REPUBLIC OF CAMEROON REPUBLIQUE DU CAMEROUN -------------- …. Dorisse... · 2017-05-08 · Blood vessels supply oxygen and nutrients to every part of the body, including the skin

1

P.O BOX: 875, BAMENDA.

MOTTO: HOPE IS THE KEY

SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS

FOR THE AWARD OF THE HIGHER NATIONAL DIPLOMA (HND) IN

NURSING

April 2017

REPUBLIQUE DU CAMEROUN --------------------------- PAIX-TRAVAIL-PATTIE ---------------------------------- MINISTERE DE L’ESEINGNEMENT SUPERIEUR ---------------------------- DIRECTION DE L’ESEINGNEMENT SUPERIEUR PRIVE ---------------------------------------

REPUBLIC OF CAMEROON ----------------------------- PEACE-WORK-FATHERLAND

------------------------------------- MININSTRY OF HIGHER EDUCATION --------------------------------- DEPARTMENT OF PRIVATE EDUCATION -----------------------------------

A CASE STUDY ON PRESSURE ULCER IN A 62 YEARS OLD

MALE CARRIED OUT AT BAMENDA REGIONAL HOSPITAL

NORTH WEST REGION OF CAMEROON FROM THE 27

SEPTEMBER TO 29 OF OCTOBER 2016

PRESENTED BY

MEZATIO YOUTSA DORISSE

SUPERVISED BY:

Dr MFONFU DANIEL

2

Certification

This is to certify that this case study of pressure ulcer carried out at the Bamenda

regional hospital from 27 September to 29 October 2016 is the original work of

Mezatio Youtsa Dorisse submitted in the partial fulfilment for the requirement for

the HND in nursing

NAME OF STUDENT

MEZATIO YOUTSA DORISSE

DATE

25 APRIL 2017

SIGNATURE

NAME OF SUPERVISOR

DR MFONFU DANIEL

DATE.

25 APRIL 2017

SIGNATURE.

DEAN OF STUDIES

DR MFONFU DANIEL

DATE.

25 APRIL 2017

SIGNATURE

PRESIDENT OF JURY

DR MFONFU DANIEL

DATE

25 APRIL 2017

SIGNATURE

3

Dedication

This piece of work is dedicated to my father who helps me spiritually and

financially

4

Acknowledgement

Thanks go to the director and staff of capitol for their advice and encouragement,

thanks to the staff of Regional Hospital Bamenda especially the General

Supervisor and the entire staff of the various units. Special thanks go to Mr

Mboukev Biko and Dsousse Herman for their financial support, thanks to my

parents for their kindly love and support.

This work could not have been successful without the collaboration of my patient.

Thanks to my lovely friends for their cooperation and comfort given to me during

this period of case study

5

List of abbreviations

PMH; past medical history

FH; family history

SH; social history

TID; thrice daily

SC; subcutaneously

KVO; keep vein open

SRN; state register nurse

NA; nursing assistant

PO; per os

TAB; tablet

Amp; ampoule

IU; international unite

G; gram

S/N; serial number

NC; nursing care

IM; intramuscular

HND; higher national diploma

6

List of figures and pages

Fig i: Sketch of how to get to Regional Hospital Bamenda--------------------11

7

List of tables and pages

Table1: Results of wound culture -Sensitivity test-------------24

Table 2: Daily drug chart---------------------------------------------------------26

Table 3: Nursing care plan 1: Day One 02/10/2016-------------------------- 31

Table 4: Nursing care plan 2: o3/10/2016-----------------------------------------31

Table 5: Nursing care plan 3: 04/10/2016-----------------------------------------32

Table 6: Nursing care plan 4: Date - 05/10/2016---------------------------------33

Table 7: Nursing care plan 5: 06/10/2016----------------------------------------34

Table 8: Daily evolution of the patient-----------------------------------------34

Table 9:Vital signs chart ---------------------------------------------------------36

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TABLE OF CONTENTS

Certification-------------------------------------------------------------------2

