Introduction

Ms. Zona is an 83 – year - old female patient who has been admitted to the hospital for worsening of the pressure ulcers on both of her heels. She has a medical history of type 2 diabetes (T2D). Surprisingly, she demonstrates poor understanding of her illness and its management. Due to this factor, diabetic complications seem to be almost certain. With a BMI of 31, she seems to be an obese patient, which means she is either not aware or not educated enough on the health risks associated with obesity. Her heel ulcers are painful; therefore, she tends to spend most of the time on bed rather than placing the feet on the ground. The ulceration is classified as stage III ulceration, which means it is in advanced stage with a full thickness skin loss and the underlying adipose tissue should be visible (EPUAP, 2009).

Discussion

We will begin our discussion by first understanding what pressure ulcer is? A pressure ulcer is a localized injury to the skin and tissues below the skin, which occurs due to pressure (Health Quality Ontario, 2009). Such kinds of ulcers pose a significant challenge to the healthcare system; and patients with pressure sores are subjected to considerable discomfort and pain. Though, every effort needs to be made by the patient himself and his treating healthcare professionals to prevent occurrence of ulceration, not all can be prevented (Fletcher, 2011). Heel is particularly prone to development of pressure ulcers because of the fact that the entire weight of the body falls on the heels. The impact or harm can be more in cases of overweight or obese patients. Ms. Zona is obese, which is a risk factor for development of pressure ulcers.
A lot of literature shows that multifactorial pathologic conditions are responsible for development of pressure ulcers in the elderly, one of which is T2D (Jaul, 2010). Diabetes is a common risk factor for development of pressure ulcers. Diabetic neuropathy is the most common complication of uncontrolled diabetes and diabetic foot ulcer is most commonly associated with neuropathy (Jaul, 2010). Due to loss of sensation in the feet as what happens in case of diabetic neuropathy, patients normally do not realize if they hurt their feet any time; therefore, minor injuries even from an ill-fitting shoe often goes unnoticed. It has been found in clinical practice that the most common cause of foot ulcer is ill-fitting footwear. Ill-fitting shoes are found to be instrumental in development of calluses, corns, and blisters, which ultimately lead to ulceration (Birke, 2000 and Tyrrell, 2002). Since Ms. Zona is a T2D patient and she demonstrates a poor understanding of her condition, we can very well assume that Ms. Zona’s underlying pathology of T2D could be responsible for her pressure ulcers. Elderly usually have chronic diseases, nutritional deficiencies, or immobility. Pressure ulcers are just a result of these conditions that predispose the aging skin to increasing vulnerability (Jaul, 2010).
Importantly, Ms. Zona is 83 year old. For many geriatric patients, pressure sores become chronic without any apparent cause and can remain so for long periods of time, making the patient bed ridden due to pain (Jaul, 2010). Patients can even die due to a complication of ulcer (Jaul, 2010). Therefore, assessment and management of a pressure ulcer in the elderly is different from other age groups; it needs understanding the underlying pathologies, severity of the underlying pathology, comorbidity, activities of daily living, nutritional status, and degree of emotional and social support.
Taking into consideration all the contributing factors like T2D, obesity, and old age the treatment to be offered for Ms. Zona needs to be the custom-made.
Nurses are always at the forefront of any medical care. Nursing profession demands that a nurse considers the whole person (patient) while collecting and analyzing data, and not just the wound (Peterson, 2012). This is with an objective to assess, diagnose, plan, implement, and evaluate a particular case. Nurses generally work under stressful conditions and the management of individuals with foot ulcers is complex (EPUAP, 2009). There are recommendations to serve as a guide for nurses to identify and assess high risk patients like Ms. Zona.
Ms. Zona’s heel ulcer is a wound and the nurse’s role would be to facilitate wound healing. There is no gold standard for treating pressure ulcers, but clinical practice guidelines and protocols influence the standard of care (Thomas, 2006). For a nurse, just understanding the wound is not enough; but needed is an understanding of the physiological and pathological processes of the aging skin. The goal of treating a pressure ulcer is to manage to heal the wound by optimizing local blood flow, managing underlying pathologic condition, and providing adequate nutritious diet rich in proteins (by use of dietary supplements by mouth or by the use of tube feeding), all to facilitate early healing (Jaul, 2010). In case of Ms. Zona’s ulcers that have already become chronic, the goal is to control symptoms of discomfort, pain, foul smell, and prevention of infection and further, to prevent complications. This will ensure patient’s over all wellbeing.
The ulcer is already assessed for its location, number, stage, and size. The nurse needs to begin with assessment for the presence of odor, exudate, necrosis, tunneling, undermining, infection, signs of healing, and wound margins (Bluestein, 2008).
As a primary requirement, nurse should have all the required knowledge and collaboration to provide care to her patient. She should have a good understanding of ulcer as a condition. With the help of this knowledge, she should offer to educate the patient on the illness as well as general wellbeing (Nursing Best Practice Guidelines, 2005).
