Question

Pressure Injuries 149 CASE STUDY A 90-year-old patient at Valley View Hospital is currently bedfast. She is unable to turn and reposition herself. She has a reddened area on her coccyx. The nurse has delegated to you the task of turning and repositioning, as well as skin care. 4. For which complications may the person be at risk? Answer the following questions: 1. What additional information do you need before caring for this patient? A. What measures can help prevent these complications? B. To promote the person's comfort and safety, what questions might you ask? 2. What safety measures are needed when turning and repositioning? 3. After turning and repositioning, what observations do you need to report and record? DDITIONAL LEARNING ACTIVITIES

Answer 1

1.Some of the additional information needed before caring for this patient are

• The main complaint for admission, diagnosis to plan for care
• Having any past medical surgical history, medication, allergy, food types
• Confirming about restricted activity if any to prevent fracture and discomfort
• Any investigation to be performed to rule out the cause for bed fast

2.Some of the safety measures which are needed during turning and repositioning are

• Prevention of accidental fall when positioning the patient alone
• Taking care from injuring the skin during repositioning
• Always the side rails to be in a raised position
• All necessary equipment to be kept at bedside and reachable to the patient
• Providing call bell to the patient to call for help
• Taking are of any invasive lines during positioning to prevent dislodgement

3.The following observation must be recorded and reported

• The colour, moisture, temperature, turgor of the skin to be recorded
• presence of any redness, peeling,bruising,injury ,scars,edema to be recorded
• The occurance of rigidity, flacidity ofbthe musculoskeletal system

4.The person is at risk of developing bedsore ,Deep vein thrombosis, pneumonia, infection,musculoskeletal problems ,contracture, muscle weakness,urinary tract  problems

A.Some of the measures to prevent this complications are

• Positioning and skincare to prevent bedsore
• Passive range of motion exercise, physical therapy to relieve contracture and muscle weakness
• Change of wet diapers or catheterization to avoid discomfort raised out of urinary incontinence and increasing thw bedsore
• Massage therapy to ensure relaxation and blood circulation

B.Some of the questions to be asked are

• Is the patient having any problems link osteoporosis as it will lead to fracture
• Can patient be given musical therapy to relax the mind
• Is spiritual therapy allowed, people are more comfortable with this therapy at this age