Punch grafting for pain reduction in hard-to-heal ulcers

OBJECTIVE

Punch-grafting is a traditional technique to enhance wound healing, which has been associated with significant pain reduction. There are few studies measuring pain reduction after punch grafting, our study was designed to measure this outcome.

METHOD

Patients with hard-to-heal wounds treated with punch grafting were included in a single centre prospective study. Wound pain intensity was measured using a Visual Analogue Scale (VAS) at baseline (before the procedure) and at three time points after the procedure. Punch grafting was performed in an outpatient setting. Patient demographic data, wound aetiology and percentage of graft take were recorded.

RESULTS

A total of 136 patients were included (62 men and 74 women). Mean age was 60±35 years and 51 (38%) had venous leg ulcers (VLU), 29 (21%) had postoperative wounds, 15 (11%) Martorell ulcers, 15 (11%) traumatic wounds, four (3%) arterial ulcers and 22 (16%) 'other' ulcers. Of the patients, 38 (28%) did not present with painful ulcers and, after punch grafting, all of them remained painless; 29 (21%) patients obtained >70% pain reduction, whereas 73 (54%) patients achieved pain suppression. Pain suppression did not depend on the percentage of graft take.

CONCLUSION

Punch-grafting is a simple, technique that not only promotes wound healing but also reduces pain. It can also be performed on an outpatient basis. Further studies should be performed to achieve a better understanding of this beneficial finding. Declaration of interest: The authors have no conflicts of interest to declare.

Understanding and addressing dryness during wound healing

Timely wound healing supports positive outcomes for both the patient and the clinician. The cause of a non-healing wound needs both identifying and addressing. A dry wound bed will result in a lengthy healing process, impacting both the patient and the clinician, physically and financially. It is imperative to correctly identify the cause of a non-healing wound and address the causative factors using evidence-based best practice. A non-healing wound may be attributed to various factors, such as inappropriate dressing, lack of hydration, medication or underlying medical disease. Identification of the cause will support the most appropriate management choice. In order to explain the issues of a dry wound, it is imperative that the clinician first has an understanding of the concept of moist wound healing.

Audit of skin changes present in referrals to a specialist lymphoedema service

An audit of 100 new patients attending a specialist lymphoedema clinic revealed 52% presented with chronic oedema. More than half (58%) of the chronic oedema group presented with skin changes whereas 14% of those with lipoedema, 4% with lymphoedema of the arm, and 8% with lymphoedema of the leg developed skin changes. None of the primary lymphoedema group developed skin changes. Chronic venous disease (CVD) was significantly more prevalent in the chronic oedema group. More patients with bilateral chronic oedema suffered from cellulitis (41%) compared to unilateral (27%). Skin changes, CVD and red leg syndrome (RLS) also occur more often in bilateral leg swelling. Incidence of cellulitis is highest in the chronic oedema group (36.5%), closely followed by the primary lymphoedema group (33.3%). 85% of the patients who were weighed (n=93) were overweight, 39% obese, and 29% morbidly obese. The findings from this audit highlight the importance of skin care training for community nurses managing chronic oedema patients.

Calling All Nursing Students: How Much Wound Care is in Your Future?

This month, more than 2,000 student nurses and nursing faculty will attend the National Student Nurses Association Annual Convention in Orlando, FL. Thinking about this event presents the perfect time for student nurses, faculty, clinical instructors, and preceptors--anyone involved in wound prevention and care practice or education--to look ahead and ponder the future of nursing in general and wound care nursing in particular.

[Continuous nursing education to improve the quality of health care]

