A resident with a reddened area developed a Stage 4 pressure ulcer (see the case study on p. 16). Assessment data included the following:
• Braden Scale completed on admission. Score = 16 (mild risk)
- No impaired sensory perception
- Rarely moist
- Chair-fast
- Very limited mobility
- Adequate nutrition
-
Problem with friction and shear
• Fall Risk = Borderline
• Bowel & Bladder = Foley, continent bowel
• Pain assessment = no pain
• Side rails = indicated as enabler
• Assessments done by RN
• Chronic diagnoses include venous insufficiency, hypothyroidism, weight loss, GERD, HTN
• Meds: Levoxyl, Aldactone, Prevacid, Lasix, Lovenox, Prilosec
Hospital Information:
• Admit Diagnoses S/P ORIF Lt Hip fx & Pinning Lt Humeral Fx
- Hypothyroidism
- Recent weight loss? Etiology
- GERD
- Bilateral venous insufficiency
- Venous stasis changes
- History of venous stasis ulcers
- s/p Hepatitis
- s/p Breast CA (in remission)
- Foley catheter care
RAPs:
- ADL functional/rehabilitation
- Urinary incontinence & indwelling catheter
- Locomotion deficit/use of wheelchair, incongruent with previous lifestyle
- At risk for falls
- At risk poor nutrition, only eats 25 percent
- Dehydration - diuretic/laxative use
- Pressure ulcers, turning & repositioning, ulcer care, dressings, pressure relieving devices
Source: Excerpted from a handout provided as part of an Advancing Excellence Webinar presentation by Debra Bakerjian, RN, MSN, PhD.
