Which of the following clients would least likely be at risk of developing skin breakdown?
A. A client incontinent of urine feces.
B. A client with chronic nutritional deficiencies.
C. A client with decreased sensory perception.
D. A client who is unable to move about and is confined to bed.
Correct Answer: C. A client with decreased sensory perception.
Bed or chair confinement, inability to move, loss of bowel or bladder control, poor nutrition, absent or inconsistent caregiving, and decreased sensory perception can contribute to the development of skin breakdown. The least likely risk, as presented in the options, is the decreased sensory perception. Options A, B, and D identify physiological conditions, which are the risk priorities.
Option A: Assess for fecal/urinary incontinence. Stool may contain enzymes that cause skin breakdown. The urea in urine turns into ammonia within minutes and is caustic to the skin. Use of diapers and incontinence pads hastens skin breakdown.
Option B: Usually, individuals change position off pressure areas every few minutes; these occur automatically even during sleep. Patients who are unaware of sensation tend to do nothing thus results in prolonged pressure on skin capillaries and eventually in skin ischemia.
Option D: Specific areas where the skin is stretched tautly are at higher risk for breakdown because the possibility of ischemia to the skin is high as a result of compression of skin capillaries between a hard surface (e.g., mattress, chair, or table) and the bone. For lightly pigmented skin, pressure areas appear to be red. For darker skin tones, these areas appear to be red, blue, or purple hue spots.
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