Question

You have been assigned to care for Mr. Alvarez, a 74-year-old client being treated for a urinary tract infection. He suffered a cerebrovascular accident (stroke) 6 months ago and has had difficulty ambulating and attending to his own needs because of right-sided weakness. He is thin for height, incontinent of foul smelling urine, and has non-blanchable erythema on his coccyx and peritoneal area. He is alert and oriented to person, place, and time. He has decreased sensation on his entire right side. He spends most of his time in bed or sitting in a chair.

1.What data suggests that Mr. Alvarez is particularly vulnerable to pressure sore development?

2 What additional information does the nurse need in order to use the Braden Scale to determine his potential for pressure injury development?

3.How should the nurse stage the noted areas of erythema?

4.Based on the information provided in the case scenario, what nursing diagnoses are appropriate for this patient?

5.What independent nursing interventions can the nurse provide to protect him from further skin breakdown?

Answer 1

1. pressure ulcers are localised areas of necrotic soft tissues that occur when pressure applied to the skin for a long time, which is greater than normal capillary closure pressure, 32 mm Hg.patients who are more prone to pressure ulcers include those confined to bed for long periods, those with motor and sensory dysfunction, and those with muscular atrophy and reduction of padding between the overlying skin and underlying bone.

The initial sign of pressure is erythema (redness of the skin). if it continuous results in ischemia and anoxia. The cutaneous tissues become destroyed, leading to the destruction and necrosis of the underlying soft tissue which is so painful and slow to heal.

areas susceptible to pressure ulcers:

• occiput
• ear
• scapula
• elbow
• sacrum
• greater trochanter
• ischial tuberosities
• medial condyle of tibia
• fibular head
• medial malleolus
• lateral malleolus
• heel

other factors result in the development of pressure ulcer are:

decreased nutritional status, friction and shear, and increased moisture

from the history,

the patient is bedridden for 6 months due to a cerebrovascular accident, also it is clear that he has imbalanced nutrition since he is thin stature with another important risk factor for developing the pressure ulcer, which is the presence of urinary incontinence. moreover, he has early symptoms of pressure ulcer like non-blanchable erythema on his coccyx (pressure point). this data suggest the patient is vulnerable to develop the pressure sore

2.in Braden scale, there are 6 areas to analyse the bed sore. they are,

• sensory perception- decreased sensation on the entire right side-
• moisture - incontinent of foul-smelling urine
• activity- difficult ambulating
• mobility - spends time in bed or chair
• nutrition and - thin in accordance with height
• friction and shear

but the information about the friction and shear is absent which examine, the requirement of assistance, whether maintaining position in the chair or not.

3. There are four stages of pressure ulcer and differentiates according to the characteristics.

for Mr Alvarez, it is the stage 1, which patient has non-blanchable erythema on his coccyx. no other symptoms of skin breakdown

in stage 2, skin breaks, the drain may be present, appear as abrasion, blister or shallow crater,partial-thickness of wound

stage 3, extends to subcutaneous tissue, necrosis and presence of drainage,full thickness of wound,infection develops

stage 4, extends to underlying muscle and bone,infection in depth,necrosis and drainage continue

4.since pressure sore is in the first stage, the nursing diagnosis would be,

• Risk for impaired skin integrity related to immobility, decreased sensory perception excessive moisture due to incontinence with a foul smell as evidenced by non-blanchable erythema on the coccyx