What is the primary reason for repositioning a patient with a Stage 1 pressure ulcer every two hours?

C) To improve circulation and prevent tissue damage

A) To promote comfort and reduce pain

B) To prevent the development of contractures

C) To improve circulation and prevent tissue damage

D) To ensure the patient receives adequate rest

What is the primary characteristic of a Stage 1 pressure ulcer?

A) Intact skin with non-blanchable erythema

B) Partial-thickness skin loss with exposed dermis

C) Full-thickness skin loss with visible adipose tissue

D) Intact skin with a blister or serous fluid

What is the primary purpose of repositioning a patient with a Stage 1 pressure ulcer?

A) To improve circulation and prevent further skin breakdown

B) To reduce the patient's blood glucose levels

C) To enhance mobility and flexibility of the joints

D) To decrease the patient's blood pressure

What is the primary nursing intervention for managing a Stage 1 pressure ulcer?

B) Implement a regular repositioning schedule

A) Apply a topical antibiotic ointment

B) Implement a regular repositioning schedule

C) Cover the area with a hydrocolloid dressing

D) Administer analgesics for pain relief

What is the primary reason for conducting a follow-up assessment of a patient's Stage 1 pressure ulcer?

B) To evaluate the effectiveness of the current treatment plan

A) To determine the need for surgical intervention

B) To evaluate the effectiveness of the current treatment plan

C) To decide if the patient should be discharged

D) To assess the patient's nutritional status

What is the most appropriate intervention for a Stage 1 pressure ulcer?

B) Reposition the patient every 2 hours

A) Apply a hydrocolloid dressing

B) Reposition the patient every 2 hours

C) Use a topical antibiotic ointment

Which intervention is most appropriate to prevent the progression of diabetic neuropathy in this patient?

A) Implementing daily foot inspections

B) Increasing carbohydrate intake

D) Discontinuing diabetes medication

Which of the following is the most appropriate initial intervention to prevent complications related to diabetic neuropathy in a patient with diabetes?

A) Monitor blood glucose levels regularly

B) Increase dietary protein intake

C) Encourage high-intensity exercise

D) Limit fluid intake to prevent swelling

Which intervention is most important for the prevention of pressure ulcers in a bedridden patient?

B) Regularly repositioning the patient

A) Providing a high-protein diet

B) Regularly repositioning the patient

D) Administering prescribed antibiotics

What is the most appropriate nursing intervention to prevent further complications in a patient with diabetic neuropathy?

A) Encourage daily foot inspections

B) Limit physical activity to reduce stress on feet

C) Advise against wearing shoes to improve circulation

D) Reduce carbohydrate intake to less than 50 grams per day

pressure ulcer - Nursing Case Study

Pathophysiology

• Primary mechanism: Prolonged pressure over bony areas impairs blood flow, reducing oxygen and nutrient delivery to the skin and underlying tissues, leading to tissue ischemia and necrosis.

• Secondary mechanism: Shear forces, often from sliding in bed or a chair, distort and stretch tissue, further compromising blood vessels and exacerbating tissue damage.

• Key complication: Localized tissue damage can progress to open wounds, increasing the risk of infection and delaying healing.

Patient Profile

Demographics:

76-year-old female, retired school teacher

History:

• Key past medical history: Hypertension, Type 2 Diabetes

• Current medications: Lisinopril 10 mg daily, Metformin 500 mg twice daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Redness and discomfort on the lower back

• Key symptoms: Mild redness and tenderness over the sacral area, no open wounds

• Vital signs: Blood Pressure 130/80 mmHg, Heart Rate 72 bpm, Respiratory Rate 16 breaths/min, Temperature 98.6°F (37°C)

Section 1

Initial Assessment Findings:

Upon conducting a thorough skin assessment, the nursing staff notes that the patient, a 76-year-old retired school teacher, presents with a Stage 1 pressure ulcer over the sacral area. The skin is intact but exhibits non-blanchable erythema, indicating localized injury due to pressure. The surrounding area is warm to the touch but without edema or signs of infection. The patient reports mild discomfort when the area is palpated, but there is no report of severe pain. The assessment confirms the need for immediate intervention to prevent progression to more advanced stages of pressure ulcers.

In addition to the skin assessment, a comprehensive review of the patient's current health status reveals that her blood glucose levels have been slightly elevated, averaging 150 mg/dL, which is higher than her usual range. This could potentially compromise skin integrity and wound healing due to her Type 2 Diabetes. The patient is alert and oriented, with stable vital signs, yet expresses concern about her ability to reposition herself frequently due to mild arthritis. This highlights the importance of developing a suitable care plan that incorporates both preventative measures and patient education to address mobility limitations and manage her diabetes effectively.

The nursing team prioritizes interventions aimed at relieving pressure on the affected area. A turning schedule is implemented, ensuring the patient is repositioned every two hours. A pressure-relieving mattress overlay is applied to her bed to distribute her weight more evenly and reduce pressure points. Education is provided on the importance of maintaining a balanced diet to support skin health and glycemic control. These foundational nursing interventions are designed to halt the progression of the pressure ulcer and promote healing, setting the stage for evaluating the patient's response to these interventions in subsequent assessments.

Section 2

Response to Interventions:

After implementing the initial interventions, the nursing team evaluates the patient's response over the next 48 hours. The patient reports a slight reduction in discomfort, indicating that the pressure-relieving strategies are effectively alleviating pressure on the sacral area. Upon reassessment, the Stage 1 pressure ulcer shows no signs of progression. The erythema remains, but there is no development of blistering or open sores, and the skin remains intact. Mild warmth in the surrounding area persists, but there is still no edema or exudate, suggesting the absence of infection.

