VOL: 102, ISSUE: 44, PAGE NO: 50
Peter Cooke, DipHE, RGN community nurse, Watford and Three Rivers PCT, Watford
Mrs Simmons (not her real name) is 85 years old and has a five-year history of chronic venous ulceration affecting her right leg.
When I first met Mrs Simmons, her leg ulcer was treated with an alginate dressing and a four-layer compression bandaging system. In the previous six months, she had detected an offensive odour from her ulcer and this had stopped her mixing with other people. The odour had got worse in recentweeks to a point where she described it as unbearable.
The ulcer had signs of infection including localised heat and erythema combined with a purulent discharge. The alginate did not absorb all the wound exudate and slight maceration was noted to the skin surrounding the wound.
Mrs Simmons also experienced chronic pain from her leg ulcers and regularly took paracetamol. However, this did not reduce the pain associated with dressing changes.
In order for effective wound healing to occur, a holistic approach to care needs to be implemented. This must include a comprehensive understanding of the wound-healing process and patients’ psychosocial needs. If all of a patient’s needs are met, the transition from ill health to health may proceed rapidly and more efficiently (Flanagan, 1997). The two areas of concern for Mrs Simmons were odour and pain associated with dressing changes and reducing these symptoms was more important to her than wound healing.
Living with a malodorous wound is devastating (Hack, 2003). Van Toller (1994) noted that malodour associated with skin ulceration can lead to serious psychological problems, ranging from general depression to becoming a virtual social outcast.
Mrs Simmons lives alone. She no longer socialised with others because of the smell from her ulcers and avoided physical interaction where possible.
The community nurses had actively encouraged Mrs Simmons to re-establish social interactions with old friends. However, Young (2005) observed that patients can interpret this type of encouragement as a lack of understanding by nurses of the effect that their condition is having on their life. Wilkes et al (2003) conducted a qualitative study on the effect of malodour on nurses and found that adverse feelings such as nausea were common. However, nurses hide these emotions from their patients to protect the patients’ feelings.
The community nurses decided that they needed to talk to Mrs Simmons about the odour and involve her in selecting a dressing product that was designed to alleviate or reduce the problem. The assessment identified that the wound was infected with beta-haemolytic streptococci and Staphylococcus aureus and a two-week course of systemic antibiotics was prescribed.
Wound odour is often a complication of bacterial infection and the presence of infection explained why Mrs Simmons had experienced a worsening of the odour in recent weeks (Hack, 2003).
Odour is subjective and is difficult to quantify accurately (de Laat et al, 2005). The wound assessment tool we used incorporates a crude odour tick chart using the categories ‘offensive’, ‘some’ and ‘none’. Van Rijswijk (1996) notes that in relation to wound assessment ‘it is better to regularly assess using the same, possibly less- than-perfect tool than to not assess at all’.
Mrs Simmons completed the first baseline assessment of odour before the dressing regimen was changed and before she started her antibiotic therapy.
It was anticipated that the odour would improve over several weeks with antibiotics. However, the community nursing team felt that Mrs Simmons would benefit from an immediate reduction in odour by modifying her dressing regimen. An activated charcoal dressing can be used in malodorous wounds (Thomas et al, 1998) and Carboflex was prescribed. This can be used as a secondary dressing on heavily exuding wounds in conjunction with a suitable primary dressing.
Mrs Simmons had recorded a definite decrease in the odour from her leg ulcer (from ‘offensive’ to ‘some’) when the charcoal dressing was first applied. She continued to record the malodour as ‘some’ until the third week of treatment when her antibiotic course was completed, when she recorded the odour as ‘none’.
Mrs Simmons was anxious and fearful of dressing changes. Briggs et al (2002) suggest that the emotional impact of pain varies from one person to another and may manifest itself as anxiety, sorrow or fatigue. Mrs Simmons stated that she ‘tenses up in anticipation’ of a dressing change in an attempt to prepare herself mentally for the pain and this autonomic response could have influenced her perception of painful stimuli (Eichenbaum, 2002). Mrs Simmons did not want to change her analgesia as she had tried numerous drugs in the past and had experienced various unpleasant side-effects.
A multinational survey conducted in 2002 by the European Wound Management Association (EWMA) reported that practitioners found dressing removal the most painful aspect of the dressing procedure for their patients (Moffat et al, 2002).
Mrs Simmons’ ulcer had been treated with an alginate dressing. When an alginate is in contact with wound exudate, the insoluble calcium alginate is partly converted to a hydrophilic gel which should easily be removed by irrigation (Thomas, 1997). Although the alginate had formed a gel, it remained very difficult to remove from Mrs Simmons’ ulcer. Soaking the gel with saline is a recommended method of removal (Heenan, 1998) but this was not successful. In fact, Thomas (1990) notes that removing alginate dressings by soaking is not always effective or painless. In practice it was not possible to peel off the gel because it disintegrated when manipulated by hand and the only way it could be removed was by gently and carefully wiping with gauze but this was painful.