Nurses are in a unique position to promote the maintenance of healthy feet (RNAO, 2004). Research has shown that self-care in diabetes leads to better blood sugar control. Thus, improved glycemic control facilitates healing of wounds and so also heel ulcers (DCCT Research Group, 1993; RNAO, 2004; UKPDS Group 33, 1998). Since Ms. Zona has demonstrated a poor understanding of her condition of T2D, the treating nurse should assess the need to educate her on the illness and importance of self - care. Ms. Zona should be encouraged to annually carry out inspection of her feet by a healthcare professional, in addition to daily self - inspection for pricks and sores. She needs to be educated on proper skin and nail care and asked to seek immediate help if any unusual sign is observed or symptom present.
Since Ms. Zona has unbearable pain in the ulcer area, pain management should be taken up on a priority. Proper pain management helps promote a patient’s comfort and compliance with the treatment offered. As a first step, assessment of the magnitude of pain should be done and opioids or non-steroidal anti-inflammatory drugs (NSAIDs) should be given about half an hour prior to dressing (AHRQ, 2011a). Locally on the ulcerations, topical analgesia like lidocaine preparations, ibuprofen-impregnated dressings, diamorphine hydrogel should be applied (AHRQ, 2011a); topical application of analgesia should be done only after cleansing and debridement of the wound.
While offering treatment to Ms. Zona, the nurse has to keep a continuous dialogue with her on the importance of self - care in diabetes and prevention of complications. The next step in treatment is to clean and dress the ulcers appropriately. The intent of doing this is to keep the area clean and free from infection along with promoting healing of the wound (EPUAP & NPUAP, 2009). The nurse can accomplish this using a cleansing solution or irrigation solution. The devitalized tissue in and around the wound needs to be removed (EPUAP & NPUAP, 2009). To cleanse the wounds, one can use tap water, distilled water, or boiled and cooled water or normal saline (salt water) (AHRQ, 2011c). Solutions like Dakin’s solution, iodophor, povidone iodine, hydrogen peroxide, and acetic acid should not be used for cleansing because it is suspected that these solutions are cytotoxic to fibroblasts that are needed for tissue regeneration (Porter, 2007; Lundgren, 2005; Miller, 1992). Debridement can also be done as a part of cleaning. If there is slough or necrotic tissue, high pressure irrigation may be needed (Spear, 2011). This has to be followed by dressing. Dressing helps to keep the wound bed moist, controls drainage, and helps in faster healing (AHRQ, 2011c). There are few products available for dressing like transparent film dressing, hydrocolloids, hydrogels, foam dressings, or alginate dressings etc. (Peterson, 2012). Since Ms. Zona has stage III ulceration, an alginate dressing would be appropriate. Adequate cleansing and debridement is also with intent to control infection of the wound. Debridement should be by surgical intervention since the ulcers are stage III. In cases of advanced ulcers like stage III or stage IV, lasers or sharps are used to selectively remove the necrotic tissue and debris from wounds (AHRQ, 2011c). Accordingly, the nurse needs to cleanse and debride the wound, followed by appropriate dressing.
Stage III ulcer patients are ideal for an evaluation of possible surgical closure only if the patient is deemed as appropriate for surgery (Gupta, 2004). In case of Ms. Zona, it may not be possible considering her very old age. In such cases, her treating physician has to think of an alternative like negative pressure wound therapy to temporize the wound base (Mendez-Eastman, 2006). The nurse needs to assist by cutting the foam dressing to conform to specific shape and size of the wounds and placing it in the wound cavity. The foam dressing needs to be covered with an adhesive tape so that the previously open wound is now sealed and air proof. Evacuation tubing needs to be either attached to the foam dressing or inserted into it. This is further connected to a collecting canister, which is connected to an adjustable vacuum pump. The pump functions to deliver continuous or intermittent negative pressure that is transmitted uniformly to all wound surfaces. This procedure promotes wound healing by removing tissue fluids, removing wound exudate, reducing infectious material, and assisting in formation of the granulation tissue (Mendez-Eastman, 2006).
The nurse needs to inspect the area daily and change the dressing every day. She has to administer analgesics 6 hourly or 8 hourly as advised by the physician. Further, based on treatment offered, as Ms. Zona’s ulcers give an indication of healing and become shallow, hydrocolloid dressing can be applied (Heyneman, 2008). Hydrocolloid dressings have a number of key benefits; they create a moist wound-dressing interface, which facilitates autolysis and promotes the formation of granulation tissue. This creates a local wound environment conducive to wound healing. It also protects the skin around the wound; removes necrotic tissue and slough, and maintains moisture over the wound bed and at the same time does not over hydrate the wound (Heyneman, 2008).
Even at the stage during treatment, when the ulcers were categorized as grade III, i.e., in the initial stages, hydrocolloids can be used as secondary dressing owing to their waterproof backing nature and their ability to reduce friction. An alginate dressing can be usefully covered with a hydrocolloid dressing (Fletcher, 2011).

