Healing of the Infected Black Wound - Case Study Example

Knowledge & Understanding (Driscoll reflection—“What?”) This patient has a septic wound on their heel that is representing a fairly common type of infection, and is not often fatal, but it can lead to a seriously compromised lifestyle, as shown by the increasing seriousness of symptoms considering the patient’s age and other conditions, such as the gout, obesity, and Parkinson’s. Also, morbidity tends to increase, as life expectancy decreases. Still, it is possible for someone with the presenting problem, which is the black wound on the heel, with the proper treatment, to lead a relatively fulfilling and satisfying life as a contributory member of society, especially because this injury does not affect mental development. The use of assistive technology is also on the increase, showing what may be a brighter future for many individuals like this patient. Since this is a case of an infected black wound, there should always be handwashing before and after the dressing is removed or put on. The nurse should wash his/her hands about as long as singing “Happy Birthday,” and when s/he is done, s/he may stop handwashing. The nurse, once the dressing is changed, should follow certain protocol. The old dressing should be double-bagged and summarily disposed. Also, the nurse should wear gloves when first taking the dressing off. S/he should then change gloves when putting a new dressing on the wound. “Treating the cause of chronic wound pain may involve removing the source of the noxious stimulus - for example, reducing pressure in pressure ulcers and initiating strategies to increase arterial flow in ischemic ulcers may help reduce related chronic wound pain. Eliminating bacterial infection will remove the bacteria that stimulate ongoing inflammation” (Reddy et al., 2010). This patient’s case also presents issues of whether the best care would be received in a residential situation, or a home care situation. With regard to the difference between home care and being cared for in the hospital, there is differentiated care. One of the premier aspects of home care is teaching the primary caregiver about how to change the dressing. The nurse must help the caregiver to do the dressing. S/he must feel confident and satisfied that the caregiver can change the dressing suitably and correctly. The dressing should be changed every other day or every other day if it is a dry wound. If the wound is a wet wound, the wound should be changed once or more because of the possibility of excessive drainage. When changing the dressing, the caregiver and the nurse should observe several things. The length, width, and depth of the wound should be assessed. In addition, if there is any pocketing in the wound, this should be duly noted by the caregiver and the nurse. In the current healthcare environment generally, homecare nursing and hospital care are differentiated sharply in terms of policy attenuation, with hospital caregivers receiving much of the attention and home based palliative care being relegated to a position that is secondary to situations. At the root of the problem is the quality of care to the patient, which may or may not be found, based on existing research as well as the current research, to be more attenuated to the patient in the health care delivery system. The non community nature of hospital care, in terms of hospital stays and especially in terms of long-term care, for which many patients are not prepared, is also daunting both to the patient and the hospital in terms of showing this to be a potential problem as well that could potentially be alleviated by diverting more attention to a superior quality palliative care structure in other settings such as the patient’s home. “If the inflammatory stimulus cannot be reduced or removed, strategies to block peripheral nociceptors, reduce the irritability of the peripheral nerves, or block pain perception in the central nervous system should be employed. These pharmacological interventions are most effective when coupled with non-pharmacologic interventions that acknowledge patient-centered concerns” (Reddy et al, 2010). There is also the problem of caregiver versus client perceptions of quality care in palliative care environments. These perceptions may differ significantly as the result of analysis and research, in terms of what the patients expect regarding quality care and what caregivers are prepared to give considering their training or lack thereof. It is relatively easy to separate caregiver and client expectations into these categories, but this does not give the reader an example of possible difference between the expectations of clients and the perceptions of caregivers regarding true quality care. For example, in many cases, especially among the geriatric population in palliative care situations, it is more important to the patient that bonds of trust and communication are formed between the client and the caregiver. Conversely, many caregivers perceive quality care to be mainly about service delivery that is more technical than emotional, and therefore may be working from a different set of assumptions than the client base. This could be a problem in both homecare and hospital care