Premium Essay

Wound and Skin Case Study

In: Science

Submitted By djdancer125
Words 543
Pages 3
Nurs 2820

Skin Integrity and Wound Care

Student: Navjot Kaur
Case Study

Dale Gordon has been a client 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.

1. 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? Explain what the Braden score is. * Mr. Gordon has a high risk of developing a pressure ulcer because his score is a 12 on the Branden Scale. The lower the score on the Branden Scale (6-23) the higher the risk of developing a pressure ulcer. The Branden Scale is used to determine any limitations with a patient’s sensory perception, activity, nutrition, moisture, and mobility.

2. 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 and Why?

A. Stage I pressure ulcer
B. Stage II pressure ulcer – A stage II pressure ulcer includes having blistering, shallow craters, and associated pain.
C. Stage III pressure ulcer
D. Stage IV pressure ulcer

3. Mr. Gordon has drainage coming from his surgical incision and his dressing needs to be changed. What...

Similar Documents

Premium Essay

Jean Watson

...Vacuum Assisted Closure Therapy (VAC) Catherine van der Hoeven Capone Wilmington University Abstract Vacuum Assisted Closure Therapy (VAC) is a system for applying negative pressure to wounds, which is claimed to accelerate healing of chronic wounds. A foam sponge is placed into the wound, than the site is sealed with an adhesive drape, and negative pressure is applied to the wound for 22-24 hours daily. VAC decreases tissue edema and improves local circulation; it also removes the debris from the wound surface. The average cost, including the materials and nursing care ranges from $400-$500 per patient weekly. This technique has been used increasingly over the past decade for acute and chronic wounds, and studies have demonstrated improved wound healing. Its use has been extended to other types of wounds, such as surgical wounds from abdominal, chest and cardiac (heart) surgical procedures. Currently VAC can be used on all types of wounds: acute, subacute or chronic. Introduction Diabetes is becoming a common problem in most of the countries all over the world. About 1.8 million people are affected by diabetes and with rapidly increasing diabetic patients the count is estimated to go up to 2.7 million in next 25 years (Speak K, 2007). Diabetic foot complications are more frequent in males individuals aged over 60 years. The life expectancy of the diabetic patients has increased due different treatments, which in turn increases the number of complications as the...

Words: 1225 - Pages: 5

Free Essay

Msc Student

...Engineering, Rutgers, The State University of New Jersey, Piscataway, New Jersey 08854; email: ireis@sbi.org 2 Center for Engineering in Medicine, Massachusetts General Hospital, Boston, Massachusetts 02114 Annu. Rev. Chem. Biomol. Eng. 2011. 2:403–30 Keywords First published online as a Review in Advance on March 17, 2011 artificial organs, skin, cartilage, liver, stem cells The Annual Review of Chemical and Biomolecular Engineering is online at chembioeng.annualreviews.org Abstract This article’s doi: 10.1146/annurev-chembioeng-061010-114257 Copyright c 2011 by Annual Reviews. All rights reserved 1947-5438/11/0715-0403$20.00 The past three decades have seen the emergence of an endeavor called tissue engineering and regenerative medicine in which scientists, engineers, and physicians apply tools from a variety of fields to construct biological substitutes that can mimic tissues for diagnostic and research purposes and can replace (or help regenerate) diseased and injured tissues. A significant portion of this effort has been translated to actual therapies, especially in the areas of skin replacement and, to a lesser extent, cartilage repair. A good amount of thoughtful work has also yielded prototypes of other tissue...

