Question

Standardized assessment tool helps to evaluate a patients’ risk for developing a pressure ulcer. There are 6 categories you will assess about your patient 1.) Sensory Perception – How much can they feel with regards to their extremities/do they have sensory deficits (for ex: Diabetic patients)/how do they respond to stimuli (i.e. do they only respond to painful stimuli, etc.) *we know that patients with sensory deficits are at higher risk for skin breakdown 2.) Moisture – is this patient incontinent/how often are they incontinent (we know moisture on the skin increases risk for breakdown) 3.) Activity – are they bedbound/chair-bound/ambulating independently 4.) Mobility – how limited are they 5.) Nutrition – are they NPO/how much of their meals do they eat/are they getting adequate protein in their daily nutrition consumption to discourage skin breakdown 6.) Friction & Shear – will these be a problem for the patient Scoring: 19-23 (Not at risk) 15-18 (Mild Risk – we need to do preventative nursing interventions) **Turning schedule/get them moving/”float the heels”, avoid friction & shearing, manage moisture 13-14 (Moderate Risk) – same interventions as mild risk group, also position patient with foam wedges 10-13 (High Risk) – very important to do mild risk interventions and really focus on maintaining “turning schedule”/this patient may need a special “pressure-distributing” mattress 6-9 (Very High Risk) *same interventions as above and this patient will most likely need a “pressure-distributing” mattress Patient Scenario JP is a 67 yr-old male patient who fell off his bicycle and fractured his right hip. He underwent total right hip repair. JP lives alone. The incision site is dry/intact/approximated edges/no signs of infection. JP is A/O x 3. It has been difficult to manage JP’s pain since the surgery and he has not been wanting to get up, has been refusing physical therapy. Currently his pain is a 9/10. JP is very angry that he is in the hospital and won’t be able to ride his bicycle again for a while (he bought an expensive bike and has been riding with a group for the last 3 months). After he has been admitted for 24 hours you note reddened areas on his heels (bilaterally) and his sacrum. JP is sweating a lot, but insists on heavy covers claiming his is cold in the hospital. JPs’ BMI is 32. He tells you he started bicycling to try and lose weight. At home JP typically eats banana and coffee for breakfast, fast food for lunch and canned soup for dinner. JP tells you he has been skipping meals for the past 2-3 months to try and lose weight. Scoring for JP Sensory Perception Moisture- Activity- Mobility- Nutrition- Friction & Shear- Total = What interventions can we do for JP?