What is the primary characteristic of a Stage I pressure ulcer?

A) Intact skin with non-blanchable redness

B) Partial thickness skin loss involving epidermis

C) Full thickness skin loss with damage to muscle

D) Full thickness tissue loss with exposed bone

A nurse assesses a patient with a Stage I pressure ulcer in the sacral area. What is the most appropriate initial intervention to prevent the ulcer from worsening?

B) Reposition the patient every two hours.

A) Apply a topical antibiotic to the area.

B) Reposition the patient every two hours.

C) Use a heat lamp to improve circulation.

D) Cover the area with a hydrocolloid dressing.

Which of the following interventions is MOST directly aimed at preventing skin breakdown in the patient described?

B) Regular repositioning every two hours

A) Encouraging a nutritional plan rich in protein and vitamins

B) Regular repositioning every two hours

C) Coordination with physical therapy for mobility exercises

D) Monitoring vital signs regularly

What is the primary purpose of repositioning a patient every two hours in the context of pressure ulcer prevention?

C) To alleviate pressure on bony prominences

B) To improve respiratory function

C) To alleviate pressure on bony prominences

What is the primary purpose of using the Braden Scale in nursing practice?

B) To evaluate a patient's risk for pressure ulcers

A) To assess a patient's nutritional needs

B) To evaluate a patient's risk for pressure ulcers

C) To determine a patient's level of mobility

D) To monitor a patient's vital signs

Which intervention is most appropriate for preventing pressure injuries in a patient with a decreased Braden Scale score?

B) Elevate the heels using heel protectors

A) Encourage the patient to remain in the same position for extended periods

B) Elevate the heels using heel protectors

C) Increase the patient's caloric intake without adjusting nutritional components

D) Use a standard hospital mattress without any additional support

A nurse is reviewing a patient's care plan and notes a decrease in serum albumin levels. Which dietary adjustment is most appropriate to support tissue healing and improve albumin levels?

A) Increase carbohydrate intake

When monitoring a patient with a pressure injury on the heel, which intervention is most important to prevent further tissue damage?

B) Keeping the heels elevated and using heel protectors

A) Applying a cold compress to the affected area

B) Keeping the heels elevated and using heel protectors

C) Massaging the reddened area to improve circulation

D) Increasing the patient's fluid intake

What is the most appropriate initial action for the nurse to take upon noting a slight increase in the patient's respiratory rate and mild crackles at the lung bases?

B) Perform a thorough respiratory assessment

A) Increase the patient's oxygen supplementation

B) Perform a thorough respiratory assessment

C) Administer diuretics as prescribed

D) Notify the healthcare provider immediately

What is the primary purpose of using the Braden Scale in the care of patients at risk for pressure injuries?

B) To assess a patient's risk for developing pressure injuries

A) To measure the severity of existing pressure injuries

B) To assess a patient's risk for developing pressure injuries

C) To evaluate the effectiveness of nutritional interventions

D) To monitor a patient's respiratory status over time

patient that is immobile and now has a bed sore and the nurse needs to apply Braden assessment tool to assess the clients tissue - Nursing Case Study

Pathophysiology

• Primary mechanism: Prolonged pressure on the skin reduces blood flow, leading to decreased oxygen and nutrient supply to the tissue, which can cause cell death and tissue breakdown, resulting in a bed sore.

• Secondary mechanism: Moisture from sweat or incontinence can weaken the skin's protective barrier, making it more susceptible to damage and infection.

• Key complication: Without intervention, bed sores can become deeper and more serious, leading to possible infections and delayed healing, impacting the patient's overall health and recovery.

Patient Profile

Demographics:

68 years old, female, retired school teacher

History:

• Key past medical history: Hypertension, Osteoarthritis

• Current medications: Lisinopril, Acetaminophen

• Allergies: None

Current Presentation:

• Chief complaint: Development of a bed sore

• Key symptoms: Redness and tenderness in sacral area

• Vital signs: Blood pressure 130/80 mmHg, Heart rate 72 bpm, Respiratory rate 18 breaths per minute, Temperature 98.6°F, Oxygen saturation 97% on room air

Section 1

Initial assessment findings:

During the initial assessment, the nurse conducted a thorough examination of the patient's sacral area, where the bed sore was developing. The assessment revealed a Stage I pressure ulcer, characterized by intact skin with non-blanchable redness over a bony prominence. The area was warm to the touch and slightly tender, indicating the early onset of tissue damage but with no broken skin or open wound. The patient reported discomfort when lying on her back for extended periods, which prompted the nurse to explore further preventive measures to alleviate pressure and promote healing.

The nurse utilized the Braden Scale to assess the patient's risk of developing further pressure ulcers. The assessment scored the patient at 15, indicating a mild risk. The factors contributing to this score included her limited mobility due to osteoarthritis and occasional moisture presence from incontinence. The patient's nutritional status appeared adequate, and her cognitive ability to express discomfort was intact. Based on these findings, the nurse initiated a care plan focusing on regular repositioning, the use of pressure-relieving devices, and maintaining skin integrity through proper hygiene and moisture control. These interventions aimed to prevent progression to more severe stages and facilitate the healing process.

