Question

1. When selecting skin care products, the WOC nurse should consider that the products should be designed to keep the skin:

Acidic and dry

Alkaline and damp

At a pH of 7.1

Free of bacteria

2.

Which of the following is most appropriate for the prevention of Medical Adhesive Skin Injury (MARSI)?

Total avoidance of any adhesive on fragile skin

Using silicone adhesive when feasible

Routine use of transparent adhesive dressings under tape

High angle and fast approach to removal of adhesive products

3.

Richard S.is a 66 year old male with leukemia, fragile skin, and multiorgan failure who requires emergent intubation for adult respiratory distress syndrome. Which of the following is the BEST approach to stabilization of his endotracheal (ET) tube?

Liquid barrier film to protect skin; plastic tape to secure tube

Liquid barrier film to protect skin; paper tape to secure tube

Thin hydrocolloid to protect skin; standard adhesive tape to secure tube

Transparent adhesive to protect skin; silicone tape to secure tube

4.

You are asked for assistance in classifying and staging a "suspected DTI" in a patient who is immobile, diaphoretic, and incontinent.  On assessment you find a lesion at the superior aspect and base of the gluteal cleft measuring 5.0 x 0.3 x 0.1 cm; the wound base is pink and moist. This would be most accurately classified/staged as:

Intertriginous dermatitis with fissure formation

Incontinence associated dermatitis

Deep tissue pressure injury

Stage 2 pressure injury

5.

Sheri Y. is a 46 year old female admitted for acute cellulitis of the pannus. She is 5' 4" and weighs 325lbs. She is febrile and diaphoretic and has limited mobility due to pain. Which of the following is most appropriate for the prevention of intertriginous dermatitis (ITD) in this patient?

Daily application of mupirocin ointment to the pannus and body folds

Use of silver based wicking fabric underneath the pannus and body folds

Placement on support surface with low air loss feature

Twice daily application of cornstarch to skin under pannus and body folds

6.

You are the wound care nurse for a Home Health agency and are asked to provide debridement for Will H., a 79 year old who is bedbound and who has bilateral heel ulcers. Your assessment reveals the following: densely adherent dry eschar;no periwound erythema or induration;no drainage or odor; pulses non-palpable but faintly audible with Doppler.

Which of the following represents the BEST response?

Keep heels dry; instruct caregivers to paint heels with povidine iodine solution daily and wrap with dry gauze

Soak heels for 10 minutes in an antiseptic solution to reduce surface bacteria and soften eschar prior to performing instrumental debridement

Crosshatch the eschar and initiate enzymatic debridement; delay instrumental debridement until the eschar begins to separate

Initiate autolytic debridement with transparent adhesive dressing to soften the eschar; perform instrumental debridement when eschar begins to separate

Answer 1

1)When selecting skin care products, the WOC nurse should consider that the products should be designed to keep the skin:

a)acidic and dry.

Healthy skin has a natural pH between 4.7 to 5.75(mildly acidic).This contributes to the skins protective barrier by neutralizing alkaline surfactants to inhibit bacterial growth.It also promotes growth of natural skin flora.An alkaline pH disturbs the natural balance of the skin by preventing the production of essental epidermal lipids and causing the skin to lose its water content.

2)Which of the following is most appropriate for the prevention of Medical Adhesive Skin Injury (MARSI)?

b)Using silicon adhesive when feasible.

MARSI occurs when superficial skin layers are removed due the adhesive on medical products causing erythema,bullus ,skin erosions or tears which persist for more than 30 minutes post removal.It can cause pain,increase the risk for infection and delays healing.The following should be kept in mind:

• Proper selection of adhesive products:Foam and silicon tapes are gentler than cloth.
• Prepare the skin by cleansing it and drying it gently completely.Shaving off hair is advisable.

Proper application and removal of adhesive: Do not stretch the tape when applying it and remove adhesive low and slow in the direction of hair growth;keep the tape parallel to the skin when removing it and gently push skin away with the other hand.

Q3)Richard S.is a 66 year old male with leukemia, fragile skin, and multiorgan failure who requires emergent intubation for adult respiratory distress syndrome. Which of the following is the BEST approach to stabilization of his endotracheal (ET) tube?

c)Thin hydrocolloid to protect skin; standard adhesive tape to secure tube.

The hydrocolloid material prevents skin breakdown as it is breathable and adheres well to the skin,thus preventing dislodgement of the tube.

4)You are asked for assistance in classifying and staging a "suspected DTI" in a patient who is immobile, diaphoretic, and incontinent.  On assessment you find a lesion at the superior aspect and base of the gluteal cleft measuring 5.0 x 0.3 x 0.1 cm; the wound base is pink and moist. This would be most accurately classified/staged as:

d)Stage 2 pressure injury

Tissue injury can be classified as the following:

Stage 1:Intact skin with non blanchable redness mostly over bony prominences.

(Deep tissue injury is suspected when there is a purple/maroon area of discolored intact skin.)

Stage 2:Loss of dermis pesenting as a shallow open ulcer with a pink-red wound bed or open serum filled blister.

Stage 3:Subcutaneous fat may be visible but bone,muscles or tendons are not exposed.

Stage 4:Bone,tendon or muscle is exposed.

Q5)Sheri Y. is a 46 year old female admitted for acute cellulitis of the pannus. She is 5' 4" and weighs 325lbs. She is febrile and diaphoretic and has limited mobility due to pain. Which of the following is most appropriate for the prevention of intertriginous dermatitis (ITD) in this patient?

b)Use of silver based wicking fabric underneath the pannus and body folds

Rubbing of skin folds together cause intertriginous dermatitis.The warm and moist environment promotes yeast,fungal and bacterial growth.

preventive measures include:

• Keep skin cool and dry.
• Wear loose fitting clothes.
• Use absorbent cloth materal.
• Weight reduction.   

Silver based wicking fabric absorbs moisture and helps to keep the area dry.

Q6)You are the wound care nurse for a Home Health agency and are asked to provide debridement for Will H., a 79 year old who is bedbound and who has bilateral heel ulcers. Your assessment reveals the following: densely adherent dry eschar;no periwound erythema or induration;no drainage or odor; pulses non-palpable but faintly audible with Doppler.

d)nitiate autolytic debridement with transparent adhesive dressing to soften the eschar; perform instrumental debridement when eschar begins to separate.

The ulcer is not infected but it has densely adherent dry eschar which should be softened using autolysis prior to instrumental debridement.