A wound has a bloodtinged liquid that is dripping from the surgical site. How does the nurse document this finding?

Choice A reason: Psoriasis is a skin abnormality that causes patches of thick, red skin with silvery scales, usually on the elbows, knees, scalp, lower back, or genitals. Psoriasis is a chronic, inflammatory, autoimmune condition that affects the life cycle of skin cells, causing them to build up rapidly on the surface of the skin. Psoriasis can cause itching, burning, pain, or bleeding.

Choice B reason: Rosacea is a skin abnormality that causes redness, flushing, swelling, or pimples, usually on the face, especially the cheeks, nose, chin, or forehead. Rosacea is a chronic, inflammatory, vascular condition that affects the blood vessels and sebaceous glands of the skin. Rosacea can cause sensitivity, stinging, or dryness.

Choice C reason: Scabies is a skin abnormality that causes small, red bumps, blisters, or burrows, usually on the hands, wrists, feet, ankles, or genitals. Scabies is a contagious, parasitic infection that is caused by tiny mites that burrow into the skin and lay eggs. Scabies can cause intense itching, especially at night.

Choice D reason: Stasis dermatitis is a skin abnormality that causes swelling, redness, scaling, or ulcers, usually on the lower legs or ankles. Stasis dermatitis is a chronic, inflammatory condition that results from poor blood circulation in the veins of the legs, causing fluid to leak into the surrounding tissues. Stasis dermatitis can cause pain, itching, or infection.

Choice A reason: Postponing daily bed bath is not appropriate for reducing the risk of a friction and shear injury. Bed bath is a hygiene measure that helps to keep the skin clean and dry and prevent infection. Friction and shear are caused by the rubbing and pulling of the skin against the bed surface, not by the bed bath itself.

Choice B reason: Elevating the client’s head of the bed to 45 degrees is not appropriate for reducing the risk of a friction and shear injury. In fact, this may increase the risk as the client may slide down the bed due to gravity and cause more friction and shear on the skin. The head of the bed should be kept at the lowest possible angle, preferably less than 30 degrees, unless contraindicated by the client’s condition.

Choice C reason: Caregiver independently slides the client up in bed is not appropriate for reducing the risk of a friction and shear injury. This may cause more damage to the skin as the caregiver may exert excessive force and drag the client’s skin along the bed surface. The caregiver should use a draw sheet or a slide board to lift and reposition the client with the help of another person.

Choice D reason: Use a mechanical lift to reposition the client every 2 hours is the most appropriate intervention for reducing the risk of a friction and shear injury. A mechanical lift is a device that helps to transfer and reposition the client safely and comfortably. It reduces the friction and shear on the skin by lifting the client off the bed surface and avoiding any sliding or dragging. It also prevents the caregiver from injuring themselves by lifting the client manually. The client should be repositioned every 2 hours to relieve the pressure on the skin and prevent pressure ulcers.