Nursing Care and Prevention Plan for Patients with Pressure Injury - Case Study Example

Nursing Care and Prevention Plan for Patients with Pressure Injury. Name Institution Abstract. This paper presents discussion of the nursing care of a patient who was diagnosed of pressure injury after presenting to the ED in acritical health condition. The paper also identifies the underlying pathogenesis of the pressure injury in the patient and suggests a possible plan to prevent it. Besides, the paper provides an education to the client urging her to exercise a better lifestyle and avoid events and factors that trigger pressure injury. The paper finally discusses the inter-professional collaboration required to alleviate and prevent pressure injury in patients. Keywords: Pressure Injury, Nursing Care, pressure ulcers, Inter-Professional Collaboration Introduction The patient Ms. Ritter aged 85 who presented at the ED exhibited symptoms and test results which clearly indicated that she had suffered a pressure injury. The patient had three day history of urinary urgency, dehydration, lethargy, dysuria and poor appetite. The client has a BMI of 42 which means that she is obese and her body temperature of 37.8o C suggest that she has suffered favor. In addition, Ms. Ritter admits to be a prolific smoker and her water flow risk assessment score is 16. Following the above signs, the client was diagnosed of a pressure injury (Mortenson, Miller and Team 2009). A pressure injury refers to the damaged part of the skin due to prolonged and unrelieved pressure to that area. Various names used to designate pressure injury include pressure ulcers, bedsores, decubitus ulcers, and skin breakdown. Pressure injury is characterized by pain, reddening of the affected area and localized irritation of the skin. It’s confined in parts of the cellular necrosis which mostly occur in the subcutaneous tissue and skin over bony surfaces. The injury might be superficial, due to centralized skin irritation with consequent surface softening which originates from the underlying tissue. Deep lesions are usually visible when they penetrate the skin to the surface after causing damage to the subcutaneous layer (Mao, Rivet, Sidora and Pasko, 2010). Pressure injury may be painful and can sometimes cause bone infections and blood poisoning. In severe circumstances, the injury can deeply spread beneath the skin and cause destruction to the underlying bone or muscles Shahin, Dassen and Halfens 2010). Pressure injury mostly occurs due to inadequate supply of blood and nutrients to a localized part of the skin resulting to death of that part. Pressure injury is frequently found on bony parts of the body and anywhere that pressure is applied for a longer period of time. The injury generally develops in areas where the skin presses against a firm surface and where bones are close to the skin. According to Bergstrom, (2005) pressure injury can also lead to a prolonged stay in the hospital, pain, and slower healing from health problems. The nerves normally send messages of discomfort feelings and pain to the brain to inform the patient that, he/she has to change position. Pressure injuries range from minor reddening of the skin to deep craters extending down to the bone and muscle. Main parts of the body prone to pressure injuries in seated patients are the tailbone, shoulder blades, back of the knee, buttocks and the heels. There are many causes of pressure injury, however, this discussion is confined to the underlying pathogenesis of pressure injury affecting Ms. Ritter. Pathogenesis of pressure injury development in a client with Ms. Ritter’s risk factors. Ms. Ritter is said to exhibit lethargy for the last three days. Lethargy is associated with general weakness, drowsiness and sleepy feeling. This symptom may therefore have caused the patient to sleep for longer hours as a result of feeling tired and weak. In the lying position, pressure points to the side of the head, bones upper hip, shoulders, upper thigh bones, sides of the ankles and the anterior of the knees. As a result of prolonged pressure on the skin, tiny blood vessels are squeezed cutting off the supply of oxygen and nutrients to the skin. The skin tissues consequently die resulting to a pressure injury which is characterized by localized reddening and irritation of the skin (Shahin, Dassen and Halfens, 2010). The patient’s nervous system may detect the discomfort and pain and send the message to the brain to let her change the position and relieve the pressure. However, being in lethargy, the patient’s body fails to respond to the alert leading to the development of pressure injury. Once the injury has occurred, information from the sensory nerves fail to reach the brain. Hence, the patient does not receive warning signs that she has been lying in one