Chapter 54 Nursing Care of Patients with Skin Disorders

Answers CHAPTER 54 NURSING CARE OF PATIENTS WITH SKIN DISORDERS AUDIO CASE STUDY Mr. Fletcher’s Pressure Injuries 1. Mr. Fletcher is very thin, immobile, is at risk for friction and sheer, and has poor circulation due to smoking history. 2. Stage 1: The skin is still intact, but the area is red and does not blanch when pressed. There also may be warmth, hardness, and discoloration of the skin. A stage 1 ulcer may be difficult to detect in a dark-skinned person. Stage 2: There is a break in the skin, with partial-thickness skin loss of epidermis, dermis, or both. The pressure injury may appear as an abrasion, a shallow crater, or a blister. Stage 2 pressure injuries do not contain slough (yellow fibrous tissue). Stage 3: There is full-thickness skin loss, which extends to the subcutaneous fat but not fascia. The pressure injury looks like a deep crater and may have undermining of adjacent tissue. Bone, tendon, and muscle are not visible. Stage 4: There is full-thickness skin loss with exposed muscle, bone, or support structures such as tendons. Slough or eschar may be present. There may be undermining and sinus tracts (tunneling). 3. Patrick turned and repositioned Mr. Fletcher, provided meticulous wound care, was vigilant about looking for new signs of pressure, encouraged good nutrition, and advised Mr. Fletcher to shift his weight every 15 minutes. VOCABULARY 1. (12) 2. (11) 3. (10) 4. (9) 5. (8) 6. (7) 7. (6) 8. (5) 9. (4) 10. (3) 11. (2) 12. (1) BENIGN SKIN LESIONS 1. (3) 2. (5) 3. (4) 4. (6) 5. (1) 6. (2) PLASTIC SURGERY PROCEDURES 1. rhinoplasty 2. face-lift 3. blepharoplasty CRITICAL THINKING 1. Left-sided paralysis; immobility; bedrest; confusion; nothing by mouth and lack of adequate nutrients being provided to maintain healthy tissue; diaphoresis causing skin excoriation and breakdown; and thin build, which provides less padding and greater pressure on blood vessels, resulting in ischemia and tissue necrosis. 2. Risk for Impaired Skin Integrity: Assess skin every 4 hours; keep linens and clothing clean and dry; place on turning schedule every 1 to 2 hours; keep skin dry; avoid massaging reddened or bony areas. Consider a pressure-relieving device or mattress for his bed. Impaired Mobility: Place on turning schedule every 1 to 2 hours; perform active or passive range-of-motion exercises; encourage patient to participate in activities of daily living. Imbalanced Nutrition: Less Than Body Requirements: Assess patient’s daily fluid, caloric, and nutrient needs; consult dietitian; request referral to speech therapist for swallowing studies; provide fluids and nutrition as ordered (tube feedings, parenteral nutrition). CRITICAL THINKING 1. Diabetes, immobility, pressure, hypotensive period that resulted in ischemia; poor initial circulation indicated by need for femoral-popliteal bypass. 2. Sacrum: stage 2; heel: deep tissue injury. 3. Turning every 2 hours relieves pressure, but this is not frequent enough to prevent ischemia in the high-risk patient because ischemia begins to develop in 20 minutes. Elevation of the right foot relieves pressure and is very helpful. A pressure-reducing mattress can help relieve or reduce pressure. Nursing staff can implement more 1 2 Chapter 54 Answers frequent turns without an order and initiate a care plan for the nursing diagnosis of Impaired Skin Integrity. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (3) is correct. Shear can result from pulling a patient up in bed, leading to tissue injury and a pressure injury. (1, 2, 4) help prevent pressure injuries. 2. (1) is correct. A nonocclusive dressing is typically used on an infected wound. (2, 3, 4) are occlusive dressings. REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 3. (1, 4, 5) are correct. Patting the skin dry prevents injury to skin. Short nails and gloves prevent scratching. (2, 3, 6) are incorrect. If the patient is confused, medications should not be left at the bedside. A transparent dressing is generally not recommended for a rash. Wrist restraints are not indicated. 4. (2) is correct. Serosanguineous describes light red (blood-tinged) drainage. (1, 4) are incorrect. There is no indication of infection or pus. (3) is incorrect. There is not a large amount. 5. (2) is correct. Because the wound is not infected, gentle flushing produced by a needleless syringe is desired. (1, 4) are pressure flushing techniques for infected wounds. (3) will cause further tissue damage. 6. (1) is correct. This describes basal cell carcinoma and should be reported immediately. (2, 3, 4) are incorrect. Any care of the lesion should be ordered by the health care provider. 7. (2, 1, 4, 3) is the correct order. 8. (1) is correct. A fungal infection has most likely developed due to the use of the antibiotics. (2, 3, 4) do not fit the description. 9. (4) is correct. Pressure-relieving surfaces should be used in patients who are very high risk (9 or below on the Braden Scale) with intractable pain, pain exacerbated by turning, or other risk factors.