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Case Study 102 Pressure Ulcer: Prevention and Management
You are a nurse working in the medical intensive care unit (ICU) and take the following report from the emergency department (ED) nurse: “We have a patient for you: R.L. is an 81-year-old frail woman who has been in a nursing home. Her primary admitting diagnoses are sepsis, pneumonia, and dehydration, and she has a known stage III right hip pressure ulcer. Past medical history includes remote cerebrovascular accident with residual right-sided weakness and paresthesia, remote myocardial infarction, and peripheral vascular disease. She is a full code. Her vital signs are 98/62, 88 and regular, 38 and labored, 100.4° F (38° C). Lab work is pending; she has oxygen at 4 L per nasal cannula and an IV of D5.45 at 100 mL/hr. We just inserted a Foley catheter. The infectious disease doctor has been notified, and respiratory therapy is with the patient—they are just leaving the ED and should arrive shortly.”
1. What major factors increase risk for developing a pressure-induced ulcer?
2. Each health care setting should have a policy that outlines how to assess patients for their risk of developing a pressure ulcer. What should be included in that assessment?
3. As part of R.L’s admission assessment, you conduct a skin assessment. What areas of R.L.’s body will you pay particular attention to?
4. What are the advantages of using a validated risk assessment tool to document her skin condition on admission?
Case Study Progress
During your assessment, you note that she has very dry, thin, almost transparent skin. She has limited mobility from her stroke and is currently bedridden. There are several areas of ecchymosis on her upper extremities. She is alert and oriented to person only. You review the transfer summary from the long-term care facility and note she has a history of urinary and fecal incontinence.
5. Evaluate R.L. with the Norton risk assessment scale.
6. Given R.L.’s Norton score, describe specific measures you would implement to prevent further skin breakdown.
7. Knowing that R.L. is frail, has right-sided weakness, and has a pressure ulcer, what consultations or referrals would you initiate?
Case Study Progress
As you are completing R.L.’s assessment, the wound nurse specialist comes in. She knows R.L. from a prior admission; as soon as she received the request for a wound care consultation, she ordered a specialty mattress. She states that an air overlay should be delivered to your unit before your shift ends.
8. Why is a specialty bed or mattress used for immobile or compromised patients?
9. Why do patients placed on specialty beds remain at risk for skin breakdown?
10. What essential points should all staff know about the specialty bed?
11. Why do the heels have the greatest incidence of breakdown, even when the patient is on the most advanced specialty bed?
12. What intervention can you initiate to protect R.L.’s heels?
13. Compare and contrast friction and shear.
14. What interventions are needed to reduce the possibility of shear?
15. What risk factor does using a draw sheet prevent or minimize?
16.In caring for R.L., it is important for you to instruct the UAP to do which of the following? Select all that apply.
a.Assess R.L.’s skin status every shift
b.Develop an every-2-hour turn schedule
c.Use the appropriate sheets on the airflow bed
d.Keep R.L.’s head of bed below a 30-degree angle
e.Assist with hygiene measures when R.L. is incontinent
f.Empty and measure output in the urine collection device
Case Study Progress
The wound nurse needs to evaluate the preexisting pressure ulcer. She gently removes the old dressing, using the push-pull method and adhesive remover wipes. After taking off the outside dressing, often called a secondary dressing, she pulls out the primary dressing and states that R.L. has a tunneled wound that was “packed too hard.”
17. What problems can be created by packing a wound too full?
18. The nurse systematically assesses the ulcer and confirms the presence of a stage III wound with moderate drainage. There is no tissue necrosis or debris. What does it mean to “stage a pressure ulcer”?
19. What would you expect a stage III pressure ulcer to look like?
20. What is a tunneling wound? What risk factors are associated with tunneling?
Case Study Progress
After the wound nurse obtains a set of wound cultures, you watch as she packs the wound with gauze. The wound nurse charts the findings and makes formal recommendations for management of the wound to the primary care provider.
21. Describe the technique for packing a tunneled wound.
22. What wound documentation is necessary at this time?
23. What factors influence the selection of wound dressing?
24. What do you feel would be the best option for dressing R.L.’s wound? State your rationale.

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