Question

1. You are a visiting nurse caring for a 32-year-old writer who became paraplegic as a result of a motorcycle accident 1 year ago. He is recovering from a subsequent depression; your visits are to monitor not only his emotional outlook but also to encourage his hygienic self-care and offer strategies for his success. He wears a leg bag and is incontinent of stool. You are monitoring a red spot on his left buttock, which has progressed to a pressure injury in which subcutaneous fat is visible. (Learning Objectives 3, 4, 5, and 6)
   1. What specific assessments should be performed to prevent formation of pressure injuries?

3. How would you stage his pressure injury?

4. Indicate the information that would be included in an assessment of his wound.

5. Identify appropriate outcomes for this patient’s care plan.

Answer 1

1.To prevent pressure sores:

a. Daily skin inspection.

b. Keep changing position of patient .if he is bedridden every 2 hours.

c. Keep skin healthy by appropriate hygienic measures.

d. Use water beds or cushioned protectors.

e. To keep immunity up by maintaining good nutrition.

2.His pressure injury is of Grade 3.:Full thickness skin loss with subcutaneus fat visible.

3.Information included in the assessment of his wound are: Location of ulcer, depth of ulcer, size in cms, color of ulcer, presence of sinus tracts, undermining, discharge, granulation, surrounding skin.

4.Appropriate outcomes for this patients care plan :

a. To relieve further pressure on skin by appropriate measures.

b. To reduce further skin breakdown.

c. To protect against moisture.

d. Debridement of ulcer with norma saline.

e. Remove necrotic debris.

f. Protect surrounding skin.