Question

Abigail’s HF has improved, however, due to her inability to ambulate; she has developed an open area on her coccyx, measuring 4cm by 2cm and 1cm deep and a venous stasis ulcer on her right lower leg.

Her Unasyn has been discontinued, but her other medications remain the same.

This would be classified as which stage of skin breakdown?

Abigail has also developed a venous stasis ulcer on her right lower leg.

What type of wound care might be implemented and why? (Refer to Taylor)

What would be the priority nursing diagnosis?

What would be the outcome and why?

What interventions would be implemented? What is the rationale for each intervention?

How would you evaluate the nursing interventions?

Describe what a venous stasis ulcer is?

What is the difference between a venous ulcer and an arterial ulcer? Review Health Assessment notes.

How are each treated?

Answer 1

Ans

Pressure sore leads to the gangrene of the skin and primary closure with flap is needed

Nursing dignosis-is for pressure sore is more as compare to venous ulcer as these sore are expexted in case of long term aame position lying

Pressure sore lead to ulcer formation and resist to heal itself and inhibit the primary disease

Intervention

Change in postion for atleast 10 minutes in 2-3 hour period it lead to inhibit the development of pressure sore

For venous ulcer massage and compression bandage application is needed

Venous stasis ulcer- due to verious condition like vericose vein aur incompetence of deep vein valves it lead to development of venous ulcer which is superficial and single in number and non painful

Venous ulcer-. Arterial ulcer

Site-medial side of malliolus. Tip of toe

Number-single. Multiple

Pain- non painful. Painful

Cause- vericose vein. Vessel disease