Case Study , Bilateral Neurotropic Ulcers
Introduction page 1
Ulcers as a complication of type 2 diabetes page 2
Wound care, page 2
Admission page 3
Mobility Levels page 5
Wound Management page 6
General Nursing Care page 7
Conclusion page 10
Bibliography page 11
Mrs A, aged 75, was admitted at her general practitioner’s request because of long standing bilateral neurotropic leg ulcers, a result of poor self control of her secondary diabetes, which not only brings neurological problems which result in poor circulation in her lower limbs, but also makes for difficulties with healing, being both a disease of the metabolism and of the circulation. The problems are both neurological and vascular. She has been cared for up to this point by the community nursing service, but the ulcers were getting worse rather than better, and now it was believed that secondary infections were present. Neurotropic diabetic ulcers with punched out edges and damaged surrounding skin are very common lower limb wounds and if they progress can lead to the need for to lower extremity amputation according to Armstrong and Lavery 1998, who also point out that ‘ frequent routine evaluation and meticulous preventive maintenance’ are important.. It was therefore decided that more intensive care would be required than was possible from the community nurses, especially in view of Mrs A’s increasing immobility. She seems to be a lady who values her independence, but realises that things have now got to the point where she requires more help. She has no immediate relatives near by and lives alone in warden controlled accommodation. Being under 24 hour care should bring about greater control of her diabetes, which would then will hopefully have a secondary effect and be beneficial for her circulation and give the leg ulcers a better chance of healing. Although there is no way of repairing the neurological damage that has already occurred , if sugar levels are better controlled this can slow the progress of further neurological damage according to Fishman, ( undated)
Ulcers as a complication of type 2 diabetes.
A common complication of long established type 2 diabetes is peripheral vascular disease to the blood vessels in the lower limbs. This results in reduced blood circulation and a predisposition to the formation of ulcers. Often this is accompanied by neuropathy which leads to loss of sensation and inclines patients to be less aware of damage in its early stages.
Wound care – The progress of the ulcer’s is best documented by taking an initial photograph , with the patient’s permission, and then recording various points each time the wounds are inspected. These would include the following points based upon the individual pathophysiology of the wounds:-
Vital signs i.e. the patient’s pulse rate, temperature and blood pressure are recorded.
Position and type of wounds – in this case they were vascular diabetic ulcers just above the ankle joints on the interior of both legs.
The Dressings – are they intact, loose, clean or dirty?
Strikethrough – Has the would drained through the applied dressing.
Size – the wounds are measured in centimetres . The depth of the wound can be measured using a sterile cotton bud. As in this case there is more than one would care should be taken to cut down the risk of any cross infection from one wound to the other. Therefore separate instruments, gloves etc must be used. These measurements are then compared to previous ones. Is the wound increasing, decreasing or remaining as it was?
The wound is described. Is there tracking i.e. healthy skin overhanging a dead space? Is there undermining – i.e skin that skin overhanging the ulcerous wound?
Drainage – is this serous, bloody, purulent? What colour is it? Is this thin or thick? Does this drainage actually come from the wound or is it rather the breakdown of a substance used to dress the wound on an earlier occasion? An estimate should be made of the amount of fluid draining. Yellow fluid which appears to be purulent may indicate a staphylococcus infection. Pseudomonas infection is more likely to produce a green discharge.
Is there an obvious odour? Staphylococcus infections create a fruit odour, whereas a faecal odour is more likely to be produced by a gram negative bacteria such as salmonella.
The amount of necrotic tissue should be mapped in a small diagram.
If there is infection this should be assessed by using laboratory tests including WBC counts.
Would care will need to continue for a considerable length of time. Margolis , Cantor and Berlin ( 1999) found that after 20 weeks of good care 31% of such ulcers would be healed.
In the first instance Mrs A was assessed as to her general health as well as her particular problems. The Nurses and Midwives Council has produced a code of standards and practice to be followed by health care staff. ( 2008) It therefore follows that taking care of those in their care is a primary consideration, treating them with dignity and respecting their individuality. This requires working across a number of other disciplines in order to provide the highest possible standards of care and acting with integrity. In Mrs A’s case this included assessing both her level of mobility at present and the condition of her leg ulcers as well as her diabetic condition. She was shown around the ward and told how to use such things as the call button and the radio. A diabetic diet was ordered and note taken of her present medication. The community nurse’s report was read and recorded.
