Author Question: The nurse is caring for a patient with potential skin breakdown. Which components would the nurse ... (Read 61 times)

tnt_battle · **on:** Jul 22, 2018

The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment? (Select all that apply.)

a. Mobility
b. Hyperemia
c. Induration
d. Blanching
e. Temperature of skin
f. Nutritional status

Question 2

The nurse is making a preoperative education appointment with a patient. The patient asks if he should bring family with him to the appointment. What is the best response by the nurse?

a. There is no need for an additional person at the appointment.
b. Your family can come and wait with you in the waiting room.
c. We recommend including family in this appoint to ease everyone's anxiety.
d. It is required that you have a family member at this appointment.

ricroger · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B, C, D, E
Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and abnormal reactive hyperemia (when the skin turns red after an obstruction of blood flow returns and vasodilatation causes the tissue to turn red). Assess for indurated (hardened) areas on the skin and palpate reddened areas for blanching. Changes in temperature can indicate changes in blood flow to that area of the skin. Mobility and nutritional status are certainly part of the overall assessment for pressure ulcer risk but are not part of the actual skin assessment.

Answer to Question 2

C
It is ideal to attempt perioperative education before admission, during the hospital stay, and after discharge. Including family members in perioperative education is advisable. Often a family member is a coach for postoperative exercises when the patient returns from surgery. If anxious relatives do not understand routine postoperative events, it is likely that their anxiety will heighten the patient's fears and concerns. Perioperative preparation of family members before surgery helps to minimize anxiety and misunderstanding. An additional person is needed at the appointment if at all possible, and he or she needs to be involved in the process, not just waiting in the waiting room; however, it is certainly not a requirement for actually completing the surgery that someone comes to this appointment.