Transcript Document
Lower Limb Cellulitis from the Specialist Wound Service Perspective Catherine Hammond CNS/CNE The Specialist Wound Management Service • • • • Based in Christchurch Cover CDHB Nurse led Clinic and community visits • Rural clinics • Joint vascular and ID clinics • CNS and team wound nurses • Referrals from health professionals • Mainly assessment service • Collaborative team work • Research • Education Mrs B - Presentation • • • • • • • • • • • • 47 year old women Referred to SWMS by Vascular Surgeon Lives in Ashburton, DN’s dressing wounds Recurrent cellulitis and 2 hospital admissions Gross bilateral lower leg oedema Reduced mobility Discomfort Big legs since childhood Exacerbation lymphoedema 4yrs ago following cellulitis Chronic ulcers 2 years with recurrent wound infections Known to have ESBL Very low in mood Mrs B Past medical history • Lymphoedema • Lipodema • Atrial fibrillation • Hypertension • Hypothyroidism • Morbid obesity • Chest infection • Gastric reflux Medications • Digoxin • Cilazapril • Metoprolol • Loratadine • Legothyroxine • Omeprazole • Paracetamol • Oxycotin 20mg BD • Warfarin Mrs B – Stage 3 lymphoedema • • • • • • • Brawny skin changes Oedema non pitting Not relieved by elevation Deep skin creases Dry scaling skin Pigmentation No sign fungal toe or nail infection • Cyanosed toes Mrs B - Ulceration Right leg • superficial lateral gaiter • surface 21cm² • ↑serous exudate Left leg • Superficial anterior gaiter, surface 20.5cm • Deep medial thigh, slough filled ulcer Mrs B - Investigations • • • • ABPI right 1 biphasic ABPI left biphasic + Stemmer sign Monofilament 10/10 bilaterally Mrs B - Priorities • Educate Mrs B on lymphoedema • Support Ashburton CNS, teach CNS and DN’s lymphoedema bandaging • Teach Mrs B self manual lymphatic massage • Contact isolation for multi drug resistant organisms • Provide monthly review • Funding for hosiery for prevention Mrs B - Plan of Care • Sharp debridement thigh ulcer → honey • Antimicrobial AMD foam dressings to superficial ulcers • Bilateral compression toe to thigh (3m 2 layer) • Self manual lymphatic massage Mrs B - Outcome • Mrs B is now healed and waiting for compression hosiery • Funding of hosiery an issue • Pain free • Mobile and started driving again • Says ‘I’m getting my independence back’ • 6 months free from infections Miss J - Presentation • • • • • • • • Referral GP 59 year old women Spina-bifida – paraplegia Main carer 82 year-old mother difficulty managing Recurrent cellulitis - IV antibiotics Unable to lift legs independently Unable to wear shoes Unable to attend social group activities Past medical history Medications Congenital cerebral palsy – wheelchair bound Ankle surgery to remove bony ankle spur Recurrent cellulitis – IV and oral antibiotics Hypertension Leg cramp Cilazapril Paracetamol Quinine sulphate Social Lives with mother Very supportive sister lives nearby Usually attends various groups for social life Examination • Bilateral oedema toe to upper gaiter region • Skin soft • Slight posterior erythema, no cellulitis • No ulceration • No sign venous disease • Legs warm to touch • Bilateral pedal pulse present • Aching legs Investigations Doppler ratios • Right ABPI 1 • Left ABPI 1 • Signals – biphasic Definitive diagnosis DEPENDANT OEDEMA Main Issues Identified • • • • • • Recurrent cellulitis Risk of fungal infections Risk of leg and foot ulceration Social isolation Mother stressed and her health at risk The need to commence outside carer twice daily Management Plan • Legs washed in warm water and dueoleum ointment • Compression therapy using Coban 2 layer system • Change bandage twice week at clinic • Patient and mother taught self massage to thighs Day 4 Day 21 Outcome – 3 weeks • Dependant oedema controlled • Able to lift legs independently • Can wear shoes • Comfortable • Mother able to care for daughter • No further cellulitis • Measured and fitted with flat knit compression hosiery Mr B - Presentation • • • • • Referral from DN Chronic heart failure Bilateral lower leg ulcers Copious exudate soaking continence pad 24 hrs Loss of mobility – almost housebound Mr B – Heart Failure • Referral from DN • Chronic heart failure • Bilateral lower leg ulcers • Copious exudate soaking continence pad 24 hrs • Loss of mobility Mr B Past medical history Medications • • • • • • • • • • Lymphodoema Congestive heart failure Severe right heart failure Atrial fibrillation Hypertension Morbid obesity Alcohol excess Pulmonary hypertension Osteoarthritis Type II diabetes Frusemide 250mg once daily Inhibace Plus 1 daily • Carvedilol 6.25mg once daily Digoxin 250mcgs once daily • Warfarin according to INR Mr B - Examination • Non pitting oedema toe to nipple • Brawny skin changes • Pigmentation • Bilateral leg ulcers left and right gaiter • Copious exudate • No sign fungal nail or toe infection Plan of Care – reduce risk of cellulitis while getting heart failure under control • • • • • • Daily DN visit/report GP Weight BP/pulse Reduced salt intake Restricted fluids Redress legs with antimicrobial • Continence pads • Toe to knee dressings • Refer to Cardio-resp outreach team Mr A. Presentation • Aged 78 • Increasing lymphoedema over past 4 years • Recurrent cellulitis requiring systemic antibiotics • Discomfort • Very low in mood • Difficulty in walking • Unable to lift legs into bed • Wife terminally ill • Unable to cope at home • Advised to move to hospital level residential care • PMH Hypertension and enlarged prostate symptoms Examination • • • • • • • Bilateral oedema toe to knee Brawny skin changes Erythema, no cellulitis No sign of fungal infection No ulceration/lymphorrhoea Varicose veins Haemosiderin staining Examination cont. • Legs warm to touch • Bilateral pedal pulse present • Aching legs • No intermittent claudication • Good nutritional intake Investigations Doppler ratios • Right ABPI 0.94 • Left ABPI 0.91 • Signals – biphasic Monofiliment • 10/10 Stemmer sign + Definitive diagnosis VENO-LYMPHOEDEMA Main Issues Identified • • • • • • • • Recurrent cellulitis Risk of fungal infections Risk of leg/foot ulceration Pain Reduced mobility Loss on independence Unable to care for wife Imminent admission to hospital level care and possible parting from wife • Very low in mood Plan of Care • Massage nurse/patient • Legs washed in warm water and Dueoleum ointment • Compression therapy using Coban 2 layer system • Change bandages twice week at clinic • Individualized walking programme for calf muscle pump Outcome – 2 weeks • Right leg ↓ 15cm largest calf • Able to walk • Independent with getting into bed • Comfortable • Able to remain in home and nurse wife • No further cellulitis Oedema Reduction in the Elderly Day 4 Day 14 Key Messages • • • • • • Collaborative teamwork Work in partnership with the patient Determine underlying aetiology Control factors impacting on progress Address the patient issues Focus on quality of life Please don’t use the Specialist Wound Service as a last resort. Collaboratively we can improve patient quality of life, reduce hospital admissions and save our health service valuable dollar