Management of pressure ulcers in a high risk patient: a case study

1. Introduction

Clinically, pressure ulcers are defined as the lesions that are the result of localized tissue damage or cell death (generally necrosis), developed because of pressure over a bony prominence.More commonly, they are also known as pressure sores or bedsores as they are mainly developed by patients that are bed-bound (Wake, 2010). Approximately, 3 million adults are affected by pressure ulcers and are most common in hospitalized patients (Lyder and Ayello, 2008). However, effective management and care plans against pressure ulcers are still lacking. The role of nursing care is a fundamental aspect to pressure ulcer management, including its prevention and treatment (Wake, 2010). In this case study report, I visited a diabetic patient as a district nurse for insulin administration and provide support by assessing the patient’s risk of developing pressure ulcers due to associated pathological and other risk factors.

1.1. Purpose of the study

In all health care settings, pressure ulcers remain one of the major issues. More so, pressure sores or pressure ulcers are associated with significant cause for morbidity in the medical community. The main purpose of this patient visit was to provide healthcare support for patients who were at risk of developing pressure ulcer. The healthcare support included the risk minimisation by doing risk assessment, therapeutic interventions, suggestions for lifestyle changes including exercise and dietary habit. All these were targeted with the views of providing timely assessment of pressure ulcers in high risk patients, and suggest therapeutic interventions for timely treatment of the condition.

1.2.Patient history

The patient was 75 years old male, diabetic and paralysed due to recent stroke attack. He was completely bed bound and was on wheelchair. Furthermore, the patient was suffering from cancer of the oesophagus. Since the patient could not mobilize, his family members and carers used to transfer him from the bed to his wheelchair and wheelchair to his bed.

1.3. Risk assessments of needs, vulnerabilities and strengths of the patient

The patient was chronically ill and had several complications associated with his conditions. Stroke attack had caused him paralysis and was unable to move. This had put him in significant risk of developing pressure ulcers. The patient was also diabetic. Diabetes causes slow healing of wounds that may lead to ulcer (Guo, et.al. 2010). In this patient, the combination of factors including diabetes and immobility had increased his risk of developing pressure ulcers. Other factors such as old age of the patient, cancer and dietary factors would trigger the development of these pressure sores. Cancer is a chronic disease that may cause severe debilitation and prolonged confinement to bed. Therefore, it is expected that patients with cancer are at significant risk of developing pressure ulcers (Walker, 2001). Diet may have a supporting role in the development of pressure ulcers. Although the role of nutrition in preventing the development of pressure ulcers is still debatable, it is obvious that patients who are malnourished are at risk of developing those (Doley, 2010). Thus, nutrition therapy could be central in minimising the risk of developing pressure ulcers. It was seen that the patient was clearly underweight due to his chronic health conditions. Overall, the following risk factors of the patient were considered while making his assessment. Based on these risk factors, care plans and suggestions were made to minimise the risk in the patient.

Sensory factor:

This factor was assessed in order to identify how well the patient can process sensory input from the skin, as well as how effectively he can communicate level of sensation. Since the assessment of skin is an important way to identify patient’s risk of developing pressure ulcers, it would ensure the degree of risk of pressure ulcer in this patient and hence, take measures to prevent them before complications arise.

Moisture:

Moisture is another hallmark of pressure ulcers. Excess skin moisture puts patients at greater risk of developing pressure ulcers. It is common that patients who are confined to bed produce more sweat. Thus, it is required to evaluate what degree the skin is exposed to moisture.

Activity

Lack of activity is one of major risk factors of developing pressure ulcers in bedbound patients. Continuous friction between the skin and bed mattress may result the development of pressure sores. Measuring the activity is another important parameter to predict the patients’ risk of pressure, irrespective of their degree of mobility. Patients who are unable to move need to be physically turned by healthcare staffs or family members at regular intervals

Nutrition

As mentioned earlier, although nutrition may not have direct effects on the patient’s risk of developing pressure ulcers, it may be possible that lack of required nutrients may increase its complications. It is thus important to evaluate what constitutes the usual pattern and amount of caloric intake in the patients.

After evaluating the above risk factors in the patient, it was concluded that the patient was likely to develop pressure ulcers if timely interventions were not introduced. These would have direct effect in patient’s health. These ulcers influence the risk of bacterial and viral infections, which can become life threatening in chronically ill patients. In addition, there is a high rate of mortality associated with pressure ulcers. Mortality rate is high as 60% is reported in older patients with pressure ulcers within 1 year of hospital discharges (Lyder and Ayello, 2008).

