Question

Questions 1-14

Case Study: Prevention and Management of Pressure Ulcers You are the nurse working on a medical intensive care unit and was given the following report from the emergency department. There is a patient to be admitted to your unit, Anita Luego. She is a thin, frail woman who has been living in a nursing home for several years. Her admitting diagnosis is sepsis, pneumonia, dehydration and she has a stage Ill 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, 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 via face mask at 2 liters per minute, IV of D5 in 0.45% normal Saline started in a 20 Instye catheter in the 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 your admission summary her weight is 92 pounds and height is 4'11". there is a wound 4 cm long, 2cm 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

Answer 1

1). Electrolyte was ordered because she has been suffering from dehydration and her BP was low during admission so to monitor and improve her status from septic shock  ,, electrolyte was ordered.

Urine culture to identify the organism which caused sepsis,, sensitivity test to know any resistant antibiotics and to give appropriate antibiotic treatment for her better improvement

Pro thrombin was orderd because sepsis leads to DIC disseminated intravascular coagulation, where the patient may present with ecchymoses due to microvascular blockade and also leads to organ failure ,, thus to measure the clotting time of blood and to give appropriate dosage of heparin,, PT/INR was ordered daily .

2). The patient already has a history of cerebral vascular accident and myocardial infarction so care should be taken because sepsis may lead to relapse of these situations.

3). It is important to measure wound on admission because the progression and closure of wound should be monitored for better care of the patient .

4). According to the stages of ulcer medical management will be given it will include the size , redness , exposed part , depth of wound and presence of necrosis .

• Stage 1 intact skin with non blanchable redness of localized area
• Stage 2 partial loss of dermis with shallow open wound with redness
• Stage 3 full thickness tissue lost subcutaneous fat may be visible slough may be present
• Stage 4 full thickness muscle lost with exposed tendon or muscle

5). Dehydration will worsen the ulcer and necrosis may develop

Already existing pneumonia and parasthesia and peripheral vascular disease also contributes to poor prognosis of the ulcer .

6.) In stage 1 pressure ulcer the skin is intact redness seen and non blanchable

7).There will be damage or necrosis of the sub cutaneous tissue it usually involves the muscles, bone , tendon and  osteomyelitis can  occur .

8).Deep tissue injury - purple or maroon localized area of discoloured intact skin or blood filled blister due to damage of underlying soft tissue due to shear or pressure.

9).coumadin is an anticoagulant,, it will have a poor effect on wound healing ,, it may cause coumadin induced necrosis

10) in peripheral vascular disease, there will be narrowing of the blood vessels thus blood supply to the affected area will be low wich will cause poor prognosis of wound healing leading to necrosis .

11) ace inhibitors acts on angiotensin converting enzymes thus angiotensin 1  is not converted to angiotensin 2 thus lowering the blood pressure. It is used in hypertension. Adverse effects include dry cough , hypotension , hyperkalemia , acute renal failure in renal artery stenosis patient .its also fetopathic

12 ). Enteral nutrition is preffered because protection of gut mucosa , prevention of translocation of organisms via gut mucosa , reduction of complication rate . Pottasium , magnesium and phosphate levels must be corrected and maintained.

13). Sepsis is due to infection of organism mainly s aures and e.coli that affect the blood components and causes organ failure .so parenteral route is preffered because when given orally the chances of infection is of higher rate .

14). Paresthesia is tickling sensation caused by neuropathy due to cerebral vascular accident. Diet plays an important role because the patient is in need of high protein and energy