The nurse determines the risk for a pressure ulcer in an older adult who is 6 feet tall and weighs 155 pounds

Question

Which patient information should the nurse use in planning care to reduce this individual's risk for a pressure ulcer? (Choose all that apply.) a. Osteoarthritis of neck
b. Dry mucous membranes
c. Prealbumin level 7 mg/dl
d. Fasting glucose 140 mg/dl
e. Serum sodium 135 mEq/dl
f. Uses food stamps to get food

Answer 1

B, C, D, F

a. Incorrect. Osteoarthritis in the neck is not related to nursing care planned to reduce the risk for pressure ulcers because it should not impair this older adult's mobility or ability to ob-tain and prepare food.
b. Correct. The nurse plans care to address dehydration as a significant risk factor for pres-sure ulcers because this man is underweight, malnourished, and dehydrated as evidenced by dry mucous membranes. Dehydration increases the risk for pressure ulcers because water is essential for intracellular functioning and cell durability.
c. Correct. The nurse plans care based on the assessment of hypoproteinemia because the man is underweight and malnourished, significantly increasing his risk for pressure ulcers.
d. Correct. A fasting glucose showing hyperglycemia is a clinical indicator of diabetes mel-litus, so the nurse plans care to manage hyperglycemia. Diabetes mellitus increases the risk of pressure ulcers owing to the greater likelihood of impaired tissue perfusion, impaired wound healing, and greater occurrence of peripheral neuropathies. In addition, impaired tissue sensation due to nerve damage from hyperglycemia increases the risk of injury and infection for individuals with diabetes mellitus. A characteristic of type 1 diabetes mellitus is a low weight-for-height.
e. Incorrect. This sodium level is within normal limits.
f. Correct. This man has limited resources for obtaining food, given that he uses food stamps, and thus this is a risk factor for malnutrition, which increases the risk for pressure ulcers.