Art & science tissue viability supplement
Pressure ulcer treatment in a patient with spina bifida Porter M, Kelly J (2014) Pressure ulcer treatment in a patient with spina bifida. Nursing Standard. 28, 35, 60-69. Date of submission: May 31 2013; date of acceptance: August 15 2013.
Abstract Pressure ulcers can have a significant effect on patients’ health and quality of life. They may also be associated with increased treatment-related costs, including product selection, length of interventions, prolonged hospitalisation, and resources and time required to care for patients. Pressure ulcers may be more common in patients with comorbidities. This article presents a case study of a man with spina bifida who was admitted to hospital with a pressure ulcer on his chest. It examines the clinical and social issues that affected the patient’s wound healing, with the aim of identifying appropriate assessment and management of such patients.
Authors Michelle Porter Tissue viability nurse specialist, Queen Elizabeth Hospital NHS Foundation Trust, Norfolk. Jenny Kelly Independent tissue viability nurse consultant, King’s Lynn, Norfolk. Correspondence to: [email protected]
Keywords Necrotic tissue, pressure ulcers, spina bifida, topical negative pressure therapy, wound care, wound management
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
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PRESSURE ULCERS ARE defined as ‘localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear’ (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel 2009). They are associated with reduced quality of life as a result of pain, systemic illness, increased hospital stay, loss of earnings, low self-esteem and amputation, and 60 april 30 :: vol 28 no 35 :: 2014
may also lead to death (Franks et al 2002). Pressure ulcers are common in older people and with an increasing ageing population, the financial burden on the NHS of treating these wounds is likely to increase. Using August 2011 prices, Dealey et al (2012) reported that the cost of treating a pressure ulcer varied from £1,214 for a grade 1 pressure ulcer to £14,108 for a grade 4 pressure ulcer. Because pressure ulcers are largely avoidable, their incidence may be viewed as an indicator of the quality of patient care (Newton 2010). The NHS Institute for Innovation and Improvement (2009) set out high impact actions, one of which was to prevent all avoidable pressure ulcers to improve quality of care while reducing costs to the NHS. Therefore, care priorities need to focus on prevention of pressure ulcers to reduce the incidence and the costs associated with treating these wounds (National Patient Safety Agency 2010). In the event that a pressure ulcer does occur, treatment needs to be timely and appropriate to improve patient outcomes and quality of life (Gorecki et al 2009). This article presents a case study of a patient with spina bifida who was admitted to hospital with a pressure ulcer on his chest.
Patient history Jonathan (a pseudonym) is a 45-year-old man with spina bifida who is wheelchair bound. He is generally healthy and has rarely had to access secondary care. At home, his main carer is his father who has rheumatoid arthritis, but is still able to meet most of Jonathan’s care needs. To assist his father, Jonathan also has a carer who visits approximately four times per week. Jonathan was admitted to hospital with a grade 4 pressure ulcer (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel 2009) (Table 1) on the lower right side of his chest (Figure 1). Initial assessment of the wound indicated considerable depth of damage extending to the muscle. The pressure ulcer had been present for four months, and district nurses had been dressing the ulcer twice weekly using alginate
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packing and a foam adhesive dressing. The ulcer was caused by the tray on Jonathan’s wheelchair; he tended to lean against the tray, which put direct pressure on his chest. With no sensation from his lower chest downwards as a result of his spina bifida, Jonathan was unaware of the developing pressure ulcer. On talking to Jonathan and his father the tissue viability nurse found that no previous explanation of pressure ulcer prevention or treatment had been provided.
TABLE 1 Pressure ulcer classification in the UK Grade/ stage 1
Intact skin with non-blanchable erythema of a localised area usually over a bony prominence. Discoloration of the skin, warmth, oedema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching.
2
Partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open (ruptured) serum-filled or serosanguineous blister.
3
Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. May include undermining and tunnelling.
4
Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Frequently includes undermining and tunnelling.
Assessment On initial assessment, the wound was found to be 8cm long, 7cm wide and 4cm deep. Measuring the depth of the wound was difficult because of the presence of thick, dry necrotic tissue. The wound exudate was thick, yellow/green and malodorous. There was erythema of the surrounding skin and excoriation where the exudate had caused further skin damage. High levels of exudate, swelling and malodour are indicative of infection. The wound was cleansed with 0.9% sodium chloride using a sterile syringe to ensure adequate irrigation, and a wound swab was taken for microbiology, culture and sensitivity to identify the cause of infection. Because of concerns about the severity of the wound, intravenous antibiotics were commenced without waiting for microbiology results. Jonathan’s father expressed concern about the malodour and was worried the wound had deteriorated despite the fact that Jonathan was receiving nursing care at home. This deterioration led to a loss of confidence in the healthcare professionals caring for Jonathan. Therefore, it was not only necessary to treat the wound, but also to develop a therapeutic relationship with Jonathan and his father to ensure they understood all of the interventions required as they would then be more likely to adhere to the treatment regimen. Before admission to hospital, Jonathan’s father had been re-dressing the wound when it became soiled and was doing so without the support of a nurse. Some of the dressings used were ineffective in controlling exudate levels and had little effect on overall wound healing. A new dressing regimen was devised and this was explained carefully to Jonathan and his father. The wound was dressed using an absorbent, non-adherent calcium alginate dressing impregnated with manuka honey (Algivon) to help debride the wound, and reduce bio burden and malodour (Molan 2009). Chronic wounds, such as pressure ulcers, often contain necrotic tissue and bacteria, and can either be dry and leathery (eschar) or soft and brown, grey or yellow (slough) in appearance. Slough is made up of white blood cells, bacteria and debris, as well as
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Description
(European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel 2009)
FIGURE 1 Presenting wound (pressure ulcer) on the chest
dead tissue and is easily confused with pus, which is often present in an infected wound. Chronic wounds usually require repeated debridement as part of ongoing care because the underlying cause of the wound means that slough tends to recur (Brown 2013). A secondary dressing Sorbion Sana (a non-adherent polyethylene wound contact dressing with an absorbent core), was used to contain the exudate (Bronstering and Maassen 2012) and was covered with Mepilex Border (an absorbent soft silicone-based dressing with a polyethylene foam and adhesive border), with the aim of maintaining a moist wound environment to optimise healing (Dykes et al 2001). A protective, transparent barrier film (Cavilon No Sting Barrier Film), was applied to the surrounding skin to protect it from maceration (Williams 1998). april 30 :: vol 28 no 35 :: 2014 61
