Clinical Notes

May 28, 2013February 25, 2020 Wound Care Advisor

Study finds less-invasive method for identifying osteomyelitis is effective

Researchers have found that using hybrid 67Ga single-photon emission computed tomography and X-ray computed tomography (SPECT/CT) imaging combined with a bedside percutaneous bone puncture in patients with a positive scan is “accurate and safe” for diagnosing osteomyelitis in patients with diabetes who have a foot ulcer without signs of soft-tissue infection.

The new method, which avoids an invasive bone biopsy, has a sensitivity of 88% and a specificity of 93.6%. In the study of 55 patients, antibiotic treatment was avoided in 55% of suspected cases.

“Diagnosing diabetic foot osteomyelitis in patients without signs of soft tissue infection by coupling hybrid 67Ga SPECT/CT with bedside percutaneous bone puncture,” published by Diabetes Care, followed patients for at least a year.

MRSA strains will likely continue to coexist in hospitals and communities

The strains of methicillin-resistant Staphylococcus aureus (MRSA) differ in the hospital and community settings, and both are likely to coexist in the future, according to a study in PLOS Pathogens.

“Hospital-community interactions foster coexistence between methicillin-resistant strains of Staphylococcus aureus” notes that previously it was thought that the more invasive community strains would become more prevalent (and even eliminate) hospital strains. This new information could have significant consequences for public health because of the differences in the resistance of the two strains.

C. difficile prevention actions fail to stop spread

Despite increasing activities to prevent the spread of Clostridium difficile, infection from C. difficile remains a problem in healthcare facilities, according to a survey of infection preventionists by the Association for Professionals in Infection Control and Epidemiology (APIC).

The survey found that 70% of preventionists have adopted additional interventions in their healthcare facilities since March 2010, but only 42% have seen a decline in C. difficile infection rates; 43% saw no decline.

A total of 1,087 APIC members completed the survey in January 2013. The survey also found that more than 92% of respondents have increased emphasis on environmental cleaning and equipment decontamination practices, but 64% said they rely on observation, rather than more accurate and reliable monitoring technologies, to assess cleaning effectiveness.

In addition, 60% of respondents have antimicrobial stewardship programs at their facilities, compared with 52% in 2010. Such programs promote the appropriate use of antibiotics, which can help reduce the risk of C. difficile infection.

According to the Centers for Disease Control and Prevention, diarrhea caused by C. difficile is linked to 14,000 American deaths each year.

Mast cells may not play significant role in wound healing

“Evidence that mast cells are not required for healing of splinted cutaneous excisional wounds in mice,” published in PLOS One, analyzed wound healing in three types of genetically mast-deficient mice and found they reepithelialized their wounds at rates similar to control mice. At the time of closure, the researchers found that scars in all the mice groups were similar in both “quality of collagen deposition and maturity of collagen fibers.” The findings fail to support the previously held belief that mast cells are important in wound healing.

Study identifies effective casting for diabetes-related plantar foot ulcers

Nonremovable casts that relieve pressure are more effective than removable casts or dressings alone for the treatment of plantar foot ulcers caused by diabetes, according to an analysis of clinical trials.

The authors of “Pressure-relieving interventions for treating diabetic foot ulcers,” published by The Cochrane Library, reviewed 14 randomized clinical trials that included 709 participants. Nonremovable pressure-relieving casts were compared to dressings alone, temporary therapeutic shoes, removable pressure-relieving devices, and surgical lengthening of the Achilles tendon.

The study also notes that when combined with Achilles tendon lengthening, nonremovable devices were more successful in one forefoot ulcer study than the use of a nonremovable cast alone.

Most studies were from the United States (five) and Italy (five), with Germany, the Netherlands, Australia, and India each contributing one study.

Prescriber preference drives use of antibiotics in long-term care

“Prolonged antibiotic treatment in long-term care: Role of the prescriber,” published by JAMA Internal Medicine, found that the preferences of prescribers, rather than patient characteristics, drive antibiotic treatment.

The study of 66,901 patients from 630 long-term care facilities found that 77.8%
received a course of antibiotics. The most common length (41%) was 7 days, but the length exceeded 7 days in 44.9% of patients. Patient characteristics were similar among short-, average-, and long-duration prescribers.

