1. CONNECTIVE ISSUES 2014 Pressure Injury Case Study

2. Outline Medical History Social History Patient Assessment Lower Limb Assessment Factor affecting healing and goals setting Progress of the wound and reviewing goals What I learnt from this case

3. Medical History Mario*: 65 year old man Coronary artery disease Bisoprolol, Frusid, Astrix Coronary Artery Bypass Graft (August 2010) Depression Endep Hypertension, Hyperlidaemia Coversyl, Liptor Type 2 Diabetes (10 year duration) HbA1C 8.1% Diabex Other

4. Psychosocial environment Low mood Home supports Retired, lives with supportive wife Access to services Metro area, close to hospital Community Bus

5. Patient Assessment Mobility Nutrition Pain 4/10 VAS in wound, intermittent, background Severe right calf pain when walking +30 seconds

6. Wound History 3 week duration During hospital stay post CABG surgery Clear gel dressing in situ

7. Lower limb assessment: Peripheral Arterial Intermittent claudication at 10 metres Edinburgh Claudication Questionnaire (Leng, 1992) Pedal pulses Right – Absent Left – Normal Audible doppler Right – Monophasic with faint volume Ankle Brachial Index Right – 0.59 Left – 0.94 Toe pressure Right – 20mmHg Left – 100mmHg Conclusion : Severe peripheral arterial disease (International Diabetes Federation (IDF), 2011; Marston et al. 2005; Norgren et al., 2007)

8. Lower limb assessment Peripheral neurological 10g monofilament present Footwear Lace up runners

9. Factors affecting healing and goal setting Significant factors affecting healingGoals of therapy PressureReduce heel pressure Peripheral Arterial DiseaseImprove peripheral blood flow HyperglycaemiaOptimise glycaemic management Local wound conditionsAppropriate local wound care Other Factors to Consider Wound pain Nutrition Psychosocial aspects Infection? Assessment and management of other co-morbidities

10. Factor affecting healingGoals of therapyIntervention Heel pressureOffload heel in line with best practice standards MPO SPS (National Pressure Ulcer Advisor Panel (NPUAP), 2007) Heel pressure Image from: OAPL (2011)

11. Factor affecting healingGoals of therapyIntervention Peripheral arterial diseaseImprove blood flowVascular Surgery Revascularisation (Marston et al. 2005; Norgren et al., 2007) Peripheral Arterial Disease

12. Factor affecting healingGoals of therapyIntervention HyperglycaemiaOptimise glycaemic management Diabetes Educator (Colagiuri, Girgis, Eigenmann, Gomex, & Griffits, 2009; UK Prospective Diabetes Study Group, 1998) Hyperglycaemia

13. Other Factors to Consider Nutrition (Brown & Phillips, 2010) Wound pain (Cole-King & Harding, 2001; Solowiej, Mason, & Upton, 2009, WHO 1990) Psychosocial impact (Finestone, Alfeeli, & Fisher, 2008; Vileikyte, Rubin, & Leventhal, 2004) Monitor contral-lateral side, risk of other pressure injurys (IDF, 2011; NPUAP, 2009) Management of other co-morbidities (Nogren, et al. 2007) Infection? (Lipsky, 2004)

14. Wound bed conditionsClassification Tissue95% dry necrotic 5% sloughy Unstageable pressure injury with significant ischaemia InfectionNo obvious signs MoistureMinimal exudate Boggy feel underlying necrosis EdgesNot undermining Pain4/10 VAS Goals of therapyIntervention Prevent deterioration and wet gangrene Improve peri wound Betadine and Allevyn dressing Daily moisturiser to surrounding skin (European Wound Management Association (EWMA), 2004

15. Wound bed conditionsClassification Tissue100% necrotic Unstageable pressure injury with adequate arterial perfusion for healing InfectionNo obvious signs MoistureMinimal exudate Boggy feel underlying necrosis EdgesNot undermining, dry peri wound PainMinimal 1-2/10 Goals of therapyIntervention Remove devitalised tissue Moist wound healing Intrasite and Allevyn (EWMA, 2004; NPUAP, 2009; Schultz et al., 2003; Sussman, 2007) Whats New? Has had revascularisation and has good arterial potential for wound healing now with palpable pedal pulses and a toe pressure of 110mmHg

16. Wound bed conditionsClassification Tissue100% tenacious slough Unstageable pressure injury InfectionNo obvious signs MoistureMinimal exudate EdgesEpithelising PainMinimal Goals of therapyIntervention Debride sloughIodosorb Paste, Allevyn (EWMA, 2005; NPUAP, 2009, Ohtani, Mizuashi, Ito, & Aiba, 2007, Schultz et al. 2003)

17. Wound bed conditionsClassification Tissue100% granulation tissue Stage 3 pressure injury InfectionNo obvious signs MoistureMinimal exudate EdgesDry PainMinimal Goals of therapyIntervention Encourage granulation, epithelisation Protect peri wound Aquacel, Allevyn (EWMA, 2004; NPUAP, 2009; Schultz et al., 2003; Sussman, 2007)

