Question

Chapter 14 A 76-year-old female client is transferred to the cardiac surgery unit from the cardiac intensive care unit (ICU). She had an aortic valve replacement with a mechanical valve and a two-vessel coronary artery bypass graft (CABG) 12 days ago, which was complicated by an intraoperative left cerebrovascular accident (CVA). Her postsurgical course was complicated by delirium while she was in the ICU, and she is now taking Ativan around the clock. Her nursing admission assessment documents that she was alert and oriented to person, place, time, and situation and independent in all activities of daily living (ADLs). She has a past medical history of hypertension, atrial fibrillation, and congestive heart failure (CHF). On admission to the cardiac surgery unit, you note that she is oriented to person only; needs maximum assistance with ADLs; and needs a two-person assist to get out of bed to the chair and to the bedside commode, which means she is incontinent because it takes too long to get to the commode. The transfer summary states that she needs to be fed and that she consumes approximately 50% of her meals. The only significant changes in her medical condition are worsened CHF, requiring an increase in her diuretic. Her medications include Lasix, digoxin, captopril, and Tylenol for pain. Her skin assessment reveals the following: stage III pressure ulcer on her sacrum, eschar on left heel, and a right heel that feels “boggy” to touch. Her Braden Scale score is 13.

1. Identify the factors that make this client at high risk of developing pressure ulcers.

2. How often should this client have skin assessments?

3. List the six risk factors that are part of the Braden Scale for predicting pressure sore risk.

Answer 1