Patient scenario A 78-year-old man is living in an assisted living facility. He
ID: 52633 • Letter: P
Question
Patient scenario
A 78-year-old man is living in an assisted living facility. He is able to walk very short distances and uses a wheelchair to transport himself to the communal dining room. He administers his own medications independently and bathes himself. Over the last year he prefers to remain in the wheelchair even when in his room. He has a history of CHF, hypertension, hyperlipidemia and lower extremity weakness. He is able to state his current medications include metoprolol (Lopressor) 50 mg once daily by mouth, furosemide (Lasix) 20 mg once daily by mouth, Quinapril (Acupril) 20 mg once daily by mouth, atorvastatin (Lipitor) 20 mg once daily by mouth. During a routine examination, his physician noted a pressure ulcer over the ischium on the right buttocks. The wound is oval about 10mm x 8 mm, with red and yellow areas in the middle and black areas on some surrounding tissue. It has a foul odor. The patient had been padding the area so “it doesn’t get my pants wet”. The physician arranged for him to be admitted to the hospital in order for intravenous antibiotic therapy and wound care to be initiated. After being admitted to the hospital his medications are: metoprolol (Lopressor )50 mg orally every 12 hours, furosemide (Lasix ) 40mg once daily by mouth, quinapril HCl (Accupril) 40 mg once daily by mouth, cefazolin (Ancef)1.5 Grams in 50 mL 0.9 % Normal Saline intravenously three times a day. The result of the wound culture identified Methicilin-resistant staphylococcus aureus. After a surgical debridement of the black tissue a SilvaSorb® (antimicrobial gel) dressing was ordered daily.
Develop a Plan of Nursing Care for this patient that includes all steps of the nursing process:
One (1) actual NANDA-I nursing diagnosis statement addressing the priority problem the patient is experiencing. You need to provide the entire nursing diagnosis statement. For example: Acute pain, related to tissue trauma, as evidenced by patient rating pain at 7 on the 0-10 verbal pain scale. Provide a rationale, with evidence, why this nursing diagnosis is the priority for this patient.
What is the assessment data that supports the use of this nursing diagnosis? These are the assessments you will collect to determine if the patient has this nursing diagnosis. For example: Will assess the patient's pain using the 0-10 verbal pain scale.
One (1) expected outcome (realistic, measureable and contains a time frame). that addresses the diagnosis and meets the criteria for an expected patient outcome. Discuss whether the outcome is a cognitive, psychomotor, affective or physiologic outcome. Discuss why the time frame selected for the evaluative criteria was selected. Use evidence as the basis for the time frame and criteria. You need to be specific to this particular patient. For example: Patient will rate pain at 3 on the 0-10 verbal pain scale. Of course, you would also need to answer the rest of the items in this section.
Four (4) nursing interventions that includes at least one (1) nurse-initiated, one (1) dependent, one (1) interdependent intervention. Label your interventions as above. Provide a rationale for each intervention that is evidence-based. Lastly, your interventions must be able to move the patient toward the achievement of the outcome. Select interventions, you as the RN can perform, that could reduce the pain and provide the rationale as to why; be sure they are evidence-based. For example: Teach patient guided imagery to distract attention and reduce tension.
Explanation / Answer
Ischium pressure ulcers ; they are deep tissue injuries occurs on the bone called ischium .. it is alco called pressure sores occurs when pressure in one area is long enough period of time that it cuts off blood flow to skin resulting in the tiisue death or damage .common sites of pressure are in the sacral ,ischium and hip regions symptoms include the redness ,shiny skin,skin breakdown, open sore ,ulceration along with superfcial contamination .. they are several stages of the pressure sores
stage 1; red skin but intact
stage 2; skin loss but muslce and fat intact
stage 3; skin and fat loss but muscle and bone intact
stage4;loss into muscle and down to bone
treatmeant include ;
primary care physician sees the treatmeant plan ,a physician specialised in the wound care .nursing or medical assitants who provide both care and education for managing wounds .a social worker helps who help a physician who helps in mobility and a deitician who helps with neutrion needs
reducing pressure ; this is the first step in caring which reduces the pressure ,
repositioning ; wheel chair person should be repositioned reguarly shifting weight for every 15 minutes
using support surfaces ; use a mattreses ,bed or special cushions that help you in lie in appropriate position relive pressure on anysores and protect vulnarable skin.
cleaning and dressing of wounds ;[nurse intiated]
cleaning ; it is essential to keep the wounds clean to prevent infection, if affected skin is not broken gently wash with water and pat dry .open should be washed with saline .
dressing the wounds ; a dressing keeps wound moist creating a barrier aganasit infection,dresing choices include films , gels,foams
removing damaged tissue ; they are several ways of treatment which include , surgical ,mechanichal ,autolytic, and enzymatic
other interventions include ;
pain managment; pressure ulcers are treated with non steriodal antiinflammatory drugs ,which can be used before dressing,
antibiotic; infected sores are treated with antibiotics
healthydiet ; which promote woun d healing which include vitamin c and zinc .[independent intervention]
muscle spam relief ; muscle relaxants such as zanaflux, vallium, baclofen may inhibhit the muscle spam .
negative pressure thearapy ; it is a suction used to clean wound ,it may help in some types of pressure wounds.
surgery ; it is the last option ,