After an initial assessment it was decided that for the present the wounds should be dressed twice a day until the secondary infection had been overcome and blood sugar levels tested after each meal. The patient was advised and encouraged to drink, because fluid lost from the ulcers was excessive and could lead to some degree of dehydration. Mrs A has been prescribed Metformin to control her blood sugar levels, but admits that she does not always take them. Metformin ( MedLinePlus 2011) should be taken in conjunction with a dietary and exercise regime, but when at home Mrs A is not very careful about her diet and takes almost no exercise. The dietician was also asked to assess Mrs A. and to advise her future management. This regime was implemented, but it was found that Mrs A would only take her tablets if encouraged to do so and the diet provided had to be adjusted to take into account MrsA’s particular likes and dislikes. . Each week her wound and mobility was assessed and future care adjusted where required. There was progress, especially after secondary infection was eliminated, but it was really slow and Mrs A. got frustrated at times and wanted to get home. It was explained that there would be little point in going home until her wounds were healed.
Her fall risk was also assessed using the chart ‘Assessment of Falls Risk in Older People.’ ( 2004)
Mrs A’s mobility needs to be assessed, in the firs t instance as a base line and a way of assessing her risk of falls. Not only could a fall result in injury, it could delay healing and mean even longer in hospital and the hospital has a legal obligation to provide a safe environment. It should be remembered that her mobility while in hospital, where bed heights can be adjusted and toilets have aids etc may be rather better than her mobility at home. The timed ‘Get Up and Go Test’ .This involves the patient being timed as she gets up, walks 3 meters, then turns , returns and sits down. This is a very rapid and simple test that gives a good way of noting any improvement or deterioration.
The POMA test ( Performance Oriented Mobility Assessment) is slightly more complicated. The patient is asked to sit on an armless chair and is assessed as to whether she can do this without help, whether she sits or ‘plops’ and how centrally she does this. Balance is also assessed i.e. does the patient remain upright or does she slip forward or sideways. The amount of lean is also assessed. Finally can she get up in two attempts or less, does she take three or more attempts or does she require help. The immediate standing balance is also assessed – i.e balance within the first few seconds. Does she grab for support and wobble?. Is she steady using a cane or walker, or has only a very mild stagger which does not require her to grab at support, or ,best of all, can she stand steadily without support? The side-by-side standing balance is also part of this test as is the pull test and the bare floor test. Mrs A’s results were in itially moderately bad and she was referred to both a physiotherapist and an occupational therapist who will continue to assess her mobility and hopefully assist her to improve matters, giving her increased confidence in her own abilities. As long ago as 1966 Henderson stated that the environment could have either or negative effect upon a patient. The hospital ward is a caring , multidisciplinary environment where the staff work together with the patient to ensure her optimum level of health, physically, but also psychologically.
Because her low level of voluntary mobility and her circulation problems Mrs A’s Waterlow score was assessed as high risk, mainly because of her clinical condition, but also because of her age and weight. This would be reassessed weekly and suitable care patterns chosen. The Waterlow score system ( 2005) uses the health care staff’s professional risk assessment skills in order to provide better care for those with, or who are likely to have, pressure sore problems. Mrs A was found to have no actual pressure sores, but, because her poor mobility levels, staff were encouraged to ensure she mobilized at regular intervals – eating at a communal table for instance, instead of on her bed or at her bedside. This also encouraged socialization. She was accompanied back and forth to the bathroom or treatment room, and occasionally to the hospital shop and each week would visit the chapel for the Sunday service.
Accurate diagnosis is the basis of all ulcer care. Misdiagnosis may result in incorrect management techniques being used and so a failure to heal,. For example, venous ulcers are treated with compression. Also patients with very longstanding ulcers should have biopsies taken in order to eliminate the possibility of malignancy. ( Boike, Maier, and Logan 2000. If ischemic ulcers are mistakenly diagnosed treated with as with compression, ischemia will increase in the affected area and make matters worse.
Haynes ( 2007) points to a way of managing wounds such as those Mrs A has . This includes wound bed preparation, and the TIME system of management i.e. ‘Tissue management; Inflammation and infection control; Moisture balance; Epithelial (edge) advancement’. Swabs were taken from each wound so that any secondary infection could be properly diagnosed and then treated with antibiotics. Compression bandages were applied on top of the dressings. These aid circulation. Mrs A was also instructed to elevate her legs when seated or lying . A padded stool was provided for this purpose and when in bed her legs would be supported by a pillow. After cleaning away any dead tissue at the base of the ulcers using saline irrigation, Recombinant human platelet-derived growth factor-BB (rhPDGF-BB)in gel form was applied to the wounds after debridment of dead tissue as described by Weiman et al in 2011. To this was added saline soaked gauze dressings , followed by dry padding and pressure bandages. .
