Thick green, yellow, or brown drainage 61. ___/_ Bloody drainage 62, Clear, watery fluid Match the stage of a pressure injury with the correct description. 63, feqroauoU JonUOD 01 yNyarED 9q NOK Pynoys AYA °9/ gpunoa & ut paoeyd uresp & Jo asodind ap staeyy “S/ sioreaayp [poy jo asodind axp si ey “bL SNV18 SHL NI T14 asoyd uopemeyy ~ “sose2iout punoas axp 01 Aqddns poolg —7- y me “O 1 punoas ayp oa Aiddns poorg, el aseyd oaperagyong -ajed pue utp sowronag Aqpenauaaa 1e98 ay], ———— * ey Hd“ fed pur Ur 4 Are LL ZL aseyd Aroreurueyuy -y -punom ayp apedas on Ajdnynus sypoo onset, We -quouatvs paus09 a1 que Suspveq punom fo asvqd og3 garry yosag “gd -poSeurep sj onssn pasodxa ayy, ——- “0 ea8as OD spren Moypeys & aq Avur ary], ——— “69, zaing a “pat sL UpySs 9qL,—— “29 Tams y “paSeurep pue pasodxa are suog pur spsnyy 7 °Z9 -uopsdhuosap 120.100 o41 gatos Kanfus ounssaud v fo vss oop quip SIT — spunoyajo uonuanaiy pur aren us zz YaLdVHO. cee, 116 CHAPTER 22 Skin Care and Prevention of Wounds LABELLING 81. Place an X on four areas where pressure injuries may form on a person in the sitting position. 78, Place an X on six areas where pressure injuries may form on a person lying in the lateral position. 79. Place an X on six areas where pressure injuries may form on a person lying in the prone position. 80, Place an X on three areas where pressure injuries may form on a person lying in the Fowler's position. Copyright © 2022 Eksevier Inc. llrightsreserved. “pansesai nyu y Du pasG Z202 @ WUAdoD ‘suo qpeo ur aBeurep anssp otp 2quDs9C] “pro soar109 aq uy oquinu a8e1s yoeo apysoq 1on2] axp Supa Aq soxmfuy amssard jo saBus yp Apaup] “Z9 ZIT spunomjo uonuanaiy pue ase uns zz Y3LdWHD CROSSWORD PUZZLE 118 CHAPTER 22 _ Skin Care and Prevention of Wounds 3 fF 7) Ost | r . f T al ie 10 1 WW I [| = l =| ie fis ) fia fs jie O i Across Down 5. Pressure injury, bedsore (2 words) ‘1. Open wound with tom tissues and jagged edges 7. Thick green, yellow, or brown discharge 2. Pattial-thickness wound caused by scraping away or rubbing of the skin Clear, watery dra 8 ee 3. Open wound caused by poor blood return to 9. Disorder that results when there is not the heart from the legs and feet (2 words) enough blood supply to organs and tissues 4, Excessive loss of blood in a short period of time 11. Disorder in which there is death of tissue 5. Separation of wound layers 13. Thin, blood-tinged, watery drainage 6. Break in the skin or mucous membranes 14, Accident or violent act that injures the skin, 10+ Closed wound caused by blow to the body mucous membranes, bones, and internal 12, Open wound with clean, straight edgess organs usually intentionally produced with a sharp instrument 16. Separation of wound along with protrusion of abdominal organs 13. Break or rip in skin that separates the epidermis from the underlying tissues (2 words) 15. Collection ofblood under the skin and tissues Copyright © 2022 Elsevier Inc. Al rights reserved.

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