I have a patient who had a failed mesh placement and a panniculectomy and who has developed at least three separate fistulas with a very large amount of output (3-4 L/24 hrs). Any suggestions? I am using an Eakin wound management pouch hooked up to wall suction.
Venous Leg Ulcers in the Elderly Patient: Associated Stress, Social Support, and Coping
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The etiology of venous ulcer disease is multifactorial. Increases in vein pressure predispose persons to edema and subsequent lower extremity ulceration. This phenomena usually occurs secondary to valve incompetence and subsequent failure of the pumping action of the skeletal musculature. Additional factors include microvascular compromise, venous hypertension, history of deep vein thrombosis, family history, obesity, age, and pregnancy.1,2 A significant number of venous ulcer patients experience pain (either constant or relating to dressing changes), affecting their quality of life3 and leading to frustration and interference with normal daily activities.4 Although research has shown that psychosocial issues in wound management are critical when formulating treatment algorithms, clinicians frequently overlook them. Knowledge of stressors, social support, and coping often can “fill the void” when evaluating these patients and further elucidate the idiosyncrasies of recalcitrant wound pathologies; this is particularly germane to geriatric populations. The purpose of this overview is to provide the most pertinent concepts/models and research relevant to caring for lower extremity wounds in the elderly.
Psychosocial Issues
Numerous psychological theories and models have been crafted to explain the human condition as it relates to health behaviors.5 Understanding the Health Belief Model and health locus of control is particularly useful when examining the psychosocial effects of chronic illness.
The Health Belief Model. Rosenstock et al6 originally presented the Health Belief Model to help predict and explain preventative health behaviors; Becker and Maiman7 adapted and modified this model specifically to forecast compliance to medical regimens. The prototype suggests that an individual’s motivation to take preventative action depends on health beliefs rather than particular personality traits.8 This algorithm utilizes five psychological variables: perceived susceptibility to the disease process, perceived severity of the condition, perceived benefits of taking action, perceived cost of taking action, and internal and external cues to action.7
Health locus of control. Health locus of control, originally described by Rotter,9 suggests that behavior is a function of an individual’s belief and may be explained by either an internal or external locus of control that may occur in tandem. Wallston et al10 describe the existence of an external locus of control when patients believe their health outcomes depend on fate or powerful others. Subsequently, compliance is problematic and these patients usually fail to engage in positive health behaviors.
Conversely, an internal locus of control assumes that health outcomes are directly related to the individual’s volitional behavior8; such patients often take positive steps to improve outcomes.9
References:
1. Coleridge Smith PD, Thomas P, Scurr JH, et al. Causes of venous ulceration: a new hypothesis. Brit Med J. 1988;96:1726–1727.
2. Snyder RJ. Graftskin (Apligraf) and Regranex gel: an overview. Podiatr Manage. 2001;Nov-Dec:39–50.
3. Ryan S, Eager C, Sibbald RG. Venous leg ulcer pain. Ostomy Wound Manage. 2003;49(4A suppl):16S–23S.
4. Krasner D. Pain and venous ulcers: theme and stories about their impact on quality of life. Ostomy Wound Manage. 1998;44(9):38–39.
5. Calnan M. The Health Belief Model and participation in programmes for the early detection of breast cancer: a comparative analysis. Soc Sci Med. 1984;19(8):823–830.
6. Rosenstock IM. Historical origins of the Health Belief Model. Health Education Monographs. 1974;2:318–335.
7. Becker MH, Maiman LA. Socio-behavioural determinants of compliance with health and medical care recommendation. Medical Care. 1975;13:10.
8. Mudge E, Price P. Risk of diabetic foot ulceration: perception and behavioural change. The Diabetic Foot. 2004;7(2):95–101.
9. Rotter JB. Generalized expectations for internal verses external control of reinforcement. Psychological Monog. 1966;80(1):1–28.
10. Wallston KA, Wallston BS, DeVellis R. Development of the multidimensional health locus of control (MHLC) scales. Health Education Monograph. 1978;6:160–170.
11. Sapolsky R. Sick of poverty. Sci Am. 2005;293(6):92–99.
12. van Rijswijk L. The language of wounds. In: Krasner D (ed). Chronic Wound Care: A Clinical Sourcebook for Health Care Professionals, 3rd ed. Wayne, Pa: HMP Communications;2001.