Health care and today's medical and technical achievements and approved standards of treatment provide comprehensive quality, safety and traceability of medical procedures respecting the principles of health protection. Continuous education improves the quality of nursing health care and increases the effectiveness of patient care, consequently maintaining and enhancing patient safety. Patient health problems impose the need of appropriate, planned and timely nursing care and treatment. In providing quality nursing care, attention is focused on the patient and his/her needs in order to maintain and increase their safety, satisfaction, independence and recovery or peaceful death, so the health and nursing practices must be systematized, planned and based on knowledge and experience. Health and nursing care of patients at risk of developing acute and chronic wounds or already suffering from some form of this imply preventive measures that are provided through patient education, motivation, monitoring, early recognition of risk factors and causes, and reducing or removing them through the prescribed necessary medical treatment which is safe depending on the patient health status. Except for preventive measures, nursing care of patients who already suffer from some form of acute or chronic wounds is focused on the care and treatment of damaged tissue by providing appropriate and timely diagnosis, timely and proper evaluation of the wound and patient general status, knowledge and understanding of the wide range of local, oral and parenteral therapy and treatment, aiming to increase patient safety by preventing progression of the patient general condition and local wound status and reducing the possibility of developing infection or other complications of the underlying disease. In the overall patient management, through nursing process, medical interventions are implemented and aimed to maintain and optimize health status, prevent complications of existing diseases and conditions, provide appropriate wound treatment, increase satisfaction, reduce pain, increase mobility, reduce and eliminate aggravating factors, and achieve a satisfactory functional and aesthetic outcome. Many scientific researches and knowledge about the pathophysiological processes of wound formation and healing are currently available. Modern achievements can accelerate independence, reduce pain and encourage faster wound healing, thus it is important to continuously develop awareness, knowledge and experience, along with the treatment to achieve, maintain and enhance the quality of health care and patient safety.

Understanding methods of wound debridement

Autolytic debridement describes the body's natural method of wound-bed cleansing, helping it to prepare the wound bed for healing. In acute wounds, autolytic debridement occurs automatically and often does not require intervention, as during the inflammatory stage of a wound, neutrophils and macrophages digest and removes devitalised tissue, cell debris and contaminants, clearing the wound of any cellular barriers to healing. In chronic wounds, by contrast, healing is often delayed, frequently because of inadequate debridement. The autolytic process becomes overwhelmed by high levels of endotoxins released from damaged tissue (Broadus, 2013). Therefore wound debridement becomes an integral part of chronic-wound management and practitioners involved in wound care must be fully competent at wound-bed assessment and have an awareness of the options available for debridement. This article will review wound-bed assessment, highlighting variations in devitalised tissue, and explore options available for wound debridement, taking into consideration patients’ pain and quality of life.

Cavity wounds management: a multicentre pilot study

The objective of this study was to assess acceptability (based on pain at removal), efficacy and tolerance of an absorbent and cohesive rope(UrgoClean Rope, Laboratoires Urgo) in the local management of deep cavity wounds. This study was a prospective, multicentre (13), non comparative clinical study. Patients presenting with an acute or chronic non-infected cavity wound were followed up for four weeks and assessed weekly with a physical examination, in addition to volumetric,planimetric and photographic evaluations. Pain at removal was the primary criterion, assessed on a Visual Analogic Scale. The percentage of the wound surface area reduction and volumetric reduction were considered as secondary efficacy criteria. Forty three patients were included in this study. After one week of treatment dressing removal was painless and continued to be so throughout the period of the trial(four weeks). Median surface area at baseline was 7.74 cm2 and was reduced by 54.5% at week 4 (relative area reduction). Median wound volumetric value was noted 12 ml at baseline and was reduced by 72.7% by the end of treatment. The cohesiveness of the new rope was considered very good by health professionals. No residue was observed on the wound bed during the dressing change with the new rope. There were no adverse events related to the tested rope, during this trial.Pain-free removal associated with good efficacy and tolerance were observed with this new cohesive rope in the healing process of deep cavity wounds and could represent a therapeutic alternative to the usual ropes used in such indications.

Implications of patient shared decision-making on wound care

This article discusses the Government's drive to promote health professional and patient partnership working within healthcare, with a focus on enhancing wellbeing and how this relates to tissue viability. The literature has demonstrated how wounds impact negatively on a patient's sense of wellbeing. Assessing the impact of a wound on patient wellbeing is an essential as part of an holistic assessment process, but is even more important when the wound is chronic or recalcitrant to treatment. Scenarios are presented that illustrate how working in partnership with patients with chronic wounds can result in a therapeutic and concordant relationship when the patient's priorities of care are established, even if they differ from those of the health professionals caring for them. The article also discusses objective and subjective methods of measuring wellbeing as a means of demonstrating alternative clinical outcomes of nursing interventions within a healthcare culture where the need to meet wound healing targets still remains the norm.

