Editorial Staff

Editor Barbara Zeiger

Assistant Editor Lauren Mateja

Web Content Coordinator Katherine Blessing

Editorial Correspondence

Barbara Zeiger, Editor, OWM

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February 2014 ISSN 1943-2720 | Volume 60 - Issue 2

Tissue Changes in Patients Following Spinal Cord Injury and Implications for Wheelchair Cushions and Tissue Loading: A Literature Review


  Persons using wheelchairs, especially those with spinal cord injuries (SCI), may be susceptible to tissue changes that affect their risk for pressure ulcer (PU) development. To examine the complexity of the problem of designing, selecting, and prescribing an optimal cushioning solution to help prevent PUs, a literature search was conducted examining factors that affect the biomechanical interactions of the seated buttocks with the cushion and how these factors may change over time. The majority of publications retrieved were preclinical studies and case studies, and just a small fraction was randomized clinical trials. The literature indicates that external and internal anatomy and tissue structure and function change considerably in the months and years following the loss of sensation and mobility. Specifically, these changes typically include weight and fat mass gain, skeletal muscle atrophy and fat infiltration into muscles, bone loss and bone shape adaptation at the pelvis, vascular perfusion changes, and microstructural changes in skin and muscle that are associated with disuse and affect the biomechanical behavior of these tissues. Support surfaces, particularly wheelchair cushions, should be designed to accommodate microchanges that occur for a seated person throughout the day (eg, changes in posture and position or muscle tone) as well as macrochanges in anatomy, tissue composition, and long-term tissue (patho)physiological changes. Cushions must be tailored to, and adapted for, each individual patient on a regular basis. A promising and practical bioengineering approach to fit cushions to different patient conditions is to use computer simulations (finite element [FE] modeling). As understanding about PU risk in this population increases, study designs can be refined to develop a much-needed evidence-base for the appropriate use of support surfaces in general and wheelchair cushions in particular. ...

A Cross-sectional Study of Depression and Self-Care in Patients With Type 2 Diabetes With and Without Foot Ulcers


  Depression has been recognized as a risk factor for foot ulceration in persons with diabetes mellitus. Using convenience sampling methods, a cross-sectional study was conducted among persons with type 2 diabetes treated in a diabetic foot clinic in Sao Paulo, Brazil between February 2010 and December 2011. One hundred (100) patients (average age 62 years, range 38 to 83 years), 50 with a foot ulcer and 50 at risk for developing a foot ulcer, participated. Symptoms of depression were assessed using the Beck Depression Inventory (BDI), where scores increase with severity; and patients were interviewed about foot self-care behaviors. Average BDI scores among patients with an ulcer were higher (mean 20.37; range 1 to 42) than those of patients that had not developed a foot ulcer (mean 15.70; range 2 to 49) (P = 0.030). Self-care behavior was not significantly different between the two groups. Severe depression (P = 0.049, OR= 6.56 95% CI 1.01–42.58) and male gender (P <0.001, OR=14.87 95% CI 3.83–57.82) were associated with the presence of a foot ulcer. Despite reported adequate self-care behaviors, patients with an ulcer had more symptoms of depression than patients who were at risk for developing a foot ulcer. Studies examining cause-and-effect relationships between these observations and the potential role of depression interventions are needed. The results of this and other studies suggest depression screening is important in patients with diabetes mellitus and foot ulcers. {C}...

Low-frequency Ultrasound for Patients With Lower Leg Ulcers Due to Chronic Venous Insufficiency: A Report of Two Cases


  Low-frequency ultrasound may facilitate debridement and healing of chronic wounds, including lower leg wounds in patients with chronic venous insufficiency (CVI). To evaluate the use of a low-frequency ultrasound (LFU) device with a curette, two patients with CVI and chronic wounds were treated for a period of 2 to 3 weeks. A 63-year-old woman with rheumatoid arthritis and two wounds, one on the right lower leg (250 cm3) and one wound on the left medial leg (0.80 cm3), present for 12 months; and a 77-year-old man with cardiopulmonary issues with seven wounds, three on the left medial calf (1.2 cm3, 11.40 cm3, and 0.72 cm3), one on the left anterior calf (0.30 cm3), two on the right posterior calf (0.90 cm3, 0.30 cm3), and one on the right anterior calf (0.14 cm3), present for 3 months consented to participate in the study. Both patients received low-intensity (50–70 m), low-frequency (35 kHz) ultrasound at an intensity of 50% through a saline mist in addition to antimicrobial dressing with silver, a multilayer compression bandage system applied at every visit, and pain medication as needed. Both patients received treatments every 1 to 3 weeks that were not timed. Treatment continued until no additional slough or other necrotic tissue could be removed from the wound bed; the female patient received two treatment sessions and the male received three. Average wound volume did not change significantly from the first to last treatment session (t(8) – 1.2, P = 0.26). Five wounds (56%) with initial measurements of 0.8 cm3, 0.72 cm3, 0.3 cm3, 0.3 cm3, and 0.14 cm3 reduced in volume by 100%. Mean wound characteristic scores changed significantly (P <0.05) for amount of fibrin, periwound skin, drainage amount, and color. In addition, the number of wounds filled with slough decreased from 89% at the first session to 22% at the final treatment session. The results of this study suggest LFU may have been beneficial for these patients with CVI. Additional studies using larger sample sizes are needed to evaluate the effect of this treatment on a variety of chronic wounds and to compare its effectiveness to other debridement methods. {C}...

