Introduction
A 72-year-old African female patient, Mrs. Timothy, will be discussed. She was admitted to the surgical unit from the accident and emergency department of the Scarborough General Hospital. Her primary complaint included a stage III pressure ulcer on the sacrum; the patient has a history of mental illness. According to her daughter, there is no clear explanation for the pressure ulcer to develop into such a terrible condition. No previous complaints and pain were well reported or noticed.
The purpose of this document is to discuss the main aspects of advanced wound care management. The objectives are to assess the patient’s condition, examine the wound, share the findings, and define the most appropriate management plan. Attention to this case is paid for several reasons: the level of the pressure ulcer’s severity and the patient’s mental condition. Pressure ulcers usually develop with time, and stage III is characterized by visible subcutaneous fat, the loss of full-thickness tissue, and further deterioration. Stages I and II are less critical, but discomfort and pain cannot be ignored.
The patient has diabetes, and her skin conditions should be regularly evaluated. Mrs. Timothy’s mental status must be considered a cause of her skin’s worsening. The patient is selected to discuss the contributing factors of stage III pressure ulcers and the most effective pharmacological and non-pharmacological interventions. The decision to admit the patient to a surgical unit indicates the necessity of an operative procedure to stabilize the client’s condition and predict the progress of other physiological complications.
Patient’s Assessment
The patient must be assessed for her chronic diseases, prescribed medications, family/social history, and other characteristics that might affect her health problems. The client is alert and oriented to her name and stimuli. Her blood pressure is 122/36, her pulse is 74, her respiration rate is 22, and her random blood sugar level is 225; no fever. The wound on her sacral area is deep and large, requiring specific treatment and cleaning.
Mrs. Timothy has a history of diabetes and takes Metformin 500 mg once a day. Diabetes neuropathy provokes bone destruction, especially in the feet of older adults (Jaul et al., 2018). Poor blood circulation due to diabetes and taking Heparin sodium (5000 units once a day) to prevent blood clots and Aspirin (325 mg) to reduce cardiovascular risks can be a reason for a pressure ulcer. Another essential element of the patient’s health is her one-year-old stroke (right-sided cerebral vascular accident or CVA) and the decision to spend much time in bed since then.
Finally, Mrs. Timothy has hypertension and takes Lopressor (50 mg), which means a low amount of oxygen is in the system, and the healing process is reduced. Her recent cholecystectomy should not have a severe impact on the growth of pressure ulcers. However, her inactivity and non-communicable diseases provoke new skin problems. Her history of mental illness might explain poor reporting on recent physiological changes.
The daughter spoke separately from the patient and had no idea when the mother developed bedsore, indicating that the patient does not have close relationships with her family members. Instead of focusing on the client’s condition and improving routine care (either professionally by a nurse or personally by herself), the family neglects the chronic conditions and health complications of an older adult. However, the patient cooperates with healthcare providers and responds to all questions and recommendations.
Wound Assessment
Numerous tools exist for evaluating wounds and their treatments, as each injury is unique, and its condition can change over time. The Waterlow Scale is a well-known assessment tool that assesses damages based on the patient’s BMI, skin condition, gender, age, mobility, medication, and nutrition (Al Aboud, 2022). However, for this case, the Pressure Ulcer Scale for Healing (PUSH) tool is more appropriate, as it focuses on measuring the progress of wound healing rather than just describing the wound’s current state.
The PUSH tool assesses three aspects of an injury: size (surface area), exudate amount, and wound tissue type. This quantitative approach simplifies tracking changes in the healing process (Nguyen et al., 2023). A holistic approach to wound care should consider the patient’s social context.
Using the PUSH tool for wound assessment (see Figure 1 and Figure 2) helps determine the severity of the wound. A stage III pressure ulcer penetrates deep into the skin, creating a small crater with subcutaneous damage, visible fat, and sensitive tissues (Jaul et al., 2018). A significant portion of skin is missing, revealing the extent of the injury. The skin around the wound appears dry, with multiple instances of eczema and excoriation (Gil, 2020).
While maceration is absent, the wound exhibits bleeding and causes pain during palpation. It is crucial to monitor non-blanching erythema, skin texture, pressure-induced damage, and the surrounding skin (Borojeny et al., 2020). Regular evaluation and pain management are necessary to prevent complications like excessive bleeding (Al Aboud, 2022). By employing the PUSH tool for wound assessment, healthcare providers can more effectively tailor the dressing and wound care plan to facilitate healing.
Wound Management Plan
Interventions to treat pressure ulcers on the sacrum vary. Still, they all have to be systematic and regular to predict the deterioration of the condition or the growth of the damaged area. Pharmacological and non-pharmacological steps must be taken appropriately to support the patient, relieve pain, and restore skin damage. The patient is diabetic and hypertensive, and the prevalence of pressure ulcers in these people is twice as much as that in people without diabetes (Borojeny et al., 2020). Thus, it is essential to continue taking medications, such as Metformin 500 mg, Lopressor 50 mg, and Heparin 5000 units.
A safe and cozy environment stabilizes the patient’s condition and reduces pain. Ventilation on room air is obligatory, and skin assessment is done at least once daily. In most cases, repositioning for patients should be done every six hours, but people at high risk need this procedure every four hours to predict the development of new pressure ulcers (Marshall et al., 2019). The decision to check and reposition Mrs. Timothy every four hours is made to avoid missing a change and follow the required time limitations.
