Pressure Injury Prevention and Management Strategies in SWSLHD
CONNECTIVE ISSUES 2014 Pressure Injury Case Study
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CONNECTIVE ISSUES 2014 Pressure Injury Case Study
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CONNECTIVE ISSUES 2014 Pressure 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. Medical History. Mario*: 65 year old man - PowerPoint PPT Presentation
Transcript of CONNECTIVE ISSUES 2014 Pressure Injury Case Study
CONNECTIVE ISSUES 2014Pressure Injury Case Study
OutlineMedical HistorySocial HistoryPatient AssessmentLower Limb AssessmentFactor affecting healing and goals settingProgress of the wound and reviewing goalsWhat I learnt from this case
wright
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Medical HistoryMario*: 65 year old manCoronary artery disease
Bisoprolol, Frusid, AstrixCoronary Artery Bypass Graft (August 2010)Depression
EndepHypertension, Hyperlidaemia
Coversyl, LiptorType 2 Diabetes (10 year duration)
HbA1C 8.1%Diabex
Other
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Psychosocial environmentLow moodHome supports
Retired, lives with supportive wifeAccess to services
Metro area, close to hospitalCommunity Bus
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Patient AssessmentMobilityNutritionPain
4/10 VAS in wound, intermittent, backgroundSevere right calf pain when walking +30 seconds
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Wound History3 week durationDuring hospital stay post CABG surgery“Clear gel” dressing in situ
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Lower limb assessment:Peripheral ArterialIntermittent claudication at 10 metres
Edinburgh Claudication Questionnaire (Leng, 1992)
Pedal pulsesRight – Absent Left – Normal
Audible dopplerRight – Monophasic with faint volume
Ankle Brachial IndexRight – 0.59 Left – 0.94
Toe pressureRight – 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 assessmentPeripheral neurological
10g monofilament present
FootwearLace up runners
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Factors affecting healing and goal settingSignificant factors affecting healing Goals of therapy
Pressure Reduce heel pressure
Peripheral Arterial Disease Improve peripheral blood flow
Hyperglycaemia Optimise glycaemic management
Local wound conditions Appropriate local wound care
Other Factors to Consider
Wound pain
Nutrition
Psychosocial aspects
Infection?
Assessment and management of other co-morbidities
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Factor affecting healing Goals of therapy Intervention
Heel pressure Offload heel in line with best practice standards
MPOSPS
(National Pressure Ulcer Advisor Panel (NPUAP), 2007)
Heel pressure
Image from: OAPL (2011)
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Factor affecting healing Goals of therapy Intervention
Peripheral arterial disease Improve blood flow Vascular SurgeryRevascularisation
(Marston et al. 2005; Norgren et al., 2007)
Peripheral Arterial Disease
wright
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Factor affecting healing Goals of therapy Intervention
Hyperglycaemia Optimise glycaemic management
Diabetes Educator
(Colagiuri, Girgis, Eigenmann, Gomex, & Griffits, 2009; UK Prospective Diabetes Study Group, 1998)
Hyperglycaemia
wright
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Other Factors to ConsiderNutrition (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)
wright
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Wound bed conditions Classification
Tissue 95% dry necrotic5% sloughy
Unstageable pressure injury with significant ischaemia
Infection No obvious signs
Moisture Minimal exudateBoggy feel underlying necrosis
Edges Not undermining
Pain 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
wright
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Wound bed conditions Classification
Tissue 100% necrotic
Unstageable pressure injury with adequate arterial perfusion for healing
Infection No obvious signs
Moisture Minimal exudateBoggy feel underlying necrosis
Edges Not undermining, dry peri wound
Pain 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
wright
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Wound bed conditions Classification
Tissue 100% tenacious slough
Unstageable pressure injuryInfection No obvious signs
Moisture Minimal exudate
Edges Epithelising
Pain Minimal
Goals of therapy Intervention
Debride slough Iodosorb Paste, Allevyn
(EWMA, 2005; NPUAP, 2009, Ohtani, Mizuashi, Ito, & Aiba, 2007, Schultz et al. 2003)
wright
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Wound bed conditions Classification
Tissue 100% granulation tissue
Stage 3 pressure injuryInfection No obvious signs
Moisture Minimal exudate
Edges Dry
Pain Minimal
Goals of therapy Intervention
Encourage granulation, epithelisationProtect peri wound
Aquacel, Allevyn
(EWMA, 2004; NPUAP, 2009; Schultz et al., 2003; Sussman, 2007)
wright
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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)
wright
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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
wright
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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.
wright
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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/
wright
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