You are assigned to care for Mr. Roberts, a 74-year-old patient being treated for a urinary tract infection. Mr. Roberts suffered a cerebrovascular accident 6 months ago and has difficulty ambulating and attending to his own needs because of right sided paresis. While assessing Mr. Roberts you note that he is thin for his height, is incontinent of foul smelling urine and has deeply reddened areas on his right hip and coccyx. Mr. Roberts is alert and oriented to person, place and time, but he has decreased sensation on his entire right side. Due to his difficulty with ambulation, he spends most of his time in bed or in a chair at his bedside.
a. What data suggests that Mr. Roberts is at risk for pressure ulcer development?
b. Describe what additional information you need if you were to use the Braden scale to determine Mr. Roberts’ risk for pressure ulcer development?
c. Identify 3 nursing measures with associated scientific rationales that can be taken to protect Mr. Roberts from further skin breakdown?
d. You have identified that Mr. Roberts has a poor appetite. Identify strategies you can use to promote intake.
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