Question

Dale Gordon has been a patient in the ICU for 6 days after developing complications after open heart surgery. He is an 82-year-old African American who is disoriented to place and time. He lives with his daughter Claudia in her home. Claudia and her two brothers visit Mr. Gordon daily since he has been hospitalized. Mr. Gordon has not been eating well since the surgery and has lost 3 pounds. Mr. Gordon has type 2 diabetes and is on oral antihyperglycemic medication. Before he came to the hospital, Mr. Gordon was able to only ambulate for short distances. He has orders to get up in a chair twice a day. Joan, a student nurse, is caring for Mr. Gordon this morning. She has reviewed his medical record and is now ready to start caring for him.

1. Joan assesses Mr. Gordon using the Braden Scale and determines that his score is 12. What does this score indicate about Mr. Gordon's pressure ulcer risk?

2. Joan is assessing Mr. Gordon's skin and notices that he has a 3 cm blister and a shallow crater on his buttock. Mr. Gordon winces when Joan palpates the area. How should Joan stage this area? A. Stage I pressure ulcer B. Stage II pressure ulcer C. Stage III pressure ulcer D. Stage IV pressure ulcer

3. Mr. Gordon has drainage coming from his surgical incision, and his dressing needs to be changed. What assessments of the incision should Joan perform while changing the dressing?

4. Claudia asks Joan what she can do when she takes her father home to help prevent more pressure ulcers. How should she answer?

Answer 1

1. Braden scale is a scale used to assess patients risk to develop a pressure ulcer . It has 6components :-

- sensory perception

- mobility

- moisture

- activity

- friction and shear

- nutrition

A Braden score of 12 indicates high risk pressure ulcer

It has four risks :-

- mild risk (Braden score of 15-18)

- moderate risk (score of 13-14)

- high risk (score of 10-12)

- very high risk (score of 9or less)

2. The stage of ulcer is stage 3 .

Four stages of pressure ulcer are there :-

- first stage = mildest stage ,affects only the upper layer of skin

- second stage = sore digs deeper below the surface of skin

- third stage = these sores have gone through the second layer of skin into the fat tissue . It looks like crater.

- fourth stage = most serious , some may even affect your ligament and muscles

3. While changing the dressing assess the following :-

- any active bleeding

- any pus discharge or collection

- any changes in colour like blackish / bluish due to insufficient blood supply .

- look for any redness and rise in temperature along the side of incision that indicates infection.

- any bacterial contamination or colonial formation .

4. The following should be done to avoid pressure ulcer are :-

- change position of patient every two hourly

- use of comfort devices

- advice to drink plenty of water, it will help in healing

- advice to take protein rich ,vitamin C rich diet it will help in healing of wound

- proper dressing of the wound

- avoiding friction and shear

- avoiding moisture accumulation

- remobilization of the patient