The study authors conclude: “Future trials should evaluate antibiotic stewardship interventions targeting prescriber preferences to systematically shorten average treatment durations to reduce the complications, costs, and resistance associated with antibiotic overuse.”

Electrophysical therapy may be helpful for diabetic foot ulcers

“Electrophysical therapy for managing diabetic foot ulcers: A systematic review” concludes that electrophysical therapy is potentially beneficial because in each randomized clinical trial it outperformed the control or sham electrical stimulation.

The authors of the study in International Wound Journal reviewed eight trials with a combined total of 325 patients. Five studies were on electrical stimulation, two on phototherapy, and one on ultrasound. Because of the small number of trials, the possibility of harmful effects can’t be ruled out, and the authors recommend “high-quality trials with larger sample sizes.”

Significant geographic variations in spending, mortality exist for diabetic patients with foot ulcers and amputations

“Geographic variation in Medicare spending and mortality for diabetic patients with foot ulcers and amputations” reports healthcare spending and mortality rates vary “considerably” across the United States.

The study in Journal of Diabetes and Its Complications found that higher spending wasn’t associated with a significant reduction in 1-year patient mortality. In addition, rates of hospital admission were associated with higher per capita spending and higher mortality rates for patients.

Home-based exercise program improves life for lymphedema patients

An individualized, home-based progressive resistance exercise program improves upper-limb volume and circumference and quality of life in postmastectomy patients with lymphedema, according to a study published in the Journal of Rehabilitation Research and Development.

“Effect of home-based exercise program on lymphedema and quality of life in female postmastectomy patients: Pre-post intervention study” included 32 women who participated in an 8-week program. The women received education about the program and an initial training session from a physiotherapist. They practiced the exercise sequence and received a program and logbook once their performance was satisfactory. Patients were told to increase weight only when two sets of 15 repetitions became easy to perform.

Is your wound-cleansing practice up to date?

May 28, 2013February 25, 2020 Wound Care Advisor

By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS

With so much focus on dressing choices, it’s easy to forget the importance of wound cleansing. Cleaning a wound removes loose debris and planktonic (free-floating) bacteria, provides protection to promote an optimal environment for healing, and facilitates wound assessment by optimizing visualization of the wound. You should clean a wound every time you change a dressing, unless it’s contraindicated.

Here’s a review of how to choose and use a wound cleanser so you can see if your practice is up to date. (more…)

What you need to know about hydrocolloid dressings

May 28, 2013January 15, 2024 Wound Care Advisor

By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS

Each month, Apple Bites brings you a tool you can apply in your daily practice.

Description

A hydrocolloid dressing is a wafer type of dressing that contains gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer layer. Some formulations contain an alginate to increase absorption capabilities. The wafers are self-adhering and available with or without an adhesive border and in various thicknesses and precut shapes for such body areas as the sacrum, elbows, and heels. Click here to see examples of
hydrocolloid dressings.

(more…)

Understanding peristomal skin complications

May 28, 2013February 25, 2020 Wound Care Advisor

By Rosalyn Jordan, RN, BSN, MSc, CWOCN, WCC, and Marci Christian, BBE

Any patient with a fecal or urinary ostomy may experience complications on the skin surface around the stoma. These complications may occur lifelong, although they’re more common during the first 5 years after the initial ostomy surgery. Causative factors include infection, trauma, certain diseases, and chemical irritation; most of these problems stem from the pouching system or pouch leakage.

Peristomal skin complications can cause a wide range of signs and symptoms, from skin discoloration to polyp-like growths, from erythema to full-thickness wounds. They can lead to discomfort, pain, poor self-image, social isolation, and impaired quality of life, not to mention additional care costs.

Incidence and types of these complications are hard to compare or contrast across multiple patients. Until recently, no standardized assessment or documentation tools were available to characterize or define complications. For this reason, reported rates ranged widely, from 10% to 70%. And because no designated common language or categories related to peristomal skin complications existed, documentation was inconsistent.

Download “How to Use” education program for the Ostomy Skin Tool

Ostomy Skin Tool

In the late 2000s, a group of nurses experienced in caring for ostomy patients worked with the World Council of Enterostomal Therapists to develop a resource called the Ostomy Skin Tool, which clinicians can use to categorize and describe peristomal skin complications in a consistent, objective manner. The tool also provides a common language for documentation.

