The nurse understands that certain patients are more susceptible ...

[beccaep]

The nurse understands that certain patients are more susceptible to pressure ulcer development. Which patients should the nurse identify as being at an increased risk for this health problem?
 
  Select all that apply.
  1. patient with restricted activity
  2. patient with decreased sensation
  3. patient who is very thin
  4. patient with urinary and fecal incontinence
  5. patient with good nutrition

Question 2

The nurse is assessing a patient's risk for pressure ulcer development. Which factors should the nurse include in this assessment?
 
  Select all that apply.
  1. sensory perception
  2. moisture
  3. mobility
  4. nutrition
  5. social interaction

[itsakadoozi]

Answer to Question 1

Correct Answer: 1, 2, 3, 4
Patients who have restricted activity, as would occur with quadriplegia, strokes, and fractured hips, are at risk for pressure ulcer development. Decreased sensation prevents patients from feeling the pain associated with the development of a pressure ulcer, which increases the risk of development and progression. Patients who are very thin or have decreased protein in the diet have skin that is more likely to ulcerate. Patients who have urinary or fecal incontinence or are exposed to other types of moisture such as perspiration, wound drainage, or emesis are more prone to ulcers. Patients with good nutrition are at a decreased risk for pressure ulcer formation.

Answer to Question 2

Correct Answer: 1, 2, 3, 4
Decreased sensation increases the risk for pressure ulcer development. Decreased activity increases the risk for pressure ulcer development due to prolonged pressure in one area, thereby decreasing the circulation to that area, resulting in decreased oxygen supply. Moisture increases skin breakdown, thereby increasing the risk for pressure ulcer development. Decreased mobility level increases the risk for pressure ulcer development due to prolonged pressure in one area. Nutrition supplementation is an essential intervention for pressure ulcer development. Protein is the building block for collagen synthesis, interstitial fluid balance, granulation, and epithelialization. The patient's social interaction is not a risk level since a chair-bound person may socialize a lot, but not move.