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Art & science tissue viability supplement A Waterlow assessment (judy-waterlow.co.uk) was carried out as part of his initial pressure ulcer risk assessment on admission. The risk assessment identifies areas that increase a person’s risk of developing a pressure ulcer, including, mobility, skin integrity, age, gender, comorbidities, nutrition, weight and continence. The score showed that Jonathan was at high risk of pressure ulcer development and deterioration, in addition to having an existing ulcer. It highlighted Jonathan’s spina bifida and immobility as key factors in the development of his pressure ulcer. Pressure ulcer prevention was discussed with Jonathan and his father as a part of the initial assessment. A chest X-ray was undertaken to determine the severity of the wound because of its close proximity to the rib cage. Results confirmed that there was no danger to Jonathan’s lung and oxygen saturation, and respiratory tests supported this. Jonathan was keen to return home and was discharged the following day with a confirmed bacterial infection. He attended the hospital daily for review and to complete the course of intravenous antibiotics. Two weeks following initial presentation, Jonathan was seen as an outpatient in the tissue viability clinic. The district nurses caring for him were concerned about the increasing amount of wound exudate and decided to pack the wound with Aquacel (a soft non-woven pad containing hydrocolloid fibres) (Morgan 2009). The wound was covered with 60% thick necrosis and 40% slough (Figure 2). It was leaking large amounts of yellow viscous exudate and remained malodorous. A mild skin reaction surrounded the wound, which appeared to have resulted from using Tegaderm Foam – a polyurethane foam film dressing with an adhesive border. The wound measured 12cm by 8cm and was 7cm deep (Figure 2). Jonathan remained healthy and viewed his wound as more of an irritation than a serious problem because he could not feel or see it. A photograph was taken and shown to Jonathan to explain the severity of the wound. On viewing the wound, Jonathan demonstrated a desire to comply with new treatments. A trial using UrgoClean (a pad with hydrocolloid fibres coated with a soft, adherent lipo-colloidal wound contact layer) was commenced to deslough the wound and help manage the exudate. Two pads of UrgoClean were placed in the wound with Sorbion Sana and covered with Mepilex Border. Topical negative pressure (TNP) therapy was discussed, but because of the large amount of necrotic tissue, this therapy was not suitable at this time. TNP therapy has a multimodal action, increasing dermal perfusion (Morykwas et al 1997, 62 april 30 :: vol 28 no 35 :: 2014
Chen et al 2005, Timmers et al 2005, Bovill et al 2008), stimulating granulation tissue formation (Fabian et al 1994, Morykwas et al 1997, Saxena et al 2004, Bovill et al 2008), reducing oedema and interstitial tissue fluid (Morykwas et al 1997, Bovill et al 2008), reversing tissue expansion (Banwell and Téot 2003, Bovill et al 2008) and reducing bacterial colonisation (Banwell and Téot 2003, Pinocy et al 2003, Mouës et al 2005, Bovill et al 2008). However, it cannot achieve this through dead tissue and is therefore contraindicated in wounds with significant necrotic tissue or eschar. At four weeks, and following two weeks of treatment with UrgoClean, the amount of slough had reduced. The necrosis had begun to soften and the surrounding skin appeared healthier because of reduced excoriation and oedema (Figure 3). The amount of exudate had also decreased. Jonathan and his father demonstrated a positive attitude towards the treatment because they could see an improvement in the appearance of the wound. The reduction of exudate was a significant achievement and meant that Jonathan did not need multiple dressing changes throughout the day.
FIGURE 2 Wound at two weeks
FIGURE 3 Wound at four weeks
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Art & science tissue viability supplement Because of the decrease in exudate levels, it was decided to trial the use of fewer dressings to reduce application time and cost. UrgoClean was continued and Sorbion Sana adhesive was trialled to simplify the dressing procedure. This reduced the layering of dressings because Sorbion Sana had previously been used under a Mepilex Border. The following week, some of the necrosis was removed by the tissue viability nurse using sharp debridement and the eschar was scored with a sterile scalpel to promote autolytic debridement (Kelly 2011). Debridement is beneficial because it removes dead, devitalised, or contaminated tissue, and any foreign material from the wound, which helps to reduce the number of microbes, toxins, and other substances that inhibit healing (Elek 1956, Fowler 1992, Berger 1993, Fowler and van Rijswijk 1995, Enoch and Harding 2003). All wounds experience some level of autolytic debridement, which is the natural and highly selective process by which endogenous proteolytic enzymes break down necrotic tissue. These endogenous enzymes are mainly produced by neutrophils and include elastase, collagenase, myeloperoxidase, acid hydrolase, and lysosomal enzymes (Sinclair and Ryan 1993, Enoch and Harding 2003). However, autolytic debridement may not take place fast enough to encourage rapid wound healing and closure, although the use of occlusive dressings can enhance this process, while maintaining a moist wound bed and managing excess exudate (Nemeth and Eaglstein 1993, Enoch and Harding 2003). This allows painless, selective debridement and promotes the formation of healthy granulation tissue (Eaglstein and Falanga 1997). Signs of epithelialisation were present at the bottom edge of the wound and there was continued reduction in the amount of exudate and slough (Figure 4). UrgoClean was used to continue autolytic debridement of the necrotic area and Aquacel (a soft non-woven pad containing hydrocolloid fibres), was used to absorb exudate and aid growth of granulation tissue. Jonathan and his father remained positive, although Jonathan’s father was anxious about the rate of healing and size of the wound. At week six, the necrosis had continued to soften and a large amount of this was sharp debrided leaving a plug of necrotic tissue within the wound. The wound measured 11cm by 7cm and was 7cm deep, with 10cm undermining to the left and 7cm to the right of the wound (Figure 5). The degree of undermining was the result of necrotic tissue being removed from the wound so that its true dimensions could be identified. There was no effect on Jonathan’s breathing or oxygen saturation, which was a major concern because of the extent of 64 april 30 :: vol 28 no 35 :: 2014
damage to the tissue in the chest area. The wound bed appeared to be free of slough. Dressing the wound with UrgoClean continued and Mepilex Border was used as the outer dressing because Sorbion Sana adhesive was thought to have caused a skin reaction and Jonathan had requested to have the dressing changed back to the Mepilex Border. The wound continued to debride well and as the necrotic tissue was removed, the actual depth of the wound was revealed. It was important, at this stage, to ensure that Jonathan and his father understood that the wound was healing and did not assume that it was continuing to deteriorate because of its appearance. The depth of the wound increased as necrotic tissue was removed, and by week nine, Jonathan’s ribs were palpable. This caused Jonathan’s father some anxiety, but Jonathan showed no signs of infection or ill health. Jonathan was still unable to feel the wound so pain management was not required. The wound measured 10cm by 5cm with up to 10cm undermining (Figure 6). At this point, TNP therapy was discussed as a viable option and Jonathan requested some time to discuss this with his father. The wound was packed with UrgoClean and a
