How living with a leg ulcer affects people's daily life: a nurse-led study

Chronic Wounds and Employment: Assessing Occupation-Related Burden of Patients With Chronic Wounds-Results of a Pilot Study

Chronic wounds can impact the quality of life of working-age individuals. However, the specific challenges and burdens these patients face in the workplace remain understudied. This study aimed to 1) investigate how chronic wounds affect work life and 2) develop a screening tool for identifying highly affected patients. In total, 51 patients with chronic wounds answered a questionnaire on demographics, employment status, wound-related limitations, workplace conditions, social welfare use and subjective burden of disease. To assess the subjective burden, we developed a specific research tool on employment and chronic wounds (REACH Score) to measure and quantify the impact of the chronic wound on working patients. The patients, who answered the questionnaire, were employed (78%), on sick leave (18%) or retired (4%). They spent an average of 5.3 h per week on wound-related activities. Regarding workplace stressors, we found that taking breaks when needed was correlated with less time off sick and better work-related quality of life. Patients reported career concerns and reduced productivity. The REACH score was significantly correlated with sick leave, work difficulties, time consumed by the wound and overall quality of life. According to our pilot-study, the impact of chronic wounds on patients of working age is most evident in the form of sick leave and reduced work performance and in a reduced quality of life. It is crucial to identify the key factors contributing to stress in the work environment in a larger sample in order to improve the working conditions of patients and detrimental socioeconomic effects on the workforce. The REACH score is a novel tool to screen employed patients with chronic wounds for reduced work capacity and quality of life.

A systematic review of the impact of compression therapy on quality of life and pain among people with a venous leg ulcer

AIM

To gain a greater understanding of how compression therapy affects quality of life, this systematic review appraised existing published studies measuring the impact of compression therapy on health quality of life (HRQoL), and pain, among people with venous leg ulcers (VLU).

METHOD

Five databases were searched, and two authors extracted data and appraised the quality of selected papers using the RevMan risk of bias tool. Due to heterogeneity in the types of compression and instruments used to evaluate HRQoL, meta-analysis was not appropriate; thus, a narrative synthesis of findings was undertaken.

RESULTS

Ten studies were included, 9 RCTs and one before-after study. The studies employed nine different HRQoL tools to measure the impact of a variety of compression therapy systems, with or without an additional exercise programme, versus other compression systems or usual care, and the results are mixed. With the use of the Cardiff Cardiff Wound Impact Schedule, the SF-8 and the SF-12, study authors found no differences in QoL scores between the study groups. This is similar to one study using QUALYs (Iglesias et al., 2004). Conversely, for studies using EuroQol-5D, VEINES-QOL, SF-36 and CIVIQ-20 differences in QoL scores between the study groups were noted, in favour of the study intervention groups. Two further studies using QUALYs found results that favoured a two-layer cohesive compression bandage and the TLCCB group, respectively. Results for the five studies that assessed pain are also mixed, with one study finding no difference between study groups, one finding that pain increased over the study period and three studies finding that pain reduced in the intervention groups. All studies were assessed as being at risk of bias in one or more domains.

CONCLUSION

Results were varied, reflecting uncertainty in determining the impact of compression therapy on quality of life and pain among people with a venous leg ulcer. The heterogeneity of the compression systems and the measures used to evaluate HRQoL make it a challenge to interpret the overall evidence. Further studies should strive for homogeneity in design, interventions and comparators to enhance both internal and external validity.

Assessing the healthcare costs associated with venous leg ulcer compression bandages - A scoping review

AIM

To determine the monetary costs identified in economic evaluations of treatment with compression bandages among adults with venous leg ulcers (VLU).

METHOD

A scoping review of existing publications was conducted in February 2023. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used.

RESULTS

Ten studies met the inclusion criteria. To place the costs of treatment into context, these are reported in conjunction with the healing rates. Three comparisons were made: 1.4 layer compression versus no compression (3 studies). One study reported that 4 layer compression was more expensive than usual care (£804.03 vs £681.04, respectively), while the 2 other studies reported the converse (£145 vs £162, respectively) and all costs (£116.87 vs £240.28 respectively). Within the three studies, the odds of healing were statistically significantly greater with 4 layer bandaging (OR: 2.20; 95% CI: 1.54-3.15; p = 0.001).; 2.4 layer compression versus other compression (6 studies). For the three studies reporting the mean costs per patient associated with treatment (bandages alone), over the treatment period, analysis identified a mean difference (MD) in costs for 4 layer vs comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) of -41.60 (95% CI: 91.40 to 8.20; p = 0.10). The OR of healing for 4 layer compression vs comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) is: 0.70 (95% CI: 0.57-0.85; p = 0.004). For 4 layer vs comparator 2 (2 layer compression) the MD is: 14.00 (95% CI: 53.66 to -25.66; p < 0.49). The OR of healing for 4 layer compression vs comparator 2 (2 layer compression) is: 3.26 (95% CI: 2.54-4.18; p < 0.00001). For comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) vs comparator 2 (2 layer compression) the MD in costs is: 55.60 (95% CI: 95.26 to -15.94; p = 0.006). The OR of healing with Comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) is: 5.03 (95% CI:4.10-6.17; p < 0.00001). Three studies presented the mean annual costs per patient associated with treatment (all costs). The MD is 172 (150-194; p = 0.401), indicating no statistically significant difference in costs between the groups. All studies showed faster healing rates in the 4 layer study groups. 3. Compression wrap versus inelastic bandage (one study). Compression wrap was less expensive than inelastic bandage (£201 vs £335, respectively) with more wounds healing in the compression wrap group (78.8%, n = 26/33; 69.7%, n = 23/33).

CONCLUSION

The results for the analysis of costs varied across the included studies. As with the primary outcome, the results indicated that the costs of compression therapy are inconsistent. Given the methodological heterogeneity among studies, future studies in this area are needed and these should use specific methodological guidelines to generate high-quality health economic studies.

