The patient with a colostomy has been incorrectly applying his ...

[Jipu 123]

The patient with a colostomy has been incorrectly applying his ostomy appliance. The continuous contact with liquid stool has caused a skin wound around the ostomy. The nurse assesses bleeding and purulent drainage that has extended into the dermis.
 
  How will the nurse classify and document this contaminated wound?
  a. Acute, full-thickness, open
  b. Chronic, partial-thickness, closed
  c. Acute, partial-thickness, closed
  d. Chronic, unstageable, open

Question 2

The nurse assesses assigned patients and determines which patient is at highest risk for altered skin integrity?
 
  a. Young adult in traction who has a low-protein diet and dehydration
  b. Elderly patient diagnosed with well-controlled type 2 diabetes
  c. Middle-aged adult with metabolic syndrome taking antihypertensives
  d. Adolescent in bed with influenza having periods of high fever and diaphoresis

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Answer to Question 1

A
The wound is acute because it developed recently. The wound is full-thickness because it involves the dermis. The wound is open because it was bleeding, so the skin must be broken. The wound is contaminated because it is exposed to stool and appears to be infected.

Answer to Question 2

A
The young adult patient in traction has multiple risk factors including immobility, dehydration, and inadequate protein intake. Healthy skin depends on adequate protein levels to maintain the skin, repair minor defects, and preserve intravascular volume. Therefore, this patient is at greatest risk for altered skin integrity. An elderly patient with well-controlled diabetes has only one risk factor, and therefore is not at highest risk among the group of patients in the scenario. The middle-aged adult with metabolic syndrome, which involves obesity, hyperlipidemia, and hypertension, has compromised health, although not necessarily compromised skin integrityunless the patient were immobile, which he is not. Although fever and skin moisture can compromise skin integrity, the adolescent's condition is likely transient.

[Jipu 123]

Thank you!

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Always glad to help...