A case study of the initial treatment of a suspected ‘hard to heal’ wound

For several decades, health care professionals have been under increasing financial and political pressure to optimise care and above all minimise costs. Chronic wound management is estimated to cost the NHS £1bn a year (Harding, 1998) and as longevity increases and medical, nursing and pharmaceutical knowledge and care develop, this figure will inevitably rise. Venous leg ulcers, diabetic foot ulcers and pressure ulcers account for more than 90% of what are defined as chronic wounds (Mustoe, O’Shaughnessy, Kloeters, 2006). Clearly, some of this enormous sum could be invested elsewhere if those dealing with wounds were better informed about current wound management research and had access to a wide range of dressings.
For the individual, chronic wounds can be physically debilitating and painful, but the psychological effects are equally detrimental, disruption in self-image and self-consciousness about odour and visible dressings. It was for this reason that I chose to study the holistic care of someone who had sustained a wound that would, in all likelihood, be chronic and ‘hard to heal’.
For the purposes of this essay, the patient will be referred to with the pseudonym ‘Annie S.’, to protect her identity and maintain patient confidentiality. Mrs Annie S. is a 66-year-old woman with a past medical history of hypertension, short-term memory loss, a CVA 12 years ago and newly diagnosed Type 2 diabetes. Her GP had recently treated her for a chest infection with oral antibiotics. At 14 stone and 5″2, she had a body mass index of 35.85 indicating she was clinically obese. She lives with her husband who is her main carer in a downstairs maisonette. Once a week Annie goes shopping with her daughter and afterwards stays at her daughter’s house for the day to give Mr S some respite from his carer role. They privately employ a cleaner who comes once a week to tackle the heavier housework.
Mrs S. presented at her local casualty department following a fall four days previously outside her house. Annie had no recall of the fall itself, a neighbour who noticed Annie sitting on the wall of the garden, had alerted her husband. She appeared to have fallen and had sustained a few cuts and grazes. Later in the day, Mr S noticed there was a rash below her left knee, the skin was oedematous and dented and oozing serous fluid. Annie also had an area of broken skin partway down her leg measuring 2 by 3cm and two other smaller wounds. Mr S. applied a dry dressing to his wife’s leg but as the swelling, redness and pain increased, they attended their GP’s surgery and Annie was referred to the hospital with a provisional diagnosis of cellulitis of the left leg.
Annie had recently suffered from a chest infection and this was significant because of the effect that would have on her diabetes. In both diabetics and non-diabetics with infections, the counter-regulatory hormones such as adrenaline, noradrenaline, growth hormones, glucagons and cortisol increase and cause the liver to produce glycogen and fat breakdown, in this way the blood glucose rises (Jerreat, 1999). A person who does not have diabetes is able to compensate and produce more insulin to maintain a normal blood sugar, but a diabetic’s body cannot do this and this has important ramifications for blood sugar control and recovery from illness. According to Axelrod (1985), diabetics are five times more susceptible to fungal and bacterial infections. For this reason, diabetics should regularly test their urine or blood and a temporarily increase in their insulin or diabetic medication dose may be warranted during periods of illness.
Annie was admitted to hospital, blood cultures and wound swabs were taken to ascertain that the bacteria causing infection were not resistant to the antibiotics that were being administered. The normal battery of tests such as ECG, chest x-ray, routine blood counts were conducted; blood, sputum and urine samples were also sent for culture and sensitivity. The borders of the cellulitic area were marked to detect whether the infection was resolving or spreading. Annie was initially treated with intravenous antibiotics for seven days: benzylpenicillin and flucloxacillin then continued on oral antibiotics, amoxicillin and flucloxacillin. Her regular medications are Aspirin, Perindopril, Metoclopromide, Betahistamine, Co-amilofruse and Metformin.
The admitting SHO requested that nurses should monitor Annie’s blood pressure whilst Mrs S was sitting and then standing in case she suffered from postural hypertension or the Perindopril was lowering her blood pressure too far and causing dizziness. Another contributing factor to the fall could be the hyperglycaemia affecting the lens of the eye whilst the diabetes was coming under control.
