Name Class/Group Date
Scenario
You are a nurse working on the unit and take the following report from the emergency department
(ED) nurse: “We have a patient for you: R.L. is an 81-year-old frail woman who has been in
...
Name Class/Group Date
Scenario
You are a nurse working on the unit and take the following report from the emergency department
(ED) nurse: “We have a patient for you: R.L. is an 81-year-old frail woman who has been in a nursing
home. Her primary admitting diagnoses are sepsis, pneumonia, and dehydration, and she has a
known stage 3 right hip pressure injury. Past medical history includes remote cerebrovascular
accident with residual right-sided weakness and paresthesia, remote myocardial infarction, and
peripheral vascular disease. She is a full code. Her vital signs are 98/62, 88 and regular, 38 and
labored, 100.4° F (38° C). Lab work is pending; she has oxygen at 4 L per nasal cannula and an IV
of D5.45 at 100 mL/hr. We just inserted an indwelling catheter. The infectious disease doctor has
been notified, and respiratory therapy is with the patient—they are just leaving the ED and should
arrive shortly.”
1. What major factors increase risk for developing a pressure injury?
Mobility, Sensory, Moisture, Nutrition, Friction, and Shear
2. Each health care setting should have a policy that outlines how to assess patients’ risk for
developing a pressure injury. What should be included in that assessment?
3. As part of R.L.’s admission assessment, you conduct a skin assessment. What areas of R.L.’s
body will you pay particular attention to?
Right side, bony prominences, sacrum, heels
4. What are the advantages of using a validated risk assessment tool to document her skin condition
on admission?
Braden Scale, Joint Commission’s patient safety goals
5. How often should patients be reassessed for the risk of developing an injury?
Every shift
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