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Wound and Skin Case Study

In: Science

Submitted By djdancer125
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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...

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