Question

Skin Disorders 1

Mrs. B is an 87 year old female patient that is new to the Sunny Pastures nursing home. She had a stroke approximately 2 weeks ago. She is currently bedbound and total care. She is awake and alert but unable to communicate. She is able to respond to painful stimuli. She is currently being fed by mouth but eats only ½ of her meals due to dysphagia.

Based on the above stated information please determine Mrs. Bs risk for skin breakdown. What scale will be used?

When moving Mrs. B onto her side you notice a 4 by 2.5 cm reddened, non-blanchable area to her sacrum. There is no blistering of the skin, nor break in integrity. What type of skin alteration is this and what stage? What will likely be the treatment?

When changing her diaper, Mrs. B is noticed to have a red shiny rash in the skin folds of her lower stomach and labia minora. There are some yellow/white patches on portions of the rash that are easily wiped away. What type of rash is this? How will it likely be treated?

Please name some priority nursing diagnoses for this patient. How will your nursing care attend to these diagnoses?

Answer 1

1 Braden scale for predicting pressure sore risk.

2 Based on the situation,Braden scale assessment shows she is in stage 1 ,because the skin is intact with non balanchable redness of a localized area usually over a bony prominence.Darkly pigmented skin may not have visible blanching,its colour may differ from surrounding areas.Following precautions can help minimize the risk of developing pressure ulcers in at-risk patients.Avouid massaging bony prominences,turn patients every 2 hrs,,use positioning devices to prevent prolonged pressure bony prominences,keep the head of the bed as low as possible. Hydrocolloid and transparent dressing

3 Sores covered in dead skin that is yellow,tan,green or brown.The deadskin makes it hard to tell how deep the sore is.This type of sore is unstageable.

4 Impaired skin integrity related to ma;lnutrition and pressure ulcers as evidenced by disruption of epidermal and dermal tissues.

Nursing interventions

• Assess skin for signs of hydration pressure injury.
• monitor for signs of infection.
• Reposition the patient atleast every 2 hours.
• Assess patients level of sensation.