Question

PN 200 Fundamentals of Nursing II Concept Map: Care of the Patient with A Stage IV Pressure Ulcer You are the nurse working in a medical intensive care unit and take the following report from the emergency department. There is a patient to be admitted to your unit; Rosa Long is an 82 year old frail woman who has been in a nursing home. Her admitting diagnosis is sepsis, pneumonia, dehydration, and she has a stage VI pressure ulcer. Her past medical is CVA with residual right sided weakness and parasthesia, MI, and peripheral vascular disease. Her vital signs are: B/P 96/62, P 88, R. 38 and labored, T 100.4. Labs have been drawn and are pending: she has 02 by face mask at 10 L/min, IV of D5 in 1/2NS at 100mL/hr., and an indwelling Foley catheter. The infectious disease doctors have been notified, and respiratory therapy is with the patient - they are just leaving the emergency department and will be arriving on the floor shortly. During your admission skin assessment, you note that she has very dry, thin, almost transparent skin. There are several areas of ecchymosis on her upper arms. As you proceed with the assessment, an enterostomal therapist and wound nurse specialist comes in. She knows Ms. Long from a prior admission and had ordered a specialty mattress as soon as she received the wound bed consult. She state she has ordered an air overlay and it should be delivered to your unit before the end of your shift The wound nurse gently removes the old dressing, using the push-pull method and adhesive remover wipes. After she takes off the outside dressing, often called a secondary dressing, she pulls out the primary dressing and tells you it was packed too hard". Question #1 State two problems that packing a wound too full can create.

Answer 1

Stage IV pressure ulcer

Pressure ulcers have been found to be increasing owing to the increasing aging population with disability. Impaired lymphatic drainage, along with ischemia and localized tissue injury is the major contributing factors. Certain extrinsic and intrinsic factors such as long term immobilization on a spinal board, or bed and diabetes, smoking have also been emphasized. Preplanning repositioning and frequent assessment of skin condition should be done taking into account the risk factors involved.

On diagnosis of a pressure ulcer, documentation and staging should be done, Pressure ulcers can be classified,based on the condition of the skin, tenderness, suppuration as:

Stage I: intact skin with non-blanchable erythema

Stage II: partial-thickness damage of the skin, possible formation of blisters, no visible subcutaneous tissue

Stage III: tissue loss with exposed subcutaneous fat, but bones, muscles, tendons are not visible

Stage IV: tissue loss with exposure of muscles, bones, tendons.

The line of management of pressure ulcers is:

1.Relieve the pressure from the wound area

2.Debridement

3.Drainage

4.Anti-infective therapy

5. Dressings and topical agent application

The present case is a stage IV pressure ulcer, with risk factors including the previous history of MI,Peripheral vascular disease, paresthesia, all adding up to the development of pressure ulcers. examination,it was observed that the dressing was packed too full.

Two problems associated with packing a wound too full are:

1. increased pressure from a surgical dressing can result in extension of the wound beyond its edges

2. a dry environment will be created , owing to reduced tissue perfusion and venous return, causing the wound to be more concave. It is imperative to maintain moisture balance ,in order to enhance re epithelialisation. Otherwise a tunnelling wound that takes more healing time may ensue.

Hence it is advisable to develop a systematic approach,while dealing with pressure ulcers. The risk factors, physical and psychological aspects of the patients should also be considered, alon with adherence to proper dressing protocol, for effective treatment.