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Supporting the healing process

by
01 June 2016, at 1:00am

Nikki Cumberbeach recalls a recent case of wound management in a greyhound and suggests it is nurses who are ideally placed to take the lead

VETERINARY NURSES LOVE A GOOD WOUND. Anything that can be squeezed (the more disgusting the expelled contents, the better) can cause fights between who can do the deed (I’ve seen it happen!) – it is just such a satisfying experience to see a painful abscess shoot smelly pus across the exam table and the cat breathe a sigh of relief at the pressure being released.

It never ceases to amaze me the amount of pus that can accumulate. I also find it interesting how this mechanism works, and fascinating as to how rabbits create cottage cheese pus as opposed to the creamy yellow pus from cat bite abscesses – all to do with how their neutrophils engulf bacteria.

Pus has also been on my mind just recently as my horse has had a foot abscess which after bursting out at the coronet band is still draining weeks later.

But I digress – I wanted to talk about wounds as a case we had in recently reminded what an important part us veterinary nurses can play in wound management.

Stanley was brought in to us one evening by his owners. They had returned from a trip out and were greeted by an excited Stanley who ran across the shingle gravel drive to greet them and promptly fell over.

This sounds like a fairly innocent incident, but Stanley was a greyhound. Greyhounds have thin skin and the grazing that occurred from the fall was not only extensive but full skin thickness, and Stanley presented to us with a posterior which made us all wince and a degloving type injury to his tarsus.

Extent unknown

His owners had not realised the extent of his injuries, thinking he had just grazed himself and decided initially that the best course of action was giving him his evening meal to cheer him up!

This unfortunately meant we were unable to anaesthetise Stanley on presentation to sort the injuries and the “golden hour” for dealing with the wounds had already passed by the time his owners realised he was in discomfort and came to us.

Initial treatment was pain relief, antibiotics and a brave Stanley let us lavage and clean the wound, conscious to try to remove some of the contamination before we were able to do a proper job. I have to say in my experience greyhounds tend to be wimps – often even before we have done anything! Stanley, however, was a particularly stoic individual.

When anaesthetised, the wounds had KY jelly applied, were clipped, with an initial cleansing with dilute iodine and then copiously lavaged with saline.

The saying that “dilution is the solution to pollution” is so very true and I believe cannot be overdone. A minimum of 100ml of lavage per cm of wound should be used as a guide.

The skin was then prepped for surgical debridement using iodine again. Scrub solutions of chlorhexidine or iodine should not be used on open wounds as damage to the tissue can occur.

More lavage using a 20ml syringe and a 19g needle after the surgical debridement followed, which helps debride the tissue.

The main wounds to Stanley’s left rump were able to be closed and a penrose drain was used. The degloving injury to his tarsus was bandaged after cleansing and lavage using melolin with intrasite and manuka honey applied against the wound.

We used the honey as we were worried about contamination as it would be healing as an open wound.

Post-surgery

Stanley came in every three days after the surgery to have his bandage changed and re-applied, and his wounds checked as we were worried about breakdown.

He proved to be a great healer and there was only a small area on his rump where the wound broke down, and the tarsus wound granulated beautifully and after four bandage changes we stopped bandaging and using the intrasite/honey as there was a danger of overgranulation and proud tissue. The owners were advised to just keep the area clean and gently bathe with swabs and water if required.

The main reason for issues with healing wounds is patient interference or excessive movement, so a buster collar was issued and strict instructions to continue with lead exercise only.

A rewarding case

What was so rewarding about this case was that the nurses were able to use their experience and knowledge to deal with Stanley’s wounds. Bandaging and wound care is something that if done well can yield great results, but done badly can cause further problems.

I remember when at college (many years ago now!) we bandaged our own forearms. I was shocked how tight it felt despite padding and the finished bandage was uncomfortable to say the least. Friction wounds from bandages that are too loose or tight can be worse than the wound you were trying to help heal!

Following bandaging rules is important and not only for the comfort of your patient. We are taught to bandage correctly and can help the vets learn – I certainly have had a sharp intake of breath at the sight of a vet applying a bandage and had to gently advise re-application.

Dressings in bandaging seem to go in and out of fashion and there seems to be an exhausting variation of dressings, from silver to honey- impregnated and all those in between – but what shouldn’t be forgotten is that it is the body that heals the wounds, not us.

We can help, but mostly our role is to support the healing process which is already taking place.