Pressure Ulcer - Critical Incident Analysis - Essay Example

PRESSURE ULCER - CRITICAL INCIDENT ANALYSIS Lecturer’s Introduction Pressure ulcers also referred to as "bedsores" are localized skin injuries of underlying tissue occur on the bony prominences of specific regions in the body such as the coccyx, hips, heels and the sacrum (Reddy 2011, 6). Other sites where the sore occur include the ankles, elbows, cranium and the knees (Thomas 2010, 403). Pressure ulcers results from pressure with a combination of friction and shear effects on the areas discussed. When pressure is applied on the soft tissues of the body, it obstructs blood flow on the soft tissues. Shear effects then exact pulling effect on the blood vessels that supply the skin with blood resulting to their occurrence (Grey et al. 2006, 472). There are four stages of pressure ulcer occurrence from stage I to stage IV. Stage I involves an intact skin where an ulceration results that indicates a reactive hyperemia. Stage II involves partial skin loss of the dermis and epidermis while stage III entails full thickness skin loss with extension into the subcutaneous tissue. Stage IV entails a full thickness of tissue loss with extension in to adjacent muscles, bones, tendons and joint capsule (Lyder & Ayello 2005, 281). Pressure ulcers develop in risk prone individuals i.e. those who are immobile especially the sick and elderly patients confined to wheelchairs. However, a number of factors influence the tolerance of the skin, the shear and pressure effect thus increases the risk of pressure ulcer development. These factors include protein calorie malnutrition, wetness of the skin as a result of incontinence or sweating and medical conditions limiting blood flow to the skin such as paralysis or neuropathy (Reddy et al. 2006, 977).They are preventable skin conditions, but their rate of occurrence continue to escalate yet at an increasing alarming rate. Between the period of 1995 and 2008 pressure ulcers incidence increased by 80 percent, and the rate is not expected to decline due to poor patient’s acre in the nursing homes and hospitals (Bennett et al. 2004, 230). About 2.5 million patients develop pressure ulcer each year in the United States, while more than a million patients remain affected annually (White-Chu et al. 2011, 245). The rate is expected to increase due to the increase of the population at risk i.e. the obese, elderly, diabetic patients (Bader, 2005, 25). Therefore, addressing and preventing the condition is of utmost importance to the public, as it will prevent patients from further harm and reduce the cost of care (Clay, 2008, 12). Pressure ulcers occurrence prolongs the hospital stay of the patients making care expensive to them and the hospital and at times, late stage pressure ulcers will result to a life threatening condition as a result of infection. In this regard, 60,000 patients in the U.S. die each year due to complications of hospital-acquired pressure ulcers (Stockton et al. 2009, 102). The critical incidence analysis Case scenario and patient presentation Susan, a pleasant woman in her fifties, has her tales to tell about pressure ulcers. She was faced with a difficult decision of admitting her mother to a nursing home facility after her mother fell ill. Before her mother had fallen ill, she was living independently in her own apartment with no one around since her husband had fallen ill and died six year before due to a heart attack. All her children were married, and they lived with their families. Susan mother was in her middle 70’s and did all right before she suffered a minor stroke, fell and broke her leg and developed a mental condition. Due to her age and factors of osteoporosis her leg did not get better and after incidence she was unable to get around or do normal chaos such as going to the bathroom and needed help in rehabilitating her leg. Two years after the incident, her condition became life threatening and her mental health deteriorated. Her mother was often disoriented and confused, and she needed more care and supervision that her daughter Susan and family could not manage to provide. Therefore, to take care of her mother needs she looked for a facility that accepted taking care of her for 24 hours every day. This was a relieve for Susan and her family as the nursing care facility would meet her mother’s needs as she hoped that the facility was going to take good care of her mother. She then made arrangements for her mother’s admission. Three months down the line, Susan was shocked. She visited her month every day and although her mother’s confusion continued to worsen, there was no any physical signs that caused the deterioration of the health status until when she discovered a baseball sized gaping hole of rotting fresh on her mother’s buttocks. The skin on the right buttock was broken with dermal and epidermal skin loss about 2-3 cm in diameter and with moderate exudate coming out of the site. Susan became confused and had to seek for alternative help because her mother condition was deteriorating. She did not know what actions to take to the nursing facility and was so bitter of letting her mother out of her hands. This time while seeking help in the new nursing care facility; Susan was very careful with her mother’s condition. Significance of the case The case is significant to me as it is a representation of what elderly and predisposed patients to pressure ulcers experience in the inpatient clinical care settings (Reddy 2011, 9). Pressure ulcers occurrence is very common among nursing home residents due to poor quality of care the patients receive (Schindler et al. 2011, 34). According to a study conducted by Reddy et al. (2006), nearly 20,000 patients in 51 nursing homes had developed a pressure ulcer. Of the total patients exposed to the sores, 11.3 percent posed a stage two or deeper pressure ulcer while 13.2 percent had developed the ulcers in the nursing care facilities. In the contrary, this should not be the case as the hospital facilities and nursing homes provide the only hope for the patients yet they predispose the patients to other conditions like pressure sores (Thomas & Compton, 2014, 35). Susan’s mother case is a representation of an example of such an incident as her mother developed the bedsores will in the nursing care facility. Pressure ulcers are a menace that needs to be addressed promptly as the population at risk is on the rise (White-Chu et al. 2011, 255). A recent survey estimated that in one out of four patients in an acute condition and at least one out of three patients with a long-term conditions and needed medical care had a pressure ulcer (Shahin et al. 2009, 419). Therefore, the issue needs to be taken into consideration appropriately with control measures and treatment modalities being adopted to improve on the current incidence of the condition (Bennett et al. 2004, 232). Actions taken to the patient and determination of treatment modalities Assessment It is impossible to implement and create a plan of addressing the patients concerns if the problem is not identified in the first place. Therefore, assessment of the patient was the first action taken on the patient. It is the initial patient’s assessment that will enable for an appropriate care planning protocol for the patient to be undertaken that will be aimed at meeting the patient’s care needs. If the initial assessment is not done the resulting care of plan adequately will be deficient. This entails an assessment of the stage of the pressure ulcer, as a sore will not evolve from stage 1 to stage 4 overnight (Cox & Cwocn 2011, 371). According to the scenario, Susan’s mother case was in stage 4 as the bone was involved. There are four stages of pressure ulcers development. Stage 1 involves a reddened area on the skin that when pressed will not turn to the normal skin color. This is a clear sign that a pressure ulcer is starting. Stage two of pressure ulcer development entails the formation of a skin blister or an open sore while stage three involves the development of an open, sunken hole referred to as a crater and tissue below the skin becomes damaged. In stage four, the pressure ulcer is so deep that damage to the adjacent bones and muscles develop and at times joints and tendons are involved (Bluestein & Javaheri 2008, 78). Modification of the patient’s situation This entailed the utilization of higher-specification foam mattress to reduce the risk of the patient from further complicating her condition. Treating the cause of the condition is an essential part of the treatment plan. The primary causes of bedsores results in regions of high pressure that are usually over the bony prominences. The positioning checklist of patients at risk of pressure ulcers recommends avoiding positioning the patient with areas that are at risk of developing the ulcer as well as using pillows and wedges to facilitate patients positioning. Therefore, pillows and wedges were used in helping patients positioning. A repositioning schedule was also developed for the patient that involved a two hourly turning. The patient was placed at a 30 degree side lying position and 90 degrees supine and lateral positions, as they are the recommended positions for removing the ulcers from the bony prominence’s (Pancorbo-Hidalgo et al. 2006, 95). A dynamic surface was recommended and used for the patient since the patient could not make positions by herself. In determining the best surface of the patient, the computerized pressure mapping technique was used to evaluate the surfaces. This involves a computer monitoring the patient’s visual image as pressures are changed to determine the best surface to use. Appropriate positioning, establishment of a schedule for positioning where patient was turned after two hours and utilization of therapeutic management devices proved appropriate for the care of the patient (Stannard 2012, 342). Pain assessment and control Pain control measures were used to reduce pain such as effective medications and other therapies such as appropriate positioning and utilization of appropriate supportive surfaces. Analgesics and sedatives were used to depress the central nervous system to reduce alertness and activity by the patient to promote proper wound healing. Patient was assessed for pain regularly and routinely. To ensure that the patient was free from pain, a two-step pain assessment measure was used where the process includes a self-report by the patient and a second comprehensive report on the quality of pain. Assessment also entailed behavioral and physiological indicators of pain. In pain management, the accurate assessment and diagnosis of the type of pain, intensity and effects on the patient was appropriate for treatments and determining interventions for the patient (Reddy et al. 2006, 977). Maximizing the patients nutritional status Maximizing the nutrition status of the patient is important to enhance wound healing of the patient. Vitamin E