situations, but this could possibly be countered when the palliative care team may facilitate family conferences and conversations with members of the health care team. When talking about the wound, the wound should be addressed as a clock. For example, let’s say there is pocketing on the right side of the wound. This would be described as three o’clock. The nurse should notice what the wound looks like. Is the wound black? Does the tissue look necrotic? Is the tissue healthy? Does the tissue look red and healthy? The caregiver might look into buying ointment for debridement. Chemical debridements are available. The caregiver should be careful not to get the debridement on the healthy tissue. Hospital nurses doing the dressing have the same protocol to follow as far as doing dressings. There are some separate issues that the hospital nurse must worry about in terms of caring for the patient. Things that the hospital nurse should look out for vary. She should worry about preventing pressure, turning the patient. Of course, as mentioned above, handwashing is vital throughout this whole process for the nurse. “Alcohol-based handrub is the new standard for hand hygiene action worldwide and usually requires a system change for its successful introduction in routine care” (Seifert, 2002). The importance of this subject for the patient in this case example is cited by many scholarly articles. Healthcare professionals need to prevent the spread and development of micro-organisms, and hand washing can help to prevent infections. It is vitally important for workers to also remember to wash their hands before and after each patient contact. In most hospitals, this is relatively easy to remember, as all patient areas have antiseptic gel or anti-bacterial soap at ready access, clearly labeled. Usually this type of scenario happens when the patient is in hospice, but not necessarily. If the patient receives no nutritional treatment, how long he will survive is basically left to fate. Another good tip to keep in mind is that if the patient is really demented, there needs to be a 24-hour system of care in place. With dementia, there are going to be certain safety issues that need to be addressed. Usually what happens is, typically with dementia patients, there needs to be a device next to the patient’s bed in order to monitor them. For example, many people use baby monitors. Another typical type of device is a bell to hear what’s going on in the room. The bed should be kept in a low position. The patient should continually be re-orientated to his or her surroundings. The patient may be very confused, so this is an important step in his education. Calendars and clocks should be used. This way, there is some sense of order in this patient’s very confused life. Nurses working with the elderly client like this face unique challenges a well as opportunities in working with a diverse set of clients. “With more than 50% of patients in hospitals over age 65, the men and women of this nursing specialty are a necessary force in taking care of older adults.  Whether working in the hospital or in a Long-Term Care facility, these nurses have extensive knowledge about the special care needed in rehabilitating and maintaining the mental and physical health of the elderly” (Gerontological, 2009). In terms of analysis, in any model, following detection, diagnosis can proceed in the healthcare model. In the proposed model, the prevalence of a theory based attitude would perhaps decrease due to new efforts in early detection. However, if there is nothing that the healthcare provider can do in terms of treatment, it is not in the current proposed model for application to the patient that is tantamount to a reason to deny older adults treatment for their affliction and say that the situation cannot be resolved. It is also the position of the proposed nursing process used that treatment should begin with a supportive environment of actively involved intervention-oriented caregivers who care about their clients, are independent free thinkers, and are able to work in the field. The conflation of obesity and hypertension is also a conditional issue to regard in the face of the intervention with this patient. “Stuart (1967) was a classic study responsible for the subsequent widespread use of behavioral treatment of obesity. His program consisted of gradually restricting and eliminating stimuli that elicited maladaptive eating behavior. For example, the program involved guidelines such as the following: restrict eating to certain times and places” (Gatchel and Oordt, 2004). From this impetus, current interventions for patients who have obesity as a condition are mainly behavioral. Evidence now exists to indicate that those like this patient, who exceed established standards of fatness, have increased risk factors for chronic lifestyle disease. Further, people become fatter with age and therefore an increasing number of people age as adults with increased risk. Current national health goals suggest that good health should reflect a state of well-being, quality of life and freedom from disease. Given the importance of well-being as a national health goal it is necessary to determine the extent to which patients exceeding physiological