Wound Recurrence Case study & Practice points on an individual with a category 4 PU
Authors: Jennie Hodges and Samantha Haynes
Practice Points: Samantha Holloway and Sue Flavin
This case study discusses an individual with a category 4 pressure ulcer (PU).
Patient: Mr X, a 69-year-old man with a medical history of paraplegia secondary to Ependymoma* and post-spinal operation, hypertension, obstructive sleep apnoea, urinary incontinence and smoker.
*type of primary central nervous system tumour that starts in the brain or spinal cord
Diagnosis: Category 4 pressure ulcer over the coccyx.
History: Mr X went on a long-haul holiday and during the journey he was unable to reposition. He developed a pressure ulcer to his coccyx. His wife cared for his wound for 3 months, applying a barrier cream. During this time, he continued with his normal activities, spending all day in his wheelchair. The wound deteriorated and his general practitioner (GP) referred him to community nurses. His wife was his main carer, and she was supported by a private carer visited once a day to assist with personal care.
Initial Assessment
A community nurse visited to carry out an assessment. She immediately contacted the tissue viability team for telephone advice, and a joint visit was arranged. The tissue viability nurse visited and carried out a holistic assessment.
Presentation: Mr X presented withan ulcer to his coccyx. The wound was a cavity with full-thickness skin loss, muscle exposure and a maximum depth of 25 mm, length 60 mm and width 60 mm (Figure 1). The wound bed was a mixture slough, thick in areas, and pale granulation. The surrounding skin was macerated and excoriated. There were no signs of spreading infection and Mr X reported no systemic signs of infection, nausea or fever. Based on the Skin Tone Tool1, the patient’s skin tone would be classified as 3 (Figure 1b).
The rest of his skin was intact, but his legs were oedematous and his heels vulnerable. His risk of developing further pressure ulcer was high.
Wound Management
Wound hygiene was performed using a surfactant to cleanse and soak the wound bed. A barrier film was used to protect and restore the surrounding skin. A hydrofiber dressing was used to layer into the wound bed to promote debridement and a silicone foam was used to cover and absorb. The aim of management was to optimise the wound bed so that negative pressure wound therapy (NPWT) could be considered.
The aSSKINg bundle was used to document and guide both prevention and management strategies:
(S) Pressure relieving surface: A foam pressure redistributing mattress was used on a profiling bed. The patient had a bespoke wheelchair with a gel pressure relieving cushion. It was not possible to change the mattress to an alternating mattress as the patient smokes so an alternating device would have posed a fire risk. Consideration was given to the use of an inflatable wedge to off-load Mr X’s heels but this would have affected his transfers from bed to wheelchair.
(K) Keeping Moving: the patient transferred from bed to chair using a transfer board but he tended to drag himself across the board causing further trauma, friction and shearing forces. The patient sat in his wheelchair most of the day with an afternoon rest on the bed for about 4 hours. The patient could turn in bed independently and turned himself at night. The patient agreed to a referral to the Community Neurological Rehabilitation Team to reassess his transfers and to Wheelchair Services to reassess his seating.
(I) Continence: Mr X had a urethral catheter. He often sat on a commode for up to 2 hours a day every morning carrying out manual evacuation. He agreed to a referral to the Bladder and Bowel Team so that they could assess for bowel irrigation.
(N) Nutrition: Mr X’s BMI was 35, he was already on a high protein diet.
(g) Giving Information: Education on nutritional intake and smoking cessation were provided to aid wound healing. Time was spent discussing the cause of the wound, the importance of pressure off-loading, use of the 30-degree tilt when in bed and reducing the amount of time spent in his wheelchair to mealtimes and personal care only. An increase in formal care provision was discussed as Mr X was going to spend more time in bed but he and his wife felt they could cope. The impact of the development of the pressure ulcer on Mr X’s life was discussed as was the potential implications of not offloading pressure i.e. deterioration of the wound, spreading infection and hospitalisation.
