Which term is used to describe the following condition in a patient’s medical record: perineal skin breakdown after sitting in wet underclothes for many hours?
Debridement.
Evisceration.
Maceration.
Dehiscence.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Shearing force is the primary factor that contributes to the formation of pressure injuries when a patient's body slides downward. It occurs when two surfaces move in opposite directions, causing stress and strain on the tissues between them.
Compression of Tissues: When the patient's body slides downward, the skin and underlying tissues are compressed between the bony prominences (such as the sacrum or heels) and the surface of the bed. This compression restricts blood flow to the area, depriving the tissues of oxygen and nutrients.
Tissue Stretching and Tearing: As the body slides, the skin and underlying tissues are also stretched and pulled in opposite directions. This shearing force disrupts the normal alignment of cells and tissues, leading to microscopic tears and damage.
Impaired Blood Flow: Shearing force further compromises blood flow by stretching and compressing blood vessels. This reduces the delivery of oxygen and nutrients to the tissues, while also hindering the removal of waste products.
Tissue Damage and Necrosis: The combination of compression, stretching, and impaired blood flow leads to cell death and tissue necrosis. This is the hallmark of pressure injuries, which can range from superficial blisters to deep ulcers that extend into muscle and bone.
Factors that Increase Shearing Force: Certain factors can increase the risk of shearing force and pressure injury development, including:
Increased moisture (from sweat or incontinence) Decreased mobility
Poor skin integrity
Malnutrition
Friction from bedsheets
In conclusion, shearing force is the main factor that contributes to pressure injury formation when a patient's body slides downward. It disrupts blood flow, damages tissues, and can lead to significant wounds.
Correct Answer is D
Explanation
Choice A rationale:
Soaking the wound in an Epsom salt solution is not recommended for abscessed wounds. While Epsom salt has some potential benefits for wound healing, such as reducing inflammation and drawing out fluids, it can also be irritating to the skin and may actually worsen the abscess. Additionally, there's a risk of introducing bacteria from the Epsom salt into the wound, which could lead to further infection.
Choice B rationale:
Administering warm water sitz baths is not directly applicable to an abscessed leg wound. Sitz baths are typically used for conditions affecting the perineal area, such as hemorrhoids or postpartum discomfort. They may help to soothe and cleanse the affected area, but they would not be effective in treating an abscess on the leg.
Choice C rationale:
Applying cold moist compresses is not the most appropriate intervention for an abscessed wound. Cold compresses can help to reduce pain and inflammation, but they can also constrict blood vessels and potentially hinder the healing process. Warm compresses are generally preferred for abscesses because they can help to promote drainage and healing.
Choice D rationale:
Applying warm moist compresses is the most appropriate nursing intervention for an abscessed leg wound. Warm compresses have several beneficial effects:
They promote vasodilation, which increases blood flow to the area and helps to deliver white blood cells and other healing agents to the site of infection.
They help to soften and loosen hardened pus, making it easier for the abscess to drain.
They provide a moist environment that promotes healing and prevents the wound from drying out. They can help to reduce pain and inflammation.
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