An elderly patient is admitted to the hospital for a bowel ...

[jho37]

An elderly patient is admitted to the hospital for a bowel obstruction. The patient is immobile and the nurse notices that there is a reddened area on the right heel. When the nurse presses on the area it does not turn lighter in color.
 
  How should the nurse document the tissue condition? a. Reactive hyperemia
  b. Blanchable hyperemia
  c. Nonblanchable hyperemia
  d. Tissue ischemia

Question 2

The patient was involved in a motor vehicle accident. The patient has a fractured right hip and is on bed rest. Because of the prolonged immobility the nurse is concerned about complications such as which of the following? (Select all that apply.)
 
  a. Decreased nutrients/fluids
  b. Increased disuse osteoporosis
  c. Increased gastrointestinal motility
  d. Decreased lung expansion
  e. Decreased pooling of lung secretions

[wuly]

Answer to Question 1

C
Nonblanchable hyperemia is redness that persists after palpation and indicates tissue damage. When you press a finger against the red or purple area, it does not turn lighter in color. Deep tissue damage is present and is commonly the first stage of pressure ulcer development. Reactive hyperemia is a redness of the skin resulting from dilation of the superficial capillaries. Reactive hyperemia blanches. In blanchable hyperemia, the area that appears red and warm will blanch (turn lighter in color) following fingertip palpation. Tissue ischemia, decreased blood flow to tissue, usually results in tissue death and occurs when capillary blood flow is obstructed, as in the case of pressure.

Answer to Question 2

A, B, D
Physiological outcomes from immobility include: decreased nutrients/fluids, decreased lung expansion, increased (not decreased) pooling of lung secretions, and increased disuse osteoporosis. Decreased (not increased) gastrointestinal motility occurs.

[jho37]

Thanks

[wuly]

Welcome