Most of us have had days when we jump from meeting to meeting and at the end of the day wonder, “Did I get anything accomplished or am I more behind than ever?”
Many clinicians tell me that although their wound team meets regularly, the meetings aren’t meaningful enough, leaving the team still facing issues with their wound care program. As a consultant, when I review the wound team agenda, it’s typically missing one or more of four key ingredients:
appropriate member representation
proactive approach that highlights prevention
review of the plan of care and update of the medical record
review of supplies and products. Here’s a closer look at each of these ingredients.
Build a top team
Having the appropriate members on the wound care team is the first ingredient for success. A comprehensive, interdisciplinary team approach is the key to preventing skin breakdown and ensuring good clinical outcomes for residents with skin breakdown. Teams should include representation from nursing, dietary, and physical and occupational therapy, as well as a nurse practitioner or physician.
Nursing representation should include nurses from all three shifts and nursing assistants, who are too often missing from the team. Keep in mind that when it comes to preventing pressure ulcers, nursing assistants carry out most of interventions (for example, turning, incontinence management, heel lift). Even when a patient has a wound, the only intervention carried out by the nurses is the topical treatment; nursing assistants perform all other interventions necessary to ensure healing. Clinicians who empower nursing assistants to have a strong influence with the wound care team—and the program—tend to have very successful prevention programs and good clinical outcomes.
Think prevention
The second key ingredient is prevention. Most wound team meetings only discuss the patients with wounds, missing the bigger goal of preventing wounds in the first place. Once the patients with wounds are discussed, the team should review all high-risk patients to ensure proper preventative measures are in place and care planned. All patients should be quickly reviewed for evidence of:
decline or change in mobility and activity
new onset or change in continence status
decline in nutritional status
decline or change in cognition.
Any triggers in these areas should prompt a review of the plan of care to ensure they are being effectively addressed.
Review and update the plan
The third key ingredient for success is to use meeting time to review and update the plan of care. I’ve observed highly productive meetings and great discussions of the care the facility is providing. Then I review the medical record and discover that none of the interventions discussed are on the plan of care. Always review the patient’s plan of care to ensure it’s accurate, reflects all interventions, and is up to date. This will give you peace of mind that the medical record reflects all the good work you’re doing and helps make the team meetings feel productive.
Discuss products and supplies
The fourth key ingredient is to take the time to quickly discuss current wound care supplies and products with the team. Ask the team if the current supplies are user-friendly, are adequate, provide good outcomes, and are in good working condition.
Many times staff will not say how they’re struggling with, modifying, or not using something until they’re asked. Remember that the most expensive product is the one that doesn’t work or doesn’t get used.
A recipe for success
Using these four key ingredients will lead you to a successful wound team meeting—and a successful program. The mix may not solve your too-many-meetings days, but will give you peace of mind that at least one meeting is productive.
Jeri Lundgren is director of clinical services at Pathway Health in Minnesota. She has been specializing in wound prevention and management since 1990.
Chronic venous insufficiency (CVI) is the most common cause of lower extremity wounds. The venous tree is defective, incapable of moving all the blood from the lower extremity back to the heart. This causes pooling of blood and intravascular fluid at the lowest gravitational point of the body—the ankle.
This article has two parts. Part 1 enhances your understanding of the disease and its clinical presentation. Part 2, which will appear in a later issue, explores the differential diagnosis of similar common diseases, the role that coexisting peripheral artery disease (PAD) may play, disease classification of venous insufficiency, and a general approach to therapy.
The most common form of lower extremity vascular disease, CVI affects 6 to 7 million people in the United States. Incidence increases with age and other risk factors. One study of 600 patients with CVI ulcers revealed that 50% had these ulcers for 7 to 9 months, 8% to 34% had them for more than 5 years, and 75% had recurrent ulcers.
Thrombotic complications of CVI include thrombophlebitis, which may range from superficial to extensive. If the thrombophlebitis extends up toward the common femoral vein leaving the leg, proximal ligation may be needed to prevent clot extension or embolization.
Understanding normal anatomy and physiology
Lower extremity veins flow horizontally from the superficial veins to the perforating veins and then into the deep veins. Normally, overall venous blood flows vertically against gravity from the foot and ankle upward toward the inferior vena cava (IVC). This antigravity flow toward the IVC results from muscular contraction around nonobstructed veins and one-way valves that close as blood passes them. These valves prevent abnormal backward blood flow toward the foot and ankle region.
The lower extremities have four types of veins. Superficial veins are located within the subcutaneous tissue between the dermis and muscular fascia. Examples are the greater and lesser (smaller) saphenous veins. Perforating veins connect the superficial veins to the deep veins of the leg. The deep veins are located below the muscular fascia. The communicating veins connect veins within the same system.
The greater saphenous vein is on the leg’s medial (inner) side. It originates from the dorsal veins on top of the foot and eventually drains into the common femoral vein in the groin region. By way of perforating veins, the greater saphenous vein drains into the deep venous system of both the calf and thigh.
The lesser saphenous vein is situated on the lateral (outer) side of the leg and originates from the lateral foot veins. As it ascends, it drains into the deep system at the popliteal vein behind the knee. Communicating veins connect the greater saphenous vein medially and the lesser saphenous vein laterally.
Intramuscular veins are the deep veins within the muscle itself, while the intermuscular veins are located between the muscle groups. The intermuscular veins are more important than other veins in development of chronic venous disease. Below the knee, the intermuscular veins are paired and take on the name of the artery they accompany—for example, paired anterior tibial, paired posterior tibial, and paired peroneal veins. Eventually, these veins form the popliteal vein behind the knee, which ultimately drains into the femoral vein of the groin.
