A 59-year old female with noninsulin-dependent diabetes mellitus, severe periph

A 59-year old female with noninsulin-dependent diabetes mellitus, severe peripheral artery disease, ahistory of tobacco abuse and a recent right transmetatarsal amputation (TMA) was referred to ourhospital-based outpatient department by her home health nurse. Her surgery was one month prior topresentation. During her intake visit with the foot and ankle surgeon, she recounted her post-surgicalinstructions to include “wash incision once daily with betadine.” The home health nurse had referredher back to the surgeon’s office with concerns that the surgical incision was not approximating beneaththe staples and wound closure strips.1. List and describe the different intentions of healing.2. What does “not approximating” mean?At that time, the surgeon removed all closure devices, leaving the wound open. He did not change thepatient’s care regimen. Assessment during her first visit to the clinic revealed trophic skin changes ofchronic ischemia, and non-palpable dorsal pedis (DP) or posterior tibial (PT) pulses. Capillary refill wassluggish. The contralateral limb presented similarly. The periwound was boggy and mottled, and thewound bed was a dry, dull red. Bone from the first metatarsal was visible, but appeared viable. Bothbone and tissue specimens were taken for PCR (polymerase chain reaction) plus culture and sensitivity,of which only the tissue revealed significant growth of pathogens; osteomyelitis was not suspected atthis juncture. The patient’s wound was covered with a moisture retentive dressing and she wasimmediately referred to the lower extremity vascular specialist at the neighboring heart institute, whereshe underwent successful, albeit complex, vascular intervention.3. What interventions would you anticipate to be included in the plan of care?4. What is the rationale for each intervention?Within an 8 week period, the client received targeted oral antimicrobial therapy and conservativewound care inclusive of sharp debridement, strict offloading, and dressings to promote moisture and2 | Pagehealthy tissue proliferation in the wound bed. The patient-centered plan also included glucose control,dietary modification to include protein supplementation, and smoking cessation. Despite all the abovemeasures, the wound continued to probe to bone, and showed little signs of healing.5. Define debridement.6. List and describe the different forms of debridement.After discussion with the foot and ankle surgeon and consideration of other options, she elected toundergo revision of the TMA. Incisional NPWT (negative pressure wound therapy) was applied in the ORand left intact for one week. The photograph shows the area after dressing removal. Incisional NPWTwas applied again as a bolster dressing, in efforts to support the injured tissue again for one week.Approximately 2 weeks later, the wound bed had improved considerably in appearance, but not indepth (still nearly 5cm deep at the most lateral aspect). The patient elected to receive an epidermalautograft (EA)1. The EA was transferred and affixed using a permeable foam dressing, and covered witha non-adherent contact layer and NPWT with standard black foam on low continuous suction(100mmHg), changed twice weekly for two weeks in the clinic. The permeable foam dressing with the EAwas not disturbed for 2 weeks.7. Define skin graft.8. List and describe the different types of skin graft.9. What are the nursing considerations for the client with an epidermal autograft?3 | Page10. What is the intention of healing for this client?A considerable difference was noted after application of the EA and NPWT. The distal “shelf” ofundermining was not probed, and an ionic silver-containing alginate powder dressing was applied to themacerated periwound. Collagen with silver and ORC6 and hydroconductive non-adherent dressing wereapplied to the wound bed, changed twice weekly in the clinic.11. What are the different types of dressings?12. What is the purpose of the alginate dressing for this client?The series of images below were taken at periodic intervals. At 5 weeks post-graft application:13. Below is an image at 8 weeks post-graft application. Note new hair growth to the dorsum of thefoot. What is the significance of this new hair growth?4 | Page14. The wound treatment changed to collagen with ORC and foam border once weekly. What is thepurpose of collagen?15. How will you describe and document the wound below, in terms of:a. Granulation tissue -b. Exudate -c. Eschar -Approximately 12 weeks post graft application, wound is completely epithelialized (difficult to see in theprevious image). Moisturizer and protective dressing were applied. At this time, the patient was sent toa prosthetics and orthotics specialist for fitting of a toe filler and custom diabetic Health Science Science Nursing PREL 3355 Share EmailCopy link Comments (0)

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