Case study pressure ulcer Student PDF

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Case Study...

Description

Name _________________________________

Class/Group _______________

Date

_______________

Scenario You are a nurse working on the unit and take the following report from the emergency department (ED) nurse: “We have a patient for you: R.L. is an 81-year-old frail woman who has been in a nursing home. Her primary admitting diagnoses are sepsis, pneumonia, and dehydration, and she has a known stage 3 right hip pressure injury. Past medical history includes remote cerebrovascular accident with residual right-sided weakness and paresthesia, remote myocardial infarction, and peripheral vascular disease. She is a full code. 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 4 L per nasal cannula and an IV of D5.45 at 100 mL/hr. We just inserted an indwelling catheter. The infectious disease doctor has been notified, and respiratory therapy is with the patient—they are just leaving the ED and should arrive shortly.” 1. What major factors increase risk for developing a pressure injury? Mobility, Sensory, Moisture, Nutrition, Friction, and Shear 2. Each health care setting should have a policy that outlines how to assess patients’ risk for developing a pressure injury. What should be included in that assessment?  Activity and mobility level  General condition of the skin  Presence of coexisting physical conditions, including diabetes, cardiovascular instability, low BP, and oxygen use  Nutritional status, including hemoglobin, anemia, serum albumin levels, and weight  Fecal and urinary incontinence and general skin moisture 3. As part of R.L.’s admission assessment, you conduct a skin assessment. What areas of R.L.’s body will you pay particular attention to? Right side, bony prominences, sacrum, heels 4. What are the advantages of using a validated risk assessment tool to document her skin condition on admission? Braden Scale, Joint Commission’s patient safety goals 5. How often should patients be reassessed for the risk of developing an injury? Every shift

CASE STUDY PROGRESS During your assessment, you note that R.L. 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 person only. You review the transfer summary from the long-term care facility and note she has a history of urinary and fecal incontinence. 6. Evaluate R.L. with the Norton risk assessment scale. Physical

Mental Condition Activity

Mobility

Incontinence

Condition Date Good 4 Alert

4 Ambulant

4 Full

4

Not

4 Total

Fair Poor

3 Apathetic 2 Confused

3 Walk/help 2 Chair bound

3 Slightly Limited 2 Very limited

3 2

Occasional Usually/urine

3 Score 2 7

Very

1 Stupor

1 Bed rest

1 Immobile

1

Urinary and

1

bad

fecal

7. Knowing that R.L. is frail, has right-sided weakness, and has a pressure injury, what consultations or referrals could you initiate? PT/OT, wound care, speech therapy, infectious disease, Nutrition, Respiratory

CASE STUDY PROGRESS As you are completing R.L.’s assessment, the wound nurse specialist comes in. She knows R.L. from a prior admission; as soon as she received the request for a wound care consultation, she ordered a specialty mattress. She says an air overlay should be delivered to your unit before your shift ends. 8. Why is a specialty mattress used for immobile or compromised patients? The help reduce pressure, provide comfort, and eliminate bottoming out 9. Why are patients placed on specialty mattresses still at risk for skin breakdown? Because they will still need to be turned q2 hours, friction and shearing, 10. Why do the heels have the greatest incidence of breakdown, even when the patient is on a specialty mattress? Heels are covered by a thin layer of skin and fat, so they are a high risk for breakdown 11. What intervention can you initiate to protect R.L.’s heels? Apply heel protectors, Monitor skin on feet and ankles daily, elevate her calves on pillow position lengthwise to help relieve any pressure.

