connective issues 2014 pressure injury case study of the wound and reviewing goals ... wound...
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CONNECTIVE ISSUES 2014Pressure Injury Case Study
Outline Medical History Social History Patient Assessment Lower Limb Assessment Factor affecting healing and goals setting Progress of the wound and reviewing goals What I learnt from this case
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Medical History Mario*: 65 year old man Coronary artery disease Bisoprolol, Frusid, Astrix
Coronary Artery Bypass Graft (August 2010) Depression Endep
Hypertension, Hyperlidaemia Coversyl, Liptor
Type 2 Diabetes (10 year duration) HbA1C 8.1% Diabex
Other
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Psychosocial environment Low mood Home supports Retired, lives with supportive wife
Access to services Metro area, close to hospital Community Bus
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Patient Assessment Mobility Nutrition Pain 4/10 VAS in wound, intermittent, background Severe right calf pain when walking +30 seconds
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Wound History 3 week duration During hospital stay post CABG surgery “Clear gel” dressing in situ
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Lower limb assessment:Peripheral Arterial Intermittent claudication at 10 metres Edinburgh Claudication Questionnaire (Leng, 1992)
Pedal pulses Right – Absent Left – Normal
Audible doppler Right – Monophasic with faint volume
Ankle Brachial Index Right – 0.59 Left – 0.94
Toe pressure Right – 20mmHg Left – 100mmHg
Conclusion: Severe peripheral arterial disease (International Diabetes Federation (IDF), 2011; Marston et al. 2005; Norgren et al 2007)
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Lower limb assessment Peripheral neurological 10g monofilament present
Footwear Lace up runners
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Factors affecting healing and goal settingSignificant factors affecting healing Goals of therapyPressure Reduce heel pressurePeripheral Arterial Disease Improve peripheral blood flowHyperglycaemia Optimise glycaemic managementLocal wound conditions Appropriate local wound care
Other Factors to ConsiderWound painNutritionPsychosocial aspectsInfection?Assessment and management of other co-morbidities
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Factor affecting healing Goals of therapy InterventionHeel pressure Offload heel in line with
best practice standardsMPOSPS
(National Pressure Ulcer Advisor Panel (NPUAP), 2007)
Heel pressure
Image from: OAPL (2011)
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Factor affecting healing Goals of therapy InterventionPeripheral arterial disease Improve blood flow Vascular Surgery
Revascularisation(Marston et al. 2005; Norgren et al., 2007)
Peripheral Arterial Disease
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Factor affecting healing Goals of therapy InterventionHyperglycaemia Optimise glycaemic
managementDiabetes Educator
(Colagiuri, Girgis, Eigenmann, Gomex, & Griffits, 2009; UK Prospective Diabetes Study Group, 1998)
Hyperglycaemia
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Other Factors to Consider Nutrition (Brown & Phillips, 2010)
Wound pain (Cole-King & Harding, 2001; Solowiej, Mason, & Upton, 2009, WHO 1990)
Psychosocial impact (Finestone, Alfeeli, & Fisher, 2008; Vileikyte, Rubin, & Leventhal, 2004)
Monitor contral-lateral side, risk of other pressure injurys (IDF, 2011; NPUAP, 2009)
Management of other co-morbidities (Nogren, et al. 2007)
Infection? (Lipsky, 2004)
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Wound bed conditions ClassificationTissue 95% dry necrotic
5% sloughyUnstageable pressure injury with significant ischaemia
Infection No obvious signs Moisture Minimal exudate
Boggy feel underlying necrosisEdges Not underminingPain 4/10 VAS
Goals of therapy Intervention
Prevent deterioration and wet gangreneImprove peri wound
Betadine and Allevyn dressingDaily moisturiser to surrounding skin
(European Wound Management Association (EWMA), 2004
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Wound bed conditions ClassificationTissue 100% necrotic
Unstageable pressure injury with adequate arterial perfusion for healing
Infection No obvious signsMoisture Minimal exudate
Boggy feel underlying necrosisEdges Not undermining, dry peri woundPain Minimal 1-2/10
Goals of therapy Intervention
Remove devitalised tissueMoist wound healing
Intrasite and Allevyn
(EWMA, 2004; NPUAP, 2009; Schultz et al., 2003; Sussman, 2007)
What’s New?Has had revascularisation and has good arterial potential for wound healing now with palpable pedal pulses and a toe pressure of 110mmHg
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Wound bed conditions ClassificationTissue 100% tenacious slough
Unstageable pressure injuryInfection No obvious signsMoisture Minimal exudateEdges EpithelisingPain Minimal
Goals of therapy Intervention
Debride slough Iodosorb Paste, Allevyn
