Wound Care Case Study PDF

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Wound Care: Case Study Mrs. Vincent, 80 years old, was admitted to a medical surgical unit from a nursing home. Admitting diagnosis is altered mental status and stage III pressure ulcer on sacrum. She also presented with surgical incision on abdomen with staples and draining serosanguineous discharge. According to the daughter “she had no idea when she developed this bedsore and how?” She mentioned she has been in bed since the last one after she had a stroke. Mrs. Vincent is White American, has a history of diabetes, CAD, hypertension and right sided CVA. Surgical history: recent Cholecystectomy. Pharmacologic: Metformin 500mg once a day, aspirin 325mg daily, Lopressor 50mg twice a day and Heparin sodium 5000 Units once a day. Questions: 1. Describe the factors that affect skin integrity? Skin integrity can be affected by genetics, age, and the underlying health of the individual as well as external factors such as activity. Genetics and heredity determine many aspects of a person’s skin including skin color, sensitivity to light, and allergies. Age influences skin integrity in that the skin of both the very young is more fragile and susceptible to injury than that of the average adult. Many chronic illnesses and their treatments also affect skin integrity.

2. What is pressure ulcer? Please describe the stages of pressure ulcer. Pressure ulcers consist of injury to the skin and/or underlying tissue usually over a bony prominence as a result of force alone or in combination with movement. They are due to localized ischemia, a deficiency in the blood supply to the tissue. Stage 1 is a nonblanchable erythema area signaling potential ulceration. Stage 2 is partial-thickness skin loss involving the epidermis and

possibly the dermis. Stage 3 is full-thickness skin loss involving damage or necrosis undermining of adjacent tissue. Stage 4 is full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such a tendon or joint capsule. An unstable/unclassified pressure ulcer is a full-thickness skin or tissue loss. A pressure ulcer with an unknown depth is a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

3. What were some contributory factors for Mrs. Vincent to develop pressure on ulcers? Friction and shearing had a role in her developing a pressure ulcer because of prolonged sitting, immobility for the same reason as stated before, decreased mental status, advanced age and she also has a few chronic medical conditions such as CAD, hypertension, diabetes, and right sided CVA.

4. Describe the three phases of wound healing. The three phases of wound healing consists of the inflammatory phase, the proliferative phase, and the maturation or remodeling phase. The inflammatory phase begins immediately after injury and consists of two major processes which are hemostasis and phagocytosis. Hemostasis is vasoconstriction of the larger blood vessels, retraction is injured blood cells, deposit of fibrin and the formation of blood clots. Proliferative phase is the second phase of healing which occurs from day 3-21 postinjury. Collagen forms in the wound and capillaries grow across it as well. The area may also be covered with dried plasma proteins and dead cells. Lastly, the maturation phase begins on day 21 and can extend a year or two. Fibroblasts continue to synthesize collagen and the wound is remodeled and contracted. Scarring can occur as well as keloids. 5. What are different types of wound exudate? Exudate is material, like fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces. The different types of

exudate are serous exudate, purulent exudate which is thicker than serous exudate because of pus, and sanguineous exudate that consists of large amounts of red blood cells, often seen in open wounds.

6. Describe care and nursing strategies to treat pressure ulcers and promote wound healing. The nurse would teach the client how to maintain intact skin and how to promote wound healing. A nurse would also use the technique of moist wound healing to ensure that the wound isn’t too wet or dry. The nurse would also encourage the client to drink at least 2,500 mL of fluid and ensure that the patient is receiving adequate vitamin C, A, B, B5 and zinc. The nurse will also maintain aseptic techniques to keep the wound from microorganisms and pathogens. The nurse will even implement off-loading, or positioning to keep pressure off of the wound. To prevent pressure ulcers a nurse will maintain skin hygiene while minimizing friction and skin irritants. Avoiding skin trauma by providing a wrinkle-free foundation and positioning. Also, by using supportive devices to maintain circulation like pillows and wedges, alternating pressure mattress and beds made for improved circulation.

7. Describe some of the complications of wound healing. Complications of wound healing include hemorrhage, infection, and dehiscence and evisceration. Hemorrhage is a massive bleed that is abnormal and has the greatest risk of occurring the first 48 hours, infection is the contamination of a wound with microorganisms at the time of injury, during surgery or after. Dehiscence is partial or total rupturing of a sutured wound and usually involves an abdominal wound in which the layers below the skin also separate. Evisceration is the protrusion of internal viscera through an incision.

8. Discuss the Braden scale for Mrs. Vincent.

The Braden scale for Mrs. Vincent would be under 15 which means that she is at a fall risk. I got approximately a 12-13 because I didn’t have enough information on her nutrition. The Braden scale is separated into 6 parts which are sensory perception, moisture, activity, mobility, nutrition and friction and shear. The maximum score is a 23 with anything below 15 being a fall risk. Each category has a maximum of 4 points except friction and shear which has three. Mrs. Vincent is at a 1 in sensory perception because she has a limited ability to feel pain from the pressure ulcer. She is occasionally moist because she is bed ridden. Her activity level is confined to the bed. Her mobility level is very limited because she cannot move her body without moderate help with the exception of her limbs. Her nutrition is unknown but from her medications, she may need assistance with nutrition. Lastly, her friction and shear score is a problem because she is unable to move without assistance....