Case study demonstrating best practice
By Amanda Palmer, Wound Management Consultancy.
This Case study won The National 3M Tegaderm Challenge 2003.
This case study presents the management of an elderly
gentleman who had developed a pressure sore during a time of illness at home.
It demonstrates how effective evidence based management as part of a team approach
can effectively promote healing.
Pressure damage occurs rapidly as the pressure between the
person’s skeleton and the object taking their weight compresses the capillaries
within the tissues (Waterlow 1994). Joe was a 79-year-old gentleman who was
admitted following a period of self-neglect due to the loss of his wife the
previous year and a recent episode of influenza leading to a chest infection.
He had mild congestive cardiac failure, was a non-smoker, with no significant
previous medical history.
Over the previous 3 weeks he had spent much of his time
sitting in his chair with his feet on a stool, feeling unwell. Joe lived alone,
and his family lived in another town, so he had tried to manage alone and had eaten
very little, become under-nourished, dehydrated and run down (Desai 1997).
The medical team requested a surgical review of the
necrotic pressure sore on his right heel, and referral to myself to review the
wound management. The surgical team felt that amputation might be necessary,
but after discussion I negotiated with them to try dressings and pressure
relief first and then review again in a weeks time to reassess progress.
Joe was referred to the dieticians to address his
nutritional needs (Balance 2002), Social worker to review his home situation,
support, and so forth. A dynamic pressure relief mattress and cushion were
provided (Waterlow 1994).
Subjective:
Joe described having sat in his chair for most of the day
and night over the previous couple of weeks. He noticed his heels were feeling
sore just over a week ago, but hadn’t looked at them and hadn’t asked for any
help. Joe described only a mild itch and numbness at this time, but no pain. I
used a 1 – 10 pain scale to monitor his pain, 1 - no pain, to 10 - extreme pain
(Allan 2002). Joe rated his heel as 2 at the initial assessment.
Objective:
The pressure sore wound was covered with a dehydrated,
necrotic Escher of approximately 17cm squared. The edges were devitalised, with
fluff and debris attached, as he had not realised the wound was present and so
it had not been covered.
The peri-wound area was dry with mild erythema. The wound
was not malodorous and there was no ooze or exudate at this initial assessment
(Thomas 1997).
There were several priorities to managing this wound:
v Re-hydrate
the necrotic tissue
v Prevent
maceration
v Control
the bacterial loading
v Encourage
repair and regeneration of the capillaries – angiogenisis, and neoangiogenisis.
v Prevent
deterioration.
v Be
acceptable to Joe.
v To be
cost and time efficient.
In 1962 George Winter identified that a moist wound-healing
environment was necessary for effective regeneration and migration of skin cells.
His work has been supported and built upon over the past 4 decades. Since his
initial research, wound product development has focused around achieving this
environment. Turner (1982), Morrison and Moffat (1997) and Sussman and
Bates-Jensen (1998) identify the aims of an ideal dressing:
v Has
thermal properties,
v Manages
exudate
v Prevents
further trauma,
v Does not
contaminate the wound
v Protects
the wound
v Is
comfortable and acceptable to the patient
With this in mind the first wound management plan consisted
of mapping the wounds overall dimensions, and rehydrating. For this a hydrogel
was applied, which was occluded with 3M Tegaderm. This was replaced at 24 hours
and then at 48 hours. By this time the area was softening and the hydrogel was
placed under the edges of the necrotic Escher as it was beginning to lift. The
exudate levels were increasing as the local vascular system recovered (Sibbald
2002).
At day 5 I was able to remove 80% of the debriding Escher,
to reveal fibrous sloughy tissue on the base of the wound (Sibbald 2002). This
was hydrated and being broken down by the macrophages through the process of
autolysis (Moore 1999). I estimated the wound as being full thickness, although
this could still not be confirmed as too much devitalised tissue remained
(Allan 2002). There were signs of infection, Joe was pyrexial at 38 degrees C,
the wound exudate was increasing – although this was due in part to the
rehydration, the peri-wound area has warm and erythema was present. There was
an increase in the malodour from the wound, which Joe was finding difficult to
tolerate. Broad-spectrum IV antibiotics had been commenced on admission due to
the chest infection. As the wound bed was now accessible a swab was taken. The
IV antibiotics were supported with topical application of a Cadexomer Iodine
based product (Cooper and Lawrence 1996, Gilcrist 1997), covered with an
absorbent pad and secured with 3M Tegaderm, to maintain the moist, warm wound
environment which was proving so successful.
At the 7th day the surgical team returned to
review progress. It was decided to continue providing the warm, moist
environment and enabling the process of autolysis, that was proving effective,
to continue. The pressure relief was significant in enabling neoangiogenisis, and
the input of the dietician was helping to improve Joe’s nutritional status.
Joe was feeling better with the IV antibiotics and was
mobilising daily with the physiotherapist, during this he wore an extra thick
layer of padding over the pressure sore dressing. He had been able to talk to
the chaplain service, and the social worker was looking into finding Joe a
place in a retirement village. Joe was feeling generally more positive about
the future.
The pressure sore continued to progress well with application
of Cadexomer Iodine paste daily initially, and then alternate days from day 5
to day 11. By day 11 the wound had debrided, and the malodour was gone. Calcium
alginate was commenced to fill the cavity and manage the exudate (Carville
1998), secured with 3M Tegaderm and left in situ for 3 days. The 3M Tegaderm
enabled the nursing staff to monitor the calcium alginate and see when it had
become a gel to know to change the dressing. By day 14 there was a healthy base
of granulation tissue. The wound edges were contracting, leaving the wound now
reduced to an area of 11cm squared. The exudate volumes were reducing, the
malodour and erythema were gone. 3M Tegaderm remained pivotal in the dressing
regimen, to secure the dressing and maintain the moist, warm environment. It
was also comfortable for Joe and enabled him to mobilise gently and to shower
without requiring re dressing.
Joe was discharged home with increased support and on the
waiting list for his chosen retirement home. The district Nurses continued his
wound management at home, and he began to socialise again.
This case study demonstrates how evidence based nursing
management can prove so effective for patients. It also demonstrates how
working as part of the multi disciplinary team can promote holistic healing for
the client in a supportive, client centred way, if we consider that a dressing
is only as good as the body it is placed on (MacLellan 1998). The attributes of
3M Tegaderm in providing a semi occlusive environment and the ability to monitor
the wound without disturbing the dressing are significant in promoting client
comfort and cost effectiveness.
References
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College of pharmacy, Monash University, Australia. 2002
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K “General Assessment” in Wound Care
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H "Aging and Wounds: Healing in old age" In Journal of wound care, vol 6, no. 5 May 1997, pp 237-239.
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J A 1994 “Pressure sore prevention Manual.” Newtons, England.
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G, 1962, Nature.