[Expert Solution]: Skin Integrity and Wound CareCase study…

Skin Integrity and Wound CareCase study CJMKelly Johnson is a first-year nursing student assigned to care for Mrs. Stein. Mrs. Stein, an 86-year-old patient, fell at her assisted-living residence and fractured her left hip. Prior to this fall she was independent in activities of daily living, enjoyed congregate meals at her facility, and participated in social activities. She had hip replacement surgery 2 days ago, and her postoperative physical therapy activities are progressing slowly. She is reluctant to move or participate in physical therapy because of pain and fear of falling. When asked to participate in repositioning, she slides her body up and down in bed while protecting her hip. She does not like the staff to reposition her in bed and is fearful of assisting because of pain. Her significant medical problems include heart failure, hypertension, and diabetes mellitus Type 2. She becomes slightly diaphoretic when moving, causing her to sweat on movement. Kelly notes drainage on her gown over the area of the left hip. Kelly reviews Mrs. Steins electronic health record (EHR). The nurses notes describe Mrs. Steins reluctance to reposition or actively participate in rehabilitation activities in physical therapy. Although Mrs. Stein has orders for pain medication, she rarely takes it because she is afraid of addiction. The night nurse documented a red, blistered area on the right hip and reddened area on the sacral region.Kelly recognizes the importance of reviewing postoperative care guidelines for a fractured hip and information about Mrs. Steins other medical problems. The information will provide a background for understanding Mrs. Steins risks for wound-healing problems and assist in directing the assessment. However, she also knows that the risks to Mrs. Steins skin integrity are a priority problem. Kelly works as an assistive personnel in a skilled nursing facility and has cared for patients with pressure injuries. From this experience she knows the costly and debilitating effects of pressure injuries and that prevention is a priority. Kelly reviews the current literature, professional guidelines, and risk assessment tools about pressure injuries. She suspects that the blistered and reddened area is a Stage 1 injury and can progress to Stage 2. If that occurs, Mrs. Steins length of hospital stay and subsequent admission to a rehabilitation facility may increase, which may ultimately affect her independence. She wants to work with Mrs. Stein to help improve her pain control and increase her confidence and participation in physical therapy and as a result prevent further injury to her skin and underlying tissues.This is Mrs. Steins second postoperative day. Prior to starting care, Kelly reviews the electronic health record and organizes her plan for assessmentKelly sees that Mrs. Stein had one dose of pain medication 10 hours ago, as patient is afraid of addiction and did not request any pain medication was noted in the record. Kelly asks Mrs. Stein to rate her pain level. Mrs. Stein describes her pain as an 8 out of 10. Before Kelly performs any assessment activities, she discusses pain control with Mrs. Stein and lets Mrs. Stein further describe her fear of addiction. Kelly discusses the fear of addiction and why Mrs. Stein might be more comfortable and better able to participate in physical therapy if she receives something for pain, and Mrs. Stein agrees. Kelly administers the ordered analgesic and tells Mrs. Stein she will leave her alone for 30 minutes to allow the medication to reach its peak effect. Kelly returns to Mrs. Steins bedside. A skin assessment reveals that the reddened, blistered area on Mrs. Steins right hip is 2.5 cm (1 inch) in diameter. The area is not draining, but the underlying skin is not intact. Kelly recognizes this as a Stage 2 pressure injury. Kelly also assesses nonblanchable erythema in the periwound area about 2.5 cm (1 inch) around the wound. On palpation Kelly notes that the periwound underlying tissue has nonblanchable erythema.. On palpation Kelly notes that the periwound underlying tissue has nonblanchable erythema.These findings indicate structural damage to the capillary bed and microcirculation and support the conclusion that a Stage 2 pressure injury is present. On the sacrum there is a 4.0-cm (approximately 2-inch) area of redness. When Kelly applies pressure to this area it blanches and becomes pale, and it reddens when the pressure is relieved. She knows this is blanchable erythema (normal reactive hyperemia) and indicates that the underlying capillary bed is intact. The underlying skin and tissue are normal on palpation. However, although the assessment findings in the sacral area are not abnormal, the redness, Mrs. Steins mobility and activity status, and pain are all risks for continued pressure to the sacral region and a risk for further impaired skin integrity. Kelly conducts a wound assessment. She notes drainage on the left side of Mrs. Steins gown. On wound inspection Kelly notes wound drainage and small openings between staples. The periwound area is warm and tender to palpation. Kelly notifies the charge nurse. Because all patients on this nursing unit have a standing order for a wound culture when assessment findings indicate a possible wound infection, the charge nurse tells Kelly to obtain a specimen for wound culture. Kellys faculty provides guidance and observes Kelly obtaining the culture