Words: 6720 - Pages: 27

Free Essay

Potat

...treat burns. Doctors have learnt that in case of minor burns, potato peel bandages work better than conventional dressing. Dr.P.V.Naryanan, a plastic surgeon of Jubilee Mission Medical College, in Thrissur, Kerala, told this correspondent The hospital realized the use of potato peel when renowned plastic surgeon of Mumbai, Dr M.H. Keswani, came visiting. He had been experimenting with potato peels for years. Dr.Narayanan said,”Dr.Keswani told us he started thinking about it after a friend said innocuously how similar dried potato peel was to stored skin used by plastic surgeons. He then realized potato peel did not desiccate quickly. Burns patients lose a lot of water through evaporation from the wound and potato peels prevent quick evaporation. Dr.Dattareya, an Indian-born doctor working in Holland, visited the jubilee Hospital and was amazed at the healing properties of potato peel. “He has published an article on it in a medical journal,” said Dr Narayanan. It’s been mentioned even in the ancient books. Potato peels provide moisture; they also have anti-bacterial properties that help in healing burn injuries. It’s the moisture that helps. The juices in a peel keep the wound moist. Perhaps this helps speed up the healing process. A dry wound is very painful and takes longer to heal. Read more at http://scienceblog.com/11009/treat-burns-with-potato-peel/#Ei6hG7qojDoGbAg4.99 Histological and bacteriological studies of burn wounds treated with boiled potato peel......

Words: 1115 - Pages: 5

Premium Essay

Surgical Wound Infection

...Surgical Wound Infection ? I will like to identify patients conditions and other factors contribute to the development of Surgical Wound infections. * Determine the aims or purposes of analysis The purpose is to understand the effect of environment in surgical wound infections. Prevention of infection requires the application of the principles of microbiology and accept practice. Measure of this concept is based on the stages of wound healing and the Centers of Disease Control and Prevention guidelines defining surgical site infection as occurring 30 days postoperative. * Identify all uses of the concept The Merriam-Webster Dictionary was used to explore the general definition of surgical wound infection Surgical of or relating to the process of performing a medical operation: of or relating to surgery. Wound an injury that is caused when a knife, bullet, etc., cuts or breaks the skin. Infection is the act or process of infecting someone or something: the state of being infected. The Oxford English Dictionary (OED) was also used to explore the definition. Surgical relating or used in surgery. Wound is an injury to living tissue caused by a cut, blow, or other impact, typically one in which the skin is cut or broken. Infection is the process of infecting or the state of being infected History of Surgical Wound Infection Hippocrates (Greek physician and surgeon, 460-377 BC), known as the father of medicine, used vinegar to irrigate open wounds and......

Words: 1509 - Pages: 7

Free Essay

Care Plan of Venous Leg Ulcer

...A venous leg ulcer is a chronic wound as it takes longer than six weeks to heal. It is caused by venous hypertension which is high blood pressure exerted in the veins of the legs which causes damage to the skin. Fluid can leak from the veins and pool under the skin causing swelling and thickening, this then leads to the skin breaking down to form an ulcer. Before a venous ulcer can be treated it is important to rule out peripheral arterial disease being the cause of the ulcer. Symptoms of peripheral arterial disease include pain in limb when exercising or walking, intermittent claudication, skin changes such as hair loss, cold to touch, oedema and ulceration. An arterial leg ulcer is caused by poor blood flow in the arteries and due to the current treatment of venous ulcers which is bandaging. This would reduce blood flow further and cause more damage making the ulcer worse. Having a history of varicose veins and a lack of mobility increases the chance of developing venous leg ulcers . According to SIGN (2010) when assessing a patient for the first time with a venous ulcer it is important to obtain their medical history in case of previous varicose veins and deep vein thrombosis as well as their mobility. Knowing these factors will contribute to managing the patients treatment, care and help with the rate of improvement. The framework model used to assess leg ulcers is the leg ulcer care pathway which is dived up into four stages 1.......

