Patients at Risk- HESI Case Study (Evolve)

Using the Braden Scale, Mr. Espreaux's activity risk score is determined to be:

1 (Using the Braden Scale, Mr. Espreaux's activity risk score is 1, 'bedfast.')

When Mr. Esserman is in a chair, his weight should be shifted every:

15 minutes When in a chair, Mr. Esserman's weight should be shifted every 15 minutes.

Using the Braden Scale, Mr. Espreaux's friction and shear risk score is determined to be:

2 (Because he requires some assistance with moving in the bed, but is able to maintain good position most of the time, Mr. Espreaux's Braden Scale friction and shear risk score is 2, 'potential problem.')

Using the Braden Scale, Mr. Espreaux's mobility risk score is determined to be:

2 (Using the Braden Scale, Mr. Espreaux's mobility risk score is 2, 'very limited.')

Using the Braden Scale, Mr. Espreaux's moisture risk score is determined to be:

2 (Using the Braden Scale, Mr. Espreaux's moisture risk score is 2, 'very moist,' due to his perspiration.)

You teach the Essermans that when Mr. Esserman is in bed his position should be changed at least every:

2 hours (When in bed, Mr. Esserman should change position at least every two hours, although this schedule should be individualized based on his tolerance.)

Using the Braden Scale, which of the following scores would indicate that a person was at low risk for developing a pressure ulcer?

23 (Using the Braden Scale, low numerical scores mean that a person is at high risk for developing a pressure ulcer. The cut-off score for identifying persons at high risk is 16. 23 is the highest score possible. It represents the lowest risk for pressure ulcer development.)

Using the Braden Scale, Mr. Espreaux's nutrition risk score is determined to be:

4 (Mr. Espreaux is a well-nourished adult with no indication of nutritional risk prior to today's accident; his Braden Scale nutrition risk score is 4, 'excellent.')

Using the Braden Scale, Mr. Espreaux's sensory perception risk score is determined to be:

4 (Using the Braden Scale, Mr. Espreaux's sensory perception risk score is 4, 'no impairment'.)

With Sally, you prepare to teach the Essermans about pressure ulcer prevention. Which of the following approaches is best?

A combination of both of the above (Optimally, teaching is accomplished with verbal instruction and discussion, supplemented by written materials.)

Which of the following wound care dressing choices are acceptable for this Stage II pressure ulcer?

A sacral specific hydrocolloid dressing (Hydrocolloid dressings, available in many forms (pastes, powders, wafers, granules), contain substances that form a gel when in contact with fluid. They are useful for filling in superficial wounds (pastes, powders, granules), maintaining a moist surface, and providing protection (wafers which are occlusive). They also absorb drainage and can be used for autolytic debridement, in wounds with small-moderate amounts of drainage. A hydrocolloid wafer can be molded to fit unusual shapes, such as a heel or elbow. However, these products do not work well on the sacrum unless specifically designed for the sacrum. Non-wafer hydrocolloid dressings require a cover dressing. A hydrocolloid wafer can be used as a cover dressing. Hydrocolloid dressings should not be changed frequently and may be left on for up to a week. A sacral specific hydrocolloid wafer dressing would be useful on Mr. Espreaux's Stage II pressure ulcer, which is small and not draining much fluid.) A transparent film membrane dressing (A transparent film dressing can be used on Mr. Espreaux's Stage II pressure ulcer, which is small and not draining much fluid, to protect the wound, and maintain a moist environment supportive of healing. Transparent film dressings are semi permeable, meaning that oxygen and water vapor can easily pass through, although bacteria and external contaminants cannot enter through the dressing. Wound fluid cannot escape. Transparent film dressings are useful on open areas when hydration of the wound is needed and/or to promote autolytic debridement (absorption of necrotic tissue). Transparent dressings can be left in place for up to a week and should not be changed often. The adhesive of a transparent dressing can damage the skin when removed, particularly when skin is fragile.)

What should the Essermans be taught about moving and positioning?

