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Patient, Mrs. B is 87 years old and has a long term diagnosis of Rheumatoid arthritis(RA),  Congestive Heart failure (CHF),  Osteoarthritis and Fibromyalgia.  She takes steroids which make her skin very thin and easily torn.  She takes pain patches as well as large doses of oral pain medications.  She has significant swelling of both lower legs and has some sensation loss as well.  The day prior to home health care admission she fell asleep while on the toilet and suffered injuries to her face and right arm.  Her face has extensive bruising and swelling to the right side and her right forearm had the skin torn all the way around at the wrist and it was pushed up (degloved) to the elbow.  She was seen at the emergency room and because she had developed a relationship with a home health company, she talked the ER as well as her PCP to allow her to go home and be treated by home health. 

Home health admitted and began safety teaching to prevent falls.  PT was ordered to increase strengthening and teach fall prevention.  Nursing began treating skin tears and provided daily care to heal the wound and prevent loss of full thickness of skin.  Patient’s plastic surgeon told patient that she would more than likely lose the torn skin and would have to have surgical intervention for grafting.  He told her that she was a very high risk patient for surgery and wanted home health to continue to treat wound to prevent as much skin loss as possible.  PT worked with patient and set up a belt system for while patient was on toilet so that if she fell asleep she would not fall.  They also, discussed with patient to use good fitting shoes that had non skid soles.  Nursing visited patient daily for 2 weeks and then changed wound care 6 times over a 4 month period and completely healed all patient’s wounds without the need for high-risk surgery.