Realistic outcomes

Patient-centred care is one of the new mantras of nursing and medicine. However, I wonder if this is a concept we are starting to take for granted, and if our understanding of it is based more on assumptions than we'd like to admit. I've often interpreted it as the need to involve patients in decision-making and ensure they are happy with the care they receive. In short, we want their involvement and, ultimately, stamp of approval.

Teaching home care electronic documentation skills to undergraduate nursing students

Although there is general consensus that nursing students need knowledge and significant skill to document clinical findings electronically, nursing faculty face many barriers in ensuring that undergraduate students can practice on electronic health record systems (EHRS). External funding supported the development of an educational innovation through a partnership between a home care agency staff and nursing faculty. Modules were developed to teach EHRS skills using a case study of a homebound person requiring wound care and the Medicare-required OASIS documentation system. This article describes the development and implementation of the module for an upper-level baccalaureate nursing program located in New York City. Nursing faculty are being challenged to develop creative and economical solutions to expose nursing students to EHRSs in nonclinical settings.

French national wound management survey: choice criteria of dressings

Across Europe, wound care management is organized differently, and in some countries such as the UK or Denmark, wound healing centres have been implemented. In France, a large number of health professionals are not sufficiently educated in wound care management during their vocational training. The rapid evolution of dressings has changed wound management practices and has given rise to new professional recommendations. This national survey was carried out in France in 2009, including 465 health professionals, to determine the criteria they use to choose a dressing and their habits of care with acute or chronic wounds. Around 73% of respondents were nurses and, on average, participants took care of 43 wounds per month. It was also found that 89% of the health professionals who took part prefer the sequential treatment of the wound based on its appearance. Regardless of whether the wound is acute or chronic, the priorities for wound care and the choice of dressing are the management of the exudate and the prevention or treatment of infection. These results put into evidence the adequacy of the recommendations by these practitioners and the good correlation between the choice of dressing and the local therapeutic goal. To reach the same level of expertise, the professional training for health professionals who are less frequently involved in wound care is necessary.

Evaluating a super absorbent dressing (Flivasorb) in highly exuding wounds

This article reports an observational evaluation of 19 patients with highly exuding wounds. Flivasorb was used as a super absorbent dressing that could remove the harmful exudate fluid and promote a healthy wound bed. The outcomes demonstrated that Flivasorb is successfully absorbs large amounts of fluid, reduces the number of dressing changes required and therefore, reduces the cost of the patient's care.

Evaluating Cutimed Sorbact: using a case study approach

This article uses a case study approach to demonstrate good clinical outcomes using a bacterial binding dressing range on a variety of difficult wounds. A case study approach can demonstrate a clinician's perspective on the practicalities of dressing choice in practice. All wounds, whether acute or chronic, offer pathogenic micro-organisms the opportunity to flourish - this can result in slow healing. Antimicrobial dressings use active ingredients but the Cutimed Sorbact range is a bacterial binding wound dressing that offers an alternative approach to the management of bio-burden. All dressings have a cost implication and holistic wound assessment is the key to accurate diagnosis and treatment, as well as directing the practitioner to an appropriate management strategy.

An interview with Keith Cutting

Having acquired experience in medical and surgical nursing and subsequently working part-time in what became the Wound Healing Research Unit (Cardiff) I came to the conclusion that wound care offered opportunities beyond other clinical specialties, particularly that of being able to make a personal difference. Another aspect that attracted me to wound care was that of continuity of care. Working in a university hospital and a busy wound clinic, before the advent of Trusts, enabled close contact with patients to be maintained and allowed participation in their care virtually from start to finish of the care process.

