Asked by Jessica Stewart on Jul 09, 2024
Verified
Which nursing observation would indicate that the patient was at risk for pressure injury formation?
A) The patient ate two thirds of breakfast.
B) The patient has fecal incontinence.
C) The patient has a raised red rash on the right shin.
D) The patient's capillary refill is less than 2 seconds.
Pressure Injury
Damage to the skin and underlying tissue caused by prolonged pressure, frequently seen in patients who are bedridden or use wheelchair.
Fecal Incontinence
The inability to control bowel movements, leading to the involuntary loss of stool.
Capillary Refill
The time taken for color to return to an external capillary bed after pressure is applied; a measure of peripheral perfusion and circulatory status.
- Acquire knowledge about the hazards and prevention techniques for the onset of pressure ulcers.
Verified Answer
DA
Dr Atul SinghJul 12, 2024
Final Answer :
B
Explanation :
The presence and duration of moisture on the skin increase the risk of pressure injury formation by making it susceptible to injury.Moisture can originate from wound drainage,excessive perspiration,and fecal or urinary incontinence.Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened,which causes maceration.Eating a balanced diet is important for nutrition,but eating just two thirds of the meal does not indicate that the individual is at risk.A raised red rash on the leg is a concern and can affect the integrity of the skin,but it is located on the shin,which is not a high-risk area for skin breakdown.Pressure can influence capillary refill,leading to skin breakdown,but this capillary response is within normal limits.
Learning Objectives
- Acquire knowledge about the hazards and prevention techniques for the onset of pressure ulcers.