1. Psychosocial Risk Factors
1.1. Anxiety
1.1.1. Prolonged increased levels of Cortisol.
1.1.1.1. Impairs Immune system function
1.1.1.1.1. Deficient wound healing.
1.1.2. Not leaving the house as often and lives alone.
1.2. Decreased socialisation (not currently participating in her usual Lawn Bowls)
1.2.1. Activates stress response
1.3. Reduced mobilisation
1.3.1. Decreases peripheral circulation
1.3.2. Reduces Insulin sensitivity
2. Physical Risk Factors
2.1. Diet: Eating fastfood meals over several months
2.1.1. Nutritional Imbalance.
2.1.1.1. Suboptimal cell membrane maintanence and repair.
2.1.1.1.1. Decreased cell functioning
2.2. High BMI
2.2.1. More Adipose tissue
2.2.1.1. Marophages increase production of pro-inflammatory cytokines
2.2.1.1.1. Leads to Chronic Inflammation and delayed wound healing
2.3. High Blood Glucose Levels (17.8mmol/L)
2.3.1. Endothelial cells exposed to high glucose cannot function optimally.
2.3.1.1. Impairs Angiogenesis
2.3.1.1.1. Wound helaing compromised.
2.3.2. Compromised Leukocyte funciton
2.4. Heavy daily smoking
2.4.1. Suppresses the immune system
2.4.1.1. Increased risk of infection
2.4.1.1.1. Delayed wound healing
2.4.2. Carbon monoxide replaces oxygen and binds to Haemaglobin
2.5. Chronic Obstructive Pulmonary Disorder
2.5.1. Decrease Oxygen Saturation in the blood (92%)
2.6. Age, 78 years old
2.6.1. Decreased Stem cell differentiation
2.6.1.1. Epithelialisation impaired.
2.6.1.1.1. Delayed wound healing
2.6.2. Increased inflammatory process
2.6.2.1. When prolonged can cause tissue injury and delayed wound healing.
2.7. Hypertension
2.7.1. Increases peripheral vascular resistance
2.7.1.1. Decreased perfusion and oxygenation to tissues.
2.7.1.1.1. Cells do not receive the oxygen required to continue performing wound healing functions.
2.8. Hypothyroidism congestive cardiac failure
2.8.1. Underactive Thyroid
2.8.1.1. Impairs vascular smooth muscle relaxation
2.8.1.1.1. Inceases afterload required
2.8.2. Reduced Cardiac Output.
2.8.2.1. Decreased perfusion of body tissues.
3. Wound Assessment
3.1. Wound #1 (Sacral Pressure Injury)
3.1.1. Tissue Type: - Is viable - Wound bed is pink - No Slough present
3.1.2. Inflammation/infection: - Chronic Inflammation (surpassed 5 days) - No signs of local infection (limited pain, minimal exudate)
3.1.3. Moisture Management: - No oedema - Too much moisture has led to maceration. - Means exudate needs to be confined to the wound.
3.1.4. Edges: - Irregular - Level edges. - Some skin flaps.
3.1.5. Surrounding skin: - Macerated. - Pink, perfused.
3.1.6. Staging: Stage 2 Pressure Injury (PI)
3.2. Wound #2 (Foot)
3.2.1. Tissue type: - Pink, Viable (healthy granulation tissue) - Small amount of slough present. - Exudate.
3.2.2. Inflammation or infection: - Chronic Inflammation - No infection evident (no purulent exudate, low pain, no pyrexia)
3.2.3. Moisture management: - Too much moisture has led to maceration.
3.2.4. Edges: - Demarcated - Rolled - Undermining cannot be determined due to slough
3.2.5. Surrounding Skin: - White (Maceration)
3.2.6. Stageing: An Unstageable PI or Neuropathic Foot ulcer due to undiagnosed Diabetes Mellitus.
3.3. Patient Assessment:
3.3.1. Co-morbidities that could impact wound healing: - Undernutrition - Hypertension - COPD - Anxiety - Social Isolation. - Potential Undiagnosed Diabetes Mellitus.
