Question

A nurse assesses a patient's risk for developing a pressure ulcer using the Norton scale. The patient's score is 18. What nursing action should be implemented?

a. Call the physician immediately.
b. Implement a pressure ulcer prevention program.
c. Document the score.
d. Order an alternating air mattress.

Answer 1

With a score of 18 on the Norton scale, a nurse should implement a pressure ulcer prevention program and document the score. Immediate physician contact or ordering an alternating air mattress is not required based solely on the Norton scale score; instead, preventive care is customized to the patient's risk and needs.

Step-by-step explanation:

The Norton scale is a tool used by nurses to assess a patient's risk of developing pressure ulcers, also known as bedsores. A score of 18 on the Norton scale does not require immediate calling of a physician, which would be indicated for a more severe score. The appropriate nursing action with a score of 18 would be to implement a pressure ulcer prevention program which may include regular repositioning of the patient, the use of specialized mattresses or cushions, and skin care routines to protect against the development of ulcers.

It is also essential to document the score in the patient's medical records for ongoing care and assessment. While ordering an alternating air mattress could be part of a prevention program, it is not the automatic next step based solely on the Norton scale score. The priority is to initiate preventative measures tailored to the patient's individual risk and needs.