Nursing Assessment and Management of Pressure Ulcers in a 61-Year-Old Male Patient

This essay discusses the nursing assessment and management of pressure ulcers in a 61-year-old male patient with diabetic gangrene and anxiety. The assessment includes the use of the Braden Scale for Predicting Pressure Sore Risk, while the management plan is based on the patient's risk level.

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Introduction and overview of the patient
Across all age groups pressure ulcers comprise a serious health concern globally. Financial burden
associated with the treatment of pressure ulcers is inestimable. Every year most of the cases of pressure
ulcers arise in hospitalized patients, and there are even more cases in community as well as care homes
(Moore & Cowman, 2014). Therefore, this is high time that efforts should be made to prevent the
development of pressure ulcers. Nurses are the first point of contact with the patient. Training for the
management of pressure sores should be compulsory for the nurses (Gunningberg et al., 2015). This
training should help the nurses to develop basic knowledge and skills for the prevention of pressure
ulcers. A large number of pressure ulcer cases are preventable, thus, efforts should be made to identify the
risk factors of developing bed sores using pressure sore assessment tools and thus prevent the
development of pressure ulcers. This essay is aimed at discussing the case study of a selected patient. A
61-year-old male patient named Gordon has been selected for this essay. Firstly, a nursing assessment
will be done to describe the current problems of the patient. Following this, a nursing management of the
patient will be described.
Nursing assessment
Gordon, a 61-years-old male presented to the hospital with chief complaint of Diabetic gangrene in left
foot. He presented with a history of Diabetes since past 10 years, Hypertension since 3 months, and
Anxiety and mood disorders since last one month. Gordon physically appeared lean and weak. The
patient belonged to a middle class family. His family consisted of his wife and two children who were
settled in two cities. The patient seems anxious and nervous. Nursing assessment was done which
consisted of general physical examination including the pulse rate, B.P, respiratory rate and temperature.
This was followed by accessing the medical history and drug history of the patient. This was done to
access the current health state of the patient and to decide the further course of treatment (Brien, Moore,
Patton & Connor, 2018).
Upon thorough assessment the nurses found that the diabetic gangrene had worsened and the patient’s
blood glucose level was very high. Also, the patient had developed serious pressure ulcers on his buttocks
due to prolonged immobilization.
Braden Scale (Moore & Cowman, 2015) for Predicting Pressure Sore Risk was utilized:

Sensory Perception: Gordon’s sensory perception was slightly limited. He was not able to communicate
pain and discomfort. Although, he was able to respond to commands, his ability to describe his painful
stimulus and discomfort was very limited (Moore & Cowman, 2015). He had limited sensitivity in his
affected limb. Due to gangrene involvement, his sensitivity had further declined. As his leg was affected,
this reduced his mobility and due to immobility he had developed pressure sores on his buttocks ( Brien et
al., 2018)
Moisture: Gordon’s skin was often moist and thus required linen changed at least once in every alternate
day. His skin was not always moist, but it was enough moist to require linen change regularly. Moisture
content of skin is an important consideration that requires immediate attention. If skin is more moist than
regular, it might result in friction and sheet pressure (Wang et al., 2015). This can ultimately result in skin
tearing and increased chances of bacterial infection (Wang et al., 2015). Moreover, moist skin provides an
ideal environment for bacteria cultivation and colonization.
Activity: Gordon’s activity level is very limited. He remains confined to bed most of the time. However,
he goes to bathroom and toilet by receiving assistance from the nurses. He cannot bear his own weight
due to inability to put pressure on his gangrenous foot. He requires chair or wheelchair assistance for
performing the activities of daily living. Immobilized and bedridden patients are at the greatest risk of
developing bed sores or pressure ulcers. Gordon’s inactivity and immobilization due to gangrenous foot
are the risk factors for pressure ulcers (Gunningberg et al., 2015).
Mobility: Gordon’s mobility is very limited. Occasionally, he tries to get up from his bed for using the
toilet. He sometimes changes the position of his extremities. However, his ability to move independently
is restricted largely due to his inability to put pressure on his gangrenous foot (Gunningberg et al., 2015).
He can move with the assistance of a wheelchair, but he requires assistance in getting up and sitting in the
wheelchair.
Nutrition: Gordon’s nutrition is adequate. He eats sufficient potion of proteins and carbohydrates.
However, his fast food intake is very high. He likes to eat pizza, burger, chips and other sweetened cold
drinks (McInnes et al., 2015). His fluid intake is not adequate. His habit of drinking sweetened cold
drinks is constantly contributing to increase his blood sugar levels. His uncontrolled increase his blood
sugar level despite the intake of hypoglycemic medications has caused gangrene development and it’s
worsening (Thomason et al., 2016).

