What Should the Nurse Do?
Mrs. Ramos, a sixty-five-year-old female, visits her primary care physician with a nonhealing wound on her lower leg. She reports experiencing persistent pain, swelling, and foul-smelling discharge from the wound for the past three weeks. Mrs. Ramos has a medical history of type 2 diabetes and hypertension. On examination, her vital signs are within normal limits, but her lower leg wound reveals signs of infection and delayed healing.
1
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Consider Mrs. Ramos’s medical history of diabetes. How does this information contribute to the analysis of the wound’s healing challenges, and what potential complications should be considered in the context of diabetes?
2
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As the nurse, what immediate actions would you initiate to manage the infection and promote wound healing, and how would you collaborate with the health-care team to address Mrs. Ramos’s overall health and comorbidities?
A new patient is admitted to the nurse’s unit from a long-term care facility with a urinary tract infection. The nurse is performing a head-to-toe skin assessment on admission. The only injuries to note are intact “caps” of dry eschar on both heels.
3
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What information relating to the wounds should the nurse include in their skin documentation, and how should the nurse stage them?
4
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Which treatment modality should the nurse anticipate for the bilateral pressure injuries?
5
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What preventive measures should the nurse implement?
Mr. Dickinson, a seventy-year-old male, checks into the emergency room with a chronic leg ulcer on his right lower extremity. He reports persistent pain, foul-smelling discharge, and difficulty in ambulation. Mr. Dickinson has a medical history of peripheral vascular disease and type 2 diabetes, both of which contribute to compromised blood circulation and delayed wound healing. On examination, his vital signs are stable, with a blood pressure of 130/80 mmHg, heart rate of 78 bpm, respiratory rate of 18 breaths per minute, and a body temperature of 98.6°F (37°C). The leg ulcer exhibits signs of infection, including redness, warmth, and purulent discharge. Necrotic tissue is present, indicating impaired tissue viability.
6
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Considering the signs of infection and necrotic tissue in the leg ulcer, how do these cues inform the nurse’s analysis of the clinical implications for debridement therapy? What potential complications should be considered during the analysis?
7
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What debridement methods and wound care interventions would you recommend for Mr. Dickinson, considering the presence of infection and necrotic tissue? How would you tailor these solutions to meet his individual needs and promote effective wound healing?
Ms. Lankford, a fifty-five-year-old female, arrives at the emergency room with a nonhealing diabetic foot ulcer on her right foot. She reports persistent pain, foul-smelling discharge, and difficulty in bearing weight on the affected limb. Ms. Lankford has a medical history of type 2 diabetes and peripheral vascular disease. On examination, her vital signs reveal a blood pressure of 130/80 mmHg, heart rate of 88 bpm, respiratory rate of 20 breaths per minute, and body temperature of 98.7°F (37.1°C). The diabetic foot ulcer exhibits signs of infection and delayed healing.
8
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What specific cues in Ms. Lankford’s medical history and the presentation of the diabetic foot ulcer indicate the potential need for hyperbaric oxygen therapy, and how would you communicate these cues to the wound care team?
9
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What other common treatment modalities, aside from hyperbaric oxygen therapy, would you recommend for Ms. Lankford’s diabetic foot ulcer, and how would you tailor these solutions to meet her specific needs and promote effective wound healing?
10
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The provider has ordered for a postoperative patient to have his wound photographed. What would the nurse verify before photographing the wound?