The Ostomy Skin Tool has three major assessment domains—discoloration (D), erosion/ulceration (E), and tissue overgrowth (T), known collectively as DET. The DET combined rating ranges from normal, rated 0, to the worst condition possible, rated 15. Mild DET complications are documented as less than 4, moderate as less than 7, and severe as 8 or higher. (See Using the Ostomy Skin Tool by clicking the PDF icon above.)

The tool describes four categories of peristomal complications:
• chemical irritation
• mechanical trauma
• disease-related complications
• infection-related complications.

Chemical irritation

Chemical irritation can stem from irritants (as in contact dermatitis) or allergic reactions (allergic dermatitis). The most likely cause of chemical dermatitis is effluent leakage (feces or urine) from the colostomy, ileostomy, or urostomy, in which effluent comes in contact with peristomal skin. Other potential causes include contact with soap, certain adhesives, and adhesive removers.

The major treatment of chemical irritation is identification and removal of the offending agent, followed by patient and caregiver education on the new pouching procedure the patient must use. Follow-up assessment also is recommended. In a 2010 study that followed 89 patients for 1 year after ostomy surgery, about 50% of subjects experienced peristomal skin complications, most of them from pouch leakage. Another investigator estimated that 85% of ostomy patients experience pouch leakage at some time during their lives. Pouch leakage usually occurs when stool is extremely liquid (for instance, ileostomy effluent). Other causes of pouch leakage include wearing a pouch more than half full of effluent and abdominal contours that aren’t level. Besides changes in the pouching system, treatment may entail adding products to the pouching system or removing certain agents.

Some patients experience allergic dermatitis in reaction to products used in the pouching system (such as skin barriers, belts, pouch closures, or adhesives). However, allergic dermatitis is rare. One 2010 study suggested allergic reactions to these products occur in only about 0.6% of patients with peristomal skin irritation. Most major ostomy product manufacturers provide a patch test on request to help identify allergic conditions. Once the offending product is discontinued, allergic dermatitis should resolve rapidly.

Mechanical trauma

Mechanical trauma usually results from either the pouching system itself or its removal. It also may result from harsh or multiple skin-barrier removals, pressure from convex rings or pouches, and abrasive cleansing techniques. Some researchers believe the stronger the adhesive barrier and the more often a pouch is changed, the greater the risk of epidermal damage.

Mechanical trauma may present as a partial-thickness ulcer caused by pressure, shear, friction, tearing, or skin stripping. Patients with fragile skin are susceptible to mechanical trauma, so less aggressive pouching systems may be preferred for them. Of course, if the pouching system is changed, the patient or caregiver needs to learn about the new system.

Disease-related complications

Disease-related peristomal complications may be linked to preexisting skin conditions, such as psoriasis, eczema (atopic dermatitis), or seborrheic dermatitis. Hyperplasia also may occur. This overgrowth of cells, which may appear as gray or reddish brown pseudoverrucous lesions, usually is linked to urinary ostomies, although it can occur with fecal ostomies as well. Vinegar soaks are the recommended treatment, in addition to a change in the pouching system and corresponding patient education.

Occasionally, other disease-related complications occur, including primary adenocarcinoma of the peristomal skin and peristomal pyoderma gangrenosum, a painful and problematic condition that presents as peristomal ulcers. Ulcer borders are well-defined with a bluish purple coloration at the edges. Infection must be ruled out, as this condition usually is linked to an autoimmune condition. Treatment includes pain management and, in most cases, a topical corticosteroid. Crohn’s disease also may manifest as a peristomal skin ulcer.

Infection-related complications

Infection-related complications may be bacterial or fungal. Two common peristomal skin infections are folliculitis and Candida fungal infections. An infection of the hair follicle that causes pustules, folliculitis usually stems from traumatic hair pulling in the peristomal area during pouch removal. It may warrant a prescribed antibiotic, along with patient teaching regarding proper hair removal using an electric razor.

Candida infections may arise because peristomal skin provides a warm, dark, moist environment that promotes fungal growth. These infections appear as erythema with pustules or papules and satellite lesions. Treatment usually involves antifungal powder and use of the crusting technique to secure the pouching system. (See Using the crusting technique by clicking the PDF icon above.)