position for a long time. In addition the client is 85 years old. Aging results to the skin getting dryer, thinner, less elastic and fragile. Thickness of the fat and tissue layers beneath the skin reduces exposing the blood circulation. This implies that, as the client grows older, her skin becomes delicate and get easily get damaged following incidents of minor bruises. Besides the skin has lost elasticity and it can easily break when exposed to harsh weather conditions or when it comes in contact with surfaces of objects even for a smaller period of time. The easy breaking of the skin in aged patients is major cause of pressure injury (Mortenson, Miller and Team, 2009).). Furthermore, assessments show that Ms. Ritter has a BMI of 42 which indicates that she is obese. Being obese means that it is difficult for the client to shift her weight and perform pressure reliefs by relieving the parts exposed to pressure. Obesity is also associated with larger amounts of fat deposits under the skin. According to Posthauer, (2010), these fats use nutrients and oxygen that could otherwise be used to nourish the skin. Lack of nutrients and oxygen causes the skin and the underlying tissues to die leading a pressure injury. Moreover, Ms. Ritter admitted to be a smoker smoking at least twenty cigarettes per day when she presented at the hospital. Smoking causes damage to blood vessels and results to deterioration of the skin health. The blood vessels get constricted resulting to reduce of the blood to the skin. Consequently, the skin cells and the underlying tissues die causing a pressure injury (Mortenson, Miller and Team, 2009). Further assessments also indicated that, the client had a water flow risk assessment score is 16 which suggests that she has a higher risk of pressure injury infection (Kottner, Dassen, and Tannen, 2009). Finally, it is reported that Ms. Ritter suffered poor appetite for three days just before she presented at the hospital. Nutrients including proteins and vitamins are essential for general body development. According to Posthauer (2009) healthy skin requires proteins to repair worn and dead cells and synthesize new tissues. Vitamins, especially vitamin C is vital the general skin growth. Poor appetite implies poor nutrient supplement to the body which weakens the skin making it vulnerable to pressure injuries (Mortenson, Miller and Team, 2009). Suitable prevention plan for the pressure injury client. The pressure injury prevention plan for the patient will involve developing a nutritional care plan for the patient (Watterson, Fraser, Banks, Isenring, Miller, Silvester, Hoevenaars Bauer, Vivanti, and Ferguson, 2009). This relates to providing and encouraging the patient to intake more fluids on a daily basis and administering intravenous fluids to mitigate dehydration. Fluids function as solvents for minerals, vitamins, and glucose and transport these nutrients to the skin where they used to synthesize and develop the skin tissues and cells. We will also provide the patient with mineral and vitamin supplements because her dietary intake is considerably poor. The client’s skin will have enough nutrients, rejuvenate and mitigate incidents of pressure injury. Besides, a healthy diet will keep skin healthy and improve its ability to resist breakdown due unrelieved pressure. Furthermore, improved nutrition will improve healing of the wound that resulted from the pressure injury The plan will also involve regular repositioning of the client to minimize the magnitude and duration of pressure over the areas of the body vulnerable to pressure injury. To accomplish effective repositioning, we will establish schedules of pressure relief to specify the duration and frequency of weight shifts. We will frequently assess the client’s general comfort and skin condition to determine whether she is responding to the repositioning strategy according to the expectation. This will also help us to identify early symptoms of the patient’s pressure damage and her tolerance of the suggested repositioning schedule. In our prevention plan, we will reposition the client in a way that will redistribute and relieve pressure and this will help to protect the vulnerable areas (Moore, and Cowman, 2009). In addition, the prevention plan will include maintaining the patient’s skin as dry and clean at all times as possible (O’Meara, Al-Kurdi, and Ovington, 2010). This will accomplished by ensuring that the beddings are dry and getting rid of any damp clothing around the patient. We will also provide moisturizing lotion to the patient to help prevent her skin from cracking and drying out. Besides, we will provide a warm shower and mild cleansing soap to the patient during admission and ask her to dry her skin gently to avoid damaging her skin further. Besides, the plan will entail restricting the