A nurse assesses that the periwound area of a patient's large abdominal wound is macerated. What change in nursing management will be required because of the maceration?
1. Apply a petroleum-based product to the periwound area.
2. Keep the moist dressing off the periwound area.
3. No new measures are necessary, as this is a normal finding.
4. Apply a separate moist dressing to the periwound area.
2
Rationale 1: It is not necessary to introduce another product into the care of this wound.
Rationale 2: Maceration occurs when excessive moisture destroys the skin's integrity. Periwound skin becomes macerated when the wet dressing from the wound extends to the skin around the wound. The most appropriate nursing measure is to keep the skin around the wound dry.
Rationale 3: Maceration is not a normal finding and requires nursing intervention.
Rationale 4: Applying moist dressings to the periwound area would worsen the maceration.
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1. 50% 2. 10% 3. 40% 4. 25%
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