FIGURE 4 Wound at five weeks
FIGURE 5 Wound at six weeks
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sorbion pad was used underneath the Mepilex Border to manage increasing levels of exudate. After consideration by Jonathan and his father and obtaining agreed funding – the local primary care trust did not support the use of TNP therapy – this therapy was commenced at -60mmHg continuous pressure for one hour before increasing the rate to -80mmHg, since there were no adverse effects on Jonathan’s breathing. Jonathan was discharged home and requested to return in three days for an outpatient appointment to change his dressings. It was agreed that the dressing would be changed twice weekly on an outpatient basis, with telephone support from the tissue viability nurses. An additional appointment could be made if required. Since the use of TNP was not supported by the primary care service at this time Jonathan’s care was provided by the acute trust. During the outpatient appointment, the dressing was removed and the wound bed appeared to be covered with a ‘curtain’ of necrotic tissue (Figure 7). Jonathan’s father stated that the TNP therapy pump was making loud ‘sucking noises’ and he had disconnected it several times to make sure that the suction was working. This did not, however, account for the level of tissue damage observed. Another issue highlighted was that where Jonathan and his father lived there were not many electrical sockets available and it was not possible to have more installed. This caused problems when charging the pump because the sockets were located in areas that were difficult to access. This problem was resolved following discussion with Jonathan and his father about the safe use of extension leads. Jonathan was admitted to hospital and reviewed by the surgical team. Jonathan and his father were anxious about a stay in hospital because they were used to their routine at home. Jonathan’s father stayed with him in hospital so that he could continue to be his main carer. A chest X-ray confirmed there was no lung involvement and surgical debridement was planned to remove any necrotic or infected tissue. Surgical debridement is the fastest way to remove dead tissue. Although surgical debridement is thought to be selective, there may be some damage to viable tissue, and bleeding is likely. Nevertheless, this may help to revitalise the wound and encourage healing by inundating the wound bed with growth factors and cytokines. Surgical assessment of the wound identified some necrosis; the wound remained malodorous and areas of the ribs were visible (Figure 8). Jonathan was referred to the plastic surgeons who performed surgical debridement of the wound to remove the remaining necrotic tissue (Figure 9) and assessed its suitability for
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closure or skin grafting. By week 12, osteomyelitis was a major concern as the exposed rib felt rough and pitted. However, tests for osteomyelitis were negative. A plastic surgeon reviewed the wound again and agreed to surgically close the wound. On return to the hospital at 14 weeks, the wound had not been operated on and skin grafting had not taken place, however the wound had been surgically debrided. At this point, Jonathan started
FIGURE 6 Wound at nine weeks
FIGURE 7 Wound at ten weeks
FIGURE 8 Wound at 11 weeks
april 30 :: vol 28 no 35 :: 2014 65
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Art & science tissue viability supplement to show signs that he was anxious to go home and was slightly disillusioned with the treatment he was receiving. A tissue viability nurse spent time with Jonathan and his father discussing past problems and explaining that the surgeons were unable to close the wound because the volume of tissue loss had been too great. TNP therapy was re-commenced on an inpatient basis, allowing nursing staff to assess and monitor the wound throughout the day to ensure wound granulation was taking place. This was especially important because previous use of TNP therapy has resulted in increased necrosis. Friable granulation tissue was present in the lower half of the wound and areas of the rib remained exposed. One large roll of gauze was used with an underlying soft silicone, semi-transparent low-adherent dressing (Mepitel) to protect the exposed bone and the granulation tissue. The pump was set at -120mmHg continuous pressure. This regimen was assessed twice weekly at each dressing change. A silicone sealant (Mepiseal) was used to prevent exudate from spreading and to achieve a good seal for the dressing to enable adequate suction. The exudate was removed via the tubing and stored in the canister. Jonathan remained in hospital for one week to ensure there were no concerns about wound healing while the TNP therapy pump was in use. At the end of the week the pressure ulcer appeared to have a healthy granulating wound bed (Figure 10). A conversation about home care revealed that Jonathan naturally positioned himself on his left side while in bed, in other words on the pressure ulcer and TNP therapy tubing. It was suggested this might have contributed to the necrosis that developed when TNP therapy was first used in Jonathan’s home. While in hospital, Jonathan lay supine because he was able to use electrical controls to raise the top of the bed to get comfortable. It was clear that Jonathan’s bed at home was not suitable to meet his current needs because it could not be adjusted and a hospital bed would be more appropriate. The tissue viability team then faced a new problem as to whether the hospital bed was too heavy to be accommodated in Jonathan’s home. The hospital’s occupational therapists were contacted and conducted a home visit. They measured and discussed this problem with the supplier of the hospital bed, and determined that it would be safe to install the bed. A hospital bed was ordered and Jonathan was discharged home to continue TNP therapy as an outpatient. By week 17, the wound bed appeared healthy and granulating. The wound measured 7cm by 4cm and was 3cm deep (Figure 11). The rib was no longer visible or palpable. There had been no 66 april 30 :: vol 28 no 35 :: 2014
FIGURE 9 Wound at 12 weeks
FIGURE 10 Wound at 15 weeks
FIGURE 11 Wound at 17 weeks
complications with the TNP therapy and it was concluded that the previous bed Jonathan had been using in his home was the initial cause of the unsuccessful TNP therapy. Jonathan appeared to be well and healthy, and was more relaxed on returning home. Continual improvement in the wound was observed at week 19. It remained healthy and granulating. The areas of undermining were almost
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Art & science tissue viability supplement gone (Figure 12). Jonathan had developed a mild skin irritation following use of a film dressing (Avance) and medihoney barrier cream was applied to protect the skin (Bardsley 2008). It was also applied to a skin fold located to the left of the wound, which had become excoriated due to the build-up of moisture. Jonathan and his father could see that the wound was improving and developed a positive attitude towards the treatment. By week 20, the wound was granulating well and there were no areas of undermining. The surrounding area remained excoriated, possibly as a result of the film dressing being removed and reapplied regularly. This led to the decision to discontinue TNP therapy and following agreement with Jonathan and his father, the wound was packed with Aquacel and covered with Mepilex Border. Jonathan was reviewed at the outpatient clinic three weeks later. The wound had almost completely closed and there was a small area of overgranulation, which was being treated by the district nurses. The wound was dry and the surrounding skin appeared healthy. Jonathan was pleased with his progress and was discharged from the acute setting to be managed by the district nurses for the final part of his treatment.