Dedication---------------------------------------------------------------------3

Acknowledgement------------------------------------------------------------4

List of abbreviations----------------------------------------------------------5

List of figures and pages------------------------------------------------------6

TABLE OF CONTENTS-----------------------------------------------------8

CHAPTER ONE – INTRODUCTION------------------------------------9

CHAPTER TWO - REVIEW OF LITERATURE ON PRESSURE ULCER-13

CHAPTER THREE – PRESENTATION OF CASE--------------------23

CHAPTER FOUR - REVIEW OF MEDICATIONS--------------------38

CHAPTER FIVE - DISCHARGE SUMMARY--------------------------41

CHAPTER SIX – CONCLUSION-------------------------------------------42

REFERENCES--------------------------------------------------------------------43

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CHAPTER ONE – INTRODUCTION

Case study internship is a period of practice when the student nurse learns to apply

theoretical and knowledge to the patient. during this period the student nurses are

able to come into contact with the patient and practice on them in order to put

theories into practice .this case study was done from 27 September 2016 to 29

October 2016 in the regional hospital Bamenda, particularly in the neurological

ward and the case was on pressure ulcer in an adult male of 62years, it lays

emphasis

Literature review of the disease

Patient clerking

Daily nursing care plan of the patients’ needs

Review of drugs

It also contains problem identifying and possible solution

Motivation for the case study

I was motivated to choose this topic because I have been seeing many cases of

pressure ulcers which were not properly managed and I decided to pick up a case

so as to learn how to effectively prevent or manage a patient with pressure ulcer

General objective

i. General objective (goal): Successfully manage the case of pressure ulcer

as a member of the medical and nursing team; and to submit the report of

this case study in partial fulfilment to obtain the HND in nursing.

ii. Give a brief description of place of study and Organigram of place of

internship and source

iii. Specific objectives

a) Identify the patient

b) Describe the circumstances of arrival of the patient

c) Admit the patient

d) State the provisional diagnosis on admission, state source

e) Administer any emergency medications

f) Clerk/Assess the patient

g) Administer the medications prescribed by the medical officer,monitor and

record side effects on the patient

h) Establish daily drug chart

i) State results of confirmatory diagnostic tests

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j) Develop and implement nursing care plans

k) Describe the evolution of the patient and vital signs

l) Revue the medications administered

m) Write the discharge summary

n) Identify positive findings, weaknesses; make recommendations; make

conclusions

History of the hospital

According to the presidential degree in 2008, changing all provinces’ to region, the

formal Bamenda provincial hospital now called the regional hospital Bamenda.

Regional hospital Bamenda is a public health institution and the main referral

structure of the region that was initially located at the magistrate court at up station

in 140s. it was later transferred down town and was constructed in the early

1950s.the hospital by his Excellency sir James Roberson, the governor of the

federal republic of Nigeria. It was first headed by the chief medical officer later by

a hospital administrator and now is headed by the director. It has bed capacity of

about 400 beds

Location

Regional hospital Bamenda is located at the peripheral flank of Bamenda town

precisely at Nitop 1 between the highway leading to bali on the right and high

leading to Ntarikon , Bafut and wum of the left precisely in mankon, north west

region, Cameroon.

Services available in Bamenda regional hospital Bamenda regional hospital offer

the following services

1. Pediatric

2. Laboratory

3. Physiotherapy

4. Outpatient department

5. Imaging center

6. Theater

7. Maternity/nursery

8. Male/female medical

9. TB treatment center

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10. Gynecological unit

11. Ophthalmology

12. Pharmacy

Fig i: Sketch of how to get to Regional Hospital Bamenda

12

13. Dental department

14. Diabetic unit

15. Reanimation

16. Mortuary for prescription

The neurological ward

The neurological ward is arranged in a rectangular form with a bed capacity of 22

beds. The ward take care of patients with different neurological condition For

example paraplegia patient. The neurological ward has the main objective of

rendering medical and nursing care service to the neurological patient presenting

with different medical condition, the nurses’ station contains the following items

trolley, tables, chairs, drip stand, blood sugar machine stand for report book, boiler

and drugs cupboard

Working plan

The activities are carried out in two shifts system

The morning shift from 7am to 5pm

Night shift from 5pm to7am

During the change of each shift, a report on the health condition of patient,

treatment served, new admissions as well as other information’s are given

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CHAPTER TWO - REVIEW OF LITERATURE ON PRESSURE ULCER

A pressure ulcer is a sore, an area of skin that has been damaged due to unrelieved

and prolonged pressure. (Victorian Quality Council Secretariat)

Pressure sores are skin and tissue damage. They are caused by sitting or lying too

long on one part of the body. They can also be caused by pressure combined with

shear. Shear is when the skin moves one way and the tissue underneath moves the

opposite way. This can happen when you slide down in bed or transfer your weight

from one surface to another.(Nancy Xia, Karen Campbell)

A pressure ulcer is any lesion caused by unrelieved pressure, usually over a bony

prominence that results in damage to underlying tissue. The terms pressure ulcer

and pressure sore are preferred to the synonymous terms decubitus ulcers and bed

sores because the former terms underscore the importance of unrelieved pressure

as a primary risk factor in the pathogenesis of the lesions. In addition, these ulcers

can occur in patients who are neither bed-bound nor in decubitus positions, so “bed

sores” and “decubitus ulcers” are much less accurate terms. For the purposes of

this review, the term pressure ulcers will be used ( T. S. Dharmarajan et al).

