Advanced Diploma in Nursing: Pressure Sore Management of Mrs. ABM Case

This report presents a case study of Mrs. ABM, an 85-year-old Malay lady with multiple chronic conditions, focusing on the management of pressure sores. The report details Mrs. ABM's medical history, including hypertension, diabetes, and dementia, and the challenges posed by her bedbound state and recurrent UTIs. It identifies pressure sores as the primary problem, discussing the intrinsic and extrinsic factors contributing to their development, including diabetes complications and immobility. The report emphasizes the importance of early detection and risk assessment by caregivers and nurses. The management plan includes strategies to reduce pressure and friction, such as repositioning, and addressing comorbidities like UTI. Nutritional assessment and skin care are also highlighted. The report concludes with a multidisciplinary approach to care, involving the main caregiver (daughter) and helpers, to ensure a better health outcome for Mrs. ABM, including wound care, pain control, and infection prevention.

Client Case
Mrs. ABM, an 85-year-old Malay lady with several chronic conditions being taken care
of by her daughter who is the main caregiver along with 2 other helpers (foreign domestic
worker) as she is bed bound and thus requires a lot of assistants. She lives at a jumbo house with
lift landing and she is now lying on a hospital bed with an air mattress support. Upon primary
diagnosis, Mrs. ABM was found to have recurrent UTI and Urinary retention. She has medical
history of hypertension, hyperlipidemia, diabetes mellitus and dementia.
Problem (Pressure Sores)
In the vulnerable older population of adult patients, the incidence of pressures is still high
and costly particularly in patients with chronic illness, and extensive, preventive and therapeutic
care interventions for pressure ulcers have been increased. Nevertheless, a combination of
extrinsic forces together with a broad variety of inherent factors which affect a person's tissue
tolerance is the cause of pressure ulcers. In the pathogenesis of pressure ulcers, the intrinsic risk
factors indicating comorbidity plays a crucial role. A deteriorating diabetes mellitus complication
is diabetic ulcers, leading to increased patient morbidity (Bhattacharya & Mishra, 2015). The
stimulating factor is often a minor trauma; however, this complication can be prevented.
Increasing the chance of relapse can also lead to better outcomes when these cutaneous lesions
are detected early. Effective detection of susceptible individuals is one of the first steps to avoid
pressure ulcers. Evidence shows that a professional nurse or a caregiver has historically
undertaken risk assessments. Nevertheless, they say that risk assessments by medical staff,
clinicians and healthcare workers can also be carried out if the preparation is performed.

The total lifetime prevalence of diabetic foot ulcer complications in patients having
diabetic foot (type 1 or 2) is as high as 25% (Bhattacharya & Mishra, 2015). The neuropathic,
neuro-ischaemic and ischaemic are three different types of diabetic foot ulcers. Neuropathy
refers to most ulcers due to minor injuries that the patient is not considered and is not handled
because there are no specific discomfort signs unless a regular diagnosis test is performed.
Myocardial infarction is one of the most important events associated with an increased risk of
ischemia owing to peripheral arterial disease (Packer & Manna, 2019). Nevertheless, ischemia
inducing diabetic ulceration adds to the cost of severe morbidity, as it could be a highly
complicated condition, as the blood supply is poor. Pressure ulcers are a sort of injury to the skin
and underlying tissue, which is put into prolonged contact during a certain period of time and
which ends in ischemia of the tissue, loss of nutrients and delivery of oxygen to the tissue.
Perhaps the most accurate definition of a pressure ulcer is a continuous pressure causing
deformation or distortion injury. Any tissue produced by external force has localized, acute
ischaemic damage. "Pressure sores" is the term commonly used in the UK but again "pain
injury" that does not include open wounds, like blisters and non-blanching erythema, are not
exact sores. The European Pressure Ulcer Advisory Panel (EPUAP) has recognized "pressure
ulcers" as a phrase commonly used in the USA and other nations (Packer & Manna, 2019).
These are also called "bedsores," "decubitus ulcers," even though they are still seldom used
because the ulcers are considered not to be triggered by lying or being in bed. Pressure ulcers can
be developed because of a combination of physiologic events and other external conditions
(Stojadinovic et al., 2013). The definitive philosophy behind tissue ischemia persuaded by
prolonged external pressure on the tissue being the sole causative factor of pressure ulcer
formation has been observed more systematically. In combination with localized ischemia and