Social participation of people with chronic wounds: A systematic review

Living with chronic ulcers can be burdensome and restrictive, with regard to not only physical and psychological but also social well-being. This review aims to analyse social participation in patients with chronic wounds and to compare results across different wound types. A search string was applied in several electronic databases. Results were screened according to predefined inclusion and exclusion criteria. Data of eligible articles were extracted and synthesised narratively. The search revealed 42 eligible publications. Only minor differences across different ulcer types could be detected. Overall, family members were the main social contacts for patients; they often provided wound care and emotional support. Patients had few non-family relations, but those existing were often very close. Patients felt guilty as their condition imposed burden on family and friends, as well. A close relationship with nurses was described. Restrictions were caused by direct and indirect consequences of the wound. Overall, social support and social connections were reduced in wound patients. Inconsistent results were found regarding social isolation. In summary, people with chronic wounds experience impairments in all aspects of social participation. Therefore, social participation deserves increased attention in routine care both as a trigger of burden and as an outcome of therapy.

Chronic venous leg ulcer care: Putting the patient at the heart of leg ulcer care Part 2: Development and evaluation of the consultation template

Part 2 in this article series summarises the final two phases of a study which explored the experiences of patients with leg ulcers and the impact of this condition on their quality of life. Early phases of the study revealed a mismatch between issues that affected a patient's quality of life and what they discussed during subsequent health care consultations. In light of this, a nominal group technique was employed to facilitate the development of a new leg ulcer consultation template with patient partners. The aim of this was to include many of the issues raised in phases 1. The new template was evaluated in terms of its utility, significance and clinical potential. The application of this template during routine consultations appears to encourage the patient to disclose issues that are important to them and may have otherwise been overlooked.

Suppressed networks of inflammatory mediators characterize chronic venous insufficiency

OBJECTIVE

Chronic venous insufficiency (CVI) affects 25 million adults in the United States. Little emphasis has been placed on inflammatory changes associated with CVI. We hypothesize that in patients with early to mid-stage benign varicose vein disease, differences in circulating inflammatory mediators will be manifested in blood draining the involved area vs circulating blood in control subjects.

METHODS

Patients undergoing either endovenous ablation or sclerotherapy for Clinical, Etiology, Anatomy, and Pathophysiology clinical class 3 to 5 disease underwent phlebotomy from regional veins at the time of the procedure. The patient's age, gender, clinical class, duration of symptoms, presence of superficial truncal reflux by duplex ultrasound, and treatment modality were recorded. Plasma from patients and banked blood samples from healthy volunteers (HVs) were subjected to Luminex (EMD Millipore, Billerica, Mass) to evaluate the expression of an established panel of 20 inflammatory mediators. Mediator concentrations were compared between patients and HVs using Mann-Whitney U tests. Importantly, computational analysis allowed us to compare not only the panel of inflammatory mediators but also the inflammatory networks connecting these mediators to one another. Principal components were analyzed to assess network robustness in each group.

RESULTS

CVI venous blood revealed significantly lower levels of monokine induced by γ interferon, soluble interleukin (IL) 2 receptor α chain, IL-4, IL-6, IL-7, tumor necrosis factor α, eotaxin, and granulocyte-macrophage colony-stimulating factor than blood from controls. Inflammatory networks were significantly less complex and less robust in the CVI patients compared with HVs. Based on principal component analysis, responses among HVs were more varied than those of CVI patients.

CONCLUSIONS

We demonstrate that patients with CVI have significant differences not only in blood-borne inflammatory mediators but also in the interconnectedness of these mediators with one another and in their principal inflammatory characteristics. Results suggest hypoinflammation in chronic nonhealing changes in CVI. These novel findings, if validated in larger cohorts, may help predict the risk of disease progression or response to therapy in the future and may guide mechanistic studies on tissue responses to CVI.

The Use of PRISM (Pictorial Representation of Illness and Self Measure) in Patients Affected by Chronic Cutaneous Ulcers

OBJECTIVE

PRISM (Pictorial Representation of Illness and Self Measure) is a nonverbal visualization instrument. The authors chose to use this tool to avoid the limitation of the other tests for the assessment of quality of life by using interview methods that depend on the cognitive and cultural level of the patient. The aim of the study was to assess the impact on the quality of life of different types of chronic wounds using the PRISM test.

SETTING

The PRISM test was administered by the same medical student to each patient visiting the dermatology department for a routine visit and medication.

PARTICIPANTS

The PRISM test was administered to 77 patients with chronic cutaneous ulcers referred to the Dermatology Department of the Spedali Civili of Brescia, Italy.

MATERIALS AND METHODS

The authors analyzed the "Self-llness-Separation"' (SIS) value, which resulted from the PRISM test, and related it to sex, age, and ulcer etiology.

RESULTS

Considering all categories, the mean SIS was 9.58 cm; a different perception of the disease between the sexes was noted and also in the subgroups based on the ulcer's different etiology. In addition, the age of the affected patients influenced the SIS value.

CONCLUSIONS

PRISM is an easy and sensitive instrument to record information about the patient's expectations and suffering in order to improve the overall physician-patient relationship.

Peripheral nerve crushing to relieve chronic pain in diabetic and ischaemic foot ulcers

OBJECTIVE

We retrospectively assessed the effectiveness of peripheral nerve crushing (Smithwick operation) in relieving intractable chronic pain associated with foot ulcers caused by diabetes mellitus (DM) or atherosclerosis.

METHOD

From April 2009 to April 2012, patients underwent peripheral nerve crushing in the leg affected by foot ulceration. The cause of ulceration was either DM alone, atherosclerosis alone, or both DM and atherosclerosis. Because sensation in the foot is associated with five nerves: the tibial, deep peroneal, superficial peroneal, sural, and saphenous, one or more of these nerves were crushed over a length of 1.5cm by using a 'pean' in the distal third of leg the where there are no major motor nerves.