13. Hyland ME, Ley A, Thompson B. Quality of life of leg ulcer patients: questionnaire and preliminary finds. J Wound Care. 1994;3(6):294–298.
14. Brod M. Quality of life issues in patients with diabetes and lower extremity ulcers: patients and caregivers. Qual Life Res. 1998;7(4):365–372.
15. Walshe C. Living with a venous leg ulcer: a descriptive study of patients’ experiences. J Adv Nurs. 1995;22(6):1092.
16. Poulton B. Factors influencing patient compliance. Nurs Stand. 1991;5(36):3–5.
17. Callam MJ, Harper DR, Dale JJ, Ruckley CV. Chronic leg ulceration: socio-economic aspects. Scot Med J. 1988;33:358–360.
18. Roe B, et al. Patients perceptions of chronic leg ulcers. In: Cullum N, Roe B (eds). Leg Ulcers: Nursing Management A Research Based Guide. Harrow, UK: Scutari Press;1995.
19. Hareendran MA, Bradbury A, Budd J, et al. Measuring the impact of venous leg ulcers on quality of life. J Wound Care. 2005;14(2):53–57.
20. Newell R. Body-image disturbance: cognitive behavioral formulation and intervention. J Adv Nurs. 1991;16:1400–1405.
21. Dewing J. Altered body image. Surg Nurs. 1989;2(4):17–20.
22. Hofman D, Ryan T, Arnold F, et al. Pain in venous leg ulcer. J Wound Care. 1997;6(5):222–224.
23. Phillips T, Stanton B, Provan A, Lew R. A study of the impact of leg ulcers on quality of life: financial, social, and psychologic implications. J Am Acad Dermatol. 1994;31(1):49–53.
24. Roe BH, Luker KA, Cullum NA, et al. Assessment, prevention, and monitoring of chronic leg ulcers in the community: report of a survey. J Clin Nurs. 1993;2:299–304.
25. Hollinworth H. Nurse’s assessment and management of pain at wound dressing changes. J Wound Care. 1995;4(2):77–83.
26. Kammerlander G, Eberlein T. Nurses’ view about pain and trauma at dressing changes: a central European perspective. J Wound Care. 2002;11(2):76–79.
27. McCaffery M. Nursing Management of the Patient with Pain. Philadelphia, Pa: Lippincott;1972.
28. Krasner D. Caring for a person experiencing chronic wound pain. In: Krasner DL, Rodeheaver GT, Sibbald RG (eds). Chronic Wound Care: A Clinical Source Book for Healthcare Professionals, 3rd ed. Wayne, Pa: HMP Communications;2001;79–89.
29. Herr K, Mobily P. Comparison of selected pain assessment tools for use with the elderly. Appl Nurs Res. 1993;6(1):39–46.
30. Thomas S. Pain and wound management. Community Outlook. 1989;July 12:11–15.
31. Cunningham D. Treating venous insufficiency ulcers with soft silicone dressings. Ostomy Wound Manage. 2005;51(11A suppl):21–22.
32. Keeling D, Price P, Jones E, Harding KG. Social support for elderly patients with chronic wounds. J Wound Care. 1997;6(8):389–391.
33. Jones J. Stress responses, pressure ulcer development and adaptation. Brit J Nurs. 2003;12(11 suppl):S17–18,S20,S22.
34. White NE, Richter JM, Fry C. Coping, social support and adaptation to chronic illness. Western J Nurs Res. 1992;14(2):211–224.
35. Price P, Harding K. Measuring health-related quality of life in patients with chronic leg ulcers. WOUNDS. 1996;8(3):91–94.
36. Dewar AL, Morse JM. Unbearable incidents: failure to endure the experience of illness. J Adv Nurs. 1995;22(5):957–964.
37. Neil JA, Munjas BA. Living with a chronic wound: the voices of sufferers. Ostomy Wound Manage. 2000;46(5):28–38.
38. Franks PJ, Moffatt CJ. Who suffers most from leg ulceration? J Wound Care.1998;7(8):383–385.
39. Moos RH. The coping resources inventory (CRI). In: Milne D (ed). Assessment: A Mental Health Portfolio. Windsor, Canada: Nelson Publishing Company;1990.
40. Moos R, Shaefer JA. The crisis of physical illness: an overview and conceptual approach. In: Moos RH (ed). Coping with Physical Illness: New Perspectives, Vol 2. New York, NY: Plenum Press;1984.
