‘Nicole Peterson: 80-year-old female, fractured hip surgically repaired, nursing diagnosis: self-care deficits, pain, alteration in cognitive functioning, impaired mobility
As the nurse helps an unlicensed assistive personnel (UAP) with Mrs. Peterson’s bath, she notices a reddened area on her sacrum. Realizing that this may be the beginning of a pressure injury, the nurse examines the area carefully and notes a small skin excoriation in the area. She repositions Mrs. Peterson to prevent further pressure on her sacrum. After finishing the bath, the nurse records her findings and enters on Mrs. Peterson’s care plan a nursing diagnosis of impaired skin integrity related to mechanical forces (e.g., shearing forces, pressure, physical immobility), alteration in skin turgor, and pressure over a bony prominence as evidenced by reddened area on the skin. She writes nursing orders, including an order to observe skin over bony prominences every 4 hours, and then delegates to the UAP the task of turning and repositioning Mrs. Peterson every 2 hours. The nurse also places Mrs. Peterson on a pressure-relief mattress and obtains a foam cushion for her wheelchair.
Critical Thinking Questions
What facts and principles do you already know about the causes of pressure injury?
Do you have enough information to provide interventions for Mrs. Peterson’s actual impaired skin integrity? If not, what do you still need to find out?
What do you know about positioning clients? How would you explain to the UAP how to position Mrs. Peterson “to prevent further pressure on her sacrum”?
What reassessments would you make to evaluate Mrs. Peterson’s skin integrity problem? When evaluating the diagnosis of self-care deficit, what reassessments would you make? Who can or should evaluate the issues identified? How often, or when, would you reassess?
What is one problem not described in the scenario that might arise?