The hospital trust uses Reid and Morison’s (1994) wound grading classification, the two broken areas were assessed as Stage 2 (non-blanching erythema with superficial skin damage, epidermal ulceration), the larger wound was Stage 3 as the ulcer extended into the subcutaneous tissue. The Stage 3 sore was surrounded by reddened oedematous skin, the ulcer itself bled easily, was dark red, dry in places and the edges of the wound were raised. I took photos of the wounds and described their dimensions and characteristics as part of the wound assessment and observed that there appeared to be more exudate than might be reasonably expected but that the wounds did not have an offensive odour. Each time the wounds were dressed, nurses documented descriptions of the wounds and the dressings that had applied.
The majority of nurses routinely cleanse wounds supposedly to eliminate wound bacteria (Roe et al. 1994) but the bactericidal activity and growth factors are vital to normal wound repair (Chen et al. 1992). Therefore, wounds should only be cleansed specifically to remove surplus wound material, slough and exudate. All wounds are colonized with bacteria that do not necessarily delay or affect healing. On assessment Annie’s wounds were gently irrigated with warmed saline to remove the initial debris, further cleansing was deemed unnecessary.
I decided that povidone-iodine dressings (Inadine) were the most appropriate for the Stage 3 wound as the wounds were likely to have been contaminated with foreign and bacteria as cellulitis had developed. A small piece of Granuflex was applied to the Stage 2 ulcers. The wounds would need to be dressed daily as the iodine is rapidly deactivated by wound exudate. The dressing has a wide-ranging antimicrobial activity and is very economical as it only costs 30p for a 5 x 5cm dressing; surgical pads were also applied to absorb some of the exudate with a bandage to hold them in place.
As iodine is absorbed systemically, it is not recommended for those with thyroid disorders and obviously, iodine would be contraindicated for those who are allergic to it. Annie had no allergies, but a ‘patch test’ was conducted on healthy skin to monitor reaction. The issue of whether iodine assists in treating wound infection and aids healing is contentious; some studies appear to show that it is has no beneficial effect whatsoever. Whereas other such as Piérard-Franchimont et al’s (1997) concluded that the rate of ulcer healing was accelerated when povidone iodine was applied with hydrocolloid dressings. Moberg (1983) compared cadexomer iodine and standard treatment of pressure sores and found that pus, debris, and pain were significantly reduced and accelerated their healing and many clinical trials of cadexomer iodine confirm these findings.
Deep or wide wounds have a large tissue deficit and heal by secondary intention: granulation formation occurs at the bottom of the wound (Hinchliff SM, Montague SE, Watson R 1996). Torrance (1986) described four stages in healing: the acute inflammatory reaction, the destructive phase (involving the removal of injured tissue), the proliferative phase (where new capillary loops grow bringing fibroblasts with them and collagen synthesis begins). Finally, the maturational phase takes place and the collagen fibres grow and become orientated along the lines of tension. (Hinchliff, Norman, Schober 1993, p149) These phases tend to overlap each other and the duration of each stage varies from individual to individual, according to wound characteristics, general health and extrinsic factors. Proliferative and maturative phases are more drawn-out in wounds which heal by secondary intention.
In a wound which is being clinically ‘treated’, healing may be inadvertently delayed by contamination, mechanic stress, failure to maintain the wound at body temperature by over-exposing that area or irrigation with cool liquids and the use of dressing materials which lower the temperature of the vulnerable tissue or are inappropriate. In many ways, Annie’s own physical condition, age, diabetes, and obesity, will retard the healing process as with advancing age, the metabolic processes naturally slow down. Desai (1997) observed that the skin’s capacity to repair itself reduces with age, although no research has yet been able to quantify this delay, an elderly person’s skin has less elasticity and collagen. Adipose tissue has a poor blood supply so the wounds of overweight patients are likely to heal more slowly.
The role of compression hosiery over dressing type in healing venous ulcers has gained increasing recognition in recent years and the doctors decided Annie’s wounds would benefit from their application. “By increasing the transfer of tissue fluid from the interstitial spaces back into the vascular and lymphatic compartments and achieving a maximal increase in venous velocity in order to reduce pooling of blood in the calf veins, healing of the venous ulcers may be enhanced.” (Bennett and Moody, 1995, p96)
Patients find this concept difficult to grasp, they focus on the wound itself, rather than the underlying pathology. Annie was reluctant to wear the stockings, staff found she frequently avoided putting them back on after showering and refused to wear them at night, she disliked the fact they felt tight, restrictive and hot.
