Question

Case Study

Mrs. Ramona Garcia, a 76-year-old female, is admitted to a medical respiratory unit with pneumonia after 4 days of difficulty breathing, fever, and a productive cough with purulent sputum. She reports that she has been sleeping sitting upright in a chair for the past week because it was too difficult to breathe lying down. When Mrs. Garcia’s breathing is comfortable enough for her to be turned briefly for a full skin assessment, the nurse notes a 4-cm red area on the buttock over the left ischial tuberosity that does not blanch to pressure. Recognizing the reddened area as a stage I dermal ulcer likely related to the prolonged pressure from sitting, the nurse collaborates with the patient, family, and health team on a plan for prevention of further tissue breakdown, including frequent movement and positioning, adequate nutrition, hygiene for prevention of moisture collection from sweat or urine that might lead to skin maceration, and use of pressure-relieving devices.

Case Analysis

Mrs. Garcia has a serious medical problem that has kept her in a sitting position struggling for airflow over several days. Continuously sitting up to improve her air exchange has prevented her from relieving the pressure on her ischium, which she would normally have done by changing her position when she noticed discomfort. Poor perfusion from the near-constant pressure on her ischium and a low capillary oxygen level from her respiratory illness have begun to cause damage at the tissue level. Mrs. Garcia’s nurse identifies a reddened area of skin that does not blanch to touch as a stage I dermal ulcer and realizes that any further injury to the area could result in deep tissue damage and an open wound. In order to promote tissue healing and prevent further injury, the nurse begins tissue integrity interventions promptly and recognizes that helping Mrs. Garcia maintain comfortable air exchange will encourage her to position herself off of the dermal ulcer.

Answer the following 2 questions.

What assessment findings would indicate that Mrs. Garcia’s dermal ulcer has progressed from stage 1 to stage 2?

When discussing the importance of adequate nutrition for Mrs. Garcia, which three nutrients would the nurse identify as most essential for her?

Answer 1

A dermal ulcer is a skin sore having the characteristic feature of breakdown of tissue which leads to loss of epidermis, dermis or subcutaneous fat.

The assessment findings that indicate the dermal ulcer has progressed from stage 1 to stage 2 includes

• If the stage 1 dermal ulcer is not treated, it will progress into stage 2 dermal ulcer. Stage 2 dermal ulcer can often be treated easily and with proper management, it will usually heal quickly. The dermal ulcer in stage 2 is often characterised by intact blister or shallow open sore.
• While assessing the ulcer, we can notice that the sores are often red or pink in color and is surrounded by red and irritated skin.
• The stage 2 ulcer affects the epidermis and creates an open wound. Dermis, the second layer of skin is visible in stage 2 dermal ulcer.
• In some cases, the dermis will be broken.
• The main assessment finding we can notice in stage 2 dermal sore includes intact or ruptured blister, irritated skin, presence of pus or fluid, redness or discoloration.
• The client may likely experience some pain from the ulcer.
• If the surrounding areas of the skin is swollen, sore or red, it indicates some tissue death or damage.

The nutritional needs of clients with dermal sores are very high. They requires extra protein, vitamins and minerals to promote the healing of ulcer. If any deficiency of these nutrients occurs, it may results in delayed wound healing. Always keep in mind that hydration is very essential to promote the healing process. The nutrients which plays a key role in wound healing in dermal ulcer includes

• Protein
• Vitamins ( especially A and C)
• Minerals (especially iron and zinc)

• Proteins

Protein deficiency may adversely affects the healing process. So it is essential to maintain sufficient protein for wound healing. Usually a dermal ulcer may lose upto 90-100 gm of proteins as exudates per day. Amino acids such as arginine plays an important role in wound healing. If adequate protein is not supplied, it may leads to hypoalbuminemia. Proteins also helps to fight infection, balance the body fluids and helps to carry oxygen through the body. Provide the client a balanced diet with enough calories and plenty of proteins.

• Vitamins

Vitamin A plays an important role in all the stages of wound healing. Vitamin A helps to stimulate the epithelial growth, fibroblasts, granulation tissue, collagen synthesis and epithelialization. retinoids have the unique ability to reverse the inhibitory effects of anti inflammatory steroids in wound healing.

Vitamin C helps in the formation of collagen and promotes wound healing. Vitamin C deficiency will results in delayed healing and capillary fragility. The good sources of vitamin C are citrus fruits and goose berries.

• Minerals

The deficiency of zinc inhibits the wound healing process by reducing the rate of epithelialization and cellular proliferation and impaires the wound healing. Zinc helps to heal the ulcer and lessen the inflammation. Zinc is commonly found in sea food, meat, eggs, whole wheat bread etc.

Maintaining adequate iron level in body is very essential for proper ulcer healing peocess. Low Hb level leads to reduced oxygen content in tissues and results in delayed wound healing.