Wound Management in the Clinical Environment - Admission/Application Essay Example

Case Study: Diabetic Wounds Introduction Ulcers in the lower extremities are very common in diabetic population and these are the most common injuries leading to amputation of the lower extremity. Structural foot deformity, diabetic neuropathy and peripheral arterial disease increase the risk of foot ulcers in the diabetic patient (Armstrong and Lavery, 1998). It is important to assess and manage foot ulcers in diabetic patients properly because the risk of amputation is atleast 15-46 times higher than in non-diabetic patients (Armstrong and Lavery, 1998). In this assignment, assessment, evaluation and management of a case of diabetic foot ulcer will be described. The case is about a 63 year old man Mubako Foriz who is a known patient of diabetes mellitus type-2, and who presented to the hospital with history of ulcer in the medial aspect of the lower leg since four weeks. In the past he underwent 2 amputations, the first one was that of his arm during a war and the second one for right third to subsequent to necrosis. Patient evaluation and Wound assessment The first step in the evaluation of a patient with lower extremity ulcer is taking appropriate medical history. History should include age and sex of the patient and presenting complaints. The chronology of events, whether the onset of the wound was traumatic or spontaneous, the treatments taken for the wounds and the outcomes of the treatments must be enquired. The history should also include whether the ulcer is associated with pain and if present, whether the pain is sudden in onset, and whether it is nocturnal or present when the leg has been in the dependent position for a long time. Other details to be included in the history are history of any chronic disease like diabetes and hypertension, occupational history, history of varicose veins, previous history of lower limb wounds/ulcers/gangrene, history of amputations and history of any other surgeries. Family history of similar ulcers also must be enquired into (Kunimoto, 2001). Influence of biological and social factors also must be assessed. The next step in assessment is to determine the etiology and risk factors of the wound. Age, malnutrition, collagen disease and drugs like steroids inhibit wound healing (Kunimoto, 2001). After medical history, physical examination of the wound must be undertaken. Physical examination gives valuable information especially in the elderly who cannot recall history details. One of the aims of physical examination is to differentiate between venous leg ulcers and non-venous leg ulcers. Venous leg ulcers occur in the distal medial third of the lower extremity and they are shallow without punched margins. The amount of granulation tissue and its color must also be assessed. Decreased granulation tissue or bluish hue color of this tissue are indicators of bacterial infection. The drainage from the wound must be examined as to whether it is serous, purulent or serosanguinous. Purulent discharge is an indicator of bacterial infection. The length, depth and width of the ulcer must also be assessed. Surrounding skin examination gives a valuable clue to differentiate between venous and non-venous ulcers. Peripheral arterial circulation assessment is a must in ulcer evaluation. Palpation of the dorsalis pedis artery is useful for this purpose. However, it is absent in about 10% of people. Color and perfusion are other markers for arterial sufficiency. The enrolled nurse must document the above findings in the history sheet of the patient (Kunimoto, 2001). After physical examination, certain laboratory tests must be conducted. Routine complete blood picture, serum albumin levels, doppler examination to assess the ankle-brachial index, culture of the wounds and wound biopsy are essential to arrive at the cause of ulcer (Kunimoto, 2001). Since Mr Foriz suffers from diabetes mellitus, fasting blood sugar, postprandial blood sugar and glycosylated hemoglobin levels also must be checked. Factors influencing wound healing in the patient While assessing factors which impair wound healing in Mr.Foritz, a holistic approach including both social and biological factors is essential for proper management. The factors can be systemic or local. Systemic factors which affect wound healing are old-age, building blocks, collagen tissue disease and drugs. Local factors which contribute to delayed healing are arterial disease, bacterial infection, topical agents and presence of dead tissue. Aging causes delayed metabolic response, delayed proliferation of cells and delayed cellular migration (Kunimoto, 2001). It also causes delayed matrix biosynthetic response. Wound healing requires certain building blocks like glucose, vitamins, trace metals and proteins. Hence, deficiency of these elements as in malnutrition contributes to delayed wound healing (Kunimoto, 2001). Diabetes, in which there is deranged glucose metabolism is a risk factor for delayed wound healing. Wounds which get infected with bacteria heal slowly. Periulcer pain, fever, increased purulent redness and swelling are some of the indicators of wound infection (Kunimoto, 2001). In Mr. Foritz, increasing pain and warmth show that the wound is clinically infected with bacteria. Aging causes many normal reactions to fade. Various functions like hearing, vision, ability to respond, locomotor abilities, concentration, reflex actions and coping abilities begin to decline. At the same time, the fragility of the cells and organ systems increases the vulnerability of the organs to injury and damage (NIMHANS, 2003). The recovery process is slow as age advances and the time taken to recover from an injury increases. Also, the patterns of social life of the elderly are different from those who are young and middle-aged. Many elderly live an isolated life and some others in rest homes (NIMHANS, 2003). The change in the pattern of living, associated with increased difficulties in recognition of risk and ability to cope increases the risk of injuries in the elderly (NIMHANS, 2003). Delayed recovery and inability to take proper care of themselves results in poor quality of life which futher incapacitates the day-to-day activities (NIMHANS, 2003). All these aspects also can contribute to delayed healing in Mr. Foriz. When an aged person suffers from a wound, the number of cellular replications necessary to form granulation tissue is reduced and wound healing is impaired. Re-epithelization and deposition of collagen are diminished in aged people (Pittman, 2007). Aging also causes damage to the various genetic materials in the cells like