Section 2

Response to Interventions

In the days following the initiation of the care plan, the nurse closely monitored the patient's condition, paying particular attention to the sacral area and overall skin integrity. Regular repositioning every two hours and the use of a specialized pressure-relieving mattress were implemented diligently. The patient's skin was kept clean and dry, with gentle cleansing routines employed to minimize moisture-related skin breakdown. Additionally, the patient was encouraged to partake in a nutritional plan rich in protein and vitamins to support tissue repair, as advised by the dietitian.

After a week, the nurse conducted a follow-up assessment to evaluate the effectiveness of the interventions. The sacral area showed signs of improvement; the redness had diminished, and the skin felt less warm to the touch. The patient reported a decrease in discomfort while lying on her back, and there was no progression to an open wound or further ulceration. Vital signs remained stable, with a blood pressure of 120/80 mmHg, a heart rate of 78 beats per minute, and a temperature of 98.6°F. Her laboratory results indicated adequate albumin levels, reflecting improved nutritional status.

The nurse's consistent implementation of preventive measures and patient education appeared to be yielding positive outcomes. Encouraged by these findings, the nurse decided to continue the current care strategy while remaining vigilant for any signs of deterioration. The next step involved coordinating with physical therapy to explore safe mobility exercises tailored to the patient's osteoarthritis, aiming to enhance circulation and further reduce pressure on vulnerable areas. This approach highlighted the importance of an interdisciplinary team in managing the patient's condition effectively.

Section 3

In the following week, the nurse continued her diligent care routine, but noticed subtle changes in the patient's condition. Despite the initial improvement, the patient began to express mild discomfort in the heel area, prompting a thorough skin assessment. Upon inspection, the nurse observed slight erythema and increased warmth in the left heel, similar to the early stages of the sacral area issue. Recognizing the potential for a new pressure injury, the nurse promptly documented these findings and escalated the situation to the interdisciplinary team to adjust the care plan.

The nurse decided to apply the Braden Scale once again to comprehensively assess the patient's risk for pressure ulcers, with a particular focus on sensory perception and mobility, which had shown slight deterioration. The patient's Braden score had decreased from a 16 to a 14, emphasizing the need for heightened preventive measures. In response, heel protectors were introduced to alleviate pressure, and additional repositioning strategies were implemented to ensure the patient's heels were offloaded regularly. The nurse also reinforced the importance of the nutritional plan, ensuring the patient continued to receive adequate protein intake to aid tissue repair.

These developments underscored the importance of ongoing assessment and adaptability in the care plan. The nurse engaged in reflective practice, considering potential modifications to patient education and care strategies to prevent further complications. By maintaining clear communication with the interdisciplinary team, the nurse ensured that the patient received a comprehensive, coordinated approach to care, aligning with best practices for pressure injury prevention and management. This proactive response created a foundation for the next phase of the patient’s journey, focusing on healing and mitigating any further risks.

Section 4

As the week progressed, the nurse closely monitored the patient's response to the updated care plan, particularly focusing on the interventions aimed at offloading pressure from the heels. During a routine assessment, the nurse noted a slight improvement in the erythema of the left heel, indicating a positive response to the heel protectors and repositioning strategies. The patient's discomfort had decreased, and they expressed relief, suggesting that the preventive measures were effective in mitigating further tissue damage.

Despite these encouraging signs, the nurse remained vigilant, recognizing that the patient's overall condition still posed a risk for complications. A follow-up Braden Scale assessment was conducted, and the score remained at 14, reinforcing the need for continued preventive efforts. Vital signs remained stable, with a blood pressure of 120/80 mmHg, heart rate of 72 beats per minute, and temperature within normal limits, further indicating that the patient was not experiencing systemic complications. However, a recent lab test revealed a slight decrease in serum albumin levels, now at 3.2 g/dL, highlighting the need to enhance the nutritional plan to support tissue healing.

In response to these findings, the nurse collaborated with the dietitian to adjust the patient's nutritional intake, ensuring an increase in protein and caloric content to address the albumin deficiency. The nurse also took the opportunity to educate the patient and family on the importance of adhering to the nutritional plan and maintaining pressure-relief strategies. By reinforcing these critical aspects, the nurse set the stage for sustained recovery and prevention of further pressure injuries, paving the way for the next steps in the patient's care journey.

Section 5

As the days progressed, the nurse observed the patient's response to the enhanced nutritional plan and pressure-relief strategies. A follow-up assessment of the left heel indicated further improvement, with the erythema continuing to diminish. The patient's Braden Scale score, reassessed after these interventions, showed a slight increase to 15, reflecting a positive trend in the patient's risk for pressure injuries. The patient's comfort levels improved, and they continued to express satisfaction with the ongoing care, which included diligent repositioning and the use of heel protectors.

However, during a routine check, the nurse noted a new finding: a slight increase in the patient's respiratory rate, now at 22 breaths per minute. This prompted the nurse to conduct a more thorough respiratory assessment, revealing mild crackles at the lung bases. The patient's oxygen saturation remained stable at 95% on room air, and there were no other signs of respiratory distress. Recognizing the potential for fluid imbalance or early signs of pulmonary complications, the nurse decided to consult with the healthcare team to consider additional diagnostic tests, such as a chest X-ray, to rule out any underlying issues.

In light of these developments, the nurse prioritized continued monitoring of the patient's respiratory status while maintaining focus on pressure injury prevention. The collaborative approach with the healthcare team ensured a comprehensive evaluation, aiming to address any emerging complications early on. This proactive strategy aimed to maintain the patient's stability and promote overall recovery, setting the stage for the next steps in optimizing the patient's care plan.