3.3.2. Pain:
3.3.2.1. Wound #1: Discomfort at sacral area while sitting.
3.3.2.2. Wound #2: Burning sensation at right heel.
3.3.3. Wound Types and Location
3.3.3.1. Wound #1: - Stage 2 PI - Sacral Region.
3.3.3.2. Wound #2: - Unstageable PI - Right heel.
4. Wound #1: Sacral PI
4.1. Goals of treatment
4.1.1. Patient
4.1.1.1. To be as comfortable as possible.
4.1.1.1.1. Use of dressings
4.1.1.1.2. Repositioning frequently (Every 15mins when sitting)
4.1.2. Wound
4.1.2.1. Protecting the wound and surrounding tissue from trauma.
4.1.2.1.1. Use dressings to protect.
4.1.2.2. Prevent infection
4.1.2.2.1. Infection delays wound healing.
4.1.2.3. Create an optimal environment for healing.
4.1.2.3.1. Allows for Epithelial tissue growth
4.1.2.3.2. Balancing Moisture
4.1.2.4. Prevent further injury
4.2. Wound Management (Products)
4.2.1. Currently has an Adhesive foam dressing
4.2.2. When removing, note the direction of skin flaps and determine direction of removal so that it does not cause further trauma. (draw an arrow on the outside of the dressing)
4.2.3. Use of Hydrocolloid dressing such as Comfeel with an adhesive border.
4.2.3.1. Can conform to the shape of the Sacral area.
4.2.3.2. For shallow wounds
4.2.3.3. Is occlusive on the outside.
4.2.3.3.1. Prevent infection.
4.2.3.4. Additional use of Cavilon upon removal of Comfeel.
4.2.3.4.1. Helps prevent pulling of skin, protecting the wound.
4.2.3.5. Appropriate for low to moderately exudating wounds.
5. Wound #2: Heel
5.1. Goals of treatment
5.1.1. Wound
5.1.1.1. Create an optimal environment for healing
5.1.1.1.1. Balancing Moisture by controlling Exudate.
5.1.1.1.2. Allows Epithelial tissue growth.
5.1.1.2. Relieve pressure as much as possible.
5.1.1.2.1. Repositioning frequently. E.g 2 hourly.
5.1.1.3. Protect the wound and surrounding skin from trauma.
5.1.1.3.1. Use of dressings.
5.1.2. Patient
5.1.2.1. Reduce pain/burning sensation
5.2. Wound Management (Products)
5.2.1. Currently has a foam dressing.
5.2.1.1. Continue to use a Polyurethane foam dressing of the cavity filling and outer adhesive layer variety.
5.2.1.1.1. Requires less frequent dressing changes.
5.2.1.1.2. Absorbs and manages exudate volume.
5.2.1.1.3. Conforms to the demarcared shape.
6. Patient Goals of care:
6.1. Improve Nutritional Status
6.1.1. Increase protein and micronutrients
6.1.1.1. Utilised for healing phases
6.1.2. Decreases Systemic Inflammation
6.1.2.1. Allows normal physiological functioning for wound healing.
6.2. Manage Comorbidities that may impact wound healing.
6.2.1. Manage hypertension
6.2.2. Anxiety
6.2.3. COPD
6.2.4. Maintain BGL within normal ranges.
6.2.4.1. Reduce Glucose absorption and increase uptake into cells.
6.2.4.1.1. Metformin
6.3. Maintain social connections.
6.3.1. Outside of family as well as amongst family.
6.4. Increase and maintain mobility
6.4.1. Improves Cardiorespiratory health
6.5. Reduce Patient costs
6.5.1. Less frequent dressing changes
6.6. Maintain quality of life
7. Causes of impaired/delayed Wound healing
7.1. Can effect the function of adjacent tissues, having larger impacts.
7.2. Skin breakdown
8. Initial Pain Assessment
9. Pain
9.1. Initial Pain assessment
9.1.1. Additional pain assessment tools
9.1.1.1. 1) Brief Pain Inventory
9.1.1.1.1. Has seven focus areas that provide an overall picture of how the pain is impacting her life. Such as, her mood, walking ability, relationships, sleep, enjoyment.
9.1.1.2. 2) Functional Ability Questionnaire
9.1.1.2.1. Assesses the impact of the pain on their level of disability. Is particularly relevant as the pain and wound locations are directly related to her ability to mobilise and sit.
9.1.2. Sacral PI
9.1.2.1. Type of pain: Acute nociceptive pain.
9.1.2.2. Onset: Began during hospitalisation at development of wound. Lasts duration of being seated.
9.1.2.3. Provocation /Palliation: Pain increased when sitting, increases as time sitting lengthens. Reduces during mobilisation.