Management

Many complications are well advanced by the time patients seek assistance, perhaps because they don’t understand the significance of their symptoms and think they can manage the problem themselves. In some cases, they don’t know where to turn for assistance. Commonly, the complication progresses to the point where the patient goes to the emergency department or (particularly during the immediate postoperative period) needs to be readmitted for treatment. The best way to manage peristomal skin complications is to prevent them in the first place. (See Preventing peristomal skin complications by clicking the PDF icon above.)

Patient education

Over the past 20 years, hospital stays for ostomy surgery patients have decreased from about 2 weeks to less than 5 days. Reduced stays decrease the time available for caregivers to teach patients and family members how to empty and change the pouch. They need alternative education covering (among other topics) how to recognize peristomal skin complications and when to seek help. Not only do these complications require vigilant self-observation, but many patients don’t understand their implications or how rapidly they can worsen. In some cases, the first symptoms are itching and redness under the skin barrier. Fortunately, some patients may know or remember that itching, burning, stinging, reddened, or weeping peristomal skin requires professional attention. They can avoid serious complications by seeking assistance early, such as right after noticing pouch leakage.

Early treatment can reduce the cost of treatment. In a 2012 study, researchers estimated care costs related to peristomal skin complications for a 7-week treatment period, using the Ostomy Skin Tool as a reference. Severe complications (those with a DET score above 8) cost six times more to treat than mild cases (those with a DET score below 4) and 4.5 times more than moderate cases.

Along with early intervention by a trained ostomy care specialist, self-assessment by ostomy patients promotes a better quality of life, reduces pain, and may decrease care costs. Clinicians’ use of the Ostomy Skin Tool to assess and document peristomal skin complications promotes more reliable, objective, comparable assessment data for reporting.

Selected references
Al-Niaimi F, Lyon CC. Primary adenocarcinoma in peristomal skin: a case study. Ostomy Wound Manage. 2010;56(1):45-7.

Burch J. Management of stoma complications. Nurs Times. 2011;107(45):17-8, 20.

Jemec GB, Martins L, Claessens I, et al. Assessing peristomal skin changes in ostomy patients: validation of the Ostomy Skin Tool. Br J Dermatol. 2011; 164;330-5.

Jones T, Springfield T, Brudwick M, Ladd A. Fecal ostomies: practical management for the home health clinician. Home Healthc Nurse. 2011;29(5):306-17.

Martins L, Samai O, Fernandez A, et al. Maintaining healthy skin around an ostomy: peristomal skin disorders and self-assessment. Gastrointest Nurs. 2011;
9(2):9-13.

Martins L, Tavernelli K, Serrano JLC. Introducing a peristomal skin assessment tool: The Ostomy Skin Tool. World Council Enterostomal Therapists J. 2008;28(2):3-13.

Meisner S, Lehur P, Moran B, et al. Peristomal skin complications are common, expensive, and difficult to manage: a population based cost modeling study. PLoS One. 2012;7(5):e37813.

Nybaek H, Jemec GB. Skin problems in stoma patients. J Eur Acad Dermatol Venereol. 2010;24(3):249-57.

Omura Y, Yamabe M, Anazawa S. Peristomal skin disorders in patients with intestinal and urinary ostomies: influence of adhesive forces of various hydrocolloid wafer skin barriers. J Wound Ostomy Continence Nurs. 2010;37(3):289-98.

Ratliff CR. Early peristomal skin complications reported by WOC nurses. J Wound Ostomy Continence Nurs. 2010;37(5):505-10.

Shabbir J, Britton DC. Stomal complications: a literature overview. Colorectal Dis. 2010;12(10):958- 64.

Wound, Ostomy, Continence Clinical Practice Ostomy Subcommittee. Peristomal skin complications: Best practice for clinicians. Mt. Laurel, NJ; 2007.

The authors work for RecoverCare, LLC, in Louisville, Kentucky. Rosalyn Jordan is director of clinical education and Marci Christian is a clinical associate product specialist.

