A pseudonym of Luke will be used throughout this clinical evaluation in order to protect the patient’s confidentiality (NMC, 2015). The Trust and TVN Team have not been identified in order to further protect the patient’s identity.
Introduction
A pressure ulcer is described as “localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to a medical or other device), resulting from sustained pressure (including pressure associated with shear). The damage can be present as intact skin or an open ulcer and may be painful” (NHS Improvement, 2018).
The cost of pressure ulcers is immense, with not only physical complications and challenges but additionally the impact on emotional wellbeing and quality of life (Rutherford et al., 2018). Furthermore, the impact on nurses’ workloads and the cost of caring for pressure ulcers on the NHS is vast. With over £8.3 billion pounds being spent on managing wounds each year (Guest et al, 2018).
This case study presents the complexities of nursing a patient in their own home, considering their holistic assessment, need to maintain their independence and their declining physical condition which led to a change in care and equipment.
Community nurses have a huge task of protecting their patients most at risk of pressure damage and must think strategically about how they might minimise risk in between visits. Each patient is a unique being, with individual needs, and it is essential that when their risk assessments are completed this is taken into consideration, enabling clear individualised care plans to be formulated. They are also being cared for in their own home environment and as such, may feel they do not want a “clinical look” to their home. As part of this holistic plan of care, pressure relieving equipment and any repositioning needs of the patient are key components (Payne, 2016).
The aSSKINg model was developed as a tool to aid the education and care planning for patients at risk of developing pressure ulcers to ensure a consistent logical approach and reduce the incidence of pressure ulcers in England (NHS Improvement, 2018). This model is used to follow the patient’s journey from assessment to care planning and implementation of changes to improve his outcome.
a – Assessment
Pressure ulcers can affect anyone depending on various risk factors right from the very young, to the very elderly (Anthony, 2017). Luke is a 55-year-old gentleman who has lived with a congenital condition of Spina Bifida and its various complications for his whole life. He has very limited mobility and has been wheelchair dependent most of his adult life though he has maintained a level of independence for most of this time, until recent spells in hospital. He has previously declined “hospital equipment” in his home and has preferred sitting in his wheelchair for long periods, watching TV.
He has a nephrostomy and is catheterised, but experiences fluid leaks from a fistula causing moisture associated skin damage. Luke also has chronic respiratory failure requiring the use of CPAP overnight which necessitates him to sleep in an upright position.
Luke has had chronic Category 3 pressure ulcers to both ischial tuberosities since 2016 (figure 1) because of shear forces during prolonged sitting positions, one of which deteriorated to a Category 4 prior to his most recent admission to hospital.
These have previously led to surgery for osteomyelitis of the hip – this has resulted in altered posture and discomfort with various equipment he has tried. He has been under the care of District Nurses and the Community TVN Team for many years and he is also well known to the acute hospital TVN Team following repeated admissions for wound infection.
A recent admission to hospital involved the administration of intra-venous antibiotics to treat his recurrent wound infection. He was nursed on a dynamic alternating mattress and received 2 hourly repositioning from nursing staff.
S – Skin Inspection and care
On re-inspection of his skin and wounds following discharge after this long admission, some improvement was noted to his existing wounds, additionally he had not developed any new skin breakdown despite being quite unwell. Category 3 pressure ulcers involve full thickness skin loss with exposure of subcutaneous fat (adipose tissue), without bone, tendon, or muscle, visible (European Pressure Ulcer Advisory Panel, EPUAP, 2019); whereas a Category 4 pressure ulcer will extend to bone or tendon involvement and carries a high risk of osteomyelitis and sepsis.
Luke has had chronic Category 3 pressure ulcers to both ischial tuberosities since 2016 (figure 1) because of shear forces during prolonged sitting positions, one of which deteriorated to a Category 4 prior to his most recent admission to hospital.
Community Tissue Viability Nurse
S – Surface
Whilst in hospital, Luke had been nursed on a dynamic alternating mattress with automatic weight and posture adjustments. As it was clear his wounds improved whilst in hospital, the equipment used at home needed to be reviewed. Luke had previously trialled 8 different mattresses at home and struggling to find comfort from any of these, he was reluctant and apprehensive about changing his mattress again.
The local TVN has previously used the OSKA Series5 mattress and experienced excellent results. Delivering an alternating air and foam combination, the Series5 provides exceptional comfort and support with its highly responsive foam, whilst also aiding in the prevention and treatment of pressure ulcers up to and including Category 4.