health standards of fatness may be at risk of low health outcomes. Analysis (Driscoll reflection—“So What?”) With regards to the wound, wound care can vary depending on the type of wound it is. With a dry wound, one probably wants to use a moist dressing. With a draining or wet wound, one wants to use a dry dressing. Also, it is important that if there is exudate, that some emollient be put around the wound to protect it from the drainage. Exudate should be removed from the wound area. “Excess loose slough and exudate is removed prior to assessment and/or dressing change” (“Best Practice Statement,” 2009, p. 21). Since the patient has a heel wound, it would be helpful to put Curlex on the dressing to keep it in place. However, one should not tape the dressing directly on the skin. If, with Parkinson’s, the patient has difficulty swallowing, the caregiver should remember some aspects of caring for the patient that are differentiated from caring for other patients. One should be careful raising the head of the bed of the patient while the patient is eating. Another aspect to consider is if the patient cannot swallow at all. In this case, something must be done to either a) get the patient nourishment, or b) discontinue care. If the patient needs to get nourishment, a G-tube (gastric tube) will be inserted into the patient’s skin and goes into the stomach. That is a gastrostomy, which is more permanent. If the patient needs a less permanent G-tube, there is one which can go through the nose. This can get irritated easily if it’s a regular G-tube. There is a smaller brand of G-tube which can stay in for longer. However, those can also not stay in the patient permanently. The patient should get help when transferring from different locations. For example, if the patient is moving from the bed to the chair, he would need help. There are many ways with which incontinence can be dealt. For example, the patient could have timed restroom breaks. The patient should avoid catheterization at all costs. If the patient, for some reason, can’t empty his bladder well or it is causing skin breakdown, then the patient should get a catheter. The catheter should be changed once a month. Good handwashing techniques should be used when emptying the drainage bag. The bag should be kept lower than the bladder. There should be no kinks in the tubing. The bag should be emptied at least once in a 24-hour period. If the urine looks dark and concentrated, this should be duly noted. Also, after this observation, the nurse should advise the patient to push fluids. If the urine has a dark, cloudy look, the patient may have to be checked out for an infection. Thus, if the urine looks odd, it should be sent off to the lab. There, a full urinalysis can be done in order to rule out any infection. If there is ever blood in the urine, the nurse should make a note of this immediately. She should call the doctor and see what he has to say about it. “If the wound opening is not big enough for a wound swab to pass through, but there is concern that the wound is undermining, a venfl on cannula (with the needle removed) can be used to probe the wound. When the cannula comes into contact with tissue it will not go any further as it is too flexible and will bend on contact, unlike a finger or metal probe, and this will not cause trauma to the wound or pain to the patient” (How, 2010). Some elderly individuals have less incidence of decreased fitness in these areas than other individuals. In turn, some other older or elderly individuals show more decreases in cardiovascular fitness than representatives of the older mature years. As clients grow older, they are also at a greater risk to sustain injuries from more conflated conditions, such as the relationship between this client’s various health problems, including obesity, Parkinson’s, and perhaps dementia. However, across all age groups, those clients who have higher activity levels (walking, exercising) tend to have lower blood pressure, better muscle fitness and coordination, and more acceptable insulin levels. In determining what keeps some individuals healthy, it must be remembered that diet is important to consider as well as exercise. After symptoms of pain become less prevalent, this patient should be encouraged to change their lifestyle and behavior. “Pain or any change in pain is a key predictor of wound infection and is also one of the four cardinal signs for inflammation. Pain or the fear of pain also can influence the healing process by interfering with the immune response. Unresolved pain is often associated with delayed wound closure” (Management, 2010). Rates of depression are going to go up with these conditions as well.  Some elderly individuals have the physical ailment of a seizure disorder. They may receive little or no support from the children, and may be a retired veteran. Today in therapy situations, goals may differ with clients and screening measures. In a positive influenced definition of therapy, the meta-paradigm can also be correlated.  In terms of assessment, interrelationships of culture and heritage are taken into greater account.  A balance is sought between professional healthcare and the patient’s own understanding of care that may be culturally influenced.  