Case Study: Nursing Assessment And Management Of Pressure Ulcers In A 61-year-old Male Patient

Nursing Assessment

Across all age groups pressure ulcers comprise a serious health concern globally. Financial burden associated with the treatment of pressure ulcers is inestimable. Every year most of the cases of pressure ulcers arise in hospitalized patients, and there are even more cases in community as well as care homes (Moore & Cowman, 2014). Therefore, this is high time that efforts should be made to prevent the development of pressure ulcers. Nurses are the first point of contact with the patient. Training for the management of pressure sores should be compulsory for the nurses (Gunningberg et al., 2015). This training should help the nurses to develop basic knowledge and skills for the prevention of pressure ulcers. A large number of pressure ulcer cases are preventable, thus, efforts should be made to identify the risk factors of developing bed sores using pressure sore assessment tools and thus prevent the development of pressure ulcers. This essay is aimed at discussing the case study of a selected patient. A 61-year-old male patient named Gordon has been selected for this essay. Firstly, a nursing assessment will be done to describe the current problems of the patient. Following this, a nursing management of the patient will be described.

Gordon, a 61-years-old male presented to the hospital with chief complaint of Diabetic gangrene in left foot. He presented with a history of Diabetes since past 10 years, Hypertension since 3 months, and Anxiety and mood disorders since last one month. Gordon physically appeared lean and weak. The patient belonged to a middle class family. His family consisted of his wife and two children who were settled in two cities. The patient seems anxious and nervous. Nursing assessment was done which consisted of general physical examination including the pulse rate, B.P, respiratory rate and temperature. This was followed by accessing the medical history and drug history of the patient. This was done to access the current health state of the patient and to decide the further course of treatment (Brien, Moore, Patton & Connor, 2018).

Upon thorough assessment the nurses found that the diabetic gangrene had worsened and the patient’s blood glucose level was very high. Also, the patient had developed serious pressure ulcers on his buttocks due to prolonged immobilization.

Braden Scale (Moore & Cowman, 2015) for Predicting Pressure Sore Risk was utilized:

Sensory Perception: Gordon’s sensory perception was slightly limited. He was not able to communicate pain and discomfort. Although, he was able to respond to commands, his ability to describe his painful stimulus and discomfort was very limited (Moore & Cowman, 2015). He had limited sensitivity in his affected limb. Due to gangrene involvement, his sensitivity had further declined. As his leg was affected, this reduced his mobility and due to immobility he had developed pressure sores on his buttocks (Brien et al., 2018)

Moisture: Gordon’s skin was often moist and thus required linen changed at least once in every alternate day. His skin was not always moist, but it was enough moist to require linen change regularly. Moisture content of skin is an important consideration that requires immediate attention. If skin is more moist than regular, it might result in friction and sheet pressure (Wang et al., 2015). This can ultimately result in skin tearing and increased chances of bacterial infection (Wang et al., 2015). Moreover, moist skin provides an ideal environment for bacteria cultivation and colonization.

Nursing Care/Management

Activity: Gordon’s activity level is very limited. He remains confined to bed most of the time. However, he goes to bathroom and toilet by receiving assistance from the nurses. He cannot bear his own weight due to inability to put pressure on his gangrenous foot. He requires chair or wheelchair assistance for performing the activities of daily living. Immobilized and bedridden patients are at the greatest risk of developing bed sores or pressure ulcers. Gordon’s inactivity and immobilization due to gangrenous foot are the risk factors for pressure ulcers (Gunningberg et al., 2015).

Mobility: Gordon’s mobility is very limited. Occasionally, he tries to get up from his bed for using the toilet. He sometimes changes the position of his extremities. However, his ability to move independently is restricted largely due to his inability to put pressure on his gangrenous foot (Gunningberg et al., 2015). He can move with the assistance of a wheelchair, but he requires assistance in getting up and sitting in the wheelchair.

Nutrition: Gordon’s nutrition is adequate. He eats sufficient potion of proteins and carbohydrates. However, his fast food intake is very high. He likes to eat pizza, burger, chips and other sweetened cold drinks (McInnes et al., 2015). His fluid intake is not adequate. His habit of drinking sweetened cold drinks is constantly contributing to increase his blood sugar levels. His uncontrolled increase his blood sugar level despite the intake of hypoglycemic medications has caused gangrene development and it’s worsening (Thomason et al., 2016).

Friction and Shear Gordon requires assistance while getting up from his bed. During the uplifting movement, his skin probably slides to some extent against the linen. However, he maintains a good position in his wheelchair or his bed most of the time. The nurses should take care to prevent skin friction, especially the skin affected. The fragile skin is more sensitive to friction and shear (Gunningberg et al., 2015). Care should be taken to prevent any strain and tearing of this sensitive portion of skin from breakage.

