Question

Care Plan: Prevention and Management of Pressure Ulcers You are the nurse working on a medical intensive care unit and take the following report from the emergency department. There is a patient to be admitted to your unit, Rosa Lewis. She 15 an 82 year old frail woman who has been residing in a nursing home. Her admitting diagnosis 15 sepsis, pneumonia, dehydration and she has a stage III pressure ulcer on her sacrum. Her past medical history is CVA with residual right sided weakness and paresthesia, MI, and peripheral vascular disease. Her vital signs are B/P 96/62, P 88, and R. 38 and labored, T 100.4 She is 411" and weighs 92 pounds. Labs, urine culture, and blood cultures have been drawn in the emergency room and are pending. She has 02 by face mask at 2 liters per minute, IV of D5 in 0.45% normal saline started with a 20 Insyte catheter in her left lower arm, and an indwelling Foley catheter. The infectious disease doctors have been notified and respiratory is with the patient assisting with the transfer of the patient - they are just leaving the emergency department and will be arriving on the unit shortly. During your admission skin assessment, you note that she has very dry, thin, almost transparent skin. There are several areas of ecchymosis on her upper extremities. You note on her admission summary her weight is 92 pounds and height is 4'11" There is a wound 4 cm long, Z cm wide and 1 cm deep on her sacrum. There is no noted necrosis, no wound odor, and scant amount of serosanguinous drainage. There are no known allergies to medications, Physician Orders: D 5 in 1 normal saline at 75 ml/hour Ampicillin 250 mg IV every 6 hours Tylenol 325mg two tabs every 6 hours for pain or temperature above 100.4 Compazine 10 mg per rectum for nausea or vomiting! Coumadin 5 mg one tablet by mouth daily Digoxin 0.25 mg one tablet by mouth daily Enalapril 10mg one tablet by mouth daily Robitussin 15mL every 4 hours prn for cough PT/OT to evaluate and treat ST for swallowing evaluation Dietary consultation - skin integrity/weight management

Answer 1

1.The diet plays an important part of the treatment .A diet low in protein delays wound healing .Along with this dry and thin skin can put the patient under further risk for pressure ulcer.The patient weighs only 92 pounds where it is underweight in regards to her age.So weight management is needed for regaining the health.

2.Some of the area where special attention are needed

• Right side of the patient has weakness and paresthesia which is at risk for pressure ulcer so the right shoulder, right elbow,wrist joint,right ankle and knee needs special attention. The range of motion exercises, passive exercises can be done to prevent ulcers.

3.It is important to address the progress of the wound healing from the time of admission.Can compare the wounds progress or aggravation and help to plan for treatment

4.Stage an ulcer refers to the level of the ulcer or the grading of an ulcer depending upon how far it has affected or damaged the skin layers.