NPRO 1100 Final Case Studies Questions With Complete
Solutions
Assessment of M.J.'s right trochanter reveals a shallow open
ulcer with a red pink wound bed. This ulcer would be graded as:
A stage II ulcer: reveals partial thickness loss of dermis
presenting as a shallow open ulcer with a red pink wound bed,
without slough. It may also present as an intact or open/ruptured
serum-filled blister.
The skin on M.J.'s scapulae is intact but is boggy to touch and
purple. You identify this assessment finding as:
Stage I pressure ulcer: In a patient with darker skin tones, you
need to look for changes in skin color, such as skin that is darker
(purplish, brownish, bluish) than surrounding skin. You should
also touch the skin to feel its consistency. A boggy or edematous
feel may indicate a stage I pressure ulcer.
The pressure ulcer on M.J.'s left trochanter is covered with
eschar. You grade this ulcer as:
Unstageable: When eschar is present, accurate staging of the
pressure ulcer is not possible until enough eschar is removed to
expose the base of the wound.
In planning care for M.J., you identify all the risk factors for
pressure ulcers that he has. Select those factors that you know
apply to M.J.
,Older age
Contractures
Immobility
Incontinence
Neurologic disorders
Pain
Using the Braden Scale, you complete M.J.'s risk assessment
with the following scores obtained: sensory perception - 2,
moisture - 3, activity - 1, mobility - 1, nutrition - 2, friction and
shear - 1. TOTAL SCORE 10
The patient's risk level is HIGH risk.
You measure and stage M.J.'s pressure ulcers and clean them
with saline. What equipment should you use to best cleanse the
pressure ulcers without causing trauma or damage to the wound?
It is important to use enough irrigation pressure to adequately
clean the pressure ulcer (4 to 15 psi) without causing trauma or
damage to the wound. To obtain this pressure, a 30-mL syringe
and a 19-gauge needle can be used.
There is a moderate amount of yellow drainage from the sacral
ulcer, serous drainage from the right trochanter ulcer, and no
drainage from the left trochanter ulcer. There is black, necrotic
tissue in the sacral ulcer, and the left trochanter ulcer is covered
with eschar. You recognize that further care of these pressure
ulcers requires:
Removal of the necrotic tissue and eschar.
,In order to establish a clean granulating base for healing,
necrotic tissue and eschar must be removed from the ulcer. The
debridement method used to remove necrotic tissue can be
surgical, mechanical, enzymatic, or autolytic and should be
discussed with the health care provider. Eschar is removed by
cutting it away. Antiseptic solutions are cytotoxic and should not
be used to clean or soak pressure ulcers. Dry dressings should
not be used on newly granulating tissue, and transparent
polyurethane films are appropriate for superficial wounds
without drainage.
Dietitian ROLE
Evaluation of nutritional status
Recommendations for nutritional supplements
Home Health Aide ROLE
Assist with personal care such as bathing and hygiene
Light housekeeping and meal preparation
Social Worker ROLE
Assist with managing financial resources
Referral to volunteer MS agencies
Physician ROLE
Medical monitoring of condition
Medical & surgical strategies for pressure ulcer trtmt.
Professional Nurse ROLE
, Coordinate services of the team
Evaluation of the outcome of provided care
Wound debridement and care
Speech Therapist ROLE
Assessment of swallowing ability
Prescription of special feeding techniques
While explaining to M.J. about the importance of adequate
nutrition for the healing of pressure ulcers, you discuss the need
for laboratory testing to evaluate his nutritional status. M.J. is
adamant that he does not want any more ''needle sticks.'' In order
to provide evidence-based nursing care, you:
Accept M.J.'s decision not to have blood drawn.
Evidence-based nursing care integrates the best available
research evidence; clinician expertise; and the individual
patient's preferences, values, and attitudes. Therefore it is
important to incorporate M.J.'s preferences, values, and attitudes
in the planning of the most appropriate treatment regimen.
While completing the visit with M.J. and his wife, you initiate a
plan to care for his pressure ulcers and make an appointment
with the couple in 2 days. Select all of the following
interventions that would be appropriate to start until a
comprehensive plan can be developed with the home health care
team. There are eight correct answers.
Ask M.J.'s wife to reposition M.J. at least every 2 hours during
waking hours.