Once the pressure ulcer develops, the ulcer should be cleaned with a nontoxic solution. Cleaning the ulcer removes debris and bacteria from the ulcer bed, factors that may delay ulcer healing. The nurse should assess and stage the pressure ulcer at each dressing change. Experts believe that weekly assessments and staging of pressure ulcers will lead to earlier detection of wound infections as well as being a good parameter for gauging of wound healing (Demarre et al., 2015).

Nursing care and management depends on the amount of risk that the patient is in. According to the scores obtained by pressure sores risk assessment tool, there are majorly three categories of patients. These include: At risk, moderate risk and high risk patient. Nursing care/management consists of following:

At risk (score of 15-18)

Such patients should be managed by frequent turning the position of the patient while the patient is lying on the bed. Efforts should be made to promote maximal remobilization to protect heels (Yavuz et al., 2015). Moreover, the nurse should make efforts to manage moisture, nutrition and friction and shear pressure-reduction. The nurse can use commercial moisture barrier to hold moisture from skin surface. Excess moisture makes the skin more fragile and more prone to shear pressure and skin tear.  The nurses can provide absorbent pads or diapers to hold moisture. Bedpan/urinals should be offered in addition to turning the position of the patient (Demarre et al., 2015).

Also, adequate nutritional supplements should be provided to facilitate rapid recovery. The patient should be provided equal amount of protein and carbohydrates. Intake of fast food and sweetened drinks needs to be restricted (Yavuz et al., 2015).

Secondly, if the patient is bed or chair bound, as is the case with Gordon, the nurse should assist the patient in getting up from bed and help him with the activities of daily living. Efforts should be made to prevent skin friction while assisting the patient in getting up from the bed or getting seated in the wheelchair (Demarre et al., 2015).

If several risk factors are present such as old age, immune-compromised state of the patient, nutritional insufficiency or hypo/hypertension than the patient should be considered as moderate risk and treatment plan should be as per moderate risk level (Langer & Fink, 2014).

Moderate risk (13-14)

Foam wedges should be used for 30e lateral positioning of the patient during the turning schedule. Support surface such as fluid bed or sand bed should be used for pressure-reduction. The sand beds behave like a liquid when air is pumped in these beds and thus, these beds promote the draining of wounds or pressure sores while exerting minimal pressure on the sin surface (Qaseem et al., 2015). Also, the nurses should do a regular follow up for moisture status of skin, nutrition requirements and friction and shear resistance.

Generally, nurses are aware that keeping the skin clean and dry will prevent super infections and moisture, which increases friction, causing skin tearing. Patient schedules for changing position and the use of moisture absorbent material on skin are also prescribed (Swafford, Culpepper & Dunn, 2016). In addition, by performing subsequent skin assessments, nurses will have the ability to recognize skin breakdown at an early stage, which will lead to early intercessions. Although there is no agreement on what comprise a minor skin assessment, reports suggests adding the accompanying five parameters: skin temperature, shade, humidity, and integrity are integral part of skin assessment (Wang et al., 2015). The nurses should advise the patient for the purpose of skin care, they should be taught to not apply any pressure to the red portion of skin, or over bony prominences, as this result in deep tissue damage. Healthy skin should focus on limiting the presence of moisture on the surface. Degradation of the skin caused by friction can be moderated by the use of oils, protective ointments (eg, direct and skin adherents), protective dressings (eg hydrocolloids) and protective sealants (Thomason et al., 2016).

Also, the role of the nurse is to manage nutrition by increasing protein intake and increasing calorie intake to spare proteins. Supplement have been found to benefit such patients and thus multi-vitamin (Vit a, c & e) act quickly to alleviate deficits. Dietitian can be consulted to formulate a proper diet plan to prevent deterioration of health and promote speedy recovery.  Serum proteins of less than 3.5 g / dl tend to the increase the risk of stress ulcers (Choi, Chin, Wan & Lam, 2016). Patients admitted to hospital with malnourishment have an increased likelihood of developing pressure ulcer. Assessing the patient's ability to bite and swallow should also be accessed. Healthy patients who received protein supplements in addition to the standard diet for a healthcare facility had a lesser risk of pressure ulcers compared to those who received only the conventional diet.

The use of supporting surfaces is a fundamental thought of redistribution of weight. The idea of ??weight redistribution is taken up by NPUAP. No one can ever evict the patient's entire weight. With the chance of losing weight on one part of the body, it will increase the weight somewhere else on the body. From now on, the goal is to achieve the ideal redistribution of weight.

A unique strategy for redistribution of weight is the use of supporting surfaces. Many studies have focused on the adequacy of the use of supportive surfaces to reduce the rate of ulcer. Static fixtures include air, foam (compressed and solid), gel and water coats or memory foams (Bus et al., 2016). These surfaces are perfect when the patient is at moderate risk of developing stress ulcer. The collection of devises powered by a power supply or a pump and is regarded as unique. These support structures include rotary and low-budget beds. These sleeping pillows are useful in patients who are moderately to high risk of ulcers caused by weight, or have a full thickness ulcer (McInnes et al., 2015). The collection of 3 devices, also powerful, includes only air-fluidized beds (Swafford, Culpepper & Dunn, 2016). These beds are electric and contain silicone-covered covers. At the moment the air is pumped through the bed, the dowels are closed in liquid. These beds are used for patients with high risk of severe ulcers. More often, they are used in patients with full-thickness non-healing ulcers or when there are multiple thrombolytic ulcers with full thickness (McInnes et al., 2015).

