Cath Lab Digest

P roviding care to a patient with a complex wound can be challenging. When a history of diabetes, drug abuse, and apathetic self-care are factored into the wound management equation, hope for a positive outcome is further compromised. In this case, in addition to clinical management of the wound, the treatment plan required teaching related to wound care — early development and recognition of wounds, management of diabetes and its effects on wound healing, self care, nutrition, position changes, and referral to other social services for drug-related issues. An aggressive care regimen allowed the wound to heal better than originally expected.

Patient History

Mr. N, a 47-year-old single, ambulatory man with diabetes, was an illicit drug user and had a longstanding history of drug abuse. Another problematic social issue was that he had no fixed address. He was admitted to the care of a home health nurse and agency on June 13, 2003. When admitted, Mr. N had a pressure ulcer over the entire buttocks area (see Figure 1). He reported he was found “in a coma state” due to a hypoglycemic episode and hospitalized in the intensive care unit for 2 days. The admitting nurse was told only that the patient had a surgically debrided pressure ulcer. No other information or assessment information was provided by the discharge planner from the hospital.

Wound Diagnosis and Description

The admitting nurse assessed the open wound as a Stage IV ulcer of the bilateral buttocks, coccyx/sacral area, extending almost to the anus. The wound measured 20 cm long x 23 cm wide x 10 cm deep. Although the ulcer had been surgically debrided during hospitalization, it still contained 10% necrotic, yellow slough; 90% beefy red granulation tissue; and two large tunnels at the 2 o’clock and 7 o’clock positions. The ulcer had been present on admission to the hospital; it is speculated that diabetes, illicit drug use, lack of appropriate nutrition and fluid intake, poor personal hygiene, and an unknown time of immobility led to the development of this massive pressure ulcer.

Care Management

The care orders on admission were to cleanse the wound with antimicrobial wound cleanser and gauze. Then, an ionic silver hydrogel, followed by collagen particles, should be applied and the wound covered with a normal saline-moistened gauze and then abdominal pads secured with tape. The treatment regimen was daily times seven days, then dressing changes decreased to three times per week. Mr. N’s medication regimen included hydrocodone bitartrate/acetaminophen tablets (Vicodin, Knoll Laboratories, Mount Olive, NJ); gabapentin capsules (Neurontin, Parke-Davis, Morris Plains, NJ); resperidal (Paxil, Glaxo SmithKline, Philadelphia, Pa.); venlafaxine hydrochloride (Effexor, Wyeth-Ayerst, Philadelphia, Pa.); vitamin C 500 mg; and zinc sulphate 220 mg.

Mr. N frequently demonstrated an unwillingness to change his lifestyle to allow appropriate self-care. He rarely checked his blood sugars, did not eat regular nutritious meals, drank inadequate amounts of fluids, and spent much time positioned directly on his buttocks. During several skilled nursing visits, he refused to allow the nurse to check his vital signs, including temperature. During one home health visit, he had a fasting blood sugar of 61 at noon; he had slept in and not eaten anything for breakfast. His other fasting blood sugar readings were between 93mg/dL and 127mg/dL and random blood sugars ranged from 130mg/dL to 150mg/dL. Mr. N had febrile episodes with temperatures ranging from 100° F to 100.8° F. during the first week of treatment. Of note: Mr. N was not on diabetic or antibiotic medications.