Question

An older adult male patient is wheelchair bound with wounds to his right elbow, sacrum, and bilateral heels. He has a history of cardiovascular disease with a quadruple bypass surgery 10 years prior. His face grimaces as he tries to move around in the wheelchair. What are two appropriate diagnostic labels related to his skin integrity and wound care?

Select all that apply.
a) Impaired Physical Mobility related to pain during position changes, as evidenced by the patient's grimacing when moving in wheelchair.
b) Impaired Tissue Integrity related to pressure ulcer, secondary to immobility, as evidenced by pressure ulcers.
c) Imbalanced Nutrition: Less Than Body Requirement related to increased demand, secondary to healing wounds, as evidenced by continued weight loss.
d) Disturbed Body Image related to change in appearance, secondary to surgical incision as evidenced by patient refusal to look at the incision.
e) Knowledge Deficit related to lack of familiarity with care products, as evidenced by inability to correctly perform wound care.

Answer 1

The two appropriate diagnostic labels for the patient's condition are Impaired Tissue Integrity related to pressure ulcers (option b) and Impaired Physical Mobility related to pain during position changes (option a).

Step-by-step explanation:

Based on the case of the older adult male patient who is wheelchair-bound with various wounds and a history of cardiovascular disease, two appropriate diagnostic labels related to his skin integrity and wound care would be:

1. Impaired Tissue Integrity related to pressure ulcer, secondary to immobility, as evidenced by pressure ulcers on the right elbow, sacrum, and bilateral heels.
   
   
2. Impaired Physical Mobility related to pain during position changes, as evidenced by the patient's grimacing when moving in wheelchair.

These diagnoses recognize the patient's current conditions of ulcerations due to prolonged pressure—which can lead to tissue necrosis—and the limited mobility which contributes to the difficulty in repositioning and continues the cycle of pressure on susceptible areas.