What are some of the risk factors for skin breakdown specific to this patient?
Mamo is a 78-year-old man who fell 3 days ago. His fall resulted in a fractured left hip. He was adm Show more Mamo is a 78-year-old man who fell 3 days ago. His fall resulted in a fractured left hip. He was admitted to the hospital and underwent an open reduction and internal fixation (ORIF) of the left hip. Today is his second post-operative day. Mamos weight on admission was 140 lb (63.64Kg). His height is 73 inches. His family reports that he has been steadily losing weight. He expresses little interest in eating and says he has been depressed since his wife died last year. While performing your assessment of Mr. Harmon you notice that a large dressing covers the left hip incision. You loosen the dressing and see that the staples are intact at the incision site and that there is a minimal amount of sero-sanguineous (pink) drainage on the bandage. As you turn him in bed you see a 10cm by 6cm reddened area on his coccyx. William now has two wounds an intentional surgical wound and a pressure ulcer that has resulted from his impaired mobility. What are some of the risk factors for skin breakdown specific to this patient? List at least five. How will the care of each of these areas differ i.e. the surgical wound vs. the pressure ulcer? List 2 NANDA approved nursing diagnoses for this patient. What stage is this pressure ulcer? Justify your answer. List five preventative measures you will implement in your care plan for this patient in order to decrease the chance of further skin damage. Show less
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