Question

Mrs. Adams, 72 years of age, is admitted to the rehab unit with the diagnosis of stroke. The stroke affected the limbic area in the brain, which has caused the patient to have emotional labiality (her mood changes rapidly because she misinterprets situations). As a result of the emotional labiality, she sometimes refuses to be repositioned or to participate in physical or occupational therapy. She sometimes also refuses to eat and drink. The patient’s right side is paralyzed and flaccid. She has no feeling on her right side. She has reddened areas on her coccyx and both heels at least 1 cm in diameter that do not go away with repositioning. She is incontinent of urine and stool. She has problems with communication called global aphasia (difficulties understanding speech and the written word and difficulties with speaking and writing). She is 5 feet tall and weighs 178 pounds. She has a tendency to develop skin tears because her skin is thin, and she has several bandages on her arms. The family states they are concerned because the staff on the previous medical-surgical unit would drag their mother up in bed when she slid down. The staff would chart when their mother refused to be repositioned and then would not reposition her for hours. (Learning Objectives 2 and 4)

Explain the pathophysiology of the risk factors that predispose Mrs. Adams to developing pressure ulcers?

What nursing measures need to be instituted for Mrs. Adams based on the information presented in the case study?

Answer 1

Explain the pathophysiology of the risk factors that predispose Mrs. Adams to developing pressure ulcers?

Patient has risk factors such as age, immobility, poor nutritional status, CVA, history of pressure ulcers, have urinary and stool incontinence, refused to get repositioned ends in pressure ulcers.

All these predisposing factors lead to inadequate blood supply------>tissue damage and cell death---->reperfusion injury------> forms pressure ulcers--------> purple intact skin

What nursing measures need to be instituted for Mrs. Adams based on the information presented in the case study?

Redistributing pressures by proper repositioning every 2 hours

Adequate nutrition

Special beds

Foam mattresses

Wheelchair cushions while sitting

Good perineal hygiene