Words: 1344 - Pages: 6

Premium Essay

Mrsa

...Department of Infection Control, Vilnius, Lithuania Accepted for publication: July 2015 S36 I British Journal of Nursing, 2015 (Tissue Viability Supplement), Vol 24, No 15 © 2015 MA Healthcare Ltd Abstract Background: Methicillin-resistant Staphylococcus aureus (MRSA) infections are an increasing problem worldwide with a high risk of severe illness and mortality in hospitalised patients. Patients with chronic wounds are at particular risk of developing MRSA infections. As octenidinebased products have shown promising success in decontamination in the past, the aim of the present study was to determine its efficacy, safety, and tolerability in decontaminating hospitalised MRSApositive patients. Methods: From 1 April 2011 until 9 November 2012, 36 patients were screened MRSA-positive at the Republican Vilnius University Hospital, Vilnius, Lithuania. At least three swab tests were performed for each patient to screen for MRSA, one from each nostril and one from the perineum. In patients with wounds, an additional swab was taken from the wound surface. In the affected patients octenidine-based products were used in one or two cycles of 7 days each. In addition, adverse events were recorded and the tolerability was assessed using a 4-point scale ranging from ‘very good’ to ‘poor’. Results: Complete decontamination was achieved in 24 patients (67%) following treatment with the octenidine-based products. None of the patients...

Words: 3211 - Pages: 13

Free Essay

Wounds

...Review SKIN FUNCTION AND WOUND HEALING PHYSIOLOGY John Timmons is Clinical Manager, Wounds UK and Tissue Viabiliy Nurse, Aberdeen Regular evaluation and the setting of goals is essential to monitor the progress of the patient and their wound.To do this, is important to understand the physiology of the skin and the way normal wound healing progresses in order to plan and provide effective wound management. This article describes the structure and function of the skin and outlines the four normal phases of healing. Wound healing is an exciting and continually developing field, with new technologies and research playing a large part in improving the quality of patient care. The role of the nurse in wound care is all encompassing, stretching from the initial assessment of the wound and the patient, to making the correct decisions about treatment and beyond. Regular evaluation, and the setting of goals is essential to monitor the progress of the patient and the wound. To do this, a baseline knowledge of the functions and anatomy of the skin and wound healing physiology is required. Figure 1. When the skin is breached, it is important to close the defect as quickly as possible, thereby preventing infection from occurring. vital substances (Graham-Brown and Burns, 1998). the nerve endings present in the skin allow the body to detect pain, and changes in temperature, touch and pressure. 8Sensation: Functions of the skin The skin, often referred to as the largest......

Words: 3757 - Pages: 16

Premium Essay

Open Antibacterial Capsules

...antibacterial substances was in 1929 by Sir Alexander Fleming in which he discovers and describes the properties of antibiotic, penicillin. As he observed that the Bacterium Staphylococcus aureus was destroyed by the mold Penicillium notatum wherein it became more significant and widely used for treating soldiers with open wounds during World War II. Curing or treating battlefield wound infections and pneumonia. Today, the antibacterial capsules are routinely prescribed and the simple cure they provide for so many infectious diseases is often taken for granted. Unfortunately, the misuse of these life-saving medication is now becoming more occurring in the Philippine country side, other people might tend to use and prefer automatically antibacterial agents to treat any form of wounds & diseases as a medication for better relief while others also attempt to but a medicine to the pharmacy and ask for the available antibacterial agents, which is a habit form of malpractice in dispensing these regulated drugs without the prescription orders from the physician. In response, more scientist are now scrambling to develop new drugs. Furthermore, the result of this study will serve as a tool to provide information the people in rural communities, who were not able...

Words: 4407 - Pages: 18

Premium Essay

Wound Healing Research Paper

...Introduction 1. Wound A wound is defined as an injury or tear on the skin, which is caused by physical, chemical, mechanical, and thermal factors (Knight, 1996). The scientific definition of wound is a disruption of normal anatomic structure and function of the skin. On the basis of wound sites is classified into two types, such as open wound and closed wound. In other hand, on the basis of wound healing processes, there are divided into two types of wounds, such as acute and chronic wounds (Bryant and Nix, ). Acute wounds are caused by traumas. However, these wounds are usually healable within 8 to 12 weeks. Acute wounds can also be caused by exposure to extreme heat, irradiation and irritated with corrosive chemicals. Chronic wounds are...

