PRESSURE ULCER – GRADE 4

Problems

1)Mr K has a grade 4 pressure ulcer on his right ischial tuberosity due to abnormal posture when seated in his chair due to a cerebral vascular accident.

2)The wound bed is covered with 100% necrotic tissue, which increases the risk of infection and is causing discomfort due to offensive odour.

3)Mr K is a risk to further development of pressure ulcers due to the following identified risk factors.

  1. Incontinent of faeces and urine.
  2. Unable to reposition himself when in bed and seated.
  3. Poor dietary intake due to difficulties in feeding and swallowing.
  4. Postural abnormality – patient leans to his right side at all times.

Objectives

1)To provide an optimum wound healing environment to facilitate healing.

2)To debride the ulcer within 2 weeks. To reduce the odour within 4 days and monitor the wound for signs of infection.

3)To correct the postural abnormality, that has caused the pressure ulcer and relieve the pressure from the affected area by supplying appropriate pressure relieving equipment and implementing a repositioning regime based on skin assessment.

4)To address the potential risk factors that place Mr K at greater risk of further pressure ulcers.

Care Plan

1)Refer to treatment chart for treatment regime. Evaluate and trace wound every 4-6 weeks. Ensure that the wound bed is treated with warm, moist and occlusive dressings that facilitate autolysis. If there are no signs of debridement within 2 weeks refer to tissue viability team for alternative methods of debridement such as larvae therapy or sharp debridement.

2)Treat with antimicrobial or charcoal dressings to reduce the odour. Observe the wound bed for any signs of clinical infection such as increased odour, pain, increased exudate, erythema, swelling or inflammation. Refer to GP for systemic antibiotics and swab wound to identify organism and record identified organism on assessment /evaluation form.

3)Mr K is to be assessed for 1 week utilising the skin inspection chart and a turning regime will be developed from the results of the skin inspection chart. The carers are to be instructed on how to assess the skin and how to use the form. Mr K is to remain on bed rest until the ulcer shows signsof healing. Mr K will be allowed to get out of bed for breakfast , lunch and dinner for periods of no more than ½ hour. When sat out he will be seated on an alternating pressure reliving cushion as identified on the pressure reliving equipment form. When in bed he is to be nursed on an alternating mattress with a profiling bed, which the position is to be changed every hour. The 30 degree tilt is to be used to reposition Mr K whilst in bed every hour, until a turning regime based on skin inspection has been developed. ( Once the turning regime has been developed the care plan should say refer to turning chart for repositioning regime , it should state who is responsible for repositioning , the frequency and what techniques and equipment is to be utilised.)

4)Equipment is to be monitored for servicing or maintenance requirements as per manufacturers instructions. Equipment for pressure relief is to be reassessed every three months or if condition changes and recorded on the equipment form.

5)The patients level of risk should be routinely reassessed every three months or if condition changes and recorded on the risk assessment form and members of the multidisciplinary team who are involved in the patients care ( specify i.e. .. GP, OT, Physio,etc….) are to be informed if changes occur in the patients level of risk.

6)(Ensure a continence assessment is undertaken) Treatment regime should be based on this assessment for example, ensure the correct use of a conveen, pads or toileting regime (state toileting regime). Encourage the use of barrier creams, which contain emollients to hydrate the skin and to protect from excessive moisture. Ensure that if body worn pads are used that bed pads are not used as well as this will interfere with the efficiency of the alternating system. Try to establish a bowel pattern and implement a toileting regime based on assessment.

7)Refer to speech therapist for assessment of swallowing difficulties and referral to a dietician for assessment of his dietary intake . The carers are to keep a food and fluid diary for a week to evaluate Mr K, s intake. Supplements prescribed as necessary. Referral to Occupational therapist for adapted cutlery may be required.

8)Once the cavity ulcer has begun to fill refer to tissue viability team and occupational therapy team to assess for appropriate seating in order to address the postural abnormality and prevent further pressure ulcer development.

9)Ensure the patient and carer understand how the pressure ulcer has formed and what the potential risk factors are for pressure ulcer development, explain the importance of the repositioning regime and the use of pressure reliving equipment and ensure patient and carers have a copy of the patient information leaflet “ Your guide to pressure ulcers” and encourage to ask questions and be involved in decisions related to their care and treatment.

10) Undertake a full range of passive exercises of his limbs at least twice daily.