Discussion The treatment of pressure ulcers can be complex as a result of the interplay of several factors such as age, co-morbidities and immobility. Jonathan presented with several complications because of his lack of mobility and loss of sensation from the lower chest downwards as a result of having spina bifida, and the position of the wound, which was in close proximity to his lung. His wound required several forms of treatment, including intravenous antibiotics and invasive surgery. Initial treatment of wound infection was essential to prevent further
FIGURE 12 Wound at 19 weeks
68 april 30 :: vol 28 no 35 :: 2014
deterioration and to protect Jonathan’s lungs. TNP therapy proved to be successful when used correctly. Jonathan’s case demonstrated that social circumstances and factors can affect the success of wound healing and need to be considered in the management of complex wounds. The use of pressure-relieving devices in the home should be considered if patients are at increased risk of developing pressure ulcers. The TNP therapy system used to treat Jonathan’s wound was suitable because the associated tubing did not interfere with his ability to transfer and sit comfortably in his wheelchair. The use of gauze dressings allowed the wound’s extensive undermining and tunnelling to be packed quickly and easily without leaving any cavities, and enabled the wound to be protected. A transfer drain was used throughout TNP therapy since it was quick and easy to attach on top of the wound compared with a channel drain, which sits in the gauze dressing and drains from within. Patients with complex wound management needs require regular review and assessment by an appropriate healthcare professional; dressings need to be changed to meet the needs of a rapidly changing wound environment. The patient’s living environment also needs to be considered. In Jonathan’s case, this included the suitability of his wheelchair and his daily living requirements and nutritional intake. According to Thompson and Furhrman (2005) nutrition plays a vital role in the prevention and treatment of wounds and ulcers. Consuming a healthy balanced diet and maintaining a suitable weight can reduce the risk of developing several conditions that predispose an individual to wounds and ulcers (Astrup 2001) and encourages healing in patients with existing wounds. Healthy nutritional intake was discussed at regular intervals throughout treatment. It was important to ensure that both Jonathan and his father had an understanding of the importance of nutrition and hydration in wound healing. A dietitian review and leaflets were also offered to Jonathan. Education played a major role in Jonathan’s care and included providing Jonathan and his father with information about wound care at home, and how to maintain dressings and keep the wound clean and dry. Effective communication helped to raise awareness of the issues and develop a therapeutic relationship. This allowed healthcare professionals to work with Jonathan and his father and to teach them how to prevent future pressure ulcers. Communication barriers between acute and primary care may have contributed to the initial unsuccessful treatment of Jonathan’s wound. If hospital staff had known about Jonathan’s home environment and the problems associated with his
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sleeping arrangements, treatment may have been more successful. Improved communication between acute and primary care would help to ensure that all of the patient’s needs are understood and met.
Conclusion Complex wound management in the non-healing wound can be challenging for healthcare professionals, as well as adversely affecting the
patient’s health and quality of life. It is important to consider physical, social and environmental factors when providing holistic patient care and encouraging adherence to treatment in the prevention and management of pressure ulcers. Developing a therapeutic relationship between patients and healthcare professionals is essential to ensure patients are aware of how they can contribute to successful wound management and prevent re-occurrence NS
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the stratum corneum of the skin. Journal of Wound Care. 10, 2, 7-10. Eaglstein WH, Falanga V (1997) Chronic wounds. The Surgical Clinics of North America. 77, 3, 689-700. Elek SD (1956) Experimental staphylococcal infections in the skin of man. Annals of the New York Academy of Sciences. 65, 3, 85-90. Enoch S, Harding K (2003) Wound bed preparation: the science behind the removal of barriers to healing. Wounds. 15, 7. European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel (2009) Pressure Ulcer Prevention: Quick Reference Guide. www.epuap.org/guidelines/ Final_Quick_Prevention.pdf (Last accessed: April 11 2014.) Fabian TC, Croce MA, Pritchard FE et al (1994) Planned ventral hernia. Staged management for acute abdominal wall defects. Annals of Surgery. 219, 6, 643-653. Fowler E (1992) Instrument/ sharp debridement on non-viable tissue in wounds. Ostomy Wound Management. 38, 8, 26-33. Fowler E, van Rijswijk L (1995) Using wound debridement to help achieve the goals of care. Ostomy Wound Management. 41, 7A Suppl, 23S-35S. Franks PJ, Winterberg H, Moffatt CJ (2002) Health-related quality of life and pressure ulceration assessment in patients treated in the community. Wound Repair and Regeneration. 10, 3, 133-140. Gorecki C, Brown JM, Nelson EA et al (2009) Impact of pressure ulcers on quality of life in older patients: a
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systematic review. Journal of the American Geriatrics Society. 57, 7, 1175-1183. Kelly J (2011) Methods of wound debridement: a case study. Nursing Standard. 25, 25, 51-59. Molan P (2009) Why honey works. In Cooper R, Molan P, White RJ (Eds) Honey in Modern Wound Management. Wounds UK Publishing, Aberdeen, 7-20. Morgan DA (2009) Formulary of Wound Management Products. A Guide for Healthcare Staff. Tenth edition. Euromed Communications, Liphook, Surrey. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W (1997) Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Annals of Plastic Surgery. 38, 6, 553-562. Mouës CM, van den Bemd GJ, Meerding WJ, Hovius SE (2005) An economic evaluation of the use of TNP on full-thickness wounds. Journal of Wound Care. 14, 5, 224-227. National Patient Safety Agency (2010) NHS to Adopt Zero Tolerance Approach to Pressure Ulcers. NPSA, London. Nemeth AJ, Eaglstein WH (1993) Wound dressings and local treatment in leg ulcers: diagnosis and treatment. In Westerhof W (Ed) Leg Ulcers: Diagnosis and Treatment. Elsevier Science Publishers, Amsterdam, 325-333. Newton H (2010) Reducing pressure ulcer incidence: CQUIN payment framework in practice. Wounds UK. 6, 3, 38-46.
NHS Institute for Innovation and Improvement (2009) Your Skin Matters – One of the High Impact Actions. tinyurl.com/ qzj2poa (Last accessed: April 3 2014.) Pinocy J, Albes JM, Wicke C, Ruck P, Ziemer G (2003) Treatment of periprosthetic soft tissue infection of the groin following vascular surgical procedures by means of a polyvinyl alcohol-vacuum sponge system. Wound Repair and Regeneration. 11, 2, 104-109. Saxena V, Hwang CW, Huang S, Eichbaum Q, Ingber D, Orgill DP (2004) Vacuum-assisted closure: microdeformations of wounds and cell proliferation. Plastic and Reconstructive Surgery. 114, 5, 1086-1098. Sinclair RD, Ryan TJ (1994) Types of chronic wounds: indications for enzymatic debridement. In Westerhof W, Vanscheidt W (Eds) Proteolytic Enzymes and Wound Healing. Springer-Verlag, New York, NY, 7-20. Thompson C, Fuhrman P (2005) Nutrients and wound healing: still searching for the magic bullet. Nutrition in Clinical Practice. 20, 3, 331-347. Timmers MS, Le Cessie S, Banwell P, Jukema GN (2005) The effects of varying degrees of pressure delivered by negativepressure wound therapy on skin perfusion. Annals of Plastic Surgery. 55, 6, 665-671. Williams C (1998) 3M Cavilon No Sting Barrier Film in the protection of vulnerable skin. British Journal of Nursing. 7, 10, 613-615.
