You are a nurse working in a long-term care facility. You have been assigned to care for Mr. Johns, a 74-year-old client recently diagnosed with a urinary tract infection, resulting in frequent incontinence. Mr. Johns suffered a CVA (stroke) six months ago and has difficulties ambulating and attending to his own needs because of weakness on his right side. Mr. Johns is alert and oriented to person, place, and time, but has decreased sensation on his entire right side. He spends most of his time in bed or sitting at his bedside in a wheelchair due to his difficulty with ambulation. He eats about 50% of his meals. While assessing Mr. Johns, you note that he is thin for his height, incontinent of foul-smelling urine, and has a deepened reddened area on his sacrum.
- What additional information, including lab work, would you like to gather to further assess Mr. Johns’ potential for pressure injury development?
- What factors make him particularly vulnerable to the development of pressure injuries?