Friction and Shear Gordon requires assistance while getting up from his bed. During the uplifting
movement, his skin probably slides to some extent against the linen. However, he maintains a good
position in his wheelchair or his bed most of the time. The nurses should take care to prevent skin friction,
especially the skin affected. The fragile skin is more sensitive to friction and shear (Gunningberg et al.,
2015). Care should be taken to prevent any strain and tearing of this sensitive portion of skin from
breakage.
Nursing care / management
Once the pressure ulcer develops, the ulcer should be cleaned with a nontoxic solution. Cleaning the ulcer
removes debris and bacteria from the ulcer bed, factors that may delay ulcer healing. The nurse should
assess and stage the pressure ulcer at each dressing change. Experts believe that weekly assessments and
staging of pressure ulcers will lead to earlier detection of wound infections as well as being a good
parameter for gauging of wound healing (Demarre et al., 2015).
Nursing care and management depends on the amount of risk that the patient is in. According to the
scores obtained by pressure sores risk assessment tool, there are majorly three categories of patients.
These include: At risk, moderate risk and high risk patient. Nursing care/management consists of
following:
At risk (score of 15-18)
Such patients should be managed by frequent turning the position of the patient while the patient is lying
on the bed. Efforts should be made to promote maximal remobilization to protect heels (Yavuz et al.,
2015). Moreover, the nurse should make efforts to manage moisture, nutrition and friction and shear
pressure-reduction. The nurse can use commercial moisture barrier to hold moisture from skin surface.
Excess moisture makes the skin more fragile and more prone to shear pressure and skin tear. The nurses
can provide absorbent pads or diapers to hold moisture. Bedpan/urinals should be offered in addition to
turning the position of the patient (Demarre et al., 2015).
Also, adequate nutritional supplements should be provided to facilitate rapid recovery. The patient should
be provided equal amount of protein and carbohydrates. Intake of fast food and sweetened drinks needs to
be restricted (Yavuz et al., 2015).

Secondly, if the patient is bed or chair bound, as is the case with Gordon, the nurse should assist the
patient in getting up from bed and help him with the activities of daily living. Efforts should be made to
prevent skin friction while assisting the patient in getting up from the bed or getting seated in the
wheelchair (Demarre et al., 2015).
If several risk factors are present such as old age, immune-compromised state of the patient, nutritional
insufficiency or hypo/hypertension than the patient should be considered as moderate risk and treatment
plan should be as per moderate risk level (Langer & Fink, 2014).
Moderate risk (13-14)
Foam wedges should be used for 30e lateral positioning of the patient during the turning schedule.
Support surface such as fluid bed or sand bed should be used for pressure-reduction. The sand beds
behave like a liquid when air is pumped in these beds and thus, these beds promote the draining of
wounds or pressure sores while exerting minimal pressure on the sin surface (Qaseem et al., 2015). Also,
the nurses should do a regular follow up for moisture status of skin, nutrition requirements and friction
and shear resistance.
Generally, nurses are aware that keeping the skin clean and dry will prevent super infections and
moisture, which increases friction, causing skin tearing. Patient schedules for changing position and the
use of moisture absorbent material on skin are also prescribed (Swafford, Culpepper & Dunn, 2016). In
addition, by performing subsequent skin assessments, nurses will have the ability to recognize skin
breakdown at an early stage, which will lead to early intercessions. Although there is no agreement on
what comprise a minor skin assessment, reports suggests adding the accompanying five parameters: skin
temperature, shade, humidity, and integrity are integral part of skin assessment (Wang et al., 2015). The
nurses should advise the patient for the purpose of skin care, they should be taught to not apply any
pressure to the red portion of skin, or over bony prominences, as this result in deep tissue damage.
Healthy skin should focus on limiting the presence of moisture on the surface. Degradation of the skin
caused by friction can be moderated by the use of oils, protective ointments (eg, direct and skin
adherents), protective dressings (eg hydrocolloids) and protective sealants (Thomason et al., 2016).
Also, the role of the nurse is to manage nutrition by increasing protein intake and increasing calorie intake
to spare proteins. Supplement have been found to benefit such patients and thus multi-vitamin (Vit a, c &
e) act quickly to alleviate deficits. Dietitian can be consulted to formulate a proper diet plan to prevent
deterioration of health and promote speedy recovery. Serum proteins of less than 3.5 g / dl tend to the