Diagnosis also takes these factors into consideration, recognizing the stability of familiar resources.  Outcomes, as in the elderly, are considered to be based less on sick/well correlations than they are on the patient’s functioning within a supportive community outside of the healthcare institution. “Health care has the greatest meaning… person should refer to families group and communities; health is not distinct to any as many disciplines use this term; environment included events with meanings and interpretations given to them in particular cultural setting (sic)” (Health, 2000).  This type of care can be very emotionally taxing on a family. People get frustrated when they are “stuck” caring for their loved one, and they feel burdened by the fact that they must consistently take a shift to care for their parent, sibling, friend, or significant other. In cases of dementia, early detection is only possible through a full, direct, and knowledgeable relationship between the individual and their healthcare provider, healthcare worker, and/or nurse. In terms of accurate assessment, if the professional does not know what to expect by being well-acquainted with the individual and their history, they will be less likely to pick up on signals of change that are evinced with the onset of serious and threatening illnesses such as dementia. Considering the client’s age and state of dependence, abuse is also a risk factor. One study “found… that abusers were very likely to be dependent on the older person for housing and financial assistance. Indeed, only one-third of the abusers were financially independent of the abused elder” (Atchley, 2000, p. 399). Many elderly individuals are still worried about their position. They are undergoing emotional and psychological changes and coming to grips with the situation, as aging is a process that can’t be reversed. Those in home care situations like this client will eventually be relegated to, may be less likely to move into independent apartments or group homes than those placed in care facilities, and this difference takes into consideration the variable of severity of disability (i.e. even taking into consideration the fact that individuals in home care are less likely to be severely disabled, and thus more likely to be able to cope with independent living, moderately and even mildly disabled individuals are more rather than less likely to live in isolation from the community in a home care situation). The residential care situation establishes an environment, on the other hand, where “social relationships can be nourished through the establishment of community roles” (Seltzer et. al, 2001, p. 171) for these individuals. The argument that the patient should remain in the community, which is sometimes raised against care placement, may over look the ironical fact that caregivers’ understandable protectiveness of clients may cause them to keep them in a household situation, thus opting against community living alternatives. In a hospital care situation, “participants were supported to engage in community activities corresponding to the interests and talents discovered in an initial period of exploration” (Seltzer et. al, 2001, p. 171) in several studies. Overall problems in home care can be exacerbated by the fact that there is often too much paperwork and bureaucracy attached perhaps because of moving the patient from an institutional or residential to a home care setting. And some home care providers cannot keep up with this paperwork, so the need to implement technology and record-keeping that is efficient rather than unwieldy in this environment is the central argument. Home care should be simplified and technological solutions should be integrated to speed up the process for the patient. The necessary goal of fitness and physical well-being is important to develop in individuals during the developmental stages of their life as well as later stages of life in which individuals may be scaling down their activity level and getting older. It also must be kept in mind that obesity in general is a very serious problem, and that mass-media views that stress lifestyle choices and overeating as being the sole causes of obesity are, perhaps, not paying enough attention to some of these other factors that are more present in research literature. Obesity is, after all, categorized as a disease, rather than a lifestyle choice. In terms of national and local programs, weight loss strategies can suggest ways to work together and be more physically active as individuals, as families, and as a community. The main goal is a community based response that acts to solve the problem. This client needs such an intervention, once their heel wound is healed, so that they can have a better health future. Evaluation (Driscoll reflection—“Now What?” The patient needs to be maintained until their wound heals, and then given behavioral interventions to address their obesity, and home care to manage dementia and Parkinson’s. It is possible to give the patient milk, diluted fruit juices, and farinaceous foods. The patient’s diet should be light. The patient should not have meat more than once a day. Any kind of rich foods should be avoided. This includes