The risk of shear and friction is also reduced as the OSKA Series5 mattress cover features an anti-shear system of three horizontal slide sheets attached internally, protecting the patient against shearing and friction when being handled or moved.
Trusting his TVN, Luke consented to trial the OSKA Series5. Luke found the mattress comfortable, enabling a consistent approach to his care in the community for the first time.
K – Keep moving
Patients that are less mobile have an increased risk of developing pressure ulcers. Therefore, repositioning of these patients is an essential element of pressure ulcer prevention and management (Fletcher, 2020). When patients like Luke are in a hospital environment, they have access to 24-hour care which includes regular repositioning as opposed to the home environment where 24-hour care is far less likely (Payne, 2016). At home, Luke has only a single carer who visits 4 times a day (QDS), and as his health declines, his care has become more challenging for this carer to manage his repositioning without the need for additional equipment.
In the months leading up to September 2021, Luke’s mobility had deteriorated, and he was spending longer periods of time in his bed. Whilst in bed Luke found he was more comfortable sitting upright during the day, and during the night he would lay flat. He was reluctant to reposition and had capacity to make this decision.
Where repositioning is as challenging as in Luke’s situation, the OSKA Series5 has a combination of actions that can resolve many of the issues involved in Luke’s care by offering a lateral tilt function to provide automatic repositioning in additional to the pressure relieving alternating function.
The mattress can also be switched from alternating therapy to lateral rotation therapy, which gently tilts the patient from side to side every 10 minutes, 5 minutes on either side to alternate the pressure. The lateral tilt is achieved by four longitudinal air cells which extend from the head to just below the knees, inflating and deflating laterally. It lowers and immerses the patient into the bed rather than tipping them up and over. Its subtle tilt is both non-invasive as well as extremely comfortable.
The local TVN has previously used the OSKA Series5 mattress and experienced excellent results.
I – Incontinence and moisture management
In addition to pressure ulceration, Luke experienced long term issues with moisture associated skin damage from a combination of sweating during warmer months and leaking from his urinary fistula.
In hospital, Luke had access to 24-hour nurses who could clean and change him frequently, but at home he was reliant on his carer visits meaning his skin maybe in contact with moisture for longer periods.
The foam in the OSKA Series5 also allows circulation of air, taking heat away from the patient and reducing moisture build up. The mattress cover itself is also a breathable fabric with welded seams to protect the foam beneath from ingress of bodily fluids.
N – Nutrition and hydration
Luke has always eaten quite well and has been seen by dieticians in the past to assess for the need of supplements to aid wound healing. He currently bolsters his diet with a high protein drink recommended by his local TVN to support healing.
G – give advice / get help
Luke has always maintained the need for some independence and for his home to look like a home and not a clinical environment. His local district nurses and TVN team have worked hard to listen to his needs and concerns to find a balance between the clinical need and his wishes.
By involving him in his decision making by giving him full information about the options, Luke has been able to accept the addition of the OSKA Series5 into his home to ultimately improve his outcome and quality of life.
The Series5 trial was commenced on 9 September 2021 and his TVN reports that both of Luke’s ischial Category 3 and 4 pressure ulcers had healed by 11 January 2022 (Figure 2).
This clinical evaluation shows that implementing an individualised plan of care by using innovative ideas a spectacular difference can be made to people’s lives.
References
Anthony, D., 2017. What do we know about paediatric pressure ulcer risk assessment? Wounds UK, 13(1), pp.28-31.
European Pressure Ulcer Advisory Panel (EPUAP)., 2019. Prevention and Treatment of Pressure Ulcers/injuries: Clinical Practice Guideline. eBook Available at: https://guidelines.com/store/viewproduct.aspx?id=15036954 (Accessed: 03.03.2021).
Fletcher, J., 2020. Pressure ulcer education 5: keeping patients moving. Nursing Times [online], 116 (2), pp.28-30.
Guest JF, Fuller GW, Vowden P., 2020. Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018: update from 2012/2013
BMJ Open; 10:e045253. doi: 10.1136/bmjopen-2020-045253
NHS Improvement., 2018. Pressure ulcers: revised definition and measurement: summary and recommendations, Available at: www.england.nhs.uk/wp-content/uploads/2021/09/ (Accessed:03.03.2022).
Payne,D., 2016. Strategies to support prevention, identification and management of pressure ulcers in the community, British Journal of Community Nursing, 21(6), pp.s10-s18.
Phillips CJ, Humphreys I, Fletcher J et al., 2016. Estimating the costs associated with the management of patients with chronic wounds using linked routine data. International Wound Journal, 13(6): pp. 1193–7.
