Unfolding Case Study
1.
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.
2.
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.
3.
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.
4.
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.
5.
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.
6.
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.