Wound Care Case Study Examples

Wound Care Essay
This essay will focus on a chosen client and how, as a registered nurse, evidenced based practice was implemented to prevent the development of a pressure ulcer, as indicated by National Institute of Clinical Excellence NICE (2005) and European Pressure Ulcer Advisory Panel EPUAP (2009). Important and marked changes have taken place over the last 15years in the development of clinical practice guidance. As Van Zelm et al (2006) noted, the demand for evidence based practice, to determine the effectiveness of healthcare interventions, has seen a move away from consensus of opinion.

The author undertook online literature searches for journals held by Medline, Ovid, Cinahl and the Cochrane databases.
Keywords used to facilitate the search were pressure ulcer prevention, pressure ulcer guidelines, pressure sores, wound care, turning, shearing, and assessment, hospital acquired, either independently or in combination. To reduce the literature to workable limits, the author excluded non English language studies, studies over 20 years old and used the literature abstracts to reduce the numbers further and identify relevant articles.

Gebhardt (2002a) identified pressure ulcers as localised, acute ischemic damage to any tissue caused by the application of external force (either shear, compression, or a combination of the two). More recently the European Pressure Ulcer Advisory Panel EPUAP and National Pressure Ulcer Advisory Panel NPUAP (2009) have added their own definitions which have become widely accepted. The EPUAP defines a pressure ulcer as “...an area of localised damage to the skin and underlying tissue caused by pressure, shear, friction, and/or a combination of these.” According to the NPUAP a pressure ulcer is “...localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.” Kottner et al (2009) puts forward the point that “...not all pressure ulcers are pressure ulcers” as shear and friction are not universally accepted as causing pressure ulcer damage. Shear would appear to work alongside compression to cause deep tissue damage whilst friction contributes to superficial skin damage (Kotner et al, 2009).

Several areas have been identified as leading to an increased risk, to a patient, of developing a pressure ulcer; immobility, failure of reactive hyperaemia (tissues ability to recover from ischemic episodes) (Allman et al, 1995), loss of sensation (trauma, congenital or disease process) (Gebhardt, 2002a) and dry sacral skin (Allman et al, 1995; Reddy et al, 2006). Guy (2007) deemed risk factors as being separated into two areas: extrinsic factors - external to the body and can be influenced (continence, mattress type, position); intrinsic factors - within the body and often cannot be influenced (as mentioned above).

Myatt (2004) determined risk to be “the probability or likelihood that harm may occur, coupled with the consequences of that harm.” It can be seen from this single definition, that risk can play a large role in hospital life, and as such risk assessment and management has developed. Potter and Perry (2005) identified risk assessment as the “formal, systematic process in which a range of tools are used to identify an individual’s risk of developing problems.” Holistic assessments take this one stage further, underpinning, effective prevention of pressure sores (European Pressure Ulcer Advisory Panel EPUAP and National Pressure Ulcer Advisory Panel NPUAP, 2009; Guy, 2007; NICE, 2005).

The client chosen was an in-patient on a thoracic surgical ward in a large Manchester teaching hospital. Confidentiality will be maintained throughout in line with The Nursing and Midwifery Council Code of Professional Conduct (NMC, 2004); the client shall be referred to as Zach. A previous biopsy had identified a cancerous tumour in Zach’s right lung, which was to be excised, by a surgical procedure to remove one third of his upper right lung (right upper lobectomy).
Zach was an 84 year old male, with a 20 year history of non insulin dependent diabetes, with a significant weight loss within a 3 month period prior to admission, due to a loss of appetite. His mobility was restricted to walking with his Zimmer frame around his bungalow; he was unable to manage stairs or more than a few hundred metres. Zach attended pre-operative clinic, where he was seen by the Lung Specialist Nurse, for assessment. At that initial appointment, several risk assessments were undertaken, using a range of tools, including Waterlow (1988) pressure ulcer risk assessment, nutrition, manual handling and falls, medication and activities of daily living assessments. The aims being to determine, any areas of need, that would require addressing before or on admission and to ensure patient safety was maintained (NHS Institute for Innovation and Improvement, 2008)

