Author Question: The nurse knows that the following factors contribute to the development of wounds and lead to ... (Read 37 times)

cool · **on:** Jul 23, 2018

The nurse knows that the following factors contribute to the development of wounds and lead to delays in wound healing: (Select all that apply.)

a. A patient who has diabetes
b. A patient with COPD on long-term steroid therapy
c. A patient with on bed rest who is repositioned
d. A patient who is obese and sweats excessively

Question 2

The nurse knows an appropriate goal for a patient with a stage III pressure ulcer with the nursing diagnosis Impaired physical mobility is:

a. the patient will remain free of wound infections during the hospitalization.
b. the patient will report pain management strategies and reduce pain to a tolerable level.
c. the patient will turn self in bed using over trapeze every two hours using assistance when needed.
d. the patient will consume adequate nutrition to meet nutritional requirements within 1 week.

zoeyesther · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: A, B, C, D
Factors that contribute to the development of wounds and lead to delays in wound healing include comorbidities such as vascular disease, which impacts the skin's ability to obtain required oxygen and nutrients, or diabetes, which affects not only the microvasculature, but also the skin's normally acidic pH; malnutrition involving inadequate proteins, cholesterol and fatty acids, and vitamins and minerals; medications such as steroids, nonsteroidal antiinflammatories, and anticoagulants; excessive moisture from sweating; and external forces such as pressure, shear, and friction that occur when turning and repositioning the patient in bed.

Answer to Question 2

ANS: B
The patient will report pain management strategies to reduce pain to a tolerable level is an appropriate goal for Impaired physical mobility. The patient remaining free of wound infections during the hospitalization is an appropriate goal for Impaired tissue integrity. The patient reporting pain management strategies to reduce pain to a tolerable level is an appropriate goal for Acute pain. The patient consuming adequate nutrition to meet nutritional requirements within 1 week is an appropriate goal for Imbalanced nutrition: less than body requirement.