Question

27. The nurse is caring for a client with a nursing diagnosis of impaired skin integrity related to a stage III pressure ulcer. What would be the most important outcome for this client?

A. The client keeps the area clean and dry

B. The nurse turns the patient every two hours

C. The client does not exhibit any signs or symptoms of infection

D. The client is unaware of the prevention measures for pressure ulcers

Answer 1

B. The nurse turns the patient every two hours.

Regularly inspecting patients skin to identify to skin abnormalities is a key practice in pressure ulcer prevention. Skin assessment is a core element of the skin care bunble for reducing the number of pressure ulcers. This recognizes that, even the absence of a structured risk assessment changes in skin signal increased and risk and may predict the occurance of deeper pressure damage.

The skin is the largest organ in the human body and is a protective barrier it protects the body from heat,light,injury and infection. A skin integrity problem might indicate the skin is damaged, exposed to injury or inefficient to repair and recover normally. The key marker of quality care is the maintenance of skin integrity and prevention of pressure ulcers with this the nurse must be aware of identifying at risk individuals and the myriad factors that place patients at risk for skin damage. Pressure ,shear and friction from immobility put an individual at risk for altered skin integrity. Other factors that hasten skin breakdown include age the normal loss of elasticity inadequate nutrition, environmental moisture and vascular insufficiency. Special beds mattress and other useful advices provide pressure relief and pressure redistribution..