Pressure ulcer - Nursing Case Study

Pathophysiology

• Primary Mechanism: Pressure ulcers primarily form due to prolonged pressure on the skin. This pressure, especially on bony prominences, compromises blood flow, depriving the skin and underlying tissues of oxygen and essential nutrients, leading to cell death and ulceration.

• Secondary Mechanism: Shear and friction contribute to pressure ulcer development. Shear occurs when skin layers move in opposite directions, damaging blood vessels and impairing circulation. Friction, caused by the rubbing of skin against surfaces, can strip away the outer skin layer, making it more susceptible to pressure ulcer.

• Key Complication: Infection is a serious complication of pressure ulcers. Open ulcers can become a breeding ground for bacteria, leading to local infections, cellulitis, and potentially life-threatening systemic infections like sepsis.

Patient Profile

Demographics:

70-year-old female, retired school teacher

History:

• Key past medical history: Diabetes Mellitus Type II, Hypertension, Osteoarthritis

• Current medications: Metformin, Lisinopril, Paracetamol

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Painful sore on the lower back

• Key symptoms: Persistent pain on the lower back, reddened skin that worsens over time, localized swelling, skin discoloration, foul-smelling discharge from the sore.

• Vital signs: Blood pressure: 160/90 mmHg, Pulse: 98 bpm, Respiratory rate: 22 breaths per minute, Temperature: 99.1°F, Blood glucose level: 180 mg/dL.

Section 1

New Diagnostic Results:

The patient's wound culture report came back positive for Methicillin-Resistant Staphylococcus Aureus (MRSA), indicating a localized infection of the pressure ulcer. Lab results revealed a raised white blood cell count of 14,000/mm3, indicating an ongoing infection. The HbA1c level was 8.5%, which is above the desired range for someone with diabetes, suggesting poor blood glucose control over the past few months. Her blood glucose level of 180 mg/dL at presentation also points towards poor diabetes management.

Further examination of the pressure ulcer using the Braden Scale for predicting pressure sore risk gave a score of 12, suggesting moderate risk. The ulcer measured 3 cm x 2 cm, with some areas of necrotic tissue. The wound was deep, extending into the subcutaneous tissue, indicating a stage 3 pressure ulcer. The presence of foul-smelling discharge from the sore and surrounding erythema further supports the infection diagnosis.

This new information requires immediate action. The infection could potentially spread, leading to cellulitis or even sepsis, a life-threatening condition. The poorly controlled diabetes could be a contributing factor to both the development and slow healing of the pressure ulcer. Effective diabetes management is crucial in her overall treatment plan.

Section 2

New Complications:

Over the next 24 hours, the patient's condition worsened. She started complaining of increased pain and discomfort around the wound site. On observation, there was increased erythema and edema around the pressure ulcer, and the foul-smelling discharge had increased. An inspection of the wound revealed that the necrotic area had grown larger, and there was some pus formation. Her temperature spiked to 38.5°C indicating a systemic inflammatory response from the worsening infection.

On reviewing her latest lab results, her white blood cell count had increased to 17,000/mm3, which further confirmed the escalated infection. Her blood glucose levels were consistently high, ranging from 200-250 mg/dL during the last 24 hours, despite the administration of insulin as per sliding scale. The nurse also noted an increased heart rate of 110 beats per minute and a drop in blood pressure to 100/60 mmHg. This could be the body's response to the infection or an indication of early septic shock. This new set of complications need immediate addressal and a change in the patient's care plan.

Section 3

Change in Patient Status:

Over the next eight hours, the patient's condition deteriorated further. She became increasingly lethargic and confused, and her pain was escalating, with her rating it as an 8 on a scale of 1 to 10. The nurse noted that her skin appeared clammy and her extremities were cold to touch. Her blood pressure had fallen to 90/55 mmHg, heart rate had spiked to 120 beats per minute and her temperature remained high at 38.7°C. Respiration was slightly labored at 22 breaths per minute. The patient's oxygen saturation levels were also lower than normal at 92% on room air.

New Diagnostic Results:

Urgent blood and wound cultures were ordered by the physician and the results came back positive for Staphylococcus aureus, a common bacteria known to cause skin and wound infections. In addition, her blood glucose levels had now risen to 280 mg/dL and her white blood cell count had further increased to 19,000/mm3, confirming the escalating infection. Lab results also showed elevated levels of lactate at 4.0 mmol/L, indicating possible tissue hypoperfusion due to sepsis. Given these findings and the patient's deteriorating clinical status, the healthcare team was suspecting septic shock, secondary to the infected pressure ulcer. Immediate changes to her care plan were required to manage these new developments.

Section 4

New Complications:

Over the next few hours, the patient's condition became more critical. She developed rapid, shallow breathing and her oxygen saturation levels dropped further to 88% despite the patient now being on supplemental oxygen. Her blood pressure continued to decline to 85/50 mmHg and her heart rate accelerated to 130 beats per minute. Meanwhile, her temperature spiked to 39.2°C, indicating a worsening infection. In addition, the patient started complaining of abdominal discomfort and nausea.

On examination, the nurse noticed that her abdomen was distended and tender to touch, particularly in the right lower quadrant. Her bowel sounds were hypoactive and she reported not having had a bowel movement for the past three days. These new findings raised concerns of a possible ileus or bowel obstruction, potentially secondary to the sepsis or as an adverse effect of the opioid medication prescribed for her pain. This new complication required immediate attention, as it could exacerbate her sepsis and further compromise her already unstable hemodynamic status. The healthcare team ordered an urgent abdominal CT scan and consulted with the gastroenterology team for further evaluation and management.

Section 5

Change in Patient Status:

Over the next few hours, the patient's condition continued to deteriorate. Her oxygen saturation levels plunged further to 84%, despite being on maximum supplemental oxygen. The patient's blood pressure nosedived to 80/45 mmHg, and her heart rate continued its upward trend, reaching 140 beats per minute. She became increasingly lethargic and her skin was clammy and pale.

The patient's abdominal distention grew worse and she started to vomit. Her abdominal pain also increased, with the patient rating it as an 8 on a scale of 0-10. Her bowel sounds were almost non-existent now, and she reported not having passed gas in addition to the absence of bowel movements. Reassessment of the pressure ulcer revealed worsening erythema and edema, with the wound now measuring 4.5 cm in length, 3 cm in width, and 1.5 cm in depth. These findings suggested a worsening of her septic state, possibly coupled with an ileus or bowel obstruction, and required urgent intervention.