A soft sheet or towel, applied under Mr. Esserman, can be used to assist with turning (Use of a "turning sheet" can help with positioning Mr. Esserman. The sheet would allow a broad area of Mr. Esserman's body to be supported when moving him from side to side, and when shifting his position while he remains on a given side. This should reduce rubbing of the skin against the sheets, and thus the effects of friction. When two people are present to help, a "turning sheet" can also make moving Mr. Esserman up or down in the bed easier, and eliminate dragging. Mr. Esserman can also be taught to use his unaffected arm to assist with moving and turning. Holding onto a side rail and pulling up with the trapeze can facilitate moving and turning. Mr. Esserman can also be taught to use his unaffected leg and arm to lift his body when shifting his weight or changing positions.) When moving Mr. Esserman, the person doing the moving should bend his/her knees (Persons helping Mr. Esserman should be aware of proper body mechanics to use when assisting with moving and positioning. Important principles of body mechanics include working with the bed at a comfortable level, facing the direction of movement, and using flexed knees when lifting. With flexed knees, the legs and hips are used, instead of the back.)

What type of dressing is Sally appropriately using on this pressure ulcer now?

Alginate (An alginate dressing is a good choice when a deep ulcer needs to be filled and a moderate to large amount of drainage is present, as with Mrs. Correo's current wound. Alginate dressings are mats of polymer/calcium that are applied to wounds that have moderate to large amounts of drainage. On contact with drainage, a hydrophilic (water absorptive) gel forms, and drainage is absorbed. Alginate dressings are applied directly to a wound, and can conform to irregular wound contours and undermined areas. They require a cover dressing, such as dry gauze. Alginate dressings can be used to fill a wound and for autolytic debridement. They are especially good in wounds with large amounts of drainage. They should be changed as necessary, usually once a day.)

Mr. Esserman needs nutrients of all types to provide calories and energy, but especially protein. What strategies do you appropriately encourage Mrs. Esserman to use in providing extra protein in her husband's diet?

At each meal, feed protein-rich foods first (Mr. Esserman has been eating only about half of what he is served at a meal. Providing protein-rich foods first is a good idea.) Offer yogurt or seasoned soft-cooked scrambled eggs to provide protein (Yogurt and soft-cooked eggs are good sources of protein, and have a consistency that Mr. Esserman should easily be able to swallow.)

Sally makes ongoing rounds, recommending prevention strategies and treatments for a wide variety of wounds, including pressure ulcers. A pressure ulcer is a/an:

Localized area of tissue necrosis A pressure ulcer is a localized area of tissue necrosis (death), caused by ischemia associated with prolonged, unrelieved pressure. Unrelieved pressure causes ischemia (poor circulation) which deprives the affected area of oxygen and nutrients, potentially leading to necrosis. Pressure ulcers usually develop in areas where soft tissue capillaries are compressed between a bony area and an external surface. Both the intensity and duration of pressure are important contributors to pressure ulcer risk.

What type of solution is used to safely clean Mrs. Correo's pressure ulcer before applying a new dressing?

Normal saline (Sterile normal saline is safe and not cytotoxic to wound tissue. It is the recommended solution for cleaning most pressure ulcers. All ulcers should be cleaned during dressing changes.)

Which of the following contribute to Mr. Esserman's risk for development of pressure ulcers?

Paralysis of arm and leg (Mr. Esserman's paralysis increases his risk for pressure ulcers. Any person who has limited ability to move himself and change position is at risk for developing a pressure ulcer. The person must rely on others to help move and change position to prevent pressure ulcer development. Also, Mr. Esserman sits in his favorite chair for most of the day. Being confined to a chair for a prolonged period of time can cause continuous unrelieved pressure on the same areas. This can lead to pressure ulcer development.) Loss of sensation (With loss of sensation, the normal ability of the nervous system to alert a person to "numbness" that happens after being in one position for too long is no longer present. Sensations of discomfort or pain may also be absent. Thus, skin damage can occur without being noticed. Mr. Esserman has some sensation, but feeling is limited on his affected side.) Difficulty swallowing (The inability to swallow properly can interfere with adequate food and fluid intake, and lead to malnutrition. Malnutrition can starve the skin of adequate nutrients and decrease tissue tolerance to pressure. Persons who are malnourished are at increased risk for developing pressure ulcers.) Slurred speech (With slurred speech, Mr. Esserman may not be able to effectively communicate any discomfort he might feel. This increases his risk for pressure ulcers.) Urinary incontinence (Incontinence increases the likelihood of moisture contact with skin and therefore the risk for pressure ulcers. Moisture is a skin irritant, which makes the skin more vulnerable to breakdown from pressure, friction, and shearing forces.)

