Skin Integrity HESI Case Study

The nurse encourages the client to select which breakfast items to provide a good source of protein? O Whole wheat toast with butter. O Bagels and cream cheese. O Oatmeal and a banana. O Eggs and orange juice.

Eggs and orange juice. The home care nurse observes that the client's PI is red, with obvious granulation tissue filling in the wound crater.

In addition to measuring the length of time the redness lasts, which assessment measure(s) should the nurse perform? (Select all that apply. One, some, or all options may be correct.) O Apply light pressure to the area with the fingertips. O Measure the diameter of the redness. O Obtain a wound culture. O Gently lift a fold of skin. O Observe for wound approximation.

- Apply light pressure to the area with the fingertips. - Measure the diameter of the redness.

To reduce the effects of moisture on the client's skin, which intervention should be implemented? O Apply a moisture-repellent ointment to intact skin areas. O Rinse ulcerated areas with an alcohol-based irrigating solution. O Position a plastic-lined pad under the buttocks. O Apply moist heat to the area following exposure to feces.

Apply a moisture-repellent ointment to intact skin areas.

How many mL of medication will the nurse administer? (Enter numerical value only. If rounding is necessary, round to the whole number.) 5mL/100mg x 400mg/? = 2000/100 = 20

20 mL

Which irrigation technique is best? O Pour the saline directly onto the wound from the bottle. O Moisten a sterile gauze pad and pat the gauze over the wound. O Irrigate as gently as possible using a 60-mL bulb syringe. O Apply steady pressure using a 35 mL syringe and 19-gauge needle.

Apply steady pressure using a 35 mL syringe and 19-gauge needle. Following wound irrigation, the nurse plans to apply a wet-to-dry dressing.

What is the total daily dosage (in mg) that the client will be receiving? (Enter numerical value only. If rounding is necessary, round to the whole number.) 100mg/5mL x 20mL/12hr x 24hr/? = 48000/60 = 800mg/24hr

800

Meet the Client

A client with paraplegia as the result of a spinal cord injury received in a motorcycle accident lives at home with their parents who assist with care. The client is attending college and has a strong social support system. The client visits the health clinic on campus for a regularly scheduled skin assessment, where the nurse observes a reddish area on their sacrum.

Section 4 A Complication Occurs

A month later, the client arrives in the emergency department at the local hospital and reports having had the flu and has spent most of their time in bed for the last several days. The client has been experiencing vomiting and diarrhea. The nurse observes that the sacral PI 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. The client is admitted to the hospital with a fever, fluid volume deficit, and possible sepsis.

Section 6 Caring for an Infected Wound

A wound culture indicates that the client's wound is infected with methicillin-resistant Staphylococcus aureus (MRSA).

Which class of medication should the nurse expect to administer? O 5HT3 receptor antagonist, such as palonosetron. O An adrenergic medication, such as epinephrine. O A tocolytic medication, such as terbutaline. O An antihistamine, such as diphenhydramine.

An antihistamine, such as diphenhydramine. The client has been receiving antibiotic therapy for several days. The client 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.

The nurse explains to the client that this precaution reduces the risk for what potential problem? O Anaphylactic reaction. O Idiosyncratic response. O Synergistic effect. O Drug incompatibility.

Anaphylactic Reaction. After the client receives the first dose of linezolid, the nurse reports to the HCP that a rash and itching develop on his thorax, but he has no respiratory symptoms.

What action should the nurse take? O Provide verbal instructions about positioning to the UAP and document the instructions in the nurse's notes. O Ask the charge nurse to assist with verbal communication to all of the staff involved in the client's care to ensure continuity of care. O Advise the charge nurse that client confidentiality is secondary to continuity of care. O Assure the charge nurse that written instructions in the client's room are effective and do not violate any client rights.

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

Section 3 Self-Care Measures

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

Section 9 Medication Administration: Administering a Liquid Suspension by Mouth

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.

After reviewing the results of the wound culture, which type of precautions should the nurse and staff use when caring for this client? O Standard precautions. O Droplet precautions. O Airborne precautions. O Contact precautions.

Contact Precautions. The nurse suspects that the client's wound has developed a sinus tract, or tunneling.