As the common femoral vein travels below the inguinal ligament of the groin, it’s called the external iliac vein. Eventually, it becomes the common iliac vein, which drains directly into the IVC.
Pathophysiology
Abnormally elevated venous pressure stems from the leg’s inability to adequately drain blood from the leg toward the heart. Blood drainage from the leg requires the muscular pumping action of the leg onto the veins, which pump blood from the leg toward the heart as well as from the superficial veins toward the deep veins. Functioning one-way valves within the veins close when blood passes them, preventing blood from flowing backward toward the ankle. This process resembles what happens when you climb a ladder with intact rungs: As you step up from one rung to the next, you’re able to ascend.
CVI and the “broken rung” analogy
If the one-way valves are damaged or incompetent, the “broken rung” situation occurs. Think how hard it would be to climb a ladder with broken rungs: You might be able to ascend the ladder, but probably you would fall downward off the ladder due to the defective, broken rungs.
Normally, one-way valves ensure that blood flows from the lower leg toward the IVC and that the superficial venous system flows toward the deep venous system. The venous system must be patent (open) so blood flowing from the leg can flow upward toward the IVC. Blockage of a vein may result from an acute thrombosis (clot) in the superficial or deep systems. With time, blood may be rerouted around an obstructed vein. If the acute thrombosis involves one or more of the one-way valves, as the obstructing thrombosis opens up within the vein’s lumen, permanent valvular damage may occur, leading to post-thrombotic syndrome—a form of CVI.
CVI may result from an abnormality of any or all of the processes needed to drain blood from the leg—poor pumping action of the leg muscles, damage to the one-way valves, and blockage in the venous system. CVI commonly causes venous hypertension due to reversal of blood flow in the leg. Such abnormal flow may cause one or more of the following local effects:
leg swelling
tissue anoxia, inflammation, or necrosis
subcutaneous fibrosis
Compromised flow of venous blood or lymphatic fluid from the extremity.
“Water balloon” analogy
The effect of elevated venous pressure or hypertension is worst at the lowest gravitational point (around the ankle). Pooling of blood and intravascular fluid around the ankle causes a “water balloon” effect. A balloon inflated with water has a thin, easily traumatized wall. When it bursts, a large volume of fluid drains out. Due to its thicker wall, a collapsed balloon that contains less fluid is more difficult to break than one distended with water.
In a leg with CVI, subcutaneous fluid that builds up requires a weaker force to break the skin and ulcerate than does a nondistended leg with less fluid. This principle is the basis for compression therapy in treating and preventing CVI ulcers.
Effects of elevated venous pressure or hypertension
Increased pressure in the venous system causes:
abnormally high pressure in the superficial veins—60 to 90 mm Hg, compared to the normal pressure of 20 to 30 mm Hg
dilation and distortion of leg veins, because blood refluxes abnormally away from the heart and toward the lower leg and may move from the deep venous system into the superficial veins.
Abnormal vein swelling from elevated pressure in itself may impair an already abnormally functioning one-way valve. For instance, the valve may become more displaced due to the increase in intraluminal fluid, which may in turn worsen hypertension and cause an increase in leg swelling. Increased pressure from swollen veins also may dilate the capillary beds that drain into the veins; this may cause leakage of fluid and red blood cells from capillaries into the interstitial space, exacerbating leg swelling. Also, increased venous pressure may cause fibrinogen to leak from the intravascular plasma into the interstitial space. This leakage may create a fibrin cuff around the capillary bed, which may decrease the amount of oxygen entering the epidermis, increase tissue hypoxia, trigger leukocyte activation, increase capillary permeability, and cause local inflammation. These changes may lead to ulceration, lipodermatosclerosis, or both.
Visible changes may include dilated superficial veins, hemosiderin staining due to blood leakage from the venous tree, atrophie blanche, and lipodermatosclerosis. (See CVI glossary by clicking the PDF icon above.) Both atrophie blanche and lipodermatosclerosis result from local tissue scarring secondary to an inflammatory reaction of the leg distended with fluid.
Lipodermatosclerosis refers to scarring of subcutaneous tissue in severe venous insufficiency. Induration is associated with inflammation, which can cause the skin to bind to the subcutaneous tissue, causing narrowing of leg circumference. Lymphatic flow from the leg also may become compromised and inhibited in severe venous hypertension, causing additional leg swelling.
Patient history
In a patient with known or suspected CVI, a thorough history may lead to a working diagnosis. Be sure to ask the patient these questions:
Do you have pain?
Is your pain worse toward the end of the day?
Is the pain relieved with leg elevation at night?
Is it relieved with leg elevation during the day?
Do you have leg pain that awakens you at night?
How would you describe the pain?
Does the skin on your leg feel tight or irritated?
Have you noticed visible changes of your leg?
Do you have a leg ulcer?
Also determine if the patient has comorbidities that may exacerbate CVI, including PAD, renal failure, venous thrombosis, lymphedema, diabetes mellitus, heart failure, or malnutrition. (See CVI risk factors by clicking the PDF icon above .)
Common CVI symptoms
Approximately 20% of CVI patients have symptoms of the disease without physical findings. These symptoms may include:
tired, “heavy” legs that feel worse toward the end of the day
discomfort that worsens on standing
legs that feel best in the morning after sleeping or after the legs have been
elevated during the day.
Although patients may report leg discomfort, the history indicates that it doesn’t awaken them at night. Be aware that discomfort from CVI differs from that caused by PAD. With PAD, patients may report pain on exercise (claudication), pain with elevation (nocturnal pain), or constant pain (resting pain).
