case study

Mrs. Willet is a 72 year old white woman who recently underwent a total hip replacement, left side. Her significant medical histpry includes rheumatoid arthritis and coronary artery disease. This is her first postoperative day, and she is resting in bed with an immobilizer (a foam wedge that is placed between her thighs to keep her hip in position) in place. She weighs 200 pounds and is approximately 5 feet 6 inches tall. A physical therapist is scheduled to see her toeay to assist her into a sitting position. When the physical tehrapist is not available, Ms. Willet is on bed rest. Skin assessment reveals a 2.5 cm, round, black right heel ulcer, as well as a 2 cm red warm spot located over the sacrum.
1.) The braden risk assessment tool was used to determine the risk factors that place Ms. Willet at risk for skin breakdown. What factors in the above scenario may contribute to the potential for skin breakdown?
According to Braden scale decrease physical ability, immobility and potential skin friction and shearing, advancing age all contributed to her skin breakdown.
2.) The black tissue on Ms. Willet's heel is best described as__thick necrotic tissue or eschar______________. What treatment will the nurse expect to manage this? Black wound require debridement or removal of the necrotic material- removing the nonviable tissue must occur the wound can heal.
3.) Identify the likely cause of the red warm area over Ms. Willett's sacrum, and name one approach to determine if there is skin breakdown. Explain your choice. This stage I pressure ulcer – nonblanchable erythema which is signaling potential ulceration