18. Wound bed conditions Healed, fragile epithelial tissue Goals of therapyIntervention Improve skin integrity Prevent injury recurrence Daily emollient Education, regular Podiatry follow up (IDF, 2011)

19. References Brown, K., & Phillips, T. (2010). Nutrition and wound healing. Clinics in Dermatology, 28(4), 432-439. doi: doi:10.1016/j.clindermatol.2010.03.028 Colagiuri, R., Girgis, S., Eigenmann, C., Gomez, M., & Griffiths, R. (2009). National evidenced based guideline for patient education in Type 2 Diabetes. Diabetes Australia and the NHMRC, Canberra. Retrieved from http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/di16-diabetes-patient-education.pdf Cole-King, A., & Harding, K. G. (2001). Psychological factors and delayed healing in chronic wounds. Psychosomatic Medicine, 63(2), 216-220. Retrieved from http://www.psychosomaticmedicine.org/content/63/2/216.full.pdf European Wound Management Association (EWMA). (2004). Position Document: Wound bed preparation in practice. Retrieved from http://www.ewma.org/english/position-documents.html Finestone, H. M., Alfeeli, A., & Fisher, W. A. (2008). Stress-induced physiologic changes as a basis for the biopsychosocial model of chronic musculoskeletal pain: a new theory? The Clinical Journal of Pain, 24(9), 767-765. doi: 10.1097/AJP.0b013e3181790342 International Diabetes Federation (IDF). (2011). International Consensus on the Diabetic Foot. Practical and Specific Guidelines on the Management and Prevention of the Diabetic Foot [DVD]. Leng, G. C., Fowkes, F.G. (1992). The Edinburgh Claudication Questionnaire: an improved version of the WHO / Rose Questionnaire for use in epidemiological surveys. Journal of Clinic Epidemiology, 45(10), 1101-1109. Lipsky, B. A. (2004). A report from the International Consensus on Diagnosing and Treating the Infected Diabetic Foot. Diabetes/Metabolism Research and Reviews, 20(Suppl 1), S68-77. doi: 10.1002/dmrr.453

20. References Marston, W. A., Davies, S. W., Armstrong, B., Farber, M. A., Mendes, R. C., Fulton, J. J.,... Hill, C. (2005). Natural history of limbs with arterial insufficiency and chronic ulceration treated without revascularization. Journal of Vascular Surgery, 44(1), 108-114. doi: 10.1016/j.jvs.2006.03.026 National Pressure Ulcer Advisory Panel (NPUAP). (2007). Pressure ulcer stages revised by NPUAP Retrieved from http://www.npuap.org./pr2.htm Norgren, L., Hiatt, W. R., Dormandy, J. A., Nehler, M. R., Harris, K. A., & Fowkes, K. F. R. (2007). Inter-society consensus for the management of peripheral arterial disease (TASC II). European Journal of Vascular and Endovascular Surgery, 33(S1), S1-S75. doi: 10.1016/j.ejvs.2006.09.024 OAPL. (2011) Retrieved from http://www.oapl.com.au/Orthopaedic&Bracing-Catalogue-Web.pdf Ohtani, T., Mizuashi, M., Ito, Y., & Aiba, S. (2007). Cadexomer as well as cadexomer iodine induces the production of proinflammatory cytokines and vascular endothelial growth factor by human macrophages. Experimental Dermatology, 16, 318-323. doi: 10.1111/j.1600-0625.2006.00532.x Schultz, G. S., Sibbald, R. G., Falanga, V., Ayello, E. A., Dowsett, C., Harding, K.,... Vanscheidt, W. (2003). Wound bed preparation: A systematic approach to wound management. Journal of Wound Repair and Regeneration, 11(Suppl 1), 1-28. doi: 10.1046/j.1524-475X.11.s2.1.x Solowiej, K., Mason, V., & Upton, D. (2009). Review of the relationship between stress and wound healing: part 1. Journal of Wound Care, 18(9), 357-366. Retrieved from http://www.internurse.com.ezproxy.lib.monash.edu.au/ Sussman, G. (2007). Management of the wound environment with dressings and topical agents. In C. Sussman & B. Bates-Jensen (Eds.), Wound care. A collaborative practice manaual for health professionals (3rd ed., Vol. 250-167). Philadelphia: Lippincot Williams & Wilkins.

21. References UK Prospective Diabetes Study Group. (1998). Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet, 352(9131), 837-853. Vileikyte, L., Rubin, R., & Leventhal, H. (2004). Psychological aspects of diabetic neuropathic foot complications: an overview. Diabetes/Metabolism Research and Reviews, 20 Suppl 1(1), S13-18. doi: 10.1002/dmrr.437 WHO. (1990). Cancer pain relief and palliative care. Retrieved from http://www.who.int/cancer/palliative/painladder/en/