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A.L. is a 75-year-old African American male who has been transferred to your floor from the emergency room. A.L. is widowed; his wife died six months ago and lives alone. He does not have any children and stopped attending church when his wife died. He has a remote diagnosis of atrial fibrillation and had a mild stroke three years ago with some mild deficits to his right arm and leg. His neighbor performed a wellness check when she had not seen him for several days. The neighbor found him in his recliner chair incontinent of stool and urine and complaining of severe pain in his right leg. A.L. told his neighbor that he had fallen down the stairs “a couple of days ago” and could not get out of his chair due to the pain in his leg. When A.L. arrives on the floor, he is looking disheveled and has poor personal hygiene. He appears thin. Orientation X 1 on name. He was arousable but confused. On assessment, his oral mucosa is dry, and he has poor oral care. When asked whether he has any dentures, he stated that they “flap around in my mouth” and has stopped wearing them. PERRLA, cap refill >3 seconds. Chest is clear to auscultation for lung sounds and cardiac auscultation shows S1/S2 and no S3 or S4 heard with increased rate, and rhythm consistent with diagnosis of atrial fibrillation. Skin is dry and flaky, and tents on slight pinch. On turning A.L. on his side, you see a stage 2 pressure injury on his right scapula and a stage 2 pressure injury on his right buttock. Due to the client’s incontinence, the perineum and scrotum are red, swollen, and the skin is macerated. Assessment of the abdomen is soft and nontender, but hypoactive bowel sounds on auscultation. Client responds to the negative when asked about nausea, vomiting, or diarrhea. When you ask A.L. about his nutrition, he stated that he did not feel like eating after his wife died and it is hard for him to open up jars or cans due to his right arm “not working very well.” He mentioned that he eats mostly soft foods since his dentures stopped fitting his mouth a couple of months ago. He knows he has lost weight and “I am on my last belt buckle to keep my pants up.” His right leg has a large contusion that extends the length of his leg. He was prescribed anti-coagulants when he had his stroke three years ago. A Foley catheter was placed when he arrived in the emergency room five hours ago and the collection bag shows 45 ml. He is on an IV of 0.9% NS and 500 ml remain in the bag. Vital signs: BP 90/42; HR 105 bpm, respirations are 22 breaths per minute; temperature 99 deg F, O2 sat 93% on room air. Pain on arrival to the emergency room was 9 out of 10. After analgesia given in the emergency room, he now states pain is 7/10. Labs are as follows:

 

 

Lab Result
Hbg 11 g/dL
Hct 55%
RBC 4.2 cells/mcL
WBC 6000/mm3
K 4.0 mmol/L
Na 167 mmol/L
Cl 123 mmol/L
Mg 1.5 mEq/L
BUN 18 mg/dL
Cr 1.8 mg/dL
Glucose 72 mg/dL
Serum Prealbumin 12 mg/dL
Serum Albumin 3.0 mg/dL
Serum Transferrin 150 mg/dL

 

 

Describe in detail the assessment and laboratory findings consistent with dehydration. How does hypernatremia contribute to the client’s confusion?

Describe in detail the assessment and laboratory findings associated with poor nutrition. Discuss the role of fluids and nutrition in skin management and how poor nutrition and dehydration affect the ability of the client to heal the pressure injuries.

Use the Braden Scale to assess the client’s skin. Describe two priority nursing diagnoses for this client associated with fluids, nutrition, and skin integrity.

 

 

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