The patient in this case study could have weakened immune system due to his old age and illnesses such as cancer and diabetes. In immune-compromised patients, the risk of infections spreading into their blood and other organs of the body are considerably high. This may result blood poisoning and septicaemia. Both these conditions are very fatal and categorised as medical emergencies (Redelings, et.al. 2005).

However, despite of several associated risk factors, the patient was provided with proper care and support by his carers and family members. He was regularly taken off from his bed with the support of wheelchair. More so, the patient was on medications to control his blood sugar. He was also supplemented with vitamin to strengthen his immunity. To conclude, patient although was receiving appropriate healthcare service, these were mainly therapeutics which included medications against the chronic illnesses which he had. Patient and family members were lacking suggestions and expert advice in regards to minimising the risk of pressure ulcers. It was also observed that the patient was provided with a normal bed and mattress that would further trigger the risk of developing sores.

2. Interventions and referrals

After evaluating the patient’s condition, as a district nurse, I provided the evidence based interventions and referrals to the patient and his family members and carers as preventive approaches of pressure ulcers. Firstly, the patient was provided with a hospital bed with pressure relieving mattresses. This would help minimise the friction between patient’s body and the bed and hence, reduce the risk of pressure ulcers. Moreover, this would provide support surfaces and help in pressure redistribution (Stannard, 2012). Several recommendations for skin care including the use of cold water instead of hot water, use of mild cleansing agents to minimise irritation and dryness of the skin and excessive moisture was suggested. The patient was also advised to avoid low humidity as it may promote scaling and dryness (Lyder and Ayello, 2008). Further suggestion such as avoiding mechanical loading was given. This is considered as one of the most effective preventive measures of pressure ulcers in hospitalized patients (Lyder and Ayello, 2008). Thus, family members were advised to frequently turn and reposit the patient while in bed. It is essential that patient intake adequate levels of both macro and micronutrients to prevent complications of pressure ulcers. This patient was already supplemented with vitamins and minerals, so no action was taken. However, the patient was suggested to eat diet high in proteins, which are essential for wound-healing and overcome malnutrition.

Management of pain is another key aspect in patients with pressure ulcers (Cooper, 2013). Pressure ulcers can be very painful and may require interventions with analgesics (Wake, 2010). However, this patient did not require analgesic treatment as the pain due to pressure ulcers was not very severe. Instead, focus was given on the preventative approaches in minimising the complications associated with pressure ulcers. Finally, the focus was given on the patient/carer education in the management of pressure ulcers. Both patient and carers/family members were made aware about the risk factors of pressure ulcers. Also, they were educated and made aware on the most vulnerable sites of the body that are at risk of developing pressure ulcers. General training was also given on how to take care of skins and methods for pressure reduction. They were told about the severity of the condition and requested to seek medical advice if symptoms of pressure ulcers persist.

3.Critical evaluation and evidence-based examination of outcomes of interventions and referrals

The interventions and referrals made for the patient in this case study were evidence based. Risk assessment was made considering the standard pressure ulcer prediction tool, Braden Scale, by observing the six vital signs of pressure ulcers as explained earlier. This tool has allowed for the early prediction of pressure ulcers and thus introduction of early interventions before the complications are developed (Sving, 2014).

Classification of pressure ulcers is one of the best ways to predict its outcome. Pressure ulcers are classified into various stages (Lyder and Ayello, 2008). Stage I is determined by the presence of redness in the skin. In case if the redness in the skin is observed, nurses are required to make thorough skin inspection and advice patients about the preventive measures. Stage II is characterized by the loss of skin with the presence of blisters. In stage III loss of skin is quite thick; however, not exposed to muscle or bone tissue. In this stage, there is a high risk of infections, so care should be given in personal hygiene (Sving, 2014). Also, patient should be suggested to include vitamins and minerals in the diet to prevent the possible risk of infection. In stage IV there may be an exposure to bone, tendon and muscle. This condition is considered as potentially dangerous, due to associated risk of life threatening bacterial infections. In many cases, this may also require hospital admission to reduce further complications (Lyder and Ayello, 2008; Sving, 2014).

