The nurse determines the risk for a pressure ulcer in an older adult who is 6 feet tall and weighs 155 pounds.Which patient information should the nurse use in planning care to reduce this individual's risk for a pressure ulcer?

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One area of concern the nurse should address is the potential for skin breakdown related to possible pain or immobility due to arthritic changes.The nurse also plans care to address dehydration as a significant risk factor for pressure ulcers because this man is underweight,malnourished,and dehydrated as evidenced by dry mucous membranes.Dehydration increases the risk for pressure ulcers because water is essential for intracellular functioning and cell durability.The nurse plans care based on the assessment of hypoproteinemia because this man is underweight and malnourished,significantly increasing his risk for pressure ulcers.
A fasting glucose showing hyperglycemia is a clinical indicator of diabetes mellitus; therefore the nurse plans care to manage the hyperglycemia.Diabetes mellitus increases the risk of pressure ulcers as a result of the greater likelihood of impaired tissue perfusion,impaired wound healing,and a greater occurrence of peripheral neuropathies.In addition,impaired tissue sensation as a result of nerve damage from hyperglycemia increases the risk of injury and infection for individuals with diabetes mellitus.A characteristic of type 1 diabetes mellitus is a low weight-for-height ratio.This man has limited resources for obtaining food,considering that he uses food stamps,and is therefore at risk for malnutrition,which increases the risk for pressure ulcers.Osteoarthritis in the neck is not related to the nursing care planned to reduce the risk for pressure ulcers; it should not impair this older adult's mobility or ability to obtain and prepare food.His sodium level is within normal limits.

The Nurse Determines the Risk for a Pressure Ulcer in an Older