Fundamentals of Nursing Q 54
A nurse is assessing several clients in a long-term health care facility. Which client is at highest risk for the development of decubitus ulcers?
A. A 79-year-old malnourished client on bed rest.
B. An obese client who uses a wheelchair.
C. An incontinent client who has had 3 diarrhea stools.
D. An 80-year-old ambulatory diabetic client.
Correct Answer: A. A 79-year-old malnourished client on bed rest.
Weighing significantly less than ideal body weight increases the number and surface area of bony prominences which are susceptible to pressure ulcers. Thus, malnutrition is a major risk factor for decubitus, due in part to poor hydration and inadequate protein intake. Both external and internal factors work simultaneously, forming these ulcers. External factors; pressure, friction, shear force, and moisture and internal factors; fever, malnutrition, anemia, and endothelial dysfunction speed up the process of these lesions.
Option B: Immobility of as little as two hours in a bedridden patient or patient undergoing surgery is sufficient to create the basis of a decubitus ulcer. The dysfunction of nervous regulatory mechanisms responsible for the regulation of local blood flow is somewhat culpable in the formation of these ulcers. Prolonged pressure on tissues can cause capillary bed occlusion and, thus, low oxygen levels in the area. Over time, the ischemic tissue begins to accumulate toxic metabolites. Subsequently, tissue ulceration and necrosis occur.
Option C: The development of decubitus ulcers is complex and multifactorial. Loss of sensory perception, locally and general impaired loss of consciousness, along with decreased mobility, are the most important causes that aid in the formation of these ulcers because patients are not aware of discomfort hence do not relieve the pressure.
Option D: Elderly patients are more prone to sacral decubitus ulcers; two-thirds of ulcers occur in patients who are over 70 years old. There is data that shows 83% of hospitalized patients with ulcers developed them within five days of their hospitalization.