Answer :
The answers to the questions are as follows:
Subjective data from the client's case are as follows: Patrick is an 82-year-old black male admitted to the hospital for surgical repair of a fractured right hip. He lives alone, and his neighbors found him lying on his bathroom floor around 7 pm.
James told them he had been lying there since the afternoon but could not reach the phone to call for help and was unable to move. James has a history of hypertension and diabetes.
Information from the case study that provides objective data are as follows: As the nurse is performing an assessment on the second postoperative day, he documents an area on James's right heel that is purplish in color and appears to be a bruise.
The area is cooler to touch than the surrounding skin. There is no redness, and there are no open areas; James denies any pain in the heel.
Priority nursing diagnoses for the client with rationales are as follows:
Nursing Diagnosis 1: Risk for impaired skin integrity related to immobility, chronic diseases, advanced age, and surgical incision, as evidenced by a purplish area on the right heel and cooler to touch than the surrounding skin.
Nursing Diagnosis 2: Risk for falls related to immobility, history of falling, and living alone, as evidenced by a history of hypertension and diabetes and lying on the bathroom floor since the afternoon.
Outcome criteria for each diagnosis:
Nursing Diagnosis 1: Client's skin integrity will not be impaired during the hospital stay, and the purplish area on the right heel will be resolved.
Nursing Diagnosis 2: Client will not fall during the hospital stay, and safety measures will be implemented to prevent falls.
Interventions for each diagnosed problem are as follows:
Nursing Diagnosis 1:
Interventions:
Assess skin frequently, particularly the right heel, for signs of breakdown or injury.
Provide a pressure relief mattress and ensure repositioning every two hours.
Administer pain medication as needed.
Encourage adequate nutrition and hydration.
Provide a therapeutic environment and instruct the client to avoid crossing his legs.
Provide gentle cleansing and moisturizing of the skin.
Documentation source: Evidence-based Nursing Practice Guidelines for Prevention of Pressure Ulcers in the Elderly
Nursing Diagnosis 2:
Interventions:
Assess the client's ability to stand, walk, and transfer before ambulation and implement appropriate measures to ensure safety.
Assist the client in using assistive devices such as a walker or cane.
Provide a safe environment by removing clutter, ensuring adequate lighting, and keeping walkways free of obstacles.
Implement a bed/chair alarm or floor mats.
Documentation source: Evidence-based Nursing Practice Guidelines for Prevention of Falls in the Elderly
PART 2: CRITICAL THINKING QUESTIONS AND ACTIVITIES
The risk factors for pressure ulcers that are present in this situation are immobility, advanced age, surgical incision, and chronic diseases such as diabetes and hypertension.
Skin color affects the presentation of deep tissue injury by making it difficult to detect the changes that occur.
The areas of the body that are susceptible to pressure ulcer development are bony prominences such as the heels, sacrum, and ischium because they are the areas most frequently subjected to pressure and shear forces.
The education that needs to be provided to the patient, staff, and family is about the risk factors for pressure ulcers, appropriate assessment of risk factors and skin, and prevention strategies that include repositioning, using a pressure relief mattress, maintaining good nutrition and hydration, and using assistive devices to prevent falls.
Interventions to enhance James's safety when he returns home are to ensure that he has adequate support from family or caregivers, an accessible and safe environment, assistive devices to facilitate mobility and transfers, and a bed/chair alarm or floor mats.
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