Upon learning that the client has a pressure-reducing gel chair cushion for their wheelchair, which action should the nurse take? O Encourage them to continue to use this device in their wheelchair at all times. O Recommend that they replace the gel pad with a donut-shaped foam cushion. O Advise them to avoid the use of any form of pressure cushion on their wheelchair. O Teach them that regular use of skin moisturizer is more important than cushion use.

Encourage them to continue to use this device in their wheelchair at all times.

Section 13

Growth and Development

Which nursing response best promotes effective communication? O Clarify the difference between an infected pressure injury and a bed sore to the client. O Explain to the client that they should not allow themself to become discouraged. O Help the client identify the concerns he is trying to cope with at this time. O Tell the client that he does not to worry about an infection that is almost resolved.

Help the client identify the concerns he is trying to cope with at this time.

What teaching should the nurse provide? O Another round of antibiotic therapy will probably be needed. O Hydrocolloid dressings should be continued over the ulcer. O Debridement of the pressure ulcer must be restarted. O The pressure ulcer should now be kept open to the air.

Hydrocolloid dressings should be continued over the ulcer.

What action should the nurse implement? O Apply heat to reduce the inflammation that has occurred at these sites. O Notify the healthcare provider (HCP) that the client is retaining excess fluid. O Reassure the client that no pressure damage is present at these sites. O Identify these areas as sites where pressure damage has occurred.

Identify these areas as sites where pressure damage has occurred.

Which etiology identified by the nurse is accurate? O Noncompliance with turning schedule. O Poor nutritional intake. O Impaired physical mobility. O Impaired adjustment.

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

Which technique should the nurse use to mix the linezolid? O Shake gently for 60 seconds. O Mix according to directions. O Shake vigorously until mixed. O Stir medicine after pouring it into the medication measuring cups.

Mix according to directions.

Section 12 Psychosocial Support

No evidence of drug toxicity is found. The client's next BP is within normal limits, and experiences no further episodes of diarrhea. The wound eschar has been removed (debrided), and there is no further drainage. A hydrocolloid dressing is placed over the wound, and the client is discharged. The client will complete the 2-week antibiotic treatment at home. The home care nurse visits the client a week after discharge to assess the wound. The nurse reviews symptoms of pressure injuries as well as preventative measures, with the client, and when to call the HCP. The client yells at the nurse and says that they do not need a nurse to tell them that they will spend the rest of their life in and out of hospitals.

What initial action should the nurse take? O Confront the client about their rude and unacceptable behavior and attitude. O Offer the client the opportunity to discuss their feelings of anger. O Ask the client's parents to calm the client so the nursing assessment can be completed. O Reassure the client that they will not need to spend the rest of their life in and out of hospitals.

Offer the client the opportunity to discuss their feelings of anger. The client apologizes to the nurse and expresses how discouraged they are about the bed sore and the infection.

Which diagnostic test should the nurse request an order for to determine if the client is developing drug toxicity? O Culture and sensitivity. O Therapeutic index. O Half life. O Peak and trough.

Peak and trough. Culture and sensitivity: determine what microorganism is present and which antibiotic will be effective; prior to antibiotic Tx. Therapeutic index: range between therapeutic level and toxic level of a medication. Half life: related to medication dosing. Peak and trough: peak = highest; trough = lowest levels, provides information regarding the amount of drug the pt has in the bloodstream. If trough is > the acceptable limit for the drug, next dose should be withheld and the blood level rechecked 6 hours later.

Who is the best member of the interdisciplinary team for the nurse to collaborate with to resolve this discrepancy? O HCP. O Pharmacist. O Client. O Charge nurse.

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

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

Place the medication cup on a flat surface at eye level.

During the course of antibiotic treatment with linezolid, which of the client's serum laboratory values requires intervention by the nurse? O Platelet count (100 x 103/mcL (100 X 109 /L). O Magnesium 1.82 mg/dL (0.75 mmol/L). O Creatinine 1.2 mg/dL (91.5 mcmol/L). O Potassium 3.5 mEq/L (3.5 mmol/L).

Platelet count (100 x 103/mcL (100 X 109 /L).