Signs of CVI (with or without ulcers) include:
leg swelling (seen in 25% to 75% of patients)
skin changes (such as hemosiderin staining or dermatitis)
telangiectasia, reticular veins, or both; while these are the most common signs, they represent an overall less severe finding
varicose veins with or without bleeding, occurring in one-third of patients with CVI.
Venous ulcers
Venous ulcers are the most common type of lower extremity ulcer. They’re commonly found on the medial aspect of the lower extremity, from the ankle to the more proximal calf area. Usually, they arise along the course of the greater saphenous vein, but also may be lateral and may occur at multiple locations. They aren’t found above the knee or on the forefoot. Venous ulcers are shallower than arterial ulcers and have considerable exudate consistent with drainage from a ruptured water balloon. They may extend completely around the leg.
CVI: From a heavy sensation to visible changes
In patients with CVI, blood flows within a lower extremity in an abnormal, reverse direction, causing build-up of blood and intravascular fluid around the ankle. Initially, this may cause only a sensation of heavy legs toward the end of the day, with no visible changes. Eventually, it may lead to venous ulcers or other visible changes. This abnormal blood flow results from dysfunction of the normal mechanisms that drain blood from the leg against gravity into the IVC.
Sardina D. Skin and Wound Management Course; Seminar Workbook. Wound Care Education Institute; 2011:92-112.
Donald A. Wollheim is a practicing wound care physician in southeastern Wisconsin. He also is an instructor for Wound Care Education Institute and Madison College. He serves on the Editorial Board for Wound Care Advisor.
If you’re keeping up on wound care, you know a lot of new things are coming to market with enough decent science behind them to make them reasonable options to consider in your practice. And as true-blooded Americans and citizens of the post-industrialized world, we want what’s newest, fastest, and best in class in everything. It’s just our nature.
But does it truly serve us to be eager to try new therapies even when the current treatment plan is successful? Perhaps. We know we must never close our eyes to new developments in our field that can lead to better outcomes. Knowing when and what to change can lead to better outcomes for the patient, the wound, and our collective pocketbook.
I’ve long maintained we can achieve excellent-quality wound care if we just stick to the basics the vast majority of the time. Why? Systemic, psychosocial, and local factors all affect wound healing—not just the dressing or cream. Our job is to provide the optimum environment possible for wound healing. That requires us to look at and support the whole body toward optimum health, not solely the wound.
The basics begin with identifying the cause of the wound and implementing interventions to reduce, control, or eliminate the cause. Next, we strive to manage local and psychosocial factors by choosing topical products that will maintain moisture balance, keep the wound warm, and protect it. If the wound doesn’t show progress toward healing within 2 weeks (or as expected, given the patient’s overall condition and ability to heal), we need to reevaluate the plan and begin making changes.
The best rule is to make one change at a time. That makes it much easier to determine what’s working and what isn’t. Once all the basics are in place and required changes have been made, if healing is still stalled or nonexistent, consider trying the available new products and specialty products.
Never close your clinical mind to advances in the field. To do that would be a disservice to your patients. But you should change the treatment plan only when a change is needed—not just for the sake of changing it.
Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS
Editor-in-Chief Wound Care Advisor
Cofounder, Wound Care Education Institute
Plainfield, Illinois
The number of people with diabetes who are meeting the ABC goals—hemoglobin A1C, blood pressure, and LDL cholesterol—has risen significantly in recent years, according to a study published by Diabetes Care. Patients meeting all three goals rose from about 2% in 1988 to about 19% in 2010.
Gains were made in each of the ABC goals, based on 2007 to 2010 data: 53% of patients met A1C goals, compared to 43% in 1988 to 1994 data; 51% met blood pressure goals, compared to 33%; and 56% met LDL goals, compared to 10%.
Younger people were less likely to meet A1C and cholesterol goals. Compared with non-
Hispanic whites, Mexican Americans were less likely to meet A1C and LDL goals and non-Hispanic blacks were less likely to meet blood pressure and LDL goals.
The researchers analyzed data from the National Health and Nutrition Examination Surveys from 1988–1994, 1999–2002, 2003–2006, and 2007–2010. Nearly 5,000 people age 20 or older participated.
Although progress had been made, the researchers conclude, “Despite significant improvement during the past decade, achieving the ABC goals remains suboptimal among adults with diabetes, particularly in some minority groups.”
Daily bathing with chlorhexidine-impregnated washcloths reduces infection risk
A study in The New England Journal of Medicine reports that daily bathing with chlorhexidine-impregnated washcloths reduces the risk of becoming infected with multidrug-resistant organisms and subsequent development of hospital-acquired bloodstream infections in intensive care unit patients.
“Effect of daily chlorhexidine bathing on hospital-acquired infection” included 7,727 patients in nine intensive care and bone marrow units in six hospitals. The units were randomly assigned to bathe patients with either no-rinse 2% chlorhexidine-impregnated washcloths or nonantimicrobial washcloths for 6 months; then, the units switched to the opposite product for 6 months.
The rate of infection with multidrug-resistant organisms was 23% lower in the chlorhexidine group and the rate of hospital-acquired bloodstream infection was 28% lower in the chlorhexidine group.
Patients tend not to wear custom-made footwear for preventing diabetic foot ulcers
Adherence to wearing prescription custom-made footwear was low among patients with diabetes, neuropathy, and a recently healed plantar foot ulcer, according to a study in Diabetes Care. The low adherence was particularly notable at home, where patients did the most walking.
Factors associated with higher adherence included lower body mass index, more severe foot deformity, and more appealing footwear.
Tedizolid works as well as linezolid in patients with acute bacterial skin infections
A JAMA study says that a 200-mg once-daily dose of oral tedizolid phosphate over 6 days was as effective as 600 mg of oral linezolid every 12 hours for 10 days in patients with acute bacterial skin and skin-structure infections, including cellulitis or erysipelas, major cutaneous abscesses, and wound infections.