specimen. Kelly assesses Mrs. Steins mobility status.Mrs. Stein is unable to assist using a bedpan, is refusing to use a bedside commode, and has episodes of incontinence. Kelly observed todays physical therapy session and noted that Mrs. Stein did become diaphoretic, but she was able to complete all activities. The physical therapist told Mrs. Stein that this was perhaps her best session, and Mrs. Stein mentioned that the therapy was not as painful as before. Kelly reviews assessment findings and uses her clinical judgment to analyze patterns of data to individualize nursing diagnoses for Mrs. Stein. The Stage 2 pressure injury, the open blistered (2.5-cm [1-inch] in diameter) area on the right hip, and the reddened (4.0-cm [approximately 2-inch]) sacral area identified in assessment support the nursing diagnosis of Impaired Skin Integrity related to pressure and shear. The small openings between staples, serous drainage, and redness and tenderness in the periwound region support the nursing diagnosis of Risk for Infection related to open surgical wound. Once the wound culture is examined, this nursing diagnosis will probably change to Infection related to open surgical wound.Mrs. Steins level of pain affects her willingness to participate in activity, and as a result there are two nursing diagnoses: Acute Pain related to incisional pain and Impaired Mobility related to incisional pain. As part of planning, Kelly takes time to talk to Mrs. Stein about the risks associated with reduced activity and movement. She explains how the injuries to her skin can worsen and what that will mean to Mrs. Steins independence and return to her residence. She tells Mrs. Stein she wants her to be informed about the potential and worsening skin and surgical wound problems. She explains the benefits of activity and the physical therapy session and how that will reduce the risks to her skin and improve her mobility. She explains to Mrs. Stein that the outcome of the activity and movement intervention is improved skin integrity on the right hip and sacral region. Kelly also includes the physical therapist and activities in the plan so that hygiene measures, wound care therapies, and pain control are coordinated with physical therapy sessions. Kelly collaborates with Mrs. Stein about pain and comfort measures. They agree on the pain-control outcome of a pain rating of 4 or less on a 10-point scale.She mentions to Mrs. Stein and the physical therapist that her tolerance and participation in therapy will be improved with adequate pain control. Kelly prioritizes two nursing diagnoses: Impaired Skin Integrity related to pressure and shear and Impaired Mobility related to incisional pain. From previous clinical experiences and postclinical conferences, Kelly knows that postoperative care is more than just pain control and that, in the case of Mrs. Stein, Kelly needs interventions to protect her skin to prevent further pressure injuries and progression of the Stage 2 pressure injury on her right hip. An important aspect to resolving impaired skin integrity issues is maintaining and improving mobility. Mrs. Stein is postoperative; comfort measures and pain control are essential to improving mobility and keeping Mrs. Stein off her sacral and right hip areas. Kelly and Mrs. Stein work together, and Kelly reinforces that managing acute pain often provides patients with physical and emotional energy for care. She explains the pain-control plan from Mrs. Steins surgeon. She also lets Mrs. Stein know that she also has nonopioid pain medications that she may want to try and that are safe and nonaddictive. Kelly gives Mrs. Stein a written schedule for when she can have pain medication and the different types of medications ordered by her surgeon.Kelly includes Mrs. Stein in evaluating the outcomes of her care. Mrs. Stein notes that her incisional and hip pain are reduced, and she reports her pain as 2 or 3 on the 0-to-10 scale and is very happy to be using nonopioid medication. Mrs. Stein can change position in bed and is more active in physical therapy. Kelly tells Mrs. Stein that the increase in activity helped reduce the redness on her sacrum and helped to improve the status of the Stage 2 pressure injury. Kelly takes time to reinforce patient education regarding pain control and mobility and ask Mrs. Stein when she will take any pain medication and how she will handle her mobility activity..Answer the questions below1. What assessment information in Mrs. Steins case study is of immediate concern to identify additional risk factors for impaired skin integrity? (Recognize Cues) 2. Considering Mrs. Steins postoperative care, what environmental factors might affect her skin integrity? (Analyze Cues)3.Reviewing the assessment data and postoperative progression, what would be additional priority nursing diagnoses that are not in the care plan for Mrs. Stein? (Prioritize Diagnoses)4. If Mrs. Steins right hip pressure injury does not heal or the sacral redness progresses to a Stage 1 pressure injury, identify two expected outcomes and describe appropriate nursing interventions and appropriate resources to achieve the expected outcomes. (Generate Solutions)5.A wound care specialist assessed Mrs. Steins wound and recommended NPWT. What nursing interventions would have priority to prevent an MDRPI? (Take Action)6. Evaluate the plan of care; what criteria support achievement of expected outcomes or support revision of treatment and the nursing care plan? (Evaluate Outcomes)