RESULTS

There were 36 patients recruited with ulcers grade 3-5 according to the Wagner ulcer classification system that affected the toes, dorsum pedis, or any part of the plantar surface or the heel. The mean duration of foot ulcerations before the nerve crushing was 22.3±9.7 weeks. In all 36 patients, the nerve crushing was performed successfully without any perioperative surgical complication. Of the 36 patients, 34 (94.4%) had substantial pain relief immediately after nerve crushing. While the mean pain level before the procedure was 86.6±0.51mm on visual analogue scale (VAS), pain level dropped significantly after the operation to 18.6 ± 5.4mm at one week, 14.8±4.8mm at one month, 13.7±4.1mm at two months, 9.8±4.1mm at three months, 11.8±5.7mm at four months, 10.1±4.7mm at five months and 8.8±3.3mm at six months. The time to regeneration of the sensory nerves was 121±6.5 days (range: 80-181 days). The surgical complications were wound infection (6 patients) and temporary toe paralysis (three patients). The foot ulcers in 20 of the 36 patients (55.6%) were resolved by debridement or minor amputation. In seven patients (19.4%), a major amputation (five below and two above the knee) was required because of ischemia or infection. No patient died within 30 days of the operation, while nine patients died during the observation period because of comorbid conditions.

CONCLUSION

Peripheral nerve crushing could be the alternative procedure for achieving analgesia in patients with intractable chronic pain from foot ulcers caused by DM or atherosclerosis.

Exploring nurses' and patients' feelings of disgust associated with malodorous wounds: a rapid review

OBJECTIVE

To identify primary empirical research related specifically to feelings of disgust associated with malodorous chronic cutaneous wounds.

METHOD

A rapid review of the literature using the key words disgust; wounds; malodour and psychosocial.

RESULTS

A total of 163 papers were retrieved with seven being included for the final review. Themes emanating from the review were malodour, health-care professionals coping with malodour and disgust. Malodour is a concern to patients, which can sometimes go unreported by nursing staff; although the reasons for this remain unclear. The coping mechanisms developed by nurses in response to 'disgusting' wounds requires further exploration in order for a fuller understanding of these mechanisms to be achieved. This review has identified that both health-care professionals and patients can become distressed at wound odours, yet there is little evidence that is available to guide people as to how to manage these feelings.

CONCLUSION

Hard-to-heal or chronic cutaneous wounds, such as leg ulcers and diabetic foot ulcers, are an increasing global health-care issue. While some research has been undertaken to explore the psychological impact of living with a fungating carcinoma; much less has been written about the management and mitigation of feelings of disgust for patients and families living with a malodorous wound or how health-care professionals can effectively provide psychosocial care.

Well-being in wounds inventory (WOWI): development of a valid and reliable measure of well-being in patients with wounds

OBJECTIVE

Physical and psychosocial deficits have been reported in people living with chronic wounds. While the negative impact of these factors on an individual's quality of life (QoL) is well documented, there has been little research into the well-being of those living with chronic wounds, despite recent calls for increased attention to this related, yet distinct construct. This paper introduces the Well-being in Wounds Inventory (WOWI) and provides support for the WOWI as a valid and reliable measure of well-being in patients living with chronic wounds.

METHOD

A draft questionnaire was administered to a convenience sample of individuals with chronic wounds (n=85) and the resulting data subject to factor analysis in order to refine the structure of the questionnaire. The reliability, validity and responsiveness of the resulting questionnaire were then tested by administration to a second sample of individuals with wounds (n=49). Socio-demographic data, issues affecting patient well-being and well-being factors, such as, emotions; perceived coping skills; social support; personal control; hope for the future, were measured.

RESULTS

Results confirmed the WOWI as a reliable and valid measure of well-being. Items loaded onto two subscales, 'personal resources' and 'wound worries'. Analysis revealed the WOWI to be highly feasible measure of well-being, with good test-retest reliability and responsiveness to changes in health status.

CONCLUSION

The current study highlights the importance of assessing well-being factors in individuals living with chronic wounds. It introduces the WOWI as a valid and reliable measure of well-being in chronic wound patients. The authors recommend health-care practitioners take account of well-being as part of a holistic treatment plan in order to maximise patient outcomes.

DECLARATION OF INTEREST

This project was funded by Urgo Medical. The authors have no conflict of interest to declare.

Nurse-patient consultations in primary care: do patients disclose their concerns?

OBJECTIVE

To quantify the extent to which patients disclose their concerns to community nurses during wound care consultations.

METHOD

Using an 'observation checklist' based on themes and subthemes that were identified in a previous study of the same patients, 20 wound care consultations were observed. The non-participant observer completed the checklist and made field notes regarding the context and nature of interactions.

RESULTS

Patient participants had 160 opportunities to raise concerns regarding previously-identified pain, exudate and odour, yet they did not do so on 64 (40%) occasions. They had 28, 32 and 84 opportunities to raise emotional, wound care and daily living issues, respectively, and they did not on 16 (56%), 3 (9%) and 32 (38%) occasions. Overall, patients did not raise 38% of their concerns. Of the concerns that were raised, 8% were either not acknowledged or were disregarded by their community nurse.

CONCLUSION

If these data are representative, this has profound implications for person-centred care and shared decision-making models of care, which are predicated on patients articulating their needs. They also have implications for the development of practitioners' communication and consulting skills.

Debridement for venous leg ulcers

BACKGROUND

Venous ulcers (also known as varicose or venous stasis ulcers) are a chronic, recurring and debilitating condition that affects up to 1% of the population. Best practice documents and expert opinion suggests that the removal of devitalised tissue from venous ulcers (debridement) by any one of six methods helps to promote healing. However, to date there has been no review of the evidence from randomised controlled trials (RCTs) to support this.

OBJECTIVES

To determine the effects of different debriding methods or debridement versus no debridement, on the rate of debridement and wound healing in venous leg ulcers.

SEARCH METHODS

In February 2015 we searched: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. There were no restrictions with respect to language, date of publication or study setting. In addition we handsearched conference proceedings, journals not cited in MEDLINE, and the bibliographies of all retrieved publications to identify potential studies. We made contact with the pharmaceutical industry to enquire about any completed studies.

SELECTION CRITERIA

We included RCTs, either published or unpublished, which compared two methods of debridement or compared debridement with no debridement. We presented study results in a narrative form, as meta-analysis was not possible.

DATA COLLECTION AND ANALYSIS

Independently, two review authors completed all study selection, data extraction and assessment of trial quality; resolution of disagreements was completed by a third review author.