A shorter course of tedizolid may be a “reasonable alternative” to linezolid for treating acute bacterial skin and skin-structure infections, the study concludes.
Water-based exercise improves ROM in patients with long-term arm lymphedema
A study of breast cancer survivors (median 10 years after surgery) with lymphedema found that a water-based exercise program improved shoulder range of motion (ROM).
The program consisted of at least twice-weekly water-based exercise for 8 weeks. At first, participants were supervised, but later they exercised independently. Although lymphedema status didn’t change, those who performed water-based exercise had an increase in ROM, showing improvement years after surgery.
Dehydrated amniotic membrane allograft possible option for treating chronic wounds
A dehydrated amniotic membrane allograft (EpiFix) was used to treat four patients whose wounds hadn’t closed after conservative and advanced measures and who had been referred for plastic procedures. A variety of wounds healed (located on the elbow, knee, hand, and ankle) after one to three applications of the amniotic material, which patients tolerated well. The wounds remained closed several months later.
Study casts doubt on MLD’s role in breast cancer–related lymphedema
A meta-analysis published in the World Journal of Surgical Oncology found the “current evidence” from randomized clinical trials “does not support” the use of manual lymphatic drainage (MLD) in preventing or treating lymphedema in patients with breast cancer.
The authors analyzed 10 randomized clinical trials with 566 patients.
CDC issues additional prevention steps for carbapenem-resistant Enterobacteriaceae
On Feb. 14, the Centers for Disease Control and Prevention (CDC) issued additional prevention steps for carbapenem-resistant Enterobacteriaceae (CRE). Increased reports of CRE prompted the action: Of the 37 unusual forms of CRE reported in the U.S., the last 15 have been reported since July 2012.
• When a CRE is identified in a patient with a history of an overnight stay in a healthcare facility (within the last 6 months) outside the U.S., send the isolate to a reference laboratory for confirmatory susceptibility testing and test to determine the carbapenem resistance mechanism.
• For patients admitted to healthcare facilities in the U.S. after recently being hospitalized (within the last 6 months) in countries outside the U.S., consider performing rectal screening cultures to detect CRE colonization, and place patients on contact precautions while awaiting the results.
Examples of Enterobacteriaceae include Klebsiella species and Escherichia coli. CRE are Enterobacteriaceae with high levels of resistance to antibiotics, including carbapenems. CRE infections most commonly occur among patients who are receiving antibiotics and significant medical treatment for other conditions.
Clinical practice guidelines help ensure we are applying the latest knowledge and expertise when we’re caring for patients. Here are a few recent guidelines that you may find useful.
Measurement of ankle-brachial index
An American Heart Association scientific statement, “Measurement and interpretation of the ankle-brachial index (ABI),” published in Circulation, outlines the use of ABI, terminology, how to calculate the value, training, standards, and suggestions for future research.
Recommendations for obtaining an ABI measurement include:
• Use the Doppler method to determine the systolic blood pressure in each arm and each ankle.
• Use the appropriate cuff size, with a width of at least 40% of the limb circumference.
• Place the ankle cuff just above the malleoli with the straight wrapping method.
• Cover open lesions with the potential for contamination with an impermeable dressing.
• Avoid using a cuff over a distal bypass.
The article also recommends measurement and interpretation of ABI be part of the standard curriculum for nursing and medical students. For more information about ABI, read “Bedside ankle-brachial index testing: Time-saving tips” in this issue of Wound Care Advisor.
Childhood obesity continues to be a significant problem in the United States, requiring innovative approaches for prevention and management. Those who are obese run the risk of poorer wound healing.
“Approaches to the prevention and management of childhood obesity: The role of social networks and the use of social media and related electronic technologies: A scientific statement from the American Heart Association,” published in Circulation, evaluates the role of social networks and social media in relation to childhood obesity and presents five steps for using social networks: 1 Define the goal of the intervention. 2 Identify the social network. 3 Develop and pilot test the intervention. 4 Implement the intervention. 5 Spread the intervention.
The guidelines conclude that social media holds promise as a tool, but more research is needed.
Guidelines for managing patients with stable ischemic heart disease
Many patients with wound or ostomy needs have comorbid heart disease. Be sure you are aware of the most current information for managing these patients by accessing “2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease,” published in Circulation.
The guidelines acknowledge the vital importance of shared decision making between the healthcare provider and the patient. The information is divided into four sections with supporting algorithms:
• approaches to diagnosis
• risk assessment
• treatment
• follow-up.
Access the top 10 things to know and the executive summary.
In each case, the synthesis includes information in the following categories:
• areas of agreement and difference
• comparison of recommendations
• strength of evidence and recommendation grading schemes
• methodology
• source(s) of funding
• benefits and harms
• abbreviations
• status.
Access these and other guideline syntheses from AHRQ.
Bonus resource: Ethical case study of a patient refusing skin ulcer treatment
Free, one-time registration is required to view the entire video and all other
content on the Medscape website.
Patients have a right to make their own decisions, but what happens when a decision is so painful for staff that it affects morale? Arthur Caplan, PhD, Division of Medical Ethics at the NYU Langone Medical Center in New York, discusses such a case: “Patients have the right to choose death from bedsores.”
In most cases, amputation (removal of an extremity, digit, or other body part) is a surgical intervention performed to remove tissue affected by a disease and, in some cases, to provide pain relief. Fecal and urinary diversion surgeries also are considered amputations. Amputations and fecal or urinary diversions (ostomies) require extensive rehabilitation and adaptation to a new way of life, with physiologic and psychological impacts. Although diversions and ostomies usually are less visible to others than other types of amputations, they call for similar patient education, rehabilitatio n, and lifelong counseling.
