Volume 59 - Issue 2 - February 2013

Letter to the Editor: Pressure ulcer management in disasters in low-resourced countries

  We read with interest the article by Sato and Ichioka1 on pressure ulcer occurrence following the great East Japan Earthquake. Because research on pressure ulcers (PU) in disasters is limited, we wanted to share our experience with PU in spinal cord injury (SCI) patients in the 2005 Pakistan earthquake.

  SCI is an established risk factor for development of PU. The 2005 Pakistan earthquake resulted in hundreds of acute SCI for which our healthcare system neither had resources nor adequate expertise.2 Evacuation priority from the disaster zone was given to persons with open wounds and broken bones, delaying evacuation of SCI patients in many cases.3 There was only one spinal rehabilitation unit in the country; patients had to be managed in makeshift paraplegic centers.3 At that time and even today, there are no trained rehabilitation or skin care nurses in Pakistan.4 PU risk assessment and monitoring is not routinely performed or documented. The attitude of our healthcare professionals (HCPs) toward pressure ulcer recognition and prevention has been described as casual5 and further complicated by the fact that Pakistan was/is a low-resourced developing country with an inadequate healthcare infrastructure.



Progress in Practice: Maintaining Skin Integrity in Patients with Incontinent Episodes

  Foam dressings are a mainstay in managing wounds. Traditionally used for exudate management, foam dressings can have a wide performance range depending on the composition of the biomaterials used. Factors that can affect dressing performance include but are not limited to wound characteristics, clinician experience, systemic patient factors, and the clinical setting.

  Maintaining dressing integrity in patients with incontinence is a frequently encountered clinical challenge. Inability to achieve dressing adherence on moist, compromised skin adversely affects patient confidence in healthcare providers, introduces bacteria into the wound, and increases cost. Dressing construction impacts these factors.1



My Scope of Practice: Blending the New with the Old

The great thing in the world is not so much where we stand, as in what direction we are moving. — Oliver Wendell Holmes

  Technology has advanced many areas of everyday life. Getting directions is simpler. Old friends are just a click away. You can shop from your couch. Likewise, patient care has been enhanced by many new tech-friendly tools. Physicians and nurses can upload patient information to a database; photos and assessments are stored in one place. But as with the use of all technology, healthcare providers must be careful not to become too immersed in the digital age and forget the value of hands-on, traditional care.

  Barbara J. Rozenboom, RN, BSN, CWON is adept at making the most of available technology while utilizing traditional bedside nursing skills. She attended Marshalltown Community College (Marshalltown, IA) in the early 1980s. She earned her LPN in 1982 before heading to Mercy School of Nursing (Des Moines, IA) to earn her RN diploma in 1987. While in school, Barbara worked as a staff nurse at Mercy Medical Center (Des Moines, IA) on a number of different units, including General Surgery and Urology, Surgical Intensive Care, and Post Anesthesia Recovery. In 1993, Barbara took a position as a staff nurse with the home care and hospice faction of Skiff Medical Center (Newton, IA).



Pearls for Practice: A Novel Tracheostomy Dressing: Extension of a Hydroconductive Wound Dressing

  Tracheostomies, which may be acute or chronic, are indicated for different conditions such as chronic obstructive pulmonary disease (COPD); bacterial, viral, or fungal pneumonia; smoke inhalation; and head injury,1 to name a few. The secretions exiting or being suctioned from the tracheostomy site associated with each of these conditions have unique characteristics2; the exudate can be copious, watery bronchorrhea; bloody; viscous; and/or contain varying amounts of exudate, debris, bacteria, and chemicals depending on the etiology of the tracheostomy. A tracheostomy to relieve thick secretions in a case of severe bacterial pneumonia will have exudate heavily laden with bacteria.3 A tracheostomy performed for COPD may have injurious cytokines and proteases in the exudate removed from it.4 A tracheostomy performed to aid in the treatment of smoke inhalation will yield debris such as carbon particles and inflammatory cytokines.5



AAWC Update

Membership Continues Upward Trend

  AAWC membership increased by 20% over the last year. Thank you for your commitment to the AAWC. If you are not yet a member, now is a great time to join. Here’s why:

    Clinician dues remain low. The AAWC’s low clinician dues are a recognized and value-added perk of AAWC clinician membership this past year. Dues will remain $115 (as opposed to $145) — a 20% savings. We also have great rates for students and retirees. Corporations and healthcare facilities also are encouraged to be part of AAWC. Individuals with wounds and lay-caregivers can join our Wounds In Need (WIN) network free of charge to access resources and help them take a proactive role in care. These specially designated categories help make the most of membership.



Nutrition 411: Changing the Malnutrition Paradigm

  The Merriam Webster Dictionary defines malnutrition as “faulty nutrition due to inadequate or unbalanced intake of nutrients or their impaired assimilation or utilization”.1 This classic dictionary definition may work for grade school and middle school science classes but is no longer applicable for diagnosing adult patients. In recent years, it has become clear that malnutrition is a complex syndrome that manifests in different ways. As a result of this new understanding, the definition of the condition and how to diagnose it have been subject to intense scientific scrutiny. Many clinicians struggle to understand this change and wonder what parameters to use in order to assign a diagnosis of malnutrition. In an attempt to understand the whys and wherefores of recent changes in the malnutrition paradigm, a summary of the evidence follows.



