Which of the following interventions is most important to prevent pressure ulcer progression in this patient?

B) Reposition the patient every two hours

A) Encourage the patient to increase fluid intake

B) Reposition the patient every two hours

C) Apply a warm compress to the wound area

D) Administer acetaminophen for pain relief

Which of the following is the most appropriate intervention to prevent further deterioration of the patient's stage 2 sacral wound?

C) Reposition the patient every 2 hours

A) Encourage the patient to drink more fluids

B) Apply a topical antibiotic to the wound

C) Reposition the patient every 2 hours

D) Administer analgesics as needed for pain

Following the implementation of the care plan, which of the following observations indicates a positive response to nutritional interventions?

A) The patient's temperature stabilizes at 99.1°F

B) The patient's pain score remains at 3 out of 10

D) The wound appears less erythematous

A nurse is evaluating a patient's response to interventions aimed at managing fever. Which of the following findings indicates that the interventions have been effective?

A) The patient's temperature decreases to 99.1°F.

B) The patient reports a pain score of 5 out of 10.

C) The patient's wound drainage increases.

D) The patient experiences increased fatigue.

What is the primary reason for initiating a urine culture and sensitivity test in a patient with a history of catheter use and recent immobility?

B) To determine the presence of a urinary tract infection

A) To evaluate kidney function and rule out renal failure

B) To determine the presence of a urinary tract infection

C) To assess glucose levels in the urine

D) To check for dehydration status

A patient with a sacral wound has developed mild tachycardia and fatigue. The nurse notes a slight increase in surrounding edema and mild leukocytosis. Which action should the nurse prioritize to address these findings?

B) Increase the frequency of vital signs monitoring and assess for signs of infection.

A) Administer antipyretic medication to control potential fever.

B) Increase the frequency of vital signs monitoring and assess for signs of infection.

C) Initiate a diuretic to reduce the edema around the wound.

D) Encourage the patient to perform more physical activity to combat fatigue.

After monitoring the patient's response to interventions, which finding indicates an improvement in her condition?

A) Heart rate stabilized to 96 beats per minute

B) Negative urine culture and sensitivity test

D) Increased fluid intake and awareness of hydration importance

Which vital sign finding indicates an improvement in the patient's condition following the interventions?

A) Heart rate of 96 beats per minute

B) Blood pressure of 160/100 mmHg

D) Respiratory rate of 24 breaths per minute

A patient recovering from surgery has a sodium level of 134 mEq/L. Which dietary recommendation should the nurse prioritize to address this mild hyponatremia?

B) Suggest increasing the consumption of salty snacks

A) Encourage the intake of fresh fruits like bananas

B) Suggest increasing the consumption of salty snacks

C) Recommend a high-fiber diet with plenty of vegetables

D) Advise drinking at least 3 liters of water daily

A patient with mild hyponatremia has a sodium level of 134 mEq/L. Which intervention should the nurse prioritize to address this condition?

C) Increase dietary sodium intake

A) Encourage increased water intake

B) Monitor the patient's weight daily

C) Increase dietary sodium intake

D) Administer potassium supplements

elevated temperature, fever, chills, loss of appetite, stage 2 sacral wound - Nursing Case Study

Pathophysiology

• Primary mechanism: The body initiates an immune response to the stage 2 sacral wound, releasing pyrogens that signal the hypothalamus to increase body temperature, resulting in fever as a defense to inhibit bacterial growth.

• Secondary mechanism: The inflammatory response at the wound site causes the release of cytokines, which can lead to systemic effects such as chills and loss of appetite, as the body diverts energy to immune functions.

• Key complication: If not managed, the ongoing inflammation and immune response can lead to further tissue breakdown and infection, complicating wound healing and potentially causing systemic infection.

Patient Profile

Demographics:

72-year-old female, retired school teacher

History:

• Key past medical history: Hypertension, osteoarthritis

• Current medications: Lisinopril 10 mg daily, Acetaminophen 500 mg as needed for pain

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Elevated temperature and discomfort

• Key symptoms: Fever, chills, loss of appetite, stage 2 sacral wound

• Vital signs: Temperature 100.4°F, Heart rate 88 bpm, Blood pressure 128/76 mmHg, Respiratory rate 18 breaths per minute, Oxygen saturation 97% on room air

Section 1

Initial Assessment Findings:

Upon conducting an initial assessment of the 72-year-old female patient, the nurse observes that the stage 2 sacral wound is characterized by partial-thickness skin loss involving the epidermis and possibly the dermis. The wound bed appears red and moist, with some serous drainage but no obvious signs of purulent discharge, which suggests that the wound is not currently infected. Surrounding skin is slightly erythematous but not excessively warm to the touch, indicating localized inflammation rather than systemic infection. The patient reports feeling generally unwell, with her fever and chills contributing to her discomfort. She describes the wound area as tender, and rates her pain as a 4 out of 10 on the pain scale, which is currently managed with acetaminophen.

The nurse notes that the patient is experiencing a reduced appetite, which is likely contributing to her lack of energy and overall fatigue. Nutritional intake is assessed, and it is apparent that the patient has been eating less than usual over the past few days, which could impact wound healing if not addressed. The patient's vital signs remain stable with a temperature of 100.4°F, heart rate of 88 bpm, blood pressure of 128/76 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 97% on room air. These findings suggest that while the patient's condition is stable, careful monitoring and intervention are necessary to prevent potential complications such as infection or delayed wound healing.

The nurse develops a plan of care focusing on maintaining skin integrity, managing fever, and ensuring adequate nutritional intake. Education is provided on the importance of repositioning to alleviate pressure on the sacral area, and a high-protein, high-calorie diet is recommended to support healing. The nurse plans to collaborate with a dietitian to enhance the patient's nutritional support. Follow-up assessments will include monitoring the wound for any signs of infection, evaluating pain levels, and ensuring adherence to the repositioning schedule to promote optimal healing conditions.