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Pressure ulcer treatment in a patient with spina bifida Porter M, Kelly J (2014) Pressure ulcer treatment in a patient with spina bifida. Nursing Standard. 28, 35, 60-69. Date of submission: May 31 2013; date of acceptance: August 15 2013.
Abstract Pressure ulcers can have a significant effect on patients’ health and quality of life. They may also be associated with increased treatment-related costs, including product selection, length of interventions, prolonged hospitalisation, and resources and time required to care for patients. Pressure ulcers may be more common in patients with comorbidities. This article presents a case study of a man with spina bifida who was admitted to hospital with a pressure ulcer on his chest. It examines the clinical and social issues that affected the patient’s wound healing, with the aim of identifying appropriate assessment and management of such patients.
Authors Michelle Porter Tissue viability nurse specialist, Queen Elizabeth Hospital NHS Foundation Trust, Norfolk. Jenny Kelly Independent tissue viability nurse consultant, King’s Lynn, Norfolk. Correspondence to: [email protected]
Keywords Necrotic tissue, pressure ulcers, spina bifida, topical negative pressure therapy, wound care, wound management
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online Guidelines on writing for publication are available at www.nursing-standard.co.uk. For related articles visit the archive and search using the keywords above.
PRESSURE ULCERS ARE defined as ‘localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear’ (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel 2009). They are associated with reduced quality of life as a result of pain, systemic illness, increased hospital stay, loss of earnings, low self-esteem and amputation, and 60 april 30 :: vol 28 no 35 :: 2014
may also lead to death (Franks et al 2002). Pressure ulcers are common in older people and with an increasing ageing population, the financial burden on the NHS of treating these wounds is likely to increase. Using August 2011 prices, Dealey et al (2012) reported that the cost of treating a pressure ulcer varied from £1,214 for a grade 1 pressure ulcer to £14,108 for a grade 4 pressure ulcer. Because pressure ulcers are largely avoidable, their incidence may be viewed as an indicator of the quality of patient care (Newton 2010). The NHS Institute for Innovation and Improvement (2009) set out high impact actions, one of which was to prevent all avoidable pressure ulcers to improve quality of care while reducing costs to the NHS. Therefore, care priorities need to focus on prevention of pressure ulcers to reduce the incidence and the costs associated with treating these wounds (National Patient Safety Agency 2010). In the event that a pressure ulcer does occur, treatment needs to be timely and appropriate to improve patient outcomes and quality of life (Gorecki et al 2009). This article presents a case study of a patient with spina bifida who was admitted to hospital with a pressure ulcer on his chest.
Patient history Jonathan (a pseudonym) is a 45-year-old man with spina bifida who is wheelchair bound. He is generally healthy and has rarely had to access secondary care. At home, his main carer is his father who has rheumatoid arthritis, but is still able to meet most of Jonathan’s care needs. To assist his father, Jonathan also has a carer who visits approximately four times per week. Jonathan was admitted to hospital with a grade 4 pressure ulcer (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel 2009) (Table 1) on the lower right side of his chest (Figure 1). Initial assessment of the wound indicated considerable depth of damage extending to the muscle. The pressure ulcer had been present for four months, and district nurses had been dressing the ulcer twice weekly using alginate
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packing and a foam adhesive dressing. The ulcer was caused by the tray on Jonathan’s wheelchair; he tended to lean against the tray, which put direct pressure on his chest. With no sensation from his lower chest downwards as a result of his spina bifida, Jonathan was unaware of the developing pressure ulcer. On talking to Jonathan and his father the tissue viability nurse found that no previous explanation of pressure ulcer prevention or treatment had been provided.
TABLE 1 Pressure ulcer classification in the UK Grade/ stage 1
Intact skin with non-blanchable erythema of a localised area usually over a bony prominence. Discoloration of the skin, warmth, oedema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching.
2
Partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough. May also present as an intact or open (ruptured) serum-filled or serosanguineous blister.
3
Full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. May include undermining and tunnelling.
4
Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Frequently includes undermining and tunnelling.
Assessment On initial assessment, the wound was found to be 8cm long, 7cm wide and 4cm deep. Measuring the depth of the wound was difficult because of the presence of thick, dry necrotic tissue. The wound exudate was thick, yellow/green and malodorous. There was erythema of the surrounding skin and excoriation where the exudate had caused further skin damage. High levels of exudate, swelling and malodour are indicative of infection. The wound was cleansed with 0.9% sodium chloride using a sterile syringe to ensure adequate irrigation, and a wound swab was taken for microbiology, culture and sensitivity to identify the cause of infection. Because of concerns about the severity of the wound, intravenous antibiotics were commenced without waiting for microbiology results. Jonathan’s father expressed concern about the malodour and was worried the wound had deteriorated despite the fact that Jonathan was receiving nursing care at home. This deterioration led to a loss of confidence in the healthcare professionals caring for Jonathan. Therefore, it was not only necessary to treat the wound, but also to develop a therapeutic relationship with Jonathan and his father to ensure they understood all of the interventions required as they would then be more likely to adhere to the treatment regimen. Before admission to hospital, Jonathan’s father had been re-dressing the wound when it became soiled and was doing so without the support of a nurse. Some of the dressings used were ineffective in controlling exudate levels and had little effect on overall wound healing. A new dressing regimen was devised and this was explained carefully to Jonathan and his father. The wound was dressed using an absorbent, non-adherent calcium alginate dressing impregnated with manuka honey (Algivon) to help debride the wound, and reduce bio burden and malodour (Molan 2009). Chronic wounds, such as pressure ulcers, often contain necrotic tissue and bacteria, and can either be dry and leathery (eschar) or soft and brown, grey or yellow (slough) in appearance. Slough is made up of white blood cells, bacteria and debris, as well as
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Description
(European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel 2009)
FIGURE 1 Presenting wound (pressure ulcer) on the chest
dead tissue and is easily confused with pus, which is often present in an infected wound. Chronic wounds usually require repeated debridement as part of ongoing care because the underlying cause of the wound means that slough tends to recur (Brown 2013). A secondary dressing Sorbion Sana (a non-adherent polyethylene wound contact dressing with an absorbent core), was used to contain the exudate (Bronstering and Maassen 2012) and was covered with Mepilex Border (an absorbent soft silicone-based dressing with a polyethylene foam and adhesive border), with the aim of maintaining a moist wound environment to optimise healing (Dykes et al 2001). A protective, transparent barrier film (Cavilon No Sting Barrier Film), was applied to the surrounding skin to protect it from maceration (Williams 1998). april 30 :: vol 28 no 35 :: 2014 61
