How should a nurse document the presence of thick, creamy yellow discharge on a patient’s dressing?

Choice A rationale:

Directly addresses the primary goal of preventing perioperative positioning injury: The absence of redness or breakdown in the skin is the most definitive indicator that the patient has not sustained any skin or tissue damage as a result of prolonged immobilization during surgery.

Focuses on the patient outcome, not just interventions: While interventions such as padding bony prominences and assessing skin prior to surgery are important, they are means to achieve the ultimate goal of preventing skin injury. This outcome statement directly measures the success of those interventions.

Aligns with best practices for pressure injury prevention: The National Pressure Injury Advisory Panel (NPIAP) and other expert organizations emphasize the importance of setting goals that focus on maintaining skin integrity and preventing injury.

Choice B rationale:

Addresses a crucial aspect of patient care, but not directly related to positioning injury: Maintaining privacy and dignity is essential for all patients, but it does not specifically address the risk of skin breakdown from prolonged immobilization.

Not a measurable outcome for positioning injury: It is difficult to objectively assess whether a patient's privacy and dignity have been maintained, making it less suitable as an outcome statement for this particular diagnosis.

Choice C rationale:

Describes an important intervention, but not a patient outcome: Padding bony prominences is a key strategy to reduce pressure and prevent skin injury. However, it is an action taken by the nurse, not a measurable outcome that reflects the patient's status.

Does not guarantee prevention of injury: Even with appropriate padding, patients can still develop pressure injuries if other risk factors are present or if repositioning is not performed adequately.

Choice D rationale:

Represents an essential assessment step, but not a final outcome: Assessing the skin prior to surgery is important for identifying areas that are at increased risk of breakdown. However, it is a preliminary step in the prevention process, not the ultimate goal.

Does not ensure prevention of injury: Identifying at-risk areas is helpful for targeting interventions, but it does not guarantee that skin breakdown will not occur.

Choice A rationale:

The dorsal gluteal site (also known as the dorsogluteal site) was previously a common injection site, but it's now not recommended due to several significant risks:

Proximity to the sciatic nerve: The sciatic nerve is the largest nerve in the body, and it runs close to the dorsal gluteal site. Accidental injection into or near the nerve can cause severe pain, nerve damage, and potential paralysis.

Difficulty in locating landmarks: The landmarks for the dorsal gluteal site can be difficult to locate accurately, especially in obese patients or those with decreased muscle mass. This increases the risk of injecting into the wrong area.

Risk of injury to blood vessels: The dorsal gluteal site also has a higher risk of injury to blood vessels, as several large vessels run through the area.

Choice B rationale:

The deltoid muscle is located in the upper arm and is a common site for intramuscular injections, but it has limitations for larger volumes:

Small muscle size: The deltoid muscle is relatively small compared to other IM injection sites. It's generally recommended for smaller volumes of medication (up to 1 mL in adults).

Subcutaneous tissue: The deltoid muscle often has a layer of subcutaneous tissue (fat) that can hinder absorption of medication.

Choice C rationale:

The vastus lateralis muscle is the preferred site for intramuscular injections in adults for several reasons:

Large muscle size: It's a large, thick muscle that can accommodate larger volumes of medication (up to 5 mL in adults). Easy to locate landmarks: The landmarks for the vastus lateralis are easy to identify, even in obese patients.

Few major nerves or blood vessels: It has fewer major nerves or blood vessels in the area, reducing the risk of injury. Pain tolerance: It's generally considered to be a less painful injection site than the deltoid or dorsogluteal sites.

Choice D rationale:

The lateral piriformis muscle is not a recognized or recommended site for intramuscular injections. It's a deep muscle located in the buttocks, and injecting into it would be difficult and potentially dangerous due to its proximity to the sciatic nerve and other important structures.