If discovered early, bed sore are treatable. However, there may sometime be fatal

(Mayo Clinic 2010).

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LOCATION OF PRESSURE ULCERS

Although pressure ulcers can develop at any site, they occur more frequently over

bony prominences, as previously suggested. Patient position and degree of

immobility can influence the site of involvement. The most common locations are

the sacrum, coccyx, and heels (when persons are in a supine position); the hips and

ankles (when persons are lying on their sides); and the buttocks (when persons are

seated).

Pressure ulcers are usually found on bony parts of the body, but can occur almost

anywhere that pressure has been applied for a period of time. They are generally

found where bones are close to the skin and where the skin presses against a firm

surface, such as a chair or mattress.

15

16

Causes of pressure ulcer

Continuous pressure, if there is pressure on the skin, on the side and bone on the

other, the skin and under lying tissues may not receive adequate supply oxygen and

other key nutrients may be lacking resulting in possible skin damage. Areas most

susceptible are those which are not well padded with flesh (muscle and fat) areas

over a bone such as the coccyx, shoulder bladder, hips, heel, ankle and elbow.

Some cause of circulation lose may seem unlikely but they exist, such as crumbs in

the patients bed, wrinkles in the sheets and clothing

Pathophysiology

Blood vessels supply oxygen and nutrients to every part of the body, including the

skin. Constant pressure in one area means that blood and nutrients are less able to

reach the skin in this area.

.

If the bones inside the body put too much pressure on the blood vessels, then the

blood cannot get through and this can cause damage to the skin and other tissues. If

the pressure of normal body weight is not relieved in people at risk, it can harm the

blood supply to the area, which can lead to skin and tissue damage.

Although unrelieved pressure is the main cause of pressure ulcers, a combination

of other factors such as friction (from rubbing, dragging) and shear (sliding down

the bed) can also contribute to skin damage leading to a pressure ulcer. When a

point pressure is placed on a hard surface the flow of fluid is obstructed. Similarly

in soft tissue unrelieved pressures obstruct the flow of blood in the

microcirculation.

Point pressure increase tissues injury by increased capillary permeability

particularly after pressure is released; increased interstitial edema, blocking

lymphatic and venous drainage. Occluding vessels cause hypoxia, ischemia and

tissue necrosis for 95% of pressure ulcers.

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Grading the pressure ulcer - stages of pressure ulcers

Based on the severity of the condition, pressure ulcers go through four different

stages and the symptom vary depending on the different stages.

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19

Risk factors

Risk Factors for Pressure Ulcers

Intrinsic

I. Aging

II. Chronic disease (eg, diabetes mellitus, peripheral vascular

diseases)

III. Impaired mobility and limited activity (in cases of contractures,

spinal cord injury, coma)

IV. Parkinson’s disease, advanced dementia)

V. Incontinence (faecal more than urinary)

VI. Malnutrition

VII. Sensory impairment (because of neuropathy, cerebrovascular

accident)

Extrinsic

I. Pressure

II. Friction

III. Shearing

IV. Moisture

V. Smokers; nicotine undermine circulation, while smoking reduces the amount

of oxygen in blood. This has a negative effect on healing

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Treatment

WHO: Prevention and management of wound infection

Wound toilette and surgical debridement

Apply one of these two antiseptics to the wound:

o Polyvidone-iodine 10% solution apply undiluted twice daily.

o Cetrimide 15% + chlorhexidine gluconate 1.5% (not recommended for

emergency situations (risk of flakes according to water quality)

1. Wash the wound with large quantities of soap and boiled water for 10 minutes,

and then irrigate the wound with saline.

2. Debridement: mechanically remove dirt particles and other foreign matter from

the wound and use surgical techniques to cut away damaged and dead tissue. Dead

tissue does not bleed when cut. Irrigate the wound again. If a local anaesthetic is

needed, use 1% lidocaine without epinephrine.

3. Leave the wound open. Pack it lightly with damp saline disinfected or clean

gauze and cover the packed wound with dry dressing. Change the packing and

dressing at least daily.

4. For patients with tetanus-prone injuries, WHO recommends TT or Td and TIG.

5. When tetanus vaccine and tetanus immunoglobulin are administered at the same

time, they should be administered using separate syringes and separates sites.

