Case 1 – Wound Healing

Dr, Gary Mumaugh – UNW St.Paul

Mrs. Peterson is a 65 year–old woman with a history of Type 2 diabetes mellitus. Even though she has been insulin dependent most of her adult life, she has enjoyed relatively good health, which she attributes to her regular self administration of insulin. She is moderately overweight and was diagnosed as being hypertensive 10 years ago. Her hypertension has been controlled since she was placed on a thiazide diuretic.

Mrs. Peterson was planning to drive to the market recently and discovered that her car would not start. After calling to have her car towed and fixed, she decided to walk three blocks to the market. Rather than change into her usual walking shoes, she wore the more fashionable dress shoes that she had put on earlier that morning. After she returned home, she removed her shoes and noticed a small blister on the bottom of her left heel. She felt no discomfort associated with the blister; in fact, she may not have noticed it’s initial appearance if she had not inspected her feet.

The following day Mrs. Peterson was alarmed to notice that the small blister had become a large open wound resembling a crater that was bluish black in color. For the next three das, Mrs. Peterson carefully cleansed her heel and covered it with sterile gauze. After four days, she noted that the wound was getting progressively worse, she reported to her family physician that afternoon, which was four days after the initial blister was seen.

Upon presentation to her doctor, Mrs. Peterson’s heel wound was 5 cm. in diameter, and the wound bed contained necrotic tissue. There was no evidence of angiogenesis or granulation tissue formation. She did have evidence of decreased circulation to her legs, and the pedal and posterior tibial pulses were not palpated bilaterally. Both feet were cool to the touch and her toes were slightly cyanotic. She had a mild temperature elevation of 100 degrees and her serum glucose was 360 mg/dl.

Wound and blood cultures were obtained. Her complete blood count revealed a leukocytosis. She was admitted to the hospital and placed on bed rest and started on IV broad-spectrum antibiotics while waiting for her culture and sensitivity reports. The wound was packed in saline-soaked kerlix gauze to facilitate debridement of necrotic tissue. Serum glucose was checked every four hours, and regular insulin was given according to a sliding scale. The wound culture reports were eventually completed and revealed a wound grossly contaminated with several species of gram-negative bacteria. Blood culture reports were negative. The wound showed no signs of healing after several days of IV antibiotics and wound treatment. A decision was made to perform a below-the-knee amputation to prevent a fatal systemic infection.

Mrs. Peterson underwent a surgery for a below-the-knee amputation ten days after the initial blister was noted. The amputation stump was closed by a skin flap and sutured with a long midline incision. The incision was covered with a petroleum gauze and soft padding. The entire stump was then wrapped with an elastic compression bandage. A drain was placed in the wound bed at the time of surgery. The orders were that the stump was to be unwrapped and inspected twice a day, and a new dressing would be applied, using sterile technique. Serum glucose was monitored every four hours, just as before the surgery. Mrs. Peterson was started on parenteral feedings and the usual postoperative practice of coughing and deep breathing exercises were started.

On the third post-operative day, the wound was unwrapped for a dressing change. The petroleum gauze quickly pulled away from the incision line and it was saturated with a mucopurulent drainage. The incision line was reddened and painful when palpated with a gloved hand. The drain is still intact with return of only a slight amount of serosanguineous drainage. Her temperature was 100.5 degrees and her white count was elevated. Her arterial oxygen pressure is 68 mm Hg. Mrs. Peterson is extremely depressed and withdrawn.

Case 1 – Wound Healing

Student Name Mailbox

1Which of the following processes of normal wound healing was impaired the most by this patient’s diabetes?

  1. Inflammation
  2. Collagen metabolism
  3. Epithelialization
  4. Contraction

2Explain your rationale for your answer to #1. ______

3. When this patient treated herself at home for three days, the wound represented an attempt to promote healing by

a. fibrin formation

b. primary intention

c. secondary intention

d. keloidal formation

e. third intention

4. Signs and symptoms of wound infection would include all of the following except:

a. pain

b. hypoxemia

c. purulent discharge

d. edema

5. Explain why this patient had discharges. ______

6. What is the purpose of the drain in the wound? ______

7. Why was additional debriding used along the suture line for the mucopurelent discharge? ______

8. What is probably one of the most essential nutrient during this patient’s phase of recovery in the hospital? ______

9. What is serosanguineous discharge and what does it indicate? ______

10. As this patient’s med-surge nurse, what would you do to address the fact that the patient is depressed and withdrawn? ______