Case Study
Introduction:
Chronic wounds refer to wounds that fail to progress through an orderly and timely sequence of repair, where healing has not been realized in a predictable time frame (Widgerow, 2009:9). Unfortunately with the burden of a Chronic wound debridement is commonly used in order to prepare the wound bed for possible healing. This is often a timely and costly process.
Although there are different methods available for debridement of a wound, surgical debridement is used as the fastest way to obtain a viable wound bed and promote healing (Baranoski & Ayello, 2012). However, sometimes patients co-morbidities contra-indicate surgical debridement under anaesthesia.
A factor that contributes to infection in a wound, according to the NERDS and STONEES acronym, is debris (Sibbald, et al., 2007, pp. 34-36). Therefore, the use of Veraflo™ Cleanse Choice as well as Veraflo™ instill therapy was used as treatment methods in this patient.
Methods:
By combining Vac Veraflo (Cleanse choice dressings as well as Veraflo), the aim was to achieve successful debridement and resultant reduction of bioload, in order to continue with normal Vac granufoam dressings and follow up with conventional wound care products, in a patient that wasn\\\\\\\’t considered a candidate for surgical debridement.
Results:
Successful debridement was achieved as well as a reduction in the bioload in the Chronic Pressure injury with the use of Veraflo dressings
Discussion:
The discussion of the patient as a whole as well as the wound will follow under the relevant headings.
Wound Classification:
Sacral Pressure injury stage 3 (NPUAP) (Mulder, 2017, p. 647)
Patient history:
A 67 year old female patient presented with a Sacral Pressure injury stage 3. She sustained the pressure injury initially due to her co-morbidities, including Major Depression. Further wound breakdown occurred due to factors such as smoking, age, immobility, Pneumonia, unhealthy diet, and the use of medication (Mulder, 2017, pp. 644-646).
She visited the Surgical clinic on an outpatient basis on 19 July 2019. She was referred for advanced wound care due to her being a high risk patient for not receiving anaesthesia due to previous complications.
The patient was diagnosed with Hypertension, Depression and Primary Progressive Aphasia and is currently receiving treatment. Other co-morbidities include an enlarged heart chamber and previous Myocardial Infarctions. She does not know the history of her childhood illnesses and has no known allergies. She had a back operation and a hip replacement within the past 5 years. The last time she was hospitalized was in May 2019 for Pneumonia and received a course of antibiotics. During this period she developed an ulcer on her Sacrum. She didn’t initially seek medical attention, until the wound regressed to a Stage 3 Ulcer.
She lives in a low socio-economic environment, residing in a sectioned part of a house including two small bedrooms with her husband, her daughter and Son-in-law. She is retired, but worked at a Medical Command as a manager of the financial department and in a hospital as an untrained nurse. Their monthly income is a Government grant, and this income helps support their daughter and husband living with them. Her diagnosis of Primary progressive aphasia impaired her cognitive abilities. She is very grateful for the care that she received, but her reaction to her illness left her feeling depressed and frustrated, as she was unable to mobilize independently.
The dietician was seen at the hospital to discuss her nutritional status. The patient has a compromised nutritional status. Her husband prepares all of her daily meals in their kitchen, using a microwave, stove, oven and pressure cooker. She has a fair appetite, but verbalized that she is very fussy when it comes to food. She is currently on a high protein diet to promote wound healing, but does not necessarily comply to the recommended standards. The dietician has prescribed a protein supplement namely Protifar to enhance adequate protein intake. She also takes supplemental Folic acid. She drinks more or less 6-8 glasses of fluids throughout the day, consisting of cold drink, coffee/tea or water. See table below:
| Dietary intake: | Type: |
| Carbohydrates | Pasta, bread and potatoes |
| Protein sources | Chicken, pork, eggs and seldomly fish |
| Milk and milk products | Full cream milk and Cremora |
| Fruits and vegetables | Apples, cabbage and carrots |
| Fats and oils | Sunflower oil and butter |
| Snacks | Chips and crackers |
She weighs 64kg and her length is 1.63m, which gives her a Body Mass Index (BMI) of 24.2kg/m2. Therefore, the patient’s BMI ranges within normal limits which indicates that she has a low risk for disease (Brazier, 2019).
The patient struggles with regular daily activities and only exercises when mobilising. She has an impaired sleeping pattern, due to her current health status. She suffers from brain atrophy which causes incontinence. She is fully-dependent on her husband for all her health-related, hygiene and self-care needs. For example, her husband gives medication as prescribed, gives full bed washes and accompanies her to the bathroom. She enjoys watching television and smokes for relaxation during the day.
Initial assessment and therapy:
A total of 8 weeks of treatment was observed for the purpose of this Case Study. Treatment consisted of 3 weeks of therapy with Veraflo™ Cleanse Choice dressings in order to debride the wound. Thereafter another 2 weeks of Veraflo™ instill was done, before continuing with normal V.A.C.® therapy for another 3 weeks.
