1. Physical Factors
1.1. Not changing wound dressing daily is not promoting healing and therefore worsening pain
1.2. Type 2 diabetes
1.2.1. Hypertension is slowing wound healing time
1.3. Age, 78 years old - slower healing time
2. Patient Assessment
2.1. Physical factors
2.1.1. Fast food diet
2.1.1.1. Impact: May lead to lack of nutrients being absorbed by bloodstream and supplied to wound sites to help timely healing
2.1.1.1.1. Goals of treatment: Encourage and inform Doris a healthy meal delivery service so she is recieving adequate nutrients particularly proteins in diet and also lower BMI
2.1.2. History of Hypertension, CCF, COPD
2.1.2.1. Impact: reducing blood supply to wound sites and reduced oxygen intake and therefore reduced oxygen to wound site which affects healing
2.1.2.1.1. Goals of treatment: Encourage lifestyle changes by reducing fast food diet, lack of exercise, smoking to improve symptoms and conditions contributing to poor health and prolonging of wound healing
2.1.3. BMI of 27.5 overweight
2.1.3.1. Impact: Put pressure on her right heel ulcer when upright and sacral wound when sitting and she's reported sitting is uncomfortable
2.1.3.1.1. Goals of treatment: Encourage and inform her to return to bowls and incorporate light exercise into her routine for optimum recovery
2.1.4. Heavy smoker
2.1.4.1. Impact: History of COPD and contributing to high respiratory rate, low blood oxygen saturation
2.1.4.1.1. Goals of treatment: Inform Doris the impacts smoking is having on her health and promote all the reasons to consider quitting
2.1.5. Age
2.1.5.1. Impact: Lowers rate of healing and increase obstacles in healting time such as decreased mobility to perform tasks to assist healing and wound care
2.1.6. Hyperclycaemia - blood glucose level 17.8 mol/L
2.1.6.1. Impact: Slows wounds healing time
2.1.6.1.1. Goals of treatment: Monitor and lower blood glucose level to normal range via dietary changes and insulin injections
2.2. Psychosocial factors
2.2.1. Doris lives alone - widow of 8 years, she sees her adult children and cares for her grandchildren twice a week, she doesn't have in home support or care
2.2.1.1. Impact: Hinder or prolong healing as her children who are supposed to help with wound dressing may not be there when necessary to change wound dressings
2.2.1.1.1. Goals of treatment: Involve her children in her healing plan to stick to the wound dressing changes so she feels supported and can heal as quickly as possible without further complications or infection
2.2.2. Anxiety surrounding wounds
2.2.2.1. Impact: Mental health decline and stop her from participating in things outside of her home and with family, friends and in her community
2.2.2.1.1. Goals of treatment: Encourage Doris to continue to engage in small activities and social interaction to prove to herself she can still do things while her wounds are healing and this will improve her confidence and ease anxiety
2.2.3. Limiting her contact with friends, no longer participating in monthly community lawn bowls
2.2.3.1. Impact: Loss of connection and social interaction can lower immune response and quality of life impacting mental health and possibly contribute to her anxiety
2.2.3.1.1. Goals of treatment: Encourage Doris to contact friends via phone when she can't see them to ensure she's not losing her social connections and sense of belonging
2.2.4. Interferes with daily living
2.2.4.1. Impact: Reduces confidence to engage in activities she once could, leave house to see friends/family
2.2.4.1.1. Goals of treatment: Increase daily activity therfore increase circulation to wounds
3. Wound Assessment
3.1. Sacral Wound
3.1.1. Stage 2; healing towards stage 1
3.1.1.1. Dressing: Adhesive foam dressing would suffice to reduce bacterial load for continual healing
3.1.2. Pressure Ulcer
3.1.2.1. Optimise circulation, offload pressure, improve mobility to avoid pressure wound worsening
3.1.3. Pink wound bed no slough, has blood flow and is viable
3.1.4. Localised pinkness indicates healing, no signs of infection at wound site
