CONNECTIVE ISSUES 2014 Pressure Injury Case Study

CONNECTIVE ISSUES 2014 Pressure Injury Case Study

r1 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

r49 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

r9 Psychosocial environment Low mood Home supports Retired, lives with supportive wife Access to services Metro area, close to hospital Community Bus

r10 Patient Assessment Mobility Nutrition Pain 4/10 VAS in wound, intermittent, background Severe right calf pain when walking +30 seconds

r23 Wound History 3 week duration During hospital stay post CABG surgery Clear gel dressing in situ

r11 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)

r31 Lower limb assessment Peripheral neurological 10g monofilament present Footwear Lace up runners

r33 Factors affecting healing and goal setting Significant factors affecting healing Pressure Peripheral Arterial Disease Hyperglycaemia Local wound conditions Goals of therapy Reduce heel pressure Improve peripheral blood flow Optimise glycaemic management Appropriate local wound care Other Factors to Consider Wound pain Nutrition Psychosocial aspects Infection? Assessment and management of other co-morbidities

r32 Heel pressure Factor affecting healing Goals of therapy Intervention Heel pressure Offload heel in line with best practice standards (National Pressure Ulcer Advisor Panel (NPUAP), 2007) MPO SPS Image from: OAPL (2011)

r34 Peripheral Arterial Disease Factor affecting healing Goals of therapy Intervention Peripheral arterial disease Improve blood flow Vascular Surgery Revascularisation (Marston et al. 2005; Norgren et al., 2007)

r35 Hyperglycaemia 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)

r51 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)

r37 Wound bed conditions Tissue 95% dry necrotic 5% sloughy Goals Infection of therapy No obvious signs Moisture Minimal exudate Prevent deterioration Boggy feel and underlying wet gangrene necrosis Improve peri wound Edges Not undermining (European Wound Management Association (EWMA), 2004 Pain 4/10 VAS Classification Unstageable pressure injury with Intervention significant ischaemia Betadine and Allevyn dressing Daily moisturiser to surrounding skin

r44 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 Wound bed conditions Classification Tissue 100% necrotic Goals Infection of therapy No obvious signs Intervention Unstageable pressure injury with Moisture Minimal exudate Remove devitalised tissue Intrasite adequate and Allevyn arterial perfusion for healing Boggy feel underlying necrosis Moist wound healing Edges Not undermining, dry peri wound (EWMA, 2004; NPUAP, 2009; Schultz et al., 2003; Sussman, 2007) Pain Minimal 1-2/10

r45 Wound bed conditions Classification Tissue 100% tenacious slough Goals of therapy Intervention Infection No obvious signs Unstageable pressure injury Debride Moistureslough Minimal exudate Iodosorb Paste, Allevyn Edges Pain Epithelising (EWMA, 2005; NPUAP, 2009, Ohtani, Mizuashi, Ito, & Aiba, 2007, Schultz et al. 2003) Minimal

r46 Wound bed conditions Classification Tissue Goals of therapy 100% granulation tissue Intervention Infection No obvious signs Encourage granulation, epithelisation Protect Moisture peri Minimal wound exudate Edges Dry (EWMA, 2004; NPUAP, 2009; Schultz et al., 2003; Sussman, 2007) Pain Minimal Aquacel, Stage Allevyn 3 pressure injury

r47 Goals of therapy Wound bed conditions Healed, Improve fragile skin integrity epithelial tissue Prevent injury recurrence (IDF, 2011) Intervention Daily emollient Education, regular Podiatry follow up

r22 References Brown, 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

r52 References Marston, 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.

r54 References UK 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/