patient from smoking during the period of hospitalization. This will ensure dilation of the blood vessels and consequently increase blood flow to the skin. Adequate supply of nutrients will speed up restoration and revitalization of the client’s skin and hence prevent future pressure injuries. Argument based on conflicting views in the literature survey. One conflicting issue occurred during the survey on literature to analyze the underlying pathogenesis of pressure injuries. Reger; Ranganathan; Orsted; Ohura, and Gefen (2010) are of the view that, pressure injury is caused by unrelieved pressure, friction and shear forces. In their insight to the principal causes of pressure injury, they remarked that, persistent pressure presses the blood vessels limiting blood flow and consequently nutrients from reaching the skin. They also noted that, repeated rubbing between the surface and the body causes friction which results to pressure injuries. However, Wounds International, International Review (2010) report that pressure injury is associated with microclimate which includes moisture. According to Wounds International, International Review, skin which has been exposed to moist environment due to incontinence or drainage is vulnerable to pressure injury. Though, according to Mortenson, Miller and Team (2009), pressure injury mainly befalls individuals due to mechanical factors. The mechanical factors include unrelieved pressure, shear and friction forces, which are also seconded by Reger; Ranganathan; Orsted; Ohura, and Gefen (2010). Besides, the client, Ms. Ritter declines having vaginal discharge and incontinence yet she has suffered pressure injury. Therefore, the allegation that moisture triggers pressure injury in this scenario is controversial and is subject to further investigation. It thus follows that, unrelieved pressure, friction, and shear forces between the skin and surfaces are the principal factors causing pressure injuries. Appropriate education for the pressure injury patient. The client has suffered a pressure injury and she requires acquisition of relevant and appropriate knowledge to help her avoid future infections. The information is also essential to facilitate quick recovery and healing of the injuries and the associated wounds. Advice the client to eat a balanced diet reach in sources of vitamins and minerals. Vitamins E and C essential in healing of the wound resulting from pressure injuries (Posthauer, 2006). The patient should therefore include adequate vegetables, fruits, cereals and wholegrain breads in her diet. The diet should also include plenty of proteins which are essential for the synthesis and repair of the skin cells and tissues. In addition, the client is advised to intake more carbohydrates rich in fiber and sufficient calories to facilitate pressure reliefs and her repositioning (Benbow, 2009). Encourage the patient to reposition herself flat or in a 30° or 35° side-lying position when sleeping. The client is also advised to limit her sitting sessions to three times a day over a period not exceeding 60 minutes. This will redistribute and relieve pressure and help to protect the areas vulnerable to pressure injury (Moore, and Cowman, 2009). In addition, advice the client keep her skin dry and clean and use a pH balanced cleaner to clean her skin. It is also recommended for the patient to avoid body massage and vigorous rubbing of the skin. According to Keast, (2010) massaging of the pressure injury patient can be painful and might cause destruction of mild tissues and induce inflammatory reactions. The patient should also use a skin moisturizer to keep her hydrated and dry skin. This helps mitigate the risk of skin destruction (O’Meara, Al-Kurdi, and Ovington, 2010). Besides, educate the client how to perform pressure reliefs and other exercises of pressure relieving. The information on pressure reliefs must be provided to the client’s caregiver to appropriately care for the patient when she leaves hospital. Furthermore, the patient is advised to check her skin regularly and note any changes like redness of which she will immediately report her clinician to prevent development of pressure injury. Moreover, advice the overweight client to engage in routine exercises and change her diet in order cut down the weight. Overweight and obesity promotes immobility which is the main cause of pressure injuries since it hinders pressure reliefs. Obesity is also associated with large fat deposits beneath the skin which inhibits oxygen supply to the skin tissues. Finally, encourage the patient to consider abandoning smoking. Smoking constricts blood vessels and prevent sufficient supply of oxygen and nutrients to skin cells and tissues. Quitting the habit will however dilate the vessels and restore blood flow the skin (Shahin, Dassen and Halfens, 