Optimizing wound management requires the clinician to develop a plan of care that keeps one eye on best practices and the other on the bottom line. Two basic steps help clinicians devise this sound wound care plan:
1.Comprehensive assessment-A systemic approach to the patient's assessment is needed to treat a chronic wound. 1 Clinicians need to look at the "whole patient," not just the "patient with the hole." Patients with chronic wounds frequently have underlying health problems that cause delayed healing. Assessing any underlying medical conditions that might cause the wound or impede wound healing is a crucial first step.
2.Wound bed preparation-The wound bed must be prepared to facilitate healing and to help ensure the care plan is cost effective. Although there are various ways to prepare the wound bed, 2 common steps include:
* debridement of necrotic tissue with an appropriate debridement method
* management of the bacterial load with proper wound-cleansing techniques
* maintenance of moisture balance with advanced wound care products that are properly matched to meet changing wound needs by filling dead space and managing the wound's exudate.
The following case report describes implementation of a wound care plan for multiple lower extremity ulcers in a patient with underlying health conditions that put her at risk for delayed wound healing.
Case History
Past management
A 79-year-old female with a history of type 1 diabetes and pulmonary fibrosis had been hospitalized for 7 days due to an exacerbation of pulmonary fibrosis. She was placed on warfarin (Coumadin) prophylactically. She was discharged to an outpatient pulmonary rehabilitation unit where, on the first day of admission, she sprained her left ankle.
The patient was forced to stop therapy due to the immediate swelling of her left ankle, and she was readmitted to the hospital. There, her left leg was elevated and ice and an elastic bandage were applied to her lower extremity. The area developed a blister and began to drain spontaneously 2 days after the injury. Eventually, 3 wounds evolved from the blistered area. Dry gauze dressings were applied to the affected areas.
A plastic surgeon who saw the patient 3 weeks after the injury manually expressed a large number of old blood clots from the wounds. The patient was discharged home and began daily outpatient whirlpool treatments and wound care. At this point, wound care consisted of application of a hydrogel followed by gauze packing.
Due to the patient's chronic respiratory condition, advanced age, and overall debility, outpatient therapy was discontinued after 2 weeks. The patient was admitted to a home health care agency for wound care and physical therapy 6 weeks after the ankle injury.
Home-care admission
On admission to home care, the patient presented with 3 left lower-extremity ulcers on the lateral side of her leg. All ulcers interconnected and had undermining ranging from 1.3 cm to 6.4 cm at multiple locations. Necrotic tissue, in the form of yellow slough, filled 10% to 20% of all 3 wound beds. The lower extremity was erythematous and edematous; all wounds had copious exudate.
The plastic surgeon ordered wound treatment twice a day for 7 days. Swabs moistened with normal saline solution were used to cleanse the wounds. Each wound was then packed with hydrogel-impregnated gauze and covered with 4" x 4" gauze sponges secured by a gauze wrapping. Finally, the left lower leg was wrapped with an elastic bandage.
Wound healing, however, did not progress and the copious exudate was not well managed, resulting in irritation to the surrounding tissue. The patient reported a pain level of 10 during the wound care procedure. The only medication she took for pain management prior to wound care was acetaminophen.
The patient's underlying medical conditions-type 1 diabetes and pulmonary fibrosis-were not well controlled. Diabetes treatment consisted of a daily regimen of glimepiride tablets (Amaryl), 4 mg once a day, and NPH insulin, 12 units injected subcutaneously each morning. Her fasting blood glucose levels ranged from 154 mg/dL to 198 mg/dL and random glucose levels, checked before meals and at bedtime, ranged from 228 mg/dL to 361 mg/dL.
The patient's pulmonary fibrosis was addressed with continuous oxygen therapy at 2 L/minute via nasal cannula and albuterol sulfate and fluticasone propionate/salmeterol (Advair) inhalers 2 to 4 times a day. She was also taking 80 mg of furosemide (Lasix) daily. Despite these treatments, the patient exhibited dyspnea on exertion, with ambulation of fewer than 20 feet. Her pulse oximetry readings were documented to dip to 84% with exertion. She was being seen by a physical therapist for postural drainage and exercises to increase endurance.