DNA, proteins, and others, all of which form linkage to one another. In young people, proteases damage the accumulated molecules. However, in the aged people, there is reduction in the quantity of proteases resulting in accumulation of the cross-linked molecules. The accumulation causes loss of intracellular transport mechanisms and intercellular transport mechanisms and also loss of elasticity. Cross-linked molecules also cause various pathological changes like cataract in the lens of the eye, changes in the kidney and brain and carcinogenesis. In the skin, these molecules lead to loss of skill elasticity, wrinkling and increased time of healing process (Pittman, 2007). Another feature in aging is accumulation of cell markers like those in the stress-related MAP kinase pathways and extracellular-signal regulated mitogen activated protein (MAP) kinase pathway. These pathways play an important role in the process of cellular responses to oxidative stress and growth signals. Some researchers have established reduction in the activity of certain enzymes like the proteases and peptidases in the keratinocytes of aged people. Because of all these factors, the skin of the aged people loses its ability to respond appropriately to stresses from the environment (Pittman, 2007). Table.1: Skin ageing and wound healing (Worley, 2006). Tissue hypoxia, which is seen in the elderly, is another factor which causes delayed wound healing in the elderly (Pittman, 2007). According to Ashcroft et al (2002), wounds in the elderly people are characterized by increased inflammation, delayed neovascularization, delayed re-epithelization and decreased deposition of matrix due to decreased fibroblast function. Early inflammatory responses or neutrophil responses are predominantly increased in the elderly (Bryant, 2007). Delay in macrophage infiltration is also seen (Hardman and Ashcroft, 2005). Thus it can be said that 2 important factors which contribute to delayed wound healing in Mr. Foriz are aging and diabetes mellitus Management of wounds in the patient Management of foot ulcers and surgical wounds in diabetic patients involves management of local and systemic factors. Precise diabetic control is pivotal in the management of the wound. In Mr. Foritz, first step is to offload the wound by advising appropriate therapeutic footwear. A moist environment must be created by daily saline dressings. If peripheral arterial insufficiency is detected, it must be corrected. Since the ulcer has been infected, antibiotic must be instituted. The wounds must be covered by either cultured human cells or heterogenic grafts or dressings. Application of hyperbaric oxygen, recombinant growth factors or negative pressure therapy (vacuum assisted closure) may also be considered. Hydrotherapy with saline pulse lavage also may be given if the wound is infected and intractable. Before applying any dressing or wound therapy product, debridement of non-viable tissue and debris which hamper wound healing must be performed. If osteomyelitis is evident, bone curettage must also be done. Revisional surgery for the architecture of the bone is essential to remove pressure points if these points are contributing to the delayed healing of ulcer. If an arterial lesion is identified which can be corrected, vascular surgery may be done (Stillman, 2008). Pain management is another important aspect which needs to be addressed while treating the patient. Pain relief can be brought about by paracetamol and other medications like opiates. Non-steroidal ant-inflammatory drugs are better avoided in the patient because they can cause delay in wound healing. Others issues in wound management are treatment of wound infection with antibiotics, nutritional supplements and education Selection of wound-management product There are many wound dressings available in the market. Alginate is useful for wounds with copious exudate. Hydrofiber is also useful for exudate wounds. Debriding agents like hypertonic saline, papain urea and collagenase can be used in necrotic wounds. Polyurethane foam is useful for cleaning wounds with granulation tissue. Hydrocolloid is useful for necrotic wounds which are dry and have clean granulation tissue and minimal exudate. Hydrogel dressings can be used in wounds with eschar (Stillman, 2008). Various grafts are also available for suitable soft tissue coverage. Since the wound in Mr. Foritz is partial thickness wound, autologous skin graft is suitable. Many tissue culture substitutes are also available. Some of them are dermagraft and apligraft. Xeno-graft is an acellular collagen matrix which is useful for inducing wound healing. One the wound is clean and well vascularised, even surgical wound closure with creation of skin flaps and myocutaneous flaps can be done (Stillman, 2008). Education and counselling of the patient Mr. Foriz is a known patient of diabetes mellitus with 2 wounds. From the history, it is obvious that he is not taking proper care of himself and is not coming for proper follow-up. Management of wounds in elderly patients with diabetes demands regular follow up, strict adherence to advice about diet, nutrition, rest, antibiotics, anti-analgesics and wound dressings. Otherwise, necrosis and gangrene can occur leading to amputation of the limb. Mr. Foriz must also advised about cleanliness considering his remote house with chicken business. Conclusion Diabetic wounds need proper evaluation and assessment to arrive at a diagnosis and to identify risk factors so that proper management can be instituted at the right time. Patients must also be counselled and educated about follow up and strict adherence to treatment regimens so as to prevent complications. References Armstrong, D.G., and Lavery, L.A. (1998). Diabetic Foot Ulcers: Prevention, Diagnosis and Classification. American Family Physician. Retrieved on 13th May, 2007 from http://www.aafp.org/afp/980315ap/armstron.html Ashcroft, G.S., Mills, S.J., Ashworth, J.J. (2002). Ageing and wound healing. Biogerontology, 3(6), 337-345. Kunimoto, B.T. (2001). Discussion of a Literature-Guided Approach. Ostomy/Wound Management, 47(5), 38–53. NIMHANS BISP Fact Sheet. (2003). Injuries among elderly. Retrieved on May 14, 2009 http://www.nimhans.kar.nic.in/epidemiology/bisp/fs3.pdf Pittman, J. (2007). Effect of Aging on Wound Healing Current Concepts. Journal of Wound, Ostomy and Continence Nursing, 34 (4), 412-417. Stillman, R.M. (2008). Diabetic Ulcers: Treatment and Medication. Emedicine from WebMD. Retrieved on may 14, 2009 from http://emedicine.medscape.com/article/460282-treatment Worley, C.A. (2006). Aging Skin and Wound Healing. Dermatology Nursing, 18(3), 264- 266. Read More