15 Oct Preventing Pressure Injuries—Learning from Linda’s Story
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. (0.5pts)
· What specific risk factors contributed to this score, and why should a score of 14 trigger preventive interventions?
· System Factors 🏥 Staffing shortages were noted during Linda’s hospitalization. (0.5pts)
· 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. (0.5pts)
· 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.” (0.5pts)
· 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. (0.5pts)
Part B – Reflection (Short Paragraph) (2.5pts)
· 💡 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?
