Question

A 6-year-old male with cerebral palsy is hospitalized for respiratory distress secondary to aspiration pneumonia. During the patient's third day in ICU, he remains ventilated and sedated. During a skin assessment, the nurse notes an open area on the patient's occiput with the skull visible adipose. During handoff, it was reported that the skin was intact. Upon review of the original assessment, there is no documentation of any open areas. 1. Identify the factors that place this patient at risk for pressure injuries? 2. Identify the stage of the pressure injury and rationale supporting why. 3. Is this pressure injury hospital-acquired? Why or Why not? Indicate any reporting actions that need to occur and why as well as any impact payment. 4. Identify two interventions that can be delegated to a UAP to assist with the management of the pressure injury? Be specific regarding what and how you would communicate to the UAP to ensure clear communication and maintain patient safety.

Answer 1

1. The factor that placed the skin of this patient at risk for pressure ulcer is immobilisation .

2. The stage of the pressure injury is stage 3 because the adipose is visible .

Stage -3 Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

3. Yes , this pressure ulcer is hospital acquired because the health care workers haven't provided necessary the skin care and positioning required for the patient .

Incident report has to be filled regarding the same and action against those healthcare workers who were caring this patient should be taken.

4. Two interventions delegated to UAP :-

- assistance in skin care

- assistance in positioning