Skin Integrity Case Study

The nurse observes that the reddish area is round, 3 cm in diameter, and is directly over the client’s sacrum. The skin is intact.

In addition to measuring the length of time the redness lasts, which assessment measure should the nurse perform?

Apply light pressure to the area with the fingertips.

The nurse applies light pressure with the fingertips to assess for blanching. This is a normal response in light-skinned clients, which indicates there is no tissue perfusion impairment.

The sacral area has remained red for two hours and does not blanch when tested.

How will the nurse document this finding?

Reactive hyperemia.

Reactive hyperemia occurs when tissue is relieved of pressure. It is considered abnormal when the redness lasts longer than one hour and the surrounding tissue does not blanch.

The nurse identifies that Aaron has developed a Stage 1 pressure ulcer. The nurse is concerned that Aaron may have other pressure ulcers.

Which areas are most important for the nurse to observe for additional pressure ulcers?

Heels and ankles.

Pressure ulcers typically occur over bony prominences, such as the heels, ankles, and sacral area. While bony prominences are the most common sites for pressure ulcer development, the nurse should perform a complete skin assessment.

During the assessment of these high-risk areas, the nurse finds no redness, but the underlying tissue feels spongy.

What action should the nurse implement?

Identify these areas as sites where pressure damage has occurred.

Palpable changes in the consistency of the tissue underlying a bony prominence, often described as “spongy” or “beefy” are an indication that pressure damage has occurred. Additional manifestations may include a change in skin temperature and induration.

The nurse identifies a priority problem for Aaron’s plan of care as “Impaired skin integrity.”

What etiology should the nurse identify?

Impaired physical mobility.

Since Aaron is paraplegic, he has impaired physical mobility, a major factor that contributes to pressure ulcer development.

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After establishing the priority diagnosis, the nurse identifies goals and expected outcomes.

Which goal will the nurse include in Aaron’s plan of care?

Client’s skin will remain intact.

A goal should be a broad statement that includes, in positive terminology, the intended effect of the planned interventions.

At the end of the appointment, the nurse provides client teaching about measures to promote healing and prevent further tissue destruction.

To provide pressure relief at night, the nurse teaches Aaron to sleep in which position?

Thirty-degree lateral inclined position.

This position best reduces pressure on bony prominences where pressure ulcers frequently develop. Pillows and foam wedges may be used for support and protection in this position.

Upon learning that Aaron has a pressure-reducing gel chair cushion for his wheelchair, which action should the nurse take?
Encourage him to continue to use this device in his wheelchair at all times.

These cushions help redistribute weight so that it is not all on the ischium. The client should also be instructed to shift weight frequently.

The nurse teaches Aaron to apply a transparent film dressing over the sacral area and advises him to follow which schedule for dressing changes?
Once weekly.

As long as the occlusive seal remains intact, a transparent film dressing may be left in place up to one week. A transparent film dressing allows visualization of the site and helps protect it from shearing force.

A month later, Aaron comes to the emergency room at the local hospital. He reports that he has had the flu and has spent most of his time in bed for the last several days. He has been experiencing vomiting and diarrhea. The nurse observes that the sacral ulcer is open, has a crater-like appearance, and is draining a large amount of thick yellow-tan fluid with an unpleasant odor. A small amount of eschar is present. Aaron is admitted to the hospital with a fever, fluid volume deficit, and possible sepsis.

Which documentation best describes the drainage from Aaron’s wound?

Purulent.

Purulent refers to something that contains or produces pus. Pus is an indication that an infection is likely.

Which intervention is important to reduce the effect of the diarrhea on Aaron’s skin?
Apply a moisture-repellent ointment to intact skin areas.

After cleaning and drying the skin, a moisture-repellent ointment should be applied to protect and moisturize the skin. Fecal toxins are damaging to tissue, and excessive moisture causes skin maceration and damage.

The nurse prepares a written positioning schedule and places it in Aaron’s room as a reminder for the unlicensed assistive personnel (UAP) assigned to help with Aaron’s care. The charge nurse removes the schedule and states that it violates Aaron’s privacy.

What action should the nurse take?

Assure the charge nurse that written instructions in the client’s room are effective and do not violate any client rights.

A written, individualized schedule is the most effective method to ensure consistent positioning and may be placed in the client’s room without compromising client confidentiality.

A wound culture indicates that Aaron’s wound is infected with methicillin-resistant Staphylococcus aureus (MRSA). Wound care prescribed by the healthcare provider includes wound irrigation.

Which protective equipment will the nurse use when providing the prescribed wound care?

Gloves, gown, goggles, and face mask.

When there is potential for wound drainage and debris to splatter during the irrigation, the nurse should be fully protected. The mode of transmission of MRSA includes direct contact, as well as contact with infected surfaces.

The nurse suspects that Aaron’s wound has developed a sinus tract, or tunneling.

What equipment will the nurse use to assess the length of the tract?

Sterile cotton-tipped applicator.

A sinus tract is an extension of the wound under the skin, and it is best assessed by gentle insertion of a sterile cotton-tipped applicator to determine the location and length of the tunneling.

After assessing for sinus tracts, the nurse irrigates the wound as prescribed with normal saline.

Which irrigation technique is best?

Apply steady pressure using a 35-ml syringe and 19-gauge needle.

Using a 35-ml syringe and 19-gauge needle provides 8 PSI, which applies adequate pressure to ensure effective irrigation. Safe, effective pressure is between 4 and 15 pounds per square inch (PSI). More than 15 PSI will drive bacteria into the wound and destroy healthy tissue.

