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Maria Hernandez is an 80-year-old Hispanic female. She is widowed and lives alone in a senior...

Maria Hernandez is an 80-year-old Hispanic female. She is widowed and lives alone in a senior housing apartment. Her two children live out of state. She spends most days watching television, rarely leaving her apartment. Mrs. Hernandez was admitted for surgical debridement of a non-healing sacral ulcer, which has been present for several months.

1. What are some non-pharmacological measures that can be used for pain relief in care for this patient?

2. What vital signs could be indicative of complications for this patient?

3. Based on what you’ve learned about the nursing process, describe one applicable nursing diagnosis, treatments, and nursing considerations for this diagnosis.

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1. Non -pharmacological measures to relieve pain:

  • Change of wound dressing and use of appropriate dressing material to relieve pain.
  • Encourage for deep breathing exercises.
  • Frequent change of position and make her sit on rubber pillow.
  • Use of Alternative therapies such as music therapy, meditation.
  • Complementary therapies of acupuncture and acupressure.
  • Muscular relaxation therapy and guided imagery practices.

2. vital signs that could be indicative of complication:

  • Temperature >101F
  • Increased pain around the wound
  • Swelling and redness on the wound area
  • purulent drainage from the wound site

3. Nursing Diagnosis:

Impaired tissue integrity related to immobility as evidenced by the destruction of skin layers, pus production.

Nursing considerations:

  • Assess the client level of sensation and infection
  • Make awareness of frequent position changing and mobility.
  • Apply non-pharmacological measures to relieve pain
  • Assess the nutritional status and improve nutritional intake.
  • Provide proper tissue care.
  • Administer antibiotics.
  • Prevent complications.
  • Educate about the surgical debridement and follow-up of care.
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