6. Antibiotic prophylaxis and treatment should be based on culture and sensitivity

test results

Complication

Sepsis; it occurs when bacterial enter the blood stream through broken skin and

spread throughout the body, it is a rapidly progressing life threatening condition

that can cause organ failure

Cellulitis; this is an infection of the skin and the connective soft tissues. It can

cause severe pain, redness and swollen. People with nerve damage often do not

feel pain with this condition.

Bone and joint infection; an infection from a pressure sore can borrow into joints

and bone joint infection(septic arthritis) can damage cartilage and tissue. Bone

infection (osteomyelitis) may reduce the function of joints and limbs. Such

infection can lead to life threatening complication

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Cancer ; another complication is the development of a type of squamous cell

carcinoma that developed in chronic wounds. This type of cancer usually required

surgery

Prognosis

Prevention and management of pressure ulcer and also surgery, prognosis is

always good

Prevention

The best treatment for a pressure ulcer is the removal of all pressure from the

location until it heals.

Remember...

✓ Move, move, move

✓ Look after your skin

✓ Eat a balanced diet

It is much easier to prevent pressure ulcer than to treat it. However, this does not

mean that bedsore cannot be cured or that they can always be prevented. There are

several option that we can option for , which include medical procedure as well as

home remedies, given below are some of the simple steps that need to be followed,

for treating and dealing with pressure ulcer

Change of position in bed

The use of Support devices

Good nutrition such as protein, vitamin c and zinc

Encouragement of exercise for conscious patient

Manage incontinence to keep skin dry

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2 Definition of nursing care plan

Nursing care plan is define as a plan of action for the care of a patient after the

nurse must have assess and diagnose the patients problem. it consist of nursing

diagnosis, objective, intervention, rational and expected outcome

2-11 Nurses’ Responsibility in the Administration of medications to patients

Nurses responsibilities in drug administration

The rights to the right patients

Right medication, to check the medication labelling and the order.

Right dose

The right route

Right time

Right documentation

Right reasons,

Right response

23

CHAPTER THREE – PRESENTATION OF CASE

3.1 The demographic identity of the case on admission

Name ;Mr X Age; 62years Sex; male

Address - residence; Abangoh Occupation; farmer

Nationality; Cameroonian Religion; Roman catholic Ward;male

surgical unit Bed No; 16 Blood group; O positive

Date of admission: 24 September 2016

3.2 Conditions on arrival

Mr X , a 62 years male from Abangoh suffering renal impairment was admitted

in Baptist hospital Mbingo on the 2/9/2016, where he spent five days. He was

later discharged and referred to the Regional Hospital Bamenda for the

management of pressure ulcer and kidney failure. He arrived at the hospital in

an unconscious state. After the casualty he was admitted in the reanimation

ward. He was later transferred to male surgical unit after regaining

consciousness.

3.3 Provisional diagnosis by MD on admission was pressure ulcer and acute

kidney failure

3.4 Medical Prescription on admission by Dr in the casualty

Metronidazole 500mg 1tab for 7days

Omeprazole 40mg IV 1AMP daily

Gentamcyin inj 1amp daily

Claxacillin 500mg 2tab orally for 8days

Oflocet 200mg tab for 9days

Ceftriaxone 2g iv start

24

The MD requested staff to take swab of the pressure ulcer for culture

and sensitivity review.

Table1: Results of wound culture -Sensitivity test

Sensitive to Intermediate to Resistant to

Gentamycin Ceftrazidime oxcillin

Netilmicine Imipeneme

Ciprofloxaxine

Chloramphenicol

Olfloxacin

Nalidixic acid

minocycline

3.5 Clerking/assessment by nurse (history taking and examination)

The clerking was done in the male surgical ward after the reanimation ward

History of present illness; he started losing consciousness day before

admission in the Baptist Hospital.

Signs and symptoms

Presence of a Pressure ulcer at the coccyx, a full skin damage ulcer – stage 3

pressure ulcer

Dehydration – dry lips

Offensive body odour

3.6 Past medical history

Has been admitted for appendicitis and hypertension

3.7 Past surgical history

Has been operated for hernia

3.8 Family history

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Diabetes and hypertension are common in the family