Words: 1018 - Pages: 5

Premium Essay

The Feasibility of Aloe Vera as Lipbalm

...ntroduction The Aloe vera plant has been known and used for centuries for its health, beauty, medicinal and skin care properties. The name Aloe vera derives from the Arabic word “Alloeh” meaning “shining bitter substance,” while “vera” in Latin means “true.” 2000 years ago, the Greek scientists regarded Aloe vera as the universal panacea. The Egyptians called Aloe “the plant of immortality.” Today, the Aloe vera plant has been used for various purposes in dermatology. History Aloe vera has been used for medicinal purposes in several cultures for millennia: Greece, Egypt, India, Mexico, Japan and China.1 Egyptian queens Nefertiti and Cleopatra used it as part of their regular beauty regimes. Alexander the Great, and Christopher Columbus used it to treat soldiers’ wounds. The first reference to Aloe vera in English was a translation by John Goodyew in A.D. 1655 of Dioscorides’ Medical treatise De Materia Medica.2 By the early 1800s, Aloe vera was in use as a laxative in the United States, but in the mid-1930s, a turning point occurred when it was successfully used to treat chronic and severe radiation dermatitis.2 Plant The botanical name of Aloe vera is Aloe barbadensis miller. It belongs to Asphodelaceae (Liliaceae) family, and is a shrubby or arborescent, perennial, xerophytic, succulent, pea- green color plant. It grows mainly in the dry regions of Africa, Asia, Europe and America. In India, it is found in Rajasthan, Andhra Pradesh, Gujarat, Maharashtra and......

Words: 3057 - Pages: 13

Free Essay

Wine in China

...layperson’s comprehension. Nonetheless, because the use of HGF seems to be the direction some skin-care companies are taking, and because there is a large body of research showing its efficacy for wound healing (but not for wrinkles), it does deserve comment. HGFs make up a complex family of hormones that are produced by the body to control cell growth and cell division in skin, blood, bone, and nerve tissue. Most significantly, HGFs regulate the division and reproduction of cells, and they also can influence the growth rate of some cancers. HGFs occur naturally in the body, but they also are synthesized and used in medicine for a range of applications, including wound healing and immune-system stimulation. HGFs are chemical messengers that bind to receptor sites on the cell surface (receptor sites are places where cells communicate with a substance to let them know what or what not to do). HGFs must communicate with cells to instruct them to activate the production of new cells, or to instruct a cell to create new cells that have different functions. Another way to think of HGFs is that they are messengers designed to be received or “heard” by specific receptor sites or “ears” on the cell. HGFs, such as transforming growth factor (TGF, stimulates collagen production) or epidermal growth factor (EGF, stimulates skin-cell production), play a significant role in healing surgical wounds. The main task of HGFs is to cause cell division, which is helpful; however, at certain......

Words: 802 - Pages: 4

Premium Essay

The Effects of Zoonotic Diseases

...The Effects of Zoonotic Diseases Case Study #13 April 17, 2011 Zoonosis refers to an infectious disease in animals that can be transmitted to people. An animal serves as the natural reservoir for such an infectious agent, ("MedTerms," 2001). Many zoonoses, which is simply the plural meaning of zoonosis, including viruses, bacteria, and parasites can be transmitted to humans by various routes. Some of these routes consist of animal bites, vectors (i.e., insects), and animal-to-human contact (i.e., inhalation of respiratory droplets or skin-to-skin contact), (Bauman 613-14) & ("Infectious Diseases," 2009). Most emerging infections that have occurred world wide are said to be a zoonotic disease. Many of these diseases are fatal or have the potential to be fatal if not treated quickly and properly identified. An example of a zoonosis case that has the potential to arise annually is listed below: Case Study#13 “You work in a small family practice in rural VA. A man in his early 50’s comes in with a complaint of intermittent fever (102-103°F) and headache for the past two weeks. The physician examines him and takes a history. The only clinical finding is a wound about the size of a quarter on his right thumb. Axillary lymph nodes are swollen and tender. The man says he cut himself while skinning a rabbit three days ago. On the basis of these observations the physician prescribes streptomycin and asks the man to call if his symptoms......

