Case Study

This is the case study of an aged resident under clinical placement. Permission was obtained from the clinical facility with regards to obtaining information about the patient. This is the case study Mr. Stephen Jones. He is a 70-year-old individual suffering from diabetes, which is the reason for his impaired skin integrity and nutrition imbalance problems. He had recently undergone an open cholecystectomy for removal of his gall bladder. Due to his existing condition of diabetes mellitus, he is suffering from impaired wound healing.

This essay will give a description of the patient and the medical conditions associated with him. Along with this descriptions will be given about the clinical characteristics of the wound, treatment aims, wound management plan, among others. Finally, a nursing care plan will be provided in a prescribed format.

Diabetes is generally associated with impaired wound healing (Mirza & Koh, 2015). There are various factors that lead to impaired wound healing in diabetes. These are impaired production of growth factors, decreased angiogenesis, altered immune response, nutritional imbalance and decrease in the rate of wound contraction (Anderson & Hamm, 2012).

Pain and stress are important contributors of delayed wound healing. Pain can result due to the wound itself or may be caused by some treatments. Patients with impaired wound healing suffer from nociceptive pain, which is characterized by a persistent ache. This is mainly caused due to tissue damage and is also associated with neuroceptive pain, which is characterized by a stabbing pain sensation. The neuroceptive pain is caused as a result of nerve damage. Moreover, the psychological impacts associated with delayed wound healing involves depression as well as low self esteem. The patient in the treatment facility also suffers from poor mental status and depression related to pain caused due to impaired wound healing. Impact of pain associated with wounds include stress and other negative emotional outcomes like fear, anxiety, depression, among others (Upton, 2012). 

Wound healing is termed as a complex biological process that is involved in restoring the integrity of tissues. The physiology of wound healing can be divided into 4 distinct stages. These are haemostatsis, inflammation, proliferation and tissue modeling. Haemostasis is linked with exposure of the subendothelial layers of the vessel wall with blood components. Platelets are involved in this process. They adhere to the vessel wall, aggregate and form a haemostatic plug. Along with these the complement and coagulation cascades are activated. Activation of prothrombin within the tissue leads to formation of thrombin, which in turn cleaves the fibrinogen to form fibrin, which in turn helps in clot formation. The inflammation stage involves the macrophages, neutrophils and lymphocytes. Bradykinin and anaphylatoxins like C3a and C5a increase the permeability of the blood vessels leading to the entry of the monocytes and the neutrophils to the region of the wound. Histamines and leukotrienes are also released from mast cells. Within the wound the neutrophils kill bacteria by secreting antimicrobial peptides, proteases and generation of reactive oxygen species. Macrophages secrete cytokines and other peptide growth factors. These growth factors are VEGF, PDGF, bFGF, among others (Barrientos et al., 2014). They enable wound healing by initiating the synthesis of extracellular matrix, cellular proliferation and angiogenesis. Lymphocytes also produce cytokines and stimulate cytolytic activity. The proliferation phase is characterized by degradation of the platelet and fibrin matrix, invasion of endothelial cells and fibroblasts. This phase is also characterized by ECM deposition, re-epithelization and formation of new blood vessels. The remodeling phase is characterized by ECM turnpver along with significant reduction in cellularity. Scar formation is the ultimate step in the physiology of wound healing (Hämmerle & Giannobile, 2014).

Factors Affecting Impaired Wound Healing

The aetiology of impaired wound healing is associated with various factors. These include diabetes, infection, drugs, nutritional problems, tissue necrosis, hypoxia, excessive stress on the wound edges, low temperature or the presence of another wound. Impaired wound healing is one of the effects associated with long-term diabetes. Diabetes causes decreased arterial inflow and sensation, which in turn affects wound healing. Improper control of diabetes can affect wound healing by causing decrease in cardiac output, impaired phagocytosis by polymorphonuclear leukocytes and reduced peripheral perfusion (Wong et al., 2015). In this case study, long term diabetes is the principal cause of poor wound healing observed in the patient. 

Wound bed can be defined as the base of a chronic ulcer, laceration or burn. Wound bed preparation is an overall approach to achieve optimum wound healing by removing various barriers. Wound beds needs to be enriched with blood vessels, be uninfected and show no presence of necrotic debris. This in turn helps in proper wound healing. Wound bed preparation is based on the concept of ‘TIME’, which includes tissue debridement, infection or inflammation, moisture balance and edge effect. Tissue necrosis can be managed by surgical debridement, dry dressing, among others. Restoration of bacterial and moisture balance is also essential for wound healing (Sibbald et al., 2016).  

Wound measurement is an important part of wound assessment and techniques are present to measure various wounds. The most common method is the linear measurement also called the ‘clock method’. The length, width and depth of the wound is measured in centimeters. During the measurement the wound is considered as the face of a clock, while the head is always meant to be at 12 o’ clock, while the feet is meant to be at 6 o’ clock (Shah, Wollak & Shah, 2013).  

The Periwound skin is the tissue that is found or is present surrounding the region of the wound. Periwound forms the immediate barrier as it is present surrounding the wound bed. It can perform functions like absorption, protection, excretion, secretion, sensory perception, thermoregulation, immunity, among others. Periwound issues can lead to burning, itching, pain, rashes, changes in skin integrity, erythema, among others (Dowsett, Groemann & Harding, 2015). 

