67 y/o Male, Stage 4 Pressure Ulcers (3), Paraplegic, Double Amputee (Legs Bilateral)

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67 y/o Male, Stage 4 Pressure Ulcers (3), Paraplegic, Double Amputee (Legs Bilateral) by Mind Map: 67 y/o Male, Stage 4 Pressure Ulcers (3), Paraplegic, Double Amputee (Legs Bilateral)

1. Interdisciplinary Connections: Nurse's Aid to help shower, shave, clean, transfer, and communicate with the patient on a daily basis. Caregiver (sister) who aids in picking up food and drinks for the patient, visits and helps create strong support system. Nurse RN (through public health system), complete wound care and full assessment of overall healthcare needs, communicates with physicians and pharmacy to address any concerns or issues that may arise, creates plan of care and works through it weekly with the patient. Physician who prescribes necessary medications to treat the patient's heart failure, diabetes, promote wound healing, and care for mental health. Physical Therapy team to work with the patient in strength and movement abilities as to better be able to complete ADLs effectively.

2. Evaluation: Goal was met. The patient was able to talk through what kind of medications they were taking as well as complete ADLs on their own with minimal help from the Nurse's Aid for the last two weeks.

3. Evaluation: Goal was met. Environment is set up in a certain way as to promote safety and prevent falls. Patient uses equipment effectively and has enough strength to lift themselves up using specialized ceiling pulls

4. Evaluation: Goal was met. Iliac wound bed less red, less tunneling and better looking edges of every pressure wound. Noted slight closing on posterior pressure wound, fill with damp cloth as to prevent any further closing of the wound from the outside-in.

5. Goal: Patient will complete self-care ADLs (brushing teeth, transferring to wheelchair, showering, getting dressed, eating/drinking, taking medications) as independently as possible each day while student nurse is caring for the patient.

6. Goal: Patient will not fall or have any accidents that cause injury while student nurse is caring for the patient.

7. Goal: Patient's wounds will not progress negatively (increased tunneling) with noticeable healing assessed weekly.

8. Priority Level: 3

9. Priority Level: 2

10. Priority Level: 1

11. Interventions: 1) Request consult for a physical or occupational therapist to develop exercise and strengthening program. 2) Adjust transfer surfaces so they are similar in height, lower the better as possible. 3) Give clear, simple instructions and allow the patient time to process the information. 4) Position mobility aids appropriately. 5) Use specially designed ceiling lifts as needed, assess the patient's upper body strengthening to evaluate if the patient is able to lift themselves as required to complete ADLs and wound care.

12. Interventions: 1) Before activity, observe for, and treat pain with alternative medicine or pharmaceuticals as to promote a more comfortable time of mobility (upper body transitioning, wound care). 2) Increase independence in ADLs, encouraging self-efficacy and discouraging helplessness as the patient gets stronger and more capable of completing daily care independently. 3) Use equipment that will safely aid the patient in movement (ceiling pull system, wheelchair, hand rails, bed and chairs low to the ground as to decrease risk of falling). 4) Create a safe environment as to reduce to the risk of injury to patient as they attempt to move around independently when no caregiver is present.

13. Interventions: 1) Determine the extent of skin impairment; full thickness stage 4 pressure ulcers. 2) Inspect and monitor site of skin impairments at least once daily for changes in color, redness, swelling, warmth, pain or for signs of infection. 3) Monitor the patient's skin and wound care practices, noting type of dressing, cleanser, lotion, and frequency of skin cleansing. 4) Wound care: use normal saline to clean out wound bed, individualize plan of care according to the patient's skin condition, needs, and preferences. Allow patient to assist as able or desired. 5) Evaluate for the use of support surfaces (mattress, chair) as appropriate. Maintain HOB as low as possible as to reduce friction and shear, and place pressure-reducing devices on bed or on patient's skin as to prevent further breakdown and promote healing.

14. Impaired Comfort r/t prolonged immobility AEB pain level 7/10 in area of pressure ulcers; exacerbated by treatment process.

15. Impaired Physical Mobility r/t neuromuscular impairment and amputated lower limbs AEB need for wheelchair, pull system above bed to maneuver self and care team to assist with ADLs

16. Self Care Deficit

17. Impaired Skin Integrity r/t altered circulation, altered sensation, immobility AEB multiple Stage 4 pressure ulcers that have tunneled severely

18. Impaired Transfer ability r/t loss of physical mobility AEB inability to walk or transfer without aid of either person or equipment

19. Interventions: 1) Assess patient's comfort level (pain scale 1-10), use FACES scale if patient is unable to express pain level verbally. 2) Create an environment that promotes comfort (bed, chairs, clothing, process of wound care). 3) Provide pain medications either prescribed or over the counter PRN (before wound care takes place).

20. Priority Level: 1

21. Goal: Patient will state pain level at a manageable level (3/10) during morning wound care daily while student nurse is caring for patient.

22. Evaluation: Goal not met, patient stated being in 5/10 pain daily during morning wound care. Refuses mild pain medication prior to care. The patient however, is in good spirits and has a positive attitude during process.

23. Increased Risk for Pressure Ulcers

24. Medications: *See attached Word Document*

25. Labs: *Most relevant in the past 3 months*. Blood Sugar 101 mmol/L, managed with insulin as needed. No other relevant labs noted.

26. Vitals: *As last taken*. BP: 138/68 mmHg. HR: 98 bpm. RR: 18 breaths/minute. Temperature: 38.1 degrees Celsius. Oxygen Saturation: 95% RA

27. Patient Pays for care through their insurance and federal aid.

28. Pictures of progression of pressure ulcers on file at the Public Health Agency

29. Patient was referred to Home Health (WCPHA) due to their need for daily aid with ADLs, in-depth and intensive wound care daily, and risk for heart/respiratory failure.