Diane Langemo

Pressure-related deep tissue injury under intact skin and the current pressure ulcer staging systems.

OBJECTIVETo identify how current pressure ulcer staging systems and experts describe pressure-related deep tissue injury under intact skin in the published research literature. DESIGNA systematic review of published English-language literature as of November 2002 with the words decubitus or pressure ulcer(s) in the title. Additional relevant articles were identified by National Pressure Ulcer Advisory Panel members and were included in the analysis. An expert commentary was developed by iterative review by the National Pressure Ulcer Advisory Panel members. MAIN OUTCOME MEASURESManuscripts were reviewed for staging systems cited or described, definitions of Stage I pressure ulcers, and descriptions or definitions of pressure-related deep tissue injury under intact skin. MAIN RESULTSNinety-four relevant articles were identified. Seventy-three articles (78%) described a staging system, and 55 of 73 (75%) cited the staging definitions from Shea, the National Pressure Ulcer Advisory Panel, or the Agency for Health Care Policy and Research. The National Pressure Ulcer Advisory Panels staging definitions were the most frequently cited overall. Twenty-three articles (25%) included some discussion that could be interpreted as relevant to the topic of pressure-related deep tissue injury under intact skin; however, no consistency in definitions of Stage I pressure ulcers or terminology for pressure-related deep tissue injury under intact skin was found. CONCLUSIONSSeveral pressure ulcer staging systems are frequently cited, but none define pressure-related deep tissue injury under intact skin. The National Pressure Ulcer Advisory Panel recommends using the terms “pressure-related deep tissue injury under intact skin” or “deep tissue injury under intact skin” for describing these lesions and encourages investigators to establish the epidemiology and natural history of these lesions.

Skin fails too: acute, chronic, and end-stage skin failure.

OBJECTIVE: To identify what has been published in the literature about acute and chronic skin failure and to propose a working definition of this phenomenon. DESIGN: A systematic review of MEDLINE and CINAHL to determine what has been published in the literature on the topics of skin failure, acute skin failure, chronic skin failure, multiple organ failure, end-of-life skin deterioration, and pressure ulcers in hospice from 1984 to 2005. MAIN OUTCOME MEASURES: Published papers were reviewed for content related to acute, chronic, and end-stage skin failure. MAIN RESULTS: Seven articles were identified that referenced either acute, chronic, or end-stage skin failure. Additional information was identified that discussed the processes of acute and chronic skin failure and pressure ulcers in individuals in hospice care or at the end of life. Care considerations and dilemmas related to a curative versus palliative goal in wound healing were discussed. CONCLUSIONS: Minimal literature exists on skin failure, yet caregivers and the public must be aware of, assess for, and consider this phenomenon in their care. Based on this literature review, skin failure was defined by the authors as an event in which the skin and underlying tissue die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organ systems. Skin failure can be categorized as acute, chronic, or end stage. Pressure ulcers, a type of skin death, frequently occur in persons with a heavy disease burden, especially those at or near the end of life, despite good care.

Pressure ulcer prevalence and incidence and a modification of the braden scale for a rehabilitation unit

Purpose We examined pressure ulcer incidence and prevalence, the cutoff score for risk for skin breakdown, and the contribution of each of the subscale risk factors of the Braden pressure ulcer risk‐assessment tool in an inpatient rehabilitation unit. Subjects and Setting One hundred seventy adult men hospitalized on a rehabilitation unit during 1 calendar year were included in the research. Subject ages ranged from 35 to 99 years (M = 69). Instruments Pressure ulcer risk was assessed using the Braden Scale. Methods A retrospective chart review of a continuous series of 170 adult male patients hospitalized during a 1‐year period on a 50‐bed rehabilitation unit was conducted. Data were documented on a standardized researcher‐designed form. Results A total of 46 pressure ulcers occurred, with the sacrum the most common location (46%), followed closely by the heel–ankle area (44%, n = 20). Most pressure ulcers (57%) were stage II, 24% were stage I, 15% stage III, and 4% stage IV. When using a cutoff score of 16, the Braden Scale demonstrated limited usefulness in predicting pressure ulcer development on our inpatient rehabilitation unit. Further calculations were completed, and a cutoff score of 18 or higher was found to provide better predictive value. With use of multiple logistic regression analysis, three of the six risk factors from the Braden Scale were found to significantly contribute to risk for pressure ulcer development in this sample: moisture, nutrition, and friction and shear. Therefore a modified Braden Scale was developed, with a possible range of scores from 3 to 11; the cutoff score was 8, sensitivity was 52%, and specificity 66%. Conclusions The mean prevalence rate of 12% was comparable, and the incidence rate of 6% for this unit was lower, compared with other skilled care and rehabilitation settings reported in the literature. The proactive, interdisciplinary approach to skin integrity on this unit likely contributed to the lower incidence rate. Risk factors most predictive of pressure ulcer development in this sample were moisture, nutrition, and friction and shear. Predicting risk for skin breakdown with use of a consistent risk‐assessment tool is essential for all rehabilitation patients. Assessing risk with the Braden Scale merits further research.

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.

Unavoidable pressure injury: state of the science and consensus outcomes.

In the vast majority of cases, appropriate identification and mitigation of risk factors can prevent or minimize pressure ulcer (PU) formation. However, some PUs are unavoidable. Based on the importance of this topic and the lack of literature focused on PU unavoidability, the National Pressure Ulcer Advisory Panel hosted a multidisciplinary conference in 2014 to explore the issue of PU unavoidability within an organ system framework, which considered the complexities of nonmodifiable intrinsic and extrinsic risk factors. Prior to the conference, an extensive literature review was conducted to analyze and summarize the state of the science in the area of unavoidable PU development and items were developed. An interactive process was used to gain consensus based on these items among stakeholders of various organizations and audience members. Consensus was reached when 80% agreement was obtained. The group reached consensus that unavoidable PUs do occur. Consensus was also obtained in areas related to cardiopulmonary status, hemodynamic stability, impact of head-of-bed elevation, septic shock, body edema, burns, immobility, medical devices, spinal cord injury, terminal illness, and nutrition.

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%).