Case+Study+Pressure+Ulcers+&+Wound+Healing

Mr Jones is an 86 y/o male admitted to the hospital two days ago with dehydration, malnutrition and dementia. You are coming on shift and making rounds. You assess his skin and note redness on his sacrum and heels. He is incontinent of both urine and feces and cannot move himself around in bed. His v/s are T 98.7 P 88 R 22 BP 106/55.

1. What are contributing factors to the development of pressure ulcers?

2. What are Mr. Jone`s risk factors in developing pressure ulcers?

3. What stage pressure ulcer does Mr Jones have? What are the different stages of pressure ulcers? Describe the characteristics of each stage?

4. What nursing interventions can you do to help prevent the advancement of the pressure ulcer?

Mr Jones continues to stay in the hospital and it is one month later. He has developed a stage IV pressure ulcer on his coccyx with undermining and tunneling. What does this mean? . 5. What are clinical signs of pressure ulcer infection?

Mr Jones is diagnosed with osteomyelitis as the result of the pressure ulcer on his coccyx. He is placed on antibiotics and is scheduled for a debridement. Why is a debridement needed?

As the nurse assessing Mr Jones, you understand that a thorough skin assessment is critical for early detection and treatment.

6. What kind of lighting should you use when assessing the skin? How often should you assess his skin? What is the Braden Scale?

7. What is the best method of assessing the temperature of his skin?

8. After assessing his heels, you note that they feel boggy. What does this mean? What can you do to help decrease this finding?

9. What is the required caloric intake for Mr Jones who weighs 65 kg? How many grams of protein should he being taking in daily?

10. When planning to care for Mr Jone’s stafge IV pressure ulcer, the wound specialist nurse prescribes to keep the area moist. What benefit does keeping a moist environment vs a dry environment have on wound healing?

11. What are nursing assessments and documentation in regards to wounds?