Authors

Beatriz Alonso Martín1, Silvia García Navarro1, Verónica de la Roca Peña1, Estrella García Navarro1, Sonia Manguán Esteban1, Pilar López Martín1, María Asunción Ajenjo Gete1

Position

1Diplomada Universitaria en Enfermería. Hospital Santos Reyes. Aranda de Duero, Burgos (España).

Contact address

Beatriz Alonso Martín. Hospital Santos Reyes. Avda. Ruperta Baraya, s/n. 09400 Aranda de Duero, Burgos (España).

Contact email: balonsom@saludcastillayleon.es

Abstract

The objective of this study was to assess the application of a new super absorbent dressing, regarding the clinical case of a patient with one pressure ulcer (PU) with high levels of exudate, maceration of the perilesional skin, discomfort and pain. The patient presented multiple comorbidities; he was institutionalized, disoriented, and presented a Grade IV PU. The patient agreed to initiate treatment with a super absorbent dressing newly implemented at the institution. There was joint assessment with his nurse at the elderly home, according to Virginia Henderson’s Needs. Based on the results of said assessment, a plan of care was stated with NANDA diagnoses, NOC outcomes with their indicators, and NIC interventions with their activities. Four nursing diagnoses were prioritized: [00032] Ineffective breathing pattern, [00129] Chronic confusion, [00312] Pressure lesion in adults, and [00132] Acute pain. The NOC outcomes stated were [0402] Respiratory Status: Gas Exchange, [0912] Neurological status: Consciousness; [1101] Tissue Integrity: Skin and mucous membranes, [110123] Necrosis, [1103] Wound healing: Second intention, [1004] Nutritional status, and [2109] Discomfort level. The plan of care was effective at reaching the target score in all indicators except for [110115] Skin lesions with high score that stays the same than at admission, at 1 “severe”. The new dressing reduced the ulcer exudate and the necrotic tissue, and improved the perilesional edges. At the same time, there was an improvement in discomfort for the patient by reducing the frequency of cures from three times to once a day.

Keywords:

Pressure ulcer; standardized nursing terminology; nursing care; Wound healing; dressing; patient safety; quality improvement

Versión en Español

Título:

Valoración de un nuevo apósito para úlceras por presión: a propósito de un caso