The nursing team decided that if an alginate were to remain the primary dressing, the frequency of dressing change would have to be increased to reduce the risk of maceration to the surrounding skin (Clay and Chen, 2005). However, this was undesirable as it would also proportionally increase both cost and episodes of pain experienced in a week. A decision was made to use a hydrofibre dressing and it was hoped that the frequency of dressing changes would continue at a rate of twice a week.
The nursing team adopted a holistic approach by explaining what measures had been taken to minimise pain and they anticipated that this would reduce some of Mrs Simmons’ fears and anxieties (Briggs et al, 2002). Mrs Simmons was informed that her pain could be managed by using an alternative dressing, a hydrofibre, which is made of sodium carboxymethylcellulose. The fibres of the dressing absorb substantial volumes of wound exudate, forming a gel that is removed in one piece (Robinson, 2000). A comparative randomised study comparing alginates and hydrofibres demonstrated a significantly longer wear time for a hydrofibre than an alginate (Harding et al, 2001). The authors also found that 82% of people experienced no pain when a hydrofibre dressing was removed compared with 62% with the alginate, and the hydrofibre was less likely to adhere to the wound bed (Harding et al, 2001).
A visual numerical pain scale using a 0-10 rating system was selected to assess pain as it is easy to use and analyse (Choiniere et al, 1990). Mrs Simmons completed the pain chart immediately after every dressing change for the first four weeks of the new treatment protocol and the progress of the ulcer was evaluated using the established wound assessment tool on a weekly basis.
Mrs Simmons assessed her pain as eight with the alginate dressing (severe pain) but, by the end of the first week of using the new dressing, she noted an immediate reduction in pain (score of six). There was no further change in pain severity in the second week. However, in the third week, Mrs Simmons noted a further reduction in pain (score of four) and it remained at this level until the completion of the fourth week.
The focus of this case study was to evaluate the specific needs of a patient with compromised tissue viability and to develop an effective management plan in view of the findings.
Four weeks after a change in care, Mrs Simmons no longer feared dressing change, although she continued to experience some pain. She is regaining her confidence and now attends the leg ulcer clinic twice a week where she socialises with patients.
Briggs, E. et al (2002)Pain at Wound Dressing Changes: A Guide to Management. EWMA position document: Pain at Wound Dressing Changes. London: MEP.
Choiniere, M. et al (1990) Comparisons between patients’ and nurses’ assessment of pain and medication efficacy in severe burn injuries. Pain; 40: 2, 143-152.
Clay, C.S., Chen, W.Y.J. (2005) Wound pain: the need for a more understanding approach. Journal of Wound Care; 14: 4, 181-184.
de Laat, E.H. et al (2005) Pressure ulcers: diagnostics and interventions aimed at wound-related complaints: a review of the literature. Journal of Clinical Nursing; 14: 4, 464-472.
Eichenbaum, H. (2002) Learning and memory: brain systems. In: Squire, L.R. et al (eds). Fundamental Neuroscience. San Diego, CA: Elsevier Science.
Flanagan, H. (1997) Wound Management.London: Churchill Livingstone.
Hack, A. (2003) Malodorous wounds - taking the patient’s perspective into account. Journal of Wound Care; 12: 8, 319-321.
Harding, K.G. et al (2001) Cost and dressing evaluation of hydrofiber and alignate dressings in the management of community-based patients with chronic leg ulceration. Wounds; 166: 229-236.
Heenan, A. (1998) Frequently Asked Questions: Alginate Dressings. www.worldwidewounds.com/1998/june/Alginates-FAQ/alginates-questions.html.
Krasner, D. (1995) The chronic wound pain experience. Ostomy Wound Management; 41, 3, 20-25.
Moffat, C.J. et al (2002) Understanding Wound Pain and Trauma: An International Perspective. EWMA position document: Pain at Wound Dressing Changes. London: MEP.
Robinson, B.J. (2000) The use of a hydrofibre dressing in wound management. Journal of Wound Care; 9: 1, 32-34.
Thomas, S. et al (1998) Odour-absorbing dressings. Journal of Wound Care; 7: 5, 246-250.
Thomas, S. (1997)SMTLDressings Datacard. www.dressings.org/Dressings/sorbsan.html.
Thomas, S. (1990) Wound Management and Dressings. London: The Pharmaceutical Press.
van Rijswijk, L. (1996) The fundamentals of wound assessment. Ostomy Wound Management; 42: 7, 40-42.
Van Toller, S. (1994) Invisible wounds: the effects of skin ulcer malodours. Journal of Wound Care; 3: 2, 103-105.
Wilkes, L.M. et al (2003) The hidden side of nursing: why caring for patients with malignant malodorous wounds is so difficult. Journal of Wound Care; 12: 2, 76-80.
Young, C.V. (2005) The effects of malodorous fungating wounds on body image and quality of life. Journal of Wound Care; 14: 8, 359-362.