Case study - Pressure injury: Nursing

Nurse Hailey works on an orthopedic unit and is caring for Margaret, a 91-year-old female with a recent fall at home requiring surgical repair of a fractured hip. After settling Margaret in her room, Nurse Hailey goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Margaret’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Hailey recognizes important cues, including Margaret’s vital signs, which are blood pressure 118/62 mmHg, heart rate 88 beats per minute, respirations 18 breaths per minute, and temperature of 100.4 F or 38 C. Nurse Hailey also notes that Margaret is incontinent; and a skin assessment reveals an area on her coccyx that’s pink and moist, without slough or eschar.

Next, Nurse Hailey analyzes these cues. She reviews the electronic health record, or EHR, and notes that Margaret has declined working with physical therapy due to the pain in her hip and coccyx. Nurse Hailey recognizes that immobility and pain can contribute to pressure injuries and realizes that Margaret is experiencing impaired tissue integrity. She shares her assessments with the wound care nurse who classifies Margaret’s coccyx redness as a stage 2 pressure injury.

Now, using the information she has gathered, along with Margaret’s medical history, Nurse Hailey chooses a priority hypothesis of impaired tissue integrity.

Then, she generates solutions to address Margaret’s impaired tissue integrity that'll include nonpharmacologic and pharmacologic interventions; and she establishes the expected outcome that after intervening, Margaret will demonstrate a healing pressure injury without further breakdown of skin or the development of infection by time of discharge.

Nurse Hailey then takes action to implement these solutions. She knows that since Margaret has a stage 2 pressure injury, she needs to complete the wound care recommended by the wound nurse; administer the prescribed pain medication; reposition Margaret at least every 2 hours; encourage Margaret to work with physical therapy; provide a diet high in protein, carbohydrates, and vitamins; and provide education.

Now that Nurse Hailey has a plan in place, she re-enters Margaret’s room.

Nurse Hailey: Hi Margaret, it’s almost time for you to change position. I also want to take another look at your wound and apply the dressing. But before I move you, I need to assess your pain.

Margaret: I feel okay right now, but it hurts when I move. Could I have my pain medication first?