Chronic venous insufficiency with lower extremity disease: Part 2

May 28, 2013February 25, 2020 Wound Care Advisor

By Donald A. Wollheim, MD, WCC, DWC, FAPWCA

To begin appropriate treatment for chronic venous insufficiency (CVI), clinicians must be able to make the correct diagnosis. Part 1 (published in the March-April edition) described CVI and its presentation. This article provides details of the CVI diagnosis (including the differential diagnosis from other diseases), disease classification to help assess the extent of CVI, diagnostic studies used to diagnose CVI, and various treatment options to “rescue” the patient from CVI. (more…)

Assessing risk of pressure and moisture-related problems in long-term care patients

May 28, 2013February 25, 2020 Wound Care Advisor

By Patricia A. Slachta, PhD, RN, ACNS-BC, CWOCN

Assessing moisture and pressure risk in elderly patients continues to be a focus for clinicians in all settings, particularly long-term care. Ongoing research challenges our ideas about and practices for cleansing and protecting damaged skin. Until recently, most wound care clinicians have cleansed long-term care patients’ skin with mild soap and water. But several studies have shown pH-balanced cleansers are more efficient than soap and water for cleansing the skin of incontinent patients.

Various terms are used to describe skin breakdown related to moisture—incontinence-associated dermatitis, perineal dermatitis, diaper rash, intertriginal dermatitis, intertrigo, moisture-related skin damage, moisture-associated skin damage, and even periwound dermatitis. This article uses moisture-associated skin damage (MASD) because it encompasses many causes of skin breakdown related to moisture. Regardless of what we call the condition, we must do everything possible to prevent this painful and costly problem.

Skin assessment

Start with an overall assessment of the patient’s skin. Consider the texture and note dryness, flaking, redness, lesions, macerated areas, excoriation, denudement, and other color changes. (See Identifying pressure and moisture characteristics by clicking the PDF icon above.)

Assessing MASD risk

A patient’s risk of MASD can be assessed in several ways. Two of the most widely used pressure-ulcer risk scales, the Norton and Braden scales, address moisture risk. The Norton and Braden subscales should drive your plan for preventing skin breakdown related to moisture or pressure. The cause of breakdown (moisture, pressure, or shear/friction) must be identified, because treatment varies with the cause.

Both the Norton and Braden scales capture activity, mobility, and moisture scores. The Braden scale addresses sensory perception, whereas the Norton scale identifies mental condition. (See Subscales identifying pressure, shear, and moisture risk by clicking the PDF icon above.) Also, be aware that two scales have been published for perineal risk, but neither has been used widely.

You must differentiate pressure- and moisture-related conditions to determine correct treatment. Patients who are repositioned by caregivers are at risk for friction or shear. Also, know that agencies report pressure-ulcer prevalence. Care providers no longer classify mucous-membrane pressure areas in skin prevalence surveys; mucous membranes aren’t skin and don’t have the same tissue layers. Furthermore, don’t report skin denudement from moisture (unless pressure is present) in prevalence surveys.

When moisture causes skin breakdown

Skin has two major layers—epidermis and dermis. The epidermis itself has five layers: The outermost is the stratum corneum; it contains flattened, keratin protein–containing cells, which aid water absorption. These cells contain water-soluble compounds called natural moisturizing factor (NMF), which are surrounded by a lipid layer to keep NMF within the cell. When skin is exposed to moisture, its temperature decreases, the barrier function weakens, and skin is more susceptible to pressure and friction/shear injury. Also, when urea in urine breaks down into ammonia, an alkaline pH results, which may reactivate proteolytic and lipolytic enzymes in the stool. (See Picturing moisture and pressure effects by clicking the PDF icon above.)

Caring for moisture-related skin breakdown

The standard of care for moisture-related skin breakdown includes four major components: cleanse, moisturize, protect, and contain. Specific products used for each component vary with the facility’s product formulary.

Cleanse

Gently wash the area using a no-rinse cleanser with a pH below 7.0. Don’t rub the skin. Pat dry.

Moisturize

Use creams containing emollients or humectants. Humectants attract water to skin cells and help hold water in the cells; don’t use these products if the skin is overhydrated. Emollients slow water loss from skin and replace intracellular lipids.

Protect

Options for skin protectants include:
• liquid film-forming acrylate sprays or wipes
• ointments with a petroleum, zinc oxide, or dimethicone base
• skin pastes. Don’t remove these products totally at each cleansing, but do remove stool, urine, or drainage from the surface and apply additional paste afterward. Every other day, remove the paste down to the bare skin using a no-rinse cleanser or mineral oil.

