Abigail’s HF has improved, however, due to her inability to ambulate; she has developed an open area on her coccyx, measuring 4cm by 2cm and 1cm deep and a venous stasis ulcer on her right lower leg.
Her Unasyn has been discontinued, but her other medications remain the same.
This would be classified as which stage of skin breakdown?
Abigail has also developed a venous stasis ulcer on her right lower leg.
What type of wound care might be implemented and why? (Refer to Taylor)
What would be the priority nursing diagnosis?
What would be the outcome and why?
What interventions would be implemented? What is the rationale for each intervention?
How would you evaluate the nursing interventions?
Describe what a venous stasis ulcer is?
What is the difference between a venous ulcer and an arterial ulcer? Review Health Assessment notes.
How are each treated?
Ans
Pressure sore leads to the gangrene of the skin and primary closure with flap is needed
Nursing dignosis-is for pressure sore is more as compare to venous ulcer as these sore are expexted in case of long term aame position lying
Pressure sore lead to ulcer formation and resist to heal itself and inhibit the primary disease
Intervention
Change in postion for atleast 10 minutes in 2-3 hour period it lead to inhibit the development of pressure sore
For venous ulcer massage and compression bandage application is needed
Venous stasis ulcer- due to verious condition like vericose vein aur incompetence of deep vein valves it lead to development of venous ulcer which is superficial and single in number and non painful
Venous ulcer-. Arterial ulcer
Site-medial side of malliolus. Tip of toe
Number-single. Multiple
Pain- non painful. Painful
Cause- vericose vein. Vessel disease
Abigail’s HF has improved, however, due to her inability to ambulate; she has developed an open...
Over the last week Abigail's heart failure has worsened and she has developed pneumonia. While you are assessing the patient you now hear bilateral crackles, note 1+ pitting edema. She has dyspnea with any exertion, and is having difficulty eating. Her VS are: BP 178/100, HR 100 and irregular, RR 26 and labored and with a pulse ox of 90% on 3L of oxygen. The US of her leg was negative for DVT, but she continues to complain of pain...
Make a concept map, using the patient below.
Report from charge nurse:
Situation: Mrs. Morrow is an obese, 80-year-old white female
who developed a venous stasis ulcer on her right medial malleolus
while still living at home. She moved into our skilled nursing home
care facility 3 days ago. The current plan of care is focused on
promoting wound healing, improving venous return, and preventing
skin breakdown.
Background: Mrs. Morrow has a past medical history of chronic
obstructive pulmonary disease...
Create Concept Map and a Care Plan for impaired skin.
Patient Introduction:
Location: Skilled Nursing Home Care Facility 0800
Report from charge nurse:
Situation: Mrs. Morrow is an obese, 80-year-old white female
who developed a venous stasis ulcer on her right medial malleolus
while still living at home. She moved into our skilled nursing home
care facility 3 days ago. The current plan of care is focused on
promoting wound healing, improving venous return, and preventing
skin breakdown.
Background: Mrs....
Draw a concept map, identifying a minimum of four nursing
diagnoses written in complete diagnostic statements.
(Nsg Dx/ rt/ aeb.) Include Actual & Risk for nursing
diagnoses. Include one psychosocial nursing diagnosis.
Location: Skilled Nursing Home Care Facility 0800
Report from charge nurse:
Situation: Mrs. Morrow is an obese, 80-year-old white female
who developed a venous stasis ulcer on her right medial malleolus
while still living at home. She moved into our skilled nursing home
care facility 3 days ago....
patient has developed some complications related to the fall. She has developed an increase in dyspnea and more difficulty ambulating. She also complains of pain when taking a deep breath. She is now on bed rest and requires help with her ADLs. She is also complaining of an increase in pain in her right leg. She states the pain in her right leg is a 6. VS: BP 160/90, HR 90, RR 26 and labored, pulse oximeter is 90% on...
Mrs Morrow is an obese 80 year old white female who developed a venous status ulcer on her right medial malleolus while still living at home. She moved into our skilled nursing home care facility 3 days ago. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown.Mrs Morrow has a past medical history of chronic obstructive pulmonary disease (COPD), chronic venous insufficiency, and deep vein thrombosis (DVT). Peripheral artery disease is...
Ruth, 82 years old, was placed in a nursing home due to her family’s inability to meet her increasing health care needs in the late stages of Alzheimer’s disease. This was a very difficult decision for the family, especially for her husband, 85-year-old E. Dale. Ruth had been on a diet for diabetes at home, but now is refusing almost all meals and fluids. Her family has been asked to decide on their plan for provision of tube feeding and...
3. A nurse is working on a general medical-surgical unit. Her assigned client is 77-year-old who has a stage II decubitus ulcer on her coccyx. The nurse is discussing strategies to prevent skin breakdown and the wound healing process with a client. What is the difference between first-intention and second-intention healing? What are some factors that can cause delayed wound healing? What are some age-related differences in the elderly with regards to wound healing? 2. A nurse is working in...
You are working a night shift in the emergency department (ED) when the security staff yells for help at the ED entrance. As you grab a pair of gloves and race to the entrance you find a young adult white male lying on the pavement of the drive, unconscious and bleeding from his torso. He does not respond to verbal or painful stimuli but he has respirations of approximately 14 breaths/min and a weak and thready pulse of 120bpm. Two...
2. A nurse is working in a community health center and is caring for a 5-year- child who was diagnosed as having a right ear infection. When collecting the nursing history, the mother states the child has had a fever to 1020F for 2 day has been irritable, and complained of feeling tired. The child has been drinking fluids well but not eating. The physician describes the tympanic membrane as erythematous, bulging with fluid levels, and dull. The nurse collects...