As Zach had been to pre-op clinic, the nurse admitting him onto the ward did not need to reassess Zach. He scored high on the Waterlow (1988) pressure ulcer risk assessment tool; therefore a pressure relieving mattress and chair cushion were ordered for him. Whether using a Waterlow, Braden scale (Bergstrom et al, 1987), Norton et al (1962) or Gosnell (1989) scales, tools should not replace clinical judgement or visual skin inspection. Skin inspection and assessment should form part of healthcare staffs routine role in preventing pressure ulcers with the EPUAP/NPUAP (2009) having included guidance for staff on skin assessment. It is noted by Dealey (2009) that this underrated skill is often left to less qualified staff. Zach’s skin was briefly and superficially assessed pre-operatively, in line with the Waterlow assessment and at this point he had no wounds. Whilst many international pressure ulcer prevention guidelines recommend the use of a risk assessment tool (NICE, 2005; EPUAP& NPUAP, 2009), it has been argued, by Franks et al (2003) and Gebhardt (2002a), that there is little evidence to support the accuracy of these tools. However they have a number of advantages, “including the fact that they provide documented evidence of what was considered when the assessment was made and are a useful aide-memoir to guide the clinician in their thought processes” Gebhardt (2002c). As recently as 2008, the Cochrane Review was unable to conclude that their use reduces the incidence of pressure ulcer development; this does not mean that they have no place in assessment and prevention, only that more systematic research is required.

Zach returned the following week and was admitted to the ward, for surgery the following day. By reading and updating the relevant parts of the admission document used on the ward, the nurse implemented other strategies for preventing Zach from developing a pressure ulcer. His pressure relieving replacement bed mattress and chair cushion were in place. Whilst these aids are in wide use throughout healthcare trusts and hospitals, the Cochrane Database (2008) determined that high specification foam mattresses be used rather than standard hospital mattresses in patients at risk and that more research was necessary to determine the “merits” of pressure relieving mattresses (McInnes et al, 2008). Junkin and Gray (2009) looked at the efficacy of protection devices and were unable, from the evidence, to determine if any one surface was superior to another. Finding only that there may be an indication, that a wedge shaped, viscoelastic foam cushion had a better probability of preventing heel PU formation than a standard hospital pillow. As shown, not all pressure relieving mattresses are the same, with a wide variety available from company to company; however pressure relieving mattresses that are less than 10cm deep, once they are inflated, appear to be less effective than deeper versions (Conine et al, 1990; Sideranko et al, 1992).

The value of pressure relieving cushions for chairs is also debatable, as evidence of their effectiveness remains slim (Gebhardt, 2002c). NICE (2003) recommended that patients who were at an increased risk of pressure ulcer damage should avoid sitting in a chair for longer than two hours, at any one time; this applies, even if using a pressure relieving cushion. A sitting position means that 75% of the body’s weight is supported by a small surface area (NICE, 2003). Patients undergoing lung surgery are encouraged to get out of bed very soon after their operation to prevent complications which could impede their recovery such as infections, pneumonia, pneumothoraces. Often they are encouraged to sit in their chairs for periods of time, throughout the day, to encourage adequate chest/ lung expansion.

Zach returned from cardio-thoracic intensive care unit on his second day post-operatively, with a high thoracic epidural, a urinary catheter as well as an intercostal drain, all of which impeded his ability to alter his position.

As the ward was a surgical ward, patients often required assistance with their activities of daily living (Roper et al, 2001) following surgery. This provided Zach’s nurse with an ideal opportunity to informally assess and carry out skin inspections, on areas at risk of pressure ulcers (PU) damage; “common sites of predilection are the ischium, sacrum, trochanter and heel” EPUAP (2009). Skin inspections provide nurses with invaluable information, as pressure damage is evident prior to a break in the skin (Gebhardt, 2002b); non-blanchable erythema of intact skin, discolouration of the skin, warmth, oedema, induration or hardness may be used as indicators, being the first visible signs of pressure ulcer damage (NICE, 2005; EUAP& NPUAP, 2009; Dealey, 2009). Whilst assisting with his hygiene needs, as Zach was unable to do this himself, the author checked the skin on his buttocks, sacral area and heels, as well as elsewhere. His sacral area was visibly grazed with dry and flaking skin, and non- blanchable erythema (stage 1 PU; NICE, 2005; EUAP& NPUAP, 2009; Dealey, 2009) possibly from Zach’s attempts to shuffle his body up the bed, thus causing shear. At this point the pressure ulcer damage is reversible, if correct preventative measures are implemented (Dealey, 2009; Ankrom et al, 2005).