The patient has been adhering to the repositioning schedule with assistance and expresses increased confidence in managing her arthritis-related mobility challenges. She has also shown improved glycemic control, with her blood glucose levels averaging 130 mg/dL, a positive shift from prior readings. This improvement is attributed to dietary adjustments and adherence to her diabetes management plan, as reinforced by the nursing staff. The patient remains alert and oriented, with stable vital signs: blood pressure at 130/80 mmHg, heart rate at 78 bpm, respiratory rate at 18 breaths per minute, and temperature at 98.6°F.

Overall, the patient demonstrates a favorable response to the interventions, and the nursing team plans to continue the current care strategies while closely monitoring her progress. They emphasize ongoing education regarding skin care, nutrition, and diabetes management to prevent further complications. The team anticipates the need for follow-up assessments to ensure continued recovery and to adjust the care plan as needed to support the patient's ongoing health and well-being.

Section 3

Three days after the initial interventions, the nursing team conducts a follow-up assessment to ensure the patient's pressure ulcer remains stable and to check for any potential changes in her health status. Upon examination, the Stage 1 pressure ulcer continues to show no progression, with the erythema slightly reduced. The skin remains intact with no signs of blistering or open sores, and the mild warmth in the surrounding area has decreased, which suggests that the pressure-relieving strategies and skin care regimen are effective. The patient reports that her discomfort has diminished further, and she feels more comfortable during repositioning, indicating enhanced tolerance to the interventions.

In addition to the pressure ulcer evaluation, the nursing team reviews the patient's diabetes management. Her blood glucose levels have remained relatively stable, averaging 125 mg/dL over the past few days, demonstrating continued adherence to dietary recommendations and insulin administration. The patient has also engaged in light mobility exercises, with the assistance of physical therapy, to improve her overall circulation and mobility. Her vital signs remain stable, with a blood pressure of 128/78 mmHg, heart rate of 76 bpm, respiratory rate of 18 breaths per minute, and temperature holding steady at 98.4°F.

The combination of stable glycemic control and effective pressure ulcer management has contributed to the patient's increased confidence and motivation to participate actively in her care. The nursing team plans to maintain the current care strategies, emphasizing the importance of consistent repositioning, diligent skin care, and regular monitoring of blood glucose levels. They also discuss the potential for gradually increasing the patient's activity level to further support her recovery and prevent future complications. This proactive approach aims to reinforce the patient's understanding of her condition and empower her to take an active role in her health management.

Section 4

A week following the initial assessment, the nursing team conducts another detailed evaluation to monitor the progress of the patient's Stage 1 pressure ulcer and overall health status. The pressure ulcer remains stable, with the erythema further reduced, indicating that the pressure-relieving strategies continue to be effective. The skin remains intact, with no development of blisters or sores, and the previously noted mild warmth has resolved completely. The patient's comfort level has improved significantly, allowing her to participate more actively in repositioning and mobility exercises without experiencing discomfort.

However, during this assessment, the patient reports experiencing some new mild tingling sensations in her feet, particularly noticeable during her mobility exercises. Concerned about the possibility of diabetic neuropathy, the nursing team decides to conduct a thorough neurological examination. The findings reveal slightly diminished sensation in the feet, but no other significant changes. This prompts a review of her diabetes management plan, ensuring that her blood glucose levels remain well-controlled to prevent further complications. The patient's blood glucose levels continue to be stable, with an average of 130 mg/dL, and her vital signs remain within normal limits, indicating no immediate cause for concern.

In response to these findings, the nursing team collaborates with the diabetes educator to reinforce the importance of foot care and regular monitoring for signs of neuropathy. They provide the patient with additional educational resources on managing diabetic neuropathy and discuss potential strategies to enhance circulation, such as appropriate footwear and continued mobility exercises. The patient expresses understanding and agreement with these recommendations, feeling encouraged by the team's proactive approach. This collaborative effort aims to address the new complication while maintaining the overall focus on her recovery and long-term health management. As the patient becomes more engaged in her care, the team plans to gradually introduce more challenging mobility exercises, aiming to improve her strength and circulation further.

Section 5

Two weeks after the initial assessment, the nursing team evaluates the patient's response to the implemented interventions for both the pressure ulcer and diabetic neuropathy. The Stage 1 pressure ulcer shows further improvement; the erythema is nearly resolved and the skin remains fully intact with no signs of further irritation or breakdown. The patient reports feeling more comfortable and has no difficulty participating in repositioning and mobility exercises, suggesting that the pressure-relieving strategies and skin care regimen continue to be highly effective.

Regarding the tingling sensations in her feet, the patient notes a slight decrease in frequency and intensity since incorporating the recommended foot care routines and mobility exercises into her daily activities. The nursing team conducts another comprehensive neurological examination, which reveals no further progression of sensory loss in her feet. Her blood glucose levels have remained well-controlled, averaging 125 mg/dL, which reinforces the effectiveness of her diabetes management plan. Vital signs continue to be stable: blood pressure at 120/80 mmHg, heart rate at 76 bpm, and respiratory rate at 18 breaths per minute, with no signs of complications.

The patient expresses gratitude for the support and education provided by the nursing team and diabetes educator. Encouraged by her progress, the team decides to introduce a new set of mobility exercises designed to further enhance circulation and build strength. They emphasize the importance of maintaining her current diabetes management plan and foot care routine to prevent any further complications. The patient feels optimistic and motivated, eager to continue her journey towards improved health and well-being. The team schedules a follow-up appointment in two weeks to monitor her ongoing progress and adjust the care plan as needed.