Section 2

Response to Interventions:

Following the implementation of the care plan, the nursing team closely monitors the patient's response to the interventions aimed at managing her fever, promoting wound healing, and improving nutritional intake. Over the next 48 hours, the patient's temperature gradually decreases, stabilizing at around 99.1°F, indicating a positive response to the fever management strategies. The acetaminophen regimen appears effective in maintaining her pain at a manageable level, with the patient consistently reporting a pain score of 3 out of 10. The regular repositioning schedule is adhered to, and the patient expresses an understanding of its importance in preventing further pressure injury.

Nutritionally, the collaboration with the dietitian results in the introduction of a high-protein, high-calorie nutritional supplement that the patient finds palatable. Her dietary intake shows improvement, with increased consumption of both meals and supplements. The patient reports feeling slightly more energetic and less fatigued, suggesting that the nutritional interventions are contributing positively to her overall condition. The nurse observes that the wound appears less erythematous, and the serous drainage has decreased slightly, which may be indicative of the early stages of healing.

Despite these improvements, the nurse remains vigilant in monitoring for any signs of complications. Daily assessments include careful evaluation of the wound for changes in appearance, such as increased redness or drainage, and monitoring the patient's overall condition. By maintaining a proactive approach to care, the team aims to support continued recovery and address any potential issues promptly. As the patient shows signs of progress, the focus will shift to further enhancing her nutritional status and reinforcing education on self-care strategies to support long-term healing.

Section 3

New Complications:

On the third day of care, the nursing team notices a slight change in the patient's condition. Although her overall temperature remains stable, the patient begins to exhibit mild tachycardia, with a heart rate of 104 beats per minute, slightly above her baseline of 88. Additionally, she reports feeling more fatigued than the previous day, despite the improvements in her nutritional intake. Concerned about these subtle changes, the nurse conducts a thorough assessment, noting that while the sacral wound continues to show signs of healing, there is a slight increase in the surrounding edema.

To further investigate, the nurse orders a complete blood count and a basic metabolic panel. The results reveal a mild leukocytosis, with a white blood cell count of 11,500/mm³, suggesting a potential underlying infection or inflammatory process. Electrolytes are within normal limits, but there is a slight decrease in hemoglobin, now at 11 g/dL from a previous 12.5 g/dL, which may account for her increased fatigue. These findings prompt the healthcare team to consider a more detailed evaluation to rule out any emerging complications such as a secondary infection or a need for adjustment in her current management plan.

In response to these new developments, the nursing team collaborates with the physician to refine the patient's care plan. They decide to initiate a urine culture and sensitivity test to rule out a urinary tract infection, given her recent immobility and history of catheter use. The team also increases the frequency of vital sign monitoring and reinforces the importance of fluid intake to support overall hydration. Education on recognizing signs of infection is provided to the patient and her family to ensure prompt reporting of any new symptoms. These steps aim to address potential complications early and continue supporting the patient's recovery trajectory.

Section 4

Response to Interventions

Following the implementation of the revised care plan, the patient shows an encouraging response to the interventions. The increased monitoring of vital signs reveals that the patient's heart rate has stabilized to 96 beats per minute, closer to her baseline. This improvement suggests that the early detection and management of potential complications are having a positive effect. The patient also reports feeling slightly more energetic, indicating that the strategies to address her fatigue, such as monitoring her hemoglobin levels and ensuring adequate nutritional intake, are beginning to take effect.

In addition to these positive changes, the urine culture and sensitivity test results return negative for any bacterial growth, effectively ruling out a urinary tract infection. This alleviates concerns about a secondary infection related to her recent immobility and catheter use. The patient's fluid intake has improved with the encouragement of the nursing team, and she appears to be more aware of the importance of hydration in her recovery process. The nursing team continues to provide education to the patient and her family regarding infection prevention, including skin care around the sacral wound and the importance of repositioning to prevent further pressure injuries.

With these interventions showing early signs of success, the healthcare team remains vigilant in monitoring the patient's progress. The focus remains on supporting her recovery through ongoing assessment and timely adjustments to her care plan as needed. This proactive approach is designed to maintain her stable condition and prevent any further complications, promoting a smooth path towards recovery. The patient's journey is now poised to continue with a strong foundation of comprehensive care and patient education.

Section 5

New Diagnostic Results

As the patient continues her recovery, the healthcare team receives updated laboratory results that further illuminate her current health status. The complete blood count (CBC) indicates a slight improvement in her hemoglobin levels, now at 11.2 g/dL, reflecting the effectiveness of nutritional support and iron supplementation efforts. Additionally, the white blood cell (WBC) count remains within normal limits at 6,500 cells/mm³, suggesting that the risk of systemic infection is low and that the immune system is effectively managing minor stressors.

However, the comprehensive metabolic panel reveals a mild electrolyte imbalance, with sodium levels at 134 mEq/L, slightly below the normal range. This finding prompts the nursing team to reassess the patient's fluid management plan, ensuring that her intake is not only adequate but also balanced with appropriate electrolyte supplementation. The patient's potassium and calcium levels remain stable, confirming that other aspects of her nutritional intake are well-managed.

These new diagnostic results guide the healthcare team in refining the patient's care plan. The focus shifts to addressing the mild hyponatremia by adjusting her dietary intake and fluid choices, emphasizing foods rich in sodium and considering a more tailored fluid management strategy. With these adjustments, the patient is expected to continue on her path of recovery, supported by a vigilant and proactive care approach that adapts to her evolving needs. The team remains committed to monitoring her progress closely, ensuring that any new challenges are promptly identified and effectively addressed.