A portion of Zach’s pressure ulcer damage had the ability to be exacerbated by his surgical procedure, with Zach lay on a theatre operating table for four hours and this, combined with time spent immobile in anaesthetics and recovery, it can be seen this could all lead to ongoing damage. This extended period of immobility combined older age group, his diabetes with Zach’s potential for being possibly dehydrated and malnourished in order to fulfil the nil-by-mouth pre op requirements, can lead to a loss of skin integrity which does not become apparent until much later (Dealey, 2009; Shannon, 2009). Delayed manifestation of pressure damage has gained acceptance in the field of peri-operative care and is recognised by tissue viability specialists (Steinmetz 1998). Despite the implications of surgery, for the development of pressure ulcers, only the Waterlow score (1988) gives a portion of its scoring system to the length or type of surgery.

Zach informed the author that he had developed a pressure ulcer in the community six months ago; it had subsequently healed with the input of district nurses.
This information was important as previous pressure ulcers, have been shown to increase the likelihood of developing a subsequent ulcer, as the skin is already compromised and only 80% the strength of the original skin (NICE, 2005) Whilst the pressure relieving mattress had been implemented, Zach was finding it extremely difficult to move around on it. The author noted that once Zach had his legs on the bed, he was unable to reposition himself and despite direction from two nurses found it almost impossible to move around, exhausting himself in the process. The author advised Zach to position himself, with his hip, in line with the pillows before he sat on the bed. This would mean that once on the bed, there would be no need to shuffle up, on his bottom, thus helping to prevent further damage. NICE (2003) also noted that clinical judgement would be necessary in patients who became more immobile on a pressure relieving mattresses, and in Zach’s case, education in, the prevention of pressure ulcers, played an important role. The RCN (2001) Philosophy of Care advised “health professions to respect and acknowledge the experiences that the patient has had, if they have suffered from pressure ulcers in the past, incorporating what the patient already knows, with new, up to date information” Zach felt that at “his age” a sore bottom was
inevitable.

The author considered how best to plan Zach’s ongoing care and decided against the use of hydrocolloid dressings as they often have difficulty staying in place in the sacral area. Dressings even foam to the sacral area would meant Zach would have difficulty keeping the area clean, which was another reason the author deemed a moisturising and turning/ mobilising routine to be more beneficial to Zach. The product chosen was medi-honey barrier cream which helps to restore and maintain the normal ph balance of skin whilst moisturising and providing a barrier against skin irritants such as urine, faeces and sweat. A hydrogel was also considered but the chosen cream appeared to provide all the necessary protection.

Zach was educated as to how even small changes in his position could help to prevent a reoccurrence of his pressure ulcer and although he disliked lying on his side, he agreed to try regular small position changes. In reality he was unable to tolerate position changes in bed and would role onto his back as soon as the nurse left the bed area. It can be seen from this small apparently insignificant action the importance of accurate documentation. The author documented her conversation with Zach in which he agreed to reposition to alleviate the pressure on his bottom. If the author had failed to undertake accurate documentation it could be seen as a lack in the duty of care. Healthcare professional have clear guidelines on our role to act in patients best interests, the Nursing and Midwifery Council NMC (2004) says “we as nurses have a duty to the patient and must act to identify and minimise the risk to patients” Thus we have a legal and moral responsibility to ensure we reduce morbidity and mortality, caused by pressure ulcer development, as best as we can. The recent Patient Safety First campaign (2008) was aimed at making hospitals safer places for patients. Patient Safety First's cause is 'to make the safety of patients everyone's highest priority' Patient Safety First's aim is 'No avoidable death, no avoidable harm.' It can be seen how risk assessment and management fall neatly under this scope.
As Zach had a urinary catheter in place, it was difficult to get him to mobilise. The catheter meant he had no need to walk to the toilet, which was often the way of encouraging patients to mobilise. The author discussed with other members of staff the need to encourage Zach to mobilise, at first ambulatory oxygen was required to enable Zach to walk to the entrance to the bay and back. The physiotherapist worked on bed side exercises that Zach could do to alleviate the pressure on his sacrum; these included marching on the spot and getting in and out of his chair. The minimum requirements for preventing pressure damage are to position change at least every two hours (NICE, 2005; EUAP& NPUAP, 2009). It was important for all staff to remember that Zach needed encouragement to mobilise, as then, a concerted effort was seen. The ward used a printed hand-over sheet, updated on the computer every shift. The author added Zach’s need to be encouraged to mobilise to this ensuring all staff had easy access to the information.

