Combined pressure ulcers and moisture lesions in acutely deteriorating patients

According to European Pressure Ulcer Advisory Panel (EPUAP, 2009) a pressure ulcer is defined as “a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear”. To complete the definition of a pressure ulcer, the author of this essay is quoting the latest guidelines of National Institute for Health and Care Excellence (NICE, 2014) which testifies that “Pressure ulcers are caused when an area of skin and the tissues below are damaged as a result of being placed under pressure sufficient to impair its blood supply.” In acute and critical care settings, the pressure ulcers are often accompanied simultaneously by moisture lesions which could appear as an inflammation with or without erosion of the skin following to a prolonged exposure to urine or faces due to incontinence (Gray et al., 2011).

This essay is a critical incident analysis regarding a patient with a sum of medical conditions which led to the appearance of a combined lesion of pressure ulcer with moisture lesion. Due to Confidentiality NHS Code of Practice (2003) the author will name the patient Mrs Smith. Mrs Smith is a 69 year old lady whose weight is 70kg, height of 161 cm and BMI of 27. She is a dialysis patient for the last year admitted in a high dependency unit feeling unwell following a failed simultaneously pancreas-kidney transplant. The established renal failure is secondary to Type 1 Diabetes Mellitus. Previously she was receiving dialysis for 6 years. During her extended admission the patient was intermittently subject to infections with MRSA, VRE, Klebsiella, and Clostridium Difficile. Mrs Smith was admitted querying sepsis of unknown cause. On admission Mrs Smith was a high risk for the development of pressure ulcers as she was critically ill and had developed a number of new comorbidities. This essay will focus solely on the predisposing factors which contributed to the appearance of the pressure and moisture ulcers, and the care management of the combined lesion. The main causes leading to Mrs Smith’s combined lesion are due to double incontinence, decreased nutritional intake and oedema. Other physical causes were: decreased mobility due to surgery, low blood pressure due to sepsis, and depression.

An inpatient risk assessment needed to be conducted when Mrs Smith was admitted in hospital in order to prevent the apparition of the pressure ulcers and to establish a correct care plan for a positive outcome during hospital admission. Using the risk assessment correctly could help to identify the patients with an increased risk of developing a pressure ulcer which can have serious health and psycho-social consequences in patient’s life (Joseph and Davies, 2013). The pressure ulcer screening tool - Waterlow score, was above 22 which placed Mrs Smith in the “at high risk” category of developing pressure ulcers. The aim in this case was to prevent and apply the treatment policy when a patient scores above 22 (Kelly, 2005). The assessment highlighted that there were already several existing risk factors such as, limited movement in bed but not yet fully restricted, and a nutritional deficiency. The poor nutritional score on the Waterlow assessment showed the need to assess in more detail the nutritional status and nutritional requirements. Scoring more than 22 made Mrs Smith eligible for the pressure-relieving equipment in order to maintain and protect further the integrity of the skin. The Royal College of Nursing (2001) discusses the need for all patients that are a very high risk of pressure ulcer development should be placed on a pressure relieving mattress as a prevention strategy. Mrs Smith was therefore put on a Nimbus 3 Mattress. A Nutrition Care Plan was also commenced and additionally she was referred to the dietitian. However, despite the approaches of prevention and the increasing efforts to reduce the occurrence of pressure ulcers, they are still seen frequently in older people in a hospital environment (Jaul, 2010). This happened with Mrs Smith.

After an ultrasound scan was done, the medical team found that Mrs Smith had developed a collection around the pancreas, and the removal of the transplanted pancreas was performed. As Scott and Buckland (2005) mentioned in their article, the surgical patients are mainly at risk to develop pressure ulcers. The authors of this article are very reputable, making this statement trusted. The references used for this article however, are quite old; circa 1998, making this source unreliable to some extent. Other articles such as Nixon et al. (2007) emphasize “the importance of detailed skin assessment and observation in the care of high risk patients”. Nixon et al. (2007) is a cohort study, based on 109 over 55 patients post-surgery within one acute hospital setting. Although the participant number of 109 is small, the validity of the authors and the references used, create a reliable source of evidence. When comparing both Scott and Buckland (2005) and Nixon et al. (2007), the articles both demonstrate the same, clear point that any patient undergoing a surgical procedure are at a higher risk of developing pressure ulcers. Mrs Smith’s condition got worse due to infection and the other comorbidities. Additional risk factors include urinary incontinence, diarrhoea, decreased level of consciousness, ability to maintain and change position, extremes of weight, nutrition and hydration status, moisture on the skin (NICE, 2005). Although Mrs Smith’s condition was continuing to deteriorate, she was subject to a continuous assessment of the pressure area since the crucial action to prevent the pressure ulcers is the skin assessment of the pressure area (Whiteing, 2009).

