Question

A 19-year-old client with cystic fibrosis is admitted to the hospital in acute respiratory distress. The client's mother tells a nurse that the client has been unable to get out of bed for the past month. While assessing the client, the nurse notes a stage II pressure ulcer on the client's sacrum. Which action is most important to include in the client's plan of care?

Answer 1

In the care plan for a 19-year-old cystic fibrosis patient with acute respiratory distress and a stage II pressure ulcer, the priority is to address both respiratory issues and the bedsore through regular repositioning, wound care, and managing cystic fibrosis with medications and pulmonary rehabilitation.

Step-by-step explanation:

The most important action to include in the care plan for a 19-year-old client with cystic fibrosis who has been admitted to the hospital in acute respiratory distress and has a stage II pressure ulcer on the sacrum, is to address both the acute respiratory condition and the pressure ulcer. The key components of the care plan should include:

• Regular repositioning of the client to relieve pressure on the affected area and to promote blood flow, which can help prevent the progression of the pressure ulcer.
• Providing wound care for the existing pressure ulcer, which may involve cleaning, applying dressings, and potentially the use of topical or systemic antibiotics if the ulcer shows signs of infection.
• Continued management of cystic fibrosis, which includes antibiotics and other medications to fight off infections and pulmonary rehabilitation exercises to maximize lung function.

Additionally, meeting nutritional needs and maintaining hydration are crucial to support the healing process of the skin and to manage the underlying cystic fibrosis.