More results...
Practical Issues in Wound, Skin and Ostomy Management
In a busy wound clinic, quick and accurate differential diagnosis of edema is essential to appropriate treatment or referral for comprehensive care. According to a 2010 article in American Family Physician, 80% of lower extremity ulcers result from chronic venous insufficiency (CVI). In 2007, the German Bonn Vein Study found 100% of participants with active venous ulcers also had a positive Stemmer’s sign, indicating lymphedema. (more…)
Read More
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.
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.
http://circ.ahajournals.org/content/126/24/2890
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.
http://circ.ahajournals.org/content/early/2012/12/03/CIR.0b013e3182756d8e
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.
http://circ.ahajournals.org/content/126/25/e354
The Agency for Healthcare Research and Quality (AHRQ) has made it easier to compare guidelines for managing pressure ulcers by publishing two guideline syntheses:
• Management of pressure ulcers
• Prevention of pressure ulcers
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.
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.”
Read MoreBy Rosalyn Jordan, BSN, MSc, RN, CWOCN, WCC
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.
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.
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.)
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.
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.
Bishop M. Quality of life and psychosocial adaptation to chronic illness and acquired disability: a conceptual and theoretical synthesis. J Rehabil. 2005 Apr. www.thefreelibrary.com/Quality+of+life+and+psychosocial+adaptation+to+chronic+illness+and…-a0133317579. Accessed December 20, 2012.
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.
Houston S. Body image, relationships and sexuality after amputation. First Step: A Guide for Adapting to Limb Loss. 2005;4. www.amputee-coalition.org/
easyread/first_step_2005/altered_states-ez.html. Accessed December 20, 2012.
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.
United Ostomy Associations of America, Inc. From US to YOU: living with an ostomy, the experience. http://www.ostomy.org/files/asg_resources/UOAA_Nursing_Information_Modules.pdf. Accessed December 20, 2012.
United Ostomy Associations of America, Inc. What is an ostomy? http://www.ostomy.org/ostomy_info/
whatis.shtml. Accessed December 20, 2012.
Rosalyn Jordan is director of clinical education at RecoverCare, LLC, in Louisville, Kentucky.
Read MoreEvery 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.
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.
Read MoreEach month, Apple Bites brings you a tool you can apply in your daily practice.
According to the American Diabetes Association, all patients with diabetes should be screened for loss of protective sensation in their feet (peripheral neuropathy) when they are diagnosed and at least annually thereafter, using simple clinical tests such as the Semmes-Weinstein monofilament exam.
The Semmes-Weinstein 5.07 monofilament nylon wire exerts 10 g of force when bowed into a C shape against the skin for 1 second. Patients who can’t reliably detect application of the 5.07, 10-g monofilament to designated sites on the plantar surface of their feet are considered to have lost protective sensation. (more…)
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
Use this handy reference tool to help you assess lower extremity ulcers. You can download a PDF of the tool.
Donna Sardina is Editor-in-Chief of Wound Care Advisor and cofounder of the Wound Care Education Institute in Plainfield, Illinois.
Read MoreBy Carrie Carls, BSN, RN, CWOCN, CHRN; Michael Molyneaux, MD; and William Ryan, CHT
Every year, 1.9% of patients with diabetes develop foot ulcers. Of those, 15% to 20% undergo an amputation within 5 years of ulcer onset. During their lifetimes, an estimated 25% of diabetic patients develop a foot ulcer. This article discusses use of hyperbaric oxygen therapy (HBOT) in treating diabetic foot ulcers, presenting several case studies.
HBOT involves intermittent administration of 100% oxygen inhaled at a pressure greater than sea level. It may be given in a:
• multi-place chamber (used to treat multiple patients at the same time), compressed to depth by air as the patient breathes 100% oxygen through a face mask or hood (more…)
There’s an app for that! Here are a variety of medical apps that you might want to try. You can download them in the iTunes store, and the basic service is free.
More than 1.4 million healthcare professionals use this app from WebMD, which includes:
• medical news
• clinical reference information, such as drugs and diseases
• medical calculators (not available for iPad).
The app is available for Android, iPad, and iPhone/iPod touch devices.
Use this app to take a photo of a wound. The app segments the image into red, yellow, and black to help with ulcer classification. You can also use the app to track changes in the wound over time. The app is available for iPad and iPhone/iPod touch devices. Note: This is free for a limited time.
The ePSS (Electronic Preventive Services Selector) app allows you to search and browse the U.S. Preventive Services Task Force recommendations on the Web or a mobile device. The app is from the U.S. Department of Health & Human Services and is available for Android, iPad, and iPhone/iPod touch devices.
This app from the University of Michigan Health System allows users to complete and store photographs of the skin. Features include:
• guidance on performing a skin cancer self-exam and full-body photographic survey
• tracking of detected skin lesions and moles for changes over time
• notifications/reminders to perform self-exams on a routine basis
• storage of photos for baseline comparisons during routine follow-up self-
exams
• informational videos and literature on skin cancer prevention and healthy skin as well as a skin cancer risk calculator function.
