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

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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).