Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 23: Nursing Assessment: Integumentary System Assessment Case Study Patient Profile R.H., a 78-year-old woman, has just been admitted to your clinical unit from the emergency department, where she was diagnosed with a fractured left hip. She was found on the floor in her room at a long-term care facility where she lives. She is in Bucks traction to stabilize the injured leg and is scheduled for surgery tomorrow if the physician, who has ordered a series of laboratory tests and an electrocardiogram, clears her medically. The unit secretary tells you that some of the test results are available, including a serum albumin level of 2.9 g/dL and a serum prealbumin level of 8 mg/dL. Her complete blood cell count includes the following: red blood cell count of 3.1 106/L, hematocrit of 28%, and hemoglobin of 9 g/dL. She is 5 feet 5 inches tall and weighs 100 pounds. She is alert and oriented but somewhat lethargic. Her lung sounds are clear, and you auscultate S1 and S2 heart sounds easily on her emaciated thorax. You can see her veins easily through her skin and you notice that there is a skin tear on her right lower arm that someone has dressed with a nonadherent dressing. She has bruising on both arms and legs, which are thin. Brainstorming 1. What is your primary concern for this patient? 2. What risk factors does she have for skin problems? 3. Do these risk factors indicate a need for a comprehensive, focused, or emergency assessment? Subjective Assessment 4. What parts of the patients health history are relevant to your skin assessment? Objective Assessment 5. What should you include in your physical assessment of this patient? 6. What laboratory values are of greatest concern to you? Extra Credit 7. What index can be calculated using her height and weight, and what is a reputable online calculator for that index? What does it tell you about her status?

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