and amino acid were supplemented in the patient’s diet to enhance healing in addition to vitamin A, vitamin C and calories. However, some scholar propose that vitamin E is not appropriate for wound healing management especially for pressure ulcers management as it is presumed to interfere with vitamin A and as well will prolong the inflammatory phase of healing but it was proved wrong in the case scenario. The nutritional modification of the patient was made possible and a success by the facility dietician who assessed comprehensively the nutritional needs of the patient. Adequate nutrition is essential in boosting the immunity of the patient (Moore & Cowman 2009, 24). The fluid and nutritional food intake of the patient was measured by the patient’s weight. As part of the nutritional status, hemoglobin level less than 100 g/l will result to poor wound healing and is an indication of iron deficiency anemia (Yarkony 1994, 911). Such a condition will determine the treatment strategy to be adopted to the patient. In ensuring that nutrition and patients care was appropriate, the platelets and hemoglobin levels of the patients were determined. The patient hemoglobin levels were normal thus; there was no need of any intervention. Patient hydration status was also optimized to enhance healing. The patient was at a risk of decreased thirst response due to his age. Therefore, parenteral and enteral nutrition was used to prevent dehydration. Management of moisture and incontinence The patients skin was cleaned gently with mild PH balanced non-sensitizing cleansing agent especially around her infected wound each day. Wound cleaning was also done once a day to promote wound healing. Warm rather than hot water was used for cleaning to minimize patient’s irritation. Wet skin is susceptible to friction and tearing accidents increasing the risk of development of another pressure ulcer. It will also delay the process of wound healing thus; the skin was kept free from urine, perspiration or any wound drainage. Incontinence results to an increased PH around the skin area making it more susceptible to irritation. Thus, a toileting and incontinence program was developed for the patient to minimize episodes of incontinence. Diapers and absorbent pads were used and changed regularly to prevent skin irritation. Moreover, cotton linen was used to promote skin aeration, evaporation and faster skin drying from perspiration. The line was changed regularly to prevent accumulation of dirt that could result to an infection (Bennett et al. 2004, 234). Dressing used to manage the pressure wound was appropriate to facilitate wound drainage as well as protect the surrounding skin. Protective creams and ointments were used in keeping the wound dry. Debridement The necrotic tissues were removed through debridement. The necrotic dead tissues provide an ideal place for bacterial micro-organisms to grow that compromises the process of wound healing therefore it was necessary (MORISON & RIJSWIJK , 2001, 16) . There are many types of debridement. In the case, scenario surgical and autolytic types were used for the patient. Surgical debridement entailed removal of the dead tissue by a surgeon while autolytic debridement entailed the use of moist dressing that promoted autolysis within the body own enzymes and the white blood cells. The patient had a good immune system thus it was effective for the method and it is a painless process (Moore & Cowman 2005, 28). Once the necrotic tissues were removed the wound was filled moisture retentive dressings and gel to facilitate wound healing. A cover dressing was then used to hold the gel in place. To improve granulation tissue formation following debridement a negative pressure wound therapy technique was used. The technique entailed placing gauze in the wound cavity creating an airtight seal. On the creation of the seal, the negative pressure will remove exudates and edema from the wound thus stimulating blood supply on the area and production of granulation tissue. The method is used for only the patients who have undergone recovery as per the case. Evaluation of the patient’s progress is also essential. Surgery was done to close the wound using tissue flap closure method. Following the operation, no pressure or tension was applied on the wound area to facilitate wound healing (Bluestein & Javaheri 2008, 78). After a while, the patient was initiated to sitting that allowed inspection for incision separation and for any pallor. Outcome of care Care of the treatment, modality was efficient for the pressure ulcer healing that took approximately seven weeks to heal. Thus, the care modality was effective. This modality entailed an initial patient’s assessment that enabled the determination of an appropriate care planning protocol for the patient that was aimed at meeting the patient’s care needs, modification of the patient’s situation that involved utilization of higher-specification foam mattress to reduce the risk of the patient further complication and pain assessment and control. The patient nutrition was modified to promote healing; incontinence and moisture were prevented before surgery was done that entailed debridement and surgical closure of the wound. In future, I recommend healthcare professionals to adopt the treatment modality as a health care policy in treatment and care of pressure ulcer especially grade three and four types. Laws to pressure ulcer care and clinical governance with regards to clinical guidelines