Skin Integrity Case Study
In addition to measuring the length of time the redness lasts, which assessment measure should the nurse perform?
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.
How will the nurse document this finding?
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.
Which areas are most important for the nurse to observe for additional pressure ulcers?
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.
What action should the nurse implement?
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.
What etiology should the nurse identify?
Since Aaron is paraplegic, he has impaired physical mobility, a major factor that contributes to pressure ulcer development.
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Which goal will the nurse include in Aaron’s plan of care?
A goal should be a broad statement that includes, in positive terminology, the intended effect of the planned interventions.
To provide pressure relief at night, the nurse teaches Aaron to sleep in which 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.
These cushions help redistribute weight so that it is not all on the ischium. The client should also be instructed to shift weight frequently.
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.
Which documentation best describes the drainage from Aaron’s wound?
Purulent refers to something that contains or produces pus. Pus is an indication that an infection is likely.
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.
What action should the nurse take?
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.
Which protective equipment will the nurse use when providing the prescribed wound care?
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.
What equipment will the nurse use to assess the length of the tract?
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.
Which irrigation technique is best?
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.
What is the purpose of this type of dressing?
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.
How many ml of medication will the nurse administer?
600 mg/100 mg × 5 ml = 30 ml.
What is the total daily dosage that Aaron will be receiving?
600 mg × 2 daily doses (q 12 hours) = 1200 mg/24 hours.
Who is the best member of the interdisciplinary team for the nurse to collaborate with to resolve this discrepancy?
Incorrectly labeled medications are the responsibility of the pharmacist.
Which technique should the nurse use to mix the linezolid (ZYVOX)?
This method mixes the suspension according to manufacturer’s specifications. Linezolid (ZYVOX) should never be shaken.
To safely measure the prescribed dose, the medication cup must be on a flat surface at eye level.
The nurse explains to Aaron that this precaution reduces the risk for what potential problem?
An anaphylactic reaction is a severe allergic response that can be life-threatening.
Which class of medication should the nurse expect to administer?
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.
Which diagnostic test should the nurse request a prescription for to determine if Aaron is developing drug toxicity?
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.
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?
Using therapeutic communication techniques, the nurse can provide the opportunity for Aaron to deal with his concerns.
How should the nurse respond to Aaron’s statement?
This response acknowledges the client’s experience and encourages further insight and verbalization by the client.
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.
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 nurse encourages him to select which breakfast items to provide a good source of protein?
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.
What teaching should the nurse provide?
The healing ulcer continues to need the protection and moist environment provided by a hydrocolloid (Duoderm-type) dressing.