Discuss the differences between acute and chronic wounds in terms of healing and management options; and with reference to Mrs Anita Bacash’s operative wound

Case Study:

Anita Bacash, aged 62 years, is a recently retired schoolteacher with a history of osteoarthritis. She is scheduled to have a total knee replacement shortly. Anita has found that the arthritic changes in her knees have made it increasingly difficult to perform her tasks as a physical education teacher. She also had to stop playing competitive tennis because of her pain worsening over the past three years. Anita has been on the waiting list for this operation for the past 18 months, as she does not have private health insurance and cannot afford to pay for the operation outright. Anita is divorced and lives with her 24 year old daughter in her two bedroom unit.

Pre-admission data:

Anita has tried many treatments for her osteoarthritis, including glucosamine, fish oil, acupuncture, and cortisone injections. She is currently on diclofenac 50 mg bd, with some effect; although she states that she is looking forward to “not having to take those tablets after the operation”.

Anita has been on hormone replacement therapy for the past 5 years. Anita wears glasses for shortsightedness, and was diagnosed with the beginning stages of glaucoma last year. She is on latanoprost (Xalatan) one drop in each eye once daily, but expresses fear about what her eyesight might be like in the future. Anita also continues to take a multivitamin tablet every day. Anita developed a rash on her body after taking amoxycillin 8 years ago, so is wary of taking antibiotics unless she has to.

Although she shares her unit with her daughter and cooks each night for both of them, Anita lives quite independently. She admits to the occasional glass of red wine with her evening meal, but hasn’t smoked cigarettes for four years.

Anita has now come in for her pre-admission interview. She expresses concern about the operation now that it is so close, and worries about how much help she might need when she gets home. Her daughter works fulltime, and often doesn’t get home until 7.30 pm.

Pre-operative data:

Anita’s assessment data and investigations pre-operatively were as follows: Vital signs: temperature 36.7ºC, pulse 84 beats per minute, respirations 18 breaths per minute, SpO2 98%, and blood pressure 130/75 mmHg. Height: 154 cm. Weight: 69 kg. Haemoglobin: 130 g/L; WBC: 11.25 x 109/L; Platelet count: 260 x 109/L; Fasting blood glucose: 4.2 mmol/L Na: 137 mmol/L; K+: 4.3 mmol/L; Cl-: 101 mmol/L; HCO3: 26 mmol/L; Urea: 6 mmol/L; Creatinine: 0.092 mmol/L INR: 2.3; APTT: 28 seconds, ESR: 22 mm/hour ECG: No abnormalities detected Xrays: Degenerative changes to both knee joints, consistent with diagnosis of osteoarthritis Anaesthetic Assessment: ASA physical status classification 2

Post-operative data:

Anita has now returned to the ward from the Post-anaesthetic Recovery Unit after 3.5 hours. She is drowsy but rousable, after having had a general anaesthetic. Her operation report states that a left total knee replacement (L) TKR) was performed. She has a 10 cm longitudinal wound on her left knee, closed with staples and covered with a semi-permeable film dressing. Anita also has a drain tube adjacent to the wound, and connected to a Provac drainage system. She also has a urinary catheter in place.

Oxygen therapy is in place via a mask at 4 litres per minute. Anita has an intravenous infusion of Normal Saline, and patient controlled analgesia (PCA) of morphine for pain relief. Anita has been commenced on intravenous metronidazole 1 gram 8 hourly. She is also to commence on a Clexane 40 mg subcutaneous injection once daily, and has an anti-embolic stocking on her right leg.

Anita’s assessment data on return to the ward were as follows: Vital signs: temperature 37.2ºC, pulse 68 beats per minute, respirations 16 breaths per minute, SpO2 98%, and blood pressure 115/60 mmHg. There is minimal drainage in the drainage bottle, and a small amount of haemoserous ooze along the suture line. Her urinary catheter is draining well.

Anita has been instructed to rest in bed for the next 12 hours, and has a Zimmer knee splint on her left leg. She is to commence her exercise program with the physiotherapist shortly.

Review the presentation and management of Ms Bacash ensuring you address the following questions:

 Discuss the differences between acute and chronic wounds in terms of healing and management options; and with reference to Mrs Anita Bacash’s operative wound

 Discuss the operative procedure that Mrs Anita Bacash has had (total knee arthroplasty) in relation to her osteoarthritis and future mobility.

 Explore the evidence underpinning the non-pharmacological management (non-surgical) of osteoarthritis that Mrs Anita Bacash has or could have utilised to relieve her pain and improve her quality of life

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