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Chapter 24: Skin Integrity

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Chapter 24: Skin Integrity

6 problems · 0 figures

Case Study 24.3.1 §24.3 source ↗

Refer to Chapter 19 Oxygenation and Perfusion and Chapter 22 Activity for Unfolding Case Study Parts 1–4 to review the patient data. Mrs. Jenson, a 72-year-old female, presents to the emergency room with worsening shortness of breath, fatigue, and swelling in her lower extremities over the last week. She reports increasing difficulty performing activities of daily living due to weakness and increased dyspnea. She has been admitted to the telemetry unit.

Past Medical History Medical history: Hypertension, type 2 diabetes, heart failure (class III), osteoarthritis
Family history: No significant family history reported.
Social history: Widowed ten years ago, currently living in an assisted care facility. No children.
Current medications:

• Lisinopril 20 mg PO once daily

• Metformin 500 mg PO twice daily

• Metoprolol 50 mg PO once daily

• Aspirin 81 mg PO once daily

• Furosemide 40 mg PO once daily

• Losartan 25 mg PO once daily

• Ibuprofen 400 mg PO Q6 hours PRN mild arthritic pain
Nursing Notes 1500:
Patient reports experiencing persistent joint pain, particularly in the shoulders and wrists, rated at 6/10 on the numerical pain scale. Patient states that pain interferes with daily activities, such as getting dressed and cooking. Patient also reports stiffness in affected joints, especially in the morning or after prolonged periods of rest, which improves with movement throughout the day. Occupational therapy referral sent per provider’s orders. Acetaminophen administered at 1415. Patient reports improvement in pain level, which she now rates as a 2/10 on the numerical scale.
Nursing Notes 1530:
During shift assessment, nonblanchable redness was noted on the patient’s sacrum. When asked about it, patient reports tenderness in the area that gets worse with prolonged sitting. Patient describes the sensation as a mild “stinging” feeling.
Recognize cues: What cues are most important for the nurse to recognize?

Answer

The most important cue for the nurse to recognize based on the provided information is the redness on the patient’s sacrum. Specifically, the nurse should recognize that the redness is nonblanchable, meaning that it does not turn white when pressed, indicating that it is a stage one pressure injury. It is also important to recognize that the patient has tenderness in that area with sitting, which is consistent with a pressure injury.

Case Study 24.3.2 §24.3 source ↗

Refer to Chapter 19 Oxygenation and Perfusion and Chapter 22 Activity for Unfolding Case Study Parts 1–4 to review the patient data. Mrs. Jenson, a 72-year-old female, presents to the emergency room with worsening shortness of breath, fatigue, and swelling in her lower extremities over the last week. She reports increasing difficulty performing activities of daily living due to weakness and increased dyspnea. She has been admitted to the telemetry unit.

Past Medical History Medical history: Hypertension, type 2 diabetes, heart failure (class III), osteoarthritis
Family history: No significant family history reported.
Social history: Widowed ten years ago, currently living in an assisted care facility. No children.
Current medications:

• Lisinopril 20 mg PO once daily

• Metformin 500 mg PO twice daily

• Metoprolol 50 mg PO once daily

• Aspirin 81 mg PO once daily

• Furosemide 40 mg PO once daily

• Losartan 25 mg PO once daily

• Ibuprofen 400 mg PO Q6 hours PRN mild arthritic pain
Nursing Notes 1500:
Patient reports experiencing persistent joint pain, particularly in the shoulders and wrists, rated at 6/10 on the numerical pain scale. Patient states that pain interferes with daily activities, such as getting dressed and cooking. Patient also reports stiffness in affected joints, especially in the morning or after prolonged periods of rest, which improves with movement throughout the day. Occupational therapy referral sent per provider’s orders. Acetaminophen administered at 1415. Patient reports improvement in pain level, which she now rates as a 2/10 on the numerical scale.
Nursing Notes 1530:
During shift assessment, nonblanchable redness was noted on the patient’s sacrum. When asked about it, patient reports tenderness in the area that gets worse with prolonged sitting. Patient describes the sensation as a mild “stinging” feeling.
Analyze cues: What other information would the nurse want to obtain from the patient at this time related to the recognized cues in the previous question?

Answer

The nurse should perform a focused skin assessment to confirm the staging of the redness on the sacrum. Based on its nonblanching status, it is likely to be stage one, but the nurse should assess more carefully to confirm. The nurse should also perform a skin assessment to determine the patient’s risk for developing pressure injuries. This will allow the nurse to discover potential causes of the skin breakdown and initiate interventions to reduce risk factors.

Case Study 24.3.3 §24.3 source ↗

Refer to Chapter 19 Oxygenation and Perfusion and Chapter 22 Activity for Unfolding Case Study Parts 1–4 to review the patient data. Mrs. Jenson, a 72-year-old female, presents to the emergency room with worsening shortness of breath, fatigue, and swelling in her lower extremities over the last week. She reports increasing difficulty performing activities of daily living due to weakness and increased dyspnea. She has been admitted to the telemetry unit.

