Case:

Maria Hernandez is an 80-year-old Hispanic female. She is widowed and lives alone in a senior housing apartment. Her two children live out of state. She spends most days watching television, rarely leaving her apartment. Mrs. Hernandez was admitted for surgical debridement of a non-healing sacral ulcer, which has been present for several months.

Question:

Based on what you have learned about the nursing process, describe one applicable nursing diagnosis, treatments, and nursing considerations for this diagnosis?

 

Answer:

Nursing diagnosis

•          Acute pain related to non healing pressure ulcer.

   Treatment

•           Use of analgesics to reduce pain.

Analgesics are a form of medicine that is used to alleviate pain. Acetaminophen (Tylenol), which is available over the counter (OTC) or by prescription when used with another medication, and opioids (narcotics), which are only available by prescription, are two examples.

•           Physiotherapy to improve circulation and manage pain.

Exercise, manipulation, and relaxation are used in physical therapy to treat the physical aspect of inflammation, fatigue, and soreness, but it often helps to help the body recover itself by facilitating the development of the body's own pain-relieving chemicals.

•          Topical pain relievers such as creams, lotions etc. 

They are commonly used to relieve pain. Can aid in the relief of joint pain.

Nursing considerations

 Using a pain scale, assess the patient's pain level and provide therapeutic support to help them manage their pain.

 Include family members in patient care and positive communication to lower anxiety levels. of the patient

Encourage the patient to perform muscle relaxation exercises to alleviate pain.

 Apply wound dressings and adjust positions to relieve pressure on the wound.

 Apply a body rub to the patient's back to relieve discomfort.

      Participate relatives in patient care and effective communication to reduce anxiety level of patient.   

Promote patient to do muscle relaxation exercises to reduce pain level.

Do not rub or massage the patients' skin vigorously.

To protect the skin from excess moisture, use a pH-appropriate skin cleanser and thoroughly dry it.

Keep your skin clean and dry at all times.

Examine and treat incontinence (Consider alternatives if incontinence is excessive for age)

Reference

Jackson, D., Durrant, L., Bishop, E., Walthall, H., Betteridge, R., Gardner, S., ... & Usher, K. (2017). Pain associated with pressure injury: a qualitative study of community?based, home?dwelling individuals. Journal of advanced nursing, 73(12), 3061-3069.