Case study: Mrs Ahmed

Mrs Ahmed is sixty-seven years old and suffered a stroke three months ago which left her with a left-sided weakness, although she remains independent and is able to mobilise around her house and small garden with the aid of a stick. Her family drive her to see relatives once a week and they do her shopping. Good quality frozen meals are delivered fortnightly and she can make snacks and cups of tea, but normally spends most of her time in an armchair watching television or listening to the radio.

Mrs Ahmed is 5′ 4″ and weighs 9st having lost 2 stone since the stroke. In the past two weeks she has been feeling unwell with a cough and has not been eating much or going out. Two days ago she was unable to get out of bed without help and the GP prescribed oral antibiotics as she had a pyrexia of 38°C, pulse 90 beats per minute, blood pressure was 120/80, and she was perspiring. Her cough has become worse and she is expectorating green sputum.

Her most comfortable position in bed was sitting up with the aid of three pillows, a position she was reluctant to move from as other positions, such as lying on her side, increased her coughing. She had little appetite and was drinking fluids only when encouraged by her family.

Mrs Ahmed refused to be admitted to hospital, insisting that she wanted to stay at home, so she is being cared for by her family with support from the District Nurse (DN). When the DN inspected her skin she found a wound on the left side of her sacrum. It was a shallow wound with the appearance of a ruptured blister. The wound measured 3×4 cm, her skin was red and shiny for approximately 3 cm around the wound. The sheets were soiled with exudate from the wound. Mrs Ahmed did not complain of pain in her left sacrum. The right side of her sacrum was red and remained red when light finger pressure was applied by the DN.

The DN has found that Mrs Ahmed has two pressure ulcers on her sacrum. What category would they be according to the EPUAP (2009) categories?

Mrs Ahmed is pyrexic and her skin is constantly damp from perspiration. How might this moisture contribute to skin damage and how would you protect her skin from further damage?

• Why is it important that Mrs Ahmed has enough food and fluids? What would you do to encourage her to eat and drink?

Case study: Mr Owusu

Mr Owusu is thirty-six years old and has Down’s syndrome with significant learning difficulties. He is also hearing impaired and often removes his hearing aid, is morbidly overweight and has type 2 diabetes.

His blood glucose levels were erratic for several years but recently this has become under control with very careful monitoring of his diet. Mr Owusu lives in a community home and tends to walk around, either indoors or around the grounds, barefoot. The staff are not concerned about him doing this because, even when walking on a stony path, he does not seem to feel any discomfort.

Yesterday a carer noticed some blood on the floor when Mr Owusu walked past. On examination Mr Owusu was found to have blood seeping from the ball of his foot. It was difficult to see where this blood was coming from due to layers of very dry, hard skin. A plaster was applied and Mr Owusu was advised to rest. The next morning the foot smelled malodourous and the skin on one area of his foot was red and felt ‘boggy’ when touched. The carer also noticed that Mr Owusu was very pale, sweating and felt hot to touch.

The GP was called and she spoke to the diabetic foot clinic at the local hospital. The community home staff were very surprised when they were asked to take Mr Owusu to the diabetic foot clinic straight away.

• Why might Mr Owusu have been able to walk on the stony path without feeling discomfort?
• Why did the GP arrange for the patient to be seen immediately?
• What will be done about the hard skin (callus) at the hospital and why?
• How can Mr Owusu be helped to protect his feet?