Question

A 78-year-old man with hypertension, hyperlipidemia, osteoporosis, and urge incontinence is admitted to a long-term care facility after having an ischemic stroke. His wife tells you that, over the past 6 months, the patient has become progressively dependent on her to assist with ADLs. You observe the patient to be a slender, frail elderly male who appears alert and cooperative. He has significant left-sided weakness and requires assistance to transfer from the wheelchair to the bed. While helping him change clothes, you notice a large reddened area on his left hip that doesn't change color when you press it with your index finger.

1. What is the most probable cause of his reddened hip?

2. How would you stage this skin change?

3. Which risk factors does this patient have for pressure injury formation?

4. What other body areas do you need to inspect for skin breakdown?

5. Which support surface would be appropriate for this patient?

Answer 1

1. The major cause for reddened hip is left sided weakness.

The left sided weakness limits their ability to change positions.

2. Stage 1

In stage 1, a reddened, painful area on the skin that does not turn white when pressed. This is a sign that a pressure ulcer is forming.

3. Risk factor is Ischemic stroke. Due to ischemic stroke patient is having left sided weakness.

4. Other body areas need to inspect for skin breakdown include

• Heels
• Ankles
• Tailbone

5. Air bed, water bed, australian medical sheepskin