Question

question # 2

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

Answer 1

1)Rational for physicians consultation

Physician has ordered for blood and urine culture because she is presented with fever,low systolic BP less than 100mmhg,and has a picture of sepsis with pneumonia.Lab investigations for CBC will help us to know the white blood cells,neutrophil count,platelets.electrolytes measurement is important as she has history of dehydration which can alter essential electrolytes like sodium,potassium.Pt,ptt,INR to be done daily as she has a history of peripheral vascular disease and a history of CVA which means she will be on some regular anticoagulants like ecospirin thus a daily measurement of pt,ptt,inr is essential.and she also has a wound which has a serosanguinous discharge so anticoagulants may have to be stopped to prevent bleeding.

Physician treatment rationale:As the patient is dehydrated as evidenced by thin and scaling skin she should be hydrated with intravenous fluids and considering the patient to be in sepsis she may have hypoglycemia because of low cortisol and glycogen level so a intravenous fluid with a combination of dextrose and normal saline would be best choice so 5% Dextrose in 0.45%normal saline.which will also help in slow correction of sodium as rapid correction of sodium is not encouraged.Patient needs a Foley's catheter as we have have to monitor a strict INtake output for the patient to correct dehydration.

2) Considering the physical structure of the patient I would give more care and concern to the following pressure prone areas which is likely to have the skin tear apart.All the areas which has a bony prominence has a potential for Injury like occiput,scapular region,sacrum,below the elbow,trocanter region,heels,lower back,ileac crest region,lateral malleolus region.

3) Importance of measuring the wound on admission.:A comprehensive head to toe assessment of the skin should be done to assess the stage of the wound to devise and plan measures to prevent further injury,treatment options to heal the wound . Assessment of the wound on admission will help us to compare the status or the development of the healing wounf and determine whether it's healing Orr worsening and to find alternative measures treat it.Pressure I'll write wound can be assessed using the PUSH score which is a scale to assess the pressure ulcers healing on a regular basis .

4) what it means to stage an ulcer.

Pressure ulcer can be varied depth and severity to stage a pressure up we means to categorize the pressure ulcer ulcer according to the depth of injury and the extend it has caused harm to the surrounding tissues .Pressure ulcers are staged as stage 1 which is nonblanchable redness in which only the epidermis of the skin is affected,stage 2 partial thickness which means dermis and epidermis is affected,stage 3 full thickness which has affected the subcutaneous tissue,dermis and epidermis,stage 4 full thickness tissue loss which means the injury has extended upto muscle and bone and it's visible,unstageable means the injury is eshscar formation or blackish discoloration which makes it difficult to stage the ulcer.

5)Three additional factors that could risk pressure ulcer in this patient are.

Dehydration which leads to dry skin and easy scaling

Malnourishment can lead to skin breakdown

Sepsis can lead the patient to be in mechanical ventilation or hemodynamical instability which can lead the patient to be supi e position for a longer period of time .