(EWMA, 2005; NPUAP, 2009, Ohtani, Mizuashi, Ito, & Aiba, 2007, Schultz et al. 2003)
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Wound bed conditions ClassificationTissue 100% granulation tissue
Stage 3 pressure injuryInfection No obvious signsMoisture Minimal exudateEdges DryPain Minimal
Goals of therapy Intervention
Encourage granulation, epithelisationProtect peri wound
Aquacel, Allevyn
(EWMA, 2004; NPUAP, 2009; Schultz et al., 2003; Sussman, 2007)
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Wound bed conditions Healed, fragile epithelial tissue
Goals of therapy Intervention
Improve skin integrityPrevent injury recurrence
Daily emollientEducation, regular Podiatry follow up
(IDF, 2011)
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ReferencesBrown, K., & Phillips, T. (2010). Nutrition and wound healing. Clinics in Dermatology, 28(4), 432-439. doi:
doi:10.1016/j.clindermatol.2010.03.028
Colagiuri, R., Girgis, S., Eigenmann, C., Gomez, M., & Griffiths, R. (2009). National evidenced based guideline for patient education in Type 2 Diabetes. Diabetes Australia and the NHMRC, Canberra. Retrieved from http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/di16-diabetes-patient-education.pdf
Cole-King, A., & Harding, K. G. (2001). Psychological factors and delayed healing in chronic wounds. Psychosomatic Medicine, 63(2), 216-220. Retrieved from http://www.psychosomaticmedicine.org/content/63/2/216.full.pdf
European Wound Management Association (EWMA). (2004). Position Document: Wound bed preparation in practice. Retrieved from http://www.ewma.org/english/position-documents.html
Finestone, H. M., Alfeeli, A., & Fisher, W. A. (2008). Stress-induced physiologic changes as a basis for the biopsychosocial model of chronic musculoskeletal pain: a new theory? The Clinical Journal of Pain, 24(9), 767-765. doi: 10.1097/AJP.0b013e3181790342
International Diabetes Federation (IDF). (2011). International Consensus on the Diabetic Foot. Practical and Specific Guidelines on the Management and Prevention of the Diabetic Foot [DVD].
Leng, G. C., Fowkes, F.G. (1992). The Edinburgh Claudication Questionnaire: an improved version of the WHO / Rose Questionnaire for use in epidemiological surveys. Journal of Clinic Epidemiology, 45(10), 1101-1109.
Lipsky, B. A. (2004). A report from the International Consensus on Diagnosing and Treating the Infected Diabetic Foot. Diabetes/Metabolism Research and Reviews, 20(Suppl 1), S68-77. doi: 10.1002/dmrr.453
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ReferencesMarston, W. A., Davies, S. W., Armstrong, B., Farber, M. A., Mendes, R. C., Fulton, J. J., . . . Hill, C. (2005).
Natural history of limbs with arterial insufficiency and chronic ulceration treated without revascularization. Journal of Vascular Surgery, 44(1), 108-114. doi: 10.1016/j.jvs.2006.03.026
National Pressure Ulcer Advisory Panel (NPUAP). (2007). Pressure ulcer stages revised by NPUAP Retrieved from http://www.npuap.org./pr2.htm
Norgren, L., Hiatt, W. R., Dormandy, J. A., Nehler, M. R., Harris, K. A., & Fowkes, K. F. R. (2007). Inter-society consensus for the management of peripheral arterial disease (TASC II). European Journal of Vascular and Endovascular Surgery, 33(S1), S1-S75. doi: 10.1016/j.ejvs.2006.09.024
OAPL. (2011) Retrieved from http://www.oapl.com.au/Orthopaedic&Bracing-Catalogue-Web.pdf
Ohtani, T., Mizuashi, M., Ito, Y., & Aiba, S. (2007). Cadexomer as well as cadexomer iodine induces the production of proinflammatory cytokines and vascular endothelial growth factor by human macrophages. Experimental Dermatology, 16, 318-323. doi: 10.1111/j.1600-0625.2006.00532.x
Schultz, G. S., Sibbald, R. G., Falanga, V., Ayello, E. A., Dowsett, C., Harding, K., . . . Vanscheidt, W. (2003). Wound bed preparation: A systematic approach to wound management. Journal of Wound Repair and Regeneration, 11(Suppl 1), 1-28. doi: 10.1046/j.1524-475X.11.s2.1.x
Solowiej, K., Mason, V., & Upton, D. (2009). Review of the relationship between stress and wound healing: part 1. Journal of Wound Care, 18(9), 357-366. Retrieved from http://www.internurse.com.ezproxy.lib.monash.edu.au/
Sussman, G. (2007). Management of the wound environment with dressings and topical agents. In C. Sussman& B. Bates-Jensen (Eds.), Wound care. A collaborative practice manaual for health professionals (3rd ed., Vol. 250-167). Philadelphia: Lippincot Williams & Wilkins.
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ReferencesUK Prospective Diabetes Study Group. (1998). Intensive blood-glucose control with sulphonylureas or insulin
compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet, 352(9131), 837-853.
Vileikyte, L., Rubin, R., & Leventhal, H. (2004). Psychological aspects of diabetic neuropathic foot complications: an overview. Diabetes/Metabolism Research and Reviews, 20 Suppl 1(1), S13-18. doi: 10.1002/dmrr.437
WHO. (1990). Cancer pain relief and palliative care. Retrieved from http://www.who.int/cancer/palliative/painladder/en/
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