Question

You have been assigned to care for Mr. Alvarez, a 74-year-old client being treated for a urinary tract infection. He suffered a cerebrovascular accident (stroke) 6 months ago and has had difficulty ambulating and attending to his own needs because of right-sided weakness. He is thin for height, incontinent of foul smelling urine, and has non-blanchable erythema on his coccyx and peritoneal area. He is alert and oriented to person, place, and time. He has decreased sensation on his entire right side. He spends most of his time in bed or sitting in a chair. What data suggests that Mr. Alvarez is particularly vulnerable to pressure sore development? What additional information does the nurse need in order to use the Braden Scale to determine his potential for pressure injury development? How should the nurse stage the noted areas of erythema? Based on the information provided in the case scenario, what nursing diagnoses are appropriate for this patient? What independent nursing interventions can the nurse provide to protect him from further skin breakdown?

Answer 1

The data like difficulty ambulation, right side weakness,non-blanchable erythema at coccyx and peritoneal area,decrease in sensation suggests the patient's vulnerability for pressure sore.

The ad ditional information needed to use the Braden scale to determine the potential for pressure ulcer are

• Diet if the patient. Lack of good nutritious diet and inadequate fluid intake can damage a skin easily
• Assessing dlr other disease condition which affects the circulation at the site
• Presence of any friction when patient lies in the bed

It is in stage one where the skin is still intact but redness is present

Nursing diagnosis

• Impaired skin integrity related to disease condition as evidenced by erythema, poor mobility
• Intervention
  • Assess the skin condition, to get baseline data and plan for care
  • Position changing ,once in two hours can relieve pressure
  • Back care daily or in every shifts
  • Keeping the skin dry because moisture can lead to skin breakdown easily
  • Application of moisturizer, oil can prevent dryness