This essay will discuss my experience of wound management, while working alongside my mentor on a rehabilitation unit, for a 72-year-old patient who was admitted to the unit for the management of a Grade 3 sacral sinus pressure ulcer. The patient has multiple sclerosis (MS) and is wheelchair bound. In accordance with the Nursing and Midwifery Council (2008) Guidelines on Confidentiality, I will refer to the patient as Ben.
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Aetiology of pressure ulcers is complex and caused by many factors but mainly a combination of unrelieved pressure, shear and friction; or pressure combined with the effects of other intrinsic elements which include disease, medication, malnourishment, age, dehydration/fluid status, lack of mobility, incontinence, skin condition, weight; and extrinsic variables, external influences which cause skin distortion like pressure, shearing forces, friction, moisture (Niezgoda and Mendez-Eastman 2006).
Pressure ulcers occur most commonly to bony or cartilaginous regions such as the sacrum, heels, etc. Pressure ulcers cause pain and discomfort and affect quality of life. Although easily preventable through regular relief of the pressure on areas of the body at risk of developing pressure ulcers, they are one of the leading iatrogenic causes of death, second only to adverse drug reactions (NICE 2005). The costs of pressure sore development can be counted in both monetary terms and in terms of distress caused to the patient (Brem et al 2004).
Pathophysiological abnormalities that may predispose the formation of pressure sores include compromised tissue perfusion as a consequence of impaired arterial supply (peripheral vascular disease) or impaired venous drainage (venous hypertension) and metabolic diseases such as diabetes mellitus (NICE 2005).
Pressure ulcers develop when persisting pressure on a bony site obstructs healthy capillary flow and blood cannot circulate, causing a lack of oxygen and nutrients to the tissue cells, leading to tissue necrosis. In addition, the lymphatic system cannot function properly to remove waste products. The pressure ulcer can range from a very mild pink coloration of the skin, which disappears in a few hours after pressure is relieved on the area, to a very deep wound extending to and sometimes through internal organs and into bone (Gunnewicht and Dunford 2004).
Grade 3 pressure ulcers develop to full thickness wounds involving necrosis of the epidermis/dermis and extend into the subcutaneous tissues. All epidermal appendages are destroyed (Gunnewicht and Dunford 2004). The NICE (2005) guidelines for the management of pressure ulcers suggest the treatment priority is the prevention or reduction of the pressure leading or contributing to skin damage.
Flanagan (2000) states that age, reduced mobility, malnutrition, incontinence, skin integrity, friction, moisture, and pain can lead to skin breakdown and ulcers developing and prolong wound healing. On admission Ben’s pressure sore risk factors were assessed to plan his nursing care and wound management by the multidisciplinary team.
Ben’s wound had caused extensive destruction of his tissues and damage to his muscle and supporting structures. On examination, there was a large necrotic plaque and ulceration on the right buttock 11cm by 12cm. The wound was malodorous; a swab was taken and reports confirmed that his wound was infected with (Methicillin-resistant Staphylococcus aureus) MRSA.
Other risk factors noted from his medical history which increase the risk of pressure ulcer development, included rheumatoid arthritis and ischaemic heart disease. His medication regime also includes methotrexate and prednisolone, both known to have an inhibitory effect on wound healing (NICE 2005). The treatment aims therefore were to review his medication related to rheumatoid arthritis and the possible factors compromising wound healing such as nutritional status, pressure relief, reducing bacterial load, sustaining skin integrity and providing skin closure.
Initial laboratory investigations requested by the medical team included a complete blood cell count to rule out underlying haematological disorders, erythrocyte sedimentation rate (which is elevated in patients with many diseases including connective tissue diseases and associated vasculitic ulcers, and infectious processes), and a fasting blood glucose test. Serum albumin and transferrin levels are very helpful in assessing the nutritional status in elderly patients (NICE 2005, Perkins 2000).
Ben’s cardiovascular and respiratory observations were taken regularly and were stable, although he did have mild pyrexia. He had a supra pubic catheter, his urine output was monitored on regular basis, and catheter care was given daily to minimize the risk of infection and monitor the tissue viability of the site. Ben’s bowel motion was also assessed and care taken that the wound would not be contaminated by providing full personal hygiene care.
The aim of wound management in this instance was infection control through strict hand washing policy and aseptic technique. A vascular surgeon performed staged sharp removal of necrotic tissue to reduce bacterial load and wound dressings with an antimicrobial agent were utilized. Necrotic tissue can prevent wound contraction and inhibit healing. Ben was also prescribed a course of IV antibiotics for systemic control of the infection (Gunnewicht and Dunford 2004).
