Asked by Sergii Voloshchuk on Jun 28, 2024
Verified
The nurse is caring for a darkly pigmented patient who is immobile and needs turning every 2 hours.While turning the patient,to what should the nurse who is performing the assessment pay particular attention?
A) Edema in the sacrum
B) Skin texture
C) Skin temperature
D) Pallor or mottling of the skin
Darkly Pigmented
Description of a skin or area that has a deeper or more intense colorization than the surrounding tissues, often due to higher levels of melanin.
Edema
Swelling caused by excess fluid trapped in the body's tissues.
Pallor
An abnormal loss of color from the skin or mucous membranes, often indicative of illness, stress, or poor blood circulation.
- Identify the initial indicators and symptoms of pressure ulcers to start interventions promptly.
- Understand the impact of medical devices on skin integrity and pressure ulcer development.
Verified Answer
AZ
Anjelika ZamoraJul 05, 2024
Final Answer :
C
Explanation :
Darkly pigmented skin does not always have visible blanching.Its color differs from that of surrounding skin.Skin temperature changes may be an important early indicator of a stage I pressure ulcer.Edema is not an initial indication of a pressure ulcer.Do not massage any reddened or discolored pressure points.Areas of nonblanchable erythema or discolored areas may indicate that deeper tissue damage is present.Massage in this area may worsen the inflammation by further damaging underlying damaged blood vessels.Pallor or mottling will be difficult or impossible to see in a patient with darkly pigmented skin.
Learning Objectives
- Identify the initial indicators and symptoms of pressure ulcers to start interventions promptly.
- Understand the impact of medical devices on skin integrity and pressure ulcer development.