Post-Fall Pressure Injury and Dehydration in an Older Adult
A 74-year-old woman from a bag is admitted to the aimag hospital after a fall at home. She lives alone, has mild cognitive impairment, and was found on the floor after an estimated 14 hours. On admission: BP 104/62, HR 104, temp 37.9°C, dry mucous membranes, urine dark and concentrated, and she has been incontinent of urine three times overnight. Skin assessment shows a 2 cm shallow open area over the sacrum with a red wound bed and no slough; Braden score 12. She weighs 48 kg and has eaten little for two days. The ward has one registered nurse and one aide for 18 patients; turning equipment is limited to two pillows. The physician has ordered IV fluids, a pressure-redistribution mattress (arriving tomorrow), and bladder training. The nurse must set priorities for the next 8-hour shift and document care.
1. Which nursing diagnosis should be the priority for this shift, and which three findings most strongly support it? Explain why other likely diagnoses are lower priority.
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The priority is impaired skin integrity related to pressure, moisture, and immobility, with risk for infection. The strongest supporting findings are: (1) an actual 2 cm open sacral wound, not just risk; (2) a Braden score of 12, which is high risk; and (3) repeated urinary incontinence overnight plus dehydration, which macerates skin and reduces perfusion. The low intake, dry mucous membranes, dark urine, HR 104, and BP 104/62 show impaired hydration and possible early hypovolemia, which worsens tissue tolerance.
Chronic confusion and impaired mobility are contributing diagnoses, but they are lower priority because they explain the mechanism rather than the immediate harm. The open wound plus moisture and poor perfusion can progress to infection or deeper injury within this shift. A diagnosis such as "impaired urinary elimination" is also lower priority because the immediate threat is skin breakdown and possible sepsis, not the incontinence itself. The nurse should still address hydration and continence, but as interventions supporting the skin-integrity priority, not as competing priorities.
2. Design a realistic repositioning and incontinence-care plan for the next 8 hours with one aide and two pillows, and state what can and cannot be delegated.
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Plan: reposition every 2 hours using a 30-degree lateral tilt, with one pillow behind the back and one between the knees; keep the head of bed at or below 30 degrees except during meals. Use a draw sheet to move her rather than dragging. Check the sacrum and heels at each turn, clean urine promptly with a pH-balanced cleanser, pat dry, and apply a barrier cream. Offer a bedpan or commode every 2 hours and before sleep, limit fluids after 20:00 only if medically allowed, and document urine colour and volume. Cluster care with the aide so turns coincide with vital signs and toileting.
The aide may perform repositioning, hygiene, application of barrier cream, intake/output measurement, and remind the patient to call. The RN cannot delegate the initial and repeat skin assessment, nursing diagnosis, care-plan changes, evaluation of wound deterioration, or patient teaching. The RN should inspect the wound at least once per shift and after each episode of incontinence, and document the turning schedule; with 18 patients, the RN should ask the charge nurse for additional help if the schedule cannot be met.
3. What evaluation findings at the end of the shift would show the plan is working, and what would trigger escalation?
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Working plan: the sacral wound remains the same size with a clean red bed, no new breakdown over heels or hips, skin is dry between episodes, urine becomes lighter, intake is adequate, BP remains at or above 100 systolic, and the patient is more alert. Temperature should stay below 37.5°C, and urine output should be at least 0.5 mL/kg/h, about 24 mL/h for a 48 kg woman.
Escalate if the wound enlarges, develops slough, foul odour, purulent drainage, or surrounding warmth; if temperature rises, confusion worsens, BP falls, urine output drops below 24 mL/h, or the patient cannot be repositioned because of pain. Also escalate if the aide reports repeated incontinence that cannot be managed with the current schedule. These findings suggest infection, worsening dehydration, or pressure injury progression and require same-shift medical review and a revised care plan.