Being a renal patient, Mrs Smith’s urinary output was decreased, and because of the drowsiness and physical issues of poor mobility, she became incontinent. An indwelling catheter was placed but after a few days it was removed due to increased risk of infection and very low drainage. Mrs Smith still remained incontinent, despite the fact the urine output was decreased it still created a moist environment on the skin. This was the moment when the skin was compromised as a consequence of medical and surgery comorbidity, and maintaining its integrity became challenging (Bardsley, 2013). A new risk assessment was performed, a repositioning and a wound chart were added to the nursing notes, Barrier Shield wipes and Cavilon cream were used, in order to protect the skin from further deterioration, losing epidermis, maceration, getting broken and being painful (Gray et al., 2007). In order to prevent the pressure ulcer the repositioning is essential, and needs to be done regularly for the patients’ benefits. The areas prone to develop pressure ulcers are sacrum, coccyx, and ischial tuberosities. The aim of maintaining an accurate schedule for repositioning with the repositioning chart is to prevent extended high pressure on these areas through changing patient’s position with the intention of relieving the pressure. Although Mrs Smith had regular repositioning sometimes due to the work environment, shortages of staff and busy shifts the repositioning was not done as per NHS guidelines. However, even though the patient is repositioned regularly using the three main position supine, turned left and turned right, the risk to develop pressure ulcer still remains. The same tissue remains exposed at pressure be it through touching the mattress or from supporting pillows in order to maintain the lateral turned position (Peterson et al., 2013). Additionally, Mrs Smith started to have diarrhoea, which she was also incontinent with. However, urinary incontinence alone could have created moisture damage due to urea-ammonia and change of the pH of the skin, but the incontinence of faeces increased further risk causing enzyme activity and microbes. Double incontinence with frequent cleansing created chemical and physical irritation, leading furthermore to increased permeability. The barrier function of the skin was diminished and became vulnerable to breakdown through friction and/or shear so that occurrence of inflammation was inevitable (Ersser et al., 2004).

As the patient’s general condition did not give any sign of improvement, the skin started to get inflamed causing erythema to occur, but with no broken skin. At this stage the lesion was clearly a grade 1 moisture lesion which was soon to expand to a grade 2 moisture lesion, erythema with less than 50% broken skin. Albeit all the prevention measures were taken and the treatment was given as per our trust Guidelines with Swash wipes and Cavilon (No Sting barrier film), washing and/or cleaning when necessary plus repositioning of the patient every 2-3 hours, the excoriation exacerbated further to a grade 3 on an extended area. All the skin layers, the epidermis, dermis, the subcutaneous tissue and the superficial fascia on the sacral area were damaged. Due to constant exposure to faeces and urine, the skin lost permeability increasingly becoming too moist and fragile. Reaching this level, the conventional management of using incontinence pads and pants proved inefficient contributing to the epithelial tissue breakdown following to a change in pH which occurred because of the increase of the activity of protease and lipase (Copson, 2006). The medical team was aware at all times of Mrs Smith’s condition regarding the moisture ulcer and recommended her for the management of the incontinence of faeces with a passing drainage device. The Flexi-Seal tube was inserted, and the moisture ulcer was more manageable, within time the wound soon showed signs of healing. However, despite the fact that the incontinence of faeces is very common the management of it is sometimes complicated (NICE, 2007). These devices are very efficient when the stool is watery, they are comfortable and well tolerated by the patients but they do have some disadvantages (Hurnauth, 2011).  Once, Mrs Smith’s stool consistency changed from a type 7 to a type 6 in the Bristol Stool Chart, the Flexi-Seal tube started to get blocked and leak making the moisture ulcer to regress back to a grade 3. Furthermore, the Flexi-Seal had a psychological effect contributing to Mrs Smith’s depression through embarrassment, humiliation and frustration (NICE, 2007).

As the author said Mrs Smith had from the beginning of her admission reduced appetite, and throughout admission her appetite deteriorated more. From all accounts of literature, the poor nutritional state is linked with impaired healing, impaired organ function through reducing the body’s oxygen supply, plus increased risk of infection through decreased immunologic activity (Johnston, 2007). According to the clinical guidelines NICE (2005) nutritional supplementation is advised for the patients with pressure ulcers in order to provide the optimal nutrition necessary for the healing process. Once the nutritional status and the nutritional requirements were established using the Nutrition Risk Assessment Tool, Mrs Smith was referred to the dietician, who in the beginning added to the patient’s nutrition supplements of Ensure Two Cal twice/daily. The patient was very reluctant and refused to have them regularly. The Royal College of Nursing document states that 'patients and their carers’ are to be fully informed and share in decision-making' (RCN 2001), this is also backed by the Department of Health (2013). This document also states that “You have the right to accept or refuse treatment that is offered to you” Nonetheless, the nutrition assessment was continuously and regularly carried out by the medical staff as per NHS guidelines and the patient was assessed every day from a nutritional point of view. Mrs Smith had a choice and decided not to have most of the nutritional supplements meaning that she did not have all of her nutritional needs met (Leaker, 2013).