3.9 Social history

Married with five children, does not smoke but drink alcohol

3.10 Physical assessment (vital signs) -ToC 37.5, BP 130/90mmgh, Pulse

88b/m, Respiration 22c/m, Bowel one, Urine nill, Vomitus nill , Intake

unknown

3.11 THE PRESSURE ULCER WAS LOCATED AT THE SACRUM-

COCCYX AREA OF THE PATIENT

Pressure ulcer of the patient situated at the sacrum-coccyx area on

admission

26

Table 2: Daily drug chart

Date Time Drug Dose Route Frequency Remark Name

of

nurse

25/9/2016 10pm cloxacillin 500mg Po

Tid

Served

SRN

26/9/2016 6am

2pm

10pm

Cloxacillin

Cloxacillin

Metronidazole

cloxacillin

2tab

2tab

1tab

2tab

Po

Po

Po

po

tid

tid

tid

tid

Served

Served

Served

Served

SRN

SRN

SRN

SRN

27/9/2016 7am

2pm

8pm

Cloxacillin

Metronidaole

Cloxacillin

Metronidaole

Cloxacillin

Metronidaole

2tab

1tab

2tab

1tab

2tab

1tab

Po

Po

Po

Po

Po

po

tid

tid

tid

tid

tid

tid

Served

Served

Served

Served

Served

Served

SRN

SRN

SRN

SRN

SRN

SRN

28/9/2016 7am

2pm

8pm

Cloxacillin

Metronidaole

Cloxacillin

Metronidaole

Cloxacillin

Metronidaole

2tab

1tab

2tab

1tab

2tab

1tab

Po

Po

Po

Po

Po

po

tid

tid

tid

tid

tid

tid

Served

Served

Served

Served

Served

Served

SRN

SRN

SRN

SRN

SRN

SRN

29/9/2016 6am Ringer

+quinine

500cc

1amp

IV daily Served

SRN

27


of

nurse

+vitamin B 1amp

30/9/2016 6am Ringer

+quinine

+vitamin B

ceftriaxone

500cc

1amp

1amp

2g

IV Daily

starte

Served

SRN

31/9/2016 6am

10pm

Ringer

+quinine

+vitamin B

Cloxacillin

metronidazole

500cc

1amp

1amp

2tab

1tab

IV

Po

Po

Daily

Tid

Tids

Served

Served

Served

SRN

SRN

SRN

1/10/2016 6am

8pm

Ringer

+quinine

+vitamin B

Cloxacillin

metronidazole

500cc

1amp

1amp

2tab

1tab

IV

Po

Po

Daily

Tid

Tids

Served

Served

Served

SRN

SRN

SRN

2/10/2016 6am

8pm

Ringer

+quinine

+vitamin B

Cloxacillin

metronidazole

500cc

1amp

1amp

2tab

1tab

IV

Po

Po

Daily

Tid

Tids

Served

Served

Served

SRN

SRN

SRN

3/10/2016 7am

2pm

Cloxacillin

Metronidaole

Cloxacillin

2tab

1tab

2tab

Po

Po

Po

tid

tid

tid

Served

Served

Served

SRN

SRN

SRN

28


of

nurse

8pm

Metronidaole

Cloxacillin

Metronidaole

1tab

2tab

1tab

Po

Po

po

tid

tid

tid

Served

Served

Served

SRN

SRN

SRN

4/10/2016 7am

2pm

8pm

Cloxacillin

Metronidaole

Cloxacillin

Metronidaole

Cloxacillin

Metronidaole

2tab

1tab

2tab

1tab

2tab

1tab

Po

Po

Po

Po

Po

po

tid

tid

tid

tid

tid

tid

Served

Served

Served

Served

Served

Served

SRN

SRN

SRN

SRN

SRN

SRN

5/10/2016 7am

2pm

8pm

Cloxacillin

Metronidaole

Cloxacillin

Metronidaole

Cloxacillin

Metronidaole

2tab

1tab

2tab

1tab

2tab

1tab

Po

Po

Po

Po

Po

po

tid

tid

tid

tid

tid

tid

Served

Served

Served

Served

Served

Served

SRN

SRN

SRN

SRN

SRN

SRN

6/10/2016 10am

Perfalgan

Normal saline

1infusio

500cc

IV 8hly

6hly

Served

served

SRN

SRN

7/10/2016 6am Perfalgan

Normal saline

Metronidazole

1infusio

500cc

2tab

IV

Po

8hly

6hly

Tid

Served

Served

Served

SRN

SRN

SRN

29


of

nurse

oflocet 1g IV Bid Served SRN


