[Answered]: A

A. Read this scenario. Decide if the situation presents potental A 65-year-old female patient was taken to the emergency department (ED) after suffering a fall at home. Her husband had been away from the house several hours and when he returned home, he found her on the floor. The patient was confused, and no one was able to ascertain how long she had been lying on the floor. She was taken to the nearest emergency department with complaints of weakness, confusion and right lower leg and foot pain. Her past medical history included Parkinson’s disease, mild dementia, hypothyroidism and anxiety. The radiology results revealed an open displaced fracture of the right tibia and fibula. An orthopedic surgeon requested the patient be prepped for surgery. However, there was over a four hour delay getting the patient to surgery for various reasons. The patient underwent surgery which lasted approximately three hours. In the intraoperative nursing (pre-operative and post-operative) assessment, documentation regarding skin integrity was incomplete as well as documentation of the position aides. The patient was taken to the surgical floor with orders to be placed on the post-surgery protocol. The protocol included comprehensive orders for vital signs, pain control, nutrition, hydration, mobilization and skin integrity prevention measures. The admitting nurse assessed the patient’s skin and gave her a risk score of 14 according to the Braden Scale® (the lower the number, the higher the risk to develop pressure ulcer). The hospital’s “Alteration in Skin Integrity” protocol required an air mattress for any patient with a score of less than 18.