MAIN RESULTS

We identified 10 RCTs involving 715 participants. Eight RCTs evaluated autolytic debridement and included the following agents or dressings: biocellulose wound dressing (BWD), non-adherent dressing, honey gel, hydrogel (gel formula), hydrofibre dressing, hydrocolloid dressings, dextranomer beads, Edinburgh University Solution of Lime (EUSOL) and paraffin gauze. Two RCTs evaluated enzymatic preparations and one evaluated biosurgical debridement. No RCTs evaluated surgical, sharp or mechanical methods of debridement, or debridement versus no debridement. Most trials were at a high risk of bias.Three RCTs assessed the number of wounds completely debrided. All three of these trials compared two different methods of autolytic debridement (234 participants), with two studies reporting statistically significant results: one study (100 participants) reported that 40/50 (80%) ulcers treated with dextranomer beads and 7/50 (14%) treated with EUSOL achieved complete debridement (RR 5.71, 95% CI 2.84 to 11.52); while the other trial (86 participants) reported the number of ulcers completely debrided as 31/46 (76%) for hydrogel versus 18/40 (45%) for paraffin gauze (RR 0.67, 95% CI 0.45 to 0.99). One study (48 participants) reported that by 12 weeks, 15/18 (84%) ulcers treated with BWD had achieved a 75% to 100% clean, granulating wound bed versus 4/15 (26%) treated with non-adherent petrolatum emulsion-impregnated gauze.Four trials assessed the mean time to achieve debridement: one (86 participants) compared two autolytic debridement methods, two compared autolytic methods with enzymatic debridement (71 participants), and the last (12 participants) compared autolytic with biosurgical debridement; none of the results achieved statistical significance.Two trials that assessed autolytic debridement methods reported the number of wounds healed at 12 weeks. One trial (108 participants) reported that 24/54 (44%) ulcers treated with honey healed versus 18/54 (33%) treated with hydrogel (RR (adjusted for baseline wound diameter) 1.38, 95% CI 1.02 to 1.88; P value 0.037). The second trial (48 participants) reported that 7/25 (28%) ulcers treated with BWD healed versus 7/23 (30%) treated with non-adherent dressing.Reduction in wound size was assessed in five trials (444 participants) in which two autolytic methods were compared. Results were statistically significant in one three-armed trial (153 participants) when cadexomer iodine was compared to paraffin gauze (mean difference 24.9 cm², 95% CI 7.27 to 42.53, P value 0.006) and hydrocolloid compared to paraffin gauze (mean difference 23.8 cm², 95% CI 5.48 to 42.12, P value 0.01). A second trial that assessed reduction in wound size based its results on median differences and, at four weeks, produced a statistically significantly result that favoured honey over hydrogel (P value < 0.001). The other three trials reported no statistically significant results for reduction in wound size, although one trial reported that the mean percentage reduction in wound area was greater at six and 12 weeks for BWD versus a non-adherent dressing (44% versus 24% week 6; 74% versus 54% week 12).Pain was assessed in six trials (544 participants) that compared two autolytic debridement methods, but the results were not statistically significant. No serious adverse events were reported in any trial.

AUTHORS' CONCLUSIONS

There is limited evidence to suggest that actively debriding a venous leg ulcer has a clinically significant impact on healing. The overall small number of participants, low number of studies and lack of meta-analysis in this review precludes any strong conclusions of benefit. Comparisons of different autolytic agents (hydrogel versus paraffin gauze; Dextranomer beads versus EUSOL and BWD versus non-adherent dressings) and Larvae versus hydrogel all showed statistically significant results for numbers of wounds debrided. Larger trials with follow up to healing are required.

Teaching and learning in the Biosciences: the development of an educational programme to assist student nurses in their assessment and management of patients with wounds

AIMS AND OBJECTIVES

The aim of this project was to develop an educational package for undergraduate student nurses that would provide them with the theoretical knowledge and clinical judgement skills to care for a patient with a wound.

BACKGROUND

Internationally there is concern over the adequacy of preparation of undergraduate nurses for the clinical skill of wound care. Deficits have also been identified in the underpinning biological sciences needed for this skill. Expectations associated with wound management have altered significantly in the last two decades with decision making around wound care coming under the scope of practice of nurses. The treatment and care options for patients with wounds must be based on a sound knowledge of how wounds are formed and healed. If nurses do not have the evidence-based knowledge, it can affect wound healing adversely leading to increased patient suffering, pain and delayed healing. From an organisational perspective, delayed healing will increase the cost of care.

DESIGN

This project used constructivism learning theory to provide a framework for the development of a wound care educational package for undergraduate Irish nurses in their penultimate year of training.

METHODS

Collaboration was formed with key stake holders. Pertinent curriculum content was mapped. Learning strategies to suit the incoming student learning styles were incorporated into newly developed theoretical content and practical skill sessions.

CONCLUSION

The developed educational programme will assist student nurses in their care of patients with wounds.

RELEVANCE TO CLINICAL PRACTICE

This study provides a model that can be followed to develop small units of the study to keep abreast of changes in health care delivery and the changing scope of practice of nurses. It also contributes to the debate on the teaching and learning of biosciences as it highlights the depth of biological knowledge required as a basis for good evidence-based nursing care.

An evaluation of short-stretch compression systems for chronic lower-limb leg ulcers

An evaluation of a new short-stretch compression system (CoFlex UBZ, TLC and TLC Lite, Aspen Medical Europe Ltd) was undertaken in four leg ulcer clinics. A total of 19 patients aged 42-93 years were treated for up to 4 weeks, or until healed. Collated data included age, underlying diseases, leg ulcer type, ulcer duration and current treatment. The evaluation included quality of life measurements, wear time, slippage, exudate strikethrough and pain using a numerical pain score. Patients were asked to document sleep patterns. Compression was applied according to clinical need. Inclusion criteria were non-healing wounds on the lower limb existing for more than 6 weeks that were suitable for compression. Exclusion criteria included patients with untreated peripheral disease, ankle-brachial pressure index (ABPI)<0.5 or those unable to consent. Staff were asked to rate performance, wear time, fluid handling and conformability. Wound tissue types improved significantly for n=16 (84%) patients. Pain scores reduced significantly by week 2, n=11 (58%) patient leg ulcers had improved, n=2 (11%) patients in standard compression noted a marked reduction in malodour and sloughy tissue. n=16 (84%) rated the overall performance as 'very good' or 'good'. A detailed cost analysis was undertaken on one patient, suggesting a potential cost saving of £186.92 per month and a cost efficiency saving of 43.4%.