Section 11 Pharmacology: Antibiotics

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

How should the nurse describe the drainage in documenting the wound? O Infectious. O Purulent. O Serous. O Sanguineous.

Purulent

The sacral area has remained red for 2 hours and does not blanch when tested. Which is the best description for the nurse to document? O Excessive pallor. O Unusual skin mottling. O Dependent sacral rubor. O Reactive hyperemia.

Reactive hyperemia. The nurse identifies that the client has developed a Stage 1 pressure injury and is concerned that the client may have other pressure injuries.

It is most important to include this group in which aspect of the client's overall care? O Reviewing class notes and studying for exams. O Helping the client plan meals to promote wound healing. O Purchasing wound care supplies for the client. O Reminiscing about life when they were all younger.

Reviewing class notes and studying for exams.

Which equipment should the nurse utilize to assess the length of the tract? O Sterile gloves and lubricant. O Sterile tape measure. O Sterile cotton-tipped applicator. O Sterile irrigation tray with syringe.

Sterile cotton-tipped applicator. The nurse notifies the HCP of sinus tracts discovered during the assessment and receives an order to irrigate the wound with sodium chloride (NS.)

To provide pressure relief at night, the nurse teaches the client to sleep in which position? O Supine with the head of the bed elevated. O Supine with a foam wedge between the knees. O Thirty-degree lateral inclined position. O Full side-lying position supported with pillows.

Thirty-degree lateral inclined position.

Section 7 Math

The nurse plans to administer an ordered dose of linezolid, an antibiotic, which interferes with the production of proteins that bacteria need to multiply and divide. The order states, "linezolid suspension 400 mg by mouth (PO) every 12 hours for 14 days." The medication is labeled, "100 mg/5 mL."

Section 5 Ethical/Legal Issue

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

Section 2 Nursing Diagnosis

The PN and RN team leader identify a priority problem for the client's plan of care as "impaired skin integrity."

Considering the client's developmental stage at the age of 20, the nurse's plan of care emphasizes interaction with which group? O The clients parents, aunts, uncles, and cousins. O A large group of the clients former high school classmates. O A small group of the clients professors from the college. O The client's girlfriend and his two best male friends from the college.

The client's girlfriend and his two best male friends from the college.

Which goal should the nurses include in the client's plan of care? O The client's skin will remain intact without deterioration. O The client's motor function will be restored. O Client teaching will be provided. O Impaired skin integrity will not occur.

The client's skin will remain intact without deterioration.

Section 15 Case Outcome

The home care nurse advises the client that their pressure injury (PI) is healing well and that they should continue the measures related to diet, positioning, and wound care that they have learned. The client returns to the college health clinic weekly, where the nurse monitors the progress of their wound healing until the goal of intact skin integrity is achieved.

Section 14 Client Teaching: Wound Healing

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

Section 10 Medication Administration: Ongoing Monitoring

The nurse monitors lab values and assesses for adverse effects during the course of the client's treatment with linezolid.

Section 1 Assessment

The nurse observes that the reddish area is round and is directly over the client's sacrum. The skin is intact.

The nurse teaches the client to apply a dressing over the sacral area. Which type of dressing is most likely to be used over the stage 1 PI? O Transparent film dressing. O Adherent film dressing. O Gauze dressing. O Hydrogel covered with a foam dressing.

Transparent film dressing The nurse also reminds the client to assess pressure points using a long-handled mirror twice a day.

Which areas are most important for the nurse to observe for additional pressure injuries (PI)? O Distal tips of the toes. O Lower abdominal folds. O Ischial tuberosities. O Thighs and calves.

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

What is the purpose of this type of dressing? O Mechanically debride the tissue. O Facilitate tissue healing. O Decrease risk of infection. O Preserve granulation tissue.

Mechanically debride the tissue.

Section 8

The order states, "linezolid suspension 400 mg by mouth (PO) every 12 hours for 14 days." The medication is labeled, "100 mg/5 mL." The nurse is scheduled to administer 20 mL per their calculation. The nurse reviews the drug reference guide, which indicates that the recommended daily dosage for the medication is 800 to 1200 mg.