Past Medical History Medical history: Hypertension, type 2 diabetes, heart failure (class III), osteoarthritis
Family history: No significant family history reported.
Social history: Widowed ten years ago, currently living in an assisted care facility. No children.
Current medications:

• Lisinopril 20 mg PO once daily

• Metformin 500 mg PO twice daily

• Metoprolol 50 mg PO once daily

• Aspirin 81 mg PO once daily

• Furosemide 40 mg PO once daily

• Losartan 25 mg PO once daily

• Ibuprofen 400 mg PO Q6 hours PRN mild arthritic pain
Nursing Notes 1500:
Patient reports experiencing persistent joint pain, particularly in the shoulders and wrists, rated at 6/10 on the numerical pain scale. Patient states that pain interferes with daily activities, such as getting dressed and cooking. Patient also reports stiffness in affected joints, especially in the morning or after prolonged periods of rest, which improves with movement throughout the day. Occupational therapy referral sent per provider’s orders. Acetaminophen administered at 1415. Patient reports improvement in pain level, which she now rates as a 2/10 on the numerical scale.
Nursing Notes 1530:
During shift assessment, nonblanchable redness was noted on the patient’s sacrum. When asked about it, patient reports tenderness in the area that gets worse with prolonged sitting. Patient describes the sensation as a mild “stinging” feeling.
Prioritize hypotheses: What factors does the nurse hypothesize are contributing to the development of the patient’s pressure injury?

Answer

The nurse should recognize that the patient has difficulty moving related to her osteoarthritis. This immobility is likely contributing to the development of the patient’s pressure injury. Additionally, the nurse may hypothesize that factors related to the patient’s hydration and nutrition status could be contributing as well.

Case Study 24.4.4 §24.4 source ↗

Refer to Unfolding Case Study #4: Part 5 for a review of the patient data.

Nursing Notes 1600:
Focused skin assessment performed. Open wound noted on bottom of left foot. Patient reports stepping on broken glass about a month ago but states, “I assumed my foot was fully healed because it doesn’t hurt at all.” Upon assessment, the wound is red with purulent drainage and surrounded by edematous tissue. Prophylactic dressing applied to sacral area. Provider notified.
Provider’s Orders 1700:

• Consultation with wound care team

• Consultation with diabetes educator

• Apply nonadherent gauze dressing on foot
Generate solutions: What are the rationales for the provider’s orders?

Answer

The provider ordered a consultation with the wound care team because of the open wound found on the patient’s foot. Based on the assessment findings, the wound appears to be infected, warranting more intense care and follow-up that are best provided by a specialized team. The provider has ordered a consultation with the diabetes educator because it is likely that the patient’s foot wound is related to her diabetes. The wound has not healed even though it has been a month since the initial accident, indicating poor wound healing, which is consistent with diabetes. Also, the patient reports being unable to feel any pain on her foot, despite obvious signs of infection. This is concerning and likely related to peripheral neuropathy associated with her diabetes, thus indicating the need for more education about her condition. The provider ordered the application of a nonadherent gauze dressing on the foot to protect the wound site and promote optimal healing. Nonadherent gauze dressings are specifically designed to minimize trauma to the wound bed during dressing changes by reducing the likelihood of the dressing sticking to the wound.

Case Study 24.4.5 §24.4 source ↗

Refer to Unfolding Case Study #4: Part 5 for a review of the patient data.

Nursing Notes 1600:
Focused skin assessment performed. Open wound noted on bottom of left foot. Patient reports stepping on broken glass about a month ago but states, “I assumed my foot was fully healed because it doesn’t hurt at all.” Upon assessment, the wound is red with purulent drainage and surrounded by edematous tissue. Prophylactic dressing applied to sacral area. Provider notified.
Provider’s Orders 1700:

• Consultation with wound care team

• Consultation with diabetes educator

• Apply nonadherent gauze dressing on foot
Take action: What are the priority actions by the nurse at this time?

Answer

The priority actions by the nurse include further assessment and documentation of the wound, initiation of ordered specialty consultations, and application of the ordered dressing. The nurse should closely assess the foot wound for size, drainage characteristics, and any other concerning findings. These should all be documented in the patient’s chart, along with a picture of the wound to use for comparisons later. The nurse should also initiate the referrals to wound care and the diabetes educator to ensure that the patient receives these services before discharge. Last, the nurse should apply the nonadherent gauze dressing as ordered. This will keep the wound covered, preventing worsening infection, until the wound care team is able to take a look at it.

Case Study 24.4.6 §24.4 source ↗

Refer to Unfolding Case Study #4: Part 5 for a review of the patient data.

Nursing Notes 1600:
Focused skin assessment performed. Open wound noted on bottom of left foot. Patient reports stepping on broken glass about a month ago but states, “I assumed my foot was fully healed because it doesn’t hurt at all.” Upon assessment, the wound is red with purulent drainage and surrounded by edematous tissue. Prophylactic dressing applied to sacral area. Provider notified.
Provider’s Orders 1700:

• Consultation with wound care team

• Consultation with diabetes educator

• Apply nonadherent gauze dressing on foot
Evaluate outcomes: The wound care team assesses the patient and orders an antibacterial cream and dressing changes every other day. What findings would indicate that these interventions were successful?

Answer

Findings that would indicate success of the interventions include a wound that is improving (as evidenced by comparison to the original photo taken during the initial assessment), improved redness and swelling, stable vital signs that do not indicate the presence of an infection, and patient understanding of the need to change the dressing often and keep the area clean. Additionally, the patient should express an understanding of any education provided to them by the diabetes educator regarding the prevention of future injuries and delayed wound healing related to peripheral neuropathy.

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Problems and answers are adapted from Fundamentals of Nursing by Christy Bowen, Lindsay Draper and Heather Moore, OpenStax, and are used under the CC BY-NC-SA 4.0 licence. Access for free at https://openstax.org/books/fundamentals-nursing/pages/1-introduction. Illustrations: Copyright Rice University, OpenStax, under CC BY-NC-SA 4.0 license. This adaptation is released under the same licence, is non-commercial, and is neither affiliated with nor endorsed by OpenStax or Rice University.