The primary goal of therapy for ostomates and amputees is to resume their presurgical lifestyle to the greatest extent possible and to adapt to their new circumstances. Preoperative assessment and training interventions have proven valuable. Having a clear understanding of the surgical intervention helps reduce postoperative anxiety and depression, which can pose roadblocks to patients’ adaptation or response to their new situation. Successful interventions should be done by healthcare professionals who are trained in caring for ostomates and amputees.
Ostomates and amputees experience similar psychosocial challenges, body-
image problems, and sexuality concerns. This article focuses on these three issues. For a summary of other issues these patients may experience, see Other problems amputees and ostomates may face by clicking the PDF icon above.
Psychosocial challenges
Ostomates and amputees may experience depression, anxiety, fear, and many other concerns related to the surgical procedure—concerns that center on whether they’ll be able to resume their presurgical lifestyle. Many worry about social isolation and loss of income. Some fear both the primary disease process and the lifestyle changes induced by surgery. Anxiety may impede their social interactions and lead to significant psychological problems. Appropriate and effective counseling and therapy must be planned and provided. (But be aware that untrained or inexperienced healthcare professionals may not be able to provide the guidance the patient needs to feel comfortable; some may be unable even to offer information about available support systems.)
These patients also may find themselves socially isolated, in part due to loss of employment or the socioeconomic consequences of a decreased income. Some experience fear and worry when anticipating lifestyle changes caused by loss in or change of function, adaptation to the prosthesis, and treatment costs.
Maintaining social contact after surgery is extremely important to recovery and adaptation to the amputation or ostomy. The United Ostomy Associations of America and the Amputee Coalition encourage patients to maintain social involvement. Both groups suggest patients discuss their feelings, thoughts, and fears with a trusted family member, friend, or partner. Both organizations sponsor and encourage support-group involvement. In some cases, emotional support from other amputees or ostomates with a similar experience may be appropriate; some patients may be more comfortable sharing thoughts and asking questions in a group of people with similar experiences. Resuming presurgical social events and activities can enhance patients’ adaptation to a new way of life.
Ostomates and amputees have to cope not only with changes in physical appearance but with how their body functions and how they feel and perceive their body. They’re keenly aware of their changed appearance and are concerned about others’ perceptions of them. They may feel anxious and depressed related to body image; the degree of anxiety and depression may relate directly to their presurgical body image and activities. Many become anxious and fearful as they adapt to the prosthesis. (See Stages of grief by clicking the PDF icon above.)
Compared to amputees, ostomates may have more concerns about body image with sexual partners, because the stoma is, in a sense, a hidden amputation. In most cases, the stoma and pouch can be obscured visually from others. The amputee, on the other hand, has fewer options for hiding the missing body part.
To help patients cope with body-image problems, care providers must offer education, therapy, and counseling to help the patient accept and successfully adapt to the body-image change. The first step in this process may simply be to have the patient look at the stoma or stump, progressing to participation in prosthesis care.
Sexuality concerns
Many ostomates and amputees have difficulty resuming sexual activity after surgery. Although the stoma usually remains hidden from others, it’s observable to the ostomate and sex partner. Most patients require an adjustment period before they feel comfortable with a sex partner. They may fear that:
• the partner will reject them or no longer find them attractive
• they will experience loss of function and sensation
• they will experience pain or injury of the stoma.
They also may feel embarrassed, causing them to avoid sex. However, counselors can help couples discuss these concerns and resume a satisfactory sexual relationship. Ostomates and amputees and their partners may need counseling to resume a satisfactory sexual relationship. If they continue to have adjustment difficulties, referral to a trained sex counselor or psychologist may be indicated. Several studies show that appropriate counseling can help prevent complications and allow amputees and ostomates to continue to express their affection physically. (See Talking to patients about sexual problems by clicking the PDF icon above.)
Resuming sexual activity may be easier if the ostomate or amputee had a sex partner before surgery. However, males who experience postsurgical erectile dysfunction are less likely than other males to resume sexual activity. Counseling encourages postsurgical patients to focus more on the pleasurable feelings they and their partners feel, rather than on sexual performance. Body-image problems and inadequate sexual adjustment go hand in hand. (See Helping ostomates resume sex by clicking the PDF icon above.)
Team approach to patient education and counseling
In many parts of the country, a designated healthcare team manages amputees’ care and rehabilitation. But until recently, nurses were the only professionals certified to participate in ostomates’ care and rehabilitation. In fact, ostomates may represent a significant underserved population. A 2012 study found many ostomy patients didn’t receive consistent training and counseling from ostomy certified nurses. Only 13% of respondents reported they had regular visits with an ostomy certified nurse; 32% said they’d never received care from an ostomy nurse. Just over half (56%) indicated they saw an ostomy nurse when they thought it was necessary. The study also reported that 57% hadn’t seen an ostomy certified nurse in more than 1 year.
A team with specialized training to address ostomates’ physical and psychosocial needs might be able to provide the specialized care these patients need. The primary medical caregiver or general practitioner would serve as team leader and make appropriate referrals. The team should include a surgeon, ostomy- and amputee-trained nurses, a prosthetist or other healthcare provider trained in selection and fitting of prosthetic equipment and devices that affect function, a physical therapist, an occupational therapist, a social worker, a vocational counselor, a psychologist, caregiver or family members, support groups, and (last but not least) the patient.
The team approach might reduce hospital stays and promote patients’ return to their home environment. It also might encourage independence and enhance the success of long-term adaptation.