Be sure to separate skinfolds and use products that wick moisture rather than trap it. These may include:
• commercial moisture-wicking products
• a light dusting with powder containing refined cornstarch or zinc oxide—not cornstarch from the kitchen or powder with talc as the only active ingredient
• abdominal pads.

Contain

To keep moisture away from skin, use absorbent underpads with wicking properties, condom catheters (for males), fecal incontinence collectors, fecal tubes (which require a healthcare provider order), or adult briefs with wicking or gel properties. Call a certified ostomy or wound care nurse for tips on applying and increasing wear time for fecal incontinence collectors.

If 4″ × 4″ gauze pads or ABD pads are saturated more frequently than every 2 hours, consider applying an ostomy or specially designed wound pouch to the area. Collecting drainage allows measurement and protects skin from the constant wetness of a saturated pad.

Don’t neglect the basics, for example, know that wet skin is more susceptible to breakdown. Turn the patient and change his or her position on schedule. Change linens and underpads when damp, and consider using a low-air-loss mattress or bed or mattress with microclimate technology.

Also, be aware that fungal rashes should be treated with appropriate medications. If the patient’s skin isn’t too moist, consider creams that absorb into the skin; a skin-protecting agent can be used as a barrier over the cream. Besides reviewing and using the standards of care, you may refer to the Incontinence-Associated Dermatitis Intervention Tool, which has categories related to skin damage. See the “Incontinence-Associated Dermatitis Intervention Tool” (IADIT).

Bottom line on skin breakdown

To help prevent skin breakdown related to moisture, assess patients’ skin appropriately, determine treatment using evidence-based guidelines, and implement an appropriate plan of care.

Selected references
Black JM, Gray M, Bliss DZ, et al. MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2011;38(4):359-70.

Borchert K, Bliss DZ, Savik K, Radosevich DM. The incontinence-associated dermatitis and its severity instrument: development and validation. J Wound Ostomy Continence Nurs. 2010;37(5):527-35.

Doughty D. Differential assessment of trunk wounds: pressure ulceration versus incontinence-associated dermatitis versus intertriginous dermatitis. Ostomy Wound Manage. 2012;58(4):20-2.

Doughty D, Junkin J, Kurz P, et al. Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges. J Wound Ostomy Continence Nurs. 2012;39(3):303-15.

Gray M, Beeckman D, Bliss DZ, et al. Incontinence-associated dermatitis: a comprehensive review and update. J Wound Ostomy Continence Nurs. 2012;
39(1):61-74.

Gray M, Black JM, Baharestani MM, et al. Moisture-associated skin damage: overview and pathophysiology. J Wound Ostomy Continence Nurs. 2011;38(3):233-41.

Langemo D, Hanson D, Hunter S, Thompson P, Oh IE. Incontinence and incontinence-associated dermatitis. Adv Skin Wound Care. 2011;24(3):126-40.

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline.Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

Sibbald RG, Krasner DL, Woo KY. Pressure ulcer staging revisited: superficial skin changes & Deep Pressure Ulcer Framework©. Adv Skin Wound Care. 2011;24(12):571-80.

Wound, Ostomy and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers. Mt. Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2010.

Wound, Ostomy and Continence Nurses Society. Incontinence-Associated Dermatitis: Best Practice for Clinicians. Mt. Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2011.

Zulkowski K. Diagnosing and treating moisture-associated skin damage. Adv Skin Wound Care. 2012;25(5):231-6.

Patricia A. Slachta is an instructor at the Technical College of the Lowcountry in Beaufort, South Carolina.

When you can’t rely on ABIs

May 28, 2013February 25, 2020 Wound Care Advisor

By Robyn Bjork, MPT, CWS, WCC, CLT-LANA

One of the worst fears of a wound care clinician is inadvertently compressing a leg with critical limb ischemia—a condition marked by barely enough blood flow to sustain tissue life. Compression (as well as infection or injury) could lead to necrosis, the need for amputation, or even death. The gold standard of practice is to obtain an ankle-brachial index (ABI) before applying compression. However, recent research and expert opinion indicate an elevated or normal ABI is deceptive in patients with advanced diabetes. What’s worse, in the diabetic foot, skin may die from chronic capillary ischemia even when total blood perfusion is normal. For information on how to perform an ABI and interpret results, click on this link. (more…)

Ostomy 101: Colostomy, ileostomy, and urostomy

March 25, 2013February 25, 2020 Wound Care Advisor

By Jackie Doubleman, BSN, RN, CWOCN

Most patients are distressed to learn they need ostomy surgery to divert stool, urine, or both. Adapting to ostomy surgery can be difficult at best, even with today’s advanced technology and the wide assortment of ostomy supplies available. While recovering from the surgery itself, patients must learn how to contain or control feces or urine and how to minimize odor—without feeling like a social outcast.