To aid continuity of care (NICE 2005), a local wound assessment chart was used for documenting the management of the wound and it was updated every time the wound was redressed. All changes and appearance of the wound were noted down in the chart, according to the wound assessment guidelines (NICE 2005). On assessment of his wound on admission, my mentor identified that the wound was not being managed with the appropriate dressing and the integrity of the skin surrounding his wound was at risk. It was also distressing for Ben because he could “smell” his wound.
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According to Ennis and Weness (2000), excess of exudates within the wound can also inhibit healing. Control of exudates is therefore essential. This is usually achieved by selecting a dressing of the appropriate absorbency. An Aquacell “Silvercel” dressing was selected for Ben’s wound because the British National Formulary (BMA & RPS 2009) suggests it is an appropriate dressing for moderate to heavily exuding wounds, and the hydrocolloid facilitates autolytic debridement in necrotic wounds and is suitable for promoting granulation. Silver is recommended for infected wounds and promotes the reduction of the bacterial load (BMA & RPS 2009).
Gunnewicht and Dunford (2004) suggest that if the wound is clean, healthy and granulating it does not require cleaning because the wound exudate itself has beneficial bactericidal properties, which may be inappropriately removed. The general strategy of my mentor in the cleansing of Ben’s wound was based on providing minimal necessary intervention. She was using normal saline to clean the wound. Griffiths et al (2001) stated that the solution should be of a non-irritant and free of bacteria. Normal saline is the most commonly used wound cleaner and it is best to use the solution at body temperature (Ennis and Weness 2000).
Ben’s ulcer had been developing over several months. Due to the progression of the MS he is unable to change his position himself while in his wheelchair, and due to his increasing immobility has increasing dependence on his carers to manage pressure relief as well as the other activities of daily living such as his nutritional needs.
Ben is therefore particularly prone to pressure ulcers. The clinical guidelines (NICE 2003) state that this patient should receive pressure relieving support surfaces such as pressure mattress and should be actively mobilized, with close observation of skin changes and a documented positioning and repositioning regime. Skin injury due to friction and shear forces should be minimized through correct positioning, transferring and repositioning techniques (NICE 2003). Patients should be repositioned every two hours when bed-bound and wheelchair bound patients need to shift their weight every 15 minutes if possible by self adjusting or reclining (NICE 2003).
Pressure ulcers are often slow to heal, and there is a plethora of research which states that nutrition plays a crucial role in wound healing. On admission we identified that Ben’s nutritional status was compromised. A daily food chart was used to document Ben’s intake. Ben was referred to the dietician to help plan interventions to improve Ben’s nutritional status. This was to provide a pureed diet high in protein, nutritional multivitamin and zinc supplements were prescribed and the supervision of his meal times planned, to aid optimum recovery and wound healing (Perkins 2000).
Williams and Leaper (2000) state that B complex vitamins are co-factors or co-enzymes in a number of metabolic functions involved in wound healing, particularly in the energy release from carbohydrates. Fats and vitamins have a key role in cell membrane structure and function, certain fatty acids are essential as they cannot be synthesized in sufficient amounts, so must be provided by diet.
Minerals like zinc, iron and copper play a vital role in wound healing. For example zinc is required for protein synthesis and also has an inhibitory effect on bacterial growth (Williams and Leaper 2000).
Ben’s wound management involved assessment of his pain which was done before and after analgesia was given. Pain is often significant and disabling for those with pressure ulcers. Paracetamol may be sufficient, but patients often require stronger analgesia especially when the wound is redressed. Non-steroidal anti-inflammatory drugs may increase peripheral oedema and are inappropriate for patients with pressure ulcers (NICE 2001).
Collier and Hollinworth (2000) suggest information should be provided so that patients can improve their knowledge and skills in the prevention and management of pressure sores. My mentor and I were spending time with Ben, providing support and reassurance and educating him about the process of his wound healing and the importance of medication, nursing interventions and nutrition. According to an article in Quality and Safety in Health Care (2008) communication looks easy when it is done well. It requires engagement, empathy, an ability to listen and respond, and it requires time. Calne (1999) suggested that it is the simplest measures of pressure relief that are often the most effective or have the most impact but guidelines should not replace clinical judgement and individualized patient care.
In conclusion, I feel that wound care requires a broad spectrum of evidence based knowledge and skills, and a collaborative multidisciplinary approach to wound care management. Caring for Ben’s provided me the opportunity to improve my knowledge, understanding and confidence about wound management in clinical practice.
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