Lack of concordance (complying with treatment) wastes time and money, but health professionals cannot legally force patients to comply with treatment. Lack of compliance may be due to lack of education, financial resources or conflicting needs rather than the patient merely being ‘awkward’. For example, no one had actually spoken to Annie about how vital the hosiery was to the healing of the ulcer. Once one of the nurses informed her and continued to remind her that they would help her leg ulcers heal, she was, with a little encouragement, less resistant to wearing them.
The nurse-patient relationship is the bedrock of nursing care, where it not allowed or able to develop, the effects can be detrimental or even dangerous to the patient’s physical and mental wellbeing. The nurses caring for Annie found that as she regularly suffered short-term memory loss, their role as patient’s advocate was especially important. Her ability to make informed decisions was often affected by her cognitive impairment. It was helpful for Mr S. to be present at significant discussions to keep him informed as Annie was likely to forget what had been said and he was able in turn to reinforce later to her what had taken place.
Her husband was initially somewhat aggressive in attitude, but in time he felt able to express his feelings of guilt and anxiety over Annie’s condition. As her main carer for some years, he was finding the responsibility somewhat overwhelming and felt remorseful about not seeking medical help sooner for what turned out to be a serious infection.
After a hospital admission of twelve days, Mrs S. was discharged home. Prior to discharge, Annie was assessed by the physiotherapist who assessed her as safe for discharge. The occupational therapist spoke to Annie and her husband and advised them on how their home might be made safer, both to prevent further falls and also because Annie’s legs were now more vulnerable to injury and infection. The couple decided it would be beneficial for some of the rugs and low-level furniture to be removed.
Two clinical nurse specialists were involved in Annie’s care, a diabetic nurse and a tissue viability nurse. The relatively recent development of clinical nurse specialists as we know them today and their role in prescribing care and initiating changes in practice has become increasingly vital in promoting good standards of care, especially since the 1990s, which saw a reduction in doctors’ working hours. The CNS has five widely accepted principle roles according to Storr (1988): practitioner, teacher and educator, consultant, researcher and change agent.
As I was studying Annie’s case, with Mr and Mrs S’ permission, I kept in touch with her district nurse for the first month after her discharge to follow how she was progressing. When it was determined that the wounds were only colonized with bacteria and the infection was resolving, the district nurse referred Annie to a tissue viability nurse who assessed her and advised that as the cellulitis had been treated changing the Inadine dressing to an hydrocolloid would be more appropriate.
It is vital that Annie’s diabetes be as well controlled as possible, not only for her future general health but also in order for her wounds to heal. Leaper and Harding (1998) found that in older diabetics whose blood sugar is poorly controlled, wound closure is delayed three times longer than that of older non-diabetics. The diabetic nurse continued to see Mr and Mrs S periodically after discharge. He reinforced the importance of following a ‘diabetic diet’, low in fat and sugar and high in fibre and carbohydrates, not only to maintain acceptable blood sugar, but also so that Annie’s weight might be reduced.
The dietician advised Annie and her husband on how her diet could be healthier and lower in fat. The dietician was also able to correct some of the erroneous health beliefs the couple had: that non-insulin dependent diabetes was “mild diabetes” or might resolve itself; the dietician reinforced what the diabetic nurse had said about the potential long-term physiological complications of diabetes such as foot, visual, circulatatory and renal problems. They also discussed the important role diet played in healing, as malnutrition results in poor healing, reduced tensile strength, increased wound dehiscence, poor quality scarring, and increased susceptibility to infection.
After four weeks, the ulcer on Mrs S’ leg did seem to be decreasing in size and depth, although it was a slow process, Annie was pleased that her leg appeared to be healing. Mr and Mrs S also appeared to be more confident about managing Annie’s diabetes and felt empowered by knowing more about the condition and the fact that they could, through their actions, improve Annie’s health.
In retrospect, Mr S said that he wished he had sought help sooner after the fall. One might suggest that his generation are more reluctant than most to ‘bother’ the doctor and are more stoic whereas a younger person is less tolerant of diminished quality of health and comfort. In the future, he realised the importance of early intervention when a diabetic person is developing health problems. Annie did still find the compression stockings hot and uncomfortable to wear but was aware of the fact they would help her leg heal and reduce the oedema in her legs.