Question

Electrolytes Urine culture and sensitivity PT/INR dally - Call results to Physician 1. Explain the rational for the consultations the physician has ordered 2. As you complete your assessment, explain what areas of the body you would pay special attention to that may also break down. 3. Explain why it is important to measure and describe the appearance of a wound on admission 4. Explain what it means to "stage an ulcer" 5. List three additional factors that would increase the risk for pressure development in the patient 6. Describe the appearance of a Stage 1 pressure ulcer. 7. List the tissues that are involved in a Stage 11 - 1V pressure ulcer. 8. Describe the appearance of "Deep Tissue Injury. 9. What effect would Coumadin have on wound healing? 10. What effect would peripheral vascular disease have on wound healing? 11. Describe how ACE inhibitors work in the body and list three (3) adverse effects you would look for when administering this medication. 12. Select a diet that would best meet this patient's needs as well as the rationale for your selection. 13. Define sepsis and why this diagnosis is of concern to your planning the daily care of your patient 14. Define paresthesia and why this diagnosis is of concern to your planning the daily care of your patient

Answer 1

1. The rational for the consultation the physician has ordered are

• Diet plays a crucial role in healing process.Nutritional deficiency can impair the skin integrity and cause skin damage and ulcer.This will lead to loss of macro and micro nutrients necessary for healing process .From a wound proteins are lost so a high protein diet is recommended to regain the growth of new tissues. The energy is lost which had to be balanced with adequate calories.Vitamin C ,zinc can enhance wound healing
• The patient weighs only 92 pound which can be a contributor for deficiency and increase the risk of pressure ulcer in these types of patients.

2. The special areas in the body which needs attention to prevent skin breakage are

• at the bony prominences like elbow,heel,shoulder ,hip, occiput
• Preventing skin damage at the perianal areas due to moisture

3.This is very important to

• To track the improvement,progress or prognosis of the wound status
• Acts a record ,in case the patient files a legal case in future in regards to it

4. Stage a pressure ulcer refers to grading of the ulcer. It denotes the level or the depth of ulcer. It is graded or staged in to four namely

1. Stage 1: superficial skin are involved
2. Stage 2:the epidermis are involved
3. Stage 3: the dermis are involved, including the subcutaneous tissues
4. Stage 4: the muscles and bones can be visible here