Essay Nursing Assessment

Words: 2978
Pages: 12

Element: Prevention of pressure ulcers

This essay is going to explore the nursing process with regard to the prevention of pressure ulcers.
Pressure ulcers are a widespread and often underestimated health problem in the UK. They occur in 4-10% of patients admitted to hospital (Ward et al, 2010).
This essay, using case study 4, will explore the holistic nursing process, and also the biological, sociological, psychological and ethical issues regarding the prevention of pressure ulcers.
Lily is frightened due to her shortness of breath (dyspnoea), and as lying down exasperates her ability to breath effectively, has been sleeping in a chair. This is the primary concern of Lily. There has also been recent weight loss. The aim of
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Patients are assessed as low risk (fully mobile and minimal risk factors/Waterlow score <10), medium risk (restricted mobility and some risk factors/Waterlow score 10—20) or high risk (immobile, multiple risk factors/Waterlow score >20) (Waterlow, 2007). Papanikolaou et al (2006) criticised the tool for containing some risk factors, for which the definition is unclear or ambiguous and difficult to understand. However, it has also been praised for its ability to effectively highlight areas of patient care which need extra input from members of the multidisciplinary team (Chamanga, 2010).
The European Pressure Ulcer Advisory Panel (EPUAP) developed a common international classification system for pressure ulcers (EPUAP, 2010). EPUAP classification is recommended by The National Institute for Clinical Excellence (NICE, 2005). The categories range from 1 – 4, with 4 being the most severe.

Lily has a red area on her sacral region; this would be assessed as a category 1 if there was an absence of blister or abrasion. Category 1 is defined as; Non-blanchable erythema of intact skin, discolouration of skin, warmth, oedema, induration or hardness may also be indicators. If the area presented clinically as an abrasion or blister then it could be indicative of a category 2 pressure ulcer (EPUAP, 2009). A record of where it is, its size and what it looks like should be made using photographs or tracings