Nursing: Pressure Ulcer Prevention Strategies for Joseph Russo

This case study focuses on Joseph Russo, who developed a fluid-filled blister on his left heel due to prolonged immobilization in the ICU. The paper identifies key factors contributing to pressure ulcer development, including immobility, age, and potential nutritional deficiencies. It emphasizes the importance of risk assessment using tools like the Modified Norton Scale and Braden Scale, along with skin inspections for dryness, cracks, and moisture. The proposed action plan includes pressure redistribution mattresses, assistive devices for patient movement, and nutritional support to promote wound healing. The case study concludes that preventing pressure injuries is a critical indicator of care quality, highlighting interventions such as proper skin assessment, nutritional management, and mobility assistance to address and prevent pressure ulcers in vulnerable patients.

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Introduction and brief overview
Pressure ulcers are necrosis of the cells of the skin and the surrounding tissues and
normally develops as the soft tissues are compresses between the hard surface and a bony
prominence for a prolonged period of time (Tayyib, Coyer and Lewis 2016).
This paper would draw and attention towards the case study of Joseph Russo, who had
been admitted in to the emergency department due to sudden unconsciousness and the
breathing trouble that he had been exposed to. Joseph used to take care of Sophia, who was
unable to take care of herself. Emma and Antonio are their two children, although it is only
Emma that kept contact with their parents. Joseph was transferred to the intensive care unit
for the close monitoring and the ongoing care. Joseph had been unconscious for long four
days and hence was immobilised. Hence, on the eighth day, a fluid filled blister was noted in
the left heel of Joseph that could have been developed due to the prolonged lying in the
supine position without any mobilisation at all.
This paper would discuss about the probable factors behind the occurrence of heel
pressure ulcers, linking to the medical condition of the Joseph Russo, supported by high level
of evidenced based literature. A care plan will also be developed keeping in the mind, the
clinical priorities of joseph Russo.
Search criteria and search terms
Electronic databases like Google Scholar and CINAHL has been used for conducting
search to find the highest level of evidence. Boolean operators like AND , OR has been used
to find the relevant papers. Some of the key words used are – pressure injury AND
hospitalisation, Bedsores OR Pressure injury, Pressure ulcers AND Ageing, Heel pressure

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injury AND immobilisation. The inclusion criteria included English, full text papers within
the years 2014-2018. The exclusion criteria were papers older than 2018.
Factors responsible for the development of pressure injury
Pressure sores or the bed sores are caused by any pressure against the skin that
restricts the flow of blood in the skin. They are painful and are likely to cause uneasiness and
pose a negative outcome on the quality of life. They are also costly to treat (Bhattacharya and
Mishra 2015). The occurrence and the severity of the preventable ulcer is an imperative
indicator of the quality of care. It is crucial to monitor the prevalence and the incidence rate
to ensure that the health care strategies executed are effective (Bhattacharya and Mishra
2015). It is essential to monitor the incidence of the pressure injuries. The frail people are
having an increased risk of developing pressure.
It is evident from the case study provided that Joseph had developed a fluid filled
blister on his left heel. Heel is normally a site, prone to the development of ulcers,
particularly for the people who had been in a supine position or in a semi-recumbent due to
the immobility (Shafipour et al. 2018). There is very small percentage of protective
subcutaneous tissue. No fascia or muscles are present within the heels, and makes it
susceptible to pressure and injury. Pressure injury in the heels remains an irrefutable
challenge for the nurses and the health care teams, as it can be an important cause of pain and
disability in the patient. It can be seen from the case study that Joseph had been hospitalised
for long eight days. Joseph was being ventilated for eight days due to some comorbidities and
he had been immobile for a long period of time. Joseph was also experiencing delirium, due
to which was necessary to keep him immobile and restricted as he can experience slips and
falls and it can further deteriorate the condition. Joseph is an aged patient and the risk of

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developing pressure injury increases with time. Elderly people are vulnerable to the
development of the pressure ulcer due to the several physiological changes. Some of the
factors are- thinning of the skin layers, lessened vascularisation, proliferation of the cells and
delays in the healing process. Again pain response, the skin sensibility, barriers function and
the inflammatory responses are also reduced because of ageing that makes the skin
vulnerable to the wear and the tear. The case study reveals that Joseph had been unconscious
for a longer period of time. Rondinelli et al. (2018) have stated that prolonged period of
unconsciousness, length of the operation all can lead to pressure injury due to infrequent
turning. However, no evidences have been found regarding the optimum frequency to
reposition the critically ill ICU patients. Normally two hours repositioning is considered to be
the standard practice on the basis of the anecdotal data, but the time of repositioning should
be entirely on the basis of the needs of the patient. Incorrectly used transfer aids and the use
of the medical devices like the endotracheal tubes, the nasal tubes, catheters, drains and
central venous catheter might lead to the development of the pressure ulcers.
Action plan
Pressure ulcer is a serious safety issue in the health care system. Hence in order to
make a care plan for the development of the pressure ulcers it is necessary to understand the
clinical priority of the Joseph. Risk assessment should be conducted initially after any major
surgical intervention as well as before the discharge. Some of the scales that can be used are
The Modified Norton Scale, the RAPS/RBT, the Braden scale and Waterlow (Moore and
Cowman 2014). It is necessary to assess the areas such as the sensory perception of the
patient, the moisture, activity, mobility, shearing and friction. Further, a thumb test can be
used to see whether the redness is blanchable or not. Mr Joseph would have to undergo and
an inspection of the skin. The inspection of the skin should include the assessment of the dry