2009). Inter-professional collaboration required to prevent pressure injury in the client. The inter-professional committee required to prevent pressure injury in the patient included the following professionals. An experienced dietitian to recommend and advice on the best diet for the patient. The other professionals included; a physician to examine the patient, nurse to care for the bedridden patient, pharmacist to provide the indicated medication, a physiatrist, wound care clinician and a physical therapist. Conclusion. Pressure injury is prevalent in most individuals in the society but often go unnoticed since some patients consider it as normal lesions or blisters. However, pressure injury may become painful and even lead to death in chronic and severe cases due blood poisoning and bone infections. Table 1. Summary of the key points from references. Moore, Z. and Cowman, S. (2009). Kottner, J.; Dassen, T. and Tannen, A. (2009) Watterson, C.; Fraser, A.; Banks, M (2009) Wound Ostomy and Continence Nurses Society (2010) Mortenson W, Miller W & Team. S. (2009). Study aim Determine best treatment and prevention of pressure ulcers. Evaluation of the Water flow pressure ulcer risk assessment tool Determine the role of nutrition in wound cycle Guidelines for the treatment and treatment of pressure ulcers Assessing risks for developing pressure ulcers in patients. Method Actual treatment Experimental analysis Evidence from treatment Experimental analysis Interviews and treatment. Study sample Repositioning involved 60. Samples of 100 patients were analyzed using the tool. Vitamin C & D supplements were given to 76 patients. 4 smokers were advised to abandon the habit 33 patients aged between 62 and 90 years were interrogated. One key point Repositioning, balance diet and taking care of the skin were considered. The tool proved to provide true and reliable results with minimum unreliability Vitamins and proteins supplements increases the rate of healing Quitting smoking, skin care and repositioning were recommended. Aging, immobility, smoking and obesity exposed the patient to higher risks of infection References. Moore, Z. and Cowman, S. (2009). Repositioning for treating pressure ulcers. Cochrane Database of Systematic Reviews. Issue 2(CD006898). Stockton, L.; Gebhardt, K. and Clark, M., Seating and pressure ulcers: Clinical practice guidelines. J Tissue Viability, 2009. 18: p. 98-108. Wound Ostomy and Continence Nurses Society (WOCNS), Guideline for Prevention and Management of Pressure Ulcers. 2010, Mount Laurel (NJ): WOCNS. Mao C, Rivet A, Sidora T, Pasko M. (2010). Update on pressure ulcer management and deep tissue injury. Annals of Pharmacotherapy. Kottner, J.; Dassen, T. and Tannen, A. (2009), Inter- and intrarater reliability of the Waterlow pressure sore risk scale: a systematic review. International Journal of Nursing Studies, 46(3): p. 369-79. Mortenson W, Miller W & Team. S. (2009). A review of scales for assessing the risk of developing a pressure ulcer in individuals with SCI. Spinal Cord.; 46(3):168-75. Shahin ES, Dassen T & Halfens RJ. (2009) Pressure ulcer prevention in intensive care patients: guidelines and practice. J Eval Clin Pract; 15(2):370-4.71-9. O’Meara, S.; Al-Kurdi, D. and Ovington, L (2010) Antibiotics and antiseptics for venous leg ulcers. Cochrane Database of Systematic Reviews. Issue 1. Pieper, B.; Langemo, D. and Cuddigan, J., Pressure ulcer pain: a systematic literature review and national pressure ulcer advisory panel white paper. Ostomy Wound Management, 2009. 55(2): p. 16-31. Gorecki, C.; Closs, J.; Nixon, J. and Briggs, M. (2011) Patient-reported pressure ulcer pain: A mixed- methods systematic review. Journal of Pain and Symptom Management, 42(3): p. 443-59. Kottner, J.; Raeder, K.; Halfens, R. and Dassen, T. (2009), A systematic review of interrater reliability of pressure ulcer classification systems. Journal of Clinical Nursing, 18(3): p. 315-36. Fife, C.; Yankowsky, K.; Ayello, E.; Capitulo, K.; Krasner, D.; Mulder, G. and Sibbald, R. ( 2011), Legal issues in the care of pressure ulcer patients: Key concepts for healthcare providers—A consensus paper from the International Expert Wound Care Advisory Panel. Advances in Skin & Wound Care, Nov: p. 493-507. Wounds International, International Review. Pressure Ulcer Prevention: Pressure, Shear, Friction and Microclimate in Context. 2010, London: Wounds International. Watterson, C.; Fraser, A.; Banks, M.; Isenring, E.; Miller, M.; Silvester, C.; Hoevenaars, R.; Bauer, J.; Vivanti, A. and Ferguson, M. (2009), DAA Evidence Based Practice Guidelines for the Nutritional Management of Malnutrition in Adult Patients across the Continuum of Care. Nutrition and Dietetics. 66(Suppl. 3): p. S1-S34. Treatment of Pressure Ulcers: Clinical Practice Guideline. 2009, Washington DC: NPUAP. Read More