Darlene Hanson

Measuring wound length, width, and area: which technique?

PURPOSE To provide practitioners with evidence-based recommendations for measuring wound size. TARGET AUDIENCE This continuing education activity is intended for physicians and nurses with an interest in wound care. OBJECTIVES After reading this article and taking this test, the reader should be able to: Describe different methods of measuring wound size and their advantages and disadvantages. Discuss a research study conducted to determine the most accurate ruler technique for measuring wounds. Identify evidence-based wound measurement data and recommendations for clinical practice.

The relationship between hemoglobin A(1c) values and healing time for lower extremity ulcers in individuals with diabetes.

PROBLEM: The diabetic population is at an increased risk, up to 15% over a lifetime, to develop leg and foot ulcers due to such factors as neuropathy, ischemia, and infection. The tight control of glucose levels as possible is necessary to prevent the diabetic complications by preventing microvascular changes that predispose the patient to neuropathy, ischemia, and infection. Although it is clear from the literature review that tight glucose control prevents complications, the relationship between HgbA1c values and healing times of ulcers is less well defined. This study explored the relationship between HgbA1c values and healing times of leg and foot ulcers. THEORETICAL/CONCEPTUAL FRAMEWORK: The theoretical framework used was Orems self-care deficit theory of nursing, which focuses on self-care of patients and nursing intervention if self-care is inadequate. SUBJECTS: Forty-one male and 22 female patients having either type 1 or type 2 diabetes were considered in this study. Of these 63 patients, 9 had type 1 and 54 had type 2 diabetes. Ages ranged from 33 to 94 years (mean, 67.7 years [SD, 14.98 years]). Weight ranged from 122 to 402 lb (mean, 221.84 lb [SD, 58.79 lb]). METHODOLOGY: As part of a larger study, a retrospective chart review was performed on 63 patients with diabetes served by a Midwestern outpatient wound care clinic from July 2001 to July 2004. Approval for this study was granted through the local institutional review board. No data collected required the consent of the individual or included any identifying data, thus protecting the privacy of the individuals whose charts were reviewed. A tool was developed by the researchers through literature review to gather needed information. The data collection tool included demographics, medical diagnoses, wound size at presentation, and most recent wound size, as well as the HgbA1c results closest to admission and closest to time of wound closure. Statistics were generated using the SPSS program. RESULTS: Of the 63 ulcers, 36 healed, 26 did not heal, and it was not possible to determine if healing occurred for 1 ulcer. Admission HgbA1c values ranged from 4.5 to 15.4 (mean, 8.05 [SD, 2.29]). HgbA1c values closest to ulcer closure ranged from 5.3 to 12.3 (mean, 7.68 [SD, 1.81]). It was found that patients with higher HgbA1c levels did experience wound healing, but in a significantly longer period than those with lower HgbA1c. Individuals with type 1 diabetes had a higher healing rate (77.8%) than individuals with type 2 diabetes (53.7%), whereas 40% of all closed ulcers reopened. A significant correlation was also noted between a history of smoking and increased HgbA1c levels. IMPLICATIONS: Healing times were decreased in those individuals who had lower HgbA1c values. Decreased healing times result in lower cost for the patient, decreased chance of infection due to lack of portal of entry, and increased quality of life. Patient education may increase self-care practices in the diabetic population regarding better glucose control.

Comparison of 2 wound volume measurement methods.

OBJECTIVE To compare 2 wound volume measurement techniques, the Kundin device and stereophotogrammetry, on 2 wound shapes. DESIGN Using 2 wound measurement techniques, the interrater and intrarater reliability and the bias and standard error of measurement of an L-shaped and a pear-shaped plaster of paris wound model were assessed. SETTING A clinical laboratory of a school of nursing. PARTICIPANTS Twenty-four raters, all but 2 being registered nurses, measured each of the wounds using both techniques. INTERVENTIONS Each rater measured each wound twice using each method in a randomly assigned order defined on a card that was drawn from a box. Measurements were recorded on a researcher-designed data collection form, which included some demographic data related to each participant. MAIN OUTCOME MEASURES The study hypothesis was that there would be no significant difference in accuracy between the 2 wound volume measurement methods. RESULTS The least biased and most accurate technique was stereophotogrammetry, with the smallest standard of error of measurement. Interrater reliability of average ratings was identical for both methods at 0.98. For single ratings, stereophotogrammetry was slightly higher than the Kundin device. Intrarater reliability was higher on the pear-shaped wound for the Kundin device, which had lower interrater reliability, suggesting that nurses were consistent in the direction and size of personal error. Intrarater reliability for stereophotogrammetry was identical to that of the Kundin device for the L-shaped wound and lower for the pear-shaped wound. CONCLUSIONS Although both techniques have acceptable accuracy, stereophotogrammetry is more accurate and has more clinical applications.

