A nurse is assessing a 75-year-old client for risk factors that may predispose to integumentary problems. Which assessment finding would be most concerning as a primary risk factor for skin breakdown?
1History of smoking 1 pack of cigarettes per day for 20 years
2Body mass index (BMI) of 32 kg/m²
3Takes daily multivitamin and vitamin C supplements
4Serum albumin level of 2.8 g/dL (normal: 3.5-5.0 g/dL)✓ 정답
해설
Low serum albumin (2.8 g/dL) indicates protein malnutrition, which impairs wound healing and increases skin breakdown risk in elderly clients. Other options (smoking, obesity, vitamin supplements) are less direct risk factors for skin integrity issues.
Core Nursing ExplanationKey Concept Analysis: This question assesses your ability to identify the primary physiological risk factor for skin breakdown, particularly in an elderly client. The core theme is the link between nutritional status and tissue integrity. Skin integrity depends on adequate protein for cell repair, collagen synthesis, and maintaining oncotic pressure to prevent edema. Serum albumin is a key laboratory indicator of protein nutritional status and visceral protein stores.
Answer Rationale: The client's serum albumin level of 2.8 g/dL is significantly below the normal range of 3.5-5.0 g/dL. Key Point! Hypoalbuminemia (low serum albumin) is a primary and direct risk factor for skin breakdown because it leads to:
1. Impaired wound healing due to lack of protein substrates.
2. Decreased oncotic pressure, causing fluid to leak into interstitial spaces (edema), which stretches the skin, reduces blood flow, and makes it more susceptible to shear and pressure.
3. General muscle wasting and loss of subcutaneous tissue, reducing natural padding over bony prominences.
In an elderly client, who already has age-related thinning of the skin and decreased tissue perfusion, this nutritional deficit dramatically increases the risk for pressure injuries (pressure ulcers).
Distractor Analysis:
• Watch out for confusion! Option 1 (Smoking history): Smoking is a secondary risk factor. It causes vasoconstriction and reduces tissue oxygenation, which impairs healing, but it is not the most concerning primary physiological risk factor identified in this specific assessment list. The direct lab value indicating malnutrition is more critical.
• Option 2 (BMI of 32 kg/m²): Obesity (BMI ≥30) is a risk factor due to immobility, increased sweating, and skin folds, but it is not as directly linked to the impaired healing capacity as severe protein deficiency. A low BMI would be a more direct nutritional risk.
• Option 3 (Daily vitamin supplements): This is actually a protective factor, not a risk factor. Vitamins, especially Vitamin C, are essential for collagen synthesis and support skin health.
Related Concepts: This integrates knowledge of gerontological nursing (age-related skin changes), nutritional assessment (using serum albumin as a marker), and fundamentals of nursing (preventing pressure injuries). Always prioritize lab data indicating systemic physiological compromise when assessing for risk.
Concept Summary
• Primary Risk for Skin Breakdown: Impaired nutritional status (specifically protein deficiency) > Impaired mobility > Moisture > Sensory perception.
• Serum Albumin: A visceral protein; half-life of ~20 days; reflects chronic protein status. Levels < 3.5 g/dL indicate risk.
• Braden Scale: A tool used to predict pressure injury risk, assessing sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Side-by-Side Comparison!
Risk Factor
Mechanism of Increasing Skin Breakdown Risk
Nursing Implication
Low Serum Albumin (
임상 시나리오
Nursing Clinical Practice GuideClinical Scenario: You are caring for Mr. Johnson, a 75-year-old admitted for generalized weakness. During your shift assessment, you note he is very thin, has slight edema in his sacral area, and is mostly bed-bound. His chart reveals a serum albumin level of 2.7 g/dL from yesterday's labs.
Nursing Intervention Strategy:
1. Assessment: Perform a comprehensive skin assessment using the Braden Scale. Document any redness (non-blanchable erythema) over bony prominences (sacrum, heels, trochanters). Assess his nutritional intake (24-hour recall), ability to chew/swallow, and any signs of depression affecting appetite.
2. Planning & Implementation:
• Skin Protection: Place him on a pressure-redistributing mattress. Implement a strict turning schedule (every 2 hours) and document positioning. Use pillows for off-loading heels and between knees.
• Nutritional Support: Collaborate with the registered dietitian. Initiate a high-protein, high-calorie diet as tolerated. Offer small, frequent meals and protein-rich snacks. If oral intake is poor, discuss the possibility of nutritional supplements (e.g., Ensure Plus) or, if necessary, a feeding tube with the healthcare team.
• Moisture Management: Keep skin clean and dry. If incontinent, use a gentle cleanser and apply a moisture-barrier ointment (e.g., zinc oxide) to protect the skin.
3. Evaluation: Monitor for any new areas of skin breakdown. Reassess Braden Scale score daily. Follow-up serum albumin and prealbumin levels to evaluate the effectiveness of nutritional interventions.
Patient Safety and Precautions: Never massage reddened areas, as this can cause further tissue damage. Use lift sheets to move the patient, avoiding friction and shear. Be cautious with adhesive tapes on fragile skin; use silicone-based or paper tape if needed.
Nursing Procedure & Medication FlowProcedure: Performing a Pressure Injury Risk Assessment
1. Gather supplies: Braden Scale form, penlight for good visualization.
2. Explain the process to the patient.
3. Systematically assess each subscale: Sensory Perception, Moisture, Activity, Mobility, Nutrition, Friction/Shear.
4. For "Nutrition," document: "Usually eats < half of most meals" or "Very poor intake" based on observation and chart review. A low albumin level directly impacts this score.
5. Total the score. A score of ≤18 indicates risk; ≤12 indicates high risk.
6. Document findings and communicate the risk level to the care team.
Medication/Nutrition Flow: When administering oral nutritional supplements:
• Check for patient allergies.
• Offer between meals to avoid affecting regular meal intake.
• For patients with swallowing difficulties (dysphagia), ensure the supplement is of the appropriate consistency (e.g., nectar-thick) as per a speech-language pathologist's recommendation.
A Word from Your Senior Nurse
"Remember, the skin is the body's largest organ and a direct reflection of internal health. When you see a low albumin level, you're not just looking at a number on a lab report—you're seeing a patient whose body is struggling to build and repair itself. Your vigilant skin assessments and proactive interventions are the first line of defense against painful and preventable pressure injuries. In clinical practice and on the NCLEX, always connect the dots: poor nutrition → weak tissue → high risk for breakdown. Your role in advocating for nutritional support is absolutely critical to patient outcomes."
핵심 개념
Serum Albumin — A protein made by the liver; a key indicator of nutritional status (specifically protein stores). Low levels (
Pressure Injury (Pressure Ulcer) — Localized damage to the skin and underlying soft tissue, usually over a bony prominence, due to prolonged pressure or pressure in combination with shear.
Braden Scale — A validated tool used to assess a patient's risk for developing pressure injuries. It scores six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.
Hypoalbuminemia — The condition of having an abnormally low level of albumin in the blood. It is associated with malnutrition, chronic illness, and poor clinical outcomes.
Oncotic Pressure — The osmotic pressure exerted by proteins (like albumin) in the blood plasma. It helps keep fluid within the blood vessels. Low oncotic pressure leads to edema.