Normal saline

Metronidazole

oflocet

1infusio

500cc

2tab

1g

IV

Po

IV

8hly

6hly

Tid

Bid

Served

Served

Served

Served

SRN

SRN

SRN

SRN


Normal saline

Metronidazole

oflocet

1infusio

500cc

2tab

1g

IV

Po

IV

8hly

6hly

Tid

Bid

Served

Served

Served

Served

SRN

SRN

SRN

SRN


Normal saline

Metronidazole

oflocet

1infusio

500cc

2tab

1g

IV

Po

IV

8hly

6hly

Tid

Bid

Served

Served

Served

Served

SRN

SRN

SRN

SRN


Normal saline

Metronidazole

oflocet

1infusio

500cc

2tab

1g

IV

Po

IV

8hly

6hly

Tid

Bid

Served

Served

Served

Served

SRN

SRN

SRN

SRN


Normal saline

Metronidazole

oflocet

1infusio

500cc

2tab

1g

IV

Po

IV

8hly

6hly

Tid

Bid

Served

Served

Served

Served

SRN

SRN

SRN

SRN


Normal saline

1infusio

500cc

IV

8hly

6hly

Served

Served

SRN

SRN

30


of

nurse

Metronidazole

oflocet

2tab

1g

Po

IV

Tid

Bid

Served

Served

SRN

SRN


Normal saline

Metronidazole

oflocet

1infusio

500cc

2tab

1g

IV

Po

IV

8hly

6hly

Tid

Bid

Served

Served

Served

Served

SRN

SRN

SRN

SRN

19/10/2016 6am Glucose 5%

Gentamycin

Omeprazole

500cc

1amp

40mg

IV

IV

IV

Daily

Served

SRN

20/10/2016 6am Glucose 5%

Gentamycin

omeprazole

500cc

1amp

40mg

IV

IV

IV

Daily

Served

SRN

DAILY WOUND DRESSING

We set and prepared a tray with plaster, gloves, gauze, normal saline, syringe,

cotton and gentamycin.

We put on gloves and remove old plaster and gauze from the wound, debride dead

tissues and clean the wound with normal saline and pour one ampoule gentamycin

on the wound.

We cover the wound with gauze and plaster the surrounding to avoid the entering

of microorganism into the wound and also allow free movement of air in and out of

the wound to encourage wound healing. We turn the patient to lie on the sides

every 6 hours.

31

Table 3: Nursing care plan 1: Day One 02/10/2016

Nursing care plan 1: Need: need to prevent the extension of pressure ulcer

Nursing diagnosis: bed sore due to immobility of the patient and poor nursing care

of pressure areas

Objectives Nursing

intervention.

Rationale Evaluation.

To prevent

the

extension

of pressure

ulcer and to

prevent

infection

and treat

bed sore

Turing patient on bed-

on the sides after

every 6 hours

To promote

blood

circulation

Patient bed

sore got finish

Prevent wrinkles and

crumbs on bed

Wrinkles and

crumbs on bed

obstruct blood

circulation

Daily wound care and

encourage daily intake

of protein, zine and

vitamins

To prevent

infection and to

facilitate

healing

Table 4: Nursing care plan 2: o3/10/2016

Need: to keep the body clean

Nursing diagnosis: alter body image related to odour and scaly skin due to poor

hygiene

Objectives Nursing intervention. Rationale Evaluation.

To keep the

patient clean

and to avoid

Bed bath every

morning

To keep the

body

Patients body

odour

disappear Use Vaseline to rub the To keep the skin

32


the

development

of pressure

ulcers

within one

week of

nursing care

patient moist after through

bedding and

rubbing

Change of patient

dressing and linen.

