Question

NM 121
Skin Case Study

Case 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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A.   ASSESS

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

B.   DIAGNOSE

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

C.   PLAN

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

D.   Intervention

1.   Write three nursing interventions with rationales. (what will you do to help Mrs. Jackson meet her goal)

Answer 1

1. Braden scale is a scale used to assess the risk of patient to develop pressure ulcer . Braden scale has 6 components :-

- sensory perception

- moisture

- mobility

- nutrition

- friction and shear

- activity

Mrs Jackson's Braden score is 16

Sensory perception - 4

Moisture - 4

Mobility - 2

Activity - 2

Nutrition - 1

Friction and shear - 3

Braden score of 16 or less is risk predicting score

2. Nursing diagnosis for Mrs . Jackson is :-

Risk for impaired skin integrity related to immobility caused by femoral- popliteal bypass graft surgery as evidenced by black -purplish area on buttocks region .

3. Outcome for Mrs . Jackson are :-

- To attain good skin integrity by providing proper skin care which include back care , position changing 2hourly , use of comfort devices, avoiding friction and moisture , providing protein and vitamin C rich diet for early healing of wound .

4. Nursing interventions for Mrs. Jackson are :-

- Changing the position of the patient 2hourly . Rationale - to allow blood circulation and avoid pressure on one site .

- Providing back care . Rationale - to improve blood circulation .

- Use of comfort devices . Rationale - to provide proper position ,comfort and to avoid pressure .

- Providing nutritional diet . Rationale - for proper healing of the wound .