Response to Others (TWO SEPARATE RESPONSES PLEASE)
For your peer response, identify
One applicable nursing diagnosis related to tissue trauma
A measurable, time-specific and realistic outcome for the identified nursing diagnosis
One nursing intervention (something the nurse does; interventions cannot be to assess)
Make sure to include a well-developed question that fosters additional thought and conversation
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#1
Group 1 A-L
Identify the factors that place this patient at risk for pressure injuries?
This patient is at risk for pressure injury due to their compromised skin integrity that is caused by uncontrolled diabetes and immobile status (TJC, 2018).
Identify the stage of the pressure injury and rationale supporting why.
This is a stage 3 pressure injury due to descriiption of “visible adipose tissue, minimal sloughing, and visible wound bed”. A stage 3 pressure injury is defined as a full thickness loss of skin, granulation of tissue, with no facia, muscle, tendon, ligament, cartilage, or bone exposed (TJC, Preventing Pressure Injuries, 2016). The definition vs. descriiption supports the stage. If there was a picture, I feel like we could further verify the stage.
Is this pressure injury hospital-acquired? Why or Why not? Indicate any reporting actions that need to occur and why as well as any impact payment.
I feel like this is a hospital-acquired pressure injury. Since a stage 3 pressure injury can happen in as little as 1-3 hours (Ahiiala, 2018), it is reasonable to believe that this patient has acquired this injury in facility especially if the documentation shows that the patient had intact skin yesterday. I initially thought that maybe the patient had not been assessed thoroughly but as quickly as these injuries happen, I feel like it is reasonable that the injury occurred in the facility.
Identify two interventions that can be delegated to a UAP to assist with the management of the pressure injury? Be specific regarding what and how you would communicate to the UAP to ensure clear communication and maintain patient safety.
Two interventions the UAP can perform are to turn the patient frequently and basic skin care. My interaction with the UAP would go as follows: “Hi (appropriate name)! I need to delegate some tasks to you, are you available for this assignment? Great! This patient has been intubated since yesterday and is developing a pressure injury. This patient is going to need frequent repositioning to avoid further injury and I will need you to do this every hour. Have you been trained how to reposition an intubated patient? I am glad to hear you have, can I watch you perform this task once to confirm proficiency? Thank you! The other thing I will need you to do is a skin care/hygiene routine to prevent any further skin deterioration. This patient specifically will need to be clean and dry. While taking vital signs will you please notify me immediately if this patient starts running a fever or is excessively diaphoretic. Thank you for listening so closely to the instructions, can you tell me specifically what you will be doing for this patient? Do you have any questions or need any clarification on any of the points? Thank you for your help with this patient’s care, I would like you to begin this routine 15 minutes from now.”
I would use direct and specific instructions as well as the teach-back method to verify the UAP’s understanding of the assignment. I would verify UAP’s skills prior to releasing this patient’s specific interventions to the UAP (Buck, 2021).
References
Ahiiala, M. (2018). Specific risk factors for pressure ulcer development in adult critical care patients-a retrospective cohort study. EWMA Journal, 2,3.
Buck, D. (2021). Policy Addresses Supervision of UAPs in Acute Care & Other Settings. Oregon State Board of Nursing Sentinel , 14, 15.
TJC. (2016, July). Preventing Pressure Injuries. Quick Safety, p. 2.
TJC. (2018, July). Managing medical device-related pressure injuries. Quick Safety, p. 1.
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#2
Scenario 2
A 6-year-old male with cerebral palsy is hospitalized for respiratory distress secondary to aspiration pneumonia. During the patient’s third day in ICU, he remains ventilated and sedated. During a skin assessment, the nurse notes an open area on the patient’s occiput with the skull visible. During the handoff, it was reported that the skin was intact. Upon review of the original assessment, there is no documentation of any open areas.
A pressure injury is an area of soft tissue that has pressure applied to it for periods of time great enough to cause an injury. This happens when the area has poor perfusion, due to the pressure being greater than the force of the blood supply through the capillaries (Hinkle et al., 2022). Some factors that place this patient at risk for a pressure injury are immobility, friction/shear, sedation and (depending on the severity) his cerebral palsy. Sedation and immobility go hand in hand with each other. Any patient that is lying still without being able to turn and move themselves could be at risk for pressure injury; not just limited to the occiput, but anywhere that has impaired tissue perfusion. This patient has cerebral palsy, which could be a risk factor if the patient is in a wheelchair with a headrest for neck support, or even if the patient spends prolonged time in bed, unable to significantly change position. Friction/shear goes along with this as well. If the patient is able to turn themselves, but not list the area turning, it can cause a skin tear, or eroding of the area from repeatedly dragging across surfaces (Hinkle et al., 2022). The example describes a stage 4 pressure injury. This is a full thickness tissue loss, and there is exposed bone (Hinkle et al., 2022). Generally speaking a stage 4 pressure injury should develop over time, but for patients with comorbidities (cerebral palsy for our case) are prone to developing these areas quicker and more frequently. A pressure injury can develop quickly, which is the reason that an at risk patient should have a skin sweep at least twice per day (Hinkle et al., 2022). Repositioning frequently is important. The use of pressure relieving devices are also important. For example, another area that could become a concern for a sedated patient are the heels. The use of a heel riser could help to decrease the chanced of boggy heels that turn to open areas. We can not determine for sure that this pressure injury was there when the patient came into the facility. The patient was documented as not having open areas to the skin, therefore, whether it was there or not, it is now classified as a hospital acquired. In this situation I would tell my UAP, “(1)This patient needs to be repositioned every two hours. While repositioning this patient please make sure to elevate the area before turning it to avoid further damage. Please make sure that the patient is not lying on the affected area. (2) I would also like you to make sure that the pillowcase and sheets are changed if they become saturated with perspiration, urine or any other bodily fluids. The reason for this, is that this patient is prone to pressure injuries, and moisture can cause the skin to become macerated, or soft (Hinkle et al., 2022).”
Reference:
Hinkle, J., Cheever, K. & Overbaugh. K. (2022). Brunner and Suddarth’s Textbook of Medical-Surgical Nursing (15th ed.). Wolters Kluwer.