New approach to wound treatment
Because the patient's wounds were not healing, her case was reviewed at the home health care agency's semi-monthly clinical case conference. The agency's certified wound care nurse (CWCN) was asked to assess the patient and recommend a revised plan of care. After a comprehensive patient and wound assessment, the CWCN established the following plan:
Treat/stabilize the underlying medical conditions and promote wound healing by:
1. stabilizing the blood glucose level
2. promoting tissue oxygenation
3. preparing the wound bed for healing
4. enhancing wound cleansing and debridement
5. improving management of exudate
6. filling space in the wounds
7. protecting the periwound skin
8. improving pain management.
Implementation of the Revised Care Plan
To better stabilize the blood glucose level, the primary care physician ordered glargine insulin (Lantus), 25 units injected subcutaneously every evening before bed, and glimepiride tablets, 4 mg twice daily.To promote tissue oxygenation, continuous oxygen therapy was increased to 3 L/minute via nasal cannula. The inhalers were changed to fluticasone propionate/ salmeterol (Advair) 2 times a day and ipratropium bromide/ albuterol sulfate (Combivent) 4 times a day.
The CWCN advised the plastic surgeon that a change of plan was needed because the current twice-daily wound care treatment was inadequately controlling the wound exudate and thus impeding debridement. The CWCN discussed the advantages of using appropriate advanced wound care products. The switch from traditional bandages would allow wounds to be dressed once daily, resulting in longer periods of homeostatic temperature regulation. Additionally, the patient would have to endure the discomfort of wound care less frequently.
The CWCN recommended a hydrocolloid fiber rope dressing (Aquacel; ConvaTec, Skillman, NJ), which assists autolytic debridement, allows wounds to heal undisturbed for longer periods of time, and manages exudate without risk of periwound maceration. The plastic surgeon agreed to the revised wound care plan and prescribed a stronger analgesic for the patient to take prior to wound treatment.
The new wound care orders were to:
* irrigate all wounds with normal saline solution using a 30-mL syringe with heparin-lock tubing leur-locked onto the end of the syringe
* pack all wounds and undermined areas with the hydrofiber rope wound dressing
* protect the periwound skin with skin-barrier ointment
* cover the wounds with a multilayer full-absorbency polyethylene/rayon/cellulose dressing (Exu-Dry; Smith & Nephew, Largo, FL)
* wrap the left lower extremity with an elastic bandage from the base of the toes to just below the knee to decrease edema and increase tissue oxygenation
* perform daily wound care.
Unfortunately, the patient's husband was in the early stages of Alzheimer's disease. It was determined that due to his condition and the complexity of the wound care, he was not a teachable caregiver. Skilled visits were ordered daily.
Under the revised care plan, careful daily monitoring and as-needed insulin dose adjustments stabilized the patient's blood glucose to a level that facilitated wound healing. Fasting levels ranged from 89 mg/dL to 120 mg/dL, and random premeal levels ranged from 118 mg/dL to 168 mg/dL.
The patient's pulmonary status stabilized once her oxygen therapy was increased to 3 L/minute. Pulse oxygenation levels ranged from 94% to 100%.
Use of compression wraps to promote tissue oxygenation and enhance wound healing reduced the lower extremity edema, and with the wound beds in optimal condition, wound healing rapidly progressed (Figures 1-7).
Conclusion
In this case study, successful wound healing was closely tied to treatments that improved and stabilized the patient's underlying conditions. Controlling glucose levels, stabilizing pulmonary status, and boosting tissue oxygenation were crucial to healing.
As for the wound care plan itself, appropriate use of the hydrofiber rope dressing met the wound's changing needs throughout the healing process, improving debridement and exudate management. Additionally, creating optimal wound bed conditions for rapid wound healing and reducing edema with compression wraps were important elements for a favorable outcome.
A healed wound is a success for all involved. The greatest benefit is to the patient, whose quality of life is improved.
References