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

r1

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

r49

Psychosocial environment Low mood Home supports Retired, lives with supportive wife

Access to services Metro area, close to hospital Community Bus

r9

Patient Assessment Mobility Nutrition Pain 4/10 VAS in wound, intermittent, background Severe right calf pain when walking +30 seconds

r10

Wound History 3 week duration During hospital stay post CABG surgery “Clear gel” dressing in situ

r23

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)

r11

Lower limb assessment Peripheral neurological 10g monofilament present

Footwear Lace up runners

r31

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

r33

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)

r32

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

r34

Factor affecting healing Goals of therapy InterventionHyperglycaemia Optimise glycaemic

managementDiabetes Educator

(Colagiuri, Girgis, Eigenmann, Gomex, & Griffits, 2009; UK Prospective Diabetes Study Group, 1998)

Hyperglycaemia

r35

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)

r51

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

r37

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

r44

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)

r45

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)

r46

Wound bed conditions Healed, fragile epithelial tissue

Goals of therapy Intervention

Improve skin integrityPrevent injury recurrence

Daily emollientEducation, regular Podiatry follow up

(IDF, 2011)

r47

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

r22

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.

r52

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/

r54