3.1.5. Small amount of serous exudate
3.1.6. Edges are close to even
3.1.7. Surrounding skin is mildly macerated
3.2. Right Heel Wound
3.2.1. Stage 2
3.2.1.1. Primary Dressing: antimocrobial dressing eg. Aquacel ag, sorbact
3.2.1.1.1. Reduce bacterial load to continue prevention of infection, assist debridement of non-viable tissue
3.2.1.2. Secondary Dressing: adhesive foam for protection of wound against pressue
3.2.1.2.1. Reduce pressure when walking/standing
3.2.2. Neuropathic Foot Ulcer from diabetes
3.2.2.1. Wear medical grade footwear to prevent future ulcers occurring
3.2.3. Mixed red and yellow wound bed, partially viable, contains granulation and slough tissues
3.2.4. Localised inflammation and redness signals no infection yet
3.2.5. Haemaserous exudate
3.2.6. Demarcated edges
3.2.7. Surrounding skin is intensely maceracted
3.2.7.1. Avoid soaking feet
4. Initial Pain Assessment
4.1. Sacral Wound
4.1.1. Onset: Developed during 2 week hospital stay, been persistent for last 4 weeks
4.1.2. No pain when mobilising, worsens/difficult to sit for long periods
4.1.3. Increasing dull, throbbing pain
4.1.4. Sacral pressure injury
4.1.5. 5-8/10 at best, currently an 8/10
4.1.6. Changing adhesive foam dressing daily, taking simple analgesia however not working effectively
4.1.7. Psychosocial Factors
4.1.7.1. Anxiety, low mood, loss of confidence, social isolation - feels like a burden to family/friends and self-conscious of wound smell
4.2. Foot Ulcer
4.2.1. Onset: Noticed it whilst in hospital, been present for last 4 weeks
4.2.2. Worsens when standing or putting pressure on it, pain not relieved by elevation nor immobilisation
4.2.3. Persisent throbbing, "unbearable" when standing
4.2.4. Right heel
4.2.5. 4-6/10 at best, currently a 7/10 and "unbearable" 10/10 when standing
4.2.6. Primary dressing is antimicrobial, secondary dressing is adhesive foam however she hasn't changed dressing in a week. Taking simple analgesia however not effective or providing any relief of intense pain
4.2.7. Recent type 2 diabetes diagnosis explains foot ulcer.
4.2.8. Psychosocial Factors
4.2.8.1. Anxiety
4.2.8.2. Low mood
4.2.8.3. Low confidence
4.2.8.4. Social isolation
4.2.8.4.1. Feels like a burden to family/friends
4.2.8.4.2. Self-concious of wound and potential smell
4.2.8.4.3. Due to her pain, an inability to engage in social activities eg. monthly lawn bowls
5. Acute Pain
5.1. Present for less than 2 months and inadequate inital pain relief, poor understanding of need to change dressing daily and fear/anxiety around wound and smell of has lead to pain persisting for about 6 weeks in total
5.2. Nociceptive, somatic pain - from superficial somatic skin wounds
5.3. Dull, throbbing descriptions of pain
5.4. Increased HR, BP, RR, anxiety
5.5. Opioid receptive
6. Goals of care
6.1. Provide pain relief and improve/promote wound healing
6.1.1. GP prescribe stronger pain relief than current simple analgesia, eg. opioids as well as medication for managing Type 2 diabetes eg.insulin
6.1.2. Encourage/inform importance of dietary changes, smoking habits to promote healing
6.1.3. Inform Doris how to change wound dressing and frequency needed to promote healing
6.2. Return to family duties and recieve support with healing
6.2.1. Family support and education to assist Doris with daily wound care/dressing changes
6.2.2. Relieve pain to be able to care for grandchildren again
6.3. Engage in social activies again
6.3.1. Relieve pain to return to social engagement/activities. Improve confidence, mood and other psychosocial effects
7. Additional Assessment Tools
7.1. Brief Pain Inventory - will identify locations on body and where the most pain is experienced as well as severity, current medication and assessment of its relief, and interference the pain has in daily activity/mobility, quality of life, mood, sleep
7.1.1. To allow Doris to further describe her subjective experience of her pain and allow appropriate and optimum care/pain relief from her medical care team