Stage 3 pressure injury - Nursing Case Study

Pathophysiology

• Primary mechanism: Prolonged pressure on the skin reduces blood supply to the area, leading to tissue hypoxia and necrosis. In Stage 3, this damage extends into the subcutaneous layer, creating a deep, open wound.

• Secondary mechanism: The impaired blood supply also hampers immune response in the affected area, increasing susceptibility to infection. These infections can exacerbate tissue damage and slow wound healing.

• Key complication: If untreated, the wound may tunnel under intact skin or involve underlying muscle and bone (Stage 4), increasing the risk of systemic infections like sepsis.

Patient Profile

Demographics:

72-year-old male, retired construction worker

History:

• Key past medical history: Type II Diabetes, Hypertension, previous Stage 2 pressure injury

• Current medications: Metformin, Lisinopril, Topical antibacterial ointment for wound care

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Persistent severe pain in the sacral area, worsening pressure injury

• Key symptoms: Increased redness and swelling around the wound, foul-smelling discharge, fever, confusion

• Vital signs: Elevated temperature (38.5°C), elevated heart rate (110 bpm), slightly elevated blood pressure (150/95 mmHg), low oxygen saturation (92%)

Section 1

Change in Patient Status:

Over the course of the next day, the patient's condition deteriorated. His temperature climbed to 39.2°C and heart rate increased to 120 bpm, while his blood pressure remained elevated at 155/100 mmHg. His oxygen saturation also dropped further to 89%. The patient exhibited increasing lethargy and confusion. His sacral wound appeared more extensive with increased redness, swelling, and purulent discharge, suggesting deepening infection and progression of the pressure injury. His pain level remained high, impeding his ability to shift positions and alleviate pressure on the wound area.

New Diagnostic Results:

To determine the cause of the patient's worsening condition, a comprehensive set of labs was ordered. The complete blood count (CBC) showed a high white blood cell count of 15,000 per microliter, indicating an ongoing infection. A wound culture was taken and it revealed the presence of Methicillin-resistant Staphylococcus aureus (MRSA), a type of bacteria that is resistant to many antibiotics. The patient's blood glucose level was found to be elevated at 210 mg/dL, reflecting poor control of his diabetes. An X-ray of the sacral area showed early signs of osteomyelitis, suggesting that the infection may have spread to the underlying bone. The worsening infection, along with the patient's uncontrolled diabetes, are likely contributing to the poor wound healing and progression of the pressure injury.

Section 2

New Complications:

In the following days, the patient's condition continued to worsen. Despite aggressive antibiotic therapy, his fever persisted and his wound infection showed no signs of improvement. He began to complain of persistent nausea and loss of appetite, leading to a significant decline in his nutritional status. His body mass index decreased from 22 to 20 within a week. The patient's blood tests revealed further complications, with elevated blood urea nitrogen (BUN) and creatinine levels indicating impaired kidney function, likely due to dehydration and sepsis from the worsening wound infection. His BUN was elevated to 30 mg/dL and creatinine was 2.0 mg/dL.

Response to Interventions:

In response to the patient's deteriorating condition, several new interventions were initiated. Intravenous fluid resuscitation was started to address dehydration and support kidney function. A nutrition consult was requested, and the dietitian recommended starting a high-protein, high-calorie diet to support wound healing and prevent further weight loss. The patient was also placed on a more potent antibiotic regimen after the wound culture results showed MRSA. Despite these interventions, the patient's wound continued to show signs of infection with increased purulent discharge and a foul smell. Wound debridement was considered, but the patient's poor overall condition and the risk of further spreading the infection made this option less viable. The team decided to continue with current management and closely monitor the patient's response.

This situation calls for a reassessment of the treatment plan and a consideration of alternate interventions to control the infection and support wound healing. It highlights the complexity of managing a patient with multiple comorbidities and a severe pressure injury, requiring a multi-disciplinary approach and ongoing clinical reasoning.

Section 3

New Diagnostic Results:

As the patient's condition did not improve, further diagnostic tests were conducted to acquire a more comprehensive understanding of his condition. An abdominal ultrasound was ordered to assess his kidney function. The results showed an increased cortical echogenicity, indicating possible renal disease. His GFR (glomerular filtration rate) was 45 mL/min/1.73 m2, suggesting moderate kidney damage, and his urine output had decreased to less than 30 mL/hr.

Additionally, a wound swab was sent off for a second culture and sensitivity test, as there was a suspicion that the infection might be resistant to the current antibiotic regimen. The results confirmed the presence of MRSA but also revealed a co-infection with Pseudomonas aeruginosa, a bacterium known for its resistance to a broad range of antibiotics. This finding explained the patient's lack of response to the current antibiotics and necessitated a change in medication.

These new diagnostic results not only confirmed existing complications but also uncovered further challenges in managing the patient's condition. They required the healthcare team to reassess the current treatment plan and consider alternate interventions to effectively combat the co-infection and manage the patient's deteriorating renal function. It emphasized the need for continuous evaluation and adaptation in clinical practice.

Section 4

New Complications:

The patient's condition continued to deteriorate over the following days. His temperature spiked to 38.7 degree Celsius, his heart rate increased to 110 beats per minute, and his blood pressure dropped to 90/60 mmHg. He also began experiencing shortness of breath, with his respiratory rate increasing to 24 breaths per minute and oxygen saturation dropping to 92% on room air. His skin became cool and clammy, further raising concerns about septic shock due to the uncontrolled infections.

Moreover, the patient began exhibiting signs of acute kidney injury (AKI). His serum creatinine level had risen to 2.0 mg/dL from a baseline of 0.9 mg/dL, and his urine output remained persistently low at 20 mL/hr. His electrolyte panel showed hyperkalemia with a potassium level of 5.5 mmol/L, and his BUN (blood urea nitrogen) level had also increased to 40 mg/dL. These findings indicated worsening renal function, likely due to a combination of the infection, potential nephrotoxic effects of the antibiotics, and his underlying moderate kidney disease. The healthcare team was faced with the challenge of managing the patient's sepsis while also addressing his renal complications. This situation called for a balance in providing aggressive treatment for the infection without exacerbating the patient's kidney injury.

Section 5

Change in Patient Status:

Over the next few hours, the patient's condition became increasingly unstable. His blood pressure continued to drop, now measuring at 85/55 mmHg, and his pulse rate climbed to 120 beats per minute. His oxygen saturation also fell further to 88% on room air, necessitating supplemental oxygen via a nasal cannula. Despite this intervention, his shortness of breath persisted, and his respiratory rate increased to 28 breaths per minute. His temperature remained elevated at 38.9 degrees Celsius, indicating ongoing infection and sepsis.

Simultaneously, the patient's renal function continued to decline. His serum creatinine level rose to 2.3 mg/dL, and his urine output fell to just 15 mL/hr. His electrolyte panel now showed severe hyperkalemia with a potassium level of 6.2 mmol/L, and his BUN level was up to 45 mg/dL. These worsening findings, combined with his deteriorating vital signs, suggested that the patient was progressing towards septic shock and acute renal failure. His healthcare team was now faced with an urgent need to stabilize his condition, while still balancing the risks and benefits of aggressive sepsis treatment against the potential for further kidney injury. This situation required rapid clinical reasoning and decision-making, as any delay could result in significant patient harm.