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Art & science tissue viability supplement A Waterlow assessment (judy-waterlow.co.uk) was carried out as part of his initial pressure ulcer risk assessment on admission. The risk assessment identifies areas that increase a person’s risk of developing a pressure ulcer, including, mobility, skin integrity, age, gender, comorbidities, nutrition, weight and continence. The score showed that Jonathan was at high risk of pressure ulcer development and deterioration, in addition to having an existing ulcer. It highlighted Jonathan’s spina bifida and immobility as key factors in the development of his pressure ulcer. Pressure ulcer prevention was discussed with Jonathan and his father as a part of the initial assessment. A chest X-ray was undertaken to determine the severity of the wound because of its close proximity to the rib cage. Results confirmed that there was no danger to Jonathan’s lung and oxygen saturation, and respiratory tests supported this. Jonathan was keen to return home and was discharged the following day with a confirmed bacterial infection. He attended the hospital daily for review and to complete the course of intravenous antibiotics. Two weeks following initial presentation, Jonathan was seen as an outpatient in the tissue viability clinic. The district nurses caring for him were concerned about the increasing amount of wound exudate and decided to pack the wound with Aquacel (a soft non-woven pad containing hydrocolloid fibres) (Morgan 2009). The wound was covered with 60% thick necrosis and 40% slough (Figure 2). It was leaking large amounts of yellow viscous exudate and remained malodorous. A mild skin reaction surrounded the wound, which appeared to have resulted from using Tegaderm Foam – a polyurethane foam film dressing with an adhesive border. The wound measured 12cm by 8cm and was 7cm deep (Figure 2). Jonathan remained healthy and viewed his wound as more of an irritation than a serious problem because he could not feel or see it. A photograph was taken and shown to Jonathan to explain the severity of the wound. On viewing the wound, Jonathan demonstrated a desire to comply with new treatments. A trial using UrgoClean (a pad with hydrocolloid fibres coated with a soft, adherent lipo-colloidal wound contact layer) was commenced to deslough the wound and help manage the exudate. Two pads of UrgoClean were placed in the wound with Sorbion Sana and covered with Mepilex Border. Topical negative pressure (TNP) therapy was discussed, but because of the large amount of necrotic tissue, this therapy was not suitable at this time. TNP therapy has a multimodal action, increasing dermal perfusion (Morykwas et al 1997, 62 april 30 :: vol 28 no 35 :: 2014
Chen et al 2005, Timmers et al 2005, Bovill et al 2008), stimulating granulation tissue formation (Fabian et al 1994, Morykwas et al 1997, Saxena et al 2004, Bovill et al 2008), reducing oedema and interstitial tissue fluid (Morykwas et al 1997, Bovill et al 2008), reversing tissue expansion (Banwell and Téot 2003, Bovill et al 2008) and reducing bacterial colonisation (Banwell and Téot 2003, Pinocy et al 2003, Mouës et al 2005, Bovill et al 2008). However, it cannot achieve this through dead tissue and is therefore contraindicated in wounds with significant necrotic tissue or eschar. At four weeks, and following two weeks of treatment with UrgoClean, the amount of slough had reduced. The necrosis had begun to soften and the surrounding skin appeared healthier because of reduced excoriation and oedema (Figure 3). The amount of exudate had also decreased. Jonathan and his father demonstrated a positive attitude towards the treatment because they could see an improvement in the appearance of the wound. The reduction of exudate was a significant achievement and meant that Jonathan did not need multiple dressing changes throughout the day.
FIGURE 2 Wound at two weeks
FIGURE 3 Wound at four weeks
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Art & science tissue viability supplement Because of the decrease in exudate levels, it was decided to trial the use of fewer dressings to reduce application time and cost. UrgoClean was continued and Sorbion Sana adhesive was trialled to simplify the dressing procedure. This reduced the layering of dressings because Sorbion Sana had previously been used under a Mepilex Border. The following week, some of the necrosis was removed by the tissue viability nurse using sharp debridement and the eschar was scored with a sterile scalpel to promote autolytic debridement (Kelly 2011). Debridement is beneficial because it removes dead, devitalised, or contaminated tissue, and any foreign material from the wound, which helps to reduce the number of microbes, toxins, and other substances that inhibit healing (Elek 1956, Fowler 1992, Berger 1993, Fowler and van Rijswijk 1995, Enoch and Harding 2003). All wounds experience some level of autolytic debridement, which is the natural and highly selective process by which endogenous proteolytic enzymes break down necrotic tissue. These endogenous enzymes are mainly produced by neutrophils and include elastase, collagenase, myeloperoxidase, acid hydrolase, and lysosomal enzymes (Sinclair and Ryan 1993, Enoch and Harding 2003). However, autolytic debridement may not take place fast enough to encourage rapid wound healing and closure, although the use of occlusive dressings can enhance this process, while maintaining a moist wound bed and managing excess exudate (Nemeth and Eaglstein 1993, Enoch and Harding 2003). This allows painless, selective debridement and promotes the formation of healthy granulation tissue (Eaglstein and Falanga 1997). Signs of epithelialisation were present at the bottom edge of the wound and there was continued reduction in the amount of exudate and slough (Figure 4). UrgoClean was used to continue autolytic debridement of the necrotic area and Aquacel (a soft non-woven pad containing hydrocolloid fibres), was used to absorb exudate and aid growth of granulation tissue. Jonathan and his father remained positive, although Jonathan’s father was anxious about the rate of healing and size of the wound. At week six, the necrosis had continued to soften and a large amount of this was sharp debrided leaving a plug of necrotic tissue within the wound. The wound measured 11cm by 7cm and was 7cm deep, with 10cm undermining to the left and 7cm to the right of the wound (Figure 5). The degree of undermining was the result of necrotic tissue being removed from the wound so that its true dimensions could be identified. There was no effect on Jonathan’s breathing or oxygen saturation, which was a major concern because of the extent of 64 april 30 :: vol 28 no 35 :: 2014
damage to the tissue in the chest area. The wound bed appeared to be free of slough. Dressing the wound with UrgoClean continued and Mepilex Border was used as the outer dressing because Sorbion Sana adhesive was thought to have caused a skin reaction and Jonathan had requested to have the dressing changed back to the Mepilex Border. The wound continued to debride well and as the necrotic tissue was removed, the actual depth of the wound was revealed. It was important, at this stage, to ensure that Jonathan and his father understood that the wound was healing and did not assume that it was continuing to deteriorate because of its appearance. The depth of the wound increased as necrotic tissue was removed, and by week nine, Jonathan’s ribs were palpable. This caused Jonathan’s father some anxiety, but Jonathan showed no signs of infection or ill health. Jonathan was still unable to feel the wound so pain management was not required. The wound measured 10cm by 5cm with up to 10cm undermining (Figure 6). At this point, TNP therapy was discussed as a viable option and Jonathan requested some time to discuss this with his father. The wound was packed with UrgoClean and a
