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) During the focussed skin assessment, moderate edema ( +2) and hyperpigmentation of the skin was bilateral from the knees and down. The patient did not show any signs of sweating and the skin's elasticity and color was normal. There was a dressing covering the skin lesion on the lower leg. The patient's pedal pulses were palpable with a rate of strong 95 beats per minutes.

2) The patient had three abnormal laboratory results:- HCO3 , Albumin and Prealbumin. HCO3 was 28 when the normal range is 22-26 mEq/L while the Albumin was 3.4 when normal range is 3.5 - 5.9 g/ dl . Prealbumin results were 14.7 when the normal range is 19- 38 mg/ dl. The patient's HCO3 result was high while the Albumin and Prealbumin were low. The Albumin and Prealbumin results are associated with the presence / status of the patient's stasis ulcer.

3) Mrs. Morrow's Braden scale assessment concluded a score of 16 which puts her at a mild risk for a pressure ulcer. Her skin is intact expect for the venous stasis ulcer on the right medial malleolus.

4) The patient's wound is shallow, 1 inch in width and looks mostly pink to red with no sign of necrosis or infection.