Question

Case Study: Prevention and Management of Pressure Ulcers You are the nurse working on a medical intensive care unit and was given the following report from the emergency department. There is a patient to be admitted to your unit, Anita Luego. She is a thin, frail woman who has been living in a nursing home for several years. Her admitting diagnosis is sepsis, pneumonia, dehydration and she has a stage il pressure ulcer on her sacrum. Her past medical history is CVA with residual right sided weakness and paresthesia, MI, and peripheral vascular disease. Her vital signs are B/P 96/62, P 88, R. 38 and labored, T 100.4. She is 4'11" and weighs 92 pounds. Labs, urine culture, and blood cultures have been drawn in the emergency room and are pending. She has 02 via face mask at 2 liters per minute, IV of D5 in 0.45% normal Saline started in a 20 Instye catheter in the left lower arm, and an indwelling Foley catheter. The infectious disease doctors have been notified and respiratory is with the patient assisting with the transfer of the patient - they are just leaving the emergency department and will be arriving on the unit shortly. During your admission skin assessment, you note that she has very dry, thin, almost transparent skin. There are several areas of ecchymosis on her upper extremities. You note on your admission summary her weight is 92 pounds and height is 4'11". there is a wound 4 cm long. 2cm wide and 1 cm deep on her sacrum. There is no noted necrosis, no wound odor, and scant amount of serosanguinous drainage There are no known allergies to medications Physician Orders Medication DS in % normal saline at 75 ml/hour Ampicillin 250 mg IV every 6 hours Tylenol 325 mg two tabs every 6 hours for pain or temperature above 100.4 Compazine 10 mg per rectum for nausea or vomiting Coumadin 5 mg one tablet by mouth daily Enalapril 10 mg one tablet by mouth daily Robitussin 15mL every 4 hours prn for cough PT, OT, ST to evaluate and treat-mobility, dexterity and swallowing evaluation Dietary consultation - skin integrity / weight management Labs CBC with differential Protein and albumin

Answer 1

1.Diet plays an important role for a patient recovery process as a whole. Here the ulcer can be healed rapidly when adequate protein is supplied ,along with this the patient weight is to be considered .A thin skin which is fragile makes a patient mote prone for skin ulcers.Henece a diet rich in protein, high calorie can aide in recovery faster.Along with this minerals like calcium,magnesium, vitamin C are needed for wound healing .

2.The special areas in the body where special attention is needed

• Pressure points ,the bony prominent areas like head (occiput) shoulder, elbow,wrist,heel are subjected to pressure continuously and can lead to pressure ulcer.

3.It is necessary to measure a wound at the time of admission because this can be helpful to correlate and compare the progression of wound healing and take appropriate interventions

4.To stage an ulcer refers to grade the level of the skin ulcers by its depth.There are four stages of ulcer.

5.The three additional factors that would increase the risk of pressure are

• Weakness and paresthesia  
• Dehydration
• Dry,thin and transparent skin

6.The stage 1 pressure ulcer will appear in the following way are

• Non blanchable skin
• Superficial skin peeling
• Redness
• Pain
• Warm to touch

7.The tissues involved in the different stages of ulcer are

1. The superficial skin is involved ,the epidermis is affected
2. The dermis layer of the skin is involved
3. The subcutaneous tissues are involved
4. The muscles, ligaments and bones are involved

8. The deep tissue injury refers to the pressure ulcer reached upto the subcutaneous tissues,It is painful,warm.The tissue looks purplish ,dark skin or a blister which is filled with blood.