duck, liver, sweets, and organ meats, which are prohibited. The patient should drink a lot of water. The patient should push fluids. With this particular patient, there are several problems that we have realized need dire attention. This case study focuses on several ailments, which will all be addressed here. The patient has gout. Gout is basically a problem wherein excessive uric acid is in the system. The drug for the gout is allopurinol. The furosemide is basically Lasix. It is a water pill which draws the moisture out of the patient’s system, and it is excreted in the urine. The sinemet is used for the Parkinson’s disease. The Prilosec or omeprazole is used to decrease the gastric secretions. This decreases the gastric acidity. The allopurinol is definitely used to reduce the effects of the gout. The paracetamol or Tylenol is used for pain. The pain with dressing time is typical and not uncommon. The nurse should arrange for the caregiver to give the Tylenol before the dressing change. Something stronger should be given if that doesn’t help. ‘The patient will not be comfortable and a good quality of life is not possible without prompt referral to the pain services. Adequate pressure relief cannot be achieved without repositioning, using appropriate pressure-relieving equipment and consulting with a physiotherapist. But most importantly none can be achieved without accurate assessment and good old fundamental nursing care” (Management, 2010) It is recommended that this patient should also receive palliative care as part of treatment. Palliative care eases the burden on hospital staff because it diffuses the burden to a larger audience. It does not just place the burden on staff members for care, but also spreads it to include the patient’s social support and family networks. This eases strain on professionals who need to improve turnover in the hospital-as-community provision model and makes the family more responsible. It eases the burden on the institution’s financial costs as well, because often the patient can be given information along with their support network on supporting caregivers and making transitions and life choices. It is less about providing expensive care through mechanisms and more about giving advice, so this is easier on the facility in terms of taking up fewer costs and less time as well. The end result is a situation in which palliative care eases the burden on staff as well as being cost effective, because it focuses more education and side than main treatment. The hospital nurse should also be concerned about the patient’s nutrition. Is the patient eating on a regular basis or is the patient avoiding meals? Then, there is the issue of the patient’s Parkinson’s disease. The nurse should assess how advanced the Parkinson’s disease is. Does the patient have the ability to swallow? This would mean that the patient might need feedings if he can’t feed himself. Perhaps the patient might need someone to be very patient with him during meals. Since the patient may have difficulty swallowing, this is a major issue. The patient may not be able to eat a lot of solid foods. If necessary, the patient’s food should be puréed. There is another idea which might be helpful to the caregiver. If solid foods are impossible to use with the patient, and perhaps puréed foods are even difficult, the caregiver could consider giving the patient thickened liquids. “Chronic wound pain is the persistent pain that the patient feels all the time, even when the wound is not being manipulated. Both non-pharmacologic and pharmacologic treatments can be used. Pain signals that are associated with tissue injury have an important function and are clinically important symptoms to acknowledge” (How, 2010). For the gout, the patient should rest his joint. This is in addition to his diet restriction and pain. For the sleep apnoea, the patient may need a mask. It might also be advisable for him to consider being on oxygen. The patient’s immobility may cause problems. He might not be able to walk and get out of bed. Another issue for the nurse to consider is if the patient is incontinent. This means he cannot control his bladder. The patient in this case may have to walk with an assistive device or use a bedside commode. With incontinence, the nurse should watch the status of the patient’s skin. Urine should be wiped away properly. The patient most likely should have an emollient on him to protect himself. Emollient is useful. It can protect a patient’s skin well from moisture and the elements. If the heel is black and not open, this is what most likely will happen. A nurse will put Betadine on the black heel ulcer to keep it dry. One doesn’t want to put any emollients on that. Hopefully it will slough off. The dressings should be done to reduce pressure. The heel should be padded for extra comfort. The foot should be elevated on a pillow. That is one idea to relieve any pain the patient might be having. If the patient is immobile, he may want to consider doing something extra. For example, the patient could use an alternating pressure mattress, in order to prevent pressure wounds. The patient should have regular routines with his caregiver. For example, in the morning, there should be some light calisthenics. Another