Pressure Ulcer Prevention and Management week 10 PDF

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Case Study Pressure Ulcer: Prevention and Management Difficulty: Advanced Setting: Hospital Index Words: pressure ulcer, decubitus, pressure relieving and reduction, risk assessment, specialty bed, friction, shear, staging, wound culture Giddens Concepts: Collaboration, Tissue Integrity HESI Concepts: Assessment, Collaboration, Nursing Interventions, Tissue Integrity

u  You are a nurse working in the medical intensive care unit (ICu) 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 III right hip pressure ulcer. 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 a Foley 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-induced ulcer?

Immobility, poor nutrition,

2. Each health care setting should have a policy that outlines how to assess patients for their risk of developing a pressure ulcer. What should be included in that assessment.

The Braden scale is used

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? The boney areas, nares should be assessed, where her wound is.

4. What are the advantages of using a validated risk assessment tool to document her skin condition on admission?

This allows to catch any changes in the skin.

CaSE StuDy ProGrESS During your 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 person only. You review the transfer summary from the long-term care facility and note she has a history of urinary and fecal incontinence.

5. Evaluate R.L. with the Norton risk assessment scale. Physical Condition Date

Mental Condition

activity

Mobility

Incontinence

Good

4 Alert

4

Ambulant

4

Full

4

Not

Fair

3 Apathetic

3

Walk/help

3

2 Confused

2

Chairbound

2

Slightly Limited

3

Poor Very bad

1 Stupor

1

Bed rest

1

Very limited 2

3 Occasional usually/urine 2 urinary and 1 fecal

Immobile

1

4

Total Score

6. Given R.L.'s Norton score, describe specific measures you would implement to prevent further skin breakdown

8, change in reposition q2hrs , adequate nutrition and fluids, avoiding shearing, change wet patient frequently.

7. Knowing that R.L. is frail, has right-sided weakness, and has a pressure ulcer, what consultations or referrals would you initiate?

Would care, nutritional, air mattress

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 states that an air overlay should be delivered to your unit before your shift ends.

8.

Why is a specialty bed or mattress used for immobile or compromised patients?

To prevent development of would offload pressure on the body parts.

9.

Why do patients placed on specialty beds remain at risk for skin breakdown? They still can get wounds

10. What essential points should all staff know about the specialty bed? Not to use extra padding, no the settings of the bed.

11. Why do the heels have the greatest incidence of breakdown, even when the patient is on the most advanced specialty bed?

Due to the heels being on the bed, less flesh and bony area.

12. What intervention can you initiate to protect R.L.'s heels?

Offload the heels

13. Compare and contrast friction and shear.

B hi

h

i li j

i

h

i h

i

i j

14. What interventions are needed to reduce the possibility of shear? Use two person for moving, lift the patient completely. 15. What risk factor does using a draw sheet prevent or minimize?

Possible risk for shearing of the skin

16. In caring for R.L., it is important for you to instruct the UAP to do which of the following? 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

CaSE StuDy ProGrESS The wound nurse needs to evaluate the preexisting pressure ulcer. She gently removes the old dressing, using the push-pull method and adhesive remover wipes. After taking off the outside dressing, often called a secondary dressing, she pulls out the primary dressing and states that R.L. has a tunneled wound that was “packed too hard.”

17. What problems can be created by packing a wound too full?

It doesn’t allow tissue healing, causing more pressure on the wound.

18. The nurse systematically assesses the ulcer and confirms the presence of a stage III wound with moderate drainage. There is no tissue necrosis or debris. What does it mean to “stage a pressure ulcer”?

Staging is measurement of depth, area of the wound, to come with

19. What would you expect a stage III pressure ulcer to look like?

You would see the exposed tissue, full thickness of the skin and may extend into the subcutaneous tissue layer

20. What is a tunneling wound? What risk factors are associated with tunneling?

The wound would spread to the surrounding tissue area.

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.

21. Describe the technique for packing a tunneled wound. Do not pack the wound to tight,

22. What wound documentation is necessary at this time?

Depth, color smell, infection.

23. What factors influence the selection of wound dressing?

Size of the wound, type of wound, condition of the wound

24. What do you feel would be the best option for dressing R.L.'s wound? State your rationale. Foam dressing, it lasts longer and collects the drainage....