increase the risk of stress ulcers (Choi, Chin, Wan & Lam, 2016). Patients admitted to hospital with
malnourishment have an increased likelihood of developing pressure ulcer. Assessing the patient's ability
to bite and swallow should also be accessed. Healthy patients who received protein supplements in
addition to the standard diet for a healthcare facility had a lesser risk of pressure ulcers compared to those
who received only the conventional diet.
Very high risk (9 or below)
The use of supporting surfaces is a fundamental thought of redistribution of weight. The idea of weight
redistribution is taken up by NPUAP. No one can ever evict the patient's entire weight. With the chance
of losing weight on one part of the body, it will increase the weight somewhere else on the body. From
now on, the goal is to achieve the ideal redistribution of weight.
A unique strategy for redistribution of weight is the use of supporting surfaces. Many studies have
focused on the adequacy of the use of supportive surfaces to reduce the rate of ulcer. Static fixtures
include air, foam (compressed and solid), gel and water coats or memory foams (Bus et al., 2016). These
surfaces are perfect when the patient is at moderate risk of developing stress ulcer. The collection of
devises powered by a power supply or a pump and is regarded as unique. These support structures include
rotary and low-budget beds. These sleeping pillows are useful in patients who are moderately to high risk
of ulcers caused by weight, or have a full thickness ulcer (McInnes et al., 2015). The collection of 3
devices, also powerful, includes only air-fluidized beds (Swafford, Culpepper & Dunn, 2016). These beds
are electric and contain silicone-covered covers. At the moment the air is pumped through the bed, the
dowels are closed in liquid. These beds are used for patients with high risk of severe ulcers. More often,
they are used in patients with full-thickness non-healing ulcers or when there are multiple thrombolytic
ulcers with full thickness (McInnes et al., 2015).
The use of oral anti-infective agents or the local sulfa-silverdiazine was further observed as successful in
reducing the microbial colonization in the stress ulcers (Bus et al., 2016). Treatment using silver
impregnated dressings appears to be somewhat viable in declining the growth of pathogenic
microorganisms. The use of topical septic to reduce bacterial infection of wounds still remains
controversial (Thomason et al., 2016). The perfect treatment for a contaminated stress ulcer would be
bactericidal for a wide variety of pathogens and non-cytotoxic for leucocytes. In addition, the use of diet
with high-protein and fewer calories for patients with protein deficiency is ideal for wound repair
(Thomason et al., 2016).

Conclusion
The prevention of pressure ulcers is a marker of the nature of nursing consideration and care provided to
the patient. Development of pressure ulcers is hugely dependent on inadequate quality of care and
examination by the nursing professionals.
Therefore, nursing care has a significant impact on the development of the ulcer and the avoidance of
ulcer. The viability of stress ulcers regularly involves the utilization of low innovations, but careful
consideration of the most reliable risk factors to improve the risk of stress ulcers is needed. At a time
when an ulcer risk is detected, the main patient Safety Goal is to help the multidisciplinary health care
team to close the ulcer as soon as possible. Nursing professionals should also be concerned about
avoiding further ulcer reoccurrence, maintaining painless and clean skin, preventing the skin from
bacterial contamination and preventing patient discomfort.

References
Bus, S. A., Armstrong, D. G., Van Deursen, R. W., Lewis, J. E. A., Caravaggi, C. F., Cavanagh, P. R., &
International Working Group on the Diabetic Foot (IWGDF). (2016). IWGDF guidance on
footwear and offloading interventions to prevent and heal foot ulcers in patients with
diabetes. Diabetes/metabolism research and reviews, 32, 25-36.
Choi, E. P., Chin, W. Y., Wan, E. Y., & Lam, C. L. (2016). Evaluation of the internal and external
responsiveness of the Pressure Ulcer Scale for Healing (PUSH) tool for assessing acute and
chronic wounds. Journal of advanced nursing, 72(5), 1134-1143.
Demarré, L., Verhaeghe, S., Annemans, L., Van Hecke, A., Grypdonck, M., & Beeckman, D. (2015). The
cost of pressure ulcer prevention and treatment in hospitals and nursing homes in Flanders: A
cost-of-illness study. International journal of nursing studies, 52(7), 1166-1179.
Gunningberg, L., Mårtensson, G., Mamhidir, A. G., Florin, J., Athlin, Å. M., & Bååth, C. (2015).
Pressure ulcer knowledge of registered nurses, assistant nurses and student nurses: a descriptive,
comparative multicentre study in Sweden. International wound journal, 12(4), 462-468.
Langer, G., & Fink, A. (2014). Nutritional interventions for preventing and treating pressure
ulcers. Cochrane Database of Systematic Reviews, (6).
McInnes, E., Jammali‐Blasi, A., Bell‐Syer, S. E., Dumville, J. C., Middleton, V., & Cullum, N. (2015).
Support surfaces for pressure ulcer prevention. Cochrane Database of Systematic Reviews, (9).
Moore, Z. E., & Cowman, S. (2014). Risk assessment tools for the prevention of pressure
ulcers. Cochrane Database of Systematic Reviews, (2).
Moore, Z. E., & Cowman, S. (2015). Repositioning for treating pressure ulcers. Cochrane Database of
Systematic Reviews, (1).
O'Brien, G., Moore, Z., Patton, D., & O'Connor, T. (2018). The relationship between nurses assessment
of early pressure ulcer damage and sub epidermal moisture measurement: A prospective
explorative study. Journal of tissue viability.

