the nurse is evaluating a client who is at risk for skin breakdown. which characteristics would the nurse observe to determine there is a stage i pressure ulcer? select all that apply.

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01-12-2022
Medicine

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the nurse is evaluating a client who is at risk for skin breakdown. which characteristics would the nurse observe to determine there is a stage i pressure ulcer? select all that apply.

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jaspreetsharma jaspreetsharma · Answer 1 · 2022-12-06T05:43:27+01:00

A 2 cm by 2 cm by 0.5 cm wound that has a brown leathery appearance, What traits would the nurse look for to identify a phase I pressure ulcer.

Stage 3 sees the sore deteriorate and spread into the tissue under the skin, creating a little crater. Muscle, tendon, as well as bone will not be visible in a sore, but fat may. Skin breakdown can be brought on by trauma, friction, shear, dampness, pressure, and friction. These elements can harm and hurt skin either together or separately. Other factors that contribute to skin disintegration include immobilization, poor nutrition, incontinence, medicines, dehydration, pressure,altered mental status, and loss of feeling. To stop skin deterioration and to encourage healing, frequently reposition the patient by nurse. At least once every two hours, the immobile patient should be turned, according a set timetable. the nurse to avoid shear, keep the patient's posture at 30 ° or lower, if necessary.

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