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William Harmon is a 78-year-old man who

William Harmon is a 78-year-old man who fell 3 days ago. His fall resulted in a fractured left hip. He was admitted to the hospital and underwent surgery of the left hip. Today is his second postoperative day. He is still bed bound and is unable to roll or pull himself up in bed. Mr. Harmon’s weight on admission was 140 lb (63.64 kg). His height is 73 in. His family reports that he has been steadily losing weight. He expresses little interest in eating and says he has been depressed since his wife died last year. A large dressing covers the incision on Mr. Harmon’s left hip. You loosen the dressing and see the staples are intact at the incision site and there is a minimal amount of serosanguineous drainage on the bandage. As you turn him in bed, you see a 10 cm by 6 cm reddened area on his coccyx and a 2 cm by 3 cm purple bruise-like area on his left heel. Mr. Harmon now has three wounds, an intentional surgical wound and two pressure injuries that have resulted from his impaired mobility. How will you care for each of these wounds? What factors contributed to each of the wounds, and how will you promote healing? 1. What was the patient’s Braden Scale Score (this is your educated opinion)? 2. What risk level does that put him at? Severe Risk: Total score 9 or less; High Risk: Total score 10 to 12; Moderate Risk: Total score 13 to 14; Mild Risk: Total score 15 to 18. 3. Name 2 possible nursing diagnosis for this patient NANDA: NANDA: 4. Identify 1 goal for each nursing diagnosis you listed Patient will: By when: Patient will: By when: 5. Identify 1 intervention for each goal you listed for the patient The Nurse will: The Nurse will:

 
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