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or the moist skin, the formation of any cracks on the heel. It is necessary to keep the skin
moisturised by using medicated moisturising agent (Dealey et al 2013). Pressure
redistributing mattresses can be used for the redistribution of the pressure. It is necessary to
access for the history of a chronic conditions that is pre-existing, as the patients with chronic
diseases normally exhibit several risk factors that predispose them to the pressure ulceration.
Mr Joseph should be assessed for any faecal and urinary incontinence. According to Tayyib,
Coyer and Lewis (2016) the urea in the urine turns in to ammonia within the skin and erosive
to the skin. Stools might contain enzymes that can cause breakdown in the skin. Again it is
necessary to assess the presence of an environmental moisture and excessive moisture might
lead to skin maceration.
According to McInnes et al. (2015) pressure ulcers can be prevented by the use of
support surfaces such as cushions at the vulnerable parts. I has been found that that people
using ordinary foam mattresses are more likely to develop pressure ulcers than the ones lying
in the higher specification foam mattresses. A randomised control trial conducted by Kalowes
et al. (2016) involving the critically ill patient have proved that the incidence rate of pressure
injury among the patients treated with foam dressing is comparatively low in comparison to
the control group. The choice of the base can be determined by the personal needs of that
person. It is necessary to use aids for moving the patients, as this helps both the users and the
staffs and reduces the risk of nay damage due to friction (Davis 2018). It should be kept in
mind that users should never be placed directly on the bony protuberances or on the surface
of the skin that has already been reddened. The lying and the sitting position should be
adapted to keep the pressure between the bony protuberances to a minimum. Again it is
necessary to assess the nutritional requirement of the patient. Saghaleini et al. (2018) in a
systematic review have investigated about the benefits of nutritional support to the patients
who are prone to develop pressure injury. Barry and Nugent (2015) have stated that

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weightless was a positive prognostic factor for the pressure ulcers and hence nutritional status
plays a great role in the process of wound healing of the pressure ulcers. According to
Muntlin Athlin et al. (2016) stress at the time of critical illness is linked with three distinct
metabolic phases- The acute, the hyper metabolic and the recovery phases. The clinical effect
of the metabolic responses at the time of the acute phase include the use of the carbohydrates,
muscle loss, sarcopenia and stress induced hyperglycemia.
Another risk factor related to the formation of the pressure injury in Joseph is that
ulceration might lead to infection if left untreated (Dealey et al. 2015). Hence the client
should be assessed for sepsis. It is necessary to assess the injury for colour, odour, tissue and
drainage (Davies 2018). Pressure ulcers that are foul smelling might indicate towards
infection.
Conclusion
In conclusion it can be said that prevention of the pressure injury is a quality indicator of
the type of care provided to the patient. A fluid filled blister in the left heel indicates category
II pressure ulceration with a partial skin damage. The main factors identified behind the
formation of the pressure injury are unconsciousness for a prolonged period of time,
immobility and nutritional deficiencies. The interventions included proper skin and sensory
assessment, nutritional assessment, mobility by using assistive devices for turning in case of
frail patient.

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References
Barry, M. and Nugent, L., 2015. Pressure ulcer prevention in frail older people. Nursing
Standard (2014+), 30(16), p.50.
Bhattacharya, S. and Mishra, R.K., 2015. Pressure ulcers: current understanding and newer
modalities of treatment. Indian Journal of Plastic Surgery: Official Publication of the
Association of Plastic Surgeons of India, 48(1), p.4.
Davies, P., 2018. Preventing the development of heel pressure ulcers. Nursing standard
(Royal College of Nursing (Great Britain): 1987), 33(7), pp.69-76.
Dealey, C., Brindle, C.T., Black, J., Alves, P., Santamaria, N., Call, E. and Clark, M., 2015.
Challenges in pressure ulcer prevention. International wound journal, 12(3), pp.309-312.
Kalowes, P., Messina, V. and Li, M., 2016. Five-layered soft silicone foam dressing to
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pp.e108-e119.
McInnes, E., Jammali‐Blasi, A., Bell‐Syer, S.E., Dumville, J.C., Middleton, V. and Cullum,
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Muntlin Athlin, Å., Engström, M., Gunningberg, L., and Bååth, C. 2016. Heel pressure ulcer,
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Rondinelli, J., Zuniga, S., Kipnis, P., Kawar, L. N., Liu, V., and Escobar, G. J. 2018.
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