Patricia Thompson

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.

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

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.

Hyperbaric oxygen therapy for chronic wounds.

Hyperbaric oxygen therapy continues to be discussed as another adjunctive therapy in the continuum of wound care. There is a dearth of evidence from randomized clinical trials on HBO therapy. For evidence-based practice, more randomized, controlled studies need to be conducted with HBO therapy to determine its efficacy in treating other chronic wounds besides those of patients with diabetes.

Heel Pressure Ulcers: Stand Guard

PURPOSE To present a comprehensive overview of current information on heel pressure ulcer (PrU) risk, development, prevention, and treatment. 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: Identify risk factors for heel PrUs. Describe assessment findings and staging of a heel PrU. Discuss current heel PrU prevention and treatment.

Use of honey for wound healing.

History Honey is one of the oldest known food substances in existence. Not only was honey discovered in the tomb of King Tut, it was still edible, as it is known to not spoil. Early in the 20th century, researchers began documenting the wound-healing properties of honey. With the advent of antibiotics in 1940, however, the use of honey was temporarily diminished. Both the growing antibiotic resistance and the expanding desire for natural remedies have renewed an interest in the antimicrobial and wound-healing properties of honey.