Pressure ulcers are understood as a localised injury caused due to unrelieved pressure over a bony prominence. A person aged 65 years in a nursing home is found as suffering from the initial stage of pressure ulcer, which has threaten his overall well-being and development. Any kind of unrelieved pressure applied with great force for a short period of time on a body part that disrupts or affects the blood supply or blood flow thereby depriving tissues of oxygen and nutrients. This unrelieved pressure should be greater than arterial capillary pressure that impedes the blood flow and tissue damage. There are internal as well as external causes of pressure ulcers, internal causes include limited mobility due to pain, fractures, spinal cord injury, neurologic disorders, and any kind of postsurgical procedures. External factors include poor nutrition, dehydration, dietary reduction, poverty or lack of access to food, depression, dementia, loss of elasticity, decreased blood flow, etc are some common causes or risk factors of pressure ulcers (Andersen and Taylor, 2017).
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There are four stages of pressure ulcers, and, the patient is suffering from second stage of it. First stage is the initial phase where skin looks red and feels warm to the touch. The skin part gets quite itchy. In second stage, a painful open sore or blister get occur results in discolouring of the skin.
Comprehensive description of client needs
Health care needs:
It includes patient repositioning schedule where head of the bed should be kept at the lowest safe elevation in order to prevent shear. An established pressure ulcer requires complete and detailed medical evaluation of the patient in order to get to know the onset and duration of ulcers, previous wound care, risk factors, wide array health problems and medications. Apart from physical health, behavioural, psychological health and cognitive status is also assessed and evaluated. Patient needs psychological and behavioural assistance in the initial assessment. The presence of pressure ulcer on a patient’s body indicates that patient does not have adequate access to support and services. There is need of more intensive support services, or else, caregivers should be provided with more training and assistance in lifting and turning the patients (Craft-Rosenberg and Pehler, 2014).
Hygiene and skin care: Proper skin care plays crucial role where daily inspection of skin is recommended. Skin care includes washing with gentle nature cleansing products, using emollients on skin, and avoiding use of any kind of adhesive products on skin. The patient also needs to ensure that skin is properly hydrated and nutrition in order to avoid any kind of skin infection (Nursing Times, 2013).
Eating and drinking: Poor diet is found as major reason increasing intensity of pressure ulcers, especially diet with lack of protein, vitamin C and zinc. It is necessary to maintain good nutrition for enhancing overall health and improving speed of wound healing and recovery. People are advised to take diet with enough fluids, calories, protein, vitamins and minerals in order to develop and maintain healthy skin, and, reducing any kind of breakdown of tissues. Dietary deficiencies can increase chances of health problems such as diabetes and vascular diseases, which, in turn, results in tissue damage (Mooney, Knox and Schacht, 2012).
Mobility and toileting: An individualised bathing schedule with warm water and mild soap is suggested. It is asked to avoid any kind of massage over bony prominences and lubricants over genitals. With respect to mobility, it is asked to provide appropriate support surface to the patient, the body should be repositioned in every two hours in bed. In case of sitting in a chair, reposition should be done in every hour, and, using pillows between legs for side lying. The patient should be moved in every 15 minutes in case of wheelchair and in every 2 hours in case of people in bed. As a part of it, physical exercises, even in bed with some assistance are also suggested as it improves blood circulation (Mason, Gardner, Outlaw and O'Grady, 2015).
In any of mobility, friction and shear is strictly asked to be reduced. Friction is a kind of mechanical force used in case skin is dragged against a coarse surface while any kind of interplay of gravity and friction give rise to mechanical force. Friction and shear is asked to be avoided as it exerts a kind of force parallel to the skin resulting in the stretching of blood vessels (Siegel, 2019).
Assessment tools: Pain assessment is done which is used as a clinical indicator of infection. A validated scale indicating type/cause and rating of pain is assessed. Along with it, additional assessment tools include duplex imaging, measuring oxygen pressure, distal pulses, colour changes, pulse volume recording, brachial index, etc (Luce and Elixhauser, 2012).
Identification of assistance
It is concerned with the daily interventions and assistance should be provided to the client including underlying points:
i) Assistance with the daily living activities: Repositioning is the most evident requirement of a patient suffering from pressure ulcer. In this case, nursing staff members are asked to turn and change the position often. They should take care of the times patient expect repositioning, and, quality of the surface they are lying on. This crucial condition requires high level assistance from nursing staff and other personnel in order to move or reposition easily. There is no definite schedule of patient repositioning; it needs to be determined empirically. The information circulated by the Agency for Health Care Policy and Research stated that patients who are bedridden should be moved in every two hours. In order to minimise shear, it is asked that head of the bed should not be highly elevated, the limit set is 30 degrees; lower degree of elevation is recommended to prevent other kinds of medical complications (Thomas, 2013).
ii) Maintaining a safe environment: It includes removing the pressure from the sore by assisting patient in using foam pads or any other thing to life the body parts. Secondly, it is also necessary that minor nature wounds should also be gently washed with water and mild soap. In order to maintain cleanliness and hygiene, saline solution should be used each time whenever dressing is changed. Safety also requires removing dead tissue for healing the wound, and, applies dressing for preventing infection. Oral antibiotics or antibiotic cream is also useful for treating an infection (Healey and Evans, 2015).
iii) Communication needs: It includes providing, sharing or exchanging adequate nature information with the patient or relatives. The status of complete medical evaluation of patient, comprehensive history regarding onset and duration of ulcers, wound frequency, risk factors and other health problems and medications. The caregivers should also communicate status of psychological health, behavioural and cognitive status, and, adequacy of social and financial resources for arriving at the best possible treatment plans and medications (Walsh, 2014).
