A pressure ulcer is a specific type of damage that occurs when there is direct pressure on the skin causing cellular damage due to lack of blood flow (ischawmia), or when there is shearing or friction forces causing mechanical stress on the tissues (Chapman and Chapman 1981). Pressure ulcers commonly occur in areas where there are bony prominences, such as the sacral area, heels, hips, and elbows (NICE 2005). For the purpose of maintaining confidentiality, the patient in this assignment will be called Mr. Brown. Mr. Brown has given consent for his nursing notes and personal information to be referenced throughout this assignment.
He acknowledges that his identity will remain undisclosed and that a fictitious name was chosen for assignment purposes, as stated in the NMC Code in relation to “respecting people’s right to confidentiality” (NMC Code 2008). Additionally, the place of work will remain anonymous and referred to as Ward 1. Mr Brown, a 90-year-old individual, resides alone in sheltered housing and receives assistance three times daily for housekeeping and basic care requirements. He has a medical history of angina and is not dependent on insulin for diabetes. Mr Brown was initially admitted to the hospital via A and E due to chest pains, indicative of Acute Coronary Syndrome.
Mr Brown’s cardiac issues have been resolved in another ward before being referred to Ward 1. However, he still needs assistance in improving his mobility due to the cardiac problems. As a result, he has been transferred to Ward 1, which specializes in rehabilitation and aims to enhance Mr Brown’s mobility while also assessing the need for an increase in his care package. Before being admitted to Ward 1, Mr Brown had pressure ulcers on both his left and right buttocks. The Preliminary Pressure Risk Assessment conducted upon admission to Ward 1 reveals that Mr Brown has seven areas of broken skin on his sacrum, classified as EPUAP grade 2 (Tissue Viability, 2009).
When Mr. Brown was admitted to the hospital, his initial score on the Adapted Waterlow Pressure Area Risk Assessment Chart was 12, placing him on treatment plan B. However, over the course of 11 days, his score significantly increased due to cardiac issues causing mobility problems. When assessed in Ward 1, his score was 20, indicating a high risk of developing pressure ulcers and requiring treatment plan C. Additionally, upon admission to Ward 1, Mr. Brown experienced difficulty managing urinary incontinence, resulting in excoriation of the skin due to excess moisture (Tissue Viability 2009).
According to Kozier et al. (2008), the risk of pressure ulcers increases when the skin becomes macerated by urine and when the epidermis is more susceptible to erosion. Therefore, the nursing staff decided to use catheterization only as a last resort, since it was interfering with the healing process. Additionally, Mr. Brown experienced double incontinence within two days due to further issues with urinary and fecal incontinence. Furthermore, fecal incontinence can cause skin irritation, resulting in breakdown of the epidermis and an increased risk of infection (Kozier et al., 2008).
Moreover, the dressings utilized by Mr. Brown for his Grade 2 pressure ulcers have external risks since they function as a barrier that heightens the likelihood of infection (Kozier et al., 2008). In addition to this, Mr. Brown’s age is an intrinsic factor that contributes to an elevated risk of pressure ulcers due to various reasons related to his skin’s condition. Being 90 years old implies that his dermis lacks elasticity and collagen, while the sebaceous glands produce less oil resulting in dryness of the skin and thinning of the epidermis. As a consequence, these factors make his skin more delicate.
As we age, the skin’s ability to heal decreases and sebaceous glands function less effectively, resulting in increased water loss (Christiansen and Grzyboskii 1993). This leads to longer healing times. Additionally, nutritional intake and fluid consumption play a significant role in determining the development of pressure ulcers. In Mr. Brown’s case, his existing pressure ulcers require a diet rich in protein, saccharides, vitamins A and C, as well as minerals like iron (Kozier et al.2008).
Furthermore, Mr. Brown’s mobility level is an external factor that increases his risk of developing pressure ulcers. Due to his current condition and restricted movement caused by pain, his mobility is compromised with a Waterlow Assessment score of three. Immobility makes it challenging for him to reposition himself and relieve pressure on vulnerable areas.
