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Describe patient safety case in hospital safety trainings


Assignment Task: Preventing Pressure Injuries - Learning from Linda's Story

Directions:

  • Read the case study carefully, and then answer the following questions in complete sentences using evidence-based nursing practice.
  • May use course materials and U Central as needed to support your answers. Please write in your own words.
  • Download and type directly into the assignment
  • Please highlight answers

Story: The Case of "Linda's Pressure Injury"

(Name changed for privacy; drawn from a real, publicly reported patient safety case used in hospital safety trainings)

Background:

Linda, a 72-year-old retired schoolteacher, was admitted to a large community hospital after elective abdominal surgery. She had several risk factors: diabetes, mild malnutrition, and limited mobility post-surgery.

Timeline of Events:

  • Day 1-2: Nurses documented that Linda had a Braden score of 14 (mild risk). The care plan included repositioning every 2 hours, but the unit was short-staffed. Turning was inconsistently done, and no pressure-relieving mattress was ordered.
  • Day 3: A small red area was noted on her sacrum, but no wound care consult was placed. Documentation was incomplete, and the day shift assumed the night shift would follow up.
  • Day 5: The redness turned into a blistered Stage 2 pressure injury. Linda began complaining of pain, but her pain was dismissed as "normal post-op discomfort."
  • Day 7: The wound deteriorated to a Stage 3 ulcer with drainage. Infection set in, requiring IV antibiotics and a longer hospital stay.
  • Outcome: Linda was discharged after an additional 12 days with a complex wound requiring home health care. She described feeling ignored and helpless and later became an advocate for pressure injury prevention in hospitals.

Part A - Questions (Answer All 5)

1. Risk Identification:

Linda's initial Braden score was 14.

  • What specific risk factors contributed to this score, and why should a score of 14 trigger preventive interventions? Need Assignment Help?
  • System Factors: Staffing shortages were noted during Linda's hospitalization.
  • How should nurses and the healthcare team respond when short staffing threatens completion of essential safety measures (e.g., repositioning every 2 hours)?

2. Communication

A red area was documented on Day 3 but not followed up.

  • Describe the correct communication and escalation steps a nurse should take when early skin changes are observed.

3. Patient-Centered Care

  • Linda reported pain that was dismissed as "normal post-op discomfort."
  • How can nurses validate and advocate for a patient's concerns to prevent harm?

4. Preventive Nursing Measures

List at least three specific interventions that should have been implemented by Day 1-2 to prevent the pressure injury from progressing.

Part B - Reflection (Short Paragraph)

Looking Forward

Based on Linda's experience, reflect on one key change you would personally make in your nursing practice (or on a unit) to prevent a similar incident.

  • How will you help ensure every patient's skin safety is protected, even during busy or understaffed shifts?

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