Continence Coach: Pelvic Floor Pain Syndrome in Chronic Pelvic Pain

  In the genitourinary world, chronic pelvic pain (CPP) is one of the most complex and difficult conditions to diagnose and treat. The pain is rarely limited to one organ; it often involves multiple systems and is further complicated by the subjectivity of pain and individual variation in pain tolerance. Definitions of the condition vary. The American College of Obstetricians and Gynecologists1 defines CPP as “noncyclic pain of at least 6 months’ duration that localizes to the anatomic pelvis, lumbosacral back, buttocks, or anterior abdominal wall at or below the umbilicus and that is severe enough to cause functional disability or lead to medical care.” Although CPP is typically attributed to a pathologic process in peripheral (somatic or visceral) as opposed to central systems of the body, it is not known whether some permanent central nervous system dysfunction or psychogenic mechanism is at work. This is especially true in cases of trauma to the pelvic region and with respect to the body’s cumulative inflammatory response. More research about causal factors is needed to improve diagnostic accuracy and thus treatment.2 Today’s clinician must approach patient symptoms via differential diagnosis, systematically comparing clinical findings.



New Products and Industry News

Common stock closed stock public offering

  Derma Sciences, Inc (Princeton, NJ) closed an underwritten public offering of 3,521,300 shares of common stock at a price to the public of $10.34 per share, which includes the exercise of the underwriters’ option to purchase 459,300 shares of common stock to cover over-allotments.

  Total net proceeds to the company were approximately $33.8 million after deducting the underwriting discount and estimated offering expenses. The company plans to use these proceeds for the continued development of its drug candidate DSC127 for the treatment of diabetic foot ulcers and for general corporate purposes.

  For more information, visit www.dermasciences.com.



A Review of Deep Tissue Injury Development, Detection, and Prevention: Shear Savvy

Index: Ostomy Wound Manage. 2013;59(2):26–35.

Abstract

  Pressure ulcer prevention strategies include the prevention, and early recognition, of deep tissue injury (DTI), which can evolve into a Stage III or Stage IV pressure ulcer. In addition to their role in pressure-induced ischemia, shearing forces are believed to contribute substantially to the risk of DTI. Because the visual manifestation of a DTI may not occur until many hours after tissues were damaged, research to explore methods for early detection is on-going. For example, rhabdomyolysis is a common complication of deep tissue damage; its detection via blood chemistry and urinalysis is explored as a possible diagnostic tool of early DTI in anatomical areas where muscle is present. Substances released from injured muscle cells have a predictable time frame for detection in blood and urine, possibly enabling the clinician to estimate the time of the tissue death. Several small case studies suggest the potential validity and reliability of ultrasound for visualizing soft tissue damage also deserve further research. While recommendations to reduce mechanical pressure and shearing damage in high-risk patients remain unchanged, their implementation is not always practical, feasible, or congruent with the overall plan of patient care. Early detection of existing tissue damage will help clinicians implement appropriate care plans that also may prevent further damage. Research to evaluate the validity, reliability, sensitivity, and specificity of diagnostic studies to detect pressure-related tissue death is warranted.

Keywords: pressure ulcer, shear, deep tissue injury, pressure redistribution, rhabdomyolysis, ultrasound



Reliability and Validity of the Chinese Version of DESIGN-R, an Assessment Instrument for Pressure Ulcers

Index: Ostomy Wound Manage. 2013;59(2):36–43.

Abstract

  Lack of a valid and reliable assessment instrument may have contributed to a lack of wound healing research in China. The DESIGN-R tool scores the severity of pressure ulcers (PUs) and monitors healing using the observable state assessment; it was developed by the Scientific Education Committee of the Japanese Society of Pressure Ulcers (JSPU) and tested for reliability and validity. A Chinese version of DESIGN-R was developed based on Brislin’s model of translation and tested for validity and reliability. Using a purposive sampling method, 44 practicing registered nurses (RNs) and 11 physicians (MDs) were recruited from 52 departments of Nanfang Hospital, Guangdong, China. Based on their experience, they were classified as general medical staff (gMS) or experienced medical staff (eMS). All used the Chinese version of DESIGN-R to assess eight photographs of PUs and descriptors. In addition, eight eMS also used the Bates-Jensen Wound Assessment Tool (BWAT) to assess the same wounds. Inter-rater reliability was high (total ICC score = 0.960). ICC inflammation/infection scores were 0.530 and 0.759 for gMS and eMS, respectively; granulation ICC scores were 0.532 and 0.794 in gMS and eMS, respectively. The correlation coefficients between the BWAT and DESIGN-R tool were >0.80 for all eight raters. The results suggest the Chinese version of DESIGN-R is valid and reliable and may be a useful scoring tool for RNs and MDs to monitor PU status in daily clinical practice. Additional research is warranted, and clinical instruments for inflammation/infection and granulation assessment must be developed for gMS.

Keywords: pressure ulcer, wound assessment, nursing, reliability, validity



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