[Nurse's experience caring for a patient with malignant fungating wound with enterocutaneous fistula]

This report describes a nurse's experience treating a metastatic skin lesion with draining enterocutaneous fistula located in the right posterolateral abdominal wall. The period of nursing care ran from April 22nd through June 25th, 2006. In studying the nursing process, Gordon's assessment tools were used to gather subjective and objective data to establish critical care issues, which included chronic pain, sleep pattern disturbance, impaired tissue integrity, and disturbed body image. The focus of care was to manage the pain and irritation caused by the fistula of enterocutaneous. Targeting the issue of impaired tissue integrity, we developed and applied various methods to decrease the wound macerated from fecal, control odor, maintain patient comfort and improve patient quality of life. We helped the patient achieve her wish to end her life in peace. This nursing experience may provide a reference in caring for such cases in the clinic.

Malodorous fungating wounds: how dressings alleviate symptoms

Fungating wounds are unlikely to heal and therefore, the prime consideration should be the treatment and, where possible, the elimination of symptoms such as malodour. Malodour is the byproduct of bacteria and the fatty acids that are part of necrotic tissue. Application of dressings that block the odour, such as charcoal, or dressings that are antimicrobial, will reduce or remove the malodour that has such a negative effect on the patient's quality of life.

Skin integrity in critically ill and injured children

BACKGROUND

Skin breakdown increases the cost of care, may lead to increased morbidity, and has negative psychosocial implications because of secondary scarring or alopecia. The scope of this problem has not been widely studied in critically ill and injured children.

OBJECTIVES

To determine the incidence of skin breakdown in critically ill and injured children and to compare the characteristics of patients who experience skin breakdown with those of patients who do not.

METHODS

Admission and follow-up data for a 15-week period were collected retrospectively on children admitted to a large pediatric intensive care unit. The incidence of skin breakdown was calculated. The risk for skin breakdown associated with potential risk factors (relative risk) and 95% confidence intervals were determined.

RESULTS

The sample consisted of 401 distinct stays in the intensive care unit for 373 patients. During the 401 stays, skin breakdown occurred in 34 (8.5%), redness in 25 (6.2%), and breakdown and redness in 13 (3.2%); the overall incidence was 18%. Patients who had skin breakdown or redness were younger, had longer stays, and were more likely to have respiratory illnesses and require mechanical ventilatory support than those who did not. Patients who had skin breakdown or redness had a higher risk of mortality than those who did not.

CONCLUSIONS

Risk factors for skin breakdown were similar to those previously reported. Compared with children of other ages, children 2 years or younger are at higher risk for skin breakdown.

Addressing a deficit: wound care and mental health nursing

This article details the development and implementation of a teaching session introduced to address one of the key clinical skills that mental health nurses require in the practice setting--wound management. The session was introduced to equip a group of final year mental health nursing students with the knowledge, skills and attitudes they will need for practicing in a professional environment. The sessions were evaluated to determine their effectiveness in terms of the students' satisfaction with the teaching process, the clinical value and relevance of the content, and to improve the quality of future clinical skills teaching.

Assessment of wound pain: overview and a new initiative

All wounds have the potential to cause pain, and the nature of the pain varies with the type of wound. Many factors may exacerbate wound pain, including infection, trauma at dressing changes and poor technique when applying compression therapy. Failure to assess wound pain or inadequate pain assessment can cause the patient further anguish and extended suffering. Nurses caring for patients with painful wounds need to identify the source of the pain and exacerbating factors, and determine whether it has nocicoceptive and/or neuropathic elements in order to optimize pain management for the individual patient. This article examines the assessment of wound pain and introduces an initiative that has been developed to improve the assessment process. The 'Heal not Hurt' initiative is an excellent example of the profession and industry working together to implement best practice guidance in patient-centred pain-free wound care in clinical care.

Wound assessment and the TIME framework

A structured wound assessment is a crucial part of managing any patient with a wound. Many different wound assessment tools currently exist but there is little standardization in the information they are used to record. A simple framework such as TIME can be used to co-ordinate the data collection into more useful elements which assist in planning cost-effective care. Clustering the information under the key headings of TIME encourages the practitioner to relate what they are seeing to what is happening at a cellular level and manage wounds in a proactive rather than reactive manner, setting clear management/care objectives to facilitate the wound to heal where this is appropriate.

