Question

Alice Bixby, an 83-year-old female client, is admitted with a cerebral vascular accident with the right-sided hemiparesis (paralysis of the right side of the body). The client has global aphasia and has difficulty speaking or understanding what is said. The client is incontinent of urine and stool and wears adult incontinent briefs. The client has a thickened diet to nectar consistency because of dysphagia (difficulty swallowing). The client has been turned every 2 hours and has a pressure relieve mattress in place. The client has a history of chronic obstructive pulmonary disease and wears continuous oxygen per nasal cannula at 2 L/minute with the SaO₂ of 90%. The vital signs are T, 99 °F; BP, 100/70 mm Hg; HR, 90 beats/minute; RR, 22 breaths/minute. The client is 5 feet in height and weighs 90 pounds. There is a red area approximately 2 cm in diameter under the right elbow that fails to blanch when pressure is relieved. There is a shallow crater with subcutaneous tissue present and white-tinged fluid, approximately 3 cm in diameter on the coccyx. On the right hip, there is a 2-cm diameter deep area, with tunneling of 2 cm in depth which is foul-smelling and has black tissue over it and presence of bone. Under the right heal is an area 1 cm in diameter, red, with a blister present. Under the ears where the nasal cannula lies are small red areas that blanch when the nasal cannula is removed. The LPN/LVN needs to use the criteria for staging pressure sores and evaluate the areas of skin breakdown appropriately.

Using the criteria for evaluating pressure sores, which stage is each of the areas of skin breakdown described in the case study?

What measures should be instituted to promote healing of the skin breakdown?

Answer 1

Answer: Pressure ulcer is an Injury occurs due to excessive pressure to a particular side of the body or the area. It occurs as insufficient supply of the blood to the pressurized area.

• It is given that the right elbow, where stage 1 ulcer is present.
• At the coccyx, stage 3 ulcer.
• The right hip has stage 2 ulcer.

To promote the healing of the skin breakdown includes:

• It is important to maintain proper hygiene. Hence if the injured skin is not broken, it should be washed and pat dry.
• Salt water should be used to clean the dead cells.
• Dressing should be performed frequently.