The main reason for the progress of ulcers is prolonged pressure and friction between human bones and the bed surface. The patient is placed on a ripple mattress to reduce pressure on the skin, predict capillaries closing, and prevent new ulcers (Shi et al., 2021). Pampers are used for elimination purposes to predict the damage of new tissues and maintain their simple replacement.
To avoid complications, the proximity of the wound should be considered because the ulcer is in the center of the elimination area. A clean area around the wound has to be created to ensure no additional bacteria or infection can develop on the patient’s body. TED (compression) stockings improve blood flow in the legs, which is critical for a patient with a history of CAD and hypertension.
It is essential to address all contributing factors in the patient’s case. In addition to supporting surfaces, nutritional supplement use is critical to provide the patient with vitamins, including vitamins A, C, E, and zinc. A nasogastric feeding tube with a kangaroo pump is a standard care element for surgical patients. It provides them with fluids and nutrition, allows them to control adequate food, and predicts intestinal obstruction. The patient is expected to get the necessary supplements and not disturb the cleaning agent or the position of the dressing.
With common non-pharmacological elements, pressure ulcer management is based on choosing an appropriate dressing type and defining its change schedule. A treatment plan includes the removal of devitalized tissues with high risks of bacterial contamination (Al Aboud, 2022). Wound dressing with hydrogels (like L-Mesitran) and saline gauze promotes tissue granulation and supports healing (Geng et al., 2020).
Mrs. Timothy receives a clean and intact dressing to the sacral region. Hydrocolloid dressing is made from combined absorbent material (pectin, gelatin, and carboxymethyl cellulose) to be changed within 3-7 days (Nguyen et al., 2023). It is a secondary dressing to the primary intervention with alginate dressing (calcium and sodium derivatives) that predicts cell death (Al Aboud, 2022). The required timeframe to change this type of dressing is between 2-4 days; thus, a current dressing change for the patient should be every fourth day.
In most cases, hydrogen peroxide is a common cleaning agent for patients with stage I or II wounds. Mrs. Timothy is prescribed acetic acid diluted in normal saline. After all damaged tissues are removed, a gauze with L-Mesitran cream is applied to rehydrate dry tissues and improve antibacterial properties. This foam introduces medical-grade honey to promote wound care formulation in a moist environment that stimulates healing faster than in dry environments (Mthanti et al., 2022). In diabetic patients with severe pressure ulcers, wound healing with L-Mesitran is observed on day 23 (Mthanti et al., 2022). The severity of Mrs. Timothy’s wound can explain the delay in healing, but positive outcomes will be observed.
The primary goal of a treatment plan is to prevent further pressure injury. Additional objectives for a wound caregiver include improving the patient’s nutritional status, proper bed placement, and changing frequency. If possible, the patient must be out of bed to change, not to allow new ulcers to emerge. A prolonged hospital stay may be associated with increased healthcare costs, but it is necessary not to miss a new complication (Al Aboud, 2022).
It is recommended for a nurse to educate the patient and her family about the complexity of pressure ulcers, especially in diabetic patients. The patient should be informed about self-management, healthy diets, and physical activity to predict pressure ulcer development risks. At this moment, regular examinations are recommended for this patient to ensure the success of the healing process.
Conclusion
Developing a dressing care plan is crucial in nursing care, as it impacts the patient’s well-being and ability to manage discomfort. My positive experience designing such programs stems from my interest in providing optimal patient environments and promoting informative communication. The patient requires additional care to treat the pressure ulcer and anticipate complications.
Although understanding the development of a stage III wound is challenging, my focus is on helping, not judging. Emphasis should be placed on systematic pharmacological and non-pharmacological interventions prescribed by doctors. In the future, I aim to apply this knowledge to ensure patients receive comprehensive care through appropriate medication and collaboration.
References
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Geng, J., Cai, Y., Zhao, Y., Wang, Z., Wang, M., & Wei, Z. (2020). Dressing interventions to heal pressure ulcers. Medicine, 99(41). Web.
Gil, S. B. (2020). Implementing the triangle of wound assessment framework to transform the care pathway for diabetic foot ulcers. Journal of Wound Care, 29(6), 363-369. Web.
Jaul, E., Barron, J., Rosenzweig, J. P., & Menczel, J. (2018). An overview of co-morbidities and the development of pressure ulcers among older adults. BMC Geriatrics, 305. Web.
Marshall, C., Shore, J., Arber, M., Cikalo, M., Oladapo, T., Peel, A., McCool, R., & Jenks, M. (2019). Mepilex border sacrum and heel dressings for the prevention of pressure ulcers: A NICE medical technology guidance. Applied Health Economics and Health Policy, 17, 453-465. Web.
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Nguyen, H. M., Le, T. T. N., Nguyen, A. T., Le, H. N. T., & Pham, T. T. (2023). Biomedical materials for wound dressing: Recent advances and applications. RSC Advances, 13(8), 5509-5528. Web.
Shi, C., Dumville, J. C., Cullum, N., Rhodes, S., Jammali-Blasi, A., Ramsden, V., & McInnes, E. (2021). Beds, overlays and mattresses for treating pressure ulcers. Cochrane Database of Systematic Reviews, 2021(5). Web.