Question

2. You are a visiting nurse caring for a 32-year-old writer who became paraplegic as a result of a motorcycle accident 1 year ago. He is recovering from a subsequent depression; your visits are to monitor not only his emotional outlook but also to encourage his hygienic self-care and offer strategies for his success. He wears a leg bag and is incontinent of stool. You are monitoring a red spot on his left buttock, which has progressed to a pressure ulcer in which subcutaneous fat is visible. (Learning Objectives #3, #4, #5, & #6)

a. Outline the mechanisms that contributed to the development of the pressure ulcer.

b. What specific assessments should be performed to prevent formation of pressure ulcers?

c. How would you stage his pressure ulcer?

d. Indicate the information that would be included in an assessment of his wound.

e. Identify appropriate outcomes for this patient’s plan of care.

Answer 1

a) mechanism of pressure ulcer formation

as the name suggests pressure ulcer is the prime result of continuous pressure between the bony prominence and external skin surface.Either increased pressure over an area for a short period or less pressure over an area for a longer period can leads to occlusion of the capillaries.This results in decresed oxygen supply(anoxia) over that area and cells there starts to die results in tissue necrosis.If the pressure continue to sustain over the same area degenerative changes occurs at all the levels simultaneously from skin to subcutaneous fat,muscles and bone.

b) assessment to prevent formation of pressure ulcer.

• daily assessment of the skin for any colour change especially in areas of bony prominance eg.buttocks,heel,shoulder blade etc.
• assess frequency of position change of the patient.
• check the condition of the legbag regularly especially after changing position of the patient for any leakage of the bag.
• assess the diaper regulraly to see it is not overly soaked by the incontinance.if it is change immediately.

c) patients ulcer is in the third stage of ulcer formation.

stage 3 - full thickness skin loss involving damage or necrosis of subcutaneous tissue and underlying fat is visible.

d) on assessment of the wound major findings are,

• risk for progression of the ulcer is present as the patient is paraplegic and is fully bedridden.
• risk for ulcer progression is increased by highly moist buttocks area due to the presence of legbag and frequent fecal incontinence.
• ulcer is progressed to stage 3 were it is beyond the subcutaneous tissue and underlying fat is visible.
• close nursing care is needed as the patients selfcare abilities are limited and also ulcer condition is worsening.

e) outcome for patients plan of care.

• pressure ulcer will start to heal by covering up the necrosed parts.
• risk for future development of ulcer will be reduced by proper hygienic measures and reduction in the friction.
• patient will start to perform selfcare activities which is possible by him.
• patient will develope a positive attitude towards life by understanding the disease condition.