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 is an 82 year old frail woman who has been residing in a nursing home. Her admitting diagnosis is 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 4'11" 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, 2 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 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 pm for cough PT/OT to evaluate and treat ST for swallowing evaluation Dietary consultation - skin integrity/weight management

Answer 1

1.

• Maintain hydration
• Treat infection
• Decrease body temperature
• Avoid nausea and vomiting
• Avoid skin peeling and complication
• Enhance wound healing
• Treat cough

2. Mainly pressure points.

Patient is having wound in scrum. Main concentration given to sacral, back, occiput, back of the knee and ankle.

3. It is important to identify the pressure ulcer is community acquired or not.

4. First step is to determine the stage of pressure ulcer decide the treatment plan.

5.

• Nutrional factors
• Immobility
• Moisture
• Less physical activity

6.

• The skin is intact
• Dermis is affected
• Not spread in to the underlying tissues.

7. Stage 2 - underlying tissues are affected stage of necrosis and partial thickness of skin affected.

Stage 3- Full thickness of skin is closed.

Stage 4 - deep tissue damage muscles, tendons are affected.

8. The deep wound muscles, tendons all become affected, blood vessels are involved

9.it is a blood thinner, smoothen the blood flow to the necrotic tissue.

10. Peripheral vascular diseases impair the blood flow so it affecting the wound healing process.

11.Adverse effects of ACE inhibitors

• Metallic taste in mouth
• Kidney failure
• Hyperkalemia

12.

• The diet should include more protein to enhance healing.
• Avoid spicy and irritant foods.
• Increase fiber rich food.
• Drink lots of water to maintain hydration

13. Sepsis is defined as the infection causing inflammation throughout the body by blood.

When sepsis occurs it is difficult to cure the pressure ulcer. Become affected to the entire body.