Managing Pressure Ulcer - Case Study Example

Managing Pressure Ulcer Name: Institution: Managing Pressure Ulcer An understanding of wound physiology The first step in proper care, management and treatment of any wound is the understanding of the patient and that of the wound itself. Thus, It is of great importance to understand that Miss Pickles’ case is influenced by a number of factors including her medical history. The diabetic history largely impacts the analysis, management and finally treatment of wound. The dietary requirement of diabetes, its effect on the psychology of the patient and its nature of long duration of recovery are some of factors to consider (Bade, Bouten & Colin, 2005). From the already undertaken research in this particular area, it is understood that diabetic’s patient’s wounds often take a longer healing period compared to what would otherwise be termed as ‘normal’. Hence in addition to exceptional wound dressing, health and diets factors come in a handy in order to cater for Miss Pickles’ hypertension as well as kidney’s disorders. This will ensure that the patient does not suffer from high pretension during wound management process as it would worsen the whole situation altogether. With that background information, the management will be more efficient (Hess, 2007). Comprehensive assessment of the bio psychosocial needs of a person (and their relevant others) suffering wounding,  From a rather close observation of the patient’s wound it is more of open wound. Many regard open wounds challenging particularly when linked by some underlying factors as the case with Miss Pickles’ however with proper bed preparation accompanied by well managed wound dressing it is possible to come up with great and satisfactory results. At this preliminary stage it is worth noting that open wounds have great risks of infection (Bales & Ritchie, 2009). In addition to the already mention determining factors of the patient’s situations it also makes sense to consider that she must be in great pain considering that the reason why she got admitted was the suffered fracture.  Pain normally serves as a warning particularly of tissue damage and if not given a priority it is likely to lead to increased stress response within the cells. More also, it occurs that there is a considerable decrease in autonomic as well as endocrine reflexes that in turn cause inefficient immunity hence negatively impacting wound healing (Myers, 2008). For Miss Pickle’s case, administration of pain relievers is very necessary as part of the primary stages managing the wound. It is after pain is managed that the aspect of critically determining the relationship between functionally bacterial balance, improper biochemical messengers as well as available abnormal cells is considered (Salvo, 2008). However these important aspects are impacted by the bio psychological as well as physical state of the patient. At this point it becomes necessary to point out that the main aim of getting the patient proper wound management preparation is to ensure creation of a healing environment, of rather high standards, stable and without exudates (Stump, 2008). The competent wound assessment Wound size forms an important factor in the determination of choice of care as well management to be provided to a patient with pressure ulcer.  Wound size can be categorized in to various grades depending on the level of depth and sensitivity. In grade one; the wound normally portrays skin discoloration, edema with some feeling of hardness. In grade two; the wound will have skin loss that is deeper and thick. At this stage, the ulcer becomes superficial and clinically in is termed as some form of abrasion. Most of the wounds fall under these two categories and are easier to manage (Morison, 2001). In grade three, the wound displays thicker and greater skin loss characterized by tissue damage sometimes to the extent of underlying fascia. In grade four; the wound is largely characterized by extensive destruction, muscle and tissue damage as well as thicker loss of skin. The intensity of the wounds in these last two grades requires the caregiver to give more careful approach in management. Any mishandling of the underlying tissues may lead to lengthened healing period (Dealey & Cameron, 2008). Considering the four stages undertaken by a developing pressure ulcer, Miss Pickles’ case falls under the very last grade where the wound is at its critical stages hence requiring very critical measures during wound management.  Implementation of safe, effective wound management strategies,  In the actual implementation of safe and efficient wound management it is of importance to ensure the integration of such aspects as bacterial balance restoration, managing cellular dysfunction, regulating biochemical balance as well as necrosis management. The combination of these aspects result to complexity during wound management hence the need to apply holistic assessment. For instance, in order to ensure that Miss Pickles’ skin integrity is preserved, it becomes necessary to administer some specific dietary measures (Romannelli, Clark & Clark, 2006). This is where cultural factors come in as most feeding habits are more or less determined by one’s way of life. In other words Miss Pickle will be required to make some adjustments in her a way of life during and after this particular process (Beek, Buller & Oudkerk, 2009). One of the reasons dietary management is importance is to keep glucose levels maintained as well as that of blood pressure. This is expected to positively impact the overall healing process moreover with regards to considerably reducing the time taken for this particular wound management (Resnick, 2009). Critical reflection and critical analysis of relevant evidence based wound management practices As mentioned earlier regarding the administration to specific dietary preferences, this cannot be appropriately carried out without undertaking Miss Pickles’ nutritional assessment more so her food preferences. Therefore blood will need to be drawn for blood glucose evaluation and haemoglobin checks. It is from results of the mentioned tests that Miss Pickles’ controls will be determined (Beek, Buller & Oudkerk, 2009).  