An older patient has a Braden Scale pressure ulcer risk score of 18. What interventions would be indicated by the nurse?
1. Provide routine skin care with soap and water daily.
2. Inspect skin when repositioning, toileting, and assisting with ADLs.
3. Avoid the use of pillows and foam slabs between bony prominences.
4. Provide routine activities, score is not concerning.
2. Inspect skin when repositioning, toileting, and assisting with ADLs.
Explanation: 1. Keep the skin clean and dry. Avoid overuse of soap which can be drying.
2. Evaluate and manage incontinence. A bowel- and bladder-management program should be in place. If soiling occurs, skin should be cleansed as soon as possible using a pH balanced skin cleanser. Underpads that absorb moisture and present a quick-drying surface to the skin should be used.
3. Use pillows or wedges to prevent the skin from touching the bed on trochanter, heels, and ankles.
4. The score is not inconclusive and it does show a risk for pressure ulcer development.
You might also like to view...
A newly promoted nurse manager would like staff to solve problems without relying on preconceived ideas. How should the manager role-model this ability?
1. When disagreements occur on the unit, the manager privately asks the dissenters to be silent about the issue at meetings. 2. Tell staff members that they must present one opinion regarding the solutions they desire. 3. Demonstrate a genuine desire to find our why there is dissention. 4. Develop "tunnel vision" when it comes to problems on the unit.
The mother of a young woman being treated for amphetamine overdose asks the nurse when the manifestations will subside. What would be the most correct answer by the nurse?
a. "Usually in 8 to 10 hours." b. "She will snap out of it in a day or two." c. "Usually in about 2 hours, but the effects will return in 2 to 3 days." d. "The manifestations may be permanent."
A patient with renal insufficiency has been hospitalized on a medical unit. The patient knows that renal function depends upon the functional status of nephrons
The patient asks the nurse when she will need to start dialysis based upon loss of nephron function. How should the nurse respond? A) "When about 50% of the nephrons are no longer functioning." B) "When about 60% of the nephrons are no longer functioning." C) "When about 70% of the nephrons are no longer functioning." D) "When about 80% of the nephrons are no longer functioning."
Which disorder may be a contributing factor to the development of hallux valgus deformity?
A. Renal insufficiency B. Rheumatoid arthritis C. Type 1 diabetes mellitus D. Congestive heart failure