Appropriate selection of primary and/or secondary dressings can lead to optimal wound management but they must be compatible. Inappropriate dressing selection can delay healing trajectory and waste valuable resources
This case study describes the care of a middle aged man with an unusual grade 4 pressure ulcer (EUPAP 2009), who was cared for at home by his wife.
George Richmond (the patient’s name has been changed), aged 48 years, has had multiple sclerosis for 25 years and is cared for by his wife at home. He uses a wheelchair and needs help with activities of daily living. He also has type 2 diabetes, which is controlled with oral hypoglycaemics.
Mr Richmond spends most of the day in his wheelchair and is hoisted to use the toilet. To aid transfer, his wife left the hoist sling in place under his sacral area but Mr Richmond found this uncomfortable.
He developed unusual nodules across the coccyx area (papilloma virus had been excluded). These nodules gradually turned black and auto-amputated, but on a later occasion the area below them became necrotic and broke down (Fig 1) over a 2-3 week period.
Mr Richmond is an extremely proud man and insists on maintaining his dignity at all times and he refused to accept he had a pressure ulcer.
His district nurses made a referral to the tissue viability associate nurse and a full assessment was completed. The ulcer measured approximately 10cm by 10cm, but it was difficult to fully assess the depth due to necrotic tissue. A wound also extended down between the nodules and linked with the main pressure ulcer. Malodour was a major problem and Mr Richmond was distressed by it. A holistic care plan was agreed with the patient and his wife and included a review of manual handling equipment, bed, mattress and cushion and also support for Mrs Richmond, who had been the sole carer for 25 years.
Initially negative pressure wound therapy was considered but was unsuitable due to the unusual wart like lesions and close proximity of the pressure ulcer to the anus.
A wound swab was taken during the assessment and the results showed no significant growth. However, an antimicrobial primary dressing (Acticoat Absorbent) was selected as Mr Richmond was at risk of infection due to co-morbidities and possibility of faecal contamination. The secondary dressing (Allevyn Gentle Border) maintained a moist wound healing environment and controlled excess exudate resulting from breakdown and rehydration of devitalised tissue.
The dressing was initially changed daily but after three weeks malodour and exudate reduced significantly and the regimen was gradually reduced to twice weekly to coincide with Mr Richmond’s bowel patterns.
The initial assessment highlighted that the patient had a reduced appetite and he was prescribed nutritional supplements. His bed frame, mattress and cushion were replaced and this improved Mr Richmond’s comfort and enabled him to spend longer periods in bed to maximise pressure relief.
The wound began to improve when healthy granulation tissue formed and the size of the ulcer reduced two weeks after treatment started (Fig 2) and healed nine weeks after the initial assessment (Fig 3).
Outcome of care
- The aim was to prevent infection, contain exudate, reduce odour and heal the pressure ulcer. This was achieved in nine weeks.
- The nursing team gained Mr Richmond’s trust and he was able to accept help.
- Mrs Richmond regained some independence after 25 years as sole carer and this enhanced her quality of life.
This case study demonstrates the use of dressing combinations when treating cavity wounds. It is common to use a cavity filler and a secondary dressing to secure the filler in place, but it is important to consider how these products work and interact together.
Wound care products cost £2.3-£3.1bn per year (Drew et al, 2007), but there is evidence that they are used inappropriately and this has implications for safety and efficacy of care as well as wasting NHS resources (Benbow, 2004; Young, 1997).
As the properties of wound dressings differ, there is no single product which is suitable for all wound types or the different stages of healing. A flexible approach to selecting wound care products is needed to optimise the healing process.
Primary and secondary dressings are often required in clinical practice, but dressing selection should be based on a clear rationale with a planned outcome. An audit of dressing selection and use found the correct choice of dressing was made in only 48% of wounds and correct choice and use were identified in only 20% (Bux and Mahli, 1996)
Drew et al (2007) suggested that effective diagnosis, ensuring appropriate treatment and active measures to prevent complications would reduce costs for both patients and the NHS. They also noted that despite appropriate clinical intervention, many wounds became chronic, with 24% of patients having their wound for six months or more.
Harding (2000) identified variations in wound care practice with inequalities in care provided to patients. Patient safety should be a key consideration, ensuring that any dressing used is correctly applied according to manufacturers’ instructions and, where appropriate, that patients or carers are trained in changing the dressing. When different dressings are used in combination, clinicians need to be aware of potential interactions between them that might reduce effectiveness. Ousey and Shorney (2009) identified that appropriate selection of treatment based on the underlying cause and condition of the wound, and accurate documentation, are key indicators of quality of care.
Many wound dressings are available on the market, but robust evidence on the comparative effectiveness of products is limited. The most important factor in wound care is assessing both the patient and the wound. Following this assessment, it is essential to match the correct type of dressing to the wound.
Patients and their wounds must be reviewed regularly as wound conditions may indicate that a change of dressing is needed.
AUTHOR Ann Pardoe, RGN, is a tissue viability associate nurse at Handsworth Ave Medical Centre.