Solutions
Assessment of M.J.'s right trochanter reveals a shallow open
ulcer with a red pink wound bed. This ulcer would be graded as:
A stage II ulcer: reveals partial thickness loss of dermis
presenting as a shallow open ulcer with a red pink wound bed,
without slough. It may also present as an intact or open/ruptured
serum-filled blister.
The skin on M.J.'s scapulae is intact but is boggy to touch and
purple. You identify this assessment finding as:
Stage I pressure ulcer: In a patient with darker skin tones, you
need to look for changes in skin color, such as skin that is darker
(purplish, brownish, bluish) than surrounding skin. You should
also touch the skin to feel its consistency. A boggy or edematous
feel may indicate a stage I pressure ulcer.
The pressure ulcer on M.J.'s left trochanter is covered with
eschar. You grade this ulcer as:
Unstageable: When eschar is present, accurate staging of the
pressure ulcer is not possible until enough eschar is removed to
expose the base of the wound.
In planning care for M.J., you identify all the risk factors for
pressure ulcers that he has. Select those factors that you know
apply to M.J.
,Older age
Contractures
Immobility
Incontinence
Neurologic disorders
Pain
Using the Braden Scale, you complete M.J.'s risk assessment
with the following scores obtained: sensory perception - 2,
moisture - 3, activity - 1, mobility - 1, nutrition - 2, friction and
shear - 1. TOTAL SCORE 10
The patient's risk level is HIGH risk.
You measure and stage M.J.'s pressure ulcers and clean them
with saline. What equipment should you use to best cleanse the
pressure ulcers without causing trauma or damage to the wound?
It is important to use enough irrigation pressure to adequately
clean the pressure ulcer (4 to 15 psi) without causing trauma or
damage to the wound. To obtain this pressure, a 30-mL syringe
and a 19-gauge needle can be used.
There is a moderate amount of yellow drainage from the sacral
ulcer, serous drainage from the right trochanter ulcer, and no
drainage from the left trochanter ulcer. There is black, necrotic
tissue in the sacral ulcer, and the left trochanter ulcer is covered
with eschar. You recognize that further care of these pressure
ulcers requires:
Removal of the necrotic tissue and eschar.
,In order to establish a clean granulating base for healing,
necrotic tissue and eschar must be removed from the ulcer. The
debridement method used to remove necrotic tissue can be
surgical, mechanical, enzymatic, or autolytic and should be
discussed with the health care provider. Eschar is removed by
cutting it away. Antiseptic solutions are cytotoxic and should not
be used to clean or soak pressure ulcers. Dry dressings should
not be used on newly granulating tissue, and transparent
polyurethane films are appropriate for superficial wounds
without drainage.
Dietitian ROLE
Evaluation of nutritional status
Recommendations for nutritional supplements
Home Health Aide ROLE
Assist with personal care such as bathing and hygiene
Light housekeeping and meal preparation
Social Worker ROLE
Assist with managing financial resources
Referral to volunteer MS agencies
Physician ROLE
Medical monitoring of condition
Medical & surgical strategies for pressure ulcer trtmt.
Professional Nurse ROLE
, Coordinate services of the team
Evaluation of the outcome of provided care
Wound debridement and care
Speech Therapist ROLE
Assessment of swallowing ability
Prescription of special feeding techniques
While explaining to M.J. about the importance of adequate
nutrition for the healing of pressure ulcers, you discuss the need
for laboratory testing to evaluate his nutritional status. M.J. is
adamant that he does not want any more ''needle sticks.'' In order
to provide evidence-based nursing care, you:
Accept M.J.'s decision not to have blood drawn.
Evidence-based nursing care integrates the best available
research evidence; clinician expertise; and the individual
patient's preferences, values, and attitudes. Therefore it is
important to incorporate M.J.'s preferences, values, and attitudes
in the planning of the most appropriate treatment regimen.
While completing the visit with M.J. and his wife, you initiate a
plan to care for his pressure ulcers and make an appointment
with the couple in 2 days. Select all of the following
interventions that would be appropriate to start until a
comprehensive plan can be developed with the home health care
team. There are eight correct answers.
Ask M.J.'s wife to reposition M.J. at least every 2 hours during
waking hours.
