VOL: 97, ISSUE: 03, PAGE NO: 9
Tracy Vernon, BA, RGN, is clinical nurse specialist (tissue viability), Doncaster Royal InfirmaryMeningitis has a 10% mortality rate, and 30% of survivors will sustain permanent defects, such as hearing loss, epilepsy, motor disturbances or hydrocephalus (Levin and Heyderman, 1991). Meningococcal septicaemia can also result in the development of haemorrhagic skin lesions (HSL).
Meningitis has a 10% mortality rate, and 30% of survivors will sustain permanent defects, such as hearing loss, epilepsy, motor disturbances or hydrocephalus (Levin and Heyderman, 1991). Meningococcal septicaemia can also result in the development of haemorrhagic skin lesions (HSL).
Eighty per cent of people with septicaemia develop such lesions, which can range in severity from petechiae - circumscribed small areas of intradermal bleeding up to 4mm in diameter - to ecchymoses, which are lesions with a diameter of 5mm or more (Brantzaez et al, 1983). This purpuric rash is associated with overwhelming infection with Gram-negative diplococcus or meningococcus, causing haemorrhage through toxic damage to capillaries.
These areas of reddish-blue discolouration most frequently develop on the trunk or lower limbs, sometimes forming vesicles filled with serosanguinous fluid. In severe cases the purpural areas come together, darken in colour and eventually become necrotic, leading to extensive tissue loss that may involve muscle and bone. This can result in the patient sustaining permanent damage.
Evidence to support the use of modern dressings which provide a moist wound environment, generally regarded as a pre-requisite for rapid, uneventful wound-healing, is currently limited. Such lack of documented evidence in relation to the management of MSLs poses a dilemma for health care professionals aiming for optimum treatment measures (National Prescribing Centre, 1999). However, the following case study illustrates how a practical step-by-step approach can be of benefit in such situations.
Katie Reed was an 11-year-old who contracted meningitis. In the acute phase she was treated in intensive care where she required ventilation, inotropic support, steroid and antibiotic therapy. Once her condition had stabilised Katie was transferred back to her local hospital where she presented with a florid meningococcal rash over her lower limbs which were reddish-blue in appearance.
Initial assessment by the tissue viability nurse established that Katie had more than 20 HSLs over the lower part of her body. These lesions varied in size, the largest being 5cm square. Close examination revealed that the wounds were moist in appearance and had been leaking moderate amounts of haemoserous fluid.
It was decided that an alginate dressing was the most clinically appropriate for these wounds. Sorbsan ribbon was laid into the cavities of the lesions and covered with an occlusive dressing. The benefits of using an alginate dressing is that it will typically absorb up to 15-20 times its own weight in exudate. This dressing combination continued until the exudate levels reduced when further treatment decisions had to be made. During this stage the smaller of the wounds had healed and the remainder had reduced in size.
The composition of hydrocolloid dressings creates an optimal environment for fast healing (Bale and Jones, 1997). Hydrocolloid sheets are occlusive and therefore permit healing without risking wound contamination from the outside environment (Jones and Milton, 2000). An additional benefit of this type of dressing in this instance was that it allowed Katie to have a bath or shower without having to remove them.
Although the ward nurses initially felt challenged as to how to provide the best care for Katie, a positive outcome resulted as a consequence of the dressing combination selected.
Nurses may, at times, be faced with wound care situations they have never dealt with before. To ensure that the patient receives the most appropriate care they must assess both the patient and the wound, using a holistic approach. This assessment, in conjunction with a review of the literature surrounding the wound care product, will in most circumstances allow the practitioner to make an informed choice as to the appropriate management for the wound.
While it is fundamental that nurses ensure that their practice is evidence-based, practitioners may find that situations arise when a common-sense approach is needed.