Focus on the future
Healthcare providers should encourage ostomates and amputees to focus on the future, not the past. Feeling comfortable with the prosthesis—the amputee’s artificial limb or the ostomate’s pouching system—is essential to adapting to a “new normal” way of life. Maintaining social relationships is important to adaptation as well. Mastering basic skills and adapting to changes in body function help improve the patient’s quality of life. Follow-up visits, phone contact, and access to a team of well-trained healthcare providers for patient education, rehabilitation, and long-term management are crucial to these patients’ successful adaptation and quality of life.
Selected references
Bhuvaneswar CG, Epstein LA, Stern TA. Reactions to amputation: recognition and treatment. Prim Care Companion J Clin Psychiatry. 2007;9(4):303-8.
Davidson T, Laberge M. Amputation. Gale Encyclopedia of Surgery: A Guide for Patients and Caregivers. 2004. www.encyclopedia.com/doc/1G2-3406200023.html. Accessed December 20, 2012.
Erwin-Toth P, Thompson SJ, Davis JS. Factors impacting the quality of life of people with an ostomy in North America: results from the Dialogue Study. J Wound Ostomy Continence Nurs. 2012;39(4):417-22.
Maguire P, Parkes CM. Surgery and loss of body parts. BMJ. 1998;316(7137):1086-8.
Pittman J, Kozell K, Gray M. Should WOC nurses measure health-related quality of life in patients undergoing intestinal ostomy surgery? J Wound Ostomy Continence Nurs. 2009;36(3):254- 65.
Pittman J. Characteristics of the patient with an ostomy. J Wound Ostomy Continence Nurs. 2011;38(3):271-9.
Racy JC. Psychological adaptation to amputation. In Bowker JH, Michael JW, ed. Atlas of Limb Prosthetics: Surgical, Prosthetic, and Rehabilitation Principles. 2nd ed. Rosemont, IL: American Academy of Orthopedic Surgeons; 1998.
Tunn PU, Pomraenke D, Goerling U, Hohenberger P. Functional outcome after endoprosthetic limb-salvage therapy of primary bone tumours—a comparative analysis using the MSTS score, the TESS and the RNL index. Int Orthop. 2008;32(5):619-25.
Turnbull G. Intimacy After Ostomy Surgery Guide. United Ostomy Associations of America, Inc. Revised 2009. www.ostomy.org. Accessed December 20, 2012.
Turnbull G. Sexuality after ostomy surgery. Ostomy Wound Manage. 2006;52(3):14,16.
Every year, all long-term care (LTC) facilities funded by Medicare or Medicaid are inspected to ensure they are in compliance with federal and state regulations. The regulations are broken down into so-called F-Tags to help track data. The F-Tag designated for review of the facility’s pressure-ulcer prevention and management program is F314. If a resident develops a pressure ulcer in the facility or if a pressure ulcer worsens while the resident is in the facility (even
if the resident was admitted with the pressure ulcer), the facility could face a citation under F314. Such a citation, if not remedied, could lead to financial penalties, Medicare and Medicaid fund stoppages, or even closing of the facility.
When preparing for this annual survey, many providers focus on the charts of residents with wounds. However, many citations are triggered from residents without wounds. For example, a surveyor may observe a resident lying in a position longer than the plan of care indicates. So when preparing for a survey, staff should always look at the big picture—wound prevention and management.
The following items should be audited to help ensure your documentation is compliant with the F314 tag:
1. The risk assessment (such as with the Braden risk assessment tool) should be current and accurate. In LTC facilities, the risk assessment should be done:
• on admission or readmission
• weekly for the first 4 weeks after
admission
• with a change in the resident’s condition
• quarterly or annually with the minimum data set (MDS).
2. The plan of care should be audited to ensure that:
• all risk factors identified from the risk assessment, MDS, care area assessment, resident history, physical examination, and overall chart review are pulled forward and listed on the skin integrity plan of care
• the plan of care identifies correlating interventions to help stabilize or modify individual risk factors
• staff have been interviewed and have physically observed the resident to ensure all risk factors and interventions provided are reflected accurately on the plan of care.
3. Nursing-assistant assignment sheets should match the information on the plan of care.
4. Head-to-toe skin checks are performed weekly on all residents by licensed staff.
5. Wound assessments are done at least every 7 days, are complete and accurate, and include evaluation of wound progress.
6. Documentation reflects that the physician or nurse practitioner, family, and interdisciplinary team are notified when a wound is discovered, when no progress has occurred in 2 weeks, when the resident declines, and when the wound heals.
7. The treatment sheet order is transcribed accurately and treatment is being provided as prescribed.
Other items to audit
Also audit these items to prepare for the survey:
• resident turning and repositioning
• incontinence care
• use of supplies, equipment, and devices (such as heel lift boots, wheelchair cushions, and powered mattresses) to ensure these are functioning properly and are in good condition
• dressing-change technique
• storage of wound care supplies to ensure they meet infection-control guidelines and haven’t expired.
Ideally, the wound care nurse or nurse manager should set aside a designated number of hours every month to audit charts and observe hands-on care. This person also can use weekly wound rounds to monitor dressing changes, nurses’ ability to assess wounds, and equipment and dressing supplies.
Jeri Lundgren is director of clinical services at Pathway Health in Minnesota. She has been specializing in wound prevention and management since 1990.
Guidelines for managing prosthetic joint infections released
The Infectious Diseases Society of America has released guidelines for diagnosing and managing prosthetic joint infections.
“Diagnosis and management of prosthetic joint infection: Clinical practice guidelines by the Infectious Diseases Society of America,” published in Clinical Infectious Diseases, notes that of the 1 million people each year who have their hips or knees replaced, as many as 20,000 will get an infection in the new joint.
