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 Ill 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 YOU Physician Orders Medication D5 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.The consultation order for diet is referred to treat her decubitus ulcer because diet plays a very important role in wound healing.A wound heals when there is adequate supply of protein which enriches rye granulation of new cells in the affected area.This also enables ger to build her muscles .Hence for a faster healing a high protein diet is required for this patient. Adequate fluids to rehydrate ,reduce her temperature.

Weight management:As her age is unknown ,in accordance to her height she should be around 45 pounds.As she is thin ,a proper dietary management can maintain a normal weight for the patient .Moreover pressure due to excess weight on the body can be reduced and thus preventing pressure ulcer

2.The following areas are at risk for skin break down

• Bony prominence like occiput in head,elbow, shoulder,heel
• Perineal area due, to moisture, Foley's catheter.

3.The wound is measured at the time of admission to see the progress,prognosis of the wound .

It helps to identify whether it heals or deteriorates

Can be useful to plan for the appropriate type of care

Can be useful tool in case of any future legal proceedings

4.To stage an ulcer refers to the categorization of the pressure ulcer or simply called as grading. There are four stages(Type 1-superficial, Type 2 epidermis, Type 3 subcutaneous, Type 4 muscles and deep tissues.