To avoid

wrinkles

Table 5: Nursing care plan 3: 04/10/2016

Need: need to eat and drink normally

Nursing diagnosis: fluid volume deficit due to anorexia


To

rehydrate

the patient

within 30

minute of

care

Encourage water intake

Of about 2liter per day

To rehydrate the

body

The patient

was strong

and no signs

of dehydration

seen

Set up iv line and fluid

administer

To rehydrate the

body

33

Table 6: Nursing care plan 4: Date - 05/10/2016

Need: to avoid danger in the environment and to avoid injury

Nursing diagnosis: potential for infection related to poor manipulation of the

wound evident as non aseptic technique


To minimize

the risk of

spreading

infection to

the wound

within the

period of

hospitalization

Use sterile instrument to

care for the wound

To avoid

infection on

the wound

Infection was

completely

eradicated

during

intensive

aseptic

technique

Apply aseptic technique To minimize

the spread of

infection

around the

wound

Change linen when

soiled

To avoid

moistening of

the wound

which may

further the

infection

Antibacterial cream was

apply to the wound to

destroy bacterial on the

wound

To kill

bacterial and

to facilitate

healing

34

Table 7: Nursing care plan 5: 06/10/2016

Need: To communicated with others in expressing emotion need and fear

Nursing diagnosis: anxiety related to uncertainty of disease outcome


To elevate

anxiety

within two

hours of

nursing

care

Reassurance of client

that everything will be

ok

To make the

patient to feel as

nothing is wrong

with him

Patient is calm Provide comfort by

discussing with the

patient

Promote

relaxation and

enhance ability

to deal with

situations

Table 8: Daily evolution of the patient

Date Time observation Name of the nurse

27/09/2016 morning Condition the same

, patient on oral

treatment and daily

dressing

SRN

28/09/2016 Morning Plaster wet and

produce more

odour

NA

29/09/2016 Morning Draining but not

severed

SRN

30/09/2016 Morning Wound was wet NA

35


and draining again

31/09/2016 Morning Patient wound

improving but still

need debridement

SRN

1/10/2016 Morning Draining but no

odour

NA

2/10/2016 Morning Litter draining but

no odour

NA

3/10/2016 Morning Plaster appear wet SRN

4/10/2016 Morning Wound still

draining

SRN

6/10/2016 Morning Wound culture

done

NA

8/10/2016 Morning No odour and the

wound appear to

be red

No signs of

infection

SRN

9/10/2016 Morning Wound improving SRN

10/10/2016 Morning No complication NA

11/10/2016 Morning Much improving NA

12/10/2016 Morning Patient much better NA

13/10/2016 Morning Much better Student

14/10/2016 Morning Much improving Student

15/10/2016 morning Wound improving SRN

36


and nill complain

from patient

Table 9: Vital signs chart

Date T BP PULSE RESP BOWEL URINE

27/09/2016 37.5 113/92 69 17 1 2

28/09/2016 37.1 115/93 70 16 1 2

29/09/2016 37.3 120/90 64 17 1 2

30/09/2016 37.5 119/90 78 18 2 2

31/09/2016 37.5 115/93 64 15 1 2

1/10/2016 37.0 120/90 79 17 2 2

2/10/2016 37.5 113/92 70 17 1 2

3/10/2016 37.5 120/90 69 17 1 1

4/10/2016 36.9 115/93 80 16 1 1

5/10/2016 38.3 113/92 78 18 1 2

6/10/2016 38.3 115/93 68 17 0 2

7/10/2016 38.3 113/92 69 17 1 2

8/10/2016 37.5 113/92 69 16 2 2

9/10/2016 37.5 115/93 63 18 1 2

10/10/2016 37.1 113/92 69 16 1 2

11/10/2016 37.5 120/90 70 16 1 2

12/10/2016 37.5 113/92 64 16 1 2

13/10/2016 37.5 115/93 70 16 1 2

14/10/2016 37.5 120/90 80 17 1 2

15/10/2016 37.5 115/93 68 17 1 2

37

EVOLUTION OF THE STATE OF THE PATIENT

The pressure ulcer responded favourable to treatment, condition was more

improved than when he came in. The patient moved around on his own but the

pressure ulcer was still present but reduced in size. I was invited to do home

dressing of the pressure ulcer for two months.

Pressure ulcer of the patient after 3 months of treatment

38

CHAPTER FOUR - REVIEW OF MEDICATIONS

ceftrixone

Generic Name: ceftriaxone

Trade Name: nocephin

Mechanism of action:

Bacteriocidalstatic inhibit cell wall synthesis

Dose and Mode of Administration:

In adult treatment of respiratory infection, bone, abdomen and urinary tract

infection the dose is 1g to 2g bid for 7 to 10 days and it administer IM or IV

Side effects:

Hypersensitivity, local irritation at the injection site, rashes, itching, oedema,

headache and fever

Contraindications:

Breast feeding and those that are allergy to cephalosporin are forbidden

Precaution:

Severed impaired kidney and liver function, those allergy to penicillin and

pregnancy

CLOXACILLIN

Generic Name: Cloxacillin

Trade Name: Cloxapen

Mechanism of action:

Bactericidal against microbes by inhibiting cell wall synthesis during cell

division

Dose and Mode of Administration: Adult 2tab to 3 times PO per day

Side effects: hypersensitivity, rashes, urticaria and anaphylaxis

Contraindications: To those that are allergy to it and to any ingredient of

penicillin

39

Precaution: Bacterostatic drugs like chloramphenicol, erythromycin and

tetracycline may reduce the bacteriocidal action of cloxacillin

GENTAMYCIN

Generic Name: GENTAMYCIN

Trade Name: GENTICIN

Mechanism of action: amino glycoside antibacterial

Dose and Mode of Administration: children and adult 3 to 6 mg per kg, the

daily dose is usually administer in 2 injection . for treatment shorter then

7day , the daily dose may be given in single injection

Side effects: it may cause renal impairment auditory and vestibular damage

,allergy reaction

Contraindications: don’t administer to person allergy to gentamycin or

aminoglycoside.