FIGURE 4 Wound at five weeks
FIGURE 5 Wound at six weeks
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sorbion pad was used underneath the Mepilex Border to manage increasing levels of exudate. After consideration by Jonathan and his father and obtaining agreed funding – the local primary care trust did not support the use of TNP therapy – this therapy was commenced at -60mmHg continuous pressure for one hour before increasing the rate to -80mmHg, since there were no adverse effects on Jonathan’s breathing. Jonathan was discharged home and requested to return in three days for an outpatient appointment to change his dressings. It was agreed that the dressing would be changed twice weekly on an outpatient basis, with telephone support from the tissue viability nurses. An additional appointment could be made if required. Since the use of TNP was not supported by the primary care service at this time Jonathan’s care was provided by the acute trust. During the outpatient appointment, the dressing was removed and the wound bed appeared to be covered with a ‘curtain’ of necrotic tissue (Figure 7). Jonathan’s father stated that the TNP therapy pump was making loud ‘sucking noises’ and he had disconnected it several times to make sure that the suction was working. This did not, however, account for the level of tissue damage observed. Another issue highlighted was that where Jonathan and his father lived there were not many electrical sockets available and it was not possible to have more installed. This caused problems when charging the pump because the sockets were located in areas that were difficult to access. This problem was resolved following discussion with Jonathan and his father about the safe use of extension leads. Jonathan was admitted to hospital and reviewed by the surgical team. Jonathan and his father were anxious about a stay in hospital because they were used to their routine at home. Jonathan’s father stayed with him in hospital so that he could continue to be his main carer. A chest X-ray confirmed there was no lung involvement and surgical debridement was planned to remove any necrotic or infected tissue. Surgical debridement is the fastest way to remove dead tissue. Although surgical debridement is thought to be selective, there may be some damage to viable tissue, and bleeding is likely. Nevertheless, this may help to revitalise the wound and encourage healing by inundating the wound bed with growth factors and cytokines. Surgical assessment of the wound identified some necrosis; the wound remained malodorous and areas of the ribs were visible (Figure 8). Jonathan was referred to the plastic surgeons who performed surgical debridement of the wound to remove the remaining necrotic tissue (Figure 9) and assessed its suitability for
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closure or skin grafting. By week 12, osteomyelitis was a major concern as the exposed rib felt rough and pitted. However, tests for osteomyelitis were negative. A plastic surgeon reviewed the wound again and agreed to surgically close the wound. On return to the hospital at 14 weeks, the wound had not been operated on and skin grafting had not taken place, however the wound had been surgically debrided. At this point, Jonathan started
FIGURE 6 Wound at nine weeks
FIGURE 7 Wound at ten weeks
FIGURE 8 Wound at 11 weeks
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Art & science tissue viability supplement to show signs that he was anxious to go home and was slightly disillusioned with the treatment he was receiving. A tissue viability nurse spent time with Jonathan and his father discussing past problems and explaining that the surgeons were unable to close the wound because the volume of tissue loss had been too great. TNP therapy was re-commenced on an inpatient basis, allowing nursing staff to assess and monitor the wound throughout the day to ensure wound granulation was taking place. This was especially important because previous use of TNP therapy has resulted in increased necrosis. Friable granulation tissue was present in the lower half of the wound and areas of the rib remained exposed. One large roll of gauze was used with an underlying soft silicone, semi-transparent low-adherent dressing (Mepitel) to protect the exposed bone and the granulation tissue. The pump was set at -120mmHg continuous pressure. This regimen was assessed twice weekly at each dressing change. A silicone sealant (Mepiseal) was used to prevent exudate from spreading and to achieve a good seal for the dressing to enable adequate suction. The exudate was removed via the tubing and stored in the canister. Jonathan remained in hospital for one week to ensure there were no concerns about wound healing while the TNP therapy pump was in use. At the end of the week the pressure ulcer appeared to have a healthy granulating wound bed (Figure 10). A conversation about home care revealed that Jonathan naturally positioned himself on his left side while in bed, in other words on the pressure ulcer and TNP therapy tubing. It was suggested this might have contributed to the necrosis that developed when TNP therapy was first used in Jonathan’s home. While in hospital, Jonathan lay supine because he was able to use electrical controls to raise the top of the bed to get comfortable. It was clear that Jonathan’s bed at home was not suitable to meet his current needs because it could not be adjusted and a hospital bed would be more appropriate. The tissue viability team then faced a new problem as to whether the hospital bed was too heavy to be accommodated in Jonathan’s home. The hospital’s occupational therapists were contacted and conducted a home visit. They measured and discussed this problem with the supplier of the hospital bed, and determined that it would be safe to install the bed. A hospital bed was ordered and Jonathan was discharged home to continue TNP therapy as an outpatient. By week 17, the wound bed appeared healthy and granulating. The wound measured 7cm by 4cm and was 3cm deep (Figure 11). The rib was no longer visible or palpable. There had been no 66 april 30 :: vol 28 no 35 :: 2014
FIGURE 9 Wound at 12 weeks
FIGURE 10 Wound at 15 weeks
FIGURE 11 Wound at 17 weeks
complications with the TNP therapy and it was concluded that the previous bed Jonathan had been using in his home was the initial cause of the unsuccessful TNP therapy. Jonathan appeared to be well and healthy, and was more relaxed on returning home. Continual improvement in the wound was observed at week 19. It remained healthy and granulating. The areas of undermining were almost
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Art & science tissue viability supplement gone (Figure 12). Jonathan had developed a mild skin irritation following use of a film dressing (Avance) and medihoney barrier cream was applied to protect the skin (Bardsley 2008). It was also applied to a skin fold located to the left of the wound, which had become excoriated due to the build-up of moisture. Jonathan and his father could see that the wound was improving and developed a positive attitude towards the treatment. By week 20, the wound was granulating well and there were no areas of undermining. The surrounding area remained excoriated, possibly as a result of the film dressing being removed and reapplied regularly. This led to the decision to discontinue TNP therapy and following agreement with Jonathan and his father, the wound was packed with Aquacel and covered with Mepilex Border. Jonathan was reviewed at the outpatient clinic three weeks later. The wound had almost completely closed and there was a small area of overgranulation, which was being treated by the district nurses. The wound was dry and the surrounding skin appeared healthy. Jonathan was pleased with his progress and was discharged from the acute setting to be managed by the district nurses for the final part of his treatment.
