Question

A. Chronic Pressure Ulcer - Stage 4 Your patient is a 47-year-old woman who has had a history of diabetes for the past 25 years, is a stroke survivor, and has congestive heart failure. She developed a stage 4 pressure ulcer following an above the knee amputation six months ago during her hospital stay. She lives at home with her daughter, who is a nurse, and also has home health care three days a week for Dressing changes Home health care is planned to last for only three weeks. Wound etiology: Pressure ulcer, stage 4 Wound location: Coccyx Thickness: Full Size: 6x4x1.4cm Undermining: 2-10 o'clock, 0.7cm Wound tissue: 80% red granulation, 20% yellow fibrinous slough Exudate: Heavy Bioburden: Yes What dressing order would you choose to benefit your patient most? a. Cleanse wound with normal saline. Pat dry. Pack wound and undermining with calcium alginate. Cover with bordered foam three times a week. b. Cleanse wound with normal saline. Pat dry. Pack wound with wet-to-dry dressing twice daily. Cover with abdominal pads. Secure with paper tape. C. Cleanse wound with normal saline. Pat dry. Pack wound and undermining with silver alginate. Cover with bordered foam daily.

Answer 1

Answer 1. The dressing order to be followed is:-

A) Cleanse the wound with normal saline. Pat dry. Pack wound and undermining with calcium alginate. Cover with bordered foam three times a week.(because calcium alginate is used in cases with heavy exudes and also has silver as an antimicrobial agent in its composition).

Answer 2. The correct order of wound dressing would be:-

A) Cleanse the foot with normal saline. Apply collagen particles to wound bed. Cover with bordered foam three times a week. (because the components of collagen like fibroblast and keratinocytes, help in skin development and hydrocolloids associated help in cases with minimum to moderate exudes).

Answer 3.

A) Assessments for the patient's health regarding pressure ulcer treatment would be that he is recovering fast because his daily routine of mobility training with a therapists, good diet and care by his wife and also with timely wound dressings done, points towards his wellbeing. The reason being that when the early care plan is initiated and with proper treatment, last stage sores or ulcers can be prevented. In this case, a mobility therapist is regularly visiting, wound dressing is being done at regular intervals and day care with all other needs is done by his wife.

B) In order to treat the pressure ulcers, the wound should be made clean and applied with antibacterial or antifungal ointments along with foam based support given to the wound. Besides this regular treatment, the patient needs to be repositioned or needs little mobility according to the situation. In this case, all such factors are being used. The healing process is going on at a good pace. The patient is given regular mobility therapy, ulcer wound dressing on regular basis and daily cleaning, timely medications and diet care is also provided to him. These aspects are helping him in the healing process.

C) As the patient is already getting a good approach for healing process. He has been provided with early care treatment plans. So, he will recover at good pace. But to keep him healthy and fit, futuristic approach should also be kept in mind. He should be continued with regular mobility therapies leading forward to a good exercise routine. His body should be cleaned with antiseptics once in a while to avoid any further infection. His clothings should be airy and comfortable to avoid rash or sweat patches on skin which might increase the risk for infection. His sitting and laying positions should be monitored by regularly changing the patterns. The supporting accessories in sitting and while sleeping should be provided. If any small observation is made, then immediate action should be made. All such care plans will help him to reduce the reoccurance of any kind of pressure ulcers.

D) The primary nursing care plans in Case of pressure ulcers include :

. Assessment of the reason behind tissue perfusion or the passage of fluids inside the body. In this aspect, the changes brought in the skin are tested along with the age of illness and that of patient too. The present status of patient is considered in his internal and external health.

. Assessment of the level or the extent of injury caused by it. The level of infection, that is, the depth of infection inside the body starting form outside is studied and the its stage is declared.

. Providing proper care plan or routine to treat the wound. According to the previous assessments the care plan is made. The wound dressings, medications, repositioning routines and methods are included in the plan.

Above all this, the dietry routine, healing therapies according to the patient's situations and maintenance of patient's body for cleanliness to avoid any further damage is considered in the care plans.