12. Compare friction and shear. Friction is the force of rubbing two surfaces against one another. Shear is a gravity force of pushing down on the patient’s body with resistance between the patient and the chair and or bed. 13. What risk factor does using a draw sheet prevent or minimize? Using a draw sheet to reposition or move the patient will help to distribute the pressure and help to minimize sheering forces to the skin that can result in skin tears. 14. Describe 6 interventions aimed at minimizing friction and shear. Establish a risk assessment per facility protocol, Pads and protect vulnerable arears, Use heel or elbow protectors, utilize positioning devices in wheelchairs or chairs to reduce shearing 15. Elevated skin temperature and perspiration increase risk for pressure injury. Write 4 specific measures to manage the microclimate. Apply skin barrier creams in sensitive areas, Apply dressings to manage drainage from wounds, Maintain a mild climate in the environment by avoiding excessive heat and humidity, Wear breathable clothing and change undergarments regularly.

16. Which instructions will you give to the UAP helping you care for R.L.? Select all that apply. a.Assess R.L.’s skin status every shift b.Develop an every-2-hour turn schedule c.Use the appropriate sheets on the airflow bed d.Keep R.L.’s head of bed below a 30-degree angle e.Assist with hygiene measures when R.L. is incontinent f. Empty and measure output in the urine collection device

17. Write an outcome related to R.L.’s skin integrity.

CASE STUDY PROGRESS The wound nurse needs to evaluate the preexisting pressure injury. She gently removes the old dressing, using the push-pull method and adhesive remover wipes. After taking off the outside

dressing, or the secondary dressing, she pulls out the primary dressing and states that R.L. has a tunneled wound that was “packed too hard.” 18. What problems can be created by packing a wound too full? If too much gauze is packed into the wound, it may create an environment that is too dry to allow the wound to heal, prompting the wound to remain concave and possibly exacerbate. Too much packing may also create more pressure within the healing wound, forcing it to extend further than its original edges. 19. The nurse systematically assesses the injury and confirms the presence of a stage 3 wound with moderate yellow drainage. There is no tissue necrosis or debris. What does it mean to “stage” a wound? Base Staging on the type of tissue visualized or palpated. Once you stage a wound it cannot be reversed when documenting a healing pressure ulcer. 20. What would you expect a stage 3 pressure injury to look like? Full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Some slough may be present.

21. What is a tunneling wound? What risk factors are associated with tunneling? A tunneling wound is any wound that has a channel that tunnels from the wound into/through the muscle or subcutaneous tissue. Risk Factors: Smoking, putting too much weight on the wound, corticosteroids, chemotherapy or immunosuppressant, Infection that has caused the destruction of tissue.

22. What are the dimensions of R.L.’s wound? 6 cm wide and 5 cm in length

CASE STUDY PROGRESS After the wound nurse obtains a set of wound cultures, you watch as she packs the wound with gauze. The wound nurse charts the findings and makes formal recommendations for management of the wound to the primary care provider. 23. When collecting a wound culture with a swab, the nurse should culture the a.Wound drainage b.Healthy-appearing tissue c.Most necrotic-appearing tissue d.Very outer edges of the wound

24. Describe the technique for packing a tunneled wound. Packing should fill the wound space completely, but not tightly. Use a cotton swab to gently guide the packing into small or tunneled ares. Open your outer dressing material and place it on the towel. Keep it away from the bowl, and don’t get it wet.

25. What factors influence the choice of a wound dressing? Wound and skin related factors, such as cause, severity, environment, condition of the peri wound skin, wound size and depth, anatomic location, volume of exudate, and the risk of infection. 26. What do you feel would be the best choice for dressing R.L.’s wound?

27. What wound documentation is necessary at this time? Location, Size, Stage, Discharge, Odor

28. Complete an example of a documentation entry for R.L.’s wound care. Wound Location Pressure Injury

Right Side Stage 3

Stage Wound Dimensions 6 cms width and 5 cm length Undermining Tissue Type Drainage

3.5 cm 60% granulation 40% slough Slightly yellow

Periwound Condition Cleansing Agents Dressing Type Applied

Normal salin Hydrogel

CASE STUDY OUTCOME

Despite aggressive treatment, R.L.’s sepsis and pneumonia are overwhelming, and she dies 9 days later from multiple organ failure....