A 75-year-old woman walks into the emergency department with ...

[washai]

A 75-year-old woman walks into the emergency department with complaints of not feeling well. Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300.
 
  Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings?
  a. Normal in the older adult
  b. A need for the patient to be evaluated for cognitive impairment
  c. A side effect of anti-hypertensive medication
  d. Pathologic impairment of sensory responses

Question 2

The nurse is instructing the nursing assistant to prevent pressure ulcers in a frail older patient. Which action indicates the nursing assistant has understood the nurse's teaching?
 
  a. Bathing and drying the skin vigorously to stimulate circulation
  b. Keeping the head of the bed elevated 30 degrees
  c. Limiting intake of fluid and offer frequent snacks
  d. Turning the patient at least every 2 hours

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Answer to Question 1

ANS: D
This degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but rather decreased ability to perceive the stimuli. Anti-hypertensive medication does not typically cause decreased skin sensation. This is more common in antineoplastic drugs. Most likely the patient has diabetes, which is causing decreased sensation. Not feeling well is secondary to a change in blood sugar as a result of the wound response.

Answer to Question 2

ANS: D
The patient should be turned at least every 2 hours as permanent damage can occur in 2 hours or less. If skin assessment reveals a stage I ulcer while on a 2-hour turning schedule, the patient must be turned more frequently. Limiting fluids will prevent healing; however, offering snacks is indicated to increase healing particularly if they are protein based, because protein plays a role in healing. Use of doughnuts, elevated heads of beds, and overstimulation of skin may all stimulate, if not actually encourage, dermal decline.

[washai]

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