9.1.2.4. Quality: Dull throbbing. Region/Radiation: Sacral region. Severity: 5-8/10
9.1.2.5. Treatment: Panadol 1g, QID (ineffective), adhesive foam dressing (protection), avoiding sitting.
9.1.2.6. Understanding: Impacts her comfort and quality of life, causes distress and anxiety surrounding mobilising and socialisation.
9.1.2.7. Values: Prioritising reducing pain levels to a level that allows comfortable movement and sitting.
9.1.3. Heel wound
9.1.3.1. Type of pain: Chronic nociceptive pain. Onset: Began several weeks ago with the development of the wound. Contant occurrence.
9.1.3.2. Provocation/ Palliation: Not relieved by elevation or immobilisation. Pain increased by pressure and weight bearing
9.1.3.3. Quality: persistent throbbing that can strengthen. Region/Radiation: Right heel area. Severity: 4-6/10 on average can reach 10/10 during weight bearing. Treatment: Panadol 1g QID (ineffective), avoiding mobilisation.
9.1.3.4. Understanding: Affecting her ability to socialise and complete daily tasks, causing self consciousness and decreasing quality of life. Limited understanding on the importance of dressing changes.
9.1.3.5. Values: Prioritises reducing pain to a level that enables mobilisation and weight bearing. To allow return to community activities.
9.2. Psychosocial Factors
9.2.1. Decreased Socialisation
9.2.1.1. Breakdown of friendships overtime due to withdrawal.
9.2.1.1.1. Less social support and increased feelings of loneliness.
9.2.1.2. Less physical activity.
9.2.2. Living alone.
9.2.2.1. Nobody to distract her or assist Doris with daily tasks of living such as hygiene, cleaning and cooking.
9.2.2.1.1. Increases the burden of pain on her daily living. Has a larger impact on other factors. (mental health, quality of life, anxiety, wound healing)
9.2.3. Low health literacy
9.2.3.1. Doesn't change her dressing as frequently as required.
9.2.3.1.1. Wound healing delayed
9.2.4. Anxiety
9.2.4.1. Doris may become overly focussed on her pain which may cause it to consume other aspects of her life.
9.2.4.1.1. Making her pain experience more distressing and traumatic.
9.2.5. Mindset: Frustration at her pain and feeling like a burden on her family.
9.2.5.1. A negative mindset will likely effect her mood. (increased irritability and decreased resilience)
9.2.5.1.1. She may project these feelings onto her family who could perceive her as ungrateful.
9.3. Physical Factors
9.3.1. Type 2 Diabetes Mellitus
9.3.1.1. Decreased levels of physical activity are counterproductive to managing this condition.
9.3.1.2. Recent diagnosis, still learning how to manage glucose levels.
9.3.1.2.1. High glucose levels
9.3.2. Daily smoking
9.3.2.1. Increased risk of infection
9.3.2.1.1. Longer healing time due to complications.
9.3.3. COPD
9.3.4. Congestive cardiac failure
9.3.4.1. Not enough oxygen reaching the wound site.
9.3.4.1.1. Delayed wound healing.
9.3.5. Hypertension
9.3.5.1. Impaired wound healing
9.3.5.1.1. Can increase or prolong pain.
9.3.6. Hypothyroidism
9.3.7. Decreased mobilisation/physical activity.
9.4. Goals of care
9.4.1. Lifestyle goals.
9.4.1.1. Manage physical factors such as Type 2 diabetes mellitus, to improve ability for wound healing.
9.4.1.1.1. Increased physical activity.
9.4.1.1.2. Reduce smoking.
9.4.1.1.3. Medications to manage the symptoms of hypertension and hypothyroidism.
9.4.1.1.4. Nutritional goals.
9.4.2. Relieve pain to a level that allows her to live and move comfortably.
9.4.2.1. Therefore she can be more involved in her usual daily activities.
9.4.2.1.1. Improving her mental health.
9.4.2.1.2. Avoid adverse effects of unrelieved pain.
9.4.3. Education into wound care.
9.4.3.1. Assist Doris to take optimal care of her wounds by changing dressings regularly to assist with the healing process and prevent excess pain.
9.4.4. Mindset goals
9.4.4.1. Can decrease anxiety and help maintain a more positive attitude. Improving her self-esteem.
9.4.5. Pressure management
9.4.5.1. Use of pressure redistribution devices to help reduce the pressure on her wounds, and prevent the development of new ones in the future.