The case study will present a case of an immobile patient, who had a recurring pressure ulcer over the left ischium after flap surgery. Appropriate repositioning could not prevent the pressure ulcer.
The wound assessment is performed by using the Triangle of Wound Assessment, which is a holistic framework that integrates the three areas of the wound (wound bed, wound edge and periwound skin) as well as the patient and their social context (Dowsett et al 2015)
After doing the initial wound assessment and creating management goals, surgical debridement was performed 3 times within 6 days, and Biatain Silicone Sacral was used. After 8 days, granulation tissue was present in the wound bed. The dressing was changed every two days for the first 20 days; thereafter, it was changed every third day. The dressings exudate management and conformability to the wound bed protected the periwound skin and the wound edge from maceration. Granulation and epithelial tissue was observed, which reduced the wound size.
The wound size was reduced by almost 50% within 29 days.
The Triangle of Wound Assessment is a holistic framework that provides a systematic approach to wound assessment. By using the Triangle of Wound Assessment, correct wound assessment can lead to correct management plan and treatment options. The Triangle of Wound Assessment is a simple and systematic approach to wound management which can be used in clinical practice.
For this case, Biatain Silicone Sacral was an optimal wound dressing choice for this individual’s pressure ulcer, both from a wound management perspective and on aspects of cost effectiveness.
Dowsett C, Drouard M, Harding KG (2015 Triangle of Wound Assessment Made Easy). Wounds International May 2015 available from www.woundsinternational.com