Question

Case Study: Preventlon 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 DS 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 normal saline at 75 ml/hour D5 in Ampicillin 250 mg IV every 6 hours tabs every 6 hours for pain or temperature above 100.4 Tylenol 325 mg two 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

Answer:The deep tissue injury is the pressure ulcer related injury which affects the subcutaneous tissues. It appears like deep bruise on the skin.

Coumadin increases the blood flow to the area as it acts a blood thinner and prevents the infection in the site of pressure ulcer.

Peripheral vascular disease causes limited blood flow to the area such as arm and legs. So this disease have adverse effects on the wound healing as the blood flow decreases.

ACE inhibitors causes vasodilation which increases the blood flow in the heart and hence lower the blood pressure. The adverse effects of medicine are:

• hyperkalemia
• Kidney impairment
• Fatigue