Title

Positive outcomes of the holistic approach to wounds by an integrated multidisciplinary wound team highlighted by two case reports

Koren, E.A Yagoda, T (2017)

Aim

This paper comes to demonstrate an approach that involves critical thinking and holistic nursing which we will show their importance and apparent benefits. This approach is not a well established practice in the wound treatment arena of the community setting according to some nursing and medical studies and in our eyes during our day to day practice. While writing this paper we were keeping in mind the importance of nursing education in the Leumit HMO that these patients were treated at.

Method

The study was conducted by a home visit nurse and a tissue viability nurse in the home visit setting of Leumit HMO Yerushalayim. Two home-ridden patients of the Ultra-Orthodox community in central Jerusalem both have a Diabetes Mellitus diagnosis and are treated for peripheral venous disease by a vascular specialist MD.

First we would like to present the younger patient, S.M. a 56y. old Yeshiva student who is being treated for Insulin dependent Diabetes for the past 44 years and was taken care of by his late mother which passed away around 5 years ago. Since her passing, his HgA1c has risen from 7.5 mg% to a 13.2 mg% level upon admission due to his foot ulcer. On the day of hospitalization he was approached by a neighbor who turned his attention to a drip that came out of his left shoe, and suggested he should go to the hospital. In the ER his blood glucose level was 483 mg% and he had 3 ulcers on his left foot. Being treated with debridement and IV antibiotics he was discharged home, after a 6 week hospital stay.

The orthopedic surgeon recommended a 3 month course of antibiotics PO and daily visit to his neighborhood clinic. Due to his anxiety disorder which presents in refraining from leaving the house in fear of Hypoglycemia, his personal community nurse referred him to a home visit nurse. First physical assessment showed a: 1. Round 7 cm in diameter, 12mm deep, yellow sloughy wound, with visible tendons on the dorsal face of the foot. 2. Toe III is black and unsettled with yellow exudates. 3. A round, 25mm in diameter, superficial wound on the medial face of MTI, yellow dry slough. Initial treatment was soaking the foot in Povidone-Iodine solution twice a day. After a reassessment a week later, it was established that he is having difficulty in organizing the medication and foot treatment on his own. A TVN nurse was sent for reevaluation and it was decided that he will begin Medicinal Maggot treatment. He received 5 treatments which were not consecutive because it was the month of high holidays in Israel.

 In accordance with the regular practice in our clinic we had a monthly discussion regarding this patient in which we tried to find a family member that can help Mr. M in his daily treatment. We asked his brother and cousin to join the meeting and we set out a holistic plan which included a schedule of dressing  changes by family members and the nurse, an overall dietary assessment that should be followed by a time table to which we would like the patient to follow regarding blood sugar checks, meals and a dressing. This process was discussed with the patient himself and he talked to his personal nurse during a few sessions in the next week. The clinical status of the foot after losing his toe around a week after the maggot treatment and his lack of in house support of Insulin shots and blood glucose levels, it was decided to treat him with alginogel on a daily basis with the TVN nurse coming and applying the alginogel with a syringe in to the apparent caverns of the foot. During 4 months of alginogel treatment the wound lessened in exudates, showed a significant decrease in size and depth, including a regeneration of new flesh over the tendons and a full epithelization of the MTI wound. At this point he suffered from septic infection in the toe site and was hospitalized for a 10 day stay in which he went through sharp, bed-side debridement, twice daily. Today, 29 months later, Mr. S.M. has one 1cm wound on the dorsal face of foot and is receiving   a weekly dressing with silicone net dressing. We are still in a process of finding new ways to decrease blood glucose levels.

Rabbi S.Z.A.  is the second patient that will be addressed in this paper. He is an 81y. old man, living with wife and both are in a state of self observed well being, on the other hand in his medical chart there is a long list of different types of chronic diagnosis which include, among others: Diabetes Mellitus, Ischemic Heart Disease with mild CHF and mitral regurgitation, Peripheral venous disease and Mild Nephropathy. During the time of treatment he underwent major cardiac assessment and was given a new drug regime.

The TVN-home visit nurse was called to his house after he was treated for a 2 year old wound on the medial face of the lower bottom third of his right leg, by a infection specialist which recommended he wash his whole body with antiseptic soap and leave a damp gauze soaked with the same soap. After trying this suggestion for 6 months his son asked our nurse to come to his house. Physical assessment revealed both legs with edema and extremely dry skin. The wound was at around 1cm in depth, 11cm in length and 7cm in width, it was mostly dry and with a thin yellow layer. After the initial first two weeks of treatment with hydrogel and elastic bandages the patient requested to be allowed to stay with a simple dressing and to change it every as opposed to a twice weekly basis. Being that the wound started to show a major activity and increased exudates, the nurse asked to stay for at least two days with honey-alginate and super-absorbent dressing.

During our monthly meeting his wife and son were invited to join while he was on the phone with them most of the meeting. We discussed what would be the most beneficial way of dressing which will help him feel free to walk to synagogue or go to family weddings without feeling handicapped.  After going through ability assessment in order to see if he is able to manage a Negative Pressure Wound Therapy device at home, he was fitted with a VAC machine and the dressing was replaced by the TVN nurse every 72 hours.

After 7 weeks of NPWT, the wound started bleeding and he was sent to the ER, where a vein was cauterized and he was given a different set of anticoagulation therapy drugs. During his stay in the hospital a swab was taken from the wound and he began taking antibiotics PO. Upon his release, he was seen by the vascular specialist at the HMO clinic. The dressing was revised and in an effort to keep the wound from soiling he pants and socks even though he didn’t agree to be dressed with elastic bandages, and he was prescribed an alginogel of two different exudating types, one for the dry skin of both legs to be spread twice a day and the other on the wound itself. This regime was kept for another 9 weeks in which the size of the wound lessened to a superficial, red and small wound of around 15mm in diameter. At this point a silicon elastic wrap was added to insure a firm and flat scar.