Element: Prevention of pressure ulcers This essay is going to explore the nursing process with regard to the prevention of pressure ulcers. Pressure ulcers are a widespread and often underestimated health problem in the UK. They occur in 4-10% of patients admitted to hospital (Ward et al, 2010).
This essay, using case study 4, will explore the holistic nursing process, and also the biological, sociological, psychological and ethical issues regarding the prevention of pressure ulcers.Lily is frightened due to her shortness of breath (dyspnoea), and as lying down exasperates her ability to breath effectively, has been sleeping in a chair. This is the primary concern of Lily. There has also been recent weight loss.
The aim of any nursing interventions will be to improve Lily’s breathing and nutritional status; allowing her to mobilise more effectively and relieve pressure on her sacral area. Dyspnoea is a common and debilitating symptom of heart failure. Patients frequently become distressed and frightened by their breathlessness, which can worsen their symptoms (Currow et al, 2009).Any nursing interventions to improve Lily’s health and well-being will need to take into account the patients perspective of her health and what goals she wants to achieve.
Collaboration and negotiation with the patient will help them identify their problems and/or goals (Field & Smith, 2008). The nursing process is a structured, systematic approach to care, based on evidence and the individual needs of the patient (Holland K. 2008). There are four main stages to this process; assessment, planning, implementation and evaluation.When Lily is admitted to hospital she will be assessed to identify her health and social needs. The main aim of the assessment process is to identify problems then design a realistic plan of nursing care to meet the individual needs of the patient and improve their health status (RCN, 2004).
This individualised assessment examines the patients’ current medical condition and identifies potential and actual problems affecting the patient (Hall & Ritchie, 2009). Through discussions with Lily, an understanding of her perspectives and needs will be gained.The primary source of information will come from Lily, and any other data will be a secondary source e. g.
Lily’s GP. The nurse will also observe Lily to collect data during the assessment. Physical signs and a patients’ appearance can be observed. Touch can also give the nurse information. Temperature of skin, rate of pulse and signs of dehydration can be gained through touch (Brooker & Waugh, 2007).
To ensure that the assessment is systematic and does not miss out anything, nursing frameworks (models) are often used.Models lead nurses to focus on a holistic assessment of the patients’ needs from the patients’ perspective, directing the nurse towards meeting the needs of the individual in a systematic and organized manner (Pridmore et al, 2010). The Roper-Logan-Tierney model is extensively used within the UK as a framework for nursing care and practice (Holland K, 2008). The model has been criticised for being too simplistic (Girot, 1990), although it could be argued that the simplicity has contributed to the popularity of the model (O’Connor, 2002).
The nurse will use this framework to establish Lily’s ability to fulfil the Activities of Living (ALs) (Roper et al 2002), these include breathing, eating and drinking, mobilising and sleeping. Many aspects of ALs interlink. Lily’s worsening heart failure and dyspnoea are preventing Lily from sleeping in her bed, and may make it difficult for her to eat, drink and mobilise effectively. Heart failure is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the heart to function as a pump to support a physiological circulation (NICE, 2003).
Causes of dyspnoea in heart failure include the inability of the weakened ventricle to pump properly, leading to pulmonary congestion, and changes in the skeletal and respiratory muscles, making breathing more of an effort, increasing the sensation of breathlessness (Katz, 2008). Losing weight, combined with sleeping in a chair, may have contributed to Lily having a suspected pressure ulcer. Unrelieved pressure, from sitting in a chair for long periods, squeezes the tiny blood vessels in the skin which supply the tissues with oxygen and nutrients. The tissues die when deprived of oxygen and nutrients for too long (Harris, 2009).Older people and those experiencing impaired nutrition are among the groups at risk of developing pressure ulcers (NICE, 2005).
The Malnutrition Advisory Group of BAPEN (British Association for Parenteral and Enteral Nutrition) developed the Malnutrition Universal Screening Tool (MUST), (Perry, 2009). The MUST is a 5 step screening tool to identify adults who are malnourished, at risk of malnourishment or obese. Lily’s body mass index (BMI) will be calculated to obtain her overall risk of malnutrition. By talking to Lily and consulting her medical notes, the nurse can establish Lily’s weight loss over the last 3-6 months (BAPEN, 2009).Asking leading questions regarding Lily’s dietary habits and appetite will give the nurse an understanding of her nutritional intake. If Lily scored 2 or more in the MUST tool then she would be considered high risk (Perry, 2009).
Lily will be assessed for her risk of developing a pressure ulcer. A number of evidence-based tools have been developed but the Waterlow pressure ulcer risk assessment tool is the most frequently used system in the UK (Thompson, 2005). The Waterlow pressure ulcer score card comprises of a risk assessment scoring system.Patients are assessed as low risk (fully mobile and minimal risk factors/Waterlow score <10), medium risk (restricted mobility and some risk factors/Waterlow score 10—20) or high risk (immobile, multiple risk factors/Waterlow score >20) (Waterlow, 2007).
Papanikolaou et al (2006) criticised the tool for containing some risk factors, for which the definition is unclear or ambiguous and difficult to understand. However, it has also been praised for its ability to effectively highlight areas of patient care which need extra input from members of the multidisciplinary team (Chamanga, 2010).The European Pressure Ulcer Advisory Panel (EPUAP) developed a common international classification system for pressure ulcers (EPUAP, 2010). EPUAP classification is recommended by The National Institute for Clinical Excellence (NICE, 2005). The categories range from 1 – 4, with 4 being the most severe. Lily has a red area on her sacral region; this would be assessed as a category 1 if there was an absence of blister or abrasion.
