Barkovic

Narrative

Ms. HS is a 90 year old Caucasian female who was recently transferred to Miami Jewish Home for long term care beginning on 9/1/13, after being in a skilled nursing facility for many weeks. The patient was initially admitted to Mount Sinai Medical Center status post right ORIF after sustaining a fracture to her right hip. She was later transferred to MJH for rehab. After careful evaluation, Dr. Blanco recommended for patient to begin long-term care because she did not believe H.S. would be safe at home alone. Mrs. HS requires intensive care with managing her diabetes, bathing, and ADL. Mrs. HS has had three surgical procedures in her past. First starting with an Appendectomy at the age of 7, Hysterectomy at the age of 21, and lastly a Hip joint replacement this past July. She has currently been diagnosed with Type two diabetes Mellitus, Neuropathy Diabetes, hypertension, healing Unstageable pressure ulcer on the right heel, Peripheral Vascular Disease, Coronary Atherosclerosis, Anemia, Constipation, full incontinence of feces, urinary incontinence, generalized pain, debility NOS, right hip fracture, COPD. She is currently taking eleven different medications. She takes Ludodem 5 % patch daily to control ventricular arrhythmias, and Gabapendin 200 mg three times a day orally, to decrease hepatic pain. The client also takes Metformin, 500 mg by mouth to maintain her glucose levels. The client is awake, alert, aware of stimuli from the environment and within the self, and responds appropriately and reasonably soon to stimuli. The person is oriented to person, but not place or time. The client is non-ambulatory, putting her at greater risk for impaired skin integrity. The client currently has a nonstageable pressure ulcer on her right heal. Factors that are complicating wound healing, is her history with diabetes. The pressure ulcer has no exudate, but

Barkovic

100% thick adherent black necrotic tissue. The clients wound size is 1.5 cm x 2.5 cm and depth not measurable. (as evidence by the chart.) Client is getting dressing changes once daily, and using float heels in bed to insure proper healing, and prevent future ulcers. The wound size decreased by 0.3 cm in length, 0.5 cm in width, and the depth of the wound is now measureable where it wasnt before. The wound was debrided via surgical incision. Subcutaneous tissue was removed along with necrotic tissue. The necrotic tissue decreased from 100% to 70% of the pressure ulcer. The ulcer is now 30% granulation tissue. The increase in granulation tissue and decrease in size indicate that the pressure ulcer condition is improving.