Words: 1160 - Pages: 5

Free Essay

Jason's Case Study

...Jason’s Case Study Abstract Jason, a twenty six year old male, is seen in the urgent care clinic with a laceration to his arm. He cut his arm on roof sheeting while at work. While assessing the laceration on Jason’s arm, the nurse notices that he has a sunburn, freckles and moles on his skin. While Jason is still in the urgent care, the patient’s wife calls and asked if the medical staff would assess a mole on her husband. The nurse also educated Jason regarding sunburns, changes in freckles, moles, and lesions. His complexion, hair and eye color puts Jason at a higher risk for cancer and complications of being in the sun. The nurse also reminded Jason to make an appointment to have his family doctor check the laceration on his arm to make sure no infection or complications have developed. Jason’s Case Study After the nurse introduces herself to Jason, she gets his vital signs, height and weight. The nurse or the doctor per facility protocol should cleanse the wound to remove any dirt or debris from the laceration site. The nurse measures the laceration in length and width. The nurse checks the laceration for foreign bodies or debris in his arm. The doctor may order an x-ray of his arm to rule out any foreign bodies that may be in Jason’s arm. Saline gauze should be placed over the laceration site until the doctor comes into the examination room to see the patient. The nurse asks Jason if he has had a tetanus shot in the past five years. Jason......

Words: 1722 - Pages: 7

Free Essay

The Role of Preoperative Chlorhexidine as an Antiseptic Solution to Reduce the Risk of Postoperative Surgical Site Infection

...surgical practice. The incidence depends on multiple factors including the type and location of surgical procedure ranging from 2%-4% in simple skin lesions (Rogues et al., 2007) to 36% in cases of reversal of stoma (Liang et al., 2013). Incidence of SSI can be kept low by simple measures such as rescheduling elective procedures in presence of infection; e.g.: Urinary Tract Infection, Respiratory Tract Infection which can seed Bacteria to surgical wounds (Ollivere et al., 2009). Prophylactic Antibiotics given prior to elective surgery remains debatable and of questionable value considering the risk of side effects, emergence of Multi-drug resistant Pathogens and Anaphylaxis, and therefore should be used according to guidelines like in patients with higher risk for developing SSI (Wright et al., 2008, Dixon et al., 2006). Also, procedures at certain body sites and those involving surgical reconstruction are better covered with prophylactic Antimicrobial agent (Rosengren and Dixon, 2010). Use of antiseptic scrub has been shown to reduce the incidence of SSI. Studies suggest that Chlorhexidine is superior to Povidone Iodine solutions in reducing Bacterial Colonization and SSI in postoperative patients (Paocharoen et al., 2009, Mimoz, 2010 and, Lee et al., 2010). Also, the use of Chlorhexidine Gluconate shower or bath for cleansing the skin by patients prior to dermatologic surgical procedures reduces the risk...

Words: 4440 - Pages: 18

Premium Essay

Cellulitis

...Pathophysiology of cellulitis in adults. Cellulitis, a bacterial infection of the skin and underlying tissue, is a common presentation to Emergency Departments (ED). The clinical spectrum of presentation can vary from local inflammation to diffuse inflammation involving a whole limb, to more severe, even life threatening presentations of necrotizing fascitis and associated sepsis. The rationale for choosing this condition is to enable me to efficiently differentiate between those cases that require immediate medical or surgical intervention and treatment and those that can be managed effectively as an outpatient, and to gain a keen understanding of the pathogenesis of the condition. The terms cellulitis and erysipelas are often used interchangeably and current usage tends to regard erysipelas as a form of cellulitis rather than a separate entity, making clear distinction difficult (Hay 2004, Kilburn et al 2010). Erysipelas affects the upper dermis and superficial lymphatics, with distinctly raised lesions and clear lines of demarcation between involved and uninvolved tissue. Cellulitis extends more deeply, involving the deeper dermis and subcutaneous fat and lacks the distinctive anatomical features of erysipelas. For the purpose of this essay I will be using the term ‘cellulitis’ to refer to both conditions. This essay will endeavor to discuss the incidence, its clinical presentation, risk factors, differential diagnosis, pathophysiology and classification......

Words: 3353 - Pages: 14