Mrs Smith’s condition deteriorated further and a new co-morbidity was added to the already complex medical condition. Patient began to present a persistent low mood (NICE, 2009) which was diagnosed as depression by the medical team, and the patient started to be seen by a counselor on a regular basis but without much improvement in her mental state. Most probably the causing factors in her case were deteriorating medical condition with loss of capacity for independent living, exacerbated pain, increased hospital stay with social isolation, multiple medications, and continuous worrying about family members’ future (Neno et al., 2007). The communication with the staff ceased taking place only when a discontent or complaints of pain were expressed. Whereas before Mrs Smith was cooperating, complying and working together with the medical staff towards her recovery, she soon started to feel helpless, lethargic, and was no longer interested in doing things. Although, Mrs Smith was still able to take decisions for herself, the depression had a major effect on her condition and the overall outcome (Keenan, 2011).

In the given situation, Mrs Smith lost her appetite completely, and a nasogastric tube was inserted in order to provide the necessary nutrients for her body to sustain the healing process. The patient’s nutritional needs and the amount of feeding were assessed by the dietician daily because of the haemodialysis patient’s fluid restriction. However, the nasogastric feeding was administrated for a short time because Mrs Smith became increasingly fluid overloaded and had to have daily haemodialysis. As the author mentioned above, the patient became non-compliant with the medical advice continuing to drink even though it was not safe as Speech and Language therapist indicated. Mrs Smith developed an Aspiration Pneumonia with Type 1 Respiratory Failure, which affected the oxygen levels and required non-invasive ventilation support through a face mask. While on respiratory support the nasogastric feeding was stopped. The sepsis was still an on-going issue which affected Mrs Smith’s blood pressure. Inotrope medication was started intravenously in order to maintain a viable blood pressure for haemodialysis. In order to raise the blood pressure, the inotrope medication works directly on the blood vessels through vasoconstriction (British National Formulary 2014), which was not very helpful in Mrs Smith’s condition regarding the extended moisture ulcer because the blood was pumped back to the heart reducing the supply to the extremities and to the skin. Yet, all the comorbidities participated and helped the appearance of the moisture lesions, to which later increased to a pressure ulcer grade 2 over sacrum area.

Mrs Smith’s skin was already damaged by the moisture, and most certainly the moist environment along with friction and shear (NICE, 2005) increased the risk and contributed to the appearance of the pressure ulcer leading further to a combined lesion with a large amount of exudate making the healing impossible. At this stage, the management of the combined lesion became challenging, clinical specialised assessment of a Tissue Viability Nurse was necessary, and a referral was done. At the initial assessment, the tissue viability nurse took photos and the medical treatment of the wound was further changed with the purpose of providing an ideal environment for the moist wound in order to make healing possible (Benbow, 2006). The new treatment involved the use of Medihoney Barrier Cream and Aquacel hydrofiber dressing. The purpose of the new medical treatment of the combined lesion was to manage the exudate so that the ideal moist environment was maintained in order to prevent and treat infection through creating a new barrier function. Aquacel dressings contain a fibre which in contact with the wound exudate turns into gel, and helps to protect the wound from micro-organisms and the wound-damaging proteases through absorbing and locking away, and also prevent maceration (Aquacel Hydrofiber Technology, 2014). In Mrs Smith’s case the Medihoney Barrier Cream helped to protect the skin from further breakdown and irritation through reducing the wound exudate, prevented the appearance of more maceration and lesions, also helped to maintain the skin pH (Medihoney Brochure, 2013). However, in this case the combination of Aquacel dressing and Medihoney Barrier Cream proved very helpful providing an ideal wound bed preparation. It also reduced the wound exudate and stimulated in a relatively reasonable time wound healing (White, 2005). Mrs Smith’s combined lesion progressed from a grade 3 to a healing grade 2.

This critical incident analysis has looked at Mrs Smith’s combined lesion with a holistic viewpoint. Initially looking at the risk assessments used to identify patients who could potentially develop a pressure ulcer, the author discusses using the Waterlow assessment. The factors that contributed to Mrs Smith’s pressure ulcer were double incontinence, decreased nutritional status, pulmonary oedema, decreased mobility, low blood pressure, sepsis, surgery and depression. As stated throughout, when Mrs Smith developed double incontinence, the skin began to break down. The contribution components of recent surgery, poor nutritional status and a slow onset of depression meant that the moisture lesion went quickly from a grade 1 to a grade 2.

To deal with the moisture lesion the medical team intervened in many different ways, placing a catheter and Flexi-Seal device, ensured that the double incontinence did not aggravate the wound and supported the healing process. Due to Mrs Smith’s deteriorating condition, she could not receive the benefits of them: slowing the healing process.

The poor nutritional further hindered the healing process more. As stated, a nasogastric tube was placed to increase the nutritional status with advice from the dietician with regards to feeding supplements. Gradually the swallow of the patient became unsafe and after a Speech and Language Therapists’ assessment, Mrs Smith’s swallow was deemed dangerous. This added to her already deteriorating condition.

These main issues delayed the healing process completely. The use of Aquacel and Medihoney dressings are a good dressing for this type of wound and will help to heal a wound of this kind. Mrs Smith’s combined lesion slowly improved from a grade 3 to a grade 2 using these dressings. However with the contributing factors that Mrs Smith had, it did not help the healing process any further. Thus indicating that for a wound to successfully heal, a holistic approach is needed as many factors play an important part in wound healing especially in the acutely deteriorating patients.

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