Question

A 6-year-old male with cerebral palsy is hospitalized for respiratory distress secondary to aspiration pneumonia. During the patient’s third day in ICU, he remains ventilated and sedated. During a skin assessment, the nurse notes an open area on the patient’s occiput with the skull visible adipose. During handoff, it was reported that the skin was intact. Upon review of the original assessment, there is no documentation of any open areas. 1. Identify the factors that place this patient at risk for pressure injuries? 2. Identify the stage of the pressure injury and rationale supporting why. 3. Is this pressure injury hospital-acquired? Why or Why not? Indicate any reporting actions that need to occur and why as well as any impact payment. 4. Identify two interventions that can be delegated to a UAP to assist with the management of the pressure injury? Be specific regarding what and how you would communicate to the UAP to ensure clear communication and maintain patient safety.

Answer 1

ANSWERS :-

1) Identify the factors that place this patient at risk for pressure injuries?

* This 6-year old child is with cerebral palsy which affects the movements, ,and muscle tone and strength, and in the hospital he is mechanically ventilated and under sedation which further reduce or restrict movements and make him at risk for developing pressure ulcers in the pressure points.

2) Identify the stage of pressure injury and rationale supporting why?

* This pressure injury is a IIIrd stage pressure ulcer because there is a open area with the exposure of adipose tissue.

-STAGES OF PRESSURE ULCER:-

*Stage I- Warmth, redness, and swelling over the area.

*Stage II- Development of blister (fluid filled bubbles ) epidermis and dermis is damaged.

* Stage III- Skin is opened, full thickness ski loss and adipose tissue under the skin is exposed and visible.

3) Is this pressure injury hospital -acquired? Why or why not? Indicate any reporting actions that need to occur and why as well as any impact payment?

* Yes, this pressure injury is hospital - acquired because he is already at risk for pressure ulcer due to his confinement to bed due to mechanical ventilator support for respiratory distress and he is sedated where his sensations and movements are deprived or lost.

* Since it is a hospital acquired injury, it needs to be reported and written in an incident report, hospital acquired pressure ulcers are bad mark for hospitals which is a indocator for poor nursing care and quality care. Reporting and documentation helps to identify the reason and problems and take necessary actions to prevent such incidents further.

* Since it is the negligence from hospital staff, the payment usually is taken by hospital itself, it is not fair to give extra burden on the patient due to hospital negligence.

4) Two interventions that can be delegated to UAP( Unlicensed Assistive Personnel ) are-

* Report any changes noted on the patient's skin like redness, blistering, warmth etc

* Keep the skin clean and dry, and reposition the patient as prescribed keeping the injured area free from further pressure.

* The patient is ventilated with all tubings and not conscious, so care must be taken to prevent accidental removal of tubings and fall.Explain the UAP to always keep the bed rails up

-not to keep the patient on the side of the bed,

-not to pull the tubings while giving care,

-to make sure that the tubings are fixed properly,

- patient may pull out the tubings, so be watchful and restrain hands if needed

- never leave the patient unattended.