Sustaining Behavior Changes Following a Venous Leg Ulcer Client Education Program

Venous leg ulcers are a symptom of chronic insufficiency of the veins. This study considered the sustainability of behavior changes arising from a client focus e-Learning education program called the “Leg Ulcer Prevention Program” (LUPP) for people with a venous leg ulcer. Data from two related studies were used to enable a single sample (n = 49) examination of behavior maintenance across an average 8 to 9 months period. Physical activity levels increased over time. Leg elevation, calf muscle exercises, and soap substitute use were seen to fluctuate over the follow up time points. The use of a moisturizer showed gradual decline over time. The provision of a client-focused venous leg ulcer program was associated with behavior changes that had varied sustainability across the evaluation period.

The psychosocial impact of chronic wounds on patients with severe epidermolysis bullosa

OBJECTIVE

To explore the lived experience of individuals with chronic wounds associated with dystrophic and junctional epidermolysis bullosa (EB),to improve understanding and, therefore, enhance the care provided to this group of patients by acquiring in depth data on the psychosocial issues that affect them.

METHOD

A phenomenological study using interpretive phenomenological analysis was employed. A purposive sampling method was used with six individuals replying to postal invitation to participate.

RESULTS

Following one-to-one interviews, six superordinate themes were identified. These were: coping, pain, perceptions, emotional impact, social impact and support network, each with subordinate themes. All of the superordinate themes have been identified by previous research into chronic wounds, burns and disfiguring conditions; however, new subordinate themes arose.

CONCLUSION

This study highlighted the need for individuals with EB to have a multidisciplinary approach to their care with a particular need for pain management, psychological intervention and nursing support from those whom clients perceive as understanding the requirements of patients with EB. Further research into identity issues in individuals with EB is advocated.

DECLARATION OF INTEREST

There were no external sources of funding for this study.The authors have no conflicts of interest to declare.

Collaboration improves outcomes: cross county, joint acute and primary care, working party to select a super absorbent dressing

This abstract highlights the work undertaken by the Bedfordshire and Hertfordshire Tissue Viability Nurses Forum (BHTVNF) to select a super absorbent dressing for local formularies. A range of super absorbent dressings was selected to be included in the evaluation based on their accessibility via FP10 or NHS Supply chain. Dressings were evaluated in the hospital setting, community setting and leg ulcer clinics. Table top evaluations were also undertaken. Performance of dressings both clinically and via table top were considered along with costs. It was interesting to find out that hospital patients had different needs to community patients and as such three recommendations were made. The acute sector has added one super absorbent which is different from the community selected one. The community has also selected a lower performing super absorbent which the acute sector has not chosen.

Exudate assessment and management

Good wound management must involve an holistic approach to care; without considering the whole person, appropriate management might not be as good as it could be. In a time of austerity, it is important that money is spent appropriately on the correct wound-management technologies. Exudate assessment and management are a vital part of wound management. In this article, the focus will be on exploring the nature of exudate and tools available to evaluate exudate. Finally, suggestions will be made on the management of exudate.

Negative pressure wound therapy: a study on patient perspectives

AIM

to explore patients' lived experience of using negative pressure wound therapy (NPWT).

METHOD

A phenomenological approach based on Heideggerian philosophy was undertaken. The study population consisted of 6 participants who had used NPWT for a minimum of 4 weeks. Semi-structured interviews were transcribed verbatim and investigated for themes using interpretative phenomenological analysis.

RESULTS

Three superordinate themes were identified: altered sense of self, new culture of technology and leading a restricted life. Themes associated with an altered sense of self and leading a restricted life were in keeping with other wound care studies. Identification of barriers such as managing technical difficulties, practicalities of daily living, and improved understanding of NPWT for both patient and practitioner, can foster hope and reduce anxiety.

CONCLUSIONS

Recommendations include holistic assessment of patient suitability for NPWT, education for patients and health professionals on NPWT, use of lighter, quieter devices, and the inclusion of a technology domain in future health-related quality of life studies on NPWT.

A meta-synthesis of research on leg ulceration and neuropathic pain component and sequelae

Leg ulceration represents a substantial health problem, and pain is likely to be an associated symptom. The aim of this meta-synthesis was to undertake a systematic review of qualitative studies investigating the experience of chronic painful leg ulceration. This study undertook the meta-synthesis approach described by Sandelowski and Barroso (2003), which is a synthesis and re-interpretation of the findings from several qualitative studies. Findings were extracted and synthesized. The overarching theme was that patients with chronic leg ulceration suffer from persistent pain with associated sequelae. Word descriptors used by participants also suggested that patients have neuropathic pain. In addition, findings from the meta-synthesis suggested that pain associated with chronic leg ulcer may have a neuropathic pain component. Pain associated with leg ulceration is likely to have nociceptive properties as well as neuropathic properties. If neuropathic pain is not identified and managed effectively, patients are at risk of developing a chronic pain condition with associated sequelae, such as poor sleep, depression and suicidal ideation. It is proposed that early identification and management may enable appropriate pain management which may prevent or reduce the associated risks.

Avaliação de sintomas depressivos em pessoas com diabetes mellitus e pé ulcerado

OBJETIVO: Avaliar a intensidade de sintomas de depressão nos pacientes diabéticos com úlceras no pé. MÉTODOS: Estudo exploratório, descritivo, analítico e transversal, realizado no ambulatório de feridas de um hospital público, de Sorocaba/SP. Participaram 50 pacientes com diabetes mellitus e pé ulcerado. Para mensurar a intensidade dos sintomas de depressão foi utilizado o inventário de Avaliação de Depressão de Beck. RESULTADOS: Dos 50 pacientes avaliados, 41 apresentavam algum grau de sintoma depressivo, sendo que 32 (64%) com depressão moderada, apresentando sintomas de autodepreciação, tristeza, distorção da imagem corporal e diminuição da libido. CONCLUSÃO: Pacientes diabéticos com pé ulcerado apresentaram graus variados de sintomas depressivos.

