solved. Question
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Asked by DeanRiverNightingale4
Your patient is a 47-year-old woman who has had a history of diabetes for the past 25 years (currently uncontrolled), is a stroke survivor, and has congestive heart failure. She developed a sacral pressure injury following an above-the-knee amputation six months ago during her hospital stay. She does not complain of pain at the wound site. She lives at home with her daughter and also has home health care three days a week. Home health care is planned to last for only three weeks. Her daughter does daily wound care in between home health visits. Vital signs today were baseline for the patient except for a temperature of 101 degrees F.
The old dressing was removed and there was a heavy amount of purulent drainage. Foul odor present.Â
What stage pressure injury is this? Explain why you chose this stage (extent of tissue injury).
Document your assessment of the wound in the image. (Parameters to include: Location, type of wound, the extent of tissue involvement, type and percentage of wound base (granulation, necrotic, slough), wound size, wound exudate, presence of odor, peri-wound area, tunneling, undermining, and pain) (Document depth as 2cm)
Would you expect this patient to have pain? Why or why not?
The dressing change order reads: Cleanse wound with normal saline. Pat dry. Pack wound and undermining with silver alginate. Cover with bordered foam daily. What is silver alginate and why would it be used on this wound?
What is the purpose of bordered foam?
After reading the last wound description by the home health nurse, you find that there was only a small amount of purulent exudate. Now the dressing has a heavy amount of purulent exudate. The daughter states it has gotten a little worse each day and did not seem too concerned about the change in the amount of exudate. Document SBAR communication with the provider about changes in the wound. (The provider decided to continue the same dressing changes and start your patient on an antibiotic for 10 days.)
What education will you provide to your patient and her daughter?
What in this patient’s history can cause poor wound healing?
Provide 2 nursing diagnosis statements for this patient. For each diagnosis provide an outcome and how you would evaluate if the outcome was met.
SCIENCE
HEALTH SCIENCE
NURSING
NURS MISC
