Case Study – Skin Care and Pressure Ulcers – Wounds

Read scenario and respond to the queries on this document. 

Marya, a first-semester nursing student, will be doing a rotation with Francis Obermyer, RN CWCN, one of the nurses on the wound care team at the hospital. Francis is a certified wound care nurse. In preparation for the rotation she was provided with the following census printout for some of the patients that Francis will be rounding on the following day. Marya will have the opportunity to do wound assessments as well as the indicated interventions for wound care.

Patient	Primary & Secondary Medical Diagnoses	Age	Wound Type	Dressing Type	Treatment Orders
A	Diabetic ketoacidosis; renal insufficiency, diabetic neuropathy	74	Diabetic foot ulcer, left great toe (arterial ulcer)	Gauze	Wet-to-moist saline dressing bid
B	Deep vein thrombosis (DVT), right leg, peripheral vascular disease, hypertension	58	Venous stasis ulcer, left lateral malleous	Alginate	Alginate dressing daily Irrigate wound with NSS with each dressing change
C	Colon cancer, s/p exploratory laparotomy with hemicolectomy, morbid obesity	49	Surgical incision with staples	Gauze Penrose drain	Advance Penrose drain 6 mm daily
D	Urosepsis, dementia, cachexia, hypertension, coronary artery disease, incontinence (bladder & bowel)	92	Pressure ulcer (coccyx)	New admission—to be determined

1. For each of the patients, discuss the factors that could be affecting their skin integrity.

Factors	Impact on Skin Integrity	Patient(s) Affected
Age-related
Mobility
Nutrition/hydration
Sensation/cognition
Circulation
Medication
Moisture on skin
Fever
Contamination/ infection
Lifestyle

• For the first three patients, what are the expected characteristics of the type of wound for each that the student can anticipate finding when the dressings are changed during the day’s rounds?

Patient	Wound Type	Expected Findings
A
B
C

• Explain why the dressing ordered for each wound is appropriate to the situation.

Wound Type	Dressing	Rationale for Ordered Dressing
Diabetic foot ulcer, left great toe (arterial)	Gauze
Venous stasis ulcer, left lateral malleous	Alginate
Surgical incision with staples	Gauze

• How will Marya know what/how much dressing materials will be needed for each type of dressing?

• When planning for implementation of these wound care procedures, what are the commonalities of procedural steps in readying the patients for the dressing change?

• Marya plans to use a gown and face shield for each of the ordered treatments. Is doing so appropriate to the procedures? Give a rationale for your decision.

The day’s rounds begin with a visit to the post-operative patient. The dressing needs to be changed and the Penrose drain advanced 6 mm per physician orders. This is the first time that the Penrose drain order will be implemented.

• What equipment will be needed to implement the order?

• The patient has Montgomery straps holding the dressings covering the Penrose drain. What is the purpose of these straps?

• The patient is extremely apprehensive about “anyone pulling on something sticking out of me.” Describe how Marya should explain the procedure to the patient.

The next dressing procedure involves irrigation of the wound and placement of the alginate dressing.

1. How should the patient be positioned to complete the irrigation?

1. What would signify that the alginate dressing is no longer indicated as treatment for this type of wound?

The last patient to be seen this morning is the new admission with the pressure ulcer on the coccyx area. This patient’s Braden score shows 1’s for sensory perception, moisture, activity, mobility, and friction and shear. No information is available regarding nutritional intake.

1. What other information can be used to determine the nutritional status of this patient? Consider the laboratory and diagnostic data found on the patient’s chart.

1. Assessment of the wound reveals the following characteristics: oval wound 10 cm length × 7.5 cm width, maceration, erythema, edema, and large amount of slough noted. To help with débridement of the wound, Marya orders a wet-to-dry dressing to be changed bid for 2 days. Why is this dressing indicated, and why is it limited to 2 days?

1. The wound care nurse assesses the student’s technique in placing the wet-to-dry gauze dressing into the pressure wound. She notes that Marya spends extra time pulling the gauze apart to expand its bulk before placing it into the wound instead of using the gauze pads as packaged. What should be the wound care nurse’s critique concerning this step of the procedure?

1. Describe the most appropriate method to secure this dressing in place. What factors did you consider in making your decision regarding securing the dressing?

1. Prevention of further pressure wounds is important in the care of this patient. Using the available patient data and the present situation, according to the decision-making tree for management of tissue loads, which type of support service is indicated for this patient?

1. A diagnosis of Impaired Tissue Integrity† is identified for this patient. How do the defining characteristics of this diagnosis differentiate it from a diagnosis of Impaired Skin Integrity?

1. The NOC outcome of Wound Healing, Secondary Intention is chosen and the NIC interventions address pressure ulcer care. In review of the individualized interventions appropriate to this problem, which interventions can be delegated to the unlicensed assistive personnel?