When Zach’s family visited, the author discussed with them how important it was to assist and encourage Zach to walk about, and how they could assist by walking with him. By giving Zach goals to reach, such as walking down the ward to the day room to watch the football or news, and then being brought back on a wheelchair if he was too tired, helped to remove some of Zach’s fear surrounding mobilisation. It has been the author experience that patients often lose their confidence post operatively, in their ability to mobilise. Zach had several devices attached to him which required assistance to move and impeded his ability to do so independently. When attempting to educate him as to the need to position change etc it became apparent that Zach felt the nurses were very busy and he did not want to bother them. The author explained it was going to be more “bother” if he developed an open wound, that would then, have required lots of attention. This was logic that Zach understood and not the author being cruel. Ensuring patients understand risk and consequences forms part of a nurses role as patient advocate (NMC, 2004) Addressing Zach’s psychological needs was an ongoing concern, both pre and post operatively however good psychological care including an understanding of the risks pre operatively ensures a good post operative recovery (The NHS Institute for Innovation and Improvement, 2008); hence the need for pre operative clinics.

When Zach became tired during the course of the day, the author encouraged him to return to bed. This was challenged by other members of the nursing team, but the author had clear reasoning for this course of action and documented such. When Zach was confined to the chair, if he fell asleep he was unable to alter his position regularly and would then spend an extended period of time on his sacrum. NICE (2005) and EUAP& NPUAP (2009) both have recommended that patients should be repositioned off, the affected area for periods of time, in order for re-oxygenation of the skin to take place. Zach was able to lie in bed at a 30 degree tilt (NICE, 2005; EUAP& NPUAP, 2009) or on his side, using the positioning of his pillows, to help maintain the positions, to some degree, for a rest period between lunch and visiting.

The nutrition assessment undertaken pre-operatively, identified a significant, recent weight loss which the nurse addressed post-operatively. Zach was started on a fluid and diet chart to monitor his intake (if a dietician referral became necessary, they required three days worth of charts), the nurse also discussed with Zach, his preference in food to ascertain if anything from the supplementary menu may have helped. These extra menu choices allowed Zach to have a cooked breakfast of scrambled egg, bacon, sausage and beans; there was also the allocation of snack food throughout the day such as crackers or malt loaf. Olde et al, (1997) described malnutrition in surgical patients’, as having been shown, to increase the risk of developing pressure ulcers. “Loss of body fat and muscle, resulting in the loss of the cushioning effect between the bones and skin, the cause” Olde et al (1997). The RCN (2001) concurred “the nutritional status of a patient influences the integrity of the skin and support structures.” Whilst nutrition has been explored by a large selection of authors including Dealey (2009), VanGuilder et al (2008) and forms part of the guidelines of NICE (2005) and EPUAP & NPUAP (2009) on pressure ulcer care, the Cochrane database was unable to reach firm conclusions regarding nutritional interventions and their ability to help prevent the development of pressure ulcers (Langer et al, 2003). Zach had been a non insulin dependent diabetic mellitus sufferer for 20 years. Diabetes mellitus had caused a reduction in Zach’s peripheral circulation, leading to a loss of sensation in Zach’s feet. The author was careful to examine his feet and heels when carrying out skin inspections, as Zach was able to sit for long periods without noticing that his heel were becoming sore due to the loss of sensation. Poor blood sugar control and peripheral vascular disease lead to poor oxygenation of the skin, making it less resilient and therefore prone to the adverse effects of shear and friction (Dealey, 2009; NICE, 2005; EPUAP&NPUAP, 2009). Zach’s general management of his blood glucose levels was poor; therefore the author contacted the Diabetic Specialist Nurse and Dietician, to assist Zach in this area. Zach also scored high on the nutritional assessment. By regularly monitoring his blood glucose levels for him, whilst in hospital the nurses were able to ensure that Zach had better control than in the community, however as Zach’s appetite was very poor, encouraging him to eat was difficult. The supplementary drinks prescribed by the doctors (before the visit from the dietician) had an adverse effect both on his blood glucose levels by elevating them, but also depleting his already reduced appetite further as Zach found them very filling. Zach’s weight was monitored throughout his admission, as the assessment protocol dictated that he was weighed on admission and every Wednesday thereafter. Zach lost weight post operatively and was weighed every other day. This aided both the nursing staff and the dietician and formed a holistic view as to Zach’s post operative progress and areas of need.