Moreover, using slide sheets for repositioning can cause shearing of the skin which further raises the risk of developing pressure sores. Shearing causes tissue ischemia by moving vessels laterally and obstructing blood flow (Kozier et al.2008). It is important to note that Mr.Brown’s diabetes also contributes to his skin’s tendency to bleed easily.
Additionally, external factors such as mattress quality can also impact the development of pressure ulcersAccording to the wound care book, infection is a possible complication that can occur in pressure ulcers (Step 3). It causes the ulcer bed and adjacent tissue to be invaded, resulting in the development of cellulitis. The presence of granulating tissue indicates this invasion and it requires protection.
In order to protect the granulating tissue from infection, it is recommended to apply a dressing. According to the Tayside wound formulary for dressing pressure ulcers, the aim for the granulating tissue is to promote angiogenesis and facilitate wound healing. The suggested treatment options include using MEPILEX, ALLEVYN Lite, TRICOTEX, and TEGASORB dressings, which also provide protection against shearing and friction.
Upon admission to the hospital, the Malnutritional Universal Screening Tool (MUST) is completed within 24 hours by NHS Tayside. This process is supported by the royal college of nursing and the registered nursing home association. NHS Tayside has adapted its MUST Tool from BAPEN, a multi-professional association consisting of healthcare professionals from various disciplines. The purpose of the MUST Tool is to identify underweight adults at risk of malnutrition, as well as obese individuals. It involves five steps that can assist in care planning.
It is important to consider nutrition when assessing pressure ulcers because inadequate nutrition can lead to delayed recovery and longer hospital stays, as mentioned in the MUST report’s 10 key points.To calculate the BMI, the first step involves measuring the height and weight of the patient. This step provides a score for Step 1. Step 2 involves determining the percentage of unplanned weight loss, which also yields a score. Step 3 evaluates the impact of acute disease and lack of nutritional intake. Finally, Step 4 consists of adding the scores from Steps 2 and 3 together.
The risk of malnutrition is higher with a higher score. Step 5 involves using management guidelines to create a care plan and determine the patient’s level of risk. When Mr. Brown arrived at ward 1, the nursing staff chose not to calculate his MUST score during the first week. This information is documented in the MUST assessment, as the staff was unable to weigh the patient due to increased sacral pain. However, when assessing if Mr. Brown has recently lost weight, his self-reported weight loss can be taken into consideration as a reliable indicator.
In addition, nursing staff were able to analyze whether Mr. Brown’s clothes were loose fitting according to the MUST explanatory booklet. Another method utilized in NHS Tayside to document pressure ulcer management is the Preliminary Pressure Ulcer Risk Assessment (PPURA). Its aim is to promptly identify individuals who are at risk of developing a pressure ulcer. However, it is important to note that this should not substitute for the clinical judgment and observations of nurses (source: tissue visibility Web). This includes an adapted version of The Waterlow Pressure Area Risk Assessment Chart.
This tool, called the Waterlow, when used alongside the nurses’ clinical judgement, can indicate a patient’s risks of developing pressure ulcers (Kozier, pg 314).
The Waterlow evaluates the level of risk a patient has for developing pressure ulcers and provides a treatment plan accordingly.
Furthermore, the multi-disciplinary team must record the care given to each patient three times a day, including risk assessments and analysis of treatment plans.
These assessments are scored using a traffic light system, which includes 18 different risk assessments.
Which NHS Tayside policies require documentation in the nursing notes for amber or red scoring? The MUST tool identifies the risk of nutrition, while the waterlow scoring system analyzes the risk of pressure ulcers. However, it is important to note that both tools do not replace a nurse’s clinical judgment. Furthermore, manual handling and mobility are assessed to identify risks of friction and shearing on the skin and to assist with repositioning. According to Step 5,
Pressure ulcers pose a risk in various healthcare settings and can be a significant financial burden on the NHS. To address this issue, many hospitals and community trusts are supported by a tissue viability service (Dealey p849). It is estimated that in the UK, treating pressure ulcers annually costs between ?1.4 and ?2.1 billion (price year 2000), which accounts for approximately 4% of total NHS expenditure (NICE guidelines p41). Additionally, pressure ulcers can have social implications for patients, as they may experience pain, discomfort, embarrassment, and may avoid social contact.
