The correlation analysis between the appearance anxiety and personality traits of the medical staff on nasal and facial pressure ulcers during the novel coronavirus disease 2019 outbreak

Aim

To investigate the psychological status of medical staff with medical device-related nasal and facial pressure ulcers (MDR PUs) during the outbreak of COVID-19, analyse the correlation between their psychological status and personality traits, so as to provide a reference for personalized psychological support.

Design

A total of 207 medical staff who were treating the COVID-19 epidemic from Hunan and Hubei provinces were enrolled in this analytic questionnaire-based study.

Methods

We used these measures: Eysenck Personality Questionnaire Short Scale (EPQ-RSC), Social Appearance Anxiety Scale (SAAS), Positive and Negative Affect Scale (PANAS) and demographic information forms online.

Results

Medical staff wearing protective equipment are particularly susceptible to nasal and facial MDR PUs, which is increasing their social appearance anxiety; neuroticism is significantly related to social appearance anxiety and negative emotion. We should pay more attention to their psychological state, cultivate good personality characteristics and reduce negative emotions, and thereby alleviate their MDR PUs-related appearance anxiety.

International mixed methods study protocol to develop a patient-reported outcome measure for all types of chronic wounds (the WOUND-Q)

INTRODUCTION

Most patient-reported outcome measures (PROM) for chronic wounds are specific to a single wound type (eg, pressure ulcer) or part of the body. A barrier to outcome assessment in wound care and research is the lack of a rigorously designed PROM that can be used across wound types and locations. This mixed method study describes the protocol for an international collaboration to develop and validate a new PROM called the WOUND-Q for adults with chronic wounds.

METHODS AND ANALYSIS

In phase I, the qualitative approach of interpretive description is used to elicit concepts important to people with wounds regarding outcome. Participants from Canada, Denmark, the Netherlands, and the USA are aged 18 years and older and have a wound that has lasted 3 months or longer. Interviews are digitally recorded, transcribed and coded. A conceptual framework and preliminary item pool are developed from the qualitative dataset. Draft scales are formed to cover important themes in the conceptual framework. These scales are refined using feedback from people with chronic wounds and wound care experts. After refinement, the scales are translated into Danish and Dutch, following rigorous methods, to prepare for an international field-test study. In phase II, data are collected in Canada, Denmark, the Netherlands, and the USA. An international sample of people with a large variety of chronic wounds complete the WOUND-Q. Rasch Measurement Theory analysis is used to identify the best subset of items to retain for each scale and to examine reliability and validity.

ETHICS AND DISSEMINATION

This study is coordinated at Brigham and Women's Hospital (Boston, USA). Ethics board approval was received at each participating site for both study phases. Findings will be published in peer-reviewed journals and presented at national and international conferences and meetings.

Pressure ulcer knowledge, beliefs and practices in a group of South Africans with spinal cord injury

Study design

A quantitative, descriptive study using a cross-sectional survey.

Objectives

To describe the pressure ulcer knowledge, beliefs and practices amongst persons with SCI, who received rehabilitation at a Cape Town rehabilitation centre.

Setting

A rehabilitation centre for clients with physical disabilities in Cape Town, South Africa.

Methods

A quantitative, descriptive study, that employed consecutive sampling, was done. Participants included inpatients (n = 30), outpatients (n = 33) and peer supporters (n = 8). Data were collected during April and March 2015 with a questionnaire developed through collating existing questionnaires and adapting it for the study context. This rendered a knowledge score and data on beliefs and practices. The Fisher's exact test was used for comparative analysis (p < 0.05).

Results

The mean combined knowledge score was 42.7%. The majority of participants (88.7%) believed pressure ulcers to be serious and 45% thought they were likely to develop a PU. They believed daily skin checks (80.3%), weight shifting (86%) and limiting sitting time (80.3%) could prevent PU development. Study participants indicated that they did not regularly follow guideline recommended practices like regular pressure relief (51%) (36 participants) or daily skin inspection (38%) (27 participants) and 37% (26 participants) reported being current smokers.

Conclusion

Participants showed a lack of knowledge, which might have affected their pressure ulcer prevention practices negatively. The study findings can be used to assist with the development of a contextually relevant training programme on pressure care.

A Descriptive, Cross-sectional Study to Assess Pressure Ulcer Knowledge and Pressure Ulcer Prevention Attitudes of Nurses in a Tertiary Health Institution in Nigeria

Globally, higher-than-expected pressure ulcer rates generally are considered a quality-of-care indicator. Nigeria currently has no national guidelines for pressure ulcer risk assessment, prevention, and treatment. A descriptive cross-sectional study was conducted to assess the pressure ulcer knowledge and the attitude of nurses regarding pressure ulcer prevention in a tertiary health institution in Nigeria. During a period of 2 months, nurses were recruited to complete a 25-item paper/pencil survey that included participant demographic information (6 items), pressure ulcer knowledge questions (11 items), and statements on participants' attitude toward pressure ulcer prevention (8 items). Data were entered manually into statistical analysis software, analyzed, and presented using descriptive statistics (frequencies and percentages). The majority of the 90 nurse participants were female (60, 66.7%), 45 (50%) were married, and 75 (83.3%) had 1 to 10 years' experience in nursing practice; 69 (76.7%) had received special training on pressure ulcer prevention. Overall, 58 (64.4%) nurses had correct pressure ulcer knowledge and 67 (74.4%) had a positive attitude toward preventing pressure ulcers. However, 56 nurses (62.2%) disagreed with regular rescreening of patients whom they deemed not at risk of developing pressure ulcer, and 70 (77.8%) believed pressure ulcer prevention should be the joint responsibility of both nurses and relatives of the patients. Thus, the majority of the 90 nurses knew the factors responsible for pressure ulcers and how to prevent them, but nurses need to be orientated to the fact that pressure ulcer risk screening of all patients with limited mobility is an integral part of their job and that it is important that nurses enlighten patients and their relatives on how to prevent pressure ulcers.

[QUALITY OF LIFE AND PSYCHOLOGICAL ASPECTS IN PATIENTS WITH CHRONIC LEG ULCER]

Wound represents a disruption of anathomic and physiologic continuity of the skin. Regarding to the healing process, wounds can be classified as acute or chronic wounds. Quality of life is primarily concerned with the impact of chronic wounds. A wound is considered chronic if healing does not occur within expected period of time regarding to its etiology and localization. Chronic wounds can be classified as typical and atypical. The majority of wounds (95 percent) are typical ones which include ischaemic, neurotrophic and hypostatic ulcer and two separate entities: diabetic foot and decubital ulcers. An 80 percent of chronic wounds localized on lower leg are result of chronic venous insufficiency, in 5-10 percent cause is of arterial etiology, whereas the remainder is mostly neuropathic ulcer. Chronic wounds represent a significant burden to patients, health care professionals and the entire health care system. Chronic wounds affect the elderly population and it is estimated that 1-2 percent of western population suffer from it. This estimate is expected to rise due to an increasing population of the elderly and the diabetic and obesity epidemic. The WHO definition of health is "A state of complite physical, mental and social well-being and not merely the absence of disease or infirmity". Based on this definition, quality of life in relation to health may be defined as "the functional effect of an illness and it's consequent therapy upon a patient, as perceived by the patient". The domains that contribute to this effect are physical, psychological and social functioning. The patient's own perceptions of an illness were found to play an important role in explainig quality of life. Chronic wounds significantly decrease the quality of life in a number of ways such as reduced mