When assessing a client for the risk of pressure ulcer development, what factors must be a part of the assessment? Select all that apply
1. Sensory perception and activity level
2. Moisture
3. Mobility
4. Nutrition
5. Friction and shear
1. Sensory perception and activity level
2. Moisture
3. Mobility
4. Nutrition
5. Friction and shear
Rationale: Sensory perception and activity level. 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. Moisture increases skin breakdown, thereby increasing the risk for pressure ulcer development. Mobility. Decreased mobility level increases the risk for pressure ulcer development due to prolonged pressure in one area. Nutrition. Nutrition supplementation is an essential intervention for pressure ulcer development. Protein is the building block for collagen synthesis, interstitial fluid balance, granulation, and epithelialization. Friction and shear. Friction and shear potentially remove layers of tissue, thereby increasing the risk for loss of skin integrity, which can progress to necrosis of the skin with pressure.
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