APA format and references. Please do not use GOOGLE as a REFERENCE ,. DO NOT CUT AND PASTE UINFORMATION FROM WEBSITE

You are a nurse working in the medical intensive care unit (ICU) and take the following report

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from the emergency department (ED) nurse: “We have a patient for you: R.L. is an 81-year-old

frail woman who has been in a nursing home. Her primary admitting diagnoses are sepsis,

pneumonia, and dehydration, and she has a known stage III right hip pressure ulcer.

Past medical history includes remote cerebrovascular accident with residual right-sided

weakness and paresthesia, remote myocardial infarction, and peripheral vascular disease.

She is a full code. Her vital signs are 98/62, 88 and regular, 38 and labored, 100.4° F (38° C).

Lab work is pending; she has oxygen at 4L per nasal cannula and an IV of D5.45 at 100mL/hr.

We just inserted a Foley catheter. The infectious disease doctor has been notified, and

respiratory therapy is with the patient—they are just leaving the ED and should arrive shortly.”


What major factors increase risk for developing a pressure-induced ulcer?


Each health care setting should have a policy that outlines how to assess patients for their risk of developing a pressure ulcer. What should be included in that assessment?


2.As part of R.L’s admission assessment, you conduct a skin assessment. What areas of R.L.’s body will you pay particular attention to?


3.What are the advantages of using a validated risk assessment tool to document her skin condition on admission?

During your assessment, you note that she has very dry, thin, almost transparent skin. She has limited mobility from her stroke and is currently bedridden. There are several areas of ecchymosis on her upper extremities. She is alert and oriented to person only. You review the transfer summary from the long-term care facility and note she has a history of urinary and fecal incontinence.

4.What is the Norton’s Risk Assessment Scale

5.Based on the scale, what are some important areas you would address on this patient’s Nursing Care Plan, For example: Nutrition, Skin Care. Safety and Infection Control . Explain your rationale.

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