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Wound Care

In: Science

Submitted By venice59
Words 3306
Pages 14
Dale Gordon has been a patient in the ICU for 6 days after developing complications after open heart surgery. He is an 82-year-old African American who is disoriented to place and time. He lives with his daughter Claudia in her home. Claudia and her two brothers visit Mr. Gordon daily since he has been hospitalized. Mr. Gordon has not been eating well since the surgery and has lost 3 pounds. Mr. Gordon has type 2 diabetes and is on oral antihyperglycemic medication. Before he came to the hospital, Mr. Gordon was able to only ambulate for short distances. He has orders to get up in a chair twice a day. Joan, a student nurse, is caring for Mr. Gordon this morning. She has reviewed his medical record and is now ready to start caring for him.
Joan assesses Mr. Gordon using the Braden Scale and determines that his score is 12. What does this score indicate about Mr. Gordon’s pressure ulcer risk?
Joan is assessing Mr. Gordon’s skin and notices that he has a 3 cm blister and a shallow crater on his buttock. Mr. Gordon winces when Joan palpates the area. How should Joan stage this area?
A. Stage I pressure ulcer
B. Stage II pressure ulcer C. Stage III pressure ulcer
D. Stage IV pressure ulcer
Rationale:
Mr. Gordon has drainage coming from his surgical incision, and his dressing needs to be changed. What assessments of the incision should Joan perform while changing?
Answer:
Rationale:
Claudia asks Joan what she can do when she takes him home to help prevent more pressure ulcers. How should she answer?
Answer:
Rationale:
Elvis Baker, a 65-year-old black male, is being admitted to the preoperative suite for a colon resection for removal of a tumor. Mr. Baker is a retired coal miner. He has a history of hypertension and type 2 diabetes. He smokes one pack of cigarettes daily. His wife and brother are both with him. He has not had surgery before,

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