Prevention of Tissue Breakdown - Essay Example

?Critical Analysis on the Prevention of Tissue Breakdown on Grade 2 Pressure Ulcer at Sacral Area of Patient with Pubic Rami Introduction This critical analysis involves the case of Patient A, a 70 year old male patient who suffered a fracture at his pubic rami. After three days of admission, the patient developed a Grade 2 pressure ulcer at his sacral area. This student has chosen the case to discuss because pressure ulcers are a common problem for patients who have suffered orthopaedic affectations mostly because of their poor mobility during the confinement. As a senior nurse, this incident was significant because it provided efficient cues on the management of pressure ulcers, including preventing infection, preventing its progression to higher pressure ulcer grades, as well as promoting efficient and speedy patient recovery. The main clinical issues which arose from the incident included the following: prevention of tissue breakdown of pressure ulcer, promoting mobility, and preventing infection. This study sought to establish how the author could make a difference or improve the care for the patient as a senior nurse in her department. Main Body The management for this patient included several nursing interventions. These interventions included the following: regular assessment of pressure ulcer and of other pressure points in the body, promoting early mobility at least every two hours, keeping the patient’s sacrum and back clean and dry at all times, regular cleaning of pressure ulcer, placing pressure-reducing overlays on mattresses, chairs, and other surfaces used by patient (Bluestein and Javaheri, 2008). These interventions help promote wound healing as well as help prevent the progression of the pressure ulcer to higher grades (Bluestein and Javaheri, 2008). Pressure ulcers are one of the most difficult wounds to manage and heal. Once they manifest, they are often not responsive to antibiotic therapy (Paquay, et.al., 2010). Moreover, complete healing is not always possible. For those under long-term care, the degree of healing often depends on the primary stages of the pressure ulcer (Paquay, et.al., 2010). Where the initial stages are managed well, the healing rate is high, however, as the grade level of the pressure ulcer progresses, the rate of healing is also reduced (Paquay, et.al., 2010). Prevention and early management of pressure ulcers is therefore an important consideration in the management of chronic care patients. Patient Assessment The assessment process in pressure ulcers is one of the initial and important elements in the management of pressure ulcers. There are various assessment scales which have been recommended for use by experts. In the UK, the European Pressure Ulcer (EUPAP) Grading System has been recommended for use (NHS, 2012). Based on patient assessment, the patient manifests with a Grade 2 pressure ulcer with some of the outer surface of the skin damaged. The ulcer manifests as an open wound or blister (NHS, 2012). The goal for this patient now is to promote the healing of such ulceration, to prevent its progression (higher grade levels), as well as its infection. Assessment of a pressure ulcer also involved the complete medical assessment of the patient, including the onset as well as the duration of the pressure ulcer, including his history of pressure ulcers (Bluestein and Javaheri, 2008). This was the patient’s first time to have a pressure ulcer and the pressure ulcer started to manifest about two weeks following his injury. His wound care mostly involved standard dressings which were changed daily. He had difficulty changing positions on the bed and mostly stayed in one position all day. He was of regular body build, with a BMI within the normal levels. He was alert and socially responsive, especially with his family and with the hospital staff. He had limited assistance when discharged as it was only him and his wife in their house. They needed support services at home. There was one grade 2 pressure ulcer at the patient’s sacrum and no other pressure ulcers appeared to be developing at any other parts of the patient’s body. There was some necrosis, minimal odour, and there were no apparent signs of healing. The pressure ulcer was about two inches wide and about 50 mm deep. Based on such assessment, the different nursing interventions were applied for the patient. Promoting movement or change of positions at least every two hours or as often as possible Pressure ulcers can be prevented and can be managed by reducing and relieving the pressure on the bony prominences of the body (Shahin, et.al., 2009). Such bony prominences include the following: sacrum, coccyx, hips, and the heels. These are the areas which are usually prone to develop pressure ulcers (Junkin and Gray, 2009). If not managed early, pressure ulcers in these areas are often known to gradually grow in size and severity, often manifesting higher ulceration grades (Shahin, et.al., 2009). Preventing