The app is available for iPad and iPhone/iPod touch devices.
This data storage utility app is perfect for your patients with diabetes who want all their information in one place. Users can manually enter their glucose results, carbohydrate consumption, insulin dosages, and activities, and then view the data in a free glucosebuddy.com online account. Another option is the ability to set reminders for when it’s time to check blood glucose.
The app is available for Android, iPad, and iPhone/iPod touch devices.
Use this app to learn more about pressure ulcer staging. It includes information about 3M pressure ulcer products.
The app is available for iPad and iPhone/iPod touch devices.
This evidence-based tool is helpful for assessing and classifying peristomal skin lesions. Click here for more information about the SACS Instrument.
The app is available for iPad and iPhone/iPod touch devices.
Do you experience chronic stress? Is your body stiff and inflexible? Does your mind seem dull and sluggish, your spirit exhausted?
Restorative yoga may help “open” your joints, ease your mind, and revive your spirit. It’s based on the concept that we’re overstimulated and don’t get enough rest. Constant stimulation activates the sympathetic nervous system, overtaxing the fight-or-flight response. The body responds by increasing cortisol and glucose production, which (along with additional unhealthy responses) raises the risk of metabolic syndrome.
Restorative yoga promotes active relaxation, helping to halt the overstimulation cycle. It promotes balance by alternately stimulating and relaxing the body, which is supported in yoga poses with such props as blankets, pillows, yoga mat, and eye covers. Research suggests restorative yoga may ease hot flashes in postmenopausal women and may promote a calm, positive mood in women with ovarian or breast cancer.
Restorative yoga takes a five-faceted approach to relieve the effects of stress. Over time, you’re likely to notice a new awareness of and appreciation for your body, mind, and spirit.
Simply put, networking is an information exchange, a forum for communicating your needs or agenda and, in return, listening and responding to others’ needs or agendas. Good networking requires emotional reciprocity, which means caring about the needs and agendas of the people you network with. Caring about others’ needs is what nurses do, so networking really shouldn’t be that difficult for a nurse.
1. Using props, restorative yoga supports the body in yoga poses, helping muscles and joints release tension and achieve muscular balance.
2. The restorative poses move the spine in all directions—flexion, extension, rotation, and lateral flexion. This enhances spinal flex-ibility, lubricates vertebrae, and strengthens the deep muscles that stabilize the spine.
3. Inverted poses, in which the feet and legs are elevated, counter the effects of gravity and promote lymph and fluid drainage to the heart.
4. The poses compress and release internal organs, cleansing them while aiding removal of cellular waste and renewing oxygen and nutrients.
5. Finally, the poses balance the body’s male (prana) and female (apana) energies.
To learn the poses, consider taking a restorative yoga class. (See Finding an instructor.) Beforehand, make sure to tell the instructor about any special health concerns you have, so the instructor can modify the poses for you. Expect to bring your own blankets, pillows, eye covers, and yoga mat. The class will last from 60 to 90 minutes.
Restorative yoga typically doesn’t involve active (hatha) yoga poses, although it may include stretching poses to warm muscles and joints before the restorative poses begin. The instructor will help you use your props to make the poses right for you, and will direct you into a pose using them. Expect to stay in the pose for 5 to 10 minutes. The instructor will guide you by helping you focus on your breath and turn your attention inward. If your mind wanders and your body stays active, accept this reaction and don’t judge yourself. Over time, you’ll learn to use your breath to release tension and to focus and calm your mind.
After you hold the pose for the required duration, the instructor will help you into the next one. Generally, the class is near-silent, with minimal talking; the lights are low and music may play.
When the class ends, you may feel more relaxed and in touch with yourself. If you feel restless and jittery instead, accept your reaction. Don’t judge yourself. Try again. Give yourself the opportunity to experience something different.
Restorative yoga is just one method to renew and reconnect with your inner being. Only you can know if it’s right for you. n
Selected references
Cohen B, Kanaya A, Macer J, Shen H, Chang A, Grady D. Feasibility and acceptability of restorative yoga for treatment of hot flushes: a pilot trial. Maturitas. 2007;56(2):198-204.
Danhauer SC, Tooze JA, Farmer DF, Campbell CR, McQuellon RP, Barrett R, Miller BE. Restorative yoga for women with ovarian or breast cancer: findings from a pilot study. J Soc Integr Oncol. 2008;6(2):47-58.
Lisa Marie Bernardo is the managing member of The PIlates Centre, LLC, in Hampton Township, Pennsylvania, and adjunct faculty at Carlow University School of Nursing in Pittsburgh, Pennsylvania.
Each month, Apple Bites brings you a tool you can apply in your daily practice.
• Nonsterile dressings protect open wounds from contamination and absorb drainage.
• Clean aseptic technique should be used to change nonsterile dressings.
• In the event of multiple wounds, each wound is considered a separate treatment. (more…)