Question

The nurse is caring for an 88-year-old diabetic client who has been admitted from a long-term care facility for treatment of an infected, stage 4 pressure ulcer.

• Identify the different stages of pressure ulcers, describing the assessment findings for each of the 4 stages.
• Discuss the risk factors for clients in the development of pressure ulcers, including the effects of aging on the immune system.
• Describe how the nurse uses the Braden Score for client assessment, when the Braden Score is used, and what nursing interventions are applied based on the score obtained.
• Identify the specific nursing considerations for diabetic clients and wound management.  
• You are ordered to start an insulin drip for this client at 2 units/hour. The pharmacy prepares the insulin drip as 100units insulin /250 ml of 0.9%NS. What rate would the nurse program the pump?

Answer 1

STAGES OF PRESSURE ULCER AND THE ASSESSMENT FINDINGS.

STAGE 1 - In this stage the skin is not yet opened.There will be skin discolouration also can feel warmth in that particular area.

STAGE 2 - In this stage we can find that the skin is opened.Sometimes we can see blister it may be broken or may not be.I t is painful.In the second stage of pressure ulcer it affects the epidermis and sometimes the dermis also.

STAGE 3 - It involves the second layer of the skin and reached the fat tissue.In this stage the skin is opened and a wound is formed which has bad odour and pus drainage.

STAGE 4 - In this stage the skinj breakdown has reached the musclea and ligaments even.The wound is deep enough that we can see the bones muscles and ligaments.The wound has black coloured skin with pus drainage of bad smell.

RISK FACTORS

1. Elderly patients who is confined to bed and dont have the ability to move by himslf or herself.Also the aging affects the immunity and which accelarate the development of pressure ulcers in the elderly patients.Because in this patients their body is not able to identify the foreign objects and macrophages occurs very slowly.

2. Poor nutritional status

3.Ptients who is bed ridden

4.Ptients with poor immune system

5.Patient who has incontinence

6. Obesity.

BRADEN SCORE

Braden score is the assessment scle to determine the chances for the development of pressure ulcer.It has the flollowing criterias

1.sensory perception

In this we check the ability to respond and the score is given from one to four.That ranges from completely limited,very limited,slightly limited and no impairment.

2.Moisture

In this we check the skin nexposure to the moisture.Which is one of the main factor for the development of pressure ulcer.It includes constantly moist very moist ,occasionaly moist and rarely moist.The score is from 1 to 4

3. Activity

In this we check the ability of the patient to do the activities.The area includes bedfast,chairfst,walks occasionaly and walks frequently.This also carries score from 1 to 4

4.Mobility

In this we assess the ablity of the patient to change his or her position.It includes completely immobile,very limited ,slightly limted and no limitation.

5 Nutrition

It includes the nutritional status of the patient and the dietary pattern.The criterias are Very poor,probably inadequate,adequate and excellent.

6 Frictiuon and shear

This includes the status of moving on the bed.Whether it is attained by with the help of assistance or independantly.

When the score is less there is high risk for the development of the pressure ulcer.As the score increases the chances for developing the prtessure sore is less.So if the score is 16 or less then the patient is in high risk and this patients need special attention like second hourly position changing,nimbuss bed,back care etc.

For the diabetic clients do the dressing as per the doctors advice,check the sugar level regularly and maintain the blood glucose value within the normal range and administer insulin according to the physician advice.Chek the wound for is healing process.

The order is 2 units per hour the formula to find the required rate is

what we want devided by waht we have in given quantity

here what we want is 2 units,whwt we have is 100 units in 250 ml.so when we put this things in the formula it becomes (2 / 100) x 250 = 5 ml/hour