The guidelines describe the best methods for diagnosing these infections, which are not easy to identify. Specifically, infection should be suspected in a patient who has any of the following: persistent wound drainage in the skin over the joint replacement, sudden onset of a painful prosthesis, or ongoing pain after the prosthesis has been implanted, especially if there had been no pain for several years or if there is a history of prior wound healing problems or infections.
Guidelines for treating infections are included and note that 4 to 6 weeks of I.V. or highly bioavailable oral antibiotic therapy is almost always necessary to treat prosthetic joint infections.
A decade of TIME
The TIME acronym (tissue, infection/inflammation, moisture balance, and edge of wound) was first developed more than 10 years ago to provide a framework for a structured approach to wound bed preparation and a basis for optimizing the management of open chronic wounds healing by secondary intention. To mark the event, the International Wound Journal has published “Extending the TIME concept: What have we learned in the past 10 years?”
The review points out four key developments:
• recognition of the importance of biofilms (and the need for a simple diagnostic)
• use of negative-pressure wound therapy
• evolution of topical antiseptic therapy as dressings and for wound lavage (notably, silver and polyhexamethylene biguanide)
• expanded insight into the role of molecular biological processes in chronic wounds (with emerging diagnostics).
The authors conclude, “The TIME principle remains relevant 10 years on, with continuing important developments that incorporate new evidence for wound care.”
Bed alarms fail to reduce patient falls
A study in Annals of Internal Medicine found that the use of bed alarms had no statistical or clinical effect on falls in an urban community hospital.
The 18-month trial included 16 nursing units and 27,672 inpatients. There was no difference in fall rates per 1,000 patient-days, the number of patients who fell, or the number of patients physically restrained on units using bed alarms, compared with control units.
Authors of “Effects of an intervention to increase bed alarm use to prevent falls in hospitalized patients: A cluster randomized trial” speculate the lack of response may be related to “alarm fatigue.”
Drug for HIV might help in Staph infections
A study in Nature reports that the drug maraviroc, used to treat HIV, might be useful for treating Staphylococcus aureus infections.
“CCR5 is a receptor for Staphylococcus aureus leukotoxin ED” found that the CCR5 receptor, which dots the surface of immune T cells, macrophages, and dendritic cells, is critical to the ability of certain strains of Staph to specifically target and kill cells with CCR5, which orchestrate an immune response against the bacteria. One of the toxins the bacterium releases, called LukED, latches on to CCR5 and subsequently punches holes through the membrane of immune cells, causing them to rapidly die.
When researchers treated cells with CCR5 with maraviroc and exposed the cells to the Staph toxin, they found maraviroc blocked toxic effects.
Dog able to sniff out C. difficile
A 2-year-old beagle trained to identify the smell of Clostridium difficile was 100% successful in identifying the bacteria in stool samples, and correctly identified 25 of 30 cases of patients with C. difficile, according to a study in BMJ.
“Using a dog’s superior olfactory sensitivity to identify Clostridium difficile in stools and patients: Proof of principle study” discusses how the dog was trained to detect C. difficile and concludes that although more research is needed, dogs have the potential for screening for C. difficile infection.
After-hours access to providers reduces ED use
Patients who have access to their primary healthcare providers after hours use emergency departments (EDs) less frequently, according to a study in Health Affairs.
“After-hours access to primary care practices linked with lower emergency department use and less unmet medical need” found that 30.4% of patients with after-hours access to their primary care providers reported ED use, compared with 37.7% of those without this access. In addition, those with after-hours access had lower rates of unmet needs (6.1% compared to 12.7%).
The findings come from the 2010 Health Tracking Household Survey of the Center for Studying Health System Change. The total sample included 9,577 respondents.
Neuropathic pain in patients with DPN might contribute to risk of falling
The presence of neuropathic pain in patients with diabetic peripheral neuropathy (DPN) contributes to gait variability, which could in turn contribute to the risk of falling, according to “Increased gait variability in diabetes mellitus patients with neuropathic pain.”
The study, published in the Journal of Diabetes and Its Complications, compared patients with at least moderate neuropathic pain with those who had no pain. Researchers used a portable device to measure gait parameters, such as step length and step velocity.
Amputation rates decrease significantly in patients with PAD
“Temporal trends and geographic variation of lower-extremity amputation in patients with peripheral artery disease (PAD): Results from U.S. Medicare 2000–2008” found that amputation rates have decreased significantly, but that significant patient and geographic variations remain.
The study, published in the Journal of the American College of Cardiology, found that among 2,730,742 older patients with identified PAD, the overall rate of lower extremity amputation decreased from 7,258 per 100,000 patients to 5,790 per 100,000. Predictors of lower-extremity amputation included male sex, black race, diabetes mellitus, and renal disease.
January is traditionally the time of year when everyone starts the New Year fresh with resolutions for change—better organization, healthy living, new beginnings. This year, I want to challenge you to include your patients in your resolution planning. Work with each patient and come up with ideas to help improve their quality of life by, for instance, healing a wound, wearing a splint, keeping blood glucose levels within normal range, elevating the feet.
For resolutions to be effective, a “buy in” must exist. Most people don’t like
being told what they must do and would rather hear what they can do. So be sure to include your patients in the planning process. Ask them their opinion. Ask “What could I do differently to help you with this?” Determine if their treatments could be interfering with their lifestyle. Set mutually compatible goals. Most of all, help promote patients’ search for their own solutions.
To make an informed choice of can do instead of must do, patients must have a clear understanding of the facts, implications, and consequences. The Institute of Medicine defines health literacy as the degree to which individuals have the capacity to understand, obtain, and process basic health information needed to make appropriate health decisions. It’s easy to assume our patients know all the facts, especially if they have had the wound, ostomy, or diagnosis for many years. However, according to the 2003 National Assessment of Adult Literacy, almost 45% of the U.S. population (about 93 million Americans) have, at best, only basic health literacy skills.
