Question

Mr. Singh is a 96-yr-old resident of a long-term care facility. He suffers from dementia and has limited mobility. He frequently needs assistance moving up in bed and currently has not been eating well. Mr. Singh has developed a stage 2 pressure injury on his right heel.

a) List 4 common sites for pressure injury development

b) Excluding immobility explain 2 other risk factors for pressure injury development for Mr. Singh based on the information provided in the scenario.

c) What is the definition of a stage 2 pressure injury?

d) Explain 2 nursing interventions the nurse can use to reduce the risk of pressure injury development

Answer 1

A) the four common site of pressure injury

These commonly occur on the bony prominence

In supine position:

Back of the head,

Shoulder

Heel

Buttocks

In side-lying:

Ear,

elbow,

hip,

leg

In prone position:

Thigh

Ribcage

Toes

Knees

B) Risk factors for development of pressure injury for mr. Singh

Poor nutrition: not eating well,poor diet cause poor norishment, weight loss, dehydration, malnutrition especially , impaired wound healing ,skin integrity and interferes with function of immune system, collangen synthesis.

Age and disease:

Aging has loss of subcutaneous fat, decreased dermis- epidermal blood flow.

Co morbidities dementia: difficult in changing position without help , if they done moving , reposition themselves while lying it may cause friction and shear forces.

C) Stage 2 pressure ulcer:

(Pressure ulcer or pressure injury or pressure sores or decubitus ulcer )

Definition:

Ulcer are partial lesions extending into the epidermis and dermis.

The ulcer is superficial and present clinically as an abrasion , blister,or shallow crater.

D) 2 nursing intervention

1)maintain proper hygiene and skin care:

• Daily examination of skin ,pay attention to bony prominence

• keep the patient dry and clean. Use warm water and mild cleansing agent.

• 2 hourly change the position , use slide sheet for Every repositioning

• supspend them by placing a pillow or foam pad lengthwise under the lower legs

• lubricate the skin of the patient to prevent cracking by using moisturizing lotion

• Bed making should done properly without wrinkles and use air or water mattress to decrease pressure

• do back care: massaging of pressure points to stimulate circulation like effeurage, pertissage, hand over hand, friction, brush stroke, kneeding, tapping.

2) Improve nutritional status :

• Assess client nutritional status in weight , serum albumin level ect.

• offer frequent fluid and diet at risk patient to meet adequate nutrition and hydration

• provide high calorie and protein diet