Guest Editorial: Getting to Know the NPUAP

  The National Pressure Ulcer Advisory Panel (NPUAP) is a national organization dedicated to improving patient outcomes in the field of pressure ulcers through education, research, and public policy. The Panel consists of a 15-member multidisciplinary Board of Directors and an advisory council comprising the Alumni Advisory Council, Corporate Advisory Council, Collaborating Organization Council, and Provider Organization Council. Three main committees carry out the mission of the NPUAP: the Education Committee, the Research Committee, and the Public Policy Committee. Each committee is chaired by members of the Board of Directors and involves representatives from each of the advisory councils. Committee projects further the knowledge base about the care, management, prevention, and treatment of pressure ulcers. ...

Pearls for Practice: Treating Enterocutaneous Fistulas With a Hydroconductive Dressing

  An enterocutaneous fistula (ECF) is an abnormal communication between the small or large bowel and the skin. ECFs most frequently occur postoperatively; the ileum is the most common source of origin.1 ECFs have posed vexing problems for clinicians since first described by Celsus in 53 BC.2 They are classified based on the amount of output of enteric contents as low output (<200 cc/day), moderate output (200–500 cc/day), and high output (>500 cc/day).3

  The standard treatment for an ECF is conservative because most fistulas will close spontaneously and operative attempts at fistula closure are fraught with complications.2 The patient needs to receive supportive care because electrolyte imbalance is common, depending on the amount of the loss of enteric contents containing fluid and electrolytes. ...

Nutrition 411: Strategies to Enhance Wound Healing in Frail Elders

  When meeting with a new patient, wound care professionals often focus on vital signs, oxygen saturation, medications, wound characteristics, and other clinical concerns. Although all of these are important to the recovery process, healing can be helped or hindered by the patient’s nutritional status, which often is not evaluated. The cause of poor nutrition in the elderly appears to be multifactorial and reflects physical and physiological limitations and psychosocial changes. Patients who are malnourished experience more complications and infections, which worsen their medical condition and decrease their survival rate.1 The accumulated effects of immobility, poor nutritional intake, and immune system challenges increase an elderly patient’s risk for pressure ulcers by 74%.2 For an already malnourished elderly patient with comorbidities, a pressure ulcer can be life-threatening. Although adequate dietary intake is important for all individuals, meeting the patient’s nutrient needs is even more important when a wound is present. This article will discuss various factors that hinder nutritional status and provide practical strategies to optimize nutrient intake and enhance wound healing....

AAWC Update

Board of Directors Election Continues through February 24

  Elections are being conducted at the Members-Only section of the AAWC website (www.aawconline.org) from January 20 to February 24. Only active, dues-paying members have voting privileges. Board members will attend the Annual Board of Directors Meeting and assume office at the Annual AAWC Membership Meeting this spring. These meetings are held in conjunction with our official spring conference, the Symposium on Advanced Wound Care (SAWC). Thank you to our members for their assistance in determining the future leaders of the AAWC. ...

My Scope of Practice: A Calling Within a Calling

“Some stories don’t have a clear beginning, middle, and end. Life is about not knowing, having to change, taking the moment and making the best of it, without knowing what’s going to happen next. Delicious ambiguity.” — Gilda Radner, American comedian and actress

  In 1975, Pamela Wilson, MSNEd, RN, CWOCN, started school part-time at the University of Pittsburgh (Pittsburgh, PA). She enrolled in night classes and worked for several years during that time as a Physical Therapist Aide at Kane Hospital (Pittsburgh, PA). Although she wasn’t entirely sure what career she wanted, she knew helping others needed to be a part of it. When Pam’s interests turned toward nursing, she transferred to a hospital-based school to gain more clinical experience. She became a registered nurse at the UPMC Shadyside School of Nursing program (Pittsburgh, PA), then finished her degree at Pennsylvania State University (McKessport, PA) in 1988. More than 20 years later, Pam’s career has come full-circle — she works at a nursing home and rehabilitation center, not as the physical therapist she once pictured, but as the Director of Wound Care. ...

Special to OWM: Highlights from the International Forum on Deep Tissue Injury Evolution: A Research-based Scientific Collaborative

 After 2 years of research and months of planning, the International Forum on Deep Tissue Injury Evolution: A Research-based Scientific Collaborative met at host site Staten Island University Hospital (SIUH), Staten Island, NY on October 15, 2013. The event was coordinated by Karen J. Farid, DNP, CWON/CNS, and moderated by Dr. Farid and Amit Gefen, PhD. More than seven researchers and a panel of five representatives from the New York State Department of Health (NYS DOH) and the Staten Island nursing community attended (see Table 1). The overarching intent of the Forum was to collate the animal, experimental, forensic, and nursing research with human studies and move toward one large body of evidence to increase current understanding of pressure-related deep tissue injury (DTI). The collaborative Forum centered on five specific goals: ...