Assessing bacterial burden in wounds: comparing clinical observation and wound swabs

A randomised controlled trial (RCT) was conducted to compare the efficacy of nanocrystalline silver and cadexomer iodine dressings in healing chronic lower leg ulcers. The relationships between wound swab culture results and nurses' clinical assessments of critical colonisation, and between bacterial burden and healing rate, were also examined. There were 281 individuals with leg ulcers recruited. The bacterial burden of wounds was assessed using semi-quantitative wound swabs collected at baseline and intervals during the study. The study found no relationship between the nurses' clinical assessments and bacterial burden as identified from wound swabs in the wounds. A significant difference in wound healing was found with the use of nanocrystalline silver as compared to cadexomer iodine in the first 2 weeks of treatment when nil or low levels of leukocytes, gram positive bacilli, gram positive cocci or gram negative cocci were reported. This study has raised a number of questions regarding the need for further investigation into methods of assessing wound bacterial burden as well as the impact of wound biofilms on wound assessment and treatment.

A systematic review of health-related quality of life instruments used for people with venous ulcers: an assessment of their suitability and psychometric properties

AIMS AND OBJECTIVES

To review the quality of life questionnaires used to measure the impact of venous ulceration and to evaluate their psychometric properties.

BACKGROUND

Venous leg ulcers have a negative impact on quality of life. Health-related quality of life can be measured using structured questionnaires. Nurses are the primary care providers for patients with venous ulceration and are ideally placed to assess and develop these types of questionnaires. There may also be an opportunity to use such quality of life instruments to measure the impact of nursing interventions in other areas where nurses are the key care providers.

DESIGN

Systematic review.

METHOD

Studies were sought that used quality of life instruments to evaluate the impact of venous ulceration. Fourteen electronic bibliographical databases and 11 Internet-based health services research related resources were searched. In addition, grey literature was sought and the reference lists of relevant articles checked. Data were extracted regarding the type of instrument used, sample, number of items and domains and psychometric performance of the instrument.

RESULTS

The initial search identified a total of 338 potential citations. After review, a total of 31 studies were included: 17 used generic and 14 used disease-specific instruments. Five different types of generic and seven disease-specific instruments were identified. There was significant heterogeneity between the studies in terms of study design, aetiology of ulceration and times of assessment. The disease-specific instruments showed limitations in relation to their applicability to venous ulcer patients because of flaws in design or validation.

CONCLUSIONS

The literature on quality of life related to venous ulceration failed to sufficiently distinguish between those with different causes of leg ulceration. There appeared to be problems with the ability of current quality of life instruments to detect changes in quality of life related to ulcer healing. Relevance to clinical practice.  There appears to be an opportunity for nurses to develop a health-related quality of life health-related quality of life instruments to evaluate their impact on patient outcomes. Such instruments could potentially allow nursing interventions to be assessed more effectively than the recently proposed nursing metrics.

Health-related quality of life and chronic venous leg ulceration: Part 2

Leg ulceration is a debilitating condition which compromises the quality of life of the sufferer, owing to factors such as pain, exudate, odour and social isolation. As nurses, much of the daily care provided for such patients focuses on the provision of wound care; often failing to fully address the wide ranging effects that the ulceration is having on the life of the sufferer. This article reviews the quantitative studies that have explored the health-related quality of life of patients with chronic venous leg ulceration and presents a synthesis of their findings.

Health-related quality of life and chronic venous leg ulceration: part 1

Leg ulceration is a debilitating condition characterized by long periods of ulceration and a high incidence of recurrence. The quality of life of sufferers is compromised by many issues including pain and social isolation. Day-to-day care focuses predominantly on the provision of wound care, often with limited attention to the wide-ranging effects that the ulceration poses to the life of the sufferer. Part 1 of this two-part series provides a review of qualitative studies that explore the health-related quality of life of patients with chronic venous leg ulceration. Part 2 will be published in the June 2010 Wound Care Alliance supplement.

Managing highly exuding wounds with Eclypse dressings

Wounds naturally produce exudate containing nutrients, blood cells, enzymes, cytokines and growth factors, which are all essential to the healing process. When this balance is altered by local or systemic conditions then exudate can become problematic. Wound healing is delayed, quality of life is detrimentally affected and nursing staff are faced with time-consuming dressings. The wound product market has always contained absorbent dressings, yet there is a need for further absorbent dressings to be made available to us. This has seen the introduction of super-absorbent dressings onto the market. One of these dressings, Eclypse, is discussed in this article. Eclypse uses highly absorbent crystal technology to increase its fluid handling capacity. The functionality of this product and the benefit for patients derived from its use are described in this article.

Wound-related pain: key sources and triggers

Wound-related pain is a common phenomenon for many patients and in recent years there has been a growing awareness of the impact it has on both wound healing and quality of life. Research in the field of wound pain and the patient experience, the development of new products and the issue of expert consensus statements have all contributed to an improvement in our understanding of wound-related pain issues and our ability to effectively manage them. However, there are a multitude of intrinsic sources of wound-related pain which can be triggered or exacerbated by numerous external factors, making management both complex and challenging at times. In this article, key sources and triggers of wound-related pain are discussed, along with practical strategies for effective, patient-focused management to help health-care practitioners reduce both the incidence and impact of wound-related pain.

The lived experience of community nurses treating clients with leg ulcers

Chronic leg ulceration impacts negatively on the quality of life of the sufferer and has financial implications for the economy. Government health policy aims to tackle long-term conditions and restructure services from acute to community care. Community nurses play a pivotal role in managing and co-ordinating care to leg ulcer patients, yet their personal experience in this clinical situation is poorly explored. This qualitative study aims to gain an understanding of community nurses' personal experience of treating clients with leg ulcers; this is necessary to develop leg ulcer services which are effective, efficient and client-centred.