regular routine besides calisthenics should be having regular mealtimes. The patient should have breakfast, lunch, and dinner at the same time every day. This will ensure that the patient’s restroom breaks are timed before or after the patient eats. This way, the patient will come full-circle. Another important thing to consider besides diet and exercise is that the patient should have something to occupy his time. For example, the patient may have certain shows that he likes to watch on TV. Ideally, the family may be able to make arrangements with an agency that gives aid to individuals who are in need of care but may not be able to afford professional help. Perhaps the family can appeal to public aid. If the patient is on Lasix, he might be showing signs of edema or swelling. The patient should be weighed periodically. This should happen if the patient is mobile enough to be weighed. If the patient is bedbound, ideally his joints should be put through some range of motion. Thus, the patient should have some kind of physical therapy. If the patient is immobile the patient should be turned regularly. Physical therapy is an important part of the healing process. Especially for the patient’s health, he needs to have regular movement. Physical therapy will improve the patient’s range of motion. It will also help him so that he doesn’t lose muscle mass. Usually, when a patient is bedbound, the hardest part of watching that patient deteriorate is that their body loses muscle mass. If this can be prevented at all, it should be. If home aides are costly to the client, the costly nature of health care in a residential facility, in terms of hospital stays and especially in terms of long-term care, for which many patients are not prepared, as mentioned. This is another way that the nurse can help the patient as an advocate. “As older people and their families have become more aware of the cost of long-term care, middle-class families have found ways of qualifying. In doing so, families have tried to avoid the harsh requirements of Medicated spend down—that is, impoverishing themselves by spending all income and assets to qualify” (Moody, 2000). With assistance, the patient still may be able to have aides. It is the nurses’ duty and part of the process to check into this for the client, because there could be a way to optimize the situation and give the patient what they want. And what they appear to want is a continuance of the situation n which they have home health aides, but an amendment of this situation which can keep the process affordable and accessible. Research supports include the substantiation of information culled from various representative sources that focus on the staffing element of the health care facility, and on “the development of a model of staff performance and the creation of self-reinforcing social communities in residential settings for persons with disabilities” (Baker et. al, 2000, p. 489). Here, the catchword is community. “Positive social interaction between staff persons and residents is among the most basic and important components of staff activity” (Baker et. al, 2000, p. 489) within this representative community. Traditionally, “Investigators addressing the frequency and quality of interactions have tended to look at the staff person as the unit of analysis” (Baker et. al, 2000, p. 489). This may not be the best outlook for future research, however, since “features of the environment outside of the staff person influence work performance as well” (Baker et. al, 2000, p. 491) in the patient-caregiver dynamic. REFERENCES Atchley, Robert C. (2000). Social Forces and Aging: An Introduction to Social Gerontology. Stamford, CT: Wadsworth Thomson Learning. Baker, D.J., Freeman, R., and R. High (2000). Resident-directed communication patterns in community homes for persons with disabilities. Mental Retardation, 38(6), 489-97. Billings, J (2000). Palliative Care. British Medical Journal. http://www.findarticles.com/p/articles/mi_m0999/is_7260_321/ai_66676927/print Gatchel, R. and M. Oordt (2004). Clinical Health Psychology and Primary Care. Washington, DC: APA. Moody, L. (2004). The home visit. Nursing. Reddy, M, R Kohr, D Queen et al (2010). Practical Treatment of Wound Pain and Trauma: A Patient-Centered Approach. An Overview. Ostomy Wound Management. Seifert, P.C. (2002). Ethics in perioperative practice--duty to foster an ethical environment. AORN Journal. Seltzer, M.M., Krauss, M.W., J. Hong, et. al (2001). Continuity or discontinuity of family involvement following residential transitions. Journal of Rehabilitation, 39(3), 181-94. Center to Advance Palliative Care (2007). http://www.capc.org. Best practice statement: prevention and management of pressure ulcers. (2009). http://www.nhshealthquality.org/nhsqis/files/PrimaryCare_PreventionAndManagementOfPressureUlcers_MAR09.pdf. Gerontological nursing (2009). http://www.discovernursing.com/jnj-specialtyID_257-dsc-specialty_detail.aspx Health education (2000).  Encyclopedia of Nursing andAllied Health.  Washington, DC:        Heineman.  HOW TO PROBE A WOUND DURING ASSESSMENT TO HELP DETERMINE TREATMENT OPTIONS (2010). MANAGEMENT OF A CAVITY PRESSURE ULCER THROUGH PRESSURE RELIEF AND NUTRITION (2010). Read More