Question

The nurse enters a patient's room and finds that the patient was incontinent of liquid stool. Because the patient has recurrent redness in the perineal area, the nurse worries about the risk of the patient developing a pressure injury. The nurse cleanses the patient, inspects the skin, and applies a skin barrier ointment to the perineal area. The nurse consults the ostomy and wound care nurse specialist for recommended skin care measures. Which of the following correctly describe the nurse's actions? (Select all that apply.) a. The application of the skin barrier is a dependent care measure. b. The call to the ostomy and wound care specialist is an indirect care measure. c. The cleansing of the skin is a direct care measure. d. The application of the skin barrier is an instrumental activity of daily living. e. Inspecting the skin is a direct care activity.

Short answer

The correct actions described by the nurse are: (b) The call to the ostomy and wound care specialist is an indirect care measure, (c) The cleansing of the skin is a direct care measure, and (e) Inspecting the skin is a direct care activity.

Step-by-step solution

Determine the Nature of Each Action

Assess each action taken by the nurse and categorize them as either a direct care measure, indirect care measure, dependent care measure, or an instrumental activity of daily living. Direct care measures are hands-on activities performed by the nurse. Indirect care measures are actions done on behalf of the patient that do not involve physical interaction. A dependent care measure is one that is based on physician's orders. An instrumental activity of daily living is a task that assists with daily life functions but doesn't include basic self-care tasks.

Classify Each Action Accordingly

From the description given: The cleansing of the skin and application of the barrier ointment are directly performed by the nurse on the patient's body, making them direct care measures. The nurse's consultation with the specialist is done on behalf of the patient's benefit without direct interaction with the patient, making it an indirect care measure. The action is not described as dependent on a physician's order, so it is not a dependent care measure. Neither action is related to assisting with daily life functions, such as managing finances or cooking, so they are not instrumental activities of daily living.

Apply the Definitions to Answer Choices

Using the classifications from Step 2, the answer choices can be evaluated as follows: (a) is incorrect, as the application of the skin barrier is a direct care measure, not a dependent one. (b) is correct, as consulting the specialist is an indirect care measure. (c) is correct, as cleansing the skin is a direct care measure. (d) is incorrect, as the application of the skin barrier ointment does not qualify as an instrumental activity of daily living. (e) is correct, as inspecting the skin is part of examining the patient directly.

Key concepts

Dependent Care Measure

In the context of nursing care, a dependent care measure is an action performed based on specific instructions or orders from a doctor or another healthcare provider. It's 'dependent' because the nurse or caregiver does not take these actions without the direction of the health care plan that has been prescribed by a physician. For example, administering medication or implementing a strict diet may be considered dependent care measures because they cannot be performed without a doctor’s order.

To differentiate from other types of care, think of dependent care measures as tasks that are not within the independent scope of nursing practice but are essential for patient well-being and are implemented as part of a collaborative healthcare team approach.

Instrumental Activities of Daily Living

The instrumental activities of daily living (IADLs) are tasks that go beyond basic self-care, encompassing the abilities required to manage one’s home and life. These activities include things like managing finances, grocery shopping, preparing meals, and maintaining personal hygiene. In the context of nursing and healthcare, IADLs are important for assessing a patient's ability to live independently and safely. When nurses aid in these activities, such as by organizing medications or creating a safe living environment, they support the patient’s autonomy and quality of life.

Understanding IADLs is essential when creating a comprehensive care plan, as they play a crucial role in determining the level of assistance a patient may need to thrive in their environment.

Pressure Injury Prevention

Pressure injuries, also known as bedsores or pressure ulcers, are areas of damaged skin caused by staying in one position for too long. Pressure injury prevention is a critical aspect of nursing care, especially for patients who are bedridden or have limited mobility. Nurses prevent these injuries by regularly repositioning patients, ensuring they receive proper nutrition and hydration, monitoring their skin condition, and using pressure-relieving devices like special mattresses or cushions.

Regular inspections of the skin, like the one conducted by the nurse in the exercise, play a pivotal role in early identification and prevention. By taking proactive steps and educating patients and their families about the importance of movement and skin care, nurses can prevent the development of these painful and sometimes serious complications.

Skin Barrier Application

The application of a skin barrier ointment, cream, or film is a proactive measure to protect the skin from irritants and moisture, particularly in areas that are prone to breakdown, such as the perineal area. This is considered a direct care activity because it involves hands-on care where the nurse applies the product directly to the patient's skin. This sort of intervention is especially important for patients who are incontinent or have compromised skin integrity, as it can prevent the development of pressure injuries and other skin complications.

The correct selection and application of a skin barrier product require careful assessment of the patient's skin condition, potential allergens, and the product's suitability for the specific situation. Educating the patient and caregivers about the importance and correct method of application is also a significant part of nursing responsibilities to ensure ongoing skin protection.