Question

NM 121

Skin Case

StudyCase Scenario

“Oh no,” muttered Ann, a registered nurse(RN), as she turned over the client and looked at her client’s back. A large, black-purple area was evident on the buttock’s region. A wave of guilt passed through Ann. She had tried to get help earlier—it took two people to turn this heavy lady—but the unit was busy, and another client’s blood pressure had crashed.

Ann pushed pillows behind Mrs. Jackson’s back and put the sheet down lightly. She knew that Mrs. Jackson was in pain and that the area on the buttocks would become a serious pressure ulcer. Ann pulled herself together and put on the call light so that she could ask the nurse manager to come down and look at the area. Then she started to think about what she should do to help this patient.

Mrs. Jackson could tell something was wrong when the nurse turned her. She heard the, “Oh no,” but all she knew was that she hurt. She wanted to lie still, so the pain would be less, but this nurse had asked so nicely, she really seemed to care. Now, Mrs. Jackson was lying in her new position, still unmoving, hoping the pain would subside.

Nursing Assessment Including Client Story

Mrs. Jackson is a 59-year-old woman admitted for femoral-popliteal bypass graft surgery. She has type II diabetes,very poor appetite and is morbidly obese. Mrs. Jackson has an indwelling Foley catheter that needs to be removed but Mrs. Jackson is refusing due to the pain when she moves. When therapy sees the patient, it takes moderate assistance of 2 therapists to get Mrs. Jackson to the bedside.

She married her high school sweetheart when she was 18 years old. She and her husband, who is chronically ill with heart disease, have three grown children. At home, she spends most of her time in an electric wheelchair watching tv or playing games on her computer.

Her leg is acutely painful, and she is difficult to move, secondary to postoperative pain. Sometimes she refuses to move. When performing morning care, the nurse finds a black-purplish soft area 4 inches in diameter on Mrs. Jackson’s buttock area.

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1. ASSESS

1. Complete a Braden Scale for Mrs. Jackson and attach to the case study

2. DIAGNOSE

1. Write one nursing diagnostic statement for Mrs. Jackson. (You need a three part-statement)
   1. The problem, etiology (rationale), and AEB (signs and symptoms)

3. PLAN

Write one outcome. (The goal needs to be a SMART goal and patient-centered)

4. Intervention

Write three nursing interventions with rationales. (What will you do to help Mrs. Jackson meets her goal)

Answer 1

A. on part of assessment Mrs. Jackson is on score of 11 or below on Braden scale which indicate high risk of pressure ulcer/sore.

B. Impaired Skin Integrity related to malnutrition, obesity and pressure ulcers as evidence by disruption of epidermal and dermal tissues.

C. Patient will not have any further skin breakdown during the hospitalization.-Patient’s wounds will be kept clean and free from any further infection.

D. -Patient will be turned every two hours. (rational- so pressure on pressure points can be relived)

-Patient’s wounds will be changed daily per wound care orders and proper hand hygiene will be performed before and after dressing changes. (rational- so further complication due to secondary infections can be prevented and fasten wound healing)

-Patient will be started on TPN per MD order and will be weighed every day. (rational- so recovery can be fasten)