We chose Puan Samsiah Binti Zakaria as our patient for the pressure ulcer case study. She suffered from pressure ulcer stage II. She is a fifty years old married Malay Muslim lady and has a twelve years old son. She was originally from Terengganu and she lives in Paka, Terengganu.
The objectives of this case study are to define pressure ulcer, to describe the pathophysiology of the pressure ulcer, to acknowledge the clinical manifestations of the pressure ulcer, to identify the therapeutic interventions for pressure ulcer, to determine the nursing care for the client with pressure ulcer and to imbue the Islamic teaching in the nursing care plans.
Generally, pressure ulcer is localized damage to the skin or underlying tissue that usually occurs over a bony prominence as a result of pressure or pressure in combination with shear or friction. It also can be known as pressure sore, bedsore or decubitus ulcers. Pressure ulcers can be categorized is one of the examples of soft tissue injury as it involved the tissue in the affected area. Furthermore, pressure sores usually occur on the skin that covering the bone such as the back of heads and ears, shoulder, elbow, hips, lower backs and buttocks, inner knees and heel. Most of the people that have the greatest risk to have this pressure ulcer are those with the medical condition that minimized their ability to change positions or for those spend most of their time on a bed or chair. People who have fragile skin also can have these bedsores.
The major element in the cause of this pressure ulcer is by the pressure at the affected side. Normally, the tissue will receive the oxygen and nutrients and secrete the waste via the blood. Thus, when there are many factors that interrupt the blood flow, it will automatically affect cellular metabolism and the function or lifespan of the cells. Strong pressure will affect cellular metabolism by decreasing blood flow and lead to tissue ischemia and tissue death. Then, there are three pressure- related factors that can lead to pressure ulcers which are pressure intensity, pressure duration and tissue tolerance.
There are 4 stages of the pressure ulcers which are stage I, stage II, stage III, and stage IV. Firstly, stage I only affects the upper layer of the skin. The common symptoms are itching, burning, and pain. Stage II is when the sore penetrate the below surface of the epidermis. During this stage, the skin is broken and makes an open wound or looks like a pus-filled blister. Stage III is when the sores have gone through the dermis and into fat tissue. This stage, the ulcers look like a crater and have a bad smell. It may represent that ulcers damage the skin. Lastly, stage IV is when the sores already dig into the muscle, bone and tendon. The skin will turn black because there is a significant amount of tissue necrosis at the base.
To relate with this case, Puan Samsiah suffers pressure ulcer at her buttock. Her pressure ulcer is already at stage II, which the formation of bubbles. At her buttock, it can be clearly seen there is a part of the skin that peeled off and has a burst blister. Before she suffers stage II of pressure sores, she identified the sign and symptoms from her house such as her buttock feel warmer than the other areas, changes in her skin colour at buttocks, and swelling. She is a bedridden person because she cannot walk almost one month. From the interview, she also cannot do the hygiene by herself and need an assistant to help her. She also has diabetes mellitus that can contribute to the pressure ulcers.
Diabetes mellitus induce the risk of having the pressure ulcers because of its association with nerve damage that also known as neuropathy and also has poor circulation. People who have decreased sensation may not notice the constant force on their tissues and therefore not feel the need to change their position. Other than that, poor circulation can bring the skin and destruct the underlying tissue easily. Besides, Puan Samsiah also suffers from chronic kidney disease which also one of the factors that lead to pressure sores. The symptoms are tiredness, nausea or vomiting, and also headache can make her do not have any ability to change position without the help. Thus, when she stays too long on the bed in a supine position, it will lead to the formation of the bedsores.
2.1 HISTORY OF THE CASE
On 21st October 2018, Puan Samsiah was brought to the Emergency Department, Hospital Tengku Ampuan Afzan (HTAA) by her husband complaining of shortness of breath three times per week. She has diabetes mellitus, hypertension and advanced chronic kidney disease stage five, and not on replacement treatment (RRT). At home, she claimed cannot walk for one month and need assistance to hygiene herself because every time she tries to stand up, she feels lethargic and headache. Due to that condition, she becomes bedridden and develops pressure ulcer stage one at her buttocks. During the admission, her pressure ulcer has become stage two.
2.2 PHYSICAL EXAMINATION
On the physical examination during her admission, her blood pressure is above the normal range with the reading of 162/81 mmHg. She has a regular pulse rate of 77 beats per minute. Her body temperature is 36.0 ?. Her oxygen saturation level is 99% which is within the normal range.
On 21st October 2018, upon admission to International Islamic University Malaysia Medical Center (IIUM MC), she was diagnosed with fluid overload secondary to advanced chronic kidney disease stage 5 and underlying by diabetes mellitus and hypertension. Besides, the patient also diagnosed with sacral sore secondary to advanced chronic kidney disease.
Based on our topic, pressure ulcer, there is no specific diagnostic investigation is used to diagnose the pressure ulcers. The diagnosis of pressure ulcer is usually made up based on;
In this test, the potassium, and chloride are below the normal range which potassium supposed to be within 3.3 -5.1 mmol/L while for chloride is between 101-109 mmol/L. Besides, the creatinine level is high from its normal range which is 58-96 mmol/L. The elevated creatinine level and the declined level of potassium and chloride in Mrs. Samsiah shows the signs of the impaired kidney function in filtering wastes and excess fluids.