Nutritional support

Throughout the period of treatment, adequate nutrition is very important for the process of timely wound healing. Nutritional screening should be a part of general evaluation of Ms. Zona. Considering Ms. Zona’s age, it is likely that she may be malnourished due to swallowing problems associated with old age. If Ms. Zona is capable of eating well, she should be encouraged to have healthy nutritious food. She should be enquired about her favorite food, which if healthy, can be provided to her along with healthy snacks throughout the day. Even high-calorie food and supplements can be used to prevent malnutrition (Bluestein, 2008). However, if she is not adequately able to have food orally or if it seems impractical, enteral or parenteral feeding should be considered, if compatible with her wishes, to achieve positive nitrogen balance (approximately 30 to 35 calories/ kg body weight/day and 1.25 to 1.5 g of protein/ kg body weight/ day). Supplements of zinc and vitamin C have shown to support the effectiveness in accelerating wound healing. Adequate protein intake is very important for wound healing as it is needed for fibroblast proliferation, collagen production, adequate immune response, and angiogenesis (RCN, 2005). The nurse should first study Ms. Zona’s nutritional status and offer adequate guidance/ modification of the dietary habits and keep a track if she is following regular and timely healthy and nutritious eating practice.
Since Ms. Zona spends most of her time on bed due to painful ulcers, the goal after the treatment period is to see to it that she is able to stand on her feet and comfortably walk around. The nurse needs to advise her to wear soft, well- fitting, and comfortable footwear every time and not walk bare feet even inside the house. This is to prevent further injury to the feet. Successful management of heel ulcers can significantly improve not only the patient’s overall quality of life, but also her family and care givers. Patient education, involvement in planning and implementing a treatment care plan are all important and offer significant benefits. Such patients who are well educated and made aware of their risks and illness can help in reducing re-occurrence. A sustained long term follow up can also enhance knowledge of the patient and produce positive outcomes (CDA, 2003).

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