On the initial visit we discovered the wounds duration is 6 weeks according to the patient. A full wound assessment was done on Friday the 26 July 2019 and the wound was in the inflammatory phase of healing. A tracing was taken and measurements were as follows:
Length 110mm,
Width 45mm,
Depth 23mm and size 4950mm2.
Instill fluid: Saline (NaCl 0.9%)
Vac Veraflo™ settings:
Pressure -125 mmHg
Instill volume 30 ml
Soak time: 15 minutes
Vac therapy™ setting: 3 hours
The wound has an offensive smell and the patient only has pain during dressing changes with a pain score of 6/10. There is 10% viable tissue and 90% non-viable tissue. NERDS show a score of 3/5, high level of exudate, debris and smell indicating a possible local infection. The appearance of the wound bed is sloughy/yellow fibrinous tissue. Proximal rolled edges because of 1200-14h00 undermining. Surrounding skin is intact.
V.A.C.® dressings were done at home and only at the wound clinic when the Surgeon needed to evaluate the wound.
Assessment week 2:
Wound is in the inflammatory phase of healing. Low levels of Seropurulent exudate was present. Offensive smell still present. Pain score 6/10 on dressing changes.
- Length 110 mm
- Width 45mm
- Depth 25mm
- Instill fluid: Saline (NaCl 0.9%)
- Vac Veraflo™ settings:
- Pressure -125 mmHg
- Instill volume 30 ml
- Soak time: 15 minutes
- Vac therapy™ setting: 3 hours
- 70 % non-viable tissue, 30 % viable tissue.
Assessment week 3:
Wound is in Proliferative phase. Granulation tissue noted. Low levels of seropurulent exudate present. Offensive smell on dressing removal. Decreased pain score 2/10.
- Length: 100 mm
- Width: 40 mm
- Depth 15 mm
- 100% viable tissue present.
- Instill fluid: Saline (NaCl 0.9%)
- Vac Veraflo™ settings:
- Pressure -125 mmHg
- Instill volume 30 ml
- Soak time: 15 minutes
- Vac therapy™ setting: 3 hours
Assessment week 4:
Proliferative phase of healing. Low levels of seropurulent exudate present. Offensive smell on dressings. Pain score 2/10.
- Length: 100 mm
- Width: 40 mm
- Depth: 14 mm
- Instill fluid: Saline (NaCl 0.9%)
- Vac Veraflo™ settings:
- Pressure -125 mmHg
- Instill volume 30 ml
- Soak time: 15 minutes
- Vac therapy™ setting: 3 hours
- 100 % viable tissue.
Veraflo™ Cleanse choice discontinued. Commenced with Veraflo™ dressings.
Assessment week 6:
Proliferative phase of healing. Serosanguinous fluid exuding, low levels. Not offensive. Pain decreased to 4/10. Veraflo™ discontinued. Normal V.A.C.® granufoam dressings commenced.
- Length: 65 mm
- Width: 30 mm
- Depth: 6 mm
- Pressure: -125 mmHg Continuous setting.
- 100 % viable tissue present.
Assessment week 8 (final week of treatment with Vac therapy):
Proliferative phase of healing. Total wound present for 13 weeks, of which 8 weeks different types of V.A.C.® therapy was used. Low levels of Serosanguinous fluids present. No pain on dressing change. No offensive smell noted.
- Length: 44 mm
- Width: 25 mm
- Depth: 4 mm
- 100% viable tissue.
Progress and follow up:
The patient is currently on conventional wound treatment. She is treated at home. This is a healable wound.
Conclusion:
The case study showed the effectiveness of V.A.C.® Veraflo™ Cleanse Choice dressings as a successful method of debridement. It was a vital step to pave the way for stepdown to conventional therapy, by incorporating Veraflo™ and V.A.C.® granufoam dressings with Veraflo™ Cleanse Choice therapy.
Furthermore the treatment is cost effective due to no hospitalization being required and more comfortable for the patient by treating her in her home environment.
References:
Baranoski, S. & Ayello, E. A., 2012. Wound bioburden. In: J. A. Kowalak & J. Munden, eds. Wound Care Essentials: Practice Principles. New York: Lippincott Williams & Wilkins, pp. 93-97.
Brazier, Y., 2019. Measuring BMI for adults, children and teens. [Online]
Available at: https://www.medicalnewstoday.com/articles/323622.php
Mulder, M., 2017. Integrated Fundamental Nursing. 2nd ed. Cape Town: Pearson.
Sibbald, G., Woo, K. & Ayello, E., 2007. Increased bacteria burdeb and infection: NERDS and STONES. Wounds, 3(2), pp. 34-36.
Widgerow, A. 2009. Deconstructing the Chronic wound. Wound healing Southern Africa, 2(1): 9-11