Wound exudates are fluids produced by the body as a result of tissue damage. Some of the types of wound exudates are serous drainage, sanguinous exudates, serosanguineous exudates, seropurulent exudates and purulent exudates (Dabiri, Damstetter & Phillips, 2016).

Physiology of Wound Healing

Treatment aims for impaired wound healing, impaired skin integrity and nutritional imbalance includes the prevention of skin breakdown by limiting the moisture content. These can be carried out by the use of barrier ointments, prevention of frictional or shearing forces that can affect the integrity of the fragile skin, promotion of proper nutrition to assist in wound healing. Medications for the treatment of impaired wound healing involve the use of growth factors, Phenytoin, prostaglandins, retinoids, vitamin A, C and zinc (In.gov, 2018). 

The wound management plan involves assessment of wounds and measurement of baseline observations like pulse rate, respiration, urinalysis, temperature and blood pressure. Optimization of the local wound environment by carrying out cleansing, debriding, management of bacterial and moisture balance. Reassessment of wounds to be carried out at every changes of wound dressing. In the presence of wound infection, wound s need to be swabbed and infected wounds must be treated topically by the application of Prontosan (Wirralct.nhs.uk, 2018). Antimicrobial dressings are to be reviewed and reevaluated. Nutritional status assessment by using the MUST score and nutrition care planning following the evaluation of the MUST score (Sandhu et al., 2016).

Progress and follow up of wound healing is essential to determine whether the wound is healing in an expected manner. These involve the need of assessments and documentation in a timely fashion. The common parameters of wound assessment include determination of the wound size, depth, wound edges, presence of exudates, periwound skin, wound pain and odour, determination of tissue type like granular, necrotic or slough. Some of the assessment tools to assess wounds include Bates-Jensen Wound assessment tool, photographic wound assessment tool, among others (Woundscanada.ca, 2018).

Conclusion

This essay is a case study of an individual who suffers from impaired wound healing, impaired skin integrity and nutritional imbalance as a result of long term diabetes. Impaired wound healing is commonly associated with diabetes and can cause significant physiological and psychological problems, which have been observed in case of this patient. Thus, a proper nursing care plan is required in order to ensure proper wound assessment, management and treatment. 

Reference List

Anderson, K., & Hamm, R. L. (2012). Factors that impair wound healing. Journal of the American College of Clinical Wound Specialists, 4(4), 84-91.

Barrientos, S., Brem, H., Stojadinovic, O., & Tomic?Canic, M. (2014). Clinical application of growth factors and cytokines in wound healing. Wound Repair and Regeneration, 22(5), 569-578.

Dabiri, G., Damstetter, E., & Phillips, T. (2016). Choosing a wound dressing based on common wound characteristics. Advances in wound care, 5(1), 32-41.

Dowsett, C., Groemann, N. M., & Harding, K. (2015). Taking wound assessment beyond the edge. Wounds International, 6(1), 19-23.

Hämmerle, C. H., & Giannobile, W. V. (2014). Biology of soft tissue wound healing and regeneration–Consensus Report of Group 1 of the 10th European Workshop on Periodontology. Journal of clinical periodontology, 41(s15).

In.gov. (2018). Cite a Website – Cite This For Me. In.gov. Retrieved 7 January 2018, from https://www.in.gov/isdh/files/Skin_Integrity_Guidelines_T2.pdf

Mirza, R. E., & Koh, T. J. (2015). Contributions of cell subsets to cytokine production during normal and impaired wound healing. Cytokine, 71(2), 409-412.

Sandhu, A., Mosli, M., Yan, B., Wu, T., Gregor, J., Chande, N., … & Rahman, A. (2016). Self-screening for malnutrition risk in outpatient inflammatory bowel disease patients using the Malnutrition Universal Screening Tool (MUST). Journal of Parenteral and Enteral Nutrition, 40(4), 507-510.

Shah, A., Wollak, C., & Shah, J. B. (2013). Wound measurement techniques: comparing the use of ruler method, 2D imaging and 3D scanner. Journal of the American College of Clinical Wound Specialists, 5(3), 52-57.

Sibbald, R. G., Elliott, J. A., Ayello, E. A., & Somayaji, R. (2016). Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015©: wound care. Wound Healing Southern Africa, 9(1), 9-15.

Wirralct.nhs.uk. (2018). Cite a Website – Cite This For Me. Wirralct.nhs.uk. Retrieved 7 January 2018, from https://www.wirralct.nhs.uk/attachments/article/19/CP04ClinicalProtocolforWoundManagement.

Wong, S. L., Demers, M., Martinod, K., Gallant, M., Wang, Y., Goldfine, A. B., … & Wagner, D. D. (2015). Diabetes primes neutrophils to undergo NETosis, which impairs wound healing. Nature medicine, 21(7), 815-819.

Woundscanada.ca. (2018). Cite a Website – Cite This For Me. Woundscanada.ca. Retrieved 7 January 2018, from https://www.woundscanada.ca/docman/public/health-care-professional/bpr-workshop/165-wc-bpr-prevention-and-management-of-wounds/file