The Theory of Wound Care Fro Podiatry - Essay Example

The case of Mrs. Freeman entails not only providing treatment to the more obvious problem, which is the foot ulcer, but also providing treatment, or at least temporizing measures, for the underlying problems. These issues should be addressed in order to provide the most plausible and appropriate treatment for the patient. A wound occurs when the integrity of any tissue is compromised (Dealey 23). A wound may be caused by an act, such as a gunshot, fall, or surgical procedure; by an infectious disease; or by an underlying condition. Types and causes of wounds are wide ranging, and health care professionals have several different ways of classifying them. They may be chronic or acute, and open or closed. The patient presented with a full thickness ulcer measuring 8 mms in diameter of approximately 6 months duration and the tissues around the ulcer are acutely inflamed. Patients with rheumatoid arthritis may develop leg and foot ulcers of varied aetiologies, including venous disease, infection and inflammation. The foot ulcers in rheumatoid arthritis patients may involve several of these aetiological factors and are often difficult to heal (Sunita). Both the ulcers and the treatments are often painful, and these ulcers may be present for years. Chronic wounds plague more than 10 million people in the world today. But even more troubling is the fact that these wounds may persist for months and even years without any healing or sign of improvement (Morgan 25). The problem is usually, if not always, not the wound itself; and therefore treating the wound will not, in chronic cases, resolve the issue. Chronic wounds have underlying causes that must be addressed in order for the wound to heal properly. Because normal skin and wound care is not enough to heal these wounds they usually remain for extended periods of time. As a rule, only 50% of leg ulcers heal within 4 months of appearing, 20% remain open at 2 years and 8% remain open at 5 years (World Wide Wounds). So we see that to effectively treat a chronic wound you must treat the cause and not simply treat the symptom. There are several factors that affect wound healing. These include the age of the patient, hydration status, presence of infection, presence of underlying conditions, medications, obesity, oxygenation and tissue perfusion, personal hygiene and nutrition (Bowler 499). In the case of Mrs. Freeman, these factors can be very well correlated. The physiological changes that occur with ageing place older patients at higher risk of poor wound healing. The age of the patient places her in a relative state of immune deficiency. The immune system also declines with age making older patients more susceptible to infection. Older people can also present with other chronic diseases, which affect their circulation and oxygenation to the wound bed. Dehydration leads to an electrolyte imbalance and impaired cellular function. The presence of infection can significantly alter the rate of wound healing. Infection has been defined as the deposition and multiplication of organisms in tissue with an associated host reaction (Dealy 56). In the given case, infection is rather evident in the patient's ulcer. The presence of unhealthy granulation, thick, bloody, and malodorous exudates indicate the presence of infection. Wound infection is a problem because, at the most fundamental level, infection stops a wound from healing by prolonging the inflammatory phase, disrupting the normal clotting mechanisms and promoting disordered leukocyte function and ultimately preventing the development of new blood vessels and formation of granulation tissue. Chronic diseases like diabetes mellitus, rheumatoid arthritis, and lupus can delay the process of healing. The patient has been diagnosed with rheumatoid arthritis of 10 years duration and this has markedly affected wound healing in her case. She also has secondary hypertension and iron deficiency anemia. The presence of chronic diseases weakens the immune system, dampening its ability to counteract the pathogens attacking the body. Certain medications have direct effects on wound healing. Anti-inflammatory, cytotoxic, immunosuppressive and anticoagulant drugs all reduce healing rates by interrupting cell division or the clotting process. The patient is on prednisolone (anti-inflammatory) and methotrexate (immunosuppressive). These drugs affect the body by reducing its capacity to ward off infections. Obesity is a condition in which the natural energy reserve, stored in the fatty tissue of humans and other mammals, exceeds healthy limits (Wikipedia). It is commonly defined in terms of body mass index. It is a systemic factor that impedes wound healing. Good wound oxygenation is essential for wound healing. The patient weighs 14 stone and if her body mass index is to be calculated, she is classified as obese. Oxygen influences angiogenesis, epithelialisation and resistance to infection. This is one of the reasons why smoking is radically discouraged in chronically ill patients. Mrs. Freeman has been a smoker since she was seventeen and this has greatly affected her health and the way her body responds to foreign bodies. It has been established that long-term smoking cumulatively and chronically impairs the immune system of the body. The need for good personal and oral hygiene should be discussed with the patient. This is because it is actually the first step in preventing a disease or an infection or avoiding its spread. Effective hand washing greatly reduces the risk of transferring pathogenic organisms from one patient to another by direct contact or by contamination of inanimate objects that are shared. Nutrition is detrimental to the process of wound healing (Patel 15). Its impact on the physiologic processes underlying wound recuperation has been a subject of interest to many studies because of its huge significance. Protein is required for all the phases of wound healing, particularly important for collagen synthesis. Glucose balance is essential for wound healing. Iron is required to transport oxygen. Minerals, like zinc and copper, are important for enzyme systems and immune systems. Zinc deficiency contributes