The use of oral anti-infective agents or the local sulfa-silverdiazine was further observed as successful in reducing the microbial colonization in the stress ulcers (Bus et al., 2016). Treatment using silver impregnated dressings appears to be somewhat viable in declining the growth of pathogenic microorganisms. The use of topical septic to reduce bacterial infection of wounds still remains controversial (Thomason et al., 2016). The perfect treatment for a contaminated stress ulcer would be bactericidal for a wide variety of pathogens and non-cytotoxic for leucocytes. In addition, the use of diet with high-protein and fewer calories for patients with protein deficiency is ideal for wound repair (Thomason et al., 2016).

Conclusion

The prevention of pressure ulcers is a marker of the nature of nursing consideration and care provided to the patient. Development of pressure ulcers is hugely dependent on inadequate quality of care and examination by the nursing professionals.

Therefore, nursing care has a significant impact on the development of the ulcer and the avoidance of ulcer. The viability of stress ulcers regularly involves the utilization of low innovations, but careful consideration of the most reliable risk factors to improve the risk of stress ulcers is needed. At a time when an ulcer risk is detected, the main patient Safety Goal is to help the multidisciplinary health care team to close the ulcer as soon as possible. Nursing professionals should also be concerned about avoiding further ulcer reoccurrence, maintaining painless and clean skin, preventing the skin from bacterial contamination and preventing patient discomfort.

References

Bus, S. A., Armstrong, D. G., Van Deursen, R. W., Lewis, J. E. A., Caravaggi, C. F., Cavanagh, P. R., & International Working Group on the Diabetic Foot (IWGDF). (2016). IWGDF guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with diabetes. Diabetes/metabolism research and reviews, 32, 25-36.

Choi, E. P., Chin, W. Y., Wan, E. Y., & Lam, C. L. (2016). Evaluation of the internal and external responsiveness of the Pressure Ulcer Scale for Healing (PUSH) tool for assessing acute and chronic wounds. Journal of advanced nursing, 72(5), 1134-1143.

Demarré, L., Verhaeghe, S., Annemans, L., Van Hecke, A., Grypdonck, M., & Beeckman, D. (2015). The cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders: A cost-of-illness study. International journal of nursing studies, 52(7), 1166-1179.

Gunningberg, L., Mårtensson, G., Mamhidir, A. G., Florin, J., Athlin, Å. M., & Bååth, C. (2015). Pressure ulcer knowledge of registered nurses, assistant nurses and student nurses: a descriptive, comparative multicentre study in Sweden. International wound journal, 12(4), 462-468.

Langer, G., & Fink, A. (2014). Nutritional interventions for preventing and treating pressure ulcers. Cochrane Database of Systematic Reviews, (6).

McInnes, E., Jammali?Blasi, A., Bell?Syer, S. E., Dumville, J. C., Middleton, V., & Cullum, N. (2015). Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews, (9).

Moore, Z. E., & Cowman, S. (2014). Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews, (2).

Moore, Z. E., & Cowman, S. (2015). Repositioning for treating pressure ulcers. Cochrane Database of Systematic Reviews, (1).

O'Brien, G., Moore, Z., Patton, D., & O'Connor, T. (2018). The relationship between nurses assessment of early pressure ulcer damage and sub epidermal moisture measurement: A prospective explorative study. Journal of tissue viability.

Qaseem, A., Humphrey, L. L., Forciea, M. A., Starkey, M., & Denberg, T. D. (2015). Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Annals of internal medicine, 162(5), 370-379.

Swafford, K., Culpepper, R., & Dunn, C. (2016). Use of a comprehensive program to reduce the incidence of hospital-acquired pressure ulcers in an intensive care unit. American Journal of Critical Care, 25(2), 152-155.

Thomason, S. S., Powell-Cope, G., Peterson, M. J., Guihan, M., Wallen, E. S., Olney, C. M., & Bates-Jensen, B. (2016). A multisite quality improvement project to standardize the assessment of pressure ulcer healing in veterans with spinal cord injuries/disorders. Advances in skin & wound care, 29(6), 269-276.

Wang, L. H., Chen, H. L., Yan, H. Y., Gao, J. H., Wang, F., Ming, Y., ... & Ding, J. J. (2015). Inter?rater reliability of three most commonly used pressure ulcer risk assessment scales in clinical practice. International wound journal, 12(5), 590-594.

Yavuz, M., Master, H., Garrett, A., Lavery, L. A., & Adams, L. S. (2015). Peak plantar shear and pressure and foot ulcer locations: a call to revisit ulceration pathomechanics. Diabetes Care, 38(11), e184-e185.