pressure on these areas can be ensured by promoting movement or changes in positions at least every two hours or as often as possible. For this patient, since the patient has suffered a fracture at his pubic rami, the movements were based on the recommendations of the rehabilitation and physical therapist (Pignolo, et.al., 2011). This may include leg lifting exercises, hip abduction, and upper arm strengthening exercises with the help of an overhead pulley which the patient can use regularly (Pignolo, et.al., 2011). Early mobilization is encouraged at the soonest time possible for patients, especially for elderly patients, since their recovery is usually longer due to their advanced age (Pignolo, et.al., 2011). The assistance of a physical therapist would be needed especially during the initial days following the injury in order to ensure that the exercises and movements being carried out are safe for the patient (Pignolo, et.al., 2011). It is also important to encourage the patient to change positions on the bed at least every two hours in order to relieve pressure on the bony prominences of the body (Moore, et.al., 2011). This will prevent the constant pressure placed on the sacrum and also allow fresh air to circulate at the patient’s back (Junkin and Gray, 2009). Some practitioners argue that turning every two hours is not a sufficient remedy against the development of pressure ulcers (Moore, et.al., 2011). This is however one of the easiest and fastest means by which pressure ulcers can be prevented. For this patient, this was not an easy process to carry out because his injury limited his mobility. Nevertheless, early mobility was still encouraged by the physical therapist because it was also important to ensure that the patient would be able to gain independence the soonest time possible (Keelaghan, et.al., 2008). This author also recognized the importance of applying appropriate methods in achieving patient mobility while preventing any further injuries and complications for the patient (Rich, et.al., 2011). Using log-rolling and regular activity must also be applied in conjunction with other interventions, especially those mentioned below. Wound management In general, wound healing has several phases which often overlap with each other. When there is injury to the skin, the inflammatory phase sets in with the blood releasing cells to remove bacteria and debris (Nguyen, et.al., 2009). The proliferative phase would then ensure the migration and division of cells. During angiogenesis, the new blood vessels would be formed through the endothelial cells. The process of fibroplasias and granulation also assists in tissue formation setting up an extracellular matrix which would provide collagen (Nguyen, et.al., 2009). The cells of the epidermis are also re-epithelialized and cover the wound bed, thereby allowing closure of the wound. Contraction follows and the wound becomes smaller as the myfibroblasts contract the wound edges (Nguyen, et.al., 2009). Promoting wound healing is also one of the main goals for this patient. The grade 2 pressure ulcer already indicates a break in the continuity of the skin which makes the patient vulnerable to infection (Sayar, et.al., 2008). Sweat, moisture, and exposure to dirt can exacerbate the patient’s pressure ulcer making it progress to higher grade levels. Regular assessment of the area is a primary intervention which was carried out for this patient (Sayar, et.al., 2008). Daily cleaning of the area with warm water was carried out in order to clear the area of dirt and exudates. After each cleaning, hydrogel dressings were applied over the pressure ulcers (Gunningberd, et.al., 2012). These dressings were absorbent and helped manage the heavy exudates. They were also changed whenever they got saturated with exudates. No additional padding was needed for the dressings because any additional dressing only served to increase the risk of maceration (Gunningberd, et.al., 2012). The importance of good skin care is one of the main considerations behind the prevention and management of pressure ulcers (Moher, et.al., 2009). Moisture on the skin can macerate and promote skin injury. Moisture can come from the patient’s sweat, wound, urine, including his faeces. Where these sources of moisture were not immediately eliminated, they often led to bacteria formation and infection of open wounds, including pressure ulcers (Moher, et.al., 2009). For this patient, the regular changing of his clothes and dressings eliminated the accumulation of moisture on the skin, especially on the pressure ulcer itself. Wound dressing was crucial in this case and significantly essential as it provided an absorption point for the pressure ulcer, ensuring that the surface of the wound would be relatively dry (Moore and Webster, 2011). Dressings support haemostasis, reduces swelling, as well as pain (Moore and Webster, 2011). Care in the removals of these dressings however had to be ensured in order to prevent secondary trauma on the skin surface. In