The management of the wound requires that the staff should not use any assumption in the treatment. This is based on the fact that different patient have different reactions to the pains that they undergo. The common assumptions are either relied on the past experiences of the patient or the experiences of other patients. This has caused either delayed healing to patients, increment of pain, and even creation of other side effects. In some cases such assumptions have lead to hospitals paying dearly for the extra costs that the patient undertakes (Beek, Buller & Oudkerk, 2009). Evidenced based practices to achieve effective wound management Ward patients who need maximum care for activities of living have the greatest risk of this kind of ulcers. These are followed in cases of occurrence by Independent ambulatory patient’s occurrence of which was on the lower extremities. Then come in the patients who had impairment in their sight ability. This kind of patients mostly bumps on equipment and furniture during their movements (Salvo, 2008). The options that some of the caregivers-especially home based – to limit the movements of these patients has been reported to have adverse psychological effects. The patients at all times feels tied and thus the body tissues are always stressed. This further aggravates the situation of the patient (Feldman & Christensen, 2007). Skin Tear Prevention in pressure ulcers management One of the dangers that face the pressure ulcers is the skin tears that may occur during the wound management. This it is paramount while giving care to a patient with pressure ulcers, to make sure that any other skin care is avoided. Though this is a topic that most authors have shied away from, the caregiver should apply the common sense protocol. The nursing staff should be well trained in the handling of the patient (Romannelli, Clark & Clark, 2006). The patients like miss pickles who are aged have frail skin and can be torn by any pulling or harsh movement. To maximize the care on patients, the nurses should at all time give heed to the transferring techniques that are laid down by the management. Also turning lifting and positioning should be handled with care. The same education should be given to any of the home caregivers in case of outpatients (Carville). Some of the equipment and gadgets that injure the patients are bed rails, wheelchairs leg and arms supports and other mobility support equipment. It should be the responsibility of the nursing staff to ensure the all this is given enough padding at all times in addition the arms and the legs of the patients should be covered by pillows and blankets (Salvo, 2008). To maximize the protection, the patient is advised to use long sleeves and pants. Instead of using high adhesive tape to cover the wounds it is recommended that the paper tape is used on frail skin. Non adherent tapes can also be used. The skin of the patient should be moisturised all the time by applying of moisturizing agents instead of lotions creams should be used on such skins. The room that the patient is kept in and the paths should be well lit to ensure that she does not bump into objects that may cause injury (Beek, Buller & Oudkerk, 2009). Managing pressure ulcers The below stated format has been tested and confirmed in a number of occasions of managing pressure ulcers; softly cleanse the skin tear with brackish or a non-toxic wound disinfectant, allow the area to air-dry or pat carefully to dry. Approximate the skin tear flap/tissue, if present, as closely as possible (Bryant & Nix, 2007). Modification of pain works towards reduction of the trauma the patient undergoes in the treatment. While the pain is caused by the wound, it is not feasible to eliminate the wound. The complexity that each person undergoes when in this kind of pain makes it complex in managing any pain. The bodies of different patient react differently to the pressure ulcers. Persistent wound pain greatly affects the patient’s quality of life and has a significant impact on the lives of the relatives, caregivers and others around them (Carville). Some of these pains are experienced specifically and exacerbated by the procedure of wound dressing-related and thus may be more temporary. Additionally, there are the emotional components of pain that may include anxiety and earlier experience that should be recognised. The patient’s perception of pain and may dent the relationship between the patient and the practitioner. Thus it is paramount to deal with the psychology of the patient. It is note worth that the period that the patient takes to heal partially depends on the psychology. All the body organs are responsive to the brain which is the centre of psychology (Salvo, 2008). The first step in this particular pressure ulcer management will be wound cleansing in order to relatively lower bio-burden levels thereby facilitating healing process. There is a wide variety of solutions utilized in wound cleansing including acetic acid, sodium hypochlorite, Povidone-iodine as well as saline solutions.  In this case, it is important that considerable time is allocated to making a choice of which among the various solutions is to be used (Flanagan, 1997). However, in cases when there is no need for germicidal action, saline solution should be used in order to generally minimize drying effects within damaged tissue. More so, saline solution also serves as a rinsing applicant once cleansers are utilized in order to moisturize wounds and considerably reduce fluid shifts occurring particularly in fresh tissue (Williams, Flanders & Whipcomb, 2007). Dressing Just like cleansing solutions utilized in the pressure ulcer management, dressing of the same can also be carried out using a variety of dressings that are more or less dependent on nature of wound in question. Among the available dressings available is transparent adhesive which are semi permeable in nature. Transparent adhesives serve where reduction of infections, water vapor movement as well as gaseous exchange is required.  