This article reviews three types of ostomy surgery—colostomy, ileostomy, and urostomy. Subsequent articles will discuss ostomy management and treatment of stomal and peristomal skin complications. (more…)

How to keep your communications professional

March 25, 2013February 25, 2020 Wound Care Advisor

By Kathleen D. Pagana, PhD, RN

As clinicians, we’re proud of the expert care we provide patients. But we also know that just doing our job isn’t enough to advance our careers. Mastering good communication skills is essential for all clinicians at all career stages—especially with today’s flatter organizational structures and more participatory management styles. Knowing how to communicate in a professional manner can give you the edge you need for career advancement.

Opportunity rarely knocks any more. Instead it may present as a phone call, voice mail, e-mail, or text message. Be sure to use proper etiquette with all communication forms.

Speaking with managers

When dealing with your manager, use a solution-focused approach. Don’t be a complainer. Some communication experts point out that people complain about things they can do something about—not things they have no power over. For example, they don’t complain about their foot size because there’s nothing they can do about it. Yet people often complain about their jobs because they’re unwilling to take the risk of making a change.

We need to take charge of our lives. We can accept the fact—without complaining—that we’re making the choice to stay where we are. Or we can make a request or take action to achieve a desired outcome. Suppose you work on a clinical unit and disagree with the way your manager makes clinical assignments. You have several options:

Complain to coworkers and make the workplace miserable for others.
Speak with your manager and make suggestions for improvement.
Leave your job and go elsewhere if you can’t work with your manager to make things better.

If you decide to stay in your job, accept the fact that you’ve made that choice. Take responsibility for it and stop complaining.

Speaking on the phone with physicians

For clinicians who are not physicians, the key to effective communication with physicians is to remember you’re an important member of the healthcare team. An effective way to guide your communication with physicians and other colleagues is to use a tool such as SBAR (Situation, Background, Assessment, Recommendation). Say, for instance, you want to suggest the doctor order an anxiolytic for your patient. Here’s how you might do it using SBAR:

Situation: “Mrs. Smith is complaining of severe anxiety.”
Background: “She is 1 day post-op from a lumbar laminectomy.”
Assessment: “She is alert and oriented and her vital signs are stable. She has no numbness or tingling in her extremities.”
Recommendation: “She said she takes lorazepam 2 mg orally at when she’s anxious. Would you like to order something for her?”

Before ending the conversation, repeat and clarify the medication order (if the doctor gives one).

Telephone

The sound of your voice and your manners are essential components of phone etiquette. Smile—the smile on your face comes through in your voice. Here are five more tips:

Get yourself organized before placing the call.
Minimize background noise.
Immediately identify yourself. Don’t assume the recipient will recognize your voice.
Concentrate on listening and avoid multitasking.
Schedule phone conversations to avoid playing phone tag.

Voice mail

Voice mail is an efficient way to communicate. Again, five tips:

Always be prepared to leave a message. Jot down your key message points before you call, to avoid stuttering and stammering.
Be concise and to the point.
State your name and the date, time, and purpose of your call.
Enunciate clearly and speak slowly.
State your name and phone number twice at the end of the message so the recipient doesn’t need to replay your message.

E-mail

In many business settings, e-mail has almost replaced letters and memos. In many cases, an e-mail is a recipient’s first impression of you, so follow these tips:

Make the subject line specific. This helps the reader prioritize the message and file it for easy retrieval.
Use a greeting and a close. It’s more polite and less impersonal.
Keep your message concise.
Keep your tone polite and businesslike.
Use your e-mail signature function, which provides several ways to contact you.