41. Myss C. Why People Don’t Heal and How They Can. New York, NY: Three Rivers Press;1997.
42. Wientjes KA. Mind-body techniques in wound healing. Ostomy Wound Manage. 2002;48(11):62–67.
43. Moffatt CJ, Franks PJ, Bosanquet N, et al. The provision of innovation in venous ulcer management in the elderly population in the community. (Report to the King Edward’s Hospital Fund for London). London, UK: King’s Fund;1991.
44. Keeling DI, Price PE, Jones E, Harding KG. Social support: some pragmatic implications for health care professionals. J Advanced Nurs. 1996;23:76–81.
45. Sosa R, Kennel J, Klaus M, Robertson S, Umitia J. The effect of a supportive companion on perinatal problems, length of labor, and mother-infant interaction. New Eng J Med. 1980;303:597–600.
46. Vachon MLS, Lyall WAL, Rogers J, Freedman-Letovsky K, Freeman SJJ. A controlled study of self-help intervention for widows. Am J Psych. 1980;137:1380–1384.
47. Wills TA. Supportive function of interpersonal relationships. In: Cohen S, Syme SL (eds). Social Support and Health. New York, NY: Academic Press;1984.
48. Dunkel-Schetter C, Bennett TL. Differentiating the cognitive and behavioral aspects of social support. In: Sarason BR, Sarason IG, Pierce GR (eds). Social Support: An Interactional View. New York, NY: John Wiley and Sons;1990.
49. Gottlieb BH. Quandaries in translating support concepts to intervention. In: Veiel HOF, Baumann U (eds.) The Meaning and Measurement: The Series in Clinical and Community Psychology. New York, NY: Hemisphere;1992.
50. Cohen S. Psychosocial models of the role of social support in the aetiology of physical disease. Health Psychol. 1988;7(3):269–297.
51. Cohen S, Wills TA. Stress, social support and the buffering hypothesis. Psychol Bulletin. 1985;98(2):310–357.
52. Cohen S, Syme SL. Issues in the study and application of social support. In: Cohen S, Syme SL (eds). Social Support and Health. Orlando: Academic Press;1985.
53. Ganster DC, Victor B. The impact of social support on mental and physical health. Brit J Med Psychol. 1988;61:17–36.
54. Gottlieb BH. Social Support Strategies: Guidelines for Mental Health Practice. Beverly Hills, Calif: Sage;1983.
55. Cohen S. Stress, social support, and disorder. In: Veiel HOF, Baumann U (eds). The Meaning and Measurement of Social Support: The Series in Clinical and Community Psychology. New York, NY: Hemisphere;1992.
56. Kaplan RM, Toshima NMT. The functional effects of social relationship on chronic illness and disability. In: Sarason BRI, Sarason IG, Pierce GR (eds.) Social Support: An Interactive View. New York, NY: Wiley and Sons;1990.
57. Wortman CB, Conway TL. The role of social support in adaptation and recovery from physical illness. In: Cohen S, Syme SL (eds). Social Support and Health. Orlando, Fla: Academic Press;1985.
58. Silver RC, Wortman CB, Crofton C. The role of coping in support provision: the self — presentational dilemma of victims of life crisis. In: Sarason BR, Sarason IG, Pierce GR (eds). Social Support: an Interactional View. New York, NY: John Wiley and Sons;1990.
59. Barrera M. Preliminary development of a scale of social support. Am J Comm Psychol. 1981;9:435–447.
60. Koster MET, Bergsma J. Problems and coping behaviour of facial cancer patients. Soc Sci Med. 1990;30(5):569–578.
61. Roberto KA, Gigliotti CM, Husser EK. Older women’s experiences with multiple health conditions: daily challenges and care practices. Health Care Women Int. 2005;26(8):672–692.
62. Kiecolt-Glaser JK, Loving TJ, Stowell JR, et al. Hostile marital interactions, proinflammatory cytokine production, and wound healing. Arch Gen Psychiatry. 2005;62:1377–1384.
63. Kiecolt-Glaser JK, Preacher KJ, MacCallum RC, et al. Chronic stress and age related increases in proinflammatory cytokine IL-6. Proc Natl Acad Sci USA. 2003;100(15):9090–9095.
