By the time home health nurse Renetta Winkler began working with a 36 year old woman with multiple sclerosis, the patient had spent 3 weeks in a hospital and 4 ½ months in a nursing home due to infected Stage III and IV pressure ulcers. Back home, the ulcers continued to plague her immobile patient. Renetta chronicles the cumbersome, complicated treatments that led to her desperate patient to learn about a new wound dressing that could simplify her treatment and improve the quality of her life.
My patient was diagnosed with multiple sclerosis 16 years ago at the age of 20. Married with a 9 year old son, she had been working as a computer data reviewer when she began suffering complications from her progressive disease. Slowly losing mobility, she also began losing feeling in her lower extremities. Due to decreased appetite and difficulty swallowing, she became malnourished. She developed pressure ulcers on her ankles, feet and knees, for which she was successfully treated with NPWT and foam dressings at a wound care clinic. During this time she also developed bilateral deep tissue injuries of ischial and sacral areas, both wounds progressing to Stage III and IV pressure ulcers. After a short period in home care, she was hospitalized with a wound infection for 3 weeks, and then spent additional 4 ½ months in a nursing home. In July 2011, she was back at home under palliative care and that’s when she became my patient.
The local wound care clinic provided tube feeding, protein supplements, a gel foam mattress, and wound treatment which included irrigation with NSS, packing of the wound with alginate and covering it with hydrocolloid, on a 3 times per week change schedule. Monthly blood tests were showing persistently low levels of albumin and prealbumin despite the use of Prosource and 5 cans of Jevity 1.2 daily. Finally starting to take some food orally during the summer (even though her protein stores were poor) began gaining enough weight she had to start buying clothing two sizes larger.
My patient’s wound care had been managed by a local clinic, but was limited due to frequent appointment cancellations (by the patient). Between July 2011 and December 2012, her care consisted of the following:
July 2011 (week 1): Santyl applied to wound bed, dead space filled with alginate and covered with thin hydrocolloid.
July 2011 (week 4): Fibercol added to pink tissue, Santyl applied to slough, dead space filled with alginate and covered with hydrocolloid.
January 2012 (week 2): Santyl discontinued, wound bed covered with Fibercol, dead space filled with Aquacel and covered with thin hydrocolloid.
March 2012 (week 3): Fibercol discontinued due to increased slough. Dead space continued to be filled with Aquacel, and then covered with foam and secured with hydrocolloid due to increased exudation.
August 2012 (week 3): Wound filled with Mesalt and covered with Drawtex in an attempt to manage the increased drainage.
September 2012 (week 3): The patient made a decision to stop her wound clinic visits due to poor results and difficulty getting to the clinic. During the home visit, wound care physician stopped Mesalt and ordered Aquacel covered with Drawtex and hydrocolloid. The bilateral hip X-ray ordered by the physician showed damage of the head of femur and acetabulum bilaterally.
October 2012 (week 4): Aquacel was changed to Aquacel AG, covered with Drawtex and secured with hydrocolloid. A CT scan was ordered.
November 2012 (week 1): The patient developed a S/S infection and was prescribed a 5-day treatment that included irrigation with Dakin’s solution and daily application of gauze soaked in Dakin’s solution. She was then returned to Aquacel AG, Drawtex and hydrocolloid.
In December of 2012, after 17 months of deterioration, my desperate patient started looking for a more effective treatment on the internet and discovered Enluxtra. We requested a sample and started using Enluxtra immediately. We irrigated the wound with NSS, applied Enluxtra, filled the dead space over Enluxtra with Aquacel and covered with thin hydrocolloid (because the patient was sensitive to tape and transparent dressing). Previously, excessive drainage would loosen the dressing in the vaginal area, but with Enluxtra this never occurred, even when the slits were cut in it in an attempt to have Aquacel absorb the exudate vertically. We quickly stopped Aquacel because it remained dry.
With continued Enluxtra applications, the wound autolytically debrided and the drainage slowed to a containable rate. After the CT scan was performed, the radiologist, certain he was seeing osteomyelitis, sent my patient to the local rural ER, from where she was transferred to a teaching hospital in the city. There she was seen by an infectious disease and plastic surgeon who changed her treatment to NSS-moistened gauze changed twice a day, in accordance with the hospital treatment protocol. Osteomyelitis was ruled out after aspiration of both hips was performed. Even though the patient had the wounds for 2 years, the plastic surgeon, possibly influenced by the patient’s choice, didn’t feel that debridement and closure with flap and graft were appropriate, stating that the wounds were very clean and very chronic. After 4 days in the hospital, the patient returned home and also returned to using Enluxtra.
We had a few setbacks related to the dressing becoming saturated with menstrual blood and the fact that the gel foam mattress was not an appropriate offloading device for a person who is bedridden. The patient, trying to maintain a normal course of life and sharing a bed with her husband, resisted using a replacement pressure-relief mattress that requires a hospital bed. She refused alternating air, as well, due to a previous negative experience with this product. During the time she was in my care, she has gone through 2 gel foam mattresses and, by January 2013, her current mattress had a deep sinkhole in it. Despite my suggestions to go to an inpatient wound clinic or have a plastic surgery, my patient preferred to stay at home, trying to spend as much time with her family as she could instead of leaving for treatment.
In the 2 years that I have been caring for her, her progressive disease started affecting her speech, her vision in the left eye, caused weakness in the left arm and poor fine motor movement of the right arm. In addition, she continued having painful BLE spasms, bilateral ankle and pedal edema, foot drop, and bilateral contractures of the ankles, knees and hips. Struggling to offset the emotional impact of the progression of her disease, my patient has continued to try to be actively involved in child rearing, maintaining family finances, managing her private caregivers, and is developing a charity organization that helps people, isolated due to a home-bound status, to get out in the world.
As with many patients attempting to maintain a certain level of control in their lives, she has been somewhat non-compliant to doctor’s orders by remaining for good part of each day in Fowler’s position which puts a lot of pressure on her wounds. In light of the dramatic improvement in her wounds from using Enluxtra my patient’s emotional state and her quality of life in general have greatly improved as well. She now has a new incentive to be more compliant with offloading. Prior to the improvement in her wounds, she would only let me or her husband help change her position. As a result, she sometimes stayed in the same position for 12 hours or longer. She is now willing to allow her caregivers to help with changing her position. She is also considering switching to an APP mattress which should decrease the setbacks caused by pressure to the wound.
It has been encouraging to see the emotional progress made in a relatively short period of time following the improvement of her wounds despite the functioning deterioration. A better patient outcome doesn't just refer to physical conditions, but rather the status of the patient as a whole.
Renetta Winkler, CWON CHPN RN, is a member of the Visiting Nurses Association (VNA) of Western Pennsylvania.
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*All stories and photos are published with expressed agreement of the patients.