Scenario

You are a nurse working in the medical intensive care unit (ICU) 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 III right hip pressure ulcer. 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 4L per nasal cannula and an IV of D5.45 at 100mL/hr. We just inserted a
Foley 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-induced ulcer?

Immobility (paralysis and paresthesia), PVD (blood not flowing to skin), incontinence, infection, poor nutrition
and hydration

2. Each health care setting should have a policy that outlines how to assess patients for their risk of developing
a pressure ulcer. What should be included in that assessment?
Sensory perception, moisture, activity, mobility, nutrition and friction/shear

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3. As part of R.L's admission assessment, you conduct a skin assessment. What areas of R.L.'s body will you

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pay particular attention to?
Bony prominences = elbows, hips, shoulder, sacrum, heels, back of head/ears

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4. What are the advantages of using a validated risk assessment tool to document her skin condition on
admission?
Brings consistency and continuity of care provided, accuracy of documentation along with progression of
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pressure ulcer
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Case Study Progress

During your assessment, you note that she 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
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extremities. She is alert and oriented to person only. You review the transfer summary from the long-term care
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facility and note she has a history of urinary and fecal incontinence.

5. Evaluate R.L. with the Norton risk assessment scale.

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PHYSICAL MENTAL ACTIVITY MOBILITY INCONTINENCE

CONDITION CONDITION
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Alert 4 Alert 4 Ambulant 4 Full 4 Not 4

Fair 3 Apathetic 3 Walk/help 3 Slightly LImited 3 Occasional 3

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Poor 2 Confused 2 Chairbound 2 Very Limited 2 Usually 2

Very Bad 1 Stupor 1 Bed rest 1 Immobile 1 Urinary / Fecal 1

TOTAL SCORE 8

6. Given R.L.'s Norton score, describe specific measures you would implement to prevent further skin
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 breakdown.
Turning and repositioning, keep peri area dry and rest of body moist, bed mobility with another staff assistance
to prevent friction and shearing, maintain good nutrition

7. Knowing that R.L. is frail, has right-sided weakness, and has a pressure ulcer, what consultations or
referrals would you initiate?
Wound care nurse, PT/OT, dietary consult

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 states that an air overlay should be delivered to your unit before your shift ends.

8. Why is a specialty bed or mattress used for immobile or compromised patients?

Offloading pressure on RL’s skin

9. Why do patients placed on specialty beds remain at risk for skin breakdown?
Staff still has to turn and reposition

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10. What essential points should all staff know about the specialty bed?

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Ensure air mattresses are plugged and working properly

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11. Why do the heels have the greatest incidence of breakdown, even when the patient is on the most
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advanced specialty bed?
Heels have less cushion and less circulation
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12. What intervention can you initiate to protect R.L.'s heels?

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Heel lift boots, pressure relief

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13. Compare and contrast friction and shear.

Friction = force of rubbing 2 surfaces against one another
Shearing = gravity force pushing down on the patient’s body with resistance between the patient and the chair
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or bed
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14. What interventions are needed to reduce the possibility of shear?

2 person assistance during transfers and repositioning or use a mechanical lift if indicated
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15. What risk factor does using a draw sheet prevent or minimize?
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Friction and skin tears

16. In caring for R.L., it is important for you to instruct the UAP to do which of the following? Select all that
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apply.
a. Assess R.L.'s skin status every shift
b. Develop an every-2-hour turn schedule
c. Use the appropriate sheets on the airflow bed
d. Keep R.L.'s head of bed below a 30-degree angle
e. Assist with hygiene measures when R.L. is incontinent
f. Empty and measure output in the urine collection device
Case Study Progress
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 The wound nurse needs to evaluate the preexisting pressure ulcer. She gently removes the old
dressing, using the push-pull method and adhesive remover wipes. After taking off the outside dressing, often
called a secondary dressing, she pulls out the primary dressing and states that R.L. has a tunneled wound that
was “packed too hard.”

17. What problems can be created by packing a wound too full?

Packing a wound too full creates more pressure and making the wound worse and may cause tearing to peri
wound

18. The nurse systematically assesses the ulcer and confirms the presence of a stage III wound with moderate
drainage. There is no tissue necrosis or debris. What does it mean to “stage a pressure ulcer”?
To determine level of skin damage has been done

19. What would you expect a stage III pressure ulcer to look like?
Skin and deep tissue damage

20. What is a tunneling wound? What risk factors are associated with tunneling?

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A narrow opening or passageway that can extend in any direction through soft tissue and result in dead space

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with potential of abscess formation making it difficult to heal

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Case Study Progress

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After the wound nurse obtains a set of wound cultures, you watch as she packs the wound with gauze. The
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wound nurse charts the findings and makes formal recommendations for management of the wound to the
primary care provider.
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21. Describe the technique for packing a tunneled wound.

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Insert a sterile cotton tipped applicator to measure how the depth of tunneled wound and packed with
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prescribed packing strip to ensure that wound heals from inside to out

22. What wound documentation is necessary at this time?

Measurement, drainage (color, odor, amount), staging
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Pictures to see progression of wound

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23. What factors influence the selection of wound dressing?

Depends on drainage of the wound, the size of wound, location of the wound, if dressing is mixed with
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medication
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24. What do you feel would be the best option for dressing R.L.'s wound? State your rationale.
Clean with cleaning solution such as normal saline or mixed with hydrogen peroxide
Pat wound dry
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Pack with iodoform sterile packing dressing

Apply alginate dressing and ABD pad and secure with tape

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