Zach’s skin was protected from maceration and tissue damage due to incontinence via a urinary catheter. Catheterisation is often necessary post operatively in patients with a high thoracic epidural. Patients are often catheterised to prevent urinary retention and monitor urinary output in order to detect retention early, whilst still reversible. On day three post operatively, Zach’s epidural was removed as well as his intercostal drain and later the same evening his urinary catheter. At this point Zach felt able to undertake more responsibility for his pressure care management. Once all of these devices were removed he was able to change his position quite easily and with the minimum of assistance although positioning himself up the bed still required precise movements to prevent any further damage to his sacral area. On discharge Zach’s stage 1 pressure ulcer had rescinded, he no longer had non blanchable erythema and the sacral skin was well moisturised.

The author failed to implement a wound care plan, which is protocol for all wounds in the hospital. This oversight could have had far reaching consequences both for the author and Zach. Wound care plans would have allowed all the staff coming into contact with Zach to follow the same path and work towards the same goal. Enabling continuity of treatment even when the person implementing a care regime is not available, as is often the case on wards. The author felt that educating Zach and his family as well as putting the information on the printed handover documentation may have been sufficient but in hindsight, a wound care plan should have been implemented. Documentation has been indicated as a large area in which nurses remain poor, failing to document accurately the care they give. Looking after a patient is than doing things to them, it also involves documenting the care we give.

It can be seen, that although the evidence base is slim, the consensus of opinion on many issues in the prevention of pressure ulcer is large. Does this mean that nurses should only follow advice that is soundly based on research and evidenced based? This would surely be detrimental to patient care, with the guidance from NICE and EPUAP & NPUAP basing recommendations on consensus of opinion not solely evidence based research. Clinical judgement should always form part of a nurse’s decision making process (Ousey, 2005; DiCenso et al, 1998) and whilst the ideal would be to always have sound, evidenced based practice to fall back on, research into pressure ulcer prevention varies across the board.

Preventing Zach’s stage 1 pressure ulcer developing further required a holistic view of his health issues and care needs, both pre and post operatively. Detecting potential problems, in conjunction with the patient is part of the nurse’s role, whilst undertaking nursing assessments (Holland et al, 2003). Risk assessment forms part of the whole assessment process upon admission, consequently, it is incorporated into the admission form. But assessment is an ongoing process (Gil et al, 1998) needing to be updated as the patients needs alter, such as on return from theatre, 2 days post operatively, before discharge.

Pre-operative assessment failed to identify that Zach had experienced previous pressure ulcers to his sacral area. This information came to light, only after his surgery, and whilst it may not have altered the course of his care, may have been useful information to have.

There has been wide spread implementation of risk assessment tools throughout hospitals in the UK. However due to the lack of consensus regarding these tools and clinical opinion, as to what determines a patients risk factors, patients still develop pressure ulcers, at unacceptably high levels. No tool will predict 100% who will develop pressure ulcers, as there still remains a deficit in knowledge regarding pressure ulcer physiology and the body’s defence mechanisms against pressure.

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