Question

Patient Introduction

Location: Skilled Nursing Home Care Facility 0800

Report from charge nurse:

Situation: Mrs. Morrow is an obese, 80-year-old white female who developed a venous stasis ulcer on her right medial malleolus while still living at home. She moved into our skilled nursing home care facility 3 days ago. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown.

Background: Mrs. Morrow has a past medical history of chronic obstructive pulmonary disease (COPD), chronic venous insufficiency, and deep vein thrombosis (DVT). Peripheral arterial disease is ruled out by duplex ultrasound. Her daughter had her admitted to this skilled nursing home care facility due to concern for her safety with impaired mobility, an unhealthy diet, and inability to adequately care for herself at home.

Assessment: Mrs. Morrow is alert and oriented, but sometimes forgetful of recent events. Vital signs have been within normal limits and are performed weekly. Results from yesterday's labs are in the chart. She is on a regular diet with nutritional supplement and has been eating the majority of her meals since admission. She requires assistance with positioning in bed and assistance times 1 to get out of bed to the chair or ambulate. Her gait is unsteady, and she is easily fatigued. Her Braden Scale score is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. She has brown hyperpigmentation on both lower legs with +2 edema. The venous stasis ulcer is covered with a hydrocolloid dressing, which is due to be changed. In preparation for her dressing change, she was medicated for pain half an hour ago.

Recommendation: You should complete a basic assessment, review the labs, perform a wound assessment and dressing change, and then reposition the patient to optimize venous return. Please provide patient education on improving venous return to prevent further stasis ulcers, and continue compression therapy with the use of elastic bandage and an antiembolism stocking.

1.Document the characteristics of Ms Morrow's venous stasis ulcer

2.Document the dressing change and irrigation of Ms Morrow's wound

3.Record patients education on ways to promote venous return

4.Prepare 3 Nursing Diagnosis and their defining characteristics for Ms Morrow's diagnosis

  

Answer 1

1.Document the characteristics of Ms. Morrow's venous stasis ulcer

• Moderate pain, which improves on elevation (unlike arterial ulcers which worsen with elevation)
• Irregular, sloping edges noted with slough tissue and pus at the base of ulcer.
• Associated edema, (due to increased hydrostatic pressure, which contributes to 'Atrophie Blanche')
• 'Atrophie blanche',present(localized loss of skin pigmentation due to death of erythrocytes and scarring)
• Lipodermatosclerosis, present (hardening of the skin which can lead to an "inverted champagne bottle" appearance to the leg)
• varicose veins

2.Document the dressing change and irrigation of Ms. Morrow's wound

Under sterile precautions the alginate dressings was removed. Debries and ungealthy granulation tissue noted over the base of ulcer. Sloping edges. Thorough wash was given with plenty of sterile normal saline. Healthy granulation tissue was notes and active bleeding after the removal of slough tissue with sterile gauze pieces. alginate dressing was given . compression stockings were given and the limb was kept elevated over a pillow.

{Frequent irrigation is considered standard practice for most contaminated wounds to debride bacteria, necrotic tissue, and debris. The “biophysical” approach to biofilm management disrupts and debrides both planktonic and biofilm bacteria to stimulate the wound bed without over-debridement of healthy tissue.Normal saline is the most frequently used irrigant. Depending upon the nature of debris, the presence of infection optimal frequency of dressing is decided. Usually daily one dressing night be enough}

3.Record patients education on ways to promote venous return

Frequent change in posture and ambulation

helps to relieve the ischemia and reestablish the blood supply to normal

Wear Compression Garments

Wearing compression garments can help blood that is pooling in the leg, ankle, or foot to flow in the right direction—toward the heart. doctor may prescribe elastic compression stockings or socks made with a flexible, gradated fabric. These garments apply varying amounts of pressure to different parts of the legs and feet to keep blood moving properly through the veins.

Maintain a Healthy Weight

Obesity may contribute to the development of blocked or weakened valves in leg veins.Dieticians can help you develop eating and exercising habits that can lead to weight loss.

Increase Activity Levels

doctor may recommend to walk, ride a stationary bicycle, or jog for 30 minutes several times a week. Being active helps improve circulation and tones muscles in legs. This can help pump blood toward the heart.Stretching r calf and thigh muscles can also help improve blood flow.

Elevate the Legs

Standing or sitting for long periods can contribute to the pooling of blood in leg veins. Taking breaks to move legs can help blood flow toward the heart. When seated, raise legs by placing them on a footstool and avoid crossing them.

Avoid Tight Clothing and High Heels

Tight clothing or shoes can restrict blood flow in the legs and increase the risk of chronic venous insufficiency. High-heeled shoes can also impede blood flow in the legs. doctor may recommend wearing shoes with a low heel.

Avoid Salt

Salt, or sodium, can cause the body to retain water. Excess fluid in the legs can cause swelling and put pressure on leg veins, weakening vein walls and leading to chronic venous insufficiency.

Moisturize the Skin

Though it doesn’t treat chronic venous insufficiency, a daily application of moisturizer can heal dry or cracked skin, improving the health of legs.

4.Prepare 3 Nursing Diagnosis and their defining characteristics for Ms Morrow's diagnosis

A . varicose veins a collection of small, dark, engorged superficial veins.They are bulging, bluish cords running just beneath the surface of skin. They almost always affect legs and feet. Visible swollen and twisted veins -- sometimes surrounded by patches of flooded capillaries known as spider veins -- are considered superficial varicose veins

B .Atrophie blanche localized loss of skin pigmentation due to death of erythrocytes and scarring

C. Lipodermatosclerosis,a hardening of the skin which can lead to an "inverted champagne bottle" appearance to the leg