Case Study: Pressure Ulcer Louise Mandrake is a 68-year-old woman with a history
ID: 122756 • Letter: C
Question
Case Study: Pressure Ulcer
Louise Mandrake is a 68-year-old woman with a history of severe rheumatoid arthritis who is confined mostly to a bed or a chair. She requires assistance in changing positions or in repositioning and cannot bear much weight when transferring to the chair. Ms. Mandrake has 24-hour care at home by family members during the day and home health assistants at night. The home care nurse visits Ms. Mandrake on a weekly basis.
1. What assessments, in relation to skin, should the nurse make at each visit? What should the nurse teach the family members and home health assistants in regards to skin care?
Explanation / Answer
1A, The nurse must do proper assessment. Make sure that the nurse's hands have been washed, The entire skin of the patient is examined for any abnormalities. It requires looking and touching of the skin from head to toe with a particular emphasis over bony prominences.
Visiting nurse should identify any pressure ulcer that may be present. Identify if there are other lesions and skin-related factors predisposing to pressure ulcer development, such as excessively dry skin or moisture-associated skin damage. Look for any reddened areas, rashes, cuts, bruises, scrapes, or indentations from seams or elastic binding. Nurse can make a document of her visit and make to understand the skin condition to family members and nursing assistant.
1B, Nurse must provide proper health education to family members and home care assistant such as
* Provide a well-balanced diet that includes plenty of protein foods, fruits and vegetables (fresh if possible) and liquids.
* Make sure that patient is in a air mattress and it is working properly.
* Change of position should be happened regularly and as much as possible.
* Teach family members to identify the skin changes due to pressure sore for identifiying earlier to treat well especially in bony prominent area
* Keep the skin clean and dry. Wash with soap and water daily, then rinse and dry thoroughly.
* Lubricate dry skin with moisturizing creams or ointments . because dryness makes breakdown of skin
* Soiled skin can break down easily. Urine and stool have irritants in them and should be cleaned up immediately to prevent weakening and breakdown of the skin surface.
* Whenever notice a problem, try to figure out its cause and make any changes necessary to prevent further problems. The first step in curing any skin problem is to eliminate the cause.
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