Clinical trial of a prevention and treatment protocol for skin breakdown in two nursing homes

Objective Our objective was to assess the effectiveness of skin care protocols, including a body wash and skin protectant, on skin breakdown in 2 nursing homes. Design This was a quasi-experimental pretest/posttest design study. Setting and subjects Adult residents (n = 136) of 2 skilled nursing homes consented to participate in this study. Seventy percent were women; the sample average age of 82 years. Instruments A researcher-designed data recording form documented resident demographics, incidence and type of skin breakdown or pressure ulcer, presence of urinary or fecal incontinence, and assessment of the effectiveness of body wash and skin protectant. Methods Baseline data on prevalence of pressure ulcers and skin protocol were collected weekly for a 3-month period followed by a week-long educational program by the researchers about skin care and the body wash and skin protectant. During the 3-month trial with the body wash and skin protectant incorporated into routine care, research assistants recorded resident data weekly and researchers again assessed prevalence and incidence of pressure ulcers and skin breakdown weekly. Results Incorporation of a body wash and skin protectant into a skin care prevention and early intervention protocol in 2 nursing homes documented a decrease in skin breakdowns from 68 pre-intervention to 40 postintervention; the decrease in agency B was statistically significant. There was a statistically significant decrease in stage I and II pressure ulcer incidence overall (pre-intervention = 19.9%, postintervention = 8.1%). Nurses evaluated the body wash and skin protectant as effective for 98% of the time used. Conclusion Implementation of a protocol for skin care along with staff education, including the prophylactic use of a body wash and skin protectant, reduced the incidence of skin breakdown, including pressure ulcers and perineal dermatitis, in 2 long-term care facilities. (J WOCN 2003;30:250-8.)

Nutritional considerations in wound care.

Statistics show that malnutrition among older adult patients is a widespread problem in US health care facilities. The 2002 Nutritional Screening Initiative, a multidisciplinary coalition led by the American Dietetic Association and the American Academy of Family Physicians, has reported rather alarming facts on the nutritional status of this patient population: 40% to 60% of hospitalized older adults are either malnourished or at risk for malnutrition; 40% to 85% of nursing home residents are malnourished; and 20% to 60% of home care patients are malnourished. 1 This is a serious problem. Lack of proper nutrition can have a significant impact on a patient’s ability to recover from illness, disease, or surgery. Malnourished patients are prone to diminished muscle strength; development of pressure ulcers, infection, or postoperative complication; and poor wound healing. 2 In addition, malnourished older adults tend to be frail or fail to thrive, 3 increasing their risk for skin breakdown. Body Response in Wound Healing Having a major wound or infection increases the body’s energy and protein needs as a result of pathologic processes and stress-induced changes. The body’s protective inflammatory response precipitates a cascade of events, including increased blood flow to the site and an increase in metabolic rate (hypermetabolism). Glycogen and protein stores are mobilized by the increased metabolism to meet the needs for glucose and stress factors (cytokines and interleukin-1 and interleukin-6). With stress, hormonal changes cause a shift in insulin and counter-regulatory hormones, such as cortisol, glucagons, and catecholamines. This results in a greater increase in counterregulatory hormones than in insulin. Because insulin assists in carbohydrate and lipid storage and protein synthesis, metabolic and energy rates increase and deplete body protein stores. Hormonal changes also lead to increased glycogen breakdown and mobilization of free fatty acids. The breakdown of glucagons increases glucose production from amino acids, ultimately resulting in a reduced storage of glucose, fatty acids, and proteins. Fat is used as an energy source, albeit

Pressure ulcer incidence in an acute care setting.

The purpose of this prospective study was to determine the incidence of pressure ulcers and to examine factors related to pressure ulcer development in patients in an acute care setting. Adult medical and surgical patients who were free of pressure ulcers at admission were assessed within 36 hours of admission and then three times per week for 2 weeks or until discharge. Instruments included a demographic data form, a skin assessment form, and the Braden Scale for Predicting Pressure Sore Risk. Most subjects had 46 assessments completed. The sample consisted of 149 subjects, with a pressure ulcer incidence rate of 13.4% (n = 20). Subjects who acquired pressure ulcers had lower hemoglobin levels (t = 2.17, p = 0.03), spent more time in bed (t = 3.90, p = 0.0001), and spent less time in a chair (t = 3.2, p = 0.002) than those who did not acquire pressure ulcers. A stepwise logistic regression analysis was used to calculate risk of pressure ulcer development. In the final model, hemoglobin level and hours spent in bed continued to be predictors of pressure ulcer development (chi 2 = 9.306, df = 2, p = 0.0095). All 20 subjects who acquired pressure ulcers were further categorized into groups with stage I (n = 12) or stage II (n = 8) ulcers. Patients with stage I pressure ulcers were primarily receiving post-surgical care (67%), whereas patients who acquired stage II ulcers had medical conditions that affected tissue perfusion, such as respiratory diseases (50%) and diabetes mellitus (12%).

The prevalence and incidence of pressure ulcers in the hospice setting: Analysis of two methodologies:

Hospice patients may be at greater risk of pressure ulcer development than most patients. This descriptive study explored the prevalence and incidence of pressure ulcers in the hospice setting, utilizing both a prospective and retrospective methodological approach. Levines theory of the four principles of conservation formed the theoretical basis for the study, and the Braden Scale for Predicting Pressure Ulcer Risk was used for data collection. Prevalence of pressure ulcers was noted to be 13 percent in the study. Incidence of pressure ulcers was found to be zero percent using prospective methodology and 13 percent using retrospective methodology. Five of eight ulcers (62 percent) occurred with Ain two weeks of patient death. Factors related to pressure ulcer development are presented, as well as a discussion of using research methodologies in the hospice setting. The article suggests the need for preventive protocols for skin care for patients who are at risk for pressure ulcer development.