With regard to the reddened area, which of the following is indicated?

Plans should be made to keep the area free of pressure (Redness indicates that the area has been oxygen-deprived. Blanching indicates that tissues are not damaged. A pressure ulcer is not present. However, because the area has been oxygen-deprived, it would be prudent to keep pressure off the area. Plans are made to temporarily avoid positions that place any pressure on this area.)

Sally reminds the nurses caring for Mr. Espreaux about the importance of staging any pressure ulcers. Which of the following are true about staging?

Pressure ulcers should be staged using a staging system (Pressure ulcers should be staged using a staging system such as the one recommended by the NPUAP (National Pressure Ulcer Advisory Panel). This system classifies pressure ulcers based on the degree of visible tissue damage present.) Pressure ulcers should be staged when discovered (Pressure ulcers should be staged when they are discovered. Stage does not change throughout treatment.) Staging is a primary criterion that guides treatment (Staging is a primary criterion for guiding treatment. A complete assessment is needed to appropriately plan care.)

Which of the following observations of peri-wound skin during a dressing change procedure would indicate a need to modify the wound care approach?

The skin around the wound is moist, soft, and wrinkled (Macerated skin (skin that is softened and wrinkled from contact with moisture) is prone to breakdown. The wound care approach would need to be changed to avoid contact of wound drainage with the skin surrounding the wound. Reddened skin with induration (hardness from swelling) would also be cause for concern. These are signs of irritation and inflammation.) The wound bed is moist and the dressing is saturated when changed (A moist wound bed is desirable for healing. However, saturated dressings are not desirable. The wound care approach would need to be changed)

Which of the following modifications are recommended when teaching older persons?

Use of large print in printed materials (The lens becomes less elastic, larger, and thicker as a person gets older. Visual acuity, the ability to see at distance of 20 feet what a normal eye sees at 20 feet, decreases. The larger the size of print, the easier it is for many older persons to read it. 12-point print is recommended. Also, as the lens of the eye ages, it becomes more opaque and yellowed, and the ability to distinguish between colors diminishes. For many older persons, reading is easier when there is a sharp contrast in the colors of print and the paper it is printed on. Solid, standard print types are easier to read than fancy prints like script or italics.) Presentation and discussion should be slow and unrushed (A slow and unrushed presentation is important when working with older persons. The recommended rate of speech is 125 words per minute or less. In many older persons, stimulus persistence is present. Sensory stimuli take longer to arrive and longer to leave. An older person may still be processing one thought while another topic is being presented by a fast speaker. An older person may need more time to focus and process information than a younger person.) A slightly louder, low-pitched speaking voice may be needed (Hearing loss is a common problem in older persons, and high-pitched voices and certain sounds are harder to hear. Because of this difficulty with discriminating sounds, especially consonants, older persons can misunderstand what word is being said. A slightly louder low-pitched speaking voice may be better heard. Shouting is not necessary and should be avoided. Words should be clearly pronounced and the person should be faced directly when content is presented and discussed. Background noises such as televisions and radios should be eliminated as much as possible.)

Mrs. Esserman asks, "How will I know if my husband is getting one of these bedsores?" Which of the following advice is appropriate?

When your husband's position is changed, check for reddened areas. (Checking for reddened areas with each position change is appropriate. If persistent redness is noted, positioning on that area should be avoided, at least temporarily. Also, more frequent positioning may be needed. A reddened area would indicate that hypoxia had occurred at the site, and blood flow was now increased to the area to replenish circulation. Skin should also be inspected for open areas. Pressure should be kept off open areas. In the event of an open area, treatment would need to be prescribed.)

Which of the following techniques can be used to determine if the air-filled static overlay on Mr. Esserman's bed is adequate in reducing pressure?

