Index: Ostomy Wound Manage. 2008;54(9):34-42.

Abstract

  The nutritional requirements of healthy people differ from those who have chronic wounds and while it is generally suggested that the nutritional status of persons with chronic wounds must be addressed, actual data about the nutritional status of older adults with venous ulcers is limited. The nutritional status of hospitalized older adults (n = 40, average age 77 ± 7.4) with vascular disease was compared to randomly selected outpatients with venous insufficiency ulcers (n = 37, average age 70.4 ± 8.13) using the Mini Nutritional Assessment instrument. Among all patients assessed, 37 (48%) were at risk for malnutrition or were malnourished. No differences between nutritional status and age or gender were found. The proportion of patients at risk for malnutrition or currently malnourished was significantly higher in the venous ulcer (24 out of 37) than in the control group (13 of 40, chi² = 15.51, P < 0.05). Statistically significant differences were found between the control and venous ulcer group for all anthropometrical assessment variables (BMI, arm circumference, calf circumference, and weight loss in past 3 months), use of more than three prescription drugs, dietary history/assessment (appetite, fluid consumption, independent feeding), and patient self-rated health. The results of this study confirm that a complete patient assessment must include evaluating patient nutritional status and that nutritional disorders are a serious problem among the elderly, especially those with venous ulcers. Additional studies to help optimize the nutritional assessment and management of older adults with venous ulcers are needed.

KEYWORDS: nutritional assessment, malnutrition, venous ulcer, elderly, comparative study

  In August 2007, the Center for Medicare and Medicaid Services (CMS) endorsed a policy of nonpayment for Stage III and Stage IV hospital-acquired pressure ulcers effective October 2008.¹ Policy has an interesting way of shaping both science and practice. Undoubtedly, this new CMS ruling will be a stimulus for intensifying prevention practice and developing new approaches for systematically monitoring the effectiveness of prevention efforts. However, we hope it will have the added effect of advancing the science of pressure ulcer prevention.

  The science of pressure ulcer prevention, like medicine and nursing, is a practical one. The focus of practical sciences is to develop and structure knowledge about things that are doable^2,3 — eg, curing a disease, promoting patient self-care, preventing pressure ulcers. Thus, the aim of practical sciences might be understood as one of developing responsible descriptions and explanations (conceptual models or theories) about things that are doable. When it comes to the science of pressure ulcer prevention, the focus seems to be on describing and explaining three doable things: 1) identifying who is at risk for getting pressure ulcers, 2) designing appropriate prevention plans, and 3) effectively implementing prevention interventions. However, what unifying conceptual model or theory drives our investigation of these prevention activities?

   Pain is an unpleasant physical and emotional experience that plays a key role in the lives of people with chronic wounds.^1-3 It is well documented that the majority of patients with chronic wounds suffer from moderate to severe pain for a protracted period of time with frequent exacerbations.^4-8 Although pain often is associated with conditions intrinsic to underlying etiologies (eg, acute lipodermatosclerosis in venous leg ulcers, Charcot changes with diabetic foot ulcers), trauma (pressure, shear, and friction), chemical irritation, infection, or inflammation, spontaneous pain may occur due to sensitization of nerve fibers.⁹ In studies conducted during dressing changes, patients describe the most excruciating pain at dressing removal as aggressive adhesives are peeled away from fragile and damaged periwound skin.^10-13 Increasing evidence also validates pain with wound cleansing, especially when abrasive materials or forceps are used to remove debris from the wound bed.^3,14,15

     Acute infection of surgical incision sites often requires specialized wound care in preparation for surgical closure. Optimal therapy for preparing such wounds for a secondary closure procedure remains uncertain. The authors report wound outcomes after administering acoustic pressure wound therapy in conjunction with negative pressure wound therapy with reticulated open-cell foam dressing changes to assist with bacteria removal from open, infected surgical-incision sites in preparation for secondary surgical closure in three patients. Before incorporating acoustic pressure wound therapy at the authors’ facility, the average negative pressure wound therapy with reticulated open-cell foam dressing course prior to secondary surgical closure was 30 days; with its addition, two of three patients underwent successful surgical closure with no postoperative complications after 21 and 14 days, respectively; one patient succumbed to nonwound-related complications before wound closure. Larger, prospective studies are needed to evaluate combining negative pressure wound therapy with reticulated open-cell foam dressing and acoustic pressure wound therapy for infected, acute post surgery wounds.

     KEYWORDS: acoustic pressure wound therapy, wound care, infection, surgery, negative pressure wound therapy