Question

A nurse is caring for a client with paraplegia. Using observation to examine the client's skin, what finding might indicate the presence of a pressure injury?

A) An intact red area on the buttocks.
B) An area of swollen, pale red bumps on the front of the neck.
C) A circular red, scaly area that itches on the top of the forearm arm.
D) An intact faded purple area on the shoulder blades, with a yellowish tint.

Answer 1

An intact red area on the buttocks might indicate the presence of a pressure injury in a client with paraplegia. Early detection is essential for preventing progression and complications such as infection. Nurses play a crucial role in bedsore prevention and treatment through regular patient assessments and interventions.

Step-by-step explanation:

To determine if a client with paraplegia has a pressure injury, a nurse would observe the skin for specific indications. One potential finding that might indicate the presence of a pressure injury is A) An intact red area on the buttocks. This area is typically under pressure when the patient is lying down or seated, and the intact redness could signify an early stage of bedsore formation, known as a Stage I pressure ulcer, where the skin is not yet broken.

Bedsore prevention is crucial and involves regular repositioning to alleviate pressure, ensuring good nutrition for skin health, and maintaining skin cleanliness and dryness to prevent infection. Recognizing the early signs of a bedsore, such as persistent redness on bony areas, can prevent progression to more severe stages where the skin breaks down and the risk of infection increases.

Bedsores can worsen and lead to serious complications like necrotizing fasciitis if not treated promptly and appropriately. The treatment includes removal of necrotic tissue and management of any infection that may have developed. Bedsores are a serious concern, particularly in individuals with limited mobility, and require diligent care and monitoring.