Mrs Green, an 84-year-old, presented to the medical centre for a scheduled wound dressing change. The patient

Mrs Green, an 84-year-old, presented to the medical centre for a scheduled wound dressing change. The patient was observed walking to the treatment room, limping with a walking stick, showing signs of pain – winces and frowns on the face. The patient noted that she has throbbing pain up to the shin, at rest rating the pain 3/10. Mrs Green reported changes in her diet, that she hasn’t been eating or drinking much as she has been in too much pain. Mrs. Green also reported that there has been a change in bowel movements, she hasn’t had her bowels open for a few days, and her urination is passing a little bit, which is straw-coloured. Vital signs were taken with BP 115/70 mmHg, HR 80 bpm – regular pulse, RR 24 bpm, Temp 37.8 degrees Celsius, and sats 98% RA. Physical assessment showed height 165cm, weight 75kg, bilateral pedal pulses present – equal and strong, capillary refill less than 2 seconds to all extremities, equal air entry to all fields, soft and palpable abdomen, bowel sounds to all quadrants and little dry oral mucosa. Wound assessment revealed exudate which is green and has a distinct smell, soaked through the current primary and secondary dressing. Slough is present on the wound. Skin in the wound bed was hot to touch, red, and very tender, with redness extending approximately 3cm out from the wound in all directions. An offensive odour was noted from the wound dressing and wound bed. Surrounding tissue is very tender. Oedema has developed on the affected limb.