Dressing-related pain in patients with chronic wounds: an international patient perspective

This cross-sectional international survey assessed patients' perceptions of their wound pain. A total of 2018 patients (57% female) from 15 different countries with a mean age of 68.6 years (SD = 15.4) participated. The wounds were categorised into ten different types with a mean wound duration of 19.6 months (SD = 51.8). For 2018 patients, 3361 dressings/compression systems were being used, with antimicrobials being reported most frequently (n= 605). Frequency of wound-related pain was reported as 32.2%, 'never' or 'rarely', 31.1%, 'quite often' and 36.6%, 'most' or 'all of the time', with venous and arterial ulcers associated with more frequent pain (P= 0.002). All patients reported that 'the wound itself' was the most painful location (n= 1840). When asked if they experienced dressing-related pain, 286 (14.7%) replied 'most of the time' and 334 (17.2%) reported pain 'all of the time'; venous, mixed and arterial ulcers were associated with more frequent pain at dressing change (P < 0.001). Eight hundred and twelve (40.2%) patients reported that it took <1 hour for the pain to subside after a dressing change, for 449 (22.2%) it took 1-2 hours, for 192 (9.5%) it took 3-5 hours and for 154 (7.6%) patients it took more than 5 hours. Pain intensity was measured using a visual analogue scale (VAS) (0-100) giving a mean score of 44.5 (SD = 30.5, n= 1981). Of the 1141 who reported that they generally took pain relief, 21% indicated that they did not feel it was effective. Patients were asked to rate six symptoms associated with living with a chronic wound; 'pain' was given the highest mean score of 3.1 (n= 1898). In terms of different types of daily activities, 'overdoing things' was associated with the highest mean score (mean = 2.6, n= 1916). During the stages of the dressing change procedure; 'touching/handling the wound' was given the highest mean score of 2.9, followed by cleansing and dressing removal (n= 1944). One thousand four hundred and eighty-five (80.15%) patients responded that they liked to be actively involved in their dressing changes, 1141 (58.15%) responded that they were concerned about the long-term side-effects of medication, 790 (40.3%) of patient indicated that the pain at dressing change was the worst part of living with a wound. This study adds substantially to our knowledge of how patients experience wound pain and gives us the opportunity to explore cultural differences in more detail.

Non healing leg ulcers and the nurse-patient relationship. Part 2: the nurse's perspective

This paper focuses on the experiences of four community nursing teams responsible for the care of a small group of patients with leg ulcers who they had identified as 'non healing' and 'non concordant' with treatment. Four focus groups were held, one with each community nursing team, to examine the issues underpinning the labelling of these patients as 'non healing' and 'non concordant'. There was an expectation that patients should obey treatment instructions and be positive and participative and there was a strongly felt link between concordance and healing of the ulcer. However, limited non concordance was considered to be acceptable as long as the patient continued to progress. Nurses viewed ulcer healing as the priority even though this was unlikely and differed from the patient's priority of achieving comfort. Patient behaviour was an important determinant of labelling by nurses. Efforts by patients to exert some control over their own care were met with them being viewed as 'difficult', 'uncooperative' and 'non compliant'. There was also a pervasive level of stress, distress and anxiety among the community nurse participants, which led to distancing and blaming that undermined the nurse-patient relationship. At the centre of a successful nurse-patient relationship is a non judgemental partnership that can often be challenging to achieve especially when ulcers fail to heal.

Non healing leg ulcers and the nurse-patient relationship. Part 1: the patient's perspective

This paper reports on a study that explored the relationship between patients with non healing leg ulcers and the nurses providing their care in a community setting. Qualitative data were collected from five patients whose leg ulcers were healing and who had been identified as experiencing difficulty with adhering to treatment. Single semi-structured interviews were used and participants were asked to share key events in their care prompted by the question 'how are you coping with your leg ulcer?' Striving to maintain balance by developing strategies to cope with the physical effects of an unhealed ulcer as well as ensuring the care they received met their unique needs was central to the experience of participants. From the participant's perspective, however, nurses often showed little understanding of the complex issues patients were grappling with. Patients, in viewing nurse behaviour, often concluded that leg ulceration was an insignificant problem that nurses had little interest in. The need to establish and to maintain a trusting therapeutic relationship with patients is essential if they are to feel they matter, that they are important as individuals and that their suffering can be eased by sensitive collaboration.

Living with leg ulceration: a synthesis of qualitative research

AIM

This paper is a report of a study to identify and synthesize all published qualitative research studies exploring patients' experiences of living with a leg ulcer.

BACKGROUND

Leg ulceration is a common chronic condition with over 40% of patients having open ulceration for over a year. Leg ulceration can have a significant and detrimental effect on a persons' life.

DATA SOURCES

Electronic searches of Ovid MEDLINE (R) (1966-2005), CINAHL (1982-2005), EMBASE (1980-2005), British Nursing Index (1985-2005), ASSIA, Social Science Citation Index (SSCI) and PsychINFO (1985-2005) were carried out in June 2005.

REVIEW METHODS

Studies were included if: they described experience of living with a leg ulcer, e.g. phenomenological studies, grounded theory, descriptive, focus groups or interview studies; included adults with chronic leg ulceration (venous, mixed or arterial); published in English. Analysis was undertaken using the Qualitative Assessment and Review Instrument software for synthesis of qualitative research.

RESULTS

Twelve studies met the inclusion criteria. There were eight phenomenological studies, two using grounded theory and two 'descriptive studies'. The location of the research was United Kingdom (7), United States of America (2), Sweden (1), Australia (1). Five common themes related to the experience of living with leg ulceration were identified: Physical effects of leg ulceration; Describing the leg ulcer journey; Patient-professional relationships; Cost of a leg ulcer; Psychological impact.

CONCLUSION

Leg ulceration should be viewed as a chronic, debilitating condition. The clinical focus of care should be symptom management through the 'leg ulcer journey'.

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.

Impact of intravenous drug use on quality of life for patients with venous ulcers

AIM

This paper is a report of a study to examine, from the perspective of patients, the impact of venous leg ulcers on health-related quality of life in current and former intravenous drug users and the general population.

BACKGROUND

Venous ulceration can be caused by intravenous drug use. There has been little examination on how this affects the quality of life of this group of patients and how they compare with other patients who have venous ulcers.

METHOD

A qualitative approach was adopted, using framework analysis. Semi-structured interviews with 19 participants who had a venous leg ulcer were conducted between August 2005 and February 2006. Interview audiotapes were analysed to identify recurring themes relating to the impact of venous leg ulcers on overall quality of life.