this case, the hydrogel dressing (occlusive dressing) was applied. This type of dressing helped absorb the moisture and promoted wound healing without causing secondary trauma on the healing surface (Bito, et.al., 2011). Occlusive dressings have been recommended for pressure ulcers because of their various advantages when compared to the standard wound dressings (Bito, et.al., 2011). These occlusive dressings include polymer films, polymer foams, hydrogels, hydrocolloids, and alginates (Bito, et.al., 2011). These dressings present with various benefits and pitfalls. The hydrogels used for this patient are made up of hydrophilic polymers which cannot be dissolved in water but are able to absorb moisture (Lohi, et.al., 2010). They do not adhere to wounds and are cool to the skin; they also ensure efficient pain control as well as eliminate swelling (Lohi, et.al., 2010). They also require secondary dressings to keep them attached to the pressure ulcer area. Most of the different types of occlusive dressings reduce and relieve pain (Holroyd-Leduc and Reddy, 2012). The choice for occlusive dressings must therefore be based on evidence-based practice, including the options recommended by the physician and appropriate for each patient. The importance of patient-centred care would help reduce patient anxiety, ensure cooperation during treatment, and help manage patient care based on patient-specific circumstances (Junkin and Gray, 2009). The healing process for the pressure ulcer is also facilitated through the growth factors applied topically. These growth factors have been known to assist in the healing process as they help transform the alpha and beta growth factors, epidermal growth factor, fibroblast growth factor, and its other elements (Baranoski and Ayello, 2008). The use of topical agents which support healing can promote rapid epidermal resurfacing. It is however important to note which topical agents promote wound healing especially as some agents can have cytotoxic effects on the skin (Baranoski and Ayello, 2008). Toxic agents include povidone-iodine, chlorhexidine gluconate, and castor oil, among others. For this patient, no topical agents were used, but the hydrogel dressing helped manage the wound healing process. Necrotic debris was also apparent for the pressure ulcer. Such debris had to be removed as they delayed wound healing and promoted the build-up of infection (Borgquist, et.al., 2009). The removal of the debris was carried out by the attending physician through mechanical debridement. This process was carried out with the assistance of the senior nurse. This process can be painful, however, it is also necessary to promote tissue granulation. Saline gauze placed over the pressure ulcer was allowed to dry and then was slowly removed by the physician (Borgquist, et.al., 2009). Mechanical debridement usually involves wet-to-dry dressings, as well as wound irrigation and hydrotherapy. The removal of the viable tissue was also important for this patient, even as it also proved to be a painful process (Bluestein and Javaheri, 2008). This helped to further promote the healing and regeneration of the tissues. The necrotic tissue was minimal and did not cause any major trauma to the continuity of the patient’s skin. There was no pus or odour seen in the area, hence no further measures were carried out to promote healing (Borgquist, et.al., 2009). The management of bacterial contamination proved to be an important aspect in managing the patient’s pressure ulcer. Bacteria is known to delay recovery and it further destroys tissues (Sinclair, et.al., 2012). The human skin is the primary organ of defence for the body. It is also known to contain organisms which may or may not be harmful for the body (Sinclair, et.al., 2012). Where the skin is no longer intact, there are fewer microorganisms needed in order to cause infection. The changing of the dressings was one of the means by which infection was prevented (Cereda, et.al., 2009). Keeping the patient dry was also ensured. With the regular assessment of the patient, any perspiration, moisture, dirt on the patient’s dressing and clothing were noted and cleaned (Cereda, et.al., 2009). Daily changes in the patient’s clothes ensured that the patient’s clothes were not soaked with sweat or soiled at any time (Vanderwee, et.al., 2009). Applying the aseptic techniques during wound cleaning also helped prevent infection. Aseptic techniques were carried out by this student washing her hands thoroughly with soap and water (Vanderwee, et.al., 2009). Gloves were then put on and dressings, forceps, scissors, cotton balls, were laid out aseptically prior to the cleaning (Vanderwee, et.al., 2009). The wound was bathed first with warm water. Iodine application was not used for this patient. The use of iodine has been reduced because of its toxicity effects (Sibbald, et.al., 2011). Although the toxicity of iodine on pressure ulcers has not been definitively proven, its use for this patient has not been favoured over other