Notes on Practice: Management of a Complex Wound in a Challenging Home Health Care Patient

    Providing care to a patient with a complex wound can be challenging. When a history of diabetes, drug abuse, and apathetic self-care are factored into the wound management equation, hope for a positive outcome is further compromised.

In this case, in addition to clinical management of the wound, the treatment plan required teaching related to wound care — early development and recognition of wounds, management of diabetes and its effects on wound healing, self care, nutrition, position changes, and referral to other social services for drug-related issues. An aggressive care regimen allowed the wound to heal better than originally expected.

Patient History

    Mr. N, a 47-year-old single, ambulatory man with diabetes, was an illicit drug user and had a longstanding history of drug abuse. Another problematic social issue was that he had no fixed address. He was admitted to the care of a home health nurse and agency on June 13, 2003. When admitted, Mr. N had a pressure ulcer over the entire buttocks area (see Figure 1). He reported he was found “in a coma state” due to a hypoglycemic episode and hospitalized in the intensive care unit for 2 days. The admitting nurse was told only that the patient had a surgically debrided pressure ulcer. No other information or assessment information was provided by the discharge planner from the hospital.

Wound Diagnosis and Description

    The admitting nurse assessed the open wound as a Stage IV ulcer of the bilateral buttocks, coccyx/sacral area, extending almost to the anus. The wound measured 20 cm long x 23 cm wide x 10 cm deep. Although the ulcer had been surgically debrided during hospitalization, it still contained 10% necrotic, yellow slough; 90% beefy red granulation tissue; and two large tunnels at the 2 o’clock and 7 o’clock positions. The ulcer had been present on admission to the hospital; it is speculated that diabetes, illicit drug use, lack of appropriate nutrition and fluid intake, poor personal hygiene, and an unknown time of immobility led to the development of this massive pressure ulcer.

Care Management

    The care orders on admission were to cleanse the wound with antimicrobial wound cleanser and gauze. Then, an ionic silver hydrogel, followed by collagen particles, should be applied and the wound covered with a normal saline-moistened gauze and then abdominal pads secured with tape. The treatment regimen was daily times seven days, then dressing changes decreased to three times per week. Mr. N’s medication regimen included hydrocodone bitartrate/acetaminophen tablets (Vicodin, Knoll Laboratories, Mount Olive, NJ); gabapentin capsules (Neurontin, Parke-Davis, Morris Plains, NJ); resperidal (Paxil, Glaxo SmithKline, Philadelphia, Pa.); venlafaxine hydrochloride (Effexor, Wyeth-Ayerst, Philadelphia, Pa.); vitamin C 500 mg; and zinc sulphate 220 mg.

    Mr. N frequently demonstrated an unwillingness to change his lifestyle to allow appropriate self-care. He rarely checked his blood sugars, did not eat regular nutritious meals, drank inadequate amounts of fluids, and spent much time positioned directly on his buttocks. During several skilled nursing visits, he refused to allow the nurse to check his vital signs, including temperature. During one home health visit, he had a fasting blood sugar of 61 at noon; he had slept in and not eaten anything for breakfast. His other fasting blood sugar readings were between 93mg/dL and 127mg/dL and random blood sugars ranged from 130mg/dL to 150mg/dL. Mr. N had febrile episodes with temperatures ranging from 100° F to 100.8° F. during the first week of treatment. Of note: Mr. N was not on diabetic or antibiotic medications.

    On four occasions, the nurses were unable to complete the skilled nursing visits as ordered because Mr. N was not at his mother’s home when they arrived and his mother could not locate him. When he finally returned to his mother’s home, he called the agency and requested the nurse to “come and change my dressing.”

Prognosis

    Mr. N’s prognosis was guarded because of his total lack of willingness to make the lifestyle changes needed to promote wound healing. His unwillingness to be an active participant in his wound care regimen and his continuing illicit drug use made successful healing unlikely. However, healing of the pressure ulcer progressed with no signs or symptoms of infection. The wound measurements on July 19, 2003 were 17 cm x 17 cm x 3.2 cm (see Figure 2) with almost 100% granulation and no further tunneling. On August 11, 2003 the wound measurements were 12.5 cm x 13.5 cm x 3 cm with 100% granulation tissue; healing continued with no undermining, tunneling, or signs or symptoms of infections (see Figure 3). The patient was discharged due to change of insurance on August 25, 2003.

Patient/Caregiver Education

    Education was provided to the patient pertaining to diabetes (eg, the importance of appropriate diet) and ways to promote healing, such as controlling blood sugar, avoiding pressure to the buttocks/coccyx area, performing appropriate pericare after bowel movements, and recognizing the signs and symptoms of wound complication and wound healing. Mr. N also was given instructions on the use of his wound product.

Discussion

    Clinicians treating a complex wound in a patient unwilling to change his lifestyle to allow appropriate self-care face numerous challenges. In this case, the patient was indigent and did not have a permanent address. However, by employing a comprehensive wound care treatment protocol and care regimen, caregivers were able to manage Mr. N’s pressure ulcer therapeutically and cost effectively. The wound product did not require a prescription; therefore, the home health care agency was able to provide all the treatment products and dressing supplies. The ionic silver hydrogel was selected for its ability to address the bacteria in the wound bed and maintain an optimal moist environment. Ionic silver has been shown to be safe, non-cytotoxic, broad spectrum antimicrobial. By eliminating the infecting organisms, the dressing prevents the wound bed from becoming colonized or infected. Collagen was selected for its ability to assist all phases of wound healing while helping to manage exudate.^1,2

    Another critical factor in selecting treatment options was the fact that the dressings could be left in place for several days, allowing for less frequent dressing changes by the nurses. During Mr. N’s treatment, the dressing was left in place for up to 5 days without any wound bed deterioration. With no infection or deterioration, granulation could continue and healing did not stall.

Conclusion

    Although Mr. N was difficult to manage due to his diabetes and his unwillingness to assume responsibility for self-care or drug addiction, the agency’s aggressive, appropriate wound care regimen helped the wound to progress toward healing. Cleansing, control of the bacterial bioburden, and providing the wound with collagen were all helpful in preventing Mr. N from becoming infected or septic, while allowing his wounds to progress far beyond his clinicians’ expectations.

1. Gibbins B. The antimicrobial benefits of silver and the relevance of microlattice technology. Ostomy Wound Manage. 2003;49(2 suppl):S4–S7.

2. Fleck C, Paustian C. The use of silver containing dressings: the new “silver bullet” in wound management? ECPN. 2003;July/August:22–25.