FINDINGS

A complex interaction between symptoms, social restriction and attribution of illness influenced the impact of venous leg ulcers. Smell and pain were the symptoms that had the most profound impacts. In addition to the physical and psychological consequences, participants' activities and social interactions were restricted. Intravenous drug users experienced more social isolation and difficulties in accessing treatment for their venous ulcers.

CONCLUSION

While leg ulcer services remain focused on the needs of older people, services for young intravenous drug users are unlikely to improve. A more coherent and earlier intervention, when the ulcers are not as difficult to treat, would decrease time and costs to the health service. The challenge is to find new ways of providing effective and accessible care to this growing population.

Randomized trial of two foam dressings in the management of chronic venous ulceration

A multicenter prospective randomized clinical trial was undertaken to compare two foam dressings (Allevyn Hydrocellular, Smith & Nephew and Mepilex, Molnlycke Health Care AB) in the management of chronic venous leg ulceration. Patients were also randomized to two compression bandage systems (4-layer vs. cohesive short stretch) as a factorial design. Those with causes of ulceration other than venous disease were excluded. In all, 156 patients met the entry criteria and were randomized from the 12 clinical centers with a median (range) ulcer size of 4.33 (0.33-123.10) cm(2). After 24 weeks a total of 100 (64.1%) patients had complete ulcer closure, 46 (29.5%) had withdrawn from the trial, nine (5.8%) remained unhealed and one patient died. Of the patients randomized to Mepilex, 50/75 (66.7%) had complete ulcer healing compared with 50/81 (61.7%) on Allevyn. The hazard ratio for healing after adjustment for bandage type and trial center was 1.48 (95% C.I. 0.87-2.54, p=0.15), which only marginally changed following adjustment for baseline variables, neither of which achieved statistical significance (p=0.16). Withdrawal rates were similar between groups (23, 30.7% Mepilex vs. 23, 28.4% Allevyn). Pain improved following treatment with both dressings (p<0.001), but with no difference between dressings.

Living with venous leg ulceration: issues concerning adherence

Compression therapy is advocated for the treatment of chronic venous leg ulceration and the proportion of patients whose ulcers heal appears to be directly related to adherence (Moffatt, 2004). The aim of this study was to examine patients' understanding of adherence, in terms of their own experiences of compression bandage systems. Following full ethical approval, a purposeful sample of 6 participants was recruited to take part in a focus group. Free-flowing conversation was encouraged so that the participants could discuss issues that were important to them, although a series of prompts were available to stimulate the conversation when necessary. Four major themes were identified using a phenomenological approach: frustration with the healthcare system leading to a feeling of complacency with primary healthcare teams; functional limitations leading to adaptation of everyday life situations (e.g. bathing and coping with pain); emotional reactions affecting well-being and body image, and perception of others; and avoidance of transport, shopping and holidays.

Do clinical and social factors predict quality of life in leg ulceration?

This cross-sectional study was undertaken to determine the association between clinical and social variables and health-related quality of life (HRQoL) in patients suffering from leg ulceration. Patients were given a questionnaire to complete that incorporated clinical and social factors with the Nottingham Health Profile (NHP). The mean difference in NHP scores was calculated between categories for social and clinical variables, after adjustment for the patients' ages and gender. The 758 patients (mean age = 74.6 years, 64% women) had leg ulceration present for a median of 10.5 months (range, 0.5-708). Bodily pain (mean difference [d] = 8.9, P < .001), emotion (d = 4.7, P = .009) and social isolation (d = 0.032) were associated with large (>10 cm(2)) ulceration, whereas pain (P = .022) and social isolation (P = .008) were significantly associated with long ulcer duration. Patients treated by district nurses in community clinics experienced significantly less pain (d = -11.5, P < .001) and better sleep quality (d = -8.3, P = .006) than other patients did, whereas patients being treated by district nurses in the patients' own homes experienced deficits in pain (d = 11.4, P < .001), sleep quality (d = 8.8, P = .001), and mobility (d = 6.3, P = .002). There is some evidence to support the notion that large, long-duration ulceration leads to poorer HRQoL. Patients treated in nurse-led leg ulcer clinics experienced better HRQoL than did patients treated in other clinical areas. This observation needs to be evaluated more fully in future studies.

Depression in patients with chronic venous ulceration

As leg ulcer research has generally focused on aspects of treatment, the psychosocial impact of leg ulceration remains understudied. This article reports the findings of a study exploring the prevalence of anxiety and depression in 190 patients with chronic venous ulceration across 9 Trusts in the northwest of England. The hospital anxiety and depression scale (HADS) was used to screen patients for the presence of anxiety and depression using a cut-off point of 9 for level of "caseness". A total of 52 (27%) people scored as depressed while 50 (26%) scored as anxious. The two symptoms which appeared to be associated with anxiety and depression were pain and odour, while there was no association found between living alone, mobility and exudate. These findings suggest that the focus of care needs to be redirected for many patients for whom cure is not an option, but who are left to live with a chronic wound. Furthermore, psychological factors, including depression, should be a focus in assessment and ongoing review of patients with leg ulceration.

Use of a hydrogel dressing for management of a painful leg ulcer

This case study is of an 82-year-old lady who was widowed and lives alone in a council house. A left lateral leg ulcer had developed over the gaiter area, and the community team were asked to assess in 2004. The main issues were her inability to tolerate compression (even when reduced) because of the pain. Nevertheless, the community nurses had tried very hard with compression, using different compression techniques at different times to try to encourage her to persevere. The nurses felt they were running out of ideas and therefore the tissue viability nurse (TVN) was asked to assess the wound. The TVN recommended ActiFormCool dressing. This article will examine the background for wound healing, provide the rational for the recommendation and describe the progress of the patient.

Preventing venous ulcer recurrence: a review

This review article examines the available evidence on both the primary and secondary prevention of venous ulceration, exploring both the individual, social and financial implications of system failures that allow patients to remain at increased risk of recurrent ulceration. The role of both venous disease assessment and corrective superficial venous surgery are discussed in the light of recently published randomised controlled studies on the role of superficial venous surgery as both an adjunct to ulcer healing and ulcer prevention.