Category 1 is defined as; Non-blanchable erythema of intact skin, discolouration of skin, warmth, oedema, induration or hardness may also be indicators.If the area presented clinically as an abrasion or blister then it could be indicative of a category 2 pressure ulcer (EPUAP, 2009). A record of where it is, its size and what it looks like should be made using photographs or tracings (NICE, 2005). This record will be used to determine the rate of healing, or any deterioration.
Falls Risk, Manual Handling and Pain Assessments will also be taken. Lily’s social circumstances will be examined to ascertain the level of support she has. Lily lives alone so home safety issues need to be considered, such as can she summon help if needed?The nurse may need to involve other health professionals including Occupational Therapist and Social Services. The NMC (2008) states that the nurse must work with others to protect and promote the health and well-being of the patient. The information gathered from the assessment will form the care plan, which will include planned nursing interventions and aims (Field and Smith, 2008). This would include reducing the pressure on Lily’s sacral area.
NICE guidelines recommend that if you are at risk of developing a category 1 or 2 pressure ulcer you should receive is a high specification foam mattress (NICE, 2005).High specification foam mattresses have demonstrated improved performance in pressure ulcer prevention (Defloor et al 2005). A manual handling plan will be put in place to relieve pressure. EPUAP (2009) advises repositioning using the 30-degree tilted side-lying position (alternately right side, back, left side).
Orthopnoea, breathlessness when lying flat, is the result of pulmonary oedema, caused by back pressure from the failing left ventricle via the left atrium and the increase in venous return to the right side of the heart and the lungs (Katz, 2008).Ensuring Lily is not laid flat, with additional pillows or bed tilted, would also aid Lily to sleep in a bed and reduce pressure on her sacrum. Orthopnoea can be eased by increasing the number of pillows used. 'V' pillows, foam wedges or electrically raised beds are useful (Churchouse & Thomas, 2010). The care plan could include referral to a dietician or Nutritional support team to improve Lily’s nutritional status (BAPEN, 2009).
Being breathless could make eating difficult, or she could be experiencing nausea.Lily’s medication could be the cause, as Furosemide, Perindopril and Digoxin can cause nausea and loss of appetite (British National Formulary, 2011). The care plan would include an evaluation of medication. Evaluation is essential to reflect on the assessment, planning, implementation and outcomes. This provides a basis for on-going assessment and planning as the persons’ circumstances or condition changes (Roper et al 2002). It allows the nurse to evaluate whether the care given has been effective in achieving the goals set.
The nursing process is a cycle of care, and will be repeated as is necessary.Each stage is dependent on the effectiveness of the other in a cyclical process (Holland, 2008). Pressure ulcer prevention is a complex, multifactorial process and although it is accepted that some pressure ulcers are unavoidable, most are considered preventable (Elliott, 2010). The nurse will need to use clinical knowledge and problem-solving skills to reduce factors that contribute to the development of pressure ulcers.
Lily’s weight loss is a contributing factor to her pressure ulcer. Inadequate nutritional intake affects serum albumin, lymphocyte count, nitrogen balance and hydration status.All of which can have a significant effect on Lily’s skin integrity, immunity and metabolic processes (Royal Marsden, 2008) Lily’s observations state that her respiration rate is 23/min, the normal range for an adult at rest is 14-18/min. Although there is an increased respiration rate (Tachypnoea), 20-30/min is regarded as moderate. However, emotion, pain and anxiety can cause an increase (Royal Marsden, 2008). Lily is frightened and has been ringing her buzzer frequently, which has resulted in her being labelled as demanding.
The effects of being an ‘unpopular patient’ were highlighted by Stockwell (1984), who found that nurses did not enjoy caring for patients’ they considered demanding (Rungapadiachy, 2005). This type of prejudice can lead to ‘depersonalisation’. Bernard (1998) suggested that nurses knew a lot less about female patients, cared for them in a different way and were more likely to be labelled ‘difficult’ than their male counterparts. He suggested nurses would distance themselves from daily confrontations of what they may become in the future.Lily’s illness and fear could be causing her stress, which causes changes in the production of adrenaline and noradrenaline thus increasing heart rate and blood pressure (Ogden, 2004).
The nurse can reassure Lily and offer emotional support. Teasdale (1995) states that being close to and communicating with a patient makes them feel safe. Therapeutic use of self techniques include; close physical presence, touch, and comforting words of assurance (Mitchell, 2005). Nurses need to prioritise care and ensure that patients’ are treated with dignity and respect.Throughout the nursing process it is essential that consent is obtained and all information is treated with confidentiality (NMC, 2008). It is the nurses’ responsibility to advise the patient on best practice in the prevention of pressure ulcers, but ultimately it is the patients’ choice to adhere to advice given.
The patient has autonomy and choice over the care they receive (NMC, 2008). The prevention of pressure ulcers is a complex, multifactorial process, which requires a holistic, systematic approach. Multi-professional and nurse-patient collaboration and negotiation is essential to this element of nursing care.Biological, sociological and psychological aspects affecting the patient need to be considered in order to gain the patients perspective. Using frameworks and assessment tools guide the nurse in the delivery of patient care, but the nurse must also use clinical judgement in order to problem solve and deliver holistic, patient-centred care.
The nurse has to respect the patients’ choices regarding the prevention of pressure ulcers and negotiate care. Whilst on placement I witnessed a patient disagreeing with advice given to relieve pressure on her sacral area.The patient would get very upset when the nurse suggested the information she was receiving from the internet was not evidence-based and could in fact cause deterioration of an already established pressure ulcer. This patient was a wheelchair user and did not have a pressure relieving cushion, and would remain seated in the wheelchair for up to 9 hours a day.
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