to disruption in granulation tissue formation. Vitamins A, B complex and C, are responsible for supporting epithelialisation and collagen formation. It is also important for the inflammatory phase of wound healing. Carbohydrates and fats provide the energy required for cell function. Fatty acids and essential for wound healing. The patient since retirement has gained 3 stone in weight, is trying to lose weight, and is on a low-fat diet. She has also been a vegetarian for the past 20 years. Being a vegetarian is a healthy option for many, but it also entails Vitamin B12 deficiency, since the said vitamin is found only in animal sources. Podiatry or podiatric medicine is defined as a field of healthcare devoted to the study and treatment of disorders of the foot, ankle, and the knee, leg and hip, collectively known as the lower extremity (Wikipedia). Wound assessment is an integral component of the overall plan to effectively manage the wound healing process and in this case, the nonhealing ulcer in the left second metatarsal of the patient. To be able to effectively conduct an assessment of an acute/chronic wound, it is important to have a clear understanding of the patient's personal environment along with the underlying aetiology and characteristics of the wound. It is critical to have a comprehensive framework for wound assessment for this is an integral part in the overall management of the patient. A detailed clinical history should include information on the duration of ulcer, previous ulceration, history of trauma, family history of ulceration, ulcer characteristics (site, pain, odour, and exudate or discharge), limb temperature, underlying medical conditions such as diabetes mellitus and connective tissues diseases such as rheumatoid arthritis, varicose veins, deep venous thrombosis, previous venous or arterial surgery, smoking, medications, and allergies to drugs and dressings. Appropriate investigations should be carried out because all these factors significantly affect the rate of wound recuperation. Wound assessment and monitoring include evaluation and examination of the location, aetiology, clinical appearance of the patient as well as the wound, presence of exudate including its amount, type, odour, and suspected infection; condition of skin surrounding the wound, pain assessment, and measurement of the length, width and depth of the wound (Dealy 149). The size of the wound should be assessed at first presentation and regularly thereafter. Although not diagnostic, examination of the edge of the wound may help to identify its aetiology in the context of the history of the wound. For example, venous leg ulcers generally have gently sloping edges, arterial ulcers often appear well demarcated and "punched out," and rolled or everted edges should raise the suspicion of malignancy. A biopsy should be taken of any suspicious wound. The site of the wound may aid diagnosis; diabetic foot ulcers often arise in areas of abnormal pressure distribution arising from disordered foot architecture. Venous ulceration occurs mostly in the gaiter area of the leg. Healthy granulation tissue is pink in colour and is an indicator of healing. Unhealthy granulation is dark red in colour, often bleeds on contact, and may indicate the presence of wound infection. Such wounds should be cultured and treated in the light of microbiological results. Excess granulation or overgranulation may also be associated with infection or non-healing wounds. These often respond to simple cautery with silver nitrate or with topically applied steroid preparations. Chronic wounds may be covered by white or yellow shiny fibrinous tissue. This tissue is avascular, and healing will proceed only when it is removed. This can be done with a scalpel at the bedside. The type of tissue at the base of the wound will provide useful information relating to expectation of total healing time and the risk of complications. Cellulitis associated with wounds should be treated with systemic antibiotics. Callus surrounding and sometimes covering neuropathic foot ulcers like those in diabetic patients must be debrided to visualise the wound, eliminate potential source of infection, and remove areas close to the wound subject to abnormal pressure that would otherwise cause enlargement of the wound. This can be done at the bedside. All open wounds are colonised. Bacteriological culture is indicated only if clinical signs of infection are present or if infection control issues need to be considered like in the particular case of methicillin resistant Staphylococcus aureus. The classic signs of infection are heat, redness, swelling, and pain. Additional signs of wound infection include increased exudate, delayed healing, contact bleeding, odour, and abnormal granulation tissue. Treatment with antimicrobials should be guided by microbiological results and local resistance patterns. Pain is a characteristic feature of many healing and nonhealing wounds. Constant pain may arise as a result of the underlying condition, such as ischaemia, neuropathy, tissue oedema, chronic tissue damage, infection, or scarring. The nature and type of pain should be identified and treated appropriately. Pain assessment tools can help to assess the nature and severity of pain. The management aims for wound ulcers include formulating a treatment plan following a holistic assessment of the patient and the ulcer (Franks 87). Significant advances have been made over the past two decades in the delivery of effective services for patients with leg ulceration. Treatment costs, however, remain high and the development of strategies to ensure future provision of effective care is important. The concept of TIME, which stands for tissue management, inflammation and infection control, moisture balance and epithelial advancement, has offered a logical and systematic approach to the assessment and delivery of wound care for patients with leg and foot ulceration, guiding practitioners in linking clinical observations and clinical outcomes (World Wide Wounds). Recent research into conditions at the wound bed has focused attention on the benefits of wound bed preparation and the use of the TIME framework to underpin care. This concept