Elizabeth Frost District Nurse Capital and Coast DHB

Transcription

1 Elizabeth Frost District Nurse Capital and Coast DHB

2 Holistic Assessment No progress Tenacity Lateral thinking Results

3 Population base of 301,510 people live within the Capital & Coast district, with two thirds of the population in Wellington City, 18% in Porirua and 14% on the Kāpiti Coast. Serves Wellington city and suburbs. (There are 3 clinics overall in CCDHB, serving the area up to Kapiti) Clinic evolving- walking wounded Monday- Friday, Sat/Sun Appointment times 30 mins Two beds, 1 FTE at present Silhouette systemphotograph, measure and document

4 Female, 52 years Presentation of left medial and lateral malleolus ulcer. Medial measures 1.8cm square, spontaneous presentation Hypertension, COPD, Asthma, Bronchiectasis Previous varicose vein stripping 6 years ago Ex IV drug user, on Methadone programme Hepatitis C positive Alcohol use, heavy at times Smoker 10+ cigarettes/day Works in retail and stands all day Two sons, marital issues with partner

5 Initial photo Left medial malleolus

6 Entry to service 19/08/13, Doppler 11/09/13- nil ulcer reduction in size, only increase Meds: Bendrofluazide, Kliogest, Quinapril, Clonazepam, Methadone Allergies: NKDA Varicose veins, previous ulceration- usually wears compression hosiery Ulcer: Superficial, slough, inflammation Atrophie blanche- lots of it: scar tissue Varicose eczema Can heel strike Eats well- increased protein discussed Impact on patient: Exquisitely PAINFUL 4-7/10, worse at night. Smoking cessation discussed ABPI Right 1.02, Left 1.04

7 ABPI indicate the ulcers as venous in origin. Referral to the Vascular service instigated in view of pain, poor healing and varicose veins.

8 High compression bandaging commenced...and removed Not tolerated...pain. Pain 0 at rest, 10/10 on movement. Not claudication more burning Unlikely to be infection. Inflammation? Vasculitis...but not constant pain.. more like extreme venous pain Liaison with GP- Swabs-(Skin flora),antibiotics, Steroid cream, analgesia- Amitriptyline- nerve like pain (Oct 13) Ulcer kit commenced 02/10. Patient tolerated better (took top layer off overnight)

9 Trials of various dressings: Zinc paste bandages, Solosite, AMD foam, Allevyn, Iodasorb, Acticoat, Duoderm thin, Dermol, Locoid to ulcer, Fucicort Ulcer continued to increase in size: now 2cm square

10 Patient overwhelmed and in pain. Anxiety and tears Balance clearly not right Skin sensitivity to products, particularly adhesives

11 Vascular appointment 18/10/13. to OPD Vascular nurses prior to appointment to handover details. Outcome: continue with current treatment.

12 Joint Reassessment with CNM: 01/11 Inflammation, oedema from wound to arch of foot, heel pain, some skin discolouration, poor ROM Action: RN liaised with GP and Vascular re: X-ray of foot, Duplex scan.? Referral to the Pain team CNS Wound care assessment requested

13 13/11/ cm square Slough 100%

14 Review Duplex scan via Vascular in December Trial change of footwear,? Rubbing Trial Lite compression bandaging and South land snail (SS): used with Allevyn initially, but patient reacted to it, so continued using SS over Solosite and Primapore and wearing an Ulcer kit

15 Pain still an issue- taking Amitriptyline b.d.- causing her some weight gain Patient reviewing pain management with GP Ulcer breaking down further, Southland Snail used medially and laterally under Ulcer kit Patient emotional, tearful, frustrated, much discussion with her

16 Recollection of trial done in Christchurch (Cathy Hammond), using NPWT under compression Results were published

17 Benefits of using NPWT in this case would be to reduce inflammatory markers, promote granulation, and balance the ulcer bed, to proceed with healing Patient s wounds superficial in nature and would suit a PICO, which could sit comfortably under an Ulcer kit Discussed with CNM and CNS Wound care- fiscal constraints. Permission granted if patient meets us half way

18 Attended Vascular OPA with patient 19/12/13 Requested we trial PICO under compression- NPWT prescription obtained from Consultant Patient agreed to give up smoking, rest and elevate legs (over Christmas period), high protein diet, pain control

19 27/12/13 First application of PICO 2.3cm square 100% slough Instant pain reduction on application of PICO Ulcer kit

20 03/01/14 1 week later 1.1cm square 52 % reduction in size 70% slough, 30% granulation Amazing!!! Patient overjoyed! So much happier to be without pain: gain psychologically and systemically PICO reapplied Ulcer kit

21 09/01/14 1cm square Slough 90%, Granulation 10% Patient back to work 2 days Pain intermittent, sharp, 8/10 PICO reapplied Ulcer kit

22 16/01/ cm square 40% size reduction Sloughy 80% Epithelializing island 20% No pain AMD foam, film and Ulcer Kit- having USS. Will apply PICO tomorrow

23 23/01/14 0.4cm square 30% reduction Slough 100% Tender when PICO off PICO Ulcer Kit

24 27/01/ cm square PICO off last 18 hours... Pain 8/10, venous eczema flared Hydrogel, Silicone dressing, film, steroid cream, Ulcer Kit

25 06/02/14: 0.4 cm square; Duoderm and Ulcer kit 12/02/14 : 0.7 cm square; Duoderm and Ulcer kit ( no PICO avail) 20/02/14: 0.3 cm square; Allevyn and Ulcer kit 27/02/14: 0.1 cm square; 95% epithelium, 5% slough. NO pain. Acticoat 7 and Allevyn adhesive, Ulcer kit 13/03/14: 0.1cm square; AMD foam and Ulcer kit 20/03/14 No change 26/03/14: HEALED. 09/04/14: Discharged from CHS. Two months from stopping PICO, to finally heal ulcer

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27 Holistic assessment, repeat as necessary Research, rethink Communication and involvement across all areas Work with the patient and get commitment from them to participate Use available technologies Never give up, not everyone follows the norm! Balance is essential in our lives for our well being

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29 To the patient for her consent to present this to you To my colleagues, CNM and CNS Wound care for their faith, support and expertise

30 Australian and New Zealand Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers, Abridged version(2011); AWMA and NZWCS Capital and Coast District Health Board Annual Plan 2014 Early healing rates and wound area measurements are reliable predictors of later complete wound closure: Wound Repair and Regeneration; Volume 16, Issue 1, pages 19 22, January-February 2008 Negative pressure wound therapy as an adjunct to compression for healing chronic venous ulcers: Journal of wound care; Volume 20,no1,January 2011