Discussion The treatment of pressure ulcers can be complex as a result of the interplay of several factors such as age, co-morbidities and immobility. Jonathan presented with several complications because of his lack of mobility and loss of sensation from the lower chest downwards as a result of having spina bifida, and the position of the wound, which was in close proximity to his lung. His wound required several forms of treatment, including intravenous antibiotics and invasive surgery. Initial treatment of wound infection was essential to prevent further
FIGURE 12 Wound at 19 weeks
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deterioration and to protect Jonathan’s lungs. TNP therapy proved to be successful when used correctly. Jonathan’s case demonstrated that social circumstances and factors can affect the success of wound healing and need to be considered in the management of complex wounds. The use of pressure-relieving devices in the home should be considered if patients are at increased risk of developing pressure ulcers. The TNP therapy system used to treat Jonathan’s wound was suitable because the associated tubing did not interfere with his ability to transfer and sit comfortably in his wheelchair. The use of gauze dressings allowed the wound’s extensive undermining and tunnelling to be packed quickly and easily without leaving any cavities, and enabled the wound to be protected. A transfer drain was used throughout TNP therapy since it was quick and easy to attach on top of the wound compared with a channel drain, which sits in the gauze dressing and drains from within. Patients with complex wound management needs require regular review and assessment by an appropriate healthcare professional; dressings need to be changed to meet the needs of a rapidly changing wound environment. The patient’s living environment also needs to be considered. In Jonathan’s case, this included the suitability of his wheelchair and his daily living requirements and nutritional intake. According to Thompson and Furhrman (2005) nutrition plays a vital role in the prevention and treatment of wounds and ulcers. Consuming a healthy balanced diet and maintaining a suitable weight can reduce the risk of developing several conditions that predispose an individual to wounds and ulcers (Astrup 2001) and encourages healing in patients with existing wounds. Healthy nutritional intake was discussed at regular intervals throughout treatment. It was important to ensure that both Jonathan and his father had an understanding of the importance of nutrition and hydration in wound healing. A dietitian review and leaflets were also offered to Jonathan. Education played a major role in Jonathan’s care and included providing Jonathan and his father with information about wound care at home, and how to maintain dressings and keep the wound clean and dry. Effective communication helped to raise awareness of the issues and develop a therapeutic relationship. This allowed healthcare professionals to work with Jonathan and his father and to teach them how to prevent future pressure ulcers. Communication barriers between acute and primary care may have contributed to the initial unsuccessful treatment of Jonathan’s wound. If hospital staff had known about Jonathan’s home environment and the problems associated with his
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sleeping arrangements, treatment may have been more successful. Improved communication between acute and primary care would help to ensure that all of the patient’s needs are understood and met.
Conclusion Complex wound management in the non-healing wound can be challenging for healthcare professionals, as well as adversely affecting the
patient’s health and quality of life. It is important to consider physical, social and environmental factors when providing holistic patient care and encouraging adherence to treatment in the prevention and management of pressure ulcers. Developing a therapeutic relationship between patients and healthcare professionals is essential to ensure patients are aware of how they can contribute to successful wound management and prevent re-occurrence NS
References Astrup A (2001) Healthy lifestyles in Europe: prevention of obesity and type II diabetes by diet and physical activity. Public Health Nutrition. 4, 2B, 499-515. Banwell PE, Téot L (2003) Topical negative pressure (TNP): the evolution of a novel wound therapy. Journal of Wound Care. 12, 1, 22-28. Bardsley A (2008) The use of honey in incontinence-associated dermatitis. Continence UK. 2, 4, 58-61. Berger MM (1993) Enzyme debriding preparations. Ostomy Wound Management. 39, 5, 61-69. Bovill E, Benwell PE, Teot L et al (2008) Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds. International Wound Journal. 5, 4, 511-529. Bronstering K, Maassen A (2012) Foam Versus Hydration Response Technology – Wound Professionals’ Rating of Exudate Management Properties. Poster presentation. Wounds UK, November 12-14, Harrogate. Brown A (2013) The role of debridement in the healing process. Nursing Times. 109, 40, 16-19. Chen SZ, Li J, Li XY, Xu LS (2005) Effects of vacuum-assisted closure on wound microcirculation: an experimental study. Asian Journal of Surgery. 28, 3, 211-217. Dealey C, Possnett J, Walker A (2012) The cost of pressure ulcers in the United Kingdom. Journal of Wound Care. 21, 6, 261-266. Dykes PJ, Heggie R, Hill SA (2001) Effects of adhesive dressings on
the stratum corneum of the skin. Journal of Wound Care. 10, 2, 7-10. Eaglstein WH, Falanga V (1997) Chronic wounds. The Surgical Clinics of North America. 77, 3, 689-700. Elek SD (1956) Experimental staphylococcal infections in the skin of man. Annals of the New York Academy of Sciences. 65, 3, 85-90. Enoch S, Harding K (2003) Wound bed preparation: the science behind the removal of barriers to healing. Wounds. 15, 7. European Pressure Ulcer Advisory Panel, National Pressure Ulcer Advisory Panel (2009) Pressure Ulcer Prevention: Quick Reference Guide. www.epuap.org/guidelines/ Final_Quick_Prevention.pdf (Last accessed: April 11 2014.) Fabian TC, Croce MA, Pritchard FE et al (1994) Planned ventral hernia. Staged management for acute abdominal wall defects. Annals of Surgery. 219, 6, 643-653. Fowler E (1992) Instrument/ sharp debridement on non-viable tissue in wounds. Ostomy Wound Management. 38, 8, 26-33. Fowler E, van Rijswijk L (1995) Using wound debridement to help achieve the goals of care. Ostomy Wound Management. 41, 7A Suppl, 23S-35S. Franks PJ, Winterberg H, Moffatt CJ (2002) Health-related quality of life and pressure ulceration assessment in patients treated in the community. Wound Repair and Regeneration. 10, 3, 133-140. Gorecki C, Brown JM, Nelson EA et al (2009) Impact of pressure ulcers on quality of life in older patients: a
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systematic review. Journal of the American Geriatrics Society. 57, 7, 1175-1183. Kelly J (2011) Methods of wound debridement: a case study. Nursing Standard. 25, 25, 51-59. Molan P (2009) Why honey works. In Cooper R, Molan P, White RJ (Eds) Honey in Modern Wound Management. Wounds UK Publishing, Aberdeen, 7-20. Morgan DA (2009) Formulary of Wound Management Products. A Guide for Healthcare Staff. Tenth edition. Euromed Communications, Liphook, Surrey. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W (1997) Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Annals of Plastic Surgery. 38, 6, 553-562. Mouës CM, van den Bemd GJ, Meerding WJ, Hovius SE (2005) An economic evaluation of the use of TNP on full-thickness wounds. Journal of Wound Care. 14, 5, 224-227. National Patient Safety Agency (2010) NHS to Adopt Zero Tolerance Approach to Pressure Ulcers. NPSA, London. Nemeth AJ, Eaglstein WH (1993) Wound dressings and local treatment in leg ulcers: diagnosis and treatment. In Westerhof W (Ed) Leg Ulcers: Diagnosis and Treatment. Elsevier Science Publishers, Amsterdam, 325-333. Newton H (2010) Reducing pressure ulcer incidence: CQUIN payment framework in practice. Wounds UK. 6, 3, 38-46.
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