Infected Stage Four Pressure Ulcer
Patient Mrs P
95 year old female, living in residential care, widowed, nil family members living in Auckland.
Presents: febrile, severely malnourished, increased pain during mobility, offensive discharge of sacral pressure ulcer.
Was being treated in community for pressure ulcer, but has increased in size and offensive smelling.
Investigations preformed: wound swabs, blood tests, wound assessment, skin assessment, nutritional status, and glasgow coma scale.
Investigations found infection localised at wound site
Surgical debridement was preformed to remove necrotic tissue and slough to create a wound bed that would promote best healing environment
Signs and Symptoms: T= Necrotic tissue + slough present. I= both inflammation and infection present (shown through offensive smell, febrile, redness of surrounding skin, increased pain). M= Copious yellow exudate. E= Red raised edges of wound.
Nursing interventions:
Regular two hourly turns in combination with alternating pressure mattress: to remove the underlying cause of injury to therefore reduce risk of further deterioration.
Keep surrounding skin dry and clean: moist environment increases risk of skin break down and infection.
Provide nutritional support: protein and calorie intake is essential in promoting good wound healing. It also reduces her risk of mortality as she is more equipped to fight infection.
Keep head as low as possible in order to reduce risk of shearing.
Keep sheets dry and wrinkle free
Maintain observations: to monitor signs of deterioration, therefore preventative actions can be put in place sooner for better results.
Regular analgesia as charted by pain nurse and doctor.
Daily wound dressings: moist wound environment to aid in healthy tissue granulation
Risk factors
Age
Pathophysiology
Age-related physiology
Dementia: Mrs P has sever dementia affecting her ability to obtain adequate nutritional supplies, mobilise and acknowledge when she needs to re-position herself resulting in an increased risk of pressure ulcer onset.
Malnourished: being underweight is a risk of pressure ulcer onset and risk of infections.
Mrs P, is also bed-ridden due to her co-morbidities therefore increasing her risk of pressure are onset as she experiences sustained pressure in localised areas of her skin.
Medical history
Osteoarthritis: bilateral hip and knees replacements (2014)
Osteoporosis
Transcient ischemic attack (2016)
Atrial fibrillation
Recurrent falls
Severe cognitive impairment: Dementia
Syncope: sudden loss of consciousness (2018)
Due to the changes to skin associated with aging Mrs P is at a increased risk as her skin has undergone both intrinsic and extrinsic changes. Resulting in her being more susceptible.
Cognitive impairment associated with age has also increased her risk of pressure injury onset.
Reduced mobility to age-related co-morbidities have also resulted in Mrs Ps vulnerability to pressure ulcer onset.
Sustained pressure to a localised area of skin, usually over a bony prominence, causing localised injury to skin.
Unless the sustained pressure is removed the wound gets increasingly bigger both in depth and width.
Prolonged pressure obstructs the blood flow, resulting in hypoxic tissue damage and reduced perfusion
Sustained obstructed blood flow results in tissue ischemia and necrosis.
Necrosis advances to the surface resulting in an ulceration
The ulceration creates a breakage in the skin, where the skin has lost its barrier function, therefore the wound becomes colonised with bacteria
If not monitored localised wound infection can occur and if not treated appropriately, systemic infection can occur resulting in possible multi-organ failure, sepsis and mortality