64. Kiecolt-Glaser JK, Malarkey WB, Chee M, et al. Negative behavior during marital conflict is associated with immunological down-regulation. Psychosom Med. 1993;55(5):395–409.
65. Cacioppo JT, Hawkley LC. Social isolation and health, with an emphasis on underlying mechanisms. Perspect Biol Med. 2003;46(3 suppl):S39–S52.
66. Kiecolt-Glaser JK, Glaser R, Cacioppo JT, Malarkey WB. Marital stress: immunologic, neuroendocrine, and autonomic correlates. Ann NY Acad Science. 1998;1(840):656–663.
67. Sheridan JF, Padgett DA, Avitsur R, Marucha PT. Experimental models of stress and wound healing. World J Surg. 2004;28(3):327–330.
68. Butterworth RJ, Jones-Williams W, Hughes LE. Quantification of cell types in human granulation tissue. J Wound Care. 1992;1(4):32–34.
69. Sarafino EP. Health Psychology: Biopsychosocial Interactions, 3rd ed. New York, NY: John Riley and Sons;1998.
70. Harker J. Influences on patient adherence with compression hosiery. J Wound Care. 2000;9(8):379–382.
71. Moffatt CJ, Dorman MC. Recurrence of leg ulcers within a community ulcer service. J Wound Care. 1995;4(2):57–61.
72. Mayberry JC, Moneta GL, Taylor LM Jr, Porte JM. Fifteen year results of ambulatory compression therapy for chronic venous ulcers. Surg. 1991;109:575–581.
73. Travers JP, Harrison JD, Makin DS. Post-operative use of compression stockings in preventing recurrence of varicose veins. Paper presented to the Venous Forum of the Royal Society of Medicine, London, UK.
74. Kemp D. Compression hosiery. Professional Nurs. 1996;11(10):697–700.
75. Johnson GV. Elastic stockings. Br Med J. 1988;296:720.
76. Moneta GI, Nicoloff AD, Porter JM. Compression treatment of chronic venous ulceration: a review. Phlebology. 2000;15:162–168.
77. DiMatteo MR. Physician-patient communication: promoting a positive health care setting: In: Rosen JC, Solomon LJ (eds). Prevention in Health Psychology. Hanover, NH: University Press of New England;1985.
78. Wallston BS, Wallston KA, Kaplan GD, Maides SA. Development and validation of the health locus of control (HCL) scale. J Consulting Clin Psychol. 1976;44:580–585.
79. Ley P. Improving patients understanding, recall, satisfaction, and compliance. In: Broome AK (ed). Health Psychology Processes and Applications. London, UK: Chapman and Hall;1989.
80. Hamer C, Cullum NA, Roe BH. Patients’ perceptions of chronic leg ulcers. J Wound Care. 1992;3(2):99–101.
81. Ruane-Morris M. Supporting patients with healed leg ulcers. Professional Nurs. 1995;10(12):765–770.
82. Gibson CH. A concept analysis of empowerment. Br J Nurs. 1991;16:354–361.
83. Detmar SB, Muller MJ, Schornagel JH, et al. Health-related quality- of- life assessments and patient-physician communication. JAMA. 2002;288:3027–3034.
84. Zoppi K, Epstein RM. Is communication a skill? Communication behaviors and being in relation. Family Med. 2002;34:319–324.
85. Neuwirth ZE. An essential understanding of physician-patient communication. Part II. J Med Pract Manage. 1999;15:68–72.
86. Curtis JR, Engelberg RA, Nielson EL, Au DH, Patrick DL. Patient-physician communication about end-of-life care of patients with severe COPD. Eur Respiratory J. 2004;24:200–205.
87. Kim SS, Kaplowitz S, Johnson MV. The effects of physician empathy on patients satisfaction and compliance. Eval Health Prof. 2004;27:237-251.
88. Zachariae R, Pedersen CG, Jenson AB, et al. Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over disease. Br J Cancer. 2003;88:658–665.
89. Beck RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systemic review. J Am Board Fam Pract. 2002;15:25–38.
90. Bedell SE, Graboys TG, Bedell E, Lown B. Words that harm, words that heal. Arch Intern Med. 2004;164:1365–1368.
91. Egede LE, Michel Y. Indigent diabetics have little trust in the medical system. Diabetes Care. 2006;29:131–132.
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