Pressure Ulcer Case study
Requirements
- No AI
- Plagiarism free
- APA 7 format
- Introduction and conclusion included.
- Ebook we use: Workman, D. I. M. L. (2020). Medical-Surgical Nursing (10th ed.). Elsevier
- It’s okay to use legit online references as well.
CASE STUDY - PRESSURE ULCER
You are a nurse working in the medical ICU and take the following report from the emergency department (ED) nurse: We have a patient for you; R.L. is an 89-year-old frail woman who has been in a nursing home. Her admitting diagnosis is sepsis, pneumonia, and dehydration, and she has a known stage III right hip pressure ulcer. Past medical history includes remote cerebrovascular accident (CVA) with residual right-sided weakness and paresthesia, remote myocardial infarction, and peripheral vascular disease. Her vital signs are 98/62, 88 and regular, 38 and labored, 100.4° F (38° C). Lab work is pending; she has oxygen at 10L via face mask, an IV of D5.45NS at 100 mL/hr, and an indwelling Foley. The infectious disease doctor has been notified, and respiratory therapy is with the patient—they are just leaving the ED and should arrive shortly.
Questions:
1. Knowing that R.L. is frail, has right-sided weakness, and a pressure ulcer, what consults would you initiate?
2. You conduct a skin assessment. What areas of R.L.'s body will you pay particular attention to? During your admission skin assessment, you note that she has very dry, thin, almost transparent skin. She has limited mobility from her stroke and is currently bedridden. There are several areas of ecchymosis on her upper extremities. She is alert and oriented to people only.
3. What major factors increase risk for the development of pressure-induced ulcers?
4. What are the advantages of using a validated risk assessment tool to document a patient's skin condition on admission?
5. Evaluate R.L. on the Norton Risk Assessment Scale. Norton scale/refer adobe version
As you are completing R.L.'s assessment, an enterostomal therapy (ET) and wound nurse specialist comes in. She knows R.L. from a prior admission; as soon as she received the wound care consult, she ordered a specialty mattress. She states an air overlay should be delivered to your unit before your shift ends.
7. Why is a specialty bed or mattress used for immobile or compromised patients?
8. Why do patients placed on specialty mattresses or beds remain at risk for breakdown?
9. What are the essential points all nurses should know about a specialty bed?
10. Why do the heels have the greatest incidence of breakdown, even when the patient is on the most advanced specialty bed?
11. What intervention can you initiate to protect R.L.'s heels?
12. Compare and contrast friction and shear.
13. What interventions are needed to reduce the possibility of shear?
14. What risk factor does using a draw sheet prevent or minimize?
15. While caring for R.L., it is important for you to instruct the UAP to: (Select all that apply.)
a. keep R.L.'s head of bed below a 30-degree angle.
b. assist with hygiene measures when incontinent.
c. develop an every 2-hour turn schedule.
d. assess R.L.'s skin status every shift.
e. use the appropriate sheets on the airflow bed.
f. empty and measure output in the urine collection device.
The wound nurse gently removes the old dressing, using the push-pull method and adhesive remover wipes. After she takes off the outside dressing, often called a secondary dressing, she pulls out the primary dressing and states that she has a tunneled wound that was packed too hard.
16. What problems can packing a wound too full create?
17. The nurse systematically assesses the ulcer and confirms the presence of a stage III wound. What does it mean to stage a pressure ulcer?
18. What is a tunneling wound? What are risk factors associated with tunneling?
19. For each of the four stages of pressure ulcers, describe the tissues involved and what you would expect the skin to look like.
After the wound nurse performs a set of cultures, you watch as she dresses the wound. The wound nurse charts the findings and makes formal recommendations for management of the wound to the primary care provider.
20. Describe the technique for packing a tunneled wound.
21. What factors influence the selection of wound dressing?
22. Describe five different types of wound dressings, including specific uses of each.
