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Case study pressure ulcer Student

Concepts of Medical Surgical Nursing (Galen College of Nursing)

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Name _________________________________ Class/Group _______________ Date

_______________

Scenario
You are a nurse working on the unit and take the following report from the emergency department
(ED) nurse: “We have a patient for you: R.L. is an 81-year-old frail woman who has been in a nursing
home. Her primary admitting diagnoses are sepsis, pneumonia, and dehydration, and she has a
known stage 3 right hip pressure injury. Past medical history includes remote cerebrovascular
accident with residual right-sided weakness and paresthesia, remote myocardial infarction, and
peripheral vascular disease. She is a full code. Her vital signs are 98/62, 88 and regular, 38 and
labored, 100.4° F (38° C). Lab work is pending; she has oxygen at 4 L per nasal cannula and an IV
of D5.45 at 100 mL/hr. We just inserted an indwelling catheter. The infectious disease doctor has
been notified, and respiratory therapy is with the patient—they are just leaving the ED and should
arrive shortly.”
1. What major factors increase risk for developing a pressure injury?
Mobility, Sensory, Moisture, Nutrition, Friction, and Shear

2. Each health care setting should have a policy that outlines how to assess patients’ risk for
developing a pressure injury. What should be included in that assessment?

 Activity and mobility level

 General condition of the skin

 Presence of coexisting physical conditions, including diabetes, cardiovascular instability, low

BP, and oxygen use

 Nutritional status, including hemoglobin, anemia, serum albumin levels, and weight

 Fecal and urinary incontinence and general skin moisture

3. As part of R.L.’s admission assessment, you conduct a skin assessment. What areas of R.L.’s
body will you pay particular attention to?
Right side, bony prominences, sacrum, heels

4. What are the advantages of using a validated risk assessment tool to document her skin condition
on admission?
Braden Scale, Joint Commission’s patient safety goals

5. How often should patients be reassessed for the risk of developing an injury?
Every shift

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CASE STUDY PROGRESS

During your assessment, you note that R.L. has very dry, thin, almost transparent skin. She has
limited mobility from her stroke and is currently bedridden. There are several areas of ecchymosis on
her upper extremities. She is alert and oriented to person only. You review the transfer summary
from the long-term care facility and note she has a history of urinary and fecal incontinence.
6. Evaluate R.L. with the Norton risk assessment scale.

Physical Mental Condition Activity Mobility Incontinence

Condition
Date Good 4 Alert 4 Ambulant 4 Full 4 Not 4 Total
Fair 3 Apathetic 3 Walk/help 3 Slightly Limited 3 Occasional 3 Score
Poor 2 Confused 2 Chair bound 2 Very limited 2 Usually/urine 2 7
Very 1 Stupor 1 Bed rest 1 Immobile 1 Urinary and 1
bad fecal

7. Knowing that R.L. is frail, has right-sided weakness, and has a pressure injury, what consultations
or referrals could you initiate?
PT/OT, wound care, speech therapy, infectious disease, Nutrition, Respiratory

CASE STUDY PROGRESS

As you are completing R.L.’s assessment, the wound nurse specialist comes in. She knows R.L.
from a prior admission; as soon as she received the request for a wound care consultation, she
ordered a specialty mattress. She says an air overlay should be delivered to your unit before your
shift ends.
8. Why is a specialty mattress used for immobile or compromised patients?
The help reduce pressure, provide comfort, and eliminate bottoming out

9. Why are patients placed on specialty mattresses still at risk for skin breakdown?
Because they will still need to be turned q2 hours, friction and shearing,

10. Why do the heels have the greatest incidence of breakdown, even when the patient is on a
specialty mattress?
Heels are covered by a thin layer of skin and fat, so they are a high risk for breakdown

11. What intervention can you initiate to protect R.L.’s heels?

Apply heel protectors, Monitor skin on feet and ankles daily, elevate her calves on pillow position
lengthwise to help relieve any pressure.

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12. Compare friction and shear.

Friction is the force of rubbing two surfaces against one another. Shear is a gravity force of pushing
down on the patient’s body with resistance between the patient and the chair and or bed.

