Author Question: A pre-teen quadriplegic patient was admitted with pressure ulcers to both ankles. The nurse should ... (Read 38 times)

Mr.Thesaxman · **on:** Jul 22, 2018

A pre-teen quadriplegic patient was admitted with pressure ulcers to both ankles. The nurse should assess which parameters for a wound assessment? (Select all that apply.)

a. Size
b. Viable versus nonviable tissue
c. Tissue type involvement
d. Preventive measures
e. Anatomical location

Question 2

On admission a patient is noted to have an alteration in skin integrity on the right heel. The nurse uses the Braden Scale. Which areas will the nurse assess when using this scale? (Select all that apply.)

a. Mobility
b. Nutrition
c. Infection
d. Friction and shear
e. Sensory perception

gasdhashg · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

A, B, C, E
Wound assessment (regardless of cause) includes the following parameters: anatomical location, extent of tissue involvement (full or partial thickness loss), size (dimensions and depth of wound), tissue type (viable or nonviable) and percentage of wound tissue (e.g., viable vs. nonviable), volume and color of wound exudate, and condition of surrounding skin.

Answer to Question 2

A, B, D, E
The Braden Scale is a highly reliable scale that uses six subscales to identify patients at greatest risk for pressure ulcers: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. Infection is not an area that is assessed on the Braden Scale.