Qaseem, A., Humphrey, L. L., Forciea, M. A., Starkey, M., & Denberg, T. D. (2015). Treatment of
pressure ulcers: a clinical practice guideline from the American College of Physicians. Annals of
internal medicine, 162(5), 370-379.
Swafford, K., Culpepper, R., & Dunn, C. (2016). Use of a comprehensive program to reduce the
incidence of hospital-acquired pressure ulcers in an intensive care unit. American Journal of
Critical Care, 25(2), 152-155.
Thomason, S. S., Powell-Cope, G., Peterson, M. J., Guihan, M., Wallen, E. S., Olney, C. M., & Bates-
Jensen, B. (2016). A multisite quality improvement project to standardize the assessment of
pressure ulcer healing in veterans with spinal cord injuries/disorders. Advances in skin & wound
care, 29(6), 269-276.
Wang, L. H., Chen, H. L., Yan, H. Y., Gao, J. H., Wang, F., Ming, Y., ... & Ding, J. J. (2015). Inter‐rater
reliability of three most commonly used pressure ulcer risk assessment scales in clinical
practice. International wound journal, 12(5), 590-594.
Yavuz, M., Master, H., Garrett, A., Lavery, L. A., & Adams, L. S. (2015). Peak plantar shear and pressure
and foot ulcer locations: a call to revisit ulceration pathomechanics. Diabetes Care, 38(11), e184-
e185.

Appendix 1
Choose a patient whose care you clearly
understand
Write here the topic area you plan to address:
Pressure ulcers, depression and pain
Ask for verbal consent from the patient to write
a case study about them – if this is declined do
not use their information
Write here details regarding consent obtained for
your case study:
A written consent form was signed and accepted by
the patient that provided consent to write a case
study about them.
Why was the patient admitted to hospital /
referred to community team / attended the
department?
Diabetic gangrene in left foot
Brief outline of medical history: Diabetes since past 10 years, Hypertension,
Anxiety and mood disorders
Overview of their physical condition,
psychological state and social circumstances:
Patient appears lean and weak. The patient belongs
to a middle class family. The patient seems anxious
and nervous.
What did the nurses assess in relation to the
problem?
General physical examination including the pulse
rate, B.P, respiratory rate and temperature. This
was followed by accessing the medical history and
drug history of the patient.
Why they did this / rationale: This was done to access the current health state of
the patient and to decide the further course of
treatment.
What they found upon assessment: The nurses found that the diabetic gangrene had
worsened and the patient’s blood glucose level was
very high. Also, the patient had developed pressure
ulcers due to prolonged immobilization.

Were the approaches useful in practice? Yes, the approaches were useful in practice.
What else could have been done to assess this
problem?
A pressure risk assessment tool should have been
used to access the risk of development of pressure
ulcers.
What did the nurse do to manage the chosen
problem?
The nurse made efforts for keeping the affected
skin clean and dry. The nurse also prevented
excessive moisture in the affected portion of skin to
prevent skin breakdown. Frequent skin assessment
of the affected area was performed to plan for
further intervention. Oral antibiotic treatment was
given after discussion with the treating physician to
prevent infection.
Why did they manage the problem in this way? They managed the problem in this way to prevent
further deterioration of the patient’s condition and
to plan the further course of intervention.
Was the management of this problem (i.e., the
nursing care given) effective for this actual
patient?
Yes, the management of this problem (i.e., the
nursing care given) effective for this actual patient.
Are there any other factors that influence the
quality of care given to manage this problem, i.e.,
warmth and compassion of nursing staff?
Yes, factors such as emotional support, warmth and
compassion are important factors that influence the
quality of nursing care. The emotional support
provided to the patients has been found to improve
the positive patient outcome and decrease the
length of hospital stay.