[The meaning of caring from the viewpoint of patients with wounds due to peripheral vascular disease]

This qualitative study describes the meaning of Caring from the viewpoint of the patient with chronic wounds due to peripheral vascular disease (PVD). Because the meaning of Caring can not be understood independent from the life context of the persons involved, the following questions have been formulated: 1) What influence does living with chronic wounds have on the everyday life of the patient? 2) What is the meaning of Caring for patients with chronic wounds? To answer these questions, qualitative research methods according to Mayring were chosen. A convenience sample of twelve patients, seven women and five men, with ages ranging from 69 to 86 years (median 77 years), were interviewed from April to November 2002. Data were analyzed according to Mayring (2000) through content analysis. The results show that the everyday life of the patient is strongly influenced by the effects of having chronic wounds. Patients view their lives with chronic wounds, the effects on their day to day life and the support from health professionals and family caregivers as a whole. Patients differentiate between Caring from Health professionals and Caring from family caregivers. Caring from health professionals is described primarily in the context of treatments and support situations. Caring from family caregivers is experienced as a part of the everyday life. Patients assume that healthcare professionals have the needed expertise, knowledge and skills. They hope, however, to be valued and respected and describe these characteristics as "kind and nice". When patients experience these attitudes from the nurses they feel they are taken seriously and are cared for. This is a requirement to enable or empower patients to understand and implement their treatment regimen. Caring must always be an element of nursing care and determines the standard of the quality of the patient-nurse relationship.

Competent patients' refusal of nursing care

Competent patients' refusals of nursing care do not yet have the legal or ethical standing of refusals of life-sustaining medical therapies such as mechanical ventilation or blood products. The case of a woman who refused turning and incontinence management owing to pain prompted us to examine these situations. We noted several special features: lack of paradigm cases, social taboo around unmanaged incontinence, the distinction between ordinary versus extraordinary care, and the moral distress experienced by nurses. We examined this case on the merits and limitations of five well-known ethical positions: pure autonomy, conscientious objection, paternalism, communitarianism, and feminism. We found each lacking and argue for a 'negotiated reliance' response where nurses and others tread as lightly as possible on the patient's autonomy while negotiating a compromise, but are obligated to match the patient's sacrifice by extending themselves beyond their usual professional practice.

Clinical nurse specialists as entrepreneurs: constrained or liberated

AIMS

This qualitative study explored the experiences of two groups of clinical nurse specialists--continence advisors and tissue viability nurses--working in primary care in the UK. In particular, the study focused on how clinical nurse specialists' relationships with other health-care professionals had an impact on their role.

BACKGROUND

Clinical nurse specialists are recognized worldwide as having expertise in a given field, which they use to develop the practice of others. Additionally, clinical nurse specialists share many of the characteristics of entrepreneurs, which they use to develop services related to their speciality. However, little research has been conducted in relation to clinical nurse specialists' experiences as they attempt to diversify nursing practice.

DESIGN/METHODS

An ethnographic approach was adopted comprising many elements of Glaserian grounded theory. Data were collected via participant observation and face-to-face interviews with 22 clinical nurse specialists.

FINDINGS

Services provided by clinical nurse specialists were not static, clinical nurse specialists being the main drivers for service developments. However, clinical nurse specialists encountered difficulties when introducing new ideas. Given their role as advisors, clinical nurse specialists lacked authority to bring about change and were dependent on a number of mechanisms to bring about change, including 'cultivating relationships' with more powerful others, most notably the speciality consultant.

CONCLUSIONS

The UK government has pledged to 'liberate the talents of nurses' so that their skills can be used to progress patient services. This study highlights the fact that a lack of collaborative working practices between health-care professionals led to clinical nurse specialists being constrained.

RELEVANCE TO CLINICAL PRACTICE

Health-care organizations need to provide an environment in which the entrepreneurial skills of clinical nurse specialists may be capitalized on. In the absence of an outlet for their ideas regarding service developments, clinical nurse specialists may remain dependent on the mechanisms witnessed in this study for some time.

Managing bleeding malignant skin lesions

Malignant skin lesions can bleed as a result of the tumour itself or after the application of inappropriate dressings. Vivien McMurray discusses some of the measures that can be taken to control light bleeding, together with other methods that should be considered when profuse bleeding occurs.