Text messages

This form of communication can be the most challenging and unpredictable. Some people send text messages routinely, while others may be unfamiliar with this method. You can’t go too far wrong if you take this advice:

Get to the point quickly. No one wants to read a long message on a mobile phone.
Don’t text during meetings. It’s rude to do so, and others can hear you clicking away or see the light from your screen.
Consider the recipient before using text abbreviations. Some people may not understand text lingo.
Consider the time when sending a text. Although you may be awake at 5 a.m., the sound of your incoming message might disturb a sleeping recipient.
Don’t expect an immediate response to your text. If the message is time sensitive, pick up the phone instead.

Improving the way we speak with managers and physicians can go a long way toward career advancement and professional satisfaction. Common courtesy is just as essential in e-mail, voice mail, and text messages as in face-to-face communication. When you follow the guidelines I’ve given, you’ll elevate your professional communications a few notches.

Selected references
Canfield J, Switzer J. The Success Principles: How to Get from Where You Are to Where You Want to Be. New York, NY: Morrow; 2006.

Kramer M, Schmalenberg, C. Confirmation of a healthy work environment. Crit Care Nurse. 2008 Apr;28(2):56-63.

Pagana K. The Nurse’s Communication Advantage: How Business Savvy Communication Can Advance Your Nursing Career. Indianapolis, IN: Sigma Theta Tau International; 2011.

Pagana K. The Nurse’s Etiquette Advantage: How Professional Etiquette Can Advance Your Nursing Career. Indianapolis, IN: Sigma Theta Tau International; 2008.

A keynote speaker, Kathleen D. Pagana is a professor emeritus at Lycoming College in Williamsport, Pennsylvania, and president of Pagana Keynotes and Presentations. She is the author of The Nurse’s Communication Advantage and The Nurse’s Etiquette Advantage. To contact her, visit www.KathleenPagana.com.

Four key ingredients make up the recipe for effective team meetings

March 25, 2013February 25, 2020 Wound Care Advisor

By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN

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.

Unna Boot

March 25, 2013February 25, 2020 Wound Care Advisor

An Unna boot is a special dressing of inelastic gauze impregnated with zinc, glycerin, or calamine that becomes rigid when it dries. It is used for managing venous leg ulcers and lymphedema in patients who are ambulatory. When the patient walks, the rigid dressing restricts outward movement of the calf muscle, which directs the contraction force inward and improves the calf-muscle pumping action, thereby improving venous flow. An Unna boot does not provide compression and is contraindicated for arterial insufficiency.
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Chronic venous insufficiency with lower extremity disease: Part 1

March 25, 2013February 25, 2020 Wound Care Advisor

By Donald A. Wollheim, MD, WCC, DWC, FAPWCA

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.

Selected references

Alguire PC, Mathes BM. Clinical evaluation of lower extremity chronic venous disease. UpToDate. Last updated April 18, 2012. http://www.uptodate.com/contents/clinical-evaluation-of-lower-extremity-chronic-venous-disease?source=search_result&
search=Clinical+evaluation+of+lower+extremity+chronic+venous+disease&selectedTitle=1%7E150. Accessed March 3, 2013.

Alguire PC, Mathes BM. Diagnostic evaluation of chronic venous insufficiency. UpToDate. Last updated May 7, 2012. www.uptodate.com/contents/diagnostic-evaluation-of-chronic-venous-insufficiency?source=search_result&search=Diagnostic+evaluation
+of+chronic+venous+insufficiency&selectedTitle=1%7E127. Accessed March 3, 2013.

Alguire PC, Mathes BM. Pathophysiology of chronic venous disease. UpToDate. Last updated April 12, 2012. www.uptodate.com/contents/pathophysiology-of-chronic-venous-disease?source=search_result&search=Pathophysiology+of+chronic+venous+disease
&selectedTitle=1%7E127. Accessed March 3, 2013.

Alguire PC, Scovell S. Overview and management of lower extremity chronic venous disease. UpToDate. Last updated June 27, 2012. www.uptodate.com/contents/overview-and-management-of-lower-extremity-chronic-venous-disease?source=search_
result&search=Overview+and+management+of+lower+extremity+chronic+venous+disease&selectedTitle=1%7E150. Accessed March 3, 2013.

Moneta G. Classification of lower extremity chronic venous disorders. UpToDate. Last updated October 22, 2011. www.uptodate.com/contents/classification-of-lower-extremity-chronic-venous-disorders. Accessed March 3, 2013.

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.

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