A nurse is caring for a client who is scheduled for surgery.

Exhibit 1

Medical History

0800:

Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus.

Mini Nutritional Assessment screening tool score of 7 points (0 to 14 points)

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply

A. History of diabetes mellitus: This is correct. Diabetes mellitus can lead to delayed wound healing due to various factors, including impaired circulation, neuropathy, and compromised immune function.

B. Cholesterol level: While abnormal cholesterol levels can impact cardiovascular health, they are not directly linked to delayed wound healing unless they are part of a broader metabolic disorder or condition that affects vascular health.

C. Prealbumin level: Prealbumin is a marker of nutritional status. Low prealbumin levels can indicate malnutrition, which is a risk factor for delayed wound healing.

D. History of hyperlipidemia: Hyperlipidemia refers to high levels of fats (lipids) in the blood, such as cholesterol and triglycerides. While hyperlipidemia is associated with cardiovascular risk, it is not a direct risk factor for delayed wound healing unless it is part of a broader metabolic syndrome or condition affecting vascular health.

E. Mini Nutritional Assessment screening tool score: This is correct. The Mini Nutritional Assessment (MNA) screening tool assesses nutritional status, and a low score indicates malnutrition or nutritional deficiencies, which can contribute to delayed wound healing.

F. History of malnutrition: This is correct. Malnutrition, whether due to inadequate intake, absorption issues, or other factors, is a significant risk factor for delayed wound healing as it affects the body's ability to repair tissues and fight infection.

A. Apply the pouch while the skin barrier is still damp.

Applying the pouch while the skin barrier is damp can lead to poor adhesion and potential leaks. It’s essential to ensure the skin is completely dry before attaching the pouch.

B. Change the pouch once every 24 hr.: The frequency of pouch changes depends on individual client needs, stoma output, and the type of pouching system used. Changing the pouch every 24 hours may be unnecessary for some clients and could potentially cause skin irritation or damage.

C. Rub the peristomal skin dry after cleaning: Rubbing the peristomal skin dry after cleaning can cause irritation and damage to the skin. Instead, the nurse should gently pat the skin dry using a soft cloth or towel to avoid causing friction or trauma to the delicate skin surrounding the stoma.

D. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma:a allows for a better fit and helps prevent the edges of the stoma from coming into contact with stool, which can cause irritation and breakdown of the skin. A proper fit also helps ensure a secure seal and prevents leakage.