Which signs would suggest to a nurse that a patient is undergoing a stress response? (Choose all that apply)

Choice A rationale:

Debridement refers to the removal of dead, damaged, or infected tissue to promote healing. It is not a term used to describe skin breakdown caused by moisture.

Choice B rationale:

Evisceration is the protrusion of internal organs through a wound or surgical incision. It is not relevant to the condition of perineal skin breakdown due to wetness.

Choice D rationale:

Dehiscence is the separation of a surgical wound. It is not applicable in this case, as there is no mention of a surgical wound.

Choice C rationale:

Maceration is a term used to describe skin that has become softened and broken down due to prolonged exposure to moisture. This is the most accurate term to describe the condition of perineal skin breakdown after sitting in wet underclothes for many hours.

Key features of maceration:

Skin softening: The skin becomes white and wrinkled, resembling a prune.

Epidermal loss: The outer layer of skin (epidermis) may slough off, leaving the underlying tissue exposed. Redness: The affected area may become red and inflamed.

Pain or tenderness: The area may be painful or tender to the touch.

Increased risk of infection: Macerated skin is more susceptible to infection due to the breakdown of the skin barrier. Causes of maceration:

Prolonged exposure to moisture: This can include sweat, urine, feces, wound drainage, or excessive bathing. Friction: Rubbing or chafing of the skin can also contribute to maceration.

Impaired circulation: Poor blood flow to the area can make it more vulnerable to maceration. Prevention of maceration:

Keep skin clean and dry: This is the most important step in preventing maceration. Change wet or soiled clothing or dressings promptly.

Apply barrier creams or ointments: These can help to protect the skin from moisture.

Use incontinence products: These can help to keep the skin dry if the patient is incontinent. Reposition the patient frequently: This helps to reduce pressure and friction on the skin.

Choice B rationale:

Heart rate: During a stress response, the sympathetic nervous system is activated, leading to a release of hormones such as adrenaline and cortisol. These hormones increase heart rate, preparing the body for a "fight or flight" response. A heart rate of 132 beats per minute is significantly elevated compared to a normal resting heart rate of 60-100 beats per minute, suggesting a stress response.

Choice C rationale:

Pupil dilation: Pupil dilation is another physiological change associated with the activation of the sympathetic nervous system during stress. The dilation allows more light to enter the eyes, enhancing visual acuity and awareness of surroundings, which can be helpful in responding to potential threats.

Choice E rationale:

Difficulty sleeping: Stress can negatively impact sleep in several ways. It can cause racing thoughts, anxiety, and physical tension, making it difficult to fall asleep and stay asleep. Sleep disturbances are a common symptom of stress and can further exacerbate its effects.

Rationale for incorrect choices:

Choice A: Blood glucose level can be affected by stress, but a low blood glucose level of 36 mg/dL is more likely to be due to other causes such as hypoglycemia or insulin therapy. It's not a direct indicator of a stress response.

Choice D: Blood pressure can increase during stress, but a blood pressure of 104/56 mmHg is within the normal range and does not necessarily indicate a stress response.