The nurse is developing unit assessment protocols for the risk of pressure ulcer development. What factors would the nurse include in this document? Note: Credit will be given only if all correct choices and no incorrect choices are selected
Select all that apply. 1. Presence of moisture
2. Potential for friction and shear
3. Adequacy of nutrition
4. Mobility status
5. Presence of confusion
1,2,3,4
Rationale 1: Moisture increases skin breakdown, thereby increasing the risk for pressure ulcer development.
Rationale 2: 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.
Rationale 3: Nutrition supplementation is an essential intervention against pressure ulcer development. Protein is the building block for collagen synthesis, interstitial fluid balance, granulation, and epithelialization.
Rationale 4: Decreased mobility level increases the risk for pressure ulcer development due to prolonged pressure in one area.
Rationale 5: There is no indication that a patient who is confused is at greater risk for developing pressure ulcers.
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