safer options, in this case, warm water. Warm water presents a safer and less toxic option in wound cleaning and prevention of infection (Sibbald, et.al., 2011). After the area was cleaned, the hydrogel dressing was applied. Pressure-reducing surfaces Mattress overlays help prevent friction and help counter the pressure presented by the bony prominences of the body, in this case, the patient’s sacrum (Rich, et.al., 2011). Mattress overlays have been known to redistribute the pressure on a patient’s back more evenly (Junkin and Gray, 2009). The theoretical goal behind the management of pressure ulcers is to temper the pressure on the tissues below the capillary closing pressure of 32mm Hg (Rich, et.al., 2011). Placing mattress overlays, foams, and similar materials over bed surfaces helps achieve this goal (Rich, et.al., 2011). The pressure-relief or reducing devices were also considered for other surfaces which the patient used, including his chair. Such devices also helped prevent the worsening of the pressure ulcers (Garrett, et.al., 2009). Devices which can help prevent pressure ulcers include pressure-relieving or pressure-reducing devices. Majority of the devices are those which reduce the pressure on the skin (Hanson, et.al., 2010). Most of the methods applied to this patient were pressure-reducing devices. Pressure-reducing devices are either static or dynamic (Phillips and Buttery, 2009). Static devices are those which are stationary, including foam mattresses and other devices made of water, gel or air (Hanson, et.al., 2010). Dynamic devices were those which alternately inflated and deflated depending on the distribution of pressure on the body surfaces (Hanson, et.al., 2010). An air mattress was applied for this patient as it was primarily preferred by the patient and it helped reduce and redistribute the pressure over the patient’s back, especially his sacrum-hip area. In various prospective, randomized trials, the application of pressure reducing devices helped decrease the incidence and severity of pressure ulcers, as compared to the use of standard hospital mattresses for orthopaedic patients or chronic care patients (McInnes, et.al., 2011; Lahmann and Kottner, 2011; Mistiaen, et.al., 2010). Other practitioners reviewing the application of dynamic devices indicated that some relief was provided for the patient in various areas of concern, however complete relief was not always possible for all prominent pressure areas of the body, especially when the head area was elevated (Chung, et.al., 2012). Nevertheless, most studies indicated that the application of dynamic or static devices were preferred over standard mattresses especially among those who were at risk of developing pressure ulcers or those who have already developed pressure ulcers (McInnes, et.al., 2011). Patient nutrition The patient’s nutrition was also evaluated as one of the causes for the pressure ulcer, especially as the patient is frail and elderly. This author ensured that the patient had a diet rich in protein and other essential nutrients (Lahmann, et.al., 2010). In nursing homes, a good percentage of residents are often known to be malnourished with pressure ulcers being a common issue among these patients (Lahmann, et.al., 2010). For those patients with low dietary protein, a higher percentage of pressure ulcer development was apparent. Patients with pressure ulcers have been known to take less than the recommended daily dose of protein, as compared to those who did not develop pressure ulcers who maintained the average daily intake for protein (Lahmann, et.al., 2010). Other vitamins and minerals did not appear to have as much an impact on the development of pressure ulcers as protein intake (Lahmann, et.al., 2010). Nevertheless, it has been deemed important for most high-risk patients to have a balanced intake of nutrients in order to prevent malnutrition (Van Gilder, et.al., 2009). Malnutrition can delay the patient’s recovery and wound healing. It can also cause weight loss and can further reduce padding over the bony prominences of the body (Banks, et.al., 2009). Conclusion The patient’s grade 2 pressure ulcer was managed appropriately using interventions based on evidence-based practice. The management of the patient’s pressure ulcer included an assessment of the pressure ulcer, evaluating its quality and grade level. This helped provide an initial foundation for the treatment. One of the primary interventions for the pressure ulcer included early mobility of the patient, mostly with the use of log-rolling techniques at least every two hours as well hip abduction exercises. The use of pressure reducing devices, specifically the air mattress also helped reduce the pressure on the skin and redistribute such to other parts of the body. Wound management played a significant part for this patient, especially with the application of aseptic techniques, wound cleaning, as well as the application of hydrogel dressing. 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