With the help of strong and effective communication, one might get to know or assess whether patient is having adequate access to required services or support. It also helps in knowing whether patient need more intensive support services, or else caregivers should be given with more training for lifting and turning the patient. Patients having communication problems or sensory disorders are highly vulnerable to pressure ulcers as they feel highly discomfort in expressing opinions and views (Black, 2016).
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iv) Required mechanical aids: Patient should be provided with pressure-reducing devices for relieving pressure. There are static and dynamic nature devices, both should be provided to patient for managing pressure. Static devices are foam, water, get and air mattresses, while dynamic nature devices are low-air loss and air fluidized surfaces, patient should be provided with enough guidance to use static and dynamic nature devices. There are also other pressure reducing devices such as chair, cushions, pillows, foam wedges, and materials used for placing between the knees for relieving heel pressure (Bonewit-West, 2015).
Clear recommendations to better meet client’s needs
The recommendations are concerned with suggesting care practices or care measures to supervisor/nurse in charge to prevent development of pressure sores. These care practices are:
a) Mechanical loading:
The first recommended care practice is to decrease or reduce mechanical load by assisting of helping patients to adequately turn or reposition. If patient is facing difficulty in turning or repositioning themselves, it would lead to ulcer development. The nurses and care practitioners are under the duty to help patients to reduce the mechanical load. It requires assisting patients in frequent training and repositioning of patients. There is very little research or evidence based research studies available regarding optimal training schedules. The landmark research study indicates that nurses should follow the golden standard of turning patient in at least every 2 hours. Some research studies also indicate that critically ill patients should be more turned or repositioned more often (DeLaune and Ladner, 2016).
b) Support surfaces:
An important consideration in nursing care practice is based on effective and optimum use of support services for pressure redistribution. It is not possible to remove all pressure for a patient, if nurse or health care practitioner is reducing pressure on one body part, it will automatically result in increased pressure on the other body part. The main purpose is to obtain the best pressure redistribution possible. For redistributing pressure, it is said that use of support surfaces is an effective solution. Through effectively using support services, nurses can reduce the incidence of pressure ulcers. There is adequate evidence showing that specially designed support services help in preventing the development of pressure ulcers. But, poor methodological design of support surfaces did not contribute in redistribution of pressure (Dossey and Keegan, 2011).
Nutritional assessment at timely and regular intervals is necessary for patients who are at risk of developing pressure ulcers. Current dietary protein level is also necessary to be assessed and monitored in this process. The protein-calorie malnutrition is highly associated with pressure ulcer development. Any individual who is undernourished pose high risk and likelihood of developing a pressure ulcer. Nutritional supplements are beneficial in lowering the risk of development of pressure ulcers. Empirical evidence suggests that use of vitamin and mineral supplements along with standard hospital diet is beneficial in preventing pressure ulcers. Therefore, patients are suggested to take regular diet of protein, vitamins and minerals for effectively intervening and reducing nutritional deficiencies and maintaining optimal nutrition in a patient’s body as a part of best practice (Elder, Evans and Nizette, 2016).
Whenever a pressure ulcer develops, respective individual or his relatives should immediately approach and contact health care team in order to treat and close the ulcer as quickly as possible. Timely reporting also enables nursing team in reducing possibilities of further ulcer deterioration, keeping the infected place clean, moisture balance, and, further development of infections, and, most importantly, keeping the patient free from every kind of pain. It is said that weekly assessment and timely reporting helps in identifying staging of pressure ulcers which leads to earlier detection of wound infections and developing sound parameter for wound healing (Gilbert, Sawyer and McNeill, 2014).
Evidence of reflection/ Conclusion
The study outlined several critical facts regarding pressure ulcers, its characteristics, extent of tissue damage and best practices to cure and treat it. In this process, it is highly important and crucial to know and assess the appropriate stage of ulcers in determining optimum management and planning intervention plan. The study showed that when a ulcer develops, it is necessary to determine its location, size, colour of the wound, amount, odour, nature and frequency of the pain (Groome, 2013).
The study also acknowledged the fact that managerial bacterial burden is an important consideration in managing pressure ulcer care. The formation and development of pressure ulcer contains several harmful nature bacteria. The bacterial contamination in pressure ulcer should not impair health. Healing is essential in case where wounds have high levels of bacteria. The occurrence of spontaneous bacteria can be controlled and minimised with timely and effective healing. The increasing pain and breakdowns are adequate indicators of seeking additional treatments for the patients in order to safeguard them from further ulcer complications (Gulanick and Myers, 2014). Much progress is being made in the field of identifying pressure ulcers and patients at risk of developing it. For this, it is necessary to consistently develop advanced therapies for pressure ulcer prevention and its treatment for reducing possibilities of occurrence of ulcers and preventing or treating it timely.
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