13. What risk factor does using a draw sheet prevent or minimize?
Using a draw sheet to reposition or move the patient will help to distribute the pressure and help to
minimize sheering forces to the skin that can result in skin tears.

14. Describe 6 interventions aimed at minimizing friction and shear.

Establish a risk assessment per facility protocol, Pads and protect vulnerable arears, Use heel or
elbow protectors, utilize positioning devices in wheelchairs or chairs to reduce shearing

15. Elevated skin temperature and perspiration increase risk for pressure injury. Write 4 specific
measures to manage the microclimate.

Apply skin barrier creams in sensitive areas, Apply dressings to manage drainage from wounds,
Maintain a mild climate in the environment by avoiding excessive heat and humidity, Wear
breathable clothing and change undergarments regularly.

16. Which instructions will you give to the UAP helping you care for R.L.? Select all that apply.

a.Assess R.L.’s skin status every shift

b.Develop an every-2-hour turn schedule

c.Use the appropriate sheets on the airflow bed

d.Keep R.L.’s head of bed below a 30-degree angle

e.Assist with hygiene measures when R.L. is incontinent

f. Empty and measure output in the urine collection device

17. Write an outcome related to R.L.’s skin integrity.

CASE STUDY PROGRESS

The wound nurse needs to evaluate the preexisting pressure injury. She gently removes the old
dressing, using the push-pull method and adhesive remover wipes. After taking off the outside

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dressing, or the secondary dressing, she pulls out the primary dressing and states that R.L. has a
tunneled wound that was “packed too hard.”
18. What problems can be created by packing a wound too full?
If too much gauze is packed into the wound, it may create an environment that is too dry to allow the
wound to heal, prompting the wound to remain concave and possibly exacerbate. Too much packing
may also create more pressure within the healing wound, forcing it to extend further than its original
edges.

19. The nurse systematically assesses the injury and confirms the presence of a stage 3 wound with
moderate yellow drainage. There is no tissue necrosis or debris. What does it mean to “stage” a
wound?
Base Staging on the type of tissue visualized or palpated. Once you stage a wound it cannot be
reversed when documenting a healing pressure ulcer.
20. What would you expect a stage 3 pressure injury to look like?
Full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon, or muscle are not
exposed. Some slough may be present.

21. What is a tunneling wound? What risk factors are associated with tunneling?
A tunneling wound is any wound that has a channel that tunnels from the wound into/through the
muscle or subcutaneous tissue.

Risk Factors: Smoking, putting too much weight on the wound, corticosteroids, chemotherapy or
immunosuppressant, Infection that has caused the destruction of tissue.

22. What are the dimensions of R.L.’s wound?

6 cm wide and 5 cm in length

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CASE STUDY PROGRESS

After the wound nurse obtains a set of wound cultures, you watch as she packs the wound with
gauze. The wound nurse charts the findings and makes formal recommendations for management of
the wound to the primary care provider.
23. When collecting a wound culture with a swab, the nurse should culture the

a.Wound drainage

b.Healthy-appearing tissue

c.Most necrotic-appearing tissue

d.Very outer edges of the wound

24. Describe the technique for packing a tunneled wound.

Packing should fill the wound space completely, but not tightly. Use a cotton swab to gently guide the
packing into small or tunneled ares. Open your outer dressing material and place it on the towel.
Keep it away from the bowl, and don’t get it wet.

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25. What factors influence the choice of a wound dressing?

Wound and skin related factors, such as cause, severity, environment, condition of the peri wound
skin, wound size and depth, anatomic location, volume of exudate, and the risk of infection.

26. What do you feel would be the best choice for dressing R.L.’s wound?

27. What wound documentation is necessary at this time?

Location, Size, Stage, Discharge, Odor

28. Complete an example of a documentation entry for R.L.’s wound care.

Wound Location Right Side

Pressure Injury Stage 3
Stage
Wound Dimensions 6 cms width and 5 cm length
Undermining 3.5 cm
Tissue Type 60% granulation 40% slough
Drainage Slightly yellow
Periwound
Condition
Cleansing Agents Normal salin
Dressing Type Hydrogel
Applied

CASE STUDY OUTCOME

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Despite aggressive treatment, R.L.’s sepsis and pneumonia are overwhelming, and she dies 9 days
later from multiple organ failure.

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