General Nursing Care
Roper, Logan and Tierney in 1980 wrote about a holistic way of considering patient care and this method should be utilized in Mrs A’s case . Included in their list of daily activities of living are maintaining a safe environment, communicating, breathing, nutrition, elimination, personal cleanliness and dressing, controlling her body temperature, mobilization., working and playing, expressing sexuality and dying. Although this model concentrates on physical needs it does provide a basis for care. Obviously some of these aspects are more relevant in this case than others. This holistic way of deciding a nursing process can be linked to ideas from Abdellah , described in 2007, Stritch University. Abdellah was very concerned with patient centered approaches to care. She looked at such things as the physical, sociological, and emotional needs of the person concerned, the interpersonal relationships between the nurse and her patient and the common elements required for patient care. This part of the nursing process extends from the assessment onwards and together with the patient and, when possible, family members and carers will seek to determine how the individuals needs and preferences in relation to their health can best be met. A plan is drawn up and then implemented and this is evaluated from time to time and perhaps adjusted as required.
A safe environment in this case included ensuring safe mobility . Mrs A. had a walking stick , but it was decided that a walking frame would give her more stability and she was taught how to use this properly and it was adjusted to suit her height. Because most falls tend to take place in toilets and bathrooms Mrs A was accompanied on visits to these places.
There were no problems with communication and so staff took the opportunity to explain to Mrs A what was being done, why, and the hoped for outcome. She in her turn was given the opportunity to ask any questions or explain particular preferences and dislikes. Over time a trusting relationship was built up which meant that Mrs A was more likely to listen to advice and take up suggestions. This fits in with Boykin and Schoenhofer’s ideas about nursing being about caring.( 1993)
There were no respiratory problems.
Dietary – the dietician devised, together with Mrs A. a more suitable diet than she had been following up to this point. The aim was to maintain her blood sugar levels at a reasonable height, somewhat lower than they had bee, with the hope that this would have a positive effect upon the healing of her ulcers.
Cleanliness. The wounds made baths difficult, but showers were possible if waterproof dressings were used . These also helped to eliminate any odours produced. Mrs A was able to dress herself.
Controlling body temperatures. The ward was maintained at a reasonable level and , because secondary infection was eliminated, Mrs A’s temperature was kept within normal levels.
Safe mobilization was encouraged, both by physiotherapy staff and others, as well as Mrs A’s own resolve to be as little trouble and possible and to maintain her independence.
Work and play. Mrs A was able to socialize and partake in such activities as Scrabble and Chairacise. She had visitors and also made good use of the hospital library trolley.
Before she left hospital Mrs A’s details were passed on to her local Foot Health Clinic. Here she would be assessed regularly , as in Nice Guidelines ‘Type 2 Diabetes’ January 2004. This includes care being shared between the patient and professional care. The aim to keep control as far as possible on any risk factors . The feet are tested for their sensitivity, the foot pulses are checked and any deformity is noted. Foot wear is checked for wear patterns and for suitability. Risk of ulceration is assessed. A management plan is decided upon with reference to the patient. Regular reviews are arranged, more frequently if there is a high risk. Anyone with a previous history of ulcers is considered to be at high risk. If considered necessary then increased education in foot care is given, as is specialized footwear, insoles and skin and nail care. Mrs A is told that if a new ulcer should develop she can contact a multidisciplinary team of foot care specialists within 24 hours and she is given information as to how this can be done. This information is of course also available to her community health nurse. This is an example of the use of available community resources as described by Abdellah ( Cited by Ruddy 2007) .
Another model of nursing that is applicable in Mrs A’s case would be Roy’s Adaption model ( 2005) in that Mrs A was gradually moved from a position where she was merely surviving with her condition to one where she was ‘transformed’ once more into a relatively able person.
This was a long slow process, but eventually Mrs A’s ulcer’s healed after some 20 weeks. The first stage was to eliminate the secondary infection present in both ulcers. She had stuck to her diabetic diet after some initial misgivings and adjustments. This meant that her blood sugar levels could be maintained at a more stable and acceptable level. Another effect of this was that this lessened the likelihood of sudden drops in blood sugar levels and so decreased the likelihood of falls. Mrs A was discharged to a unit with a lower level of dependency and went back to her own home a few weeks later, again under the supervision of the community health team. This shows that with persistent high levels of suitable care even long standing ulcers of this type can be healed without the need to resort to plastic surgery or even amputation. However it remains to be seen whether the patient will continue to maintain her diet and take medication as ordered, although on discharge she was highly motivated to do so. The occupational therapist had instituted a number of changes at her home to make mobility easier e.g. raising the level of her bed and installing a pull bar and adding bath and toilet rails. Mrs A is aware that the ulcers could return if she does not take care, and also knows that if there is even the smallest breach of the skin integrity she should contact her local health centre. This should ensure that similar problems to those which brought her into hospital care for such a prolonged period will not recur.
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