Wound Management Plan 2

Case No. 1

Holistic Assessment of Patient

Mr. Will Jackson is a 77 years old man, diagnosed with Rectal Ca almost 5 years ago. Currently, he is suffering because of poor oral intake, intermittent pain from his wounds both from diabetic foot ulcer & arterial ulcer. He had CABG 2 years ago alogn with COPD, ETOH, GORD, Postural hypotension & T2DM on insulin. Patient experiences intermittent confusion at times. His medications include Telmisartan 40 mg. b.d, Ventolin 4 puffs t.d.s, Esomeprazole, 20 mg daily, Lantus 20 units (mane), warfarin 2 mg (daily), Frusemide 20 mg b.d. PRNs : Endone 10mg (tds), Hydromorphone 2 mg (b.d).

He was admitted to the ward for pain management, SOB & wound management. Prior to admission, he had a fall at home with a head strike and had a massive bruise over his face. CT scan result: NAD. The doctor stopped his warfarin dose for a week due to this massive bruise.

Mr. Jackson has a diabetic foot ulcer behind his L) toe that requires debridement while in hospital. Apart from this he also has arterial ulcer on his R) lower leg which looks infected. The treating doctor ordered a wound swab to be taken and send to pathology. The result shown that it is infected.

He also has 1 pressure ulcer on his sacrum bone which was discovered when he first admitted into hospital post fall. It is a stage 3 pressure ulcer and caused him a lot of pain especially if he is lying in supine position. Mr Jackson thought it was pain from his cancer in the rectum. The wound base of the ulcer consists of 70% sloughy tissue and 30% granulation tissue.

On day 3 in hospital, patient suffered from a burn because he spilled a hot coffee over his L) arm. He sustained a second degree burn because of this.

Evaluation and Wound Management Plan

Diabetic Ulcer

The management of diabetic ulcers require offloading the wound and cleaning it with saline daily. Furthermore, it requires treatment that would provide moist wound environment.

Wound Management Plan

Moist Wound Healing

Saline or similar dressing

Skin & Risk Assessment

Improper care can lead to infections and gangrene. The care also requires optimal control of blood glucose with the correction of peripheral arterial insufficiency.

Wound Cleansing

Clean with saline on daily basis.

Pressure Support and Relieving Devices

Use therapeutic footwear to provide pressure relief

Preventive Programs

Control blood glucose through proper diet and medications

Wound Dressing Products

Moist dressing. antibiotic ointments

Secondary Dressing (if required)

None

Pain Management Time Frame (if required)

The pain will persist till the wound is open. Pain relief medications are necessary.

Infected Arterial Ulcer

These are poor perfusions i.e. lack of nutrient rich blood delivering vessels to the lower extremities. The covering skin and tissues are deprived of oxygen that kill the tissues and cause the area to create an open wound.

Wound Management Plan

Moist Wound Healing

Saline wash and open dressing to avoid infections.

Skin & Risk Assessment

This can lead to foot deformity, callus formation and lack of joint mobility. Furthermore, it can lead to tissue necrosis and even amputation in case of extreme conditions.

Wound Cleansing

Saline wash for cleansing the wound with topical ointment.

Pressure Support and Relieving Devices

Wearing therapeutic footwear.

Preventive Programs

Physiotherapy, diabetes control and management.

Wound Dressing Products

Open dressing and saline wash. antibiotic ointments

Secondary Dressing (if required)

None

Pain Management Time Frame (if required)

Severe and persistent pain. Pain relief medications are necessary.

Pressure Ulcer

Also known as Bed sores, these pressure ulcers are injuries to the underlying tissues and the skin because of the prolonged pressure of the skin. People with limited capability to move are more prone to these ulcers.

Wound Management Plan

Moist Wound Healing

Dry treatment is required

Skin & Risk Assessment

Improper care can lead to risks such as cellulitis, bone and joint infections, cancers and sepsis.

Wound Cleansing

Saline cleaning is required. However, the wound must be dried off.

Pressure Support and Relieving Devices

The site must avoid any pressures or contact with hard surfaces.

Preventive Programs

Constant repositioning can avoid bedsores. Good nutrition and exercise also helps in avoiding bed sores.

Wound Dressing Products

Dry and open dressing is required, antibiotic ointments

Secondary Dressing (if required)

None

Pain Management Time Frame (if required)

2-4 weeks based on the severity of the wound.

Second Degree Burn on Arm

Second degree burns are the ones in which the epidermis and partial dermis layer is damaged due to burns. The site appears red, blistered, swollen and painful.

Wound Management Plan

Moist Wound Healing

Dry wound healing is required

Skin & Risk Assessment

Improper care can lead to infections and sepsis.

