Question

1. Mrs. Adams, 72 years of age, is admitted to the rehab unit with the diagnosis of stroke. The stroke affected the limbic area in the brain, which has caused the patient to have emotional labiality (her mood changes rapidly because she misinterprets situations). As a result of the emotional labiality, she sometimes refuses to be repositioned or to participate in physical or occupational therapy. She sometimes also refuses to eat and drink. The patient's right side is paralyzed and flaccid. She has no feeling on her right side. She has reddened areas on her coccyx and both heels at least 1 cm in diameter that do not go away with repositioning. She is incontinent of urine and stool. She has problems with communication called global aphasia (difficulties understanding speech and the written word and difficulties with speaking and writing). She is 5 feet tall and weighs 178 pounds. She has a tendency to develop skin tears because her skin is thin, and she has several bandages on her arms. The family states they are concerned because the staff on the previous medical-surgical unit would drag their mother up in bed when she slid down. The staff would chart when their mother refused to be repositioned and then would not reposition her for hours. a. Explain the pathophysiology of the risk factors that predispose Mrs. Adams to developing pressure ulcers? b. What nursing measures need to be instituted for Mrs. Adams based on the information presented in the case study?

Answer 1

A.Due to the lack of movements of the body ,blood supply to the tissues get decrease.This can cause destruction or injury when blood reenter into it.this may leads to presure ulcer as it cause presure against skin.

.Her right side is paralysed therefore no movements in that area this can leads to develop constant presure in that area specially in bony prominance.it decreases blood flow to the tissues.Thus,skin and tissues get damaged due to the lack of oxygen and nutrients tk the tissues in the absence of blood flow.Then,it destructs and causing bed sore.

The other factor which relates to her bedsore is friction.she is incontinent of stool and urine.when skin have contact with cloth or bed ,friction develops in that area.it leads to skin injury .Her skin is moist due to incontinence of urine and stool so she is more prone to get bedsore.

B.1.Educate the realative for the importance of position changing.

2.staff should change the position of patient every hourly during hospital stay.

3.apply cushions or special mattress such as air bed or water bed to decrease presure.

4.elevate the head end of the bed at 30 degree to tackle shearing.

5.apply cleanser to keep tbe skin dry.

6.body prominence should be protected from friction by applying talcum powder.

7.there should not be any wrinkles on bed sheets which causes friction.

8.catherisation to be done to prevent incontinence of urine.

9.apply diaper to prevent stool incontinence.change it frequently to prevent moisturisation of the are.

10.give less carbohydrate food to prevent the development of presure ulcer.