Following wound irrigation, the nurse plans to apply a wet-to-dry dressing.

What is the purpose of this type of dressing?

Mechanically debride the tissue.

Moistened gauze is placed on the wound and allowed to dry. It then adheres to the wound tissue and debrides necrotic or infected tissue as it is removed.

The nurse plans to administer a prescribed dose of linezolid (ZYVOX), an antibiotic, which interferes with the production of proteins that bacteria need to multiply and divide. The prescription states, “ZYVOX suspension 600 mg PO q12h for 14 days.” The medication is labeled, “100 mg/5 ml.”

How many ml of medication will the nurse administer?

30 ml.

600 mg/100 mg × 5 ml = 30 ml.

The nurse reviews the drug reference guide, which indicates that the recommended daily dosage for the medication is 800 to 1200 mg.

What is the total daily dosage that Aaron will be receiving?

1200 mg.

600 mg × 2 daily doses (q 12 hours) = 1200 mg/24 hours.

Before pouring the suspension, the nurse determines that the medication and dose on the bottle’s label are correct as prescribed, but the client name listed on the bottle is incorrect.

Who is the best member of the interdisciplinary team for the nurse to collaborate with to resolve this discrepancy?

Pharmacist.

Incorrectly labeled medications are the responsibility of the pharmacist.

When the medication bottle is properly relabeled, the nurse mixes the suspension prior to pouring it.

Which technique should the nurse use to mix the linezolid (ZYVOX)?

Turn the bottle upside down 3 to 5 times.

This method mixes the suspension according to manufacturer’s specifications. Linezolid (ZYVOX) should never be shaken.

The nurse correctly uses which technique when pouring the suspension?
Place the medication cup on a flat surface at eye level.

To safely measure the prescribed dose, the medication cup must be on a flat surface at eye level.

Prior to administering the first dose of the antibiotic, the nurse asks Aaron about any drug allergies.

The nurse explains to Aaron that this precaution reduces the risk for what potential problem?

Anaphylactic reaction.

An anaphylactic reaction is a severe allergic response that can be life-threatening.

After receiving the first dose of Zyvox, Aaron develops a rash and itching on his thorax, but no respiratory symptoms.

Which class of medication should the nurse expect to administer?

An antihistamine, such as diphenhydramine (Benadryl).

An antihistamine should control the itching and rash of this reaction. Rash and itching are identified side effects of linezolid (ZYVOX). The nurse should, however, continue to monitor for a more severe allergic response.

Aaron has been receiving antibiotic therapy for several days. He has a mild elevation in blood pressure and a 2 × 2 cm bruise in the antecubital space, where blood was obtained earlier that day, and has had two diarrheal stools in 4 hours. The nurse is concerned that he is exhibiting signs of hepatoxicity related to antibiotic use.

Which diagnostic test should the nurse request a prescription for to determine if Aaron is developing drug toxicity?

Peak and trough.

Serum drug levels are obtained at the highest (peak) and lowest (trough) levels, which provides useful information regarding the amount of drug the individual client has in the bloodstream. If the trough is greater than the acceptable limit for the drug, the next dose should be withheld and the blood level rechecked six hours later.

No evidence of drug toxicity is found. Aaron’s next B/P is within normal limits for him and he has no further episodes of diarrhea. The wound eschar has all been removed, and there is no further drainage. A hydrocolloid dressing is placed over the wound, and Aaron is discharged.

Aaron will complete the 2-week antibiotic treatment at home. The home care nurse visits Aaron a week after discharge to assess the wound. The nurse reviews symptoms of pressure ulcers with Aaron as well as when to call the healthcare provider. Aaron yells at the nurse and says, “I don’t need a nurse to tell me that I will spend the rest of my life in and out of hospitals!”

What initial action should the nurse take?

Offer Aaron the opportunity to discuss his feelings of anger and hopelessness.

Using therapeutic communication techniques, the nurse can provide the opportunity for Aaron to deal with his concerns.

Aaron states, “I’m sorry I yelled at you, but I’m so discouraged about this bed sore and the infection.”

How should the nurse respond to Aaron’s statement?

“You are trying to cope with a lot of concerns right now.”

This response acknowledges the client’s experience and encourages further insight and verbalization by the client.

Considering Aaron’s developmental stage, the nurse’s plan of care emphasizes interaction with which group?
Aaron’s girlfriend and his two best male friends from the college.

As a young adult, Aaron’s primary developmental task, according to the theorist Erikson, is to develop intimacy. The nurse should emphasize interaction with a small group of intimate friends to support this developmental task.

It is most important to include this group in which aspect of Aaron’s overall care?
Reviewing class notes and studying for exams.

The young adult is developmentally involved in establishing intimacy and working toward future goals. In addition, studying together will help maintain a sense of normalcy for Aaron. Other tasks can easily be performed by other groups, such as family members. This task can best be performed by his peers.

The home care nurse teaches Aaron about dietary measures to promote wound healing and emphasizes the need for extra protein.

The nurse encourages him to select which breakfast items to provide a good source of protein?

Eggs and orange juice.

Eggs are a good source of protein, iron, and zinc, which are all important for wound healing. Citrus juices, such as orange juice, are a good source of vitamin C, which is also important for wound healing.

The home care nurse observes that Aaron’s ulcer is red, with obvious granulation tissue filling in the ulcer crater.

What teaching should the nurse provide?

Hydrocolloid dressings should be continued over the ulcer.

The healing ulcer continues to need the protection and moist environment provided by a hydrocolloid (Duoderm-type) dressing.

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