Question

Mrs Baba is an 84-year old school teacher who was widowed 10 years ago and now lives alone. She developed diabetes mellitus at the age of 58. She has been in failing health for the last 3 years and has been at home with assistance of health care aides and weekly visits by RN. Her coccyx area has had frequent skin breakdown. The home care RN determined she now has stage III pressure ulcer as a result of her being on the bedrest the past week. She is being admitted to the hospital for treatment of ulcer.

a. Identify risk factors for Mrs Baba developing pressure ulcer?

b. Describe the stage III of pressure ulcer?

c. Identify the most effective treatment for the stage III pressure ulcer?

d. Explain why massaging bony prominences should be avoided for clients at risk for pressure ulcer formation?

e. Explain why adequate fluid intake is important in pressure ulcer prevention?

f. Describe how you will prevent pressure ulcer at the bony prominences?

g. Prepare a trolley for management of pressure ulcer prevention?

2. Outline the nurse’s responsibility for insertion of nasogastric tube for a conscious patient.

(10marks)

3. Set a trolley for wound dressing (10marks)

Answer 1

Answer :

a. Here is the risk factors for Mrs. Baba developing pressure ulcer are :

• Age factors
• Diabetes mellitus
• frequent skin break down
• Her health is weak
• she have been bedrest for the past week.

Common factors for pressure ulcer include :

• Advance age
• immobility
• friction
• shear
• poor nutrition
• excessive moisture and incontinence
• altered level of consiousness
• poor perfusion
• certain skin infections
• comorbid conditions

b. It is also known as bed sore and decubitus ulcer. Pressure ulcer is the injury to the skin and underlying tissuesresulting from prolonged pressure on the skin. During stage 3 the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.

A pressure ulcers can be caused by pressure from a hard surface such as a bed or wheelchair, pressure that is placed on the skin through involuntary muscle movements such as muscle spas. moisture can break down the outer layer of the skin (epidermis).

c. Treatment for stage III pressure ulcer :

Sore that have progressed to the third stage have broken completely through the top two layers of the skin and into the fatty tissue below. An ulcer in this stage may resemble a crater. It may also smell bad. In this stage its important to look for signs of infection including :

• foul odor
• pus
• redness
• discolored drainage

Ulcers in this stage usually needs at least one two four months to heal.

• wound dressing should perform every day.
• can use special matress to releive pressure from the affected area such as water bed.
• change posintion every two hours
• skin massage can do to improve blood circulation around the skin
• Ntritional food should take including multi vitamins
• Antibiotic therapy

d. During pressure ulcer avoid vigourous massage over reddened, bony prominance because evidence suggest that this lead to deep tissue trauma. Deep tissue pressure injuries are persistant non-planchabledeep red, purple or maroon areas of intact skin, non- intact skin or blood filled blisters caused by damage to the underlying soft tissues.

e. Dehydration disturbs cell metabolism and wound heaking. Adequate fluid intake is necessory to support the blood flow to wounded tissues and to prevent additional breakdown of the skin.

f. Bony prominaance tend to put pressure on the skin. Pressure forces blood out of the tiny blood vessels, which nourish the skin and the tissue under the skin.The pressure is most likely to cause damage over bony parts. Areas where bones to close to the surface called bony prominance and areas that are under the most pressure are at great risk for developing pressure sores.

In bed, body parts can be padded with pillows or foarm to keep bony prominance free of pressure.

2. Nasogastric tube is a flexible plastic tube inserted through the nostrils, down the nasopharynx, and into the stomach or the upper portion of the small intestine. Placement of NG tube is always confirmed with an X-rayprior to use.

NG tube are used to deliver nutrients to the patient via a feeding pump and remove gastric content.

Nurese responsibilities are :

• Provide good oral hygiene ata regular and frequent intervals (offer water and mouth wash to rinse mouth every hour. Assist the patient to brush his teeth at least every four hours.)
• keep the nostrils free of accumulations of dried secretions.
• If permissible, apply lubicant such as vaseline to the lips and nostrils for the patient comfert.
• Encourage the patient to swallow saliva naturally; the tube is a constant source of annoyance and the patient may have a tendency to expectorate excessively.
• Report complaints and signs of nose or throat irritation
• Encourage the patient to change position frequently, using care not to pull on the tube and not to lie on the drainage tubing.
• Advise to follow diet orders exactly. If water or clear fluids are allowed by mouth , be sure to check on amount to be given at one time.
• Know exactly whether or not the tube is to be clambed when fluids are given and at what time interval in relation to oral intake
• Provide accurate intake and output records. Large amount of fluids and electrolytes are lost during continuous suction drainage.
• Observe the patient frequently when they in asleep noting the tube marking at the nostril. The patient may have unknowingly pulled the tube out partially or completely. If partially out, advance the tube to the required point and check for drainage. Tape securely.