Mrs Francis Owen is an 86 year
Mrs Francis Owen is an 86 year old widow who, until 2015, lived alone in her own home with good family support. She was alert but was prone to confusion at times. Mrs Owen had been a regular client of a large tertiary teaching hospital in NSW since 2005. In 210, cellulitis of the right lower leg developed into three sloughy ulcers which in time joined to form one large ulcer on the gaiter area above the medial malleolus. Medical history Mrs Owen had a complex medical history of non-insulin dependent diabetes mellitus (NIDDM), atrial fibrillation, recurrent urinary tract infections, extensive osteoarthritis, peripheral vascular disease (PVD), post-operative pulmonary embolism and a chronic leg ulcer. Mrs Owen is allergic to prawns and Micropore tape. Surgical history Her surgical history involved an amputation of (L) great toe in 2005, R/O (R) foot bunion in 2009, a partial foot amputation in 2012 and, in 2014, amputation of the third metatarsal (L) foot and debridement of the (L) forefoot. Medications On presentation Mrs Owen was taking the following medications Warfarin 3mg nocte, Mobic 15mg mane, Losec 20mg BD, Capoten 50mg tds, Glucophage 250mg tds, Lanoxin PG mane, Tramal SR 150mg BD, Normison 10mg nocte, FGF mane, Lasix 20mg BD, Prothiaden 50mg nocte, Digesic x2 qid prn. Wound profile Mrs Owen’s right lower leg ulcer was located just above the medial malleolus and occurred secondary to cellulitis. Dressings were attended three times a week by district nurses, sometimes daily depending on exudate levels. Previous dressing regimens used over the past 5 years included Jelonet, Adaptic, Kaltostat, Intrasite gel, Stomahesive powder, Allevyn, Lyofoam Extra, Duoderm Thick, Gaviscon liquid on excoriated wound edges, protective barrier wipes, Duoderm stoma paste, Eleuphrat Ung, Medihoney, SSD cream, Intrasite/ SSD soaked gauze, Biotain, as well as resident self-treatments with over the counter preparations. Numerous courses of antibiotics for Staphylococcus and Pseudomonas aeruginosa infections had been prescribed over this period. The vacuum-assisted closure dressing (VAC) was used in February 2004 when the ulcer deteriorated, with exposure to tendon and lymphatic leakage. During this period, her blood sugar levels (BSLs) ranged between 10.9 to 21.2 mmol. Mrs Owen was admitted into an aged care facility in September 2015. On admission, a comprehensive holistic assessment identified multiple underlying factors which were having a negative impact on the healing of Mrs Owen’s wound such as PVD, diabetes with high BSLs, age, obesity and inactivity, anaemia, osteoarthritis and drug therapy. Aetiology of the wound Classical clinical signs of venous disease were present. Pulses were palpable but the capillary return was delayed. Variable non-dependent pain was reported, exacerbated by cellulitis or oedema and described as burning or stinging, indicating a neuropathic origin due to persistent nerve injury. An ankle brachial pressure index (ABPI) of 6.0 from a previous consultation with a specialist in venous disease concluded arterial calcification compounded by diabetes. Assessment findings indicated an ulcer of mixed aetiology with predominantly venous characteristics. Clinical characteristics of the wound Location of the wound The wound was located over the gaiter area immediately above the medial malleolus. Wound bed status The wound exhibited deep red-coloured friable granulation tissue over an ulcer that bled on contact. No necrotic tissue was present, but about 10% of the wound was covered in slough. Wound edge Irregular margin with a gently sloping border. Wound measurements The wound measured 12.5cm x 5cm with a depth of 0.8cm with no undermining or tracking present. Wound odour The wound was slightly offensive. Peri-wound skin The skin around the wound was dry, scaly, tight, shiny and oedematous. Ankle flare was present with distended venules below the malleolus. Wound exudate Copious amounts of serous cloudy fluid were exuding from the ulcer, Laboratory tests A wound swab identified a light staphylococcus infection. Blood tests for serum albumin (38g/L) showed Mrs Owen had serum albumin of 35g/l, indicating adequate delivery of nutrients to the wound 1A low haemoglobin was treated with FGF (Fergon ferrous gluconate). Part A What is the end-of-shift handover report focussed on Mrs Owens’ leg ulcer. Part B What is the treatment plan for Mrs Owen’s wound care Part C Discuss the importance of an interdisciplinary approach to care for Mrs Owen’s wound. Part D Discuss where you will find policies, and wound care procedures in the nursing home. List possible policies and guidelines you would refer to plan the treatment.
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