With Mr. Esserman in bed, place a hand between the mattress and the overlay (When a support surface such as an air-filled static overlay is used, it is important to check for "bottoming out." This occurs when the patient's weight compresses the surface so much that the pressure reduction ability is insufficient. "Bottoming out" is checked by placing a palm-up hand with the fingers extended under the overlay. If the patient's body can be felt through the surface, more air is needed or a higher level of support surface device is required. You determine that the air-filled static overlay on Mr. Esserman's bed is adequate. The gel support surface used for his armchair and wheelchair, checked before he was put into bed, are also adequate. Turning and positioning schedules are reviewed and reinforced.)

When assessing a reddened area, it is important that it be checked for:

blanching (A reddened area should be checked for blanching, that is, whether or not finger pressure causes the skin to temporarily turn white. Blanching would indicate that skin damage has not occurred, and that reactive hyperemia is successful in restoring oxygen and nutrients to tissues that had been blood-deprived. When erythema is nonblanchable, it indicates that redness is a result of an inflammatory response to tissue damage that has occurred. Nonblanchable erythema characterizes a Stage I pressure ulcer.) sensation (A reddened area should be checked for sensation. Pain or numbness can characterize poor tissue perfusion.)

When necrotic tissue is present, it must be removed before wound healing can occur. The process of removing necrotic tissue is called:

debridement (The process of removing dead tissue is called debridement. The presence of dead tissue interferes with wound healing, so debridement is necessary before wound healing can occur. Necrotic tissue can also support the growth of pathological organisms. Debridement is important because it eliminates a source of potential infection as well as a physical barrier that retards the healing process. One exception is a heel ulcer with eschar that is stable and without edema, redness, or drainage. This eschar does not need debridement.)

When Mrs. Correo was first admitted, Sally correctly:

determined that the ulcer was not stageable at the time (On admission, this pressure ulcer was covered with black necrotic material and the depth of destroyed tissue could not be determined. Staging is a method of classifying pressure ulcers based on the depth of tissue that is destroyed. When eschar covers a pressure ulcer, the depth of the wound cannot be determined. On admission, accurate staging of this pressure ulcer could not occur.)

Mr. Espreaux's total pressure sore risk score using the Braden Scale is 15. This means that he is:

high risk for developing a pressure ulcer (Using the Braden Scale, low numerical scores mean that a person is high risk for developing a pressure ulcer. The cut-off score for identifying persons at high risk is 16. Mr. Espreaux's score of 15 is below the cut-off score of 16. Therefore, he is at high risk for developing pressure ulcers. Research suggests a cut-off high risk score of 18 for elderly African-Americans and Latinos.)

A written care plan for pressure ulcer prevention, which includes a repositioning schedule, is established for Mr. Espreaux. Important components include:

use of support surfaces (Support surfaces are recommended to reduce the intensity of pressure on areas at risk for developing pressure ulcers. A 15 cm (6 inch) high-density foam mattress is ordered for Mr. Espreaux's bed.) use of positioning devices (Positioning devices, such as pillows and foam wedges, can be used to support body surfaces in desired positions with correct alignment. They can also be used to keep skin surfaces from touching, which increases risk for pressure ulcers. Pillows or foam pads can also be used to keep bony prominences off the bed (floated). This is especially important for the heels, which are at very high risk for pressure ulcer development.) having Mr. Espreaux shift his weight periodically (Shifting of weight is important for pressure reduction. Regardless of position (back-lying or side-lying), shifting of weight while maintaining position can reduce pressure on specific spots. Mr. Espreaux can use the trapeze on his bed to assist with positioning and to shift his weight between position changes.)

Using sterile normal saline, Mrs. Correo's wound is cleansed:

using a 35 mL syringe with a 19-gauge needle (A 35 mL syringe with a 19-gauge needle/angiocatheter delivers a safe and effective pressure for cleansing an open, draining wound of debris. A 60 mL catheter-tip piston syringe, or a 250 mL saline squeeze bottle with irrigation cap, also deliver effective irrigation pressures for removing wound debris. These enable wound cleansing without causing tissue trauma.)