SUSIE WENDELBORN shares a successful case study of a category 2b skin tear which without the right treatment could have turned into a chronic leg ulcer.
Mrs S, a 95-year-old who lives in a rural town, came to stay with her daughter in order to see an eye specialist. Whilst staying there, Mrs S slipped on the carpet on the stairs and lacerated her right lower leg, lateral gaiter extending to the pre tib site.
The resulting skin tear was classified under the STAR skin tear classification system as category 2b: “A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is pale, dusky, or darkened”.
Mrs S was seen in the hospital ED and due to the extensive skin tear, her age and multiple co-morbidities, and polypharmacy admitted to the surgical ward for a surgeon’s opinion of management.
The surgeon requested the review by the wound specialty nurse and photo one (25/05/2013) shows the wound on that first assessment. It was approximately 20cms x 10cms in dimension.
Initial wound treatment in ED was to carefully cleanse the skin flap with warm saline, removing as much haematoma as possible, drainage holes put into flap to encourage further drainage and a primary dressing of Mepilex foam a safe dressing option to save the skin flap.
On assessment, Mrs S was diagnosed with venous insufficiency and the gold standard treatment is compression therapy (refer to ANZ Venous Leg Ulcer Guidelines).
A skin care plan and wound management plan was put in place from the surgical ward, with weekly dressing changes using Mepilex Ag as the primary/secondary wound dressing and compression therapy using Coban2 lite.
The choice of Mepilex Ag was to provide the antimicrobial cover and there would be no skin stripping with dressing removal and the sealing of the wound with the silicone minimising risk of maceration of wound margins and periwound skin.
Photo one taken at two weeks (11/06/2013) indicating enough skin cells from the skin flap to generate epithelium in the wound bed, and devitalised tissue lifting.
Photo two was taken at 13 weeks (27/08/2013) showing the wound almost healed.
The wound management plan remained the same using Mepilex Ag as the primary/secondary wound product and the Coban2 lite compression until week 13 then changed to a Mepilex Border dressing and a light compression stocking.
Along with the wound care and compression was the important skin care regime to reach the positive outcome.
The skin care regime consisted of after bandage removal using a soap substitute to wash the lower leg and irrigate or shower the wound with warm water. Care was taken to dry the skin well.
Mepilex dressing was applied to the wound. It was important there was no moisturiser on the periwound skin otherwise the safetac technology of the Mepilex dressing couldn’t conform to the skin pores. Once the dressing was gently placed on the wound and periwound then a Cavilon Barrier cream was applied to the surrounding skin to protect the skin before application of the Coban 2 compression bandage.
Mrs S Has consented to the publication of these photos and was thrilled with the healing outcome of her skin tear.
Susie Wendelborn is a specialty clinical nurse for wound care at NMDHB Wairau Hospital.