reperfusion injury to tissues, impaired lymphatic drainage also found to contribute to the injury.
Localized ischemia and tissue reperfusion have been shown to lead to pressure sores along with
reduced lymphatic drainage (Mäki‐Turja‐Rostedt et al., 2019). The compression prevents
drainage of lymphatic fluids that increases the formation of interstitial fluids and waste and
contributes to the development of the pressure ulcer. Tissue deformation has shown to be more a
pressure ulcer formation measure than tissue strain alone (Charalambous et al., 2018).
Development of the condition of pressure ulcer depends on many factors that include the
physiology of the patient and the pressure and shear strength on the tissue. The overall risk of
pressure ulcers is also raised by underlying risk factors such as diabetes obesity and smoke. The
patient population for spinal cord injury is most at risk of developing a pressure ulcer because of
the combination of immobility and reduced sensations (Jaul et al., 2018).
When a pressure ulcer is detected, the wound size should be examined and properly
reported. The locations underlying skin condition and the volume of exudate, smell, and
tenderness are also included in the supplementary ulcer studies. Pressure ulcers usually
differentiate themselves by underestimating the concentrations of subcutaneous tissues in the
infected skin layer (Teo et al., 2019). A tissue injury involves an unstageable pressure ulcer, as
the complete wound base contains slough tissue and/or eschar. Deep tissue injury is a new
concept introduced to define a pressure condition that has a tissue fracture covered beneath
preserved skin by the National Pressure Ulcer Advisory Panel (NPUAP). Such cuts feel like
severe bruises and can rapidly deteriorate in a high-level pressure ulcer (Boyko, Longaker&
Yang, 2018).
Management Plan

The main caregiver, her daughter taking care of Mrs. ABM must assist her with
enhancing mobility, and ensuring adequate seated areas, monitoring nutritional requirements and
recommending a good diet (Bhattacharya & Mishra, 2015). Thus, for this patient, a
multidisciplinary care is required addressing the concerns the patient is having post-discharge.
Pressure sores are common among older patients with various chronic disorders due to
immobility. Since Mrs. ABM is bedbound, she is susceptible to pressure sores. Thus, her
caregiver must turn her around often and must change her position sometimes if she is under
strain. The first phase of pressure sore management is to reduce the pressure and friction it
created. Approaches require repositioning approaches. UTI is one of the leading risk factors for
developing pressure sores, and since the patient, Mrs. ABM was suffering from UTI, it is also
important to develop and implement strategies addressing her other comorbidities (Niederhauser
et al., 2012).
In order to prevent and treat Pressure Sores, a wide variety of treatments are used.
Keeping pressures at the interface between the skin and the supporting surface (e.g. the many
types of mattress and coating) at the prevention level will be the key. Main recovery techniques
require supportive surfaces and wound dressings (Atkinson & Cullum, 2018).
The goal of the nursing safety team is, when a pressure ulcer occurs, to help the team
covering the ulcer as fast as possible. The nursing care must aim to prevent further worsening of
the ulcer, to maintain the ulcer clean and moisture-free, to prevent infection, and to keep patients
free from discomfort post-discharge.
It is important to evaluate the risk factors contributing to pressure ulcers for the patient
Mrs. ABM. Her daughter, the main caregiver and the helpers should identify all potential risk
factors for pressure ulcer formation even when patients with the current pressure ulcer tend to be

vulnerable for further harm (Bhattacharya & Mishra, 2015). By doing so, the patient’s risk will
be minimized. It is also important to determine the age of the individual and the overall skin
condition. This is because elderly patients have less elasticity, less moisture, less padding and
have an epidermis thinning which makes them more susceptible to skin damage (Bhattacharya &
Mishra, 2015). By doing this, the skin integrity of the patient will be improved and the risk of
developing pressure sores will be reduced. The care plan for managing pressure sores also
includes assessing the nutritional state of the patient including, where necessary, the weight,
weight loss and amounts of serum albumin by which the nutritional deficiency will be improved
(Posthauer et al., 2015). Her daughter can also apply some barrier cream or Sanyrene oil to
prevent pressure sores (Bhattacharya & Mishra, 2015).
Pressure sores are developed as a result of continuous pressure and friction, thus the
patients who remain at a fixed position for a very long time, are more vulnerable to pressure
sores. Thus, focusing on the causal factor for pressure sores, it is important that the patients are
continuously repositioned (Low, Vasanwala, F. F., & Tay, 2014). The caregiver must foster 2
hours rotating by placing mepilex on the entire field and adding mepilex to reposition and reduce
shearing force using a slide sheet and gel pad to protect heels which will eventually decrease the
risk of developing pressure sores. It is also necessary to evaluate the skin on bony prominences
for reducing the risk of pressure sores. This is because such areas are mainly at risk of collapse
from tissue ischemia due to hard surface stress.
Conclusion
Pressure ulcer care plan aims at reducing pressures on the affected skin, care for wounds,
pain control, infection prevention and providing a good nutrition. A multidisciplinary
methodology is typically needed to address various facets of wound management for the patient

along with other comorbidities post-discharge. A primary care provider who is her daughter in
case of Mrs. ABM supervised a health care plan providing care and support to cope with injuries
and two helpers who have helped the patient to navigate services relevant to a long-term
rehabilitation was included in the care plan of the patient post-discharge from the hospital to
ensure a better health outcome.

References
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