Precaution: don’t mix with any other drug in the same syringe

OMEPRAZOLE

Generic Name: PRILOSEC

Trade Name: OMEPRAZOLE

Mechanism of action: Belong to a group of drug called protein plump

inhibitor. It reduces the amount of acid production in the stomach

Dose and Mode of Administration: single dose a day for 14day. Allow at

least four mouth to past before u start another 14days treatment with

omeprazole

Side effects: difficulties breathing , swollen face, lips tongue and throat and

feet ,diarrhoea , confusion nausea and vomiting

Contraindications: check with your physician if u have any of the following

condition atrophy, gastritis , poor metabolism, nephritis, and low amount of

magnesium

40

Precaution: It may cause serious type of allergy reaction when use in

patient with condition treated with antibiotic

METRONIDAZOLE

Generic Name: METRONIDAZOLE

Trade Name: FLAGILE

Mechanism of action: antiprotozoal , antibiotic [group of nitrimidazole]

effective against vegetable from of gentameaba hytolystica in ulcer

Dose and Mode of Administration: amoebiasis ; in children 45mg/kg/day in

3 divided dose, in adult 500 to 800mg per day in three divided dose, the

treatment is for days in intestinal ameobiasis and 5 to 10 days in hepatic

ameobiasis

Infection due to anaerobic bacterial ; children 30mg/kg/day in three divided

dose

In adult 500mg three times a day.

According to indication, may be use in combination with other antibacterial

treatment indication depend on the indication

Side effects: hypersensitivity, nausea and vomiting

Contraindications: hypersensitivity,

Precaution; reduce total daily dose to 1/3 and give once daily to patients with

severe hepatic impairment

OBSERVATION

The patient did not react to any of the medications reviewed.

41

CHAPTER FIVE - DISCHARGE SUMMARY

5.1 Date of admission: 24/09/2016

5.2 Date of Discharge: 22/10/2016

5.3 Diagnosis on admission (DOA): pressure ulcer and kidney failure

5.4 Diagnosis on discharge (DOD) ; pressure ulcer regressing

5.5 Treatment received:

Omeprazole, gentamycin, perfalgan, metronidazole, ceftriaxone, oflocet and

cloxacillin

5.6 Response to treatment: condition more improved then when he came in

5.7 Condition On discharge: patient can moved on his own but bed sore still

present but very much reduced in size

5.8 Home treatment

Gentamycin 80mg 1 amp daily

Metronidazole 500mg 1tab daily

Wound dressing daily

5.9 Advice on discharge

Should take drugs as prescribed

Consume food rich in protein and drink much water

Daily exercise

Report any cases of redness on the skin

5.10 Appointment date

The nurse (the student) was invited to carry out home dressing for two

months

5.11 Follow up

Follow up was done in his house and on telephone

42

CHAPTER SIX – CONCLUSION

6.1 Positive findings

Pressure ulcer can be prevented as well as it can be treated if it occurs. The

ward charge and some nurses were very alert in preventing and treatment of

presser. This included turning the patient regularly on bed to lie on the sides.

6.2 Difficulties encountered

The hospital does not have bed sheet and blanket for patient and patient do

not have them also that why the bed could not be comfortably dressed to

prevent wrinkles

Shortage of nurse, at time just two nurse per duty

The private ward had no internal toilets which made most patients complain

6.3 Proposed solutions

I proposed the government should supply the hospital with enough beds, bed

sheet, mattress and other accessories needed by patient in the hospital so as to

facilitate fast recovery of patient.

I also purposed that the government should employ more nurses so that nurses

will have time to address patients problem and handle them well

6.4 Recommendations

I recommended that the hospital committee and the government should

supply the necessary equipment for patient care and also recruit more staff to

facilitate the work of the nurses

6.5 Conclusion

Pressure ulcer can be treated with appriate management as shown by this

case study.

43

REFERENCES

Kosial.m. 1958. Evalution of pressure as a factor in the production of Ischia ulcer.

Archphys ned Rehabil.39[10]623-29.

Kosial.m.1959.Etiology of ischemiculer. Arch phys med Rehabil.40[2]62-69.

Arao.H.1998.morphology characteristics of pressure sore journal of tissue

viability.8[3],17-23

Guptose.2012.optimal use of negative pressure would therapy in to treating

pressure ulcer. Internation wound journal.9[1],8.

Seiler W.O.etod[H.Bstahelin]1979.skin oxygen tension as a function of imposed

skin pressure. Implication for decabitus ulcer formation .journal of the American

geriatric society .7[7]298-301

Sundin B,M.2000,the role of alloparinal and deferoxamine in preventing pressure

ulcer in pigs, plastic and reconstructive surgery,105,[4]1408-21

Swaim.s.f.1993.the greghound dog as amedel for studying pressure ulcer decubitus

6[2]page 32-5

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