Asked by Paula Durley on Jul 29, 2024
Verified
The nurse is caring for a patient with potential skin breakdown. Which components will the nurse include in the skin assessment? (Select all that apply.)
A) Vision
B) Hyperemia
C) Induration
D) Blanching
E) Temperature of skin
Hyperemia
An excess of blood in the vessels supplying an organ or other part of the body.
Induration
Hardening of a tissue, particularly the skin, because of edema or inflammation.
Blanching
A temporary whitening of the skin due to lack of blood flow, often used as a test for skin elasticity or capillary refill.
- Teach patients and caregivers methods for the prevention and management of pressure sores and wounds.
Verified Answer
PA
Parmod AgarwalAug 02, 2024
Final Answer :
B, C, D, E
Explanation :
Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and palpate for blanching or nonblaching. Early signs of skin damage include induration, bogginess (less-than-normal stiffness), and increased warmth at the injury site compared to nearby areas. Changes in temperature can indicate changes in blood flow to that area of the skin. Vision is not included in the skin assessment.
Learning Objectives
- Teach patients and caregivers methods for the prevention and management of pressure sores and wounds.