Electrical Stimulation: A Case Study for a Stage III Pressure Ulcer
Jill Allen, Pamela E. Houghton
Case History
Mrs. L. is an active 54-year-old widow with complete
T7/8 paraplegia following a traumatic motorcycle accident more than thirty
years ago. She has a university education and holds a full-time job as
a government advocate. This entails regular traveling throughout Southwestern
Ontario. She is involved in many organizations and attends church weekly.
She lives independently with her ninety-year-old mother in a single-family
dwelling and has been ulcer free prior to this incident. She enjoys excellent
health. She relies on assistance from Personal Support Workers (PSW) for
help with activities of daily living. Her usual routine includes self-intermittent
catheterizations every four hours and at least one daily water enema.
This means transferring more than twenty times every day.
Mrs. L. sustained a Stage III pressure ulcer on her
left ischial tuberosity following a traumatic transfer from wheelchair
to toilet. She was unaware of the extent of her initial injury. The injured
tissue necrosed and became infected requiring hospitalization surgical
debridement and IV antibiotics. Daily wound care consisted of saline irrigation
and gentle packing with saline soaked1/2 inch gauze and hydrogel as recommended
by the hospital wound specialist. Gauze 4x4’s were taped over the
packing using soft cloth tape. The ulcer measured 5cmx3cm, depth 0.5cm
with 3cm of undermining from 6-9 o’clock. Mrs. L. required the ulcer
healed in order to resume her busy life, but having paraplegia meant she
needed this wound closed as quickly as possible before her body would
start to decondition. The faster the wound closed, the shorter and easier
the rehabilitation phase would be for her.
A physiotherapist who was visiting Mrs. L. to assess
and review transfers knew of ES as a treatment option to speed up the
healing of pressure ulcers. Although the PT was trained in the use of
EST therapy, the hospital administration was reluctant to begin the ES
therapy since it was unknown whether the wound care treatment could be
continued in the community. Fortunately, they were not ES was available
from a private consultant working in the community but unfortunately was
not covered by CCAC. The treatment and its risks and benefits were explained
to Mrs. L. and she was interested and was able to afford daily half hour
treatments. An interdisciplinary team meeting convened in the clients’
hospital room prior to discharge. It included the client, wound specialist
from the hospital, physiotherapist consultant specializing in the treatment
of chronic wounds, hospital physiotherapist, community wound ostomy continence
nurse (WOCN/ ET author), and case manager from CCAC. Key issues addressed
identified during the meeting were:
- Pressure off-loading of wound.
- Reduce further injury by adjusting transfers –
assess and educate PSW and patient.
- Apply standard wound care practices must be followed
(clean, maintenance of a moist wound bed, debridement, protect peri-wound
tissue)
- Physiotherapist consultant to develop a treatment
protocol for the home
- Client to order equipment and arrange delivery
–
- ES to be applied at each dressing change done on
daily basis
- Physiotherapist consultant to train nurse doing
daily dressing changes how to set up ES and apply pre set parameters
- Need for continuity of care in the community by
having one or two nurses doing most dressing changes and apply ES.
- Regular reassessment by the physiotherapist consultant
to assess wound closure and adjust treatment parameters accordingly.
This was required on a weekly basis initially and subsequently occurred
bimonthly.
Pressure Off-loading
CCAC did not cover the cost of a pressure relieving
surface therefore the client rented and arranged the delivery of a hospital
bed with an alternating pressure-relieving mattress overlay to the home
on the day of discharge. A Foley catheter was left in situ. to decrease
the number of transfers required over the course of the day. Mrs. L. agreed
to limit her time up in her wheelchair for a short period in the morning
for bowel care, in the evening for supper, and prior to retiring for the
night, up again for bowel care if required. This plan would keep the number
of transfers to a minimum therefore decreasing the risk of friction and
shear on the wounded area. It would also prevent prolonged pressure on
the ulcer. She planned to continue spending the night sleeping on her
stomach in an effort to relieve pressure to her buttocks.
Although transfer techniques were assessed and recommendations
and education occurred while Mrs. L was in the hospital areas of tissue
injury developed in the wound bed periodically. Reinforcing that a transfer
reassessment of the client in her own home was essential. The Physiotherapist
observed transfer between bed to wheelchair and chair to toilet transfers
perofmred by Mrs. L. and her PSWs. Several recommendations were made to
minimize the risk of injury to ischial tuberosity , a few of which were
adopted by Mrs. L. and her PSW. She recognized that even once healed this
wounded area would always require special attention to prevent further
breakdown. She applied padding to the toilet seat for cushioning, ensured
her RoHo cushion was secure in her wheelchair to prevent slippage, and
removed any sharp edges from the cushion that could damage tissue.
Debridement
At the time of discharge, an area of undermined tissue
remained. We discussed further debridement, but discharge plans had been
initiated and the decision was made to send Mrs. L. home and observe the
progress of the wound. However, once home Mrs. L. started the arrangements
for the de-roofing herself. It took six weeks before this was finally
accomplished. Our team felt once the de-roofing was completed, closure
would be rapid. This delay in debridement decelerated the closure of the
wound and resulted in a frustrating time for client. Even though warned
beforehand that the wound would appear larger after the de-roofing, Mrs.
L. was disheartened by the increased size of the wound. We reassured her
that the wound healing would quickly resume and she would see progress
within a short time.
Dressing and Antimicrobial Therapy
The same dressing protocol initiated in the hospital
was continued. This involved packing the wound with hydrogel and saline
soaked gauze. Because of the location of the wound, we felt there was
a high risk for wound contamination. Therefore, following de-roofing of
the undermined tissue, we applied a layer of Nanocrystalline silver burn
dressing (Actiocoat, Smith&Nephew) moistened with sterile water to
the wound bed. Acticoat is a contact dressing recently shown to have antimicrobial
properties.16 This was covered by a layer of moistened gauze
followed by dry gauze 4 x 4’s and a foam (Allevyn, Smith&Nephew)
dressing for protection. We continued to utilize this dressing until closure.
Adjunctive Therapies: Electrical Stimulation + Ultra
Violet C
To apply the ES therapy the wound first prepared by
removing old dressings and irrigating the wound. The wound was packed
and the periulcer skin was covered using gauze previously soaked with
a mixture of saline and hydrogel, The gauze packing was then covered with
a 4 X 4 inch black carbon reusable electrode that had been covered with
hydrogel (Intrasite, Smith & Nephew). This active electrode was secured
in place over the wound using paper tape and attached to the machine (Dermapulse,
Rehabilicare Inc, Co.). This machine is a , a portable battery operated
machine specifically designed for treatment of chronic wounds It was set
to deliver 30mA of pulsed monophasic current at a frequency 128 Hz and
the polarity of the active electrode was alternated between positive and
negative charge each week. A large (10 X 10 cm2) self-adhesive dispersive
electrode was applied over intact skin located no closer than 6 inches
to the wound, over the trochanter area. Refer to Figure 1 for a photograph
of the electrode set up for ES therapy used in this case. Treatments lasted
30 minutes and were applied 5-7 times per week over the 12-week period.
Using this ES protocol local skin hyperemia was consistently observed
during and after the ES therapy. Following the ES treatment, the electrodes
were carefully removed. A barrier film was applied to the periwound tissue
to prevent skin stripping. Then a secondary dressing of gauze 4x4’s
was applied over the packing and taped in place with soft cloth tape.
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