JO MORROW CASE #9
1. : Patient Introduction
Location: Nursing home
Time: 1000
Report from the charge nurse:
Situation: Josephine Morrow is an obese, 80-year-old female who developed a venous stasis ulce
on her right lower extremity while still living at home. The current plan of care is focused on
promoting wound healing, improving venous return, and preventing skin breakdown.
Background: Mrs. Morrow has a past medical history of COPD, chronic venous insufficiency, and
deep vein thrombosis (DVT). Peripheral arterial disease was ruled out by duplex ultrasound. Her
daughter recently moved her to this nearby nursing home due to concern for her safety related
to impaired mobility, an unhealthy diet, and inability to adequately care for herself at home.
Assessment: Mrs. Morrow is alert and oriented to person, time, and place but sometimes forgets
recent events. Vital signs have been within normal limits and are performed weekly. Labs are
done monthly, and results from yesterday are in the chart. She is on a regular diet with
nutritional supplement and has been eating the majority of her meals since admission. She
requires assistance with positioning in bed and with getting out of bed to sit in a chair or
ambulate. Her gait is unsteady and she is easily fatigued. Her last Braden scale assessment was
conducted 2 days ago. She scored 14, indicating moderate risk. She has brown
hyperpigmentation on both lower legs with +2 edema. The dressing was changed and the
wound cleaned this morning.
Recommendation: I would like you to complete a full-body skin assessment of Mrs.
Morrow. You should also review the labs and do patient education on promotion of circulation an
on maintaining good skin integrity.
Health Assessment
Weber, J.R., and Kelly, J.H. (2018). Health Assessment in Nursing, 6th Edition. Assessing Skin, Ha
and Nails, Chapter 14, pp. 247-279
Assessment Tool 14-1: Braden Scale for Predicting Pressure Sore Risk, Chapter 14,
Pp. 266-267
Abnormal Findings 22-1: Characteristics of arterial and Venous Insufficiency, Chap- ter 22, p. 488
Box 4-3: SBAR, Chapter 4, p. 58 Diseases and
Conditions
Expert Clinical Content from Lippincott Advisor
Obesity, long-term care
Varicose veins Diagnostic
Tests
1/
9
,JO MORROW CASE #9
Expert Clinical Content from Lippincott Advisor
Albumin level test
Complete blood count (CBC) with differential
Prealbumin test
Nursing Diagnosis Care Plans
Expert Clinical Content from Lippincott Advisor
Deficient knowledge: Disease process Impaired
physical mobility
Impaired skin integrity Signs
and Symptoms
Expert Clinical Content from Lippincott Advisor Edema
(leg)
Treatments
Expert Clinical Content from Lippincott Advisor Wound
care (pressure ulcer)
Procedures
Expert Clinical Content from Lippincott Procedures Skin
assessment, long-term care
2. Cde: The nurse is interviewing a patient who is reporting itching and a rash. Which
question(s) would be appropriate for the nurse to include in the nursing health history? (Select all
that apply).
Have you had any hair loss?
Do you have a family history of keloids? What
other symptoms occur with it?
How much does it bother you?
When did it begin?
3. A: The nurse is providing patient teaching about prevention of pressure ulcers. Which
statement, if made by the patient, indicates that the teaching was successful? Because I have
dry skin, I should avoid cold air and use moisturizers.
When sitting in the chair, I should try to reposition myself every 2 hours. When I take a
bath, I should use hot water.
To stimulate circulation, it is important for me to vigorously massage my skin.
4. Abd: Upon inspection of a patient's lower extremity, the nurse suspects venous insufficiency.
Which assessment findings would support this conclusion? (Select all that apply.)
Moderate leg edema
Thickened, tough skin
Loss of hair over the toes and dorsum of the foot
2/
9
1. : Patient Introduction
Location: Nursing home
Time: 1000
Report from the charge nurse:
Situation: Josephine Morrow is an obese, 80-year-old female who developed a venous stasis ulce
on her right lower extremity while still living at home. The current plan of care is focused on
promoting wound healing, improving venous return, and preventing skin breakdown.
Background: Mrs. Morrow has a past medical history of COPD, chronic venous insufficiency, and
deep vein thrombosis (DVT). Peripheral arterial disease was ruled out by duplex ultrasound. Her
daughter recently moved her to this nearby nursing home due to concern for her safety related
to impaired mobility, an unhealthy diet, and inability to adequately care for herself at home.
Assessment: Mrs. Morrow is alert and oriented to person, time, and place but sometimes forgets
recent events. Vital signs have been within normal limits and are performed weekly. Labs are
done monthly, and results from yesterday are in the chart. She is on a regular diet with
nutritional supplement and has been eating the majority of her meals since admission. She
requires assistance with positioning in bed and with getting out of bed to sit in a chair or
ambulate. Her gait is unsteady and she is easily fatigued. Her last Braden scale assessment was
conducted 2 days ago. She scored 14, indicating moderate risk. She has brown
hyperpigmentation on both lower legs with +2 edema. The dressing was changed and the
wound cleaned this morning.
Recommendation: I would like you to complete a full-body skin assessment of Mrs.
Morrow. You should also review the labs and do patient education on promotion of circulation an
on maintaining good skin integrity.
Health Assessment
Weber, J.R., and Kelly, J.H. (2018). Health Assessment in Nursing, 6th Edition. Assessing Skin, Ha
and Nails, Chapter 14, pp. 247-279
Assessment Tool 14-1: Braden Scale for Predicting Pressure Sore Risk, Chapter 14,
Pp. 266-267
Abnormal Findings 22-1: Characteristics of arterial and Venous Insufficiency, Chap- ter 22, p. 488
Box 4-3: SBAR, Chapter 4, p. 58 Diseases and
Conditions
Expert Clinical Content from Lippincott Advisor
Obesity, long-term care
Varicose veins Diagnostic
Tests
1/
9
,JO MORROW CASE #9
Expert Clinical Content from Lippincott Advisor
Albumin level test
Complete blood count (CBC) with differential
Prealbumin test
Nursing Diagnosis Care Plans
Expert Clinical Content from Lippincott Advisor
Deficient knowledge: Disease process Impaired
physical mobility
Impaired skin integrity Signs
and Symptoms
Expert Clinical Content from Lippincott Advisor Edema
(leg)
Treatments
Expert Clinical Content from Lippincott Advisor Wound
care (pressure ulcer)
Procedures
Expert Clinical Content from Lippincott Procedures Skin
assessment, long-term care
2. Cde: The nurse is interviewing a patient who is reporting itching and a rash. Which
question(s) would be appropriate for the nurse to include in the nursing health history? (Select all
that apply).
Have you had any hair loss?
Do you have a family history of keloids? What
other symptoms occur with it?
How much does it bother you?
When did it begin?
3. A: The nurse is providing patient teaching about prevention of pressure ulcers. Which
statement, if made by the patient, indicates that the teaching was successful? Because I have
dry skin, I should avoid cold air and use moisturizers.
When sitting in the chair, I should try to reposition myself every 2 hours. When I take a
bath, I should use hot water.
To stimulate circulation, it is important for me to vigorously massage my skin.
4. Abd: Upon inspection of a patient's lower extremity, the nurse suspects venous insufficiency.
Which assessment findings would support this conclusion? (Select all that apply.)
Moderate leg edema
Thickened, tough skin
Loss of hair over the toes and dorsum of the foot
2/
9