Month 1
Mr X reported that he spent approximately 3.5 hours in his wheelchair in the mornings and then an hour in the evening. He lays on his side when in bed. He was assessed by the physiotherapist and a risk assessment was carried out to determine if an alternating surface would be reconsidered as the patient was not smoking in bed. A hybrid air mattress was put in place. At this point in time the patient was still waiting to be seen by the Bladder and Bowel Team. The patient reported that whilst performing bowel care his dressing kept coming off.
Presentation: Deterioration of the wound was evidence has the depth had increased to 50mm, and there was undermining and tunnelling present as well as palpable bone. The wound bed was moist, the granulation tissue was unhealthy in appearance the surrounding skin was macerated. There was no spreading infection but there were signs of local infection.
Wound Management: Wound hygiene was performed using a surfactant to cleanse and soak the wound bed. A debridement pad was used to debride the wound bed. A barrier film was used to protect and restore the surrounding skin. An antimicrobial hydrofiber was used to fill the cavity and a silicone foam was used as a secondary dressing to absorb the exudate. Due to the concern of underlying, undiagnosed osteomyelitis NPWT was not considered appropriate.
The importance of pressure relief was reiterated to Mr and Mrs X. The GP was informed about the exposed bone and the concern about osteomyelitis. Blood tests and an x-ray were requested. The Local Spinal Injury Pressure Ulcer Outreach Team were contacted for advice and a referral was made for a Plastic Surgical review.
Month 3
Mr X was reviewed by the Plastic Surgical team. The x-ray and blood tests ruled out osteomyelitis at this stage. His bowel care time had reduced to about 40 minutes. Mr X was now spending most of the day on his bed to relieve pressure.
Presentation: The skin surrounding the cavity had healed, the wound was still undermining and had a depth of 40mm, bone was no longer palpable The visible wound bed was granulating but the tissue was quite pale. The surrounding tissue was slightly excoriated with evidence of scar tissue and there was a build-up of dry, thickened skin
Wound Management: Wound hygiene was performed using a surfactant to cleanse and soak the wound bed. A debridement pad was used to debride the wound bed. A barrier film was used to protect and restore the surrounding skin. As osteomyelitis had been ruled out NPWT with a gauze filler was commenced to promote wound closure.
Following discussion, a referral was made to the dieticians to optimise his nutritional intake to aid healing.
Month 5
Mr X was reviewed by the Plastics team again who did not feel that any surgery was required and he was discharged from their care.
Mr X reported that the dressings were coming off at times after a shower and his wife was having to reapply the dressings to maintain a seal. He continued to spend most of his time in bed to maintain off-loading of pressure.
Presentation: the wound was narrower, the tunnelling had resolved, the depth was still 40mm, granulation tissue was evident and the edges of the wound had become thickened with more scar tissue but this was macerated in places. There were no signs of infection.
Wound Management: Included wound hygiene, conservative sharp debridement as well as use of debridement pad was used. A barrier film was applied to protect the surrounding skin. NPWT continued.
Month 8
Presentation: Mr X’s pressure ulcer had reduced in size; the depth had decreased to 30mm and it was narrower. The wound bed was granulating, however the edges of the wound remain thickened.
Wound Management: The same wound management regime continued. A disposable NPWT system was commenced.
Month 12
Presentation: Mr X’s pressure ulcer continued to reduce in size; the depth was now 8mm and narrow. The wound bed was granulating, the edges of the wound remain thickened.
Wound Management: The same wound management approach continued. NPWT was discontinued and local wound treatment was switched to an antimicrobial hydrofiber as there was a suspicion of a biofilm. A silicone foam dressing was used as a secondary cover and to absorb exudate.
Conventional dressings continued for some months, and the wound eventually healed 12 months after the initial presentation.
Summary
The psychosocial impact of living with a pressure ulcer for Mr X was significant. Mr X experienced low mood and social isolation throughout his healing journey. The nurses were able to support him psychologically by providing consistent care and he developed strong, supportive relationships with the community nursing team.
This case study highlights the complexity of caring for a patient with a pressure ulcer. It is essential to undertake a holistic assessment and involve the multi-disciplinary team whilst working in partnership with the patient and their family throughout. Goal setting with discussions on how this can be achieved is also important as is patient involvement in self-care and supporting the patient to participate in his management.