was developed as a result of consensus meetings with key wound care opinion leaders. However, it is of limited value if clinicians fail to use it as part of a holistic approach. Leg ulceration is recognised as a multi-faceted problem requiring a holistic approach. Early diagnosis and implementation of therapies required for healing and wound bed preparation are essential. The main components of foot and leg ulcer treatment include correcting the underlying cause of the ulcer and improving the underlying arterial or venous flow, creating an optimal, local environment for wound healing, improving the wider intrinsic and extrinsic factors that may delay healing such as poor mobility, malnutrition and obesity, preventing avoidable complications such as infections, and maintaining healed ulcers. The development of an additional framework that addresses other key elements of care, used alongside the original TIME framework, may help encourage a more holistic approach to leg and foot ulcer management. The concept of quality of life reflects an individual's level of satisfaction with various aspects of daily life, including housing, environment, recreation, health and well-being. Foot ulceration can impact significantly on a person's quality of life, affecting physical and social functioning as well as psychological well-being. Patients report increased pain, restrictions around what they can wear, limitations to their social lives, low self-esteem, depression and social stigma. An understanding of the impact of the ulcer on quality of life and the development of realistic patient-focused outcomes is important if concordance is to be achieved. Poor regard for patient concerns may be particularly difficult where healing is not a realistic outcome and the focus is on chronic disease management. Patient education and active participation in treatment are important aspects of care and may improve concordance. Pain and discomfort are frequently associated with foot ulceration regardless of aetiology and may be linked to poor concordance. Ongoing, systematic pain assessment and management, as well as timely referral for specialist input where required, are integral to holistic care and should be adequately documented. Although malnutrition is frequently linked to delayed healing, clinicians tend to be poor at assessing a patient's nutritional status. A balanced diet that includes protein, carbohydrates, fats, vitamins and minerals is important in effective wound bed preparation, while obesity is linked to increased risk of venous hypertension, arteriosclerosis, atherosclerosis and diabetes. Measures to manage any co-existing medical conditions that may delay healing are integral to an effective framework of care. It is rather important to provide the patient with certain tips and guidelines regarding wound care and management (Abboud 28). Patient education is one of the most vital keys in providing optimal care and proper patient management. Making the patient understand the importance of maintaining a healthy lifestyle and guiding her step by step usually comes first. The patient should be advised to eat a healthy, balanced diet, take vitamin supplements if needed, maintain good oral and body hygiene maintain her ideal body weight, stop smoking and drinking and take her medications faithfully. Having a stable health is detrimental to the optimal functioning of the body. Her current condition (rheumatoid arthritis) can be an obstacle in maintaining good health so it may be helpful if psychological help is at hand. This can provide her with insights regarding welcoming changes and accepting the consequences accompanying her condition. Development of a plan of care for patients with venous leg ulcers must address several concomitant issues including healing of the active ulcer and prevention of ulcer recurrence. Key to achieving these goals is treatment of ulcer-associated infection, prevention of infection development, and stimulation of granulation and epithelial repair. An aggressive, multidisciplinary approach to venous leg ulcer care results in accelerated healing of these lesions, even in the presence of significant and severe comorbidities and challenges. The management of chronic wounds is a dynamic process, which is changing rapidly owing to the availability of advancing technologies and improved understanding of the barriers to wound healing. The management of wounds makes up a considerable proportion of a nurse's workload. Patients with compromised healing wounds are cared for in a variety of health care settings, by a number of clinicians, during their journey of care. For this reason the development of a consistent and structured approach to wound assessment is of value. This approach needs to be understood by all clinicians, at all levels, to improve wound assessment skills and reduce variations in practice. Bibliography Wikipedia. 1995. Wikipedia Foundation Inc. April 6, 2008 . Wikipedia. 1993. Wikipedia Foundation, Inc.. April 10, 2008 . Smeltzer, S., et al. Handbook For Brunner And Suddarth's Textbook Of Medical And Surgical Nursing 9th Edition. New York: Lippincot Williams And Wilkins, 2000. Bowler, PG. "Infection control properties of some wound dressings." Journal of Wound Care vol 8 1999. p. 499-502. World Wide Wounds. Ed. Stephen-Haynes, Jackie. 2007. April 10, 2008 . World Wide Wounds. Ed. Watrer, Lynne. 2005. April 9, 2008 . Sunita, RN. "Rheumatoid arthritis-associated inflammatory leg ulcers." International Wound Journal volume 1 issue 1 (2004): 81-84. April 11, 2008 . Patel, Girish. "The Role of Nutrition in the Management of Lower Extremity Wounds." International Journal of Lower Extremity Wounds vol 4 2005. p. 12-22. Franks, Peter J. and Bosanquet, Nick . "Cost-Effectiveness: Seeking Value for Money in Lower Extremity Wound Management." International Journal of Lower Extremity Wounds vol 3 2004. p. 87-95. Abboud, C. "Wound management: who is responsible." The Journal of Wound Care vol 24 2004. p. 28-30. Dealey, Carol. The care of wounds: a guide for nurses. Oxford, UK: Blackwell, 2005. Morgan, DA. Formulary of Wound Management Products: a guide for health care staff, 8th Ed. . Haslemere: Euromed Communications, 2000. Read More