Quiz 36: Skin Integrity and Wound Care

Nursing

The skin is the largest organ of the body. It provides mechanical and physical protection to the body from the external pathogens and chemicals. Therefore, it is important to maintain the skin integrity, which is defined by the presence of normal skin devoid of any wounding or tissue damage. As given in the question, Mr. Johns is a 74-year-old patient currently being treated for a urinary tract disorder. He has recently encountered a cerebrovascular accident (CVA), which has rendered his right side of the body weakened. A pressure ulcer is defined as a localized inflammation, tissue necrosis, and cell death at a certain region of the body due to the constant pressure. This hinders the normal blood circulation to the affected areas, resulting in reduced oxygen and nutrient circulation. The client's vulnerability to pressure ulcers can be concluded from the assessment data that can be mentioned as follows: 1. Chronic immobility : The patient is weak on his right side because of a recent CVA. This has rendered the patient physically immobile and dependent for ambulation. He spends most of the time lying on the bed or sitting in the bedside chair. 2. Decreased sensory perception : The patient reports a complete loss of sensation in his entire right side. The loss or sensation further enhances immobility and thereby increases the risk of pressure ulcers. 3. Reddened areas : The assessment data reveal patches of reddened skin on his right hip, coccyx and peritoneal area which does not blanch. This is a typical sign of pressure ulcer.

Braden scale was invented by Barbara Braden and Nancy Bergstrom in 1987. It is a scoring tool for assessing risk for the pressure ulcers. Braden scale uses six parameters to assess the risk for the pressure ulcers like sensory perception, friction, mobility, activity, nutrition as well as shear. According to the Braden scale, the client should be assessed for 24 hours when the score is above 18 and indicates normal conditions. The client is considered to be at a moderate risk for skin breakdown when he/she has a Braden score of 13 or 14. The client should be considered to be at a very high risk of skin breakdown only when the Braden score is below 9. Hence, the options 1, 3 and 4 are incorrect. Since, the client has a Braden score of 17, he/she should be subjected to routine positional changes in order to prevent skin breakdown. Hence, the correct answer is option img .

The skin is the largest organ of the body. It provides mechanical and physical protection to the body from various external pathogens and chemical compounds. Skin integrity is defined as the presence of normal skin that is devoid of any wound and tissue damage. It is important to maintain skin integrity to prevent various infections and necrosis. As given in the question, Mr. Johns is a 74-year-old patient, who is currently being treated with a urinary tract disorder. He has encountered a recent cerebrovascular accident (CVA), which has rendered his right side weakened. He is dependent for ambulation. A pressure ulcer is defined as the presence of localized inflammation, tissue necrosis, and cell death at certain regions of the body due to a constant pressure that prevents normal circulation to the affected areas, which, in turn, hinders the supply of oxygen and nutrients. The Braden scale was invented by Barbara Braden in 1987 to assess the patients for the risk of pressure ulcers. It is a scoring scale, which is based on six parameters, such as the sensory perception, mobility, activity, friction, shear, and nutrition. The patient has already been presented with a reduced sensory perception and immobility on his right side, reduced activity and friction as demonstrated by the reddened areas on his body. So, the nurse requires the patient's nutritional status and the amount of shear force applied to his body to score the patient's condition on the Braden scale.

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