To conclude, nurses are required to assess various stages of pressure ulcers and provide treatments and suggestions based on these stages. This is because; different stages of pressure ulcers may require different treatment plans. Some could be minor and may be improved through general suggestions such as encouraging patients to move and involve in physical activities and maintaining healthy diet; whereas some may require therapeutic interventions including the use of antibiotics to treat bacterial infections, dressing and cleaning of the wound and hospital admissions if complications are severe. (Wake, 2010).

Ample evidence is now available on the understanding of effective pressure ulcer treatments. Treatment strategies such as use of hospital bed, avoiding mechanical loading, and physical activity are now considered as the standard form of treatments in pressure ulcers. These approaches not only reduce the risk of pressure ulcers, but are also beneficial in lowering its complications. Furthermore, the association of pressure ulcers with other chronic diseases such as cancer, diabetes and stroke are well understood. Thus, much attention is to be given while giving care to the patients who have these conditions. Educating patient and family members on the risk factors and management is another approach to pressure ulcer management as suggested by NICE guidelines (Wake, 2010)

However, the available knowledge on the evaluation of risk assessment of pressure seems insufficient. The evidence lacks support and requires further epidemiological research to understand risk factors of pressure ulcers in greater depth. Some of the interventions and their effectiveness including re-positioning and nutrition are still questionable. Further studies on the influence of different turning intervals on the development of pressure ulcers need to be carried out. Similarly, what specific diet is suitable for pressure ulcer patients needs further clarification.

Appendix1: Care plan of the patient

Risk assessmentCare goalsInterventions and evaluations
Patient’s needs and vulnerabilities : old age, bed-bound, chronic diseases including cancer and diabetes, paralysed due to strokeTo identify the patient’s risk of developing pressure ulcersThe patient was provided with hospital bed, cushion for his wheelchair and family members were suggested to move the patient time to time
Patient’s strength: on proper medications, carers and family members providing the support, supplemented with vitamins and minerals to boost the immune functionTo build on the patient’s strengths and to meet his needsPatient was provided with full support from the family members. High protein diet was suggested as this may improve would-healing.
Signs of complications, such as pain, bacterial and viral infections.To avoid complications associated with infections including blood poisoning and septicaemiaImmune booster such as vitamins and disinfectant creams to avoid infections.

References

Cooper, K.L. 2013, “Evidence-based prevention of pressure ulcers in the intensive care unit”, Critical Care Nurse, vol. 33, no. 6, pp. 57-66.

Doley, J. 2010, “Nutrition management of pressure ulcers”, Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, vol. 25, no. 1, pp. 50-60.

Guo, S and DiPietro, L.A, 2010. Journal of dental research. Factors Affecting Wound Healing, vol. 89, no. 3, 219-229.

Lyder, C.H and Ayello, E.A, 2008. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Pressure Ulcers: A Patient Safety Issue.

Lyder, C.H, 2003. Clinician’s corner. Pressure Ulcer Prevention and Management, vol. 289, no. 2, pp. 223-226.

Lyder, C.H. 2006, “Assessing risk and preventing pressure ulcers in patients with cancer”, Seminars in oncology nursing, vol. 22, no. 3, pp. 178-184.

McInnes, E., Jammali-Blasi, A., Bell-Syer, S., Dumville, J. & Cullum, N. 2012, “Preventing pressure ulcers–Are pressure-redistributing support surfaces effectiveA Cochrane systematic review and meta-analysis”,International journal of nursing studies, vol. 49, no. 3, pp. 345-359.

Redelings, M.D., Lee, N.E. & Sorvillo, F. 2005, “Pressure ulcers: more lethal than we thought?”, Advances in Skin & Wound Care, vol. 18, no. 7, pp. 367-372.

Stannard, D. 2012, “Support surfaces for pressure ulcer prevention”, Journal of perianesthesia nursing : official journal of the American Society of PeriAnesthesia Nurses / American Society of PeriAnesthesia Nurses, vol. 27, no. 5, pp. 341-342.

Stechmiller, J.K. 2010, “Understanding the role of nutrition and wound healing”, Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition, vol. 25, no. 1, pp. 61-68.

Sving, E., Idvall, E., Hogberg, H. & Gunningberg, L. 2014, “Factors contributing to evidence-based pressure ulcer prevention. A cross-sectional study”, International journal of nursing studies, vol. 51, no. 5, pp. 717-725.

Wake, W.T. 2010, “Pressure ulcers: what clinicians need to know”, The Permanente journal, vol. 14, no. 2, pp. 56-60.