Wound Cleansing

Dry cleansing

Pressure Support and Relieving Devices

Pressure and any contact must be avoided

Preventive Programs

Avoid any hot or burning contact.

Wound Dressing Products

Antibiotic ointments, change of dressing twice a day, daiy cleaning, dead skin removal.

Secondary Dressing (if required)

None

Pain Management Time Frame (if required)

Pain relief medications are required until the wound is fresh.

Health Education Regarding Wound

Since the patient is suffering from immobility and multiple ulcers and wounds, it is important that he must be assisted in cleaning and dressing the wounds as per needed. While other ulcers need once a day cleansing and dressing, the burns must be cleaned twice or thrice day. Patient is unable to do this himself, therefore, he needs assistance at home.

Case No. 2

Holistic Assessment of Patient

Mrs. Miriam Gold, 85 years old patient has fluids overload (dialysis will be ceased due to palliative approach), Pneumonia & metastatic cervical cancer. She is also often drowsy and vague. She : lives home with husband. Pt & family wants no further treatment. Mrs. Gold was admitted to the ward for palliative treatment. Husband and children are not coping at home and she was in a lot of pain due to her malignant wound on her L) groin.

The malignant wound on her groin is oozing a lot of pus and it has developed a sinus. The odour that coming out from the wound is quite strong. The patient requires pain relief before dressing change and for any pad changes/hygiene care. It was reported that her groin and peri-anal area is burning red due to bowel incontinence & discharge from her cervical cancer.

In patient history notes stated that, Mrs.Gold had developed a rectovaginal fistula as a result of disease progress and radiotherapy. In addition to this, the patient has a long standing venous ulcer that is not healing.

Evaluation and Wound Management Plan

Malignant wound on groin

This is an open wound that can be cancerous in nature if nor treated properly. The wound is draining and looks like an open cavity on surface of the skin. The appearance is bumpy and irregular.

Wound Management Plan

Moist Wound Healing

The wound requires dry healing process.

Skin & Risk Assessment

The wound can lead to infections, sepsis, odour, inflammation, extreme pain, etc.

Wound Cleansing

Daily cleansing with saline is important to ensure no infection develops.

Pressure Support and Relieving Devices

The site should be avoided from any pressures or clothing contact.

Preventive Programs

Quality nutrition, skin assessment.

Wound Dressing Products

Antibiotic ointment, dry dressing

Secondary Dressing (if required)

None

Pain Management Time Frame (if required)

4-6 weeks based on the severity. Pain relief medications are important.

Venous Ulcer

This ulcer is more common in women and older individuals. This is also associated with venous hypertension. The clinical features of this ulcer include painful site, bony appearance, etc.

Wound Management Plan

Moist Wound Healing

Daily saline wash is required.

Skin & Risk Assessment

The condition is often associated with edema, venous dermatitis, varicosities, and lipodermatosclerosis

Wound Cleansing

Saline

Pressure Support and Relieving Devices

Leg elevation, compression therapy

Preventive Programs

Thorough skin tests and health assessment

Wound Dressing Products

Open dressing, antibiotic ointment, aspirin, surgical management

Secondary Dressing (if required)

None

Pain Management Time Frame (if required)

Depends on severity of issue.

Health Education Regarding Wound

For this patient, it is important to understand the critical nature of the wounds. Since she has two wounds at the moment – both having similar characteristics but different diagnosis. It is important that she must ensure constant cleaning and draining of her wounds to avoid sepsis and infections. Furthermore, she must ensure healthy and balanced nutrition intake to avoid further skin complications, rashes, blood supply, etc. Personal hygiene is also important to allow good blood supply to the skin and avoiding any infections.

References

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. Wound repair and regeneration, 11, S1-S28.

Bowler, P. G., Duerden, B. I., & Armstrong, D. G. (2001). Wound microbiology and associated approaches to wound management. Clinical microbiology reviews, 14(2), 244-269.

Baranoski, S., & Ayello, E. A. (2008). Wound care essentials: Practice principles. Lippincott Williams & Wilkins.

Meaume, S., & Gemmen, E. (2002). Cost-effectiveness of wound management in France: pressure ulcers and venous leg ulcers. Journal of wound care, 11(6), 219-224.

Jeffcoate, W. J., & Harding, K. G. (2003). Diabetic foot ulcers. The lancet, 361(9368), 1545-1551.

Trent, J. T., Falabella, A., Eaglstein, W. H., & Kirsner, R. S. (2005). Venous ulcers: pathophysiology and treatment options. Ostomy/wound management, 51(5), 38-54.

Alexiadou, K., & Doupis, J. (2012). Management of diabetic foot ulcers. Diabetes Therapy, 3(1), 4.