The federal and state nursing home regulations guidelines are important in providing laws in regards to pressure ulcers occurrence and states that a nursing home should; 1) Ensure that a patient entering a nursing facility without pressure ulcers does not develop the sores unless they were “unavoidable” due to the patient’s medical condition 2) Ensure that a resident coming to the facility with pressure ulcers receives the appropriate treatment to enhance recovery of the patient. According to the guidelines, the term “unavoidable” is used to mean that the patient developed the pressure sores even though the healthcare facility evaluated the clinical condition and risk factors for the development of the condition. The facility ought to also have defined and implemented relevant interventions consistent with the needs, goals and recognized the standard practices of care management by monitoring, evaluating and revising the interventions appropriately. The facility should provide evidence that it assessed the patient’s condition, developed an appropriate plan of action to prevent the condition occurrence, implemented the plan and revised the care of action yet every action failed. The facility should also inform and involve other family members in the patient care (Reddy et al. 2006, 982). If the patient is at a risk of pressure ulcer development then, the facility needs to conduct an adequate assessment of the factors involved and implement a plan to prevent pressure ulcer development. If this is done and the pressure results then the situation is “unavoidable” under the state and regulations laws. The Factual Analysis of Susan mother’s case scenario The case demands further investigation. Her mother was a stroke victim who had a broken leg, ; therefore, she had a risk of pressure ulcer development due to her limited mobility as well as her confinement to bed. However, the nursing facility that Susan took her mother to for care before developing the pressure ulcer never notified of the sore occurrence, therefore, it can be considered as a violation of the patients’ rights. It is either that the nursing home failed to communicate the patients care to Susan or they either failed to assess the mother condition and prevent the pressure ulcers occurrence. Susan had a right of knowing the concerns of her mother’s condition and as well participate in care of the patient to determine the best solution. Her mother never had any medical condition that could make pressure ulcer prevention inevitable. Although the mother had a stroke, there was no evidence of a peripheral vascular condition therefore, Susan should seek justice in her case according the pressure ulcers guidelines. References BADER, D. L. (2005). Pressure ulcer research current and future perspectives. Berlin, Springer. Bennett, G., Dealey, C. & Posnett, J., 2004. The cost of pressure ulcers in the UK. Age and Ageing, 33, pp.230–235. Bluestein, D. & Javaheri, A., 2008. Pressure ulcers: Prevention, evaluation, and management. American Family Physician, 78. CLAY, K. S. (2008). Evidence-based pressure ulcer prevention: a study guide for nurses. Marblehead, MA, HCPro. Cox, J. & Cwocn, A., 2011. Predictors of pressure ulcers in adult critical care patients. American Journal of Critical Care, 20, pp.364–375. Grey, J.E., Enoch, S. & Harding, K.G., 2006. Pressure ulcers. BMJ, 332, pp.472–475. Lyder, C.H. & Ayello, E.A., 2005. Pressure Ulcers : A Patient Safety Issue. In Patient Safety and Quality: An Evidence-Based Handbook for Nurses. pp. 268–299. Moore, Z.E.H. & Cowman, S., 2009. Repositioning for treating pressure ulcers. Cochrane Database of Systematic Reviews. Moore, Z.E.H. & Cowman, S., 2005. Wound cleansing for pressure ulcers. Cochrane database of systematic reviews (Online), p.CD004983. MORISON, M. J., & RIJSWIJK, L. V. (2001). The prevention and treatment of pressure ulcers. Edinburgh [etc.], Mosby. Pancorbo-Hidalgo, P.L. et al., 2006. Risk assessment scales for pressure ulcer prevention: A systematic review. Journal of Advanced Nursing, 54, pp.94–110. Reddy, M., 2011. Pressure ulcers. Clinical evidence, 2011. Reddy, M., Gill, S.S. & Rochon, P.A., 2006. Preventing pressure ulcers: a systematic review. JAMA : the journal of the American Medical Association, 296, pp.974–984. Schindler, C.A. et al., 2011. Protecting fragile skin: Nursing interventions to decrease development of pressure ulcers in pediatric intensive care. American Journal of Critical Care, 20, pp.26–35. Stannard, D., 2012. Support Surfaces for Pressure Ulcer Prevention. Journal of Perianesthesia Nursing, 27, pp.341–342. Yarkony, G.M., 1994. Pressure ulcers: A review. Archives of Physical Medicine and Rehabilitation, 75, pp.908–917. Shahin, E.S.M., Dassen, T. & Halfens, R.J.G., 2009. Incidence, prevention and treatment of pressure ulcers in intensive care patients: a longitudinal study. International journal of nursing studies, 46, pp.413–421. Stockton, L., Gebhardt, K.S. & Clark, M., 2009. Seating and pressure ulcers: Clinical practice guideline. Journal of Tissue Viability, 18, pp.98–108. Thomas, D.R., 2010. Does pressure cause pressure ulcers? An inquiry into the etiology of pressure ulcers. Journal of the American Medical Directors Association, 11, pp.397–405. THOMAS, D. R., & COMPTON, G. A. (2014). Pressure ulcers in the aging population: a guide for clinicians. New York, Humana Press. White-Chu, E.F. et al., 2011. Pressure ulcers in long-term care. Clinics in Geriatric Medicine, 27, pp.241–258. Read More