Question

Location: Skilled Nursing Home Care Facility 0800

Report from charge nurse:

Situation: Mrs. Morrow is an obese, 80-year-old white female who developed a venous stasis ulcer on her right medial malleolus while still living at home. She moved into our skilled nursing home care facility 3 days ago. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown.

Background: Mrs. Morrow has a past medical history of chronic obstructive pulmonary disease (COPD), chronic venous insufficiency, and deep vein thrombosis (DVT). Peripheral arterial disease is ruled out by duplex ultrasound. Her daughter had her admitted to this skilled nursing home care facility due to concern for her safety with impaired mobility, an unhealthy diet, and inability to adequately care for herself at home.

Assessment: Mrs. Morrow is alert and oriented, but sometimes forgetful of recent events. Vital signs have been within normal limits and are performed weekly. Results from yesterday's labs are in the chart. She is on a regular diet with nutritional supplement and has been eating the majority of her meals since admission. She requires assistance with positioning in bed and assistance times 1 to get out of bed to the chair or ambulate. Her gait is unsteady, and she is easily fatigued. Her Braden Scale score is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. She has brown hyperpigmentation on both lower legs with +2 edema. The venous stasis ulcer is covered with a hydrocolloid dressing, which is due to be changed. In preparation for her dressing change, she was medicated for pain half an hour ago.

Recommendation: You should complete a basic assessment, review the labs, perform a wound assessment and dressing change, and then reposition the patient to optimize venous return. Please provide patient education on improving venous return to prevent further stasis ulcers, and continue compression therapy with the use of elastic bandage and an antiembolism stocking.

Josephine Morrow

Documentation Assignments

1. Document the findings of a focused skin assessment of Ms. Morrow, including any findings that identify the presence of chronic venous insufficiency.
2. Document any abnormal laboratory results that are associated with the presence or status of Ms. Morrow's stasis ulcer.
3. Record the results of Ms. Morrow's Braden Scale assessment.
4. Document the characteristics of Ms. Morrow's venous stasis ulcer.
5. Document the dressing change and irrigation of Ms. Morrow’s wound.
6. Record patient education on ways to promote venous return.
7. Prepare 3 Nursing Diagnosis and their defining characteristics for Ms. Morrow's diagnosis.

Answer 1

1. As Ms.Morrow's Barden scale score is 16 the bed sore is preventable. The skin is intact and she is having chronc venous insufficiency as evidenced by edema and brown colored hyperpigmentation.

2. Expected and importan laboratory assessments are,

CBC shows elevated WBC level

ESR is higher than 120mm/hr

Albumin level must be optimized to at least 3.5 g/l

Blood culture should be taken to rule out septicemia.

3. Ms.Morrow's barden scale score is 16. it indicates preventable bed sore.

4. Venous stasis ulcer is present in right medial malleous with edeme 2+ and coverd with hydrocolloid dressing.

5. The wound was cleaned and irrigated with normal saline, dressing changed and hydrocolloid dressing applied.

6. Patient education:

* elevate the lower extremity which helps to reduce swelling.

*increasing activities like walking, jogging and cycling helps to improve blood circulation.

* avoid tight clothes and high heals which increase the risk of venous insufficiency.

* application of moisturizer helps to prevent dry and cracked skin.

* ensure the patient is taking for adequate amount of protein diet which helps to build the tissues and enhance wound healing.

7. Nursing diagnosis:

1. Altered comfort pain related to venous stasis ulcer

2. Impaired tissue perfusion related to insufficient blood supply.

3. Impaired physical mobility related to edema