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Leg Club Conference Workshops 24th September 2014
‘Wound Assessment: a case study approach’
Mark CollierLead Nurse Consultant – Tissue Viability
United Lincolnshire Hospital NHS [email protected]
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Process of Wound Assessment:
INCORPORATES (for practitioners)
Knowledge of relevant anatomy and physiology
The ability to identify factors that may interfere with the normal wound healing process
The ability to collect subjective and objective data
The ability to analyse and interpret the information that has been gained
The ability to identify the patient’s problems and needs through discussion
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Aim of Wound Assessment:Data collected through a systematic assessment process
should inform your next planned intervention
What is the aetiology and location of the wound?
How should the wound be graded objectively?
Based on the wound grading, what is the primary treatment objective?
What regimen is required to achieve the identified treatment objective(s)?
An example of a systematic approach to wound assess..
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‘A ten point plan for success?’
1. Wound classification? 2. Assessment framework?
3. Specific information? 4. Additional techniques?
5. Surrounding skin? 6. Primary objectives?
7. Planned interventions? 8. Documentation?
9. Photographic record? 10. Patient information?
Collier M (2002)
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Patient One
Mr A.H
39-year-old male
No health problems
In full-time employment
Works as a gamekeeper
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Background
Injured foot bathing on holiday overseas
Returned home
Continued to work as a gamekeeper
Often wore occlusive work boots for over 16-hours at a time
Self-treatment regimen based on neighbours advice
No dressings used
Developed fungal infection
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Progression
2-weeks after returning from holiday:
Wound not healing
Secondary fungal skin infection
Patient prompted to visit GP surgery
Practice Nurse prescribed anti-fungal ointment (no dressing)
Mr. AH followed this regimen for a further 2-weeks
Visited A&E as foot failed to improve
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Initial Presentation
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Initial Presentation
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• What is the aetiology of and how would you classify this wound?•
• Where do you think that this patient should be managed?
• What would your assessment involve?
• What would be your prime treatment objectives?
• Based on the above, what would your treatment choices be? Please identify your rationale for the same
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Initial Presentation
Admitted via A&E
Severely infected foot
Signs of apical necrosis to toes
60% skin loss
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Wound Management
Holistic patient assessment
Wound bed assessed via TIME framework:
T – Skin loss on all of the digits extending proximally
I – Clinical signs consistent with local infection
M – Lack of uniformity of moisture provision
E – Need to document the dimensions of the wound
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Other Challenges
The patient was reluctant to take any time off work either to rest the affected foot or to attend appointments for treatment
The patient had another forthcoming overseas holiday which he made clear he intended to take regardless of the status of his wound
Reluctant to stay in hospital due to the recent death of his father
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InterventionsIV during 24-hours stay as inpatientOral on dischargeInitial management - dressings Absorbent product with silver incorporated Rationale: swiftly reduce bacterial burden &
manage exudateSubsequent management - dressings Silver and appropriate secondary dressings Rationale: continue to reduce microbial burden
SHARP DEBRIDEMENT / ADVICE
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Improvements with new regimen
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Outcome
Wound considerably improved within 2-weeks
Use of silver dressings ceased after 3-weeks
Daily application of moisturiser
Returned to work in supervisory capacity
Regularly removed footwear and changed hosiery
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Improvement after 10-weeks
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Patient TwoMiss ZC - a 22 year old female
Severe bilateral skin lesions to the lower legs
Wound characteristics of heavily exuding grade 3 leg ulcers [European Pressure Ulcer Advisory Panel (EPUAP) 1997]
All lesions involved the epidermal and dermal skin layers
Had experienced problems with the lesions for the past 6 years
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Patient Two‘These legs have really affected my life because of the
fluid that pours out of them. I have not been able to get a job and I will not go out to see a film at the cinema now. Instead I wait to see it on video at home with my boyfriend.‘
Lower limb lesions were first noted while she was attending an outpatient's appointment in 1998.
Referred to a consultant dermatologist - biopsy, confirmed a diagnosis of Necrobiosis Lipoidica.
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Patient Two
© Mark Collier
© Mark Collier
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Other Challenges
Lesions were painful all the time, but more so at time of dressing changes.
Other significant past medical history (ongoing):
Type 1 diabetes of juvenile onset, managed with insulin.
Eczema on the skin surrounding the lesions, managed with topical corticosteroids.
Patient reluctant to have any tight bandages on her legs.
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• What is the aetiology of and how would you classify this wound?•
• Where do you think that this patient should be managed?
• What would your assessment involve?
• What would be your prime treatment objectives?
• Based on the above, what would your treatment choices be? Please identify your rationale for the same
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Interventions
Involvement of patient in decision making process
Wound considerably improved once principle of Moist Wound Healing applied
Appropriate skin protection
Absorbent dressings – topical antimicrobials when clinically indicated
Reduced Compression Therapy - now hosiery
Consistent approach
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Patient Two
© Mark Collier
© Mark Collier
© Mark Collier
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Outcome
Patients quality of life and social interaction has improved
Feels involved in all aspects of her care
Pain minimised – wounds improved!
Understands need for and happy to have Compression Therapy and Hosiery as required
Now works in a voluntary capacity at a local charity shop
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Patient Two
© Mark Collier
© Mark Collier
© Mark Collier
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ANY QUESTIONS?