To improve their health literacy, review your patients’ understanding of their situation and ask them to describe their diagnosis and treatment plan in their own words. If they can’t describe these correctly, reteach the information. Consider the possibility that you might have to use a new educational approach or method.
A new year and a new start, with a shared understanding of problems and potential solutions between the patient and wound care team can get you started on the pathway to success. To quote Zig Ziglar, “A goal properly set is halfway reached.”
Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS
Editor-in-Chief Wound Care Advisor
Cofounder, Wound Care Education Institute
Plainfield, Illinois
Renee asks her mentor, Susan, a question. Susan puts her hand near Renee’s face, gesturing for her to “Stop,” and says in a loud voice, “I told you the answer to that this morning. Why are you bothering me again?”
You’re working your shift with Amy, who’s in charge of the unit. She refuses to have a meaningful conversation with you, and ignores you or sighs impatiently when you try to share patient information with her.
These examples reflect lateral (horizontal) violence or abuse in the workplace, defined as violence or abuse occurring between workers. It includes both overt and covert acts of verbal and nonverbal aggression.
Chances are you’ve experienced or witnessed disruptive or inappropriate behavior by a peer or colleague. Intimidation, bullying, insults, humiliation, gossip, constant criticism, and angry outbursts are a few examples. More subtle examples include favoritism, unfair work assignments, inappropriate or unfair evaluations, sarcasm, snide comments, withholding information, holding a grudge, and belittling gestures.
Lateral violence in any form feels bad. It creates fear—and fear causes you to shrink and hold back from being your best. You can’t be productive in a fearful environment. Instead, you may feel violated, anxious, stressed, disrespected, and angry. A response of silence or ignoring the offender is common, but not ideal. Here are some better strategies.
Acknowledge your feelings
Admit to yourself that you’re hurting and something is wrong. Many victims dismiss or minimize the event, or even blame themselves. Resist that temptation. If it feels bad, it is bad. And if you allow the behavior, that person is sure to repeat it—not because she’s a bad person, but because she doesn’t realize her behavior is wrong. If you respond by acting surprised and assuming she doesn’t know what she’s doing and has no idea how her actions affect you, it will be easier to respond professionally and quickly.
If abuse or violence of any form is tolerated, it will continue. And the negative workplace culture will significantly affect the health and well-being of both staff and patients.
Respond appropriately
Here are the four keys to responding appropriately to lateral violence in the workplace—or anywhere else, for that matter.
Manage your emotions
Take a deep breath and pause. Don’t react right away. Self-awareness is crucial to managing your emotions and your responses. Take a time-out if you’ve become emotional. Use calming techniques, such as deep breathing, guided imagery, humor, or prayer. If you try to deal with the perpetrator while upset, you’re more likely to behave unprofessionally. Restrain yourself until you feel able to assert yourself in a professional manner.
Use empathy
Try to find out where the person’s coming from to help understand what’s going on with her that might have triggered her behavior. For example, a person may engage in negative behavior because she’s going through a divorce. (See It’s not about you by clicking the PDF icon above.)
Keep in mind that bad behavior reflects poor self-esteem and serves as a wall to keep people out. It’s also learned behavior. Someone who behaves badly has learned this behavior brings some kind of reward; otherwise, she wouldn’t do it. Perhaps the reward is attention or power. Whatever it is, she gains something from the behavior at others’ expense. Most likely, she’s unaware of this dynamic.
By using empathy, you not only learn more about the offender; that person learns more about herself. Show an interest in why she behaved that way by asking questions; for instance: “I’ve noticed you’ve been more impatient lately. Are you okay? Is there something going on I should know about?” When you’ve gained a clearer understanding of the person, you can set clear expectations and boundaries.
Assert your boundaries
Asserting your boundaries tells others what behaviors are unacceptable. When you assert your boundaries, you honor yourself. When something doesn’t feel right, tell the person directly that her behavior is inappropriate and ask her to stop it. If you say nothing, your silence implies the behavior is acceptable.
Tell the person directly that her behavior is inappropriate. Keep it simple and clear. Use such language as “This doesn’t work for me.” That way, you’re accepting responsibility for your feelings and you’re not making her wrong.
Asserting a boundary might sound like this: “Please lower your voice.” But be careful of the tone you use when making the request. You might ask, “Did you realize you were yelling?” She might not be aware of how angry or loud she is at that moment.
Make direct requests
Tell the person directly how you’d like to be treated or how you want the two of you to work together. Identify what you want instead of what you’re getting—and then ask for it. Don’t assume she knows how to treat you. Determine what your goals are and what you need from her to accomplish what’s expected. If you can, try to establish a mutual goal for you both to work on, such as a more productive relationship so there’s less tension. Clearly communicating your requests informs others of the behavior you expect.
A case of respect
You might not want to befriend people at work, and you don’t have to like them. But each of us deserves to be treated with respect. To get respect, you must give it. If it’s not reciprocated, ask for it. Treat everyone with respect.
If you experience lateral hostility or violence on the job, deal with it directly and immediately. If it happens again, deal with it directly again and report it to your supervisor.
No matter how professional and respectful you are or how assertively you express your boundaries and needs, if your work environment remains abusive and leadership doesn’t address it or do enough to change it, you may need to leave your job. Stop wasting time and energy trying to fix a problem no one else wants to fix. Life is too short, and you deserve better.
Julie Donley is nurse manager for Devereux Children’s Behavioral Health Services in Pennsylvania. She has published hundreds of articles and just released her new book, Does Change Have to Be So H.A.R.D.? Visit www.JulieDonley.com to learn more.