It is noted that transparent adhesives do not serve best for pressure ulcers characterized by some exudates. In such cases, other dressings are recommended for instance, hydro-colloids wafer that help in absorbing some considerable exudates amounts also the surface moist (Benbow, 2005). In addition to these two dressings, there is also gel and calcium alginate forms of dressings. Both serve as exudates absorbers though calcium alginate has better results in contaminated or largely infected wounds as they are more or less natural derived from some seaweed. It will be advised that calcium alginate form of dressing is utilized in Miss Pickles’ case to ensure minimal chances of reaction (Williams, Flanders & Whipcomb, 2007). While managing pain the devises that are used should be able to detect the type of pain, the causes, the duration the onset as well as the exacerbating and relieving factors. Thus each assessment should be patient centred. The occurrence of the pain whether prior, during or after the dressing session is a matter of consideration (Benbow, 2005). The World Union of Wound Healing Societies' in their consensus document have laid down some rationale equipment that can be used with the aim of structuralising the process of assessment as well as enabling an early assessment of an patients with dressing-related pain. This assists in effective and fast management strategies implementation (Irion, 2009). The tool is used hand in hand with the individual-lead questionnaire so that the patients can record the wound pain themselves. Thus the adaptation of the tool is highly recommended. Another important aspect in wound management thus is the assessment of the pain that is felt by the patient (Bernstein, 2010). There are basically two types of pain; nociceptive pain and neuropathic pain. Of the two nociceptive pains occur to most patients. This is the normal physiological rejoinder to a painful incentive. Nociceptive pain associated Trauma can cause swelling and damage to the marginal nerve endings which results in hypersensitivity, this leads to intense pain at minor stimulation (Bernstein, 2010). It is fortunate that, nociceptive pain is in most cases relieved by use of analgesia and reduces over time. In most cases the patients who report this kind of pain get used to it and might not record it in their questionnaire. Thus it is upon the nurse to ensure that he enquires from miss pickles whether she still feels the pains (Carville). On the other hand, Neuropathic pain is associated with a primary abrasion and at times dysfunction present in the nervous system. The situation also causes nociceptive pain, ischemia, diabetes and even trauma. When these occur concurrently they damage peripheral nervous system and alter the response to pain (Maklebust & Sieggreen, 2001). The common words used by the patients to describe this kind of pain are 'burning', piercing and 'shooting' some patients likens the pain to an electric shock. Assessment and management of this pain has been a challenge in the past. However, application of antidepressants and anti-epileptic medication has been effective in controlling the symptoms associated with the damage of the nerve system (Carville). Integration of culturally sensitive wound management processes  With the above knowledge about the wounds the management of the effective treatment of miss pickles would be easier. The comparison of pressure ulcers to other skin tears make so sensitive that no compromise on the safety regulations cam be made. The situation shall require that her wound be regularly dressed and each time the pain that she is experiencing be recorded. This shall require that the nurse at all times carry the patient lead questionnaire so that miss pickles can record in it (Salvo, 2008). Another important point in the treatment of miss pickles shall be the diet. The staff should at all times inspect the food that the patient is using. As already stated the situation does not accommodate any compromise. Thus the staff should be ready to advice the relative should the patient insist on deliveries from home. It is common for some patients to insist on this. As dealing with trauma is one of the objectives when dealing with our patient, this privilege cannot be deprived (Beek, Buller & Oudkerk, 2009). Conclusion Pressure ulcers are one of the common tissue illnesses that should be dealt with in great care. The research confirming effective methods of treating the ailment are however not conclusive. This calls upon the person; whether home based caregivers or the clinical nurses who are dealing with the patients to exercise due care in their operations. The management of pain as reported about is as paramount as the healing of the wounds. Thus it is expected of the caregiver to not only offer the physical help but also to offer psychological help. Cases of the ailment being terminal are rare ad thus there should be cause for alarm. Then most important thing is for the caregivers to ensure that the side effects that are associated with delayed healing do not occur. Moreover, they should maintain a good relationship with the patient so that she can corporate in wound management process. References Carville K. WOUND CARE MANUAL' 5th ed. New York: Silver Chain Clinic. Salvo S., (2008). Mosby's Pathology for Massage Therapists. California: Elsevier Health Sciences. Beek E., Buller H. & Oudkerk M., (2009). Deep Vein Thrombosis and Pulmonary Embolism. New York: John Wiley & sons Inc. Bernstein D., (2010). Essentials of Psychology. California: Cengage Brain Feldman M. & Christensen., (2007). Behavioral medicine: a guide for clinical practice. New York: Cengage Brain Romannelli M., Clark M. & Clark M., (2006). Science and practice of pressure ulcer management. California: Elsevier Health Sciences. Williams M., Flanders S. & Whipcomb W., (2007). Comprehensive hospital medicine: an evidence based approach. California: Elsevier Health Sciences. Resnick B., (2009). Assisted Living Nursing: A Manual for Management and Practice. New York: John Wiley & sons Inc. Hess C., (2007). Skin and wound care. New York: John Wiley & sons Inc. Bales C. & Ritchie C., (2009). Handbook of Clinical Nutrition and Aging. New York: Silver Chain Clinic Stump S., (2008). Nutrition and diagnosis-related care. California: Elsevier Health Sciences. Maklebust J. & Sieggreen M., (2001). Pressure ulcers: guidelines for prevention and management. New York: John Wiley & sons Inc. Morison M., (2001). 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