Proper documentation regarding the assessment of a pressure ulcer ...

[Cooldude101]

Proper documentation regarding the assessment of a pressure ulcer must include which of the following information concerning the wound? (Select all the apply.)
 
  1. Presence of pain
  2. Depth of damage
  3. Length and width
  4. Presence of drainage
  5. Description of drainage
  6. Condition of surrounding tissue

Question 2

Which of the following statements best reflects the nurse's role in the health and maintenance of a client's skin? (Select all that apply.)
 
  1. I'll note on the client's care plan to apply lotion to her dry elbows.
  2. I'm on my way in to turn the client. Will you be able to help me?
  3. The ancillary staff tells me that her skin is generally very dry.
  4. The pressure ulcer on her hip has really gotten smaller.
  5. Can you bring in some scented lotion for your mom?
  6. A 1.5-cm reddened area noted on client's left heel.

[gabrielle_lawrence]

Answer to Question 1

ANS: 2, 3, 4, 5, 6
Assessment includes depth of tissue involvement (staging), type and approximate percentage of tissue in wound bed, wound dimensions, exudate description, and condition of surrounding skin. Presence of pain is not a component of this charting.

Answer to Question 2

ANS: 1, 2, 4, 6
One of the nurse's most important responsibilities is to monitor skin integrity and to plan, imple-ment, and assess interventions to maintain skin integrity. The remaining options do not reflect nursing interventionsone reflects ancillary staff, and the other does not really mention the therapeutic role of the request.