Question

Case Study, Chapter 64, Introduction to the Integumentary System Alice Bixby, an 83-year-old female client js admifted with a cerebral vascular accident with the aphasia and hemiparesis (paralysis of the right side of the body). The client has global a has difficulty speaking or understanding what is said. The client is incontinent of urine and stool and wears adult incontinent briefs. The client has a thickened diet to nectar consistency because of dysphagia (difficulty swallowing). The client has been turned every 2 hours and has a pressure relieve mattress in place. The client has a history of chronic obstructive pulmonary disease and cannula at 2 L/minute with the SaO2 of 90%. The vital signs F: BP, loo 70 mm Hg: HR, 90 beats minute: RR, 22 breaths minute. The client is S wears continuous oxygen per nasal are T, 99° feet in height and weighs 90 pounds. There is a red area approximately 2 cm in d the right elbow that fails to blanch when pressure is relieved. There is a shallow cr subcutaneous tissue present and whi iameter under ater with in diameter on the te-tinged fluid, approximately 3 cm coccyx. On the right hip, there is a 2-em diameter deep area, with tunneling of 2 em in depth which is foul-smelling and has black tissue over it and presence of bone. Under the right heal is an area 1 cm in diameter, red, with a blister present. Under the ears where the nasal cannula lies are small red areas that blanch when the nasal cannula is removed. The LPN/LVN needs to use the criteria for staging pressure sores and evaluate the areas of skin breakdown appropriately. (Learning Objective7) breakdown described in the case study? b. What measures should be instituted to promote healing of the skin breakdown?

Answer 1

There are too many questions. I am giving answers of questions present in top 2 images.

Answers of question with case study

Answer of a.

1. under the right elbow , it is stage 1 pressure sore. Because it is just red and fail to blanch.

2. On the coccyx : it is stage 3 pressure sore because it is involving subcutaneous tissue and looks like crater and have bad smelling.

3. On the right hip : it is stage 4 pressure Sore because sore is so deep that bone is being visualising.

4. On the right heel : it is stage 2 pressure sore because only blisters are present.

5. Under the eat : it is not pressure sore. Because red area blanch when pressure removes.

Answer of b. Measure to promote healing

to promote healing, pressure relieve mattress is used and move patient in every 2 hrs. Both measures is being applied in this case. In addition to these 2 there should be adequate protein and vitamines supply through diet. Stage 1 and stage 2 Sores should be gently washed with saline and kept moist with moist gauge. Sore looks like crater(stage 3)or blister of stage 2 if broken Dead skin should be removed aseptically and pus should clear as well as dressing should be applied. Stage 4 sore need surgical interventions. Stage 3 and 4 sore also need IV antibiotics because these are infected. Foul smelling pus is sign of infection.

Answer of fill in the blank on second image.

1. Blood Dyscrassia

2. Alfa Thalassemias

3. Erythrocytosis

4.Leukemia

5. Multiple Myeloma

6. Agranulocytosis

7. Aplastic Anemia

8. Coagulopathy.