Adult Scenario Key:
Lament Cruise is 67 y/o admitted for respiratory failure with a diagnosis of Covid-19. He has history of asthma and Type I Diabetes. He is admitted in the Medical Intensive Care Unit and was placed on mechanical ventilator with on-going drip medications such as Fentanyl for pain, Propofol for sedation, Nimbex drip for paralytics and was just started on Norepinephrine drip for blood pressure support all via central line inserted on the right subclavian vein. On the start of the shift he was NPO but has a new order of TPN to be stated for nutritional management but will not come till 1200 noon. You took the finger stick at 8:00 and was 400 g/gl. You checked the patient pressure areas and have seen Stage 2 pressure ulcer on the sacral area. He has a foley catheter for strict monitoring of the intake and output. His current vital signs as follows: Temp. 102.3 , HR 122, BP=100/68, RR=33, Saturations=91%. His skin is hot to touch and continuous cooling blanket is applied . Weight is 78.8 kgs, Height 177.5 cms. He is critically guarded.
• Using the Braden Scale Assessment Tool, how would you score Lament Braden Pressure Ulcer Risk ?
• Develop a Nursing Care Plan on Integumentary nursing problem. Use the NCP format sent.
• Caveat: Nursing diagnosis should follow the and has to have a Rationale. Example: Fever: Alteration in body temperature, more than normal related to infection process as evidenced by: Rationale: During infectious process, chemical mediators such as pyrogenes are released in the bloodstream. The body’s thermo-regulating center causes the reset to a higher temperature as a response-thus fever will ensue.
• Interventions should be based on the different subscale of Braden Scale Pressure Ulcer Tool.