Skin care protocols for pressure ulcers and incontinence in long-term care: a quasi-experimental study.

OBJECTIVE: To evaluate the effect on pressure ulcer prevalence, incidence, and healing time of incorporating use of a specific body wash and a skin protectant into skin care protocols that are based on guidelines from the Agency for Health Care Policy and Research. DESIGN: Quasi-experimental intervention study. SETTING: 2 rural long-term-care facilities. PARTICIPANTS: A convenience sample of 136 residents at 2 rural long-term-care facilities during a 3-month preintervention and a 3-month postintervention period. INTERVENTIONS: A 3-month preintervention observation period (baseline) was followed by a staff in-service session, in which the use of a body wash and a skin protectant was introduced into skin care protocols, and a 3-month postintervention observation period. The skin care protocols included skin assessment techniques, prevention and treatment strategies for Stage I and Stage II pressure ulcers, and management of incontinence. MAIN OUTCOME MEASURES: Differences in the occurrence and healing time of Stage I and Stage II pressure ulcers before and after introduction of use of a body wash and a skin protectant into skin care protocols and the occurrence rate of urinary and fecal incontinence. RESULTS: Stage I and Stage II pressure ulcers significantly decreased from 35 preintervention to 14 postintervention (t = 19.48, df = 47, P = .05). The prevalence of pressure ulcers preintervention was 11.3%, compared with 4.8% postintervention (t = 2.47, df = 1.0, P = .24), The change in the incidence of pressure ulcers was significant (t = 8.48, df = -2.0, P = .01), with 32.7% preintervention and 8.9% postintervention. Healing time for pressure ulcers ranged from 4 to 70 days preintervention (mean [M] = 22.72 ± 18.25) to 6 to 49 days postintervention (M = 16.0 ± 12.93). The decrease in pressure ulcer healing time (rapid, medium, and long) preintervention to postintervention was statistically significant (χ2 = 14.9, P = .001). The presence of fecal and urinary incontinence was significantly associated with the development of Stage I and Stage II pressure ulcers (χ2= 44.8, P = .000). CONCLUSIONS: Implementation of skin care protocols that included use of a body wash and a skin protectant reduced the incidence of Stage I and Stage II pressure ulcers and decreased healing time. The skin protectant and body wash used in the protocols were found to be effective in preventing and treating Stage I and Stage II pressure ulcers.

Incontinence and incontinence-associated dermatitis.

Incontinence is a prevalent problem and can lead to many complications. Both urinary and fecal incontinence can result in tissue breakdown, now commonly referred to as incontinence-associated dermatitis. This article addresses the types of incontinence, its etiology and pathophysiology, assessment, prevention and treatment, and the latest research.

Friction and shear considerations in pressure ulcer development.

BACKGROUND Friction is blamed for a number of untoward events of the skin. In particular, it is known to be a causative factor in falls, blisters, dermatitis, skin tears, injuries during patient transfers, airbag deployment injuries, and marathon runners’ skin irritations, as well as PrUs. Friction-induced injuries also can be caused by patient skin rubbing on starched bed linens, primarily affecting the elbows, heels, and knees and, less often, the sacral areas. Increasing the likelihood of PrU development, friction/shear injuries can occur during the positioning of patients in the bed, during the placement of a bedpan, during a transfer to another bed surface or wheelchair, and when moving patients up in bed. The mechanism of injury is that the underlying skin layers move with the patient, while the epidermal/dermal layers adhere to the bed or chair surface because of friction, causing shearing of tissues under the skin. Friction may induce the injury, but the resultant damage is shear to the underlying tissue layers, in this case. Although friction against the skin is rarely noticed until it results in an injury, it is present nonetheless. As an example, consider the difference between wearing a tight, chafing garment for jogging versus wearing a smooth, stretchy material. Most individuals would likely select the latter but may not be aware that it is friction they are avoiding. And when a person sleeps on a bed that has high-thread-count linens and notices that he/she has a better night’s sleep, it might be a lack of friction that accounts for the improvement. This kind of friction might seem inconsequential to wound care and PrUs, but consider patients in hospitals who rarely choose the thread counts in linens on which they sleep or in the bed on which they lie. Their quality of life is impacted by friction 24 hours a day when they are confined to a bed, wearing starched-cotton clothing and sliding against linen washed with harsh detergents. Skin and fabric interactions, which have not received much attention in relation to PrUs, have been more closely investigated by Gerhardt et al under the umbrella of a science called tribology. Tribology, as stated by Gerhardt et al, is the ‘‘study of friction, wear and lubrication, the science and technology of interacting surfaces in relative motion.’’ Tribological studies may help clinicians to understand the role of friction in causing PrUs and how to reduce friction when attempting to prevent PrUs.