lOMoAR cPSD| 22896205
CASE STUDY PRESSURE ULCER STUDENT
CONCEPTS OF MEDICAL SURGICAL NURSING
Scenario
You are a nurse working on the unit and take the following report from the emergency department
(ED) nurse: “We have a patient for you: R.L. is an 81-year-old frail woman who has been in a
nursing home. Her primary admitting diagnoses are sepsis, pneumonia, and dehydration, and she
has a known stage 3 right hip pressure injury. Past medical history includes remote cerebrovascular
accident with residual right-sided weakness and paresthesia, remote myocardial infarction, and
peripheral vascular disease. She is a full code. Her vital signs are 98/62, 88 and regular, 38 and
labored, 100.4° F (38° C). Lab work is pending; she has oxygen at 4 L per nasal cannula and an IV
of D5.45 at 100 mL/hr. We just inserted an indwelling catheter. The infectious disease doctor has
been notified, and respiratory therapy is with the patient—they are just leaving the ED and should
arrive shortly.”
1. What major factors increase risk for developing a pressure injury?
Mobility, Sensory, Moisture, Nutrition, Friction, and Shear
2. Each health care setting should have a policy that outlines how to assess patients’ risk for
developing a pressure injury. What should be included in that assessment?
Activity and mobility level
General condition of the skin
Presence of coexisting physical conditions, including diabetes, cardiovascular instability, low
BP, and oxygen use
Nutritional status, including hemoglobin, anemia, serum albumin levels, and weight
Fecal and urinary incontinence and general skin moisture
3. As part of R.L.’s admission assessment, you conduct a skin assessment. What areas of R.L.’s
body will you pay particular attention to?
Right side, bony prominences, sacrum, heels
4. What are the advantages of using a validated risk assessment tool to document her skin
conditionon admission?
Braden Scale, Joint Commission’s patient safety goals
5. How often should patients be reassessed for the risk of developing an injury?Every shift
, CASE STUDY PRESSURE ULCER STUDENT
CASE STUDY PROGRESS
During your assessment, you note that R.L. has very dry, thin, almost transparent skin. She has
limited mobility from her stroke and is currently bedridden. There are several areas of ecchymosis on
her upper extremities. She is alert and oriented to person only. You review the transfer summary
from the long-term care facility and note she has a history of urinary and fecal incontinence.
6. Evaluate R.L. with the Norton risk assessment scale.
Physical Mental ConditionActivity Mobility Incontinence
Condition
DateGood 4 Alert 4 Ambulant 4 Full 4 Not 4 Total
Fair 3 Apathetic 3 Walk/help 3 Slightly Limited 3 Occasional 3 Score
Poor 2 Confused 2 Chair bound 2 Very limited 2 Usually/urine 2 7
Very 1 Stupor 1 Bed rest 1 Immobile 1 Urinary and 1
bad fecal
7. Knowing that R.L. is frail, has right-sided weakness, and has a pressure injury, what consultations
or referrals could you initiate?
PT/OT, wound care, speech therapy, infectious disease, Nutrition, Respiratory
CASE STUDY PROGRESS
As you are completing R.L.’s assessment, the wound nurse specialist comes in. She knows R.L.
from a prior admission; as soon as she received the request for a wound care consultation, she
ordered a specialty mattress. She says an air overlay should be delivered to your unit before your
shift ends.
8. Why is a specialty mattress used for immobile or compromised patients?
The help reduce pressure, provide comfort, and eliminate bottoming out
9. Why are patients placed on specialty mattresses still at risk for skin breakdown?
Because they will still need to be turned q2 hours, friction and shearing,
10. Why do the heels have the greatest incidence of breakdown, even when the patient is on a
specialty mattress?
Heels are covered by a thin layer of skin and fat, so they are a high risk for breakdown
11. What intervention can you initiate to protect R.L.’s heels?
Apply heel protectors, Monitor skin on feet and ankles daily, elevate her calves on pillow position
lengthwise to help relieve any pressure.
12. Compare friction and shear.
CASE STUDY PRESSURE ULCER STUDENT QUESTIONS ANSWERS
CASE STUDY PRESSURE ULCER STUDENT
CONCEPTS OF MEDICAL SURGICAL NURSING
Scenario
You are a nurse working on the unit and take the following report from the emergency department
(ED) nurse: “We have a patient for you: R.L. is an 81-year-old frail woman who has been in a
nursing home. Her primary admitting diagnoses are sepsis, pneumonia, and dehydration, and she
has a known stage 3 right hip pressure injury. Past medical history includes remote cerebrovascular
accident with residual right-sided weakness and paresthesia, remote myocardial infarction, and
peripheral vascular disease. She is a full code. Her vital signs are 98/62, 88 and regular, 38 and
labored, 100.4° F (38° C). Lab work is pending; she has oxygen at 4 L per nasal cannula and an IV
of D5.45 at 100 mL/hr. We just inserted an indwelling catheter. The infectious disease doctor has
been notified, and respiratory therapy is with the patient—they are just leaving the ED and should
arrive shortly.”
1. What major factors increase risk for developing a pressure injury?
Mobility, Sensory, Moisture, Nutrition, Friction, and Shear
2. Each health care setting should have a policy that outlines how to assess patients’ risk for
developing a pressure injury. What should be included in that assessment?
Activity and mobility level
General condition of the skin
Presence of coexisting physical conditions, including diabetes, cardiovascular instability, low
BP, and oxygen use
Nutritional status, including hemoglobin, anemia, serum albumin levels, and weight
Fecal and urinary incontinence and general skin moisture
3. As part of R.L.’s admission assessment, you conduct a skin assessment. What areas of R.L.’s
body will you pay particular attention to?
Right side, bony prominences, sacrum, heels
4. What are the advantages of using a validated risk assessment tool to document her skin
conditionon admission?
Braden Scale, Joint Commission’s patient safety goals
5. How often should patients be reassessed for the risk of developing an injury?Every shift
, CASE STUDY PRESSURE ULCER STUDENT
CASE STUDY PROGRESS
During your assessment, you note that R.L. has very dry, thin, almost transparent skin. She has
limited mobility from her stroke and is currently bedridden. There are several areas of ecchymosis on
her upper extremities. She is alert and oriented to person only. You review the transfer summary
from the long-term care facility and note she has a history of urinary and fecal incontinence.
6. Evaluate R.L. with the Norton risk assessment scale.
Physical Mental ConditionActivity Mobility Incontinence
Condition
DateGood 4 Alert 4 Ambulant 4 Full 4 Not 4 Total
Fair 3 Apathetic 3 Walk/help 3 Slightly Limited 3 Occasional 3 Score
Poor 2 Confused 2 Chair bound 2 Very limited 2 Usually/urine 2 7
Very 1 Stupor 1 Bed rest 1 Immobile 1 Urinary and 1
bad fecal
7. Knowing that R.L. is frail, has right-sided weakness, and has a pressure injury, what consultations
or referrals could you initiate?
PT/OT, wound care, speech therapy, infectious disease, Nutrition, Respiratory
CASE STUDY PROGRESS
As you are completing R.L.’s assessment, the wound nurse specialist comes in. She knows R.L.
from a prior admission; as soon as she received the request for a wound care consultation, she
ordered a specialty mattress. She says an air overlay should be delivered to your unit before your
shift ends.
8. Why is a specialty mattress used for immobile or compromised patients?
The help reduce pressure, provide comfort, and eliminate bottoming out
9. Why are patients placed on specialty mattresses still at risk for skin breakdown?
Because they will still need to be turned q2 hours, friction and shearing,
10. Why do the heels have the greatest incidence of breakdown, even when the patient is on a
specialty mattress?
Heels are covered by a thin layer of skin and fat, so they are a high risk for breakdown
11. What intervention can you initiate to protect R.L.’s heels?
Apply heel protectors, Monitor skin on feet and ankles daily, elevate her calves on pillow position
lengthwise to help relieve any pressure.
12. Compare friction and shear.
CASE STUDY PRESSURE ULCER STUDENT QUESTIONS ANSWERS
