ABSTRACT: There are many traditional methods used to treat wounds and, in most cases, a 'one size fits all approach tends to be employed. The ability to recognise the needs of different wound types and their stages of healing is a valuable nursing skill. Nurses should be encouraged to gain experience in managing wounds and trialing different dressings, wound products and techniques. This will enable better management, fewer complications and faster heating times. Continuity of care is paramount to achieving a successful outcome and will increase owner compliance and practice bonding. It will also increase job satisfaction for the nurse involved.
This is the first in a series of articles that charts the progress of wound heating using advanced wound management. This particular case focuses on the challenges which arose owing to the difficult location of the wound, and how these were overcome.
Introduction
Mouse, an 11-year-old domestic short haired (DSH) cat, presented with a large open wound on her right dorso-lateral lumbar area. The cause of the lesion was unknown, but a ruptured cat bite abscess was suspected. Initially the wound was going to be managed by leaving it open; but, as it was quite large, with a risk of contamination, a specialist opinion was sought. As a result of this, an unusual approach was taken and it was decided to dress the wound.
This article charts the progress of wound healing using a moist wound management approach and the challenges which arose when dressing the wound in such a difficult area.
Case diary
Day 1
A large, open, contaminated wound was present, the overall size of which was 2.7cm x 2.5cm (Figure 1). The wound was cleaned using a standard protocol (Table 1).
Figure 1: Day 1, post-clipping, cleaning and saline flushing |2.7cm x 2.5cm)
Owing to the location of the lesion, the patient was initially discharged with owner instructions to bathe the wound with saline and apply manuka medical honey (Activon, Advancis Medical) topically. Honey was chosen because the wound was infected and contaminated, and honey can aid debridement, is antimicrobial, antibacterial and helps maintain a moist environment.
An injection of long-acting antibiotic, cefovecin (Convenia, Pfizer) was given. A 15ml bottle of the NSAID meloxicam (Metacam Oral Suspension, Boehringer Ingleheim) was dispensed to be administered over seven days.
After further consideration, and seeking a specialist opinion, it was decided to manage the wound using dressings. So the owner was asked to bring the cat back to the surgery for this to be undertaken.
Honey was applied to the wound and a secondary hydrophilic foam dressing (Advazorb Plus, Advancis Medical) used. The foam dressing was held in place using eight skin staples, two at each corner (Figure 2). A leg from a pair of tights was used as a ‘body suit’ to help hold the dressing in place (Figure 3 & Table 2).
Figure 2: Foam dressing held in place with staples
Figure 3: Tights used as a body suit- to assist in holding dressing in place
The whole process was well tolerated by the patient. Table 3 gives details of how the dressings were changed and the wound assessed at each subsequent visit.
Day 6
The patient had removed the dressing after escaping from the house. The wound had improved and decreased in size and was now 2.3cm x 1.7cm (Figure 4).
Figure 4: Day 6, 2.3cm x 1.7cm
Healthy granulation tissue was present. The dressing was repeated, as before, using six staples.
Day 11
A huge improvement was seen. The wound was now only 1.1cm x 1.1cm and contracting well (Figure 5). The Advasorb foam dressing had stuck to the wound, so an alternative hydrophilic foam dressing was used (Cutimed Siltec, BSN Medical). This has a perforated silicone contact layer which gently adheres to wounds but is atraumatic on removal.
Figure 5: Day 11, 1.1cm x 1.1cm
Day 15
The patient had managed to remove the dressing again. The wound was healing very well and only a reduced, superficial area remained (Figure 6). The owner was instructed to leave the wound open, to bathe it twice daily with saline (1 teaspoon of salt to a pint of lukewarm water) and to apply the honey two to three times daily.
Figure 6: Day 15
Day 21
The owner had now just been using the honey for the previous two days. The wound had contracted further and was almost healed, 0.3cm x 0.2cm (Figure 7).
Figure 7: Day 21, 0.3cm x 0.2cm
Day 49
A successful outcome was achieved (Figure 8).
Figure 8: Day 49, fully healed!
Discussion
Owner compliance was very good in this case and the owner was willing to try new techniques. Stapling the foam dressing in place, experimenting with how many staples were needed, and learning how to fit the tights dressing were, for the author, all new techniques in wound management. If presented with a similar situation the author would be confident to do the same again.
When dealing with wounds it is sometimes necessary to ‘think outside the box’ and be willing to try new things. As the wound wasn’t under any great tension, the rate of wound contraction aided a faster healing time. On reflection, continuation of the dressing for a longer period of time may have aided a speedier conclusion to wound healing in the end stages. However, it was decided to leave it open at that stage as the wound was so small and the patient was not affected by it.
Continuity of nursing care in these cases is very important. Explaining dressing choices and how moist wound management works to the owners will mean you will find they begin to value the knowledge, expertise and advice that the veterinary nurse can provide when dealing with wound cases. This in turn increases client bonding to the practice.
The author followed the case through from initial presentation and found it very satisfying to see the dramatic results achieved without surgical interference. The owner was willing to bring the patient in for a final visit so the author could see the wound fully healed.
Author
Caroline Calder RVN MBVNA
Caroline qualified in 2001 after attending Myerscough College, whilst working in Carlisle. For the last six years she has worked at a small animal practice in Durham. Since attending a CPD course in 2010, she has developed a keen interest in wound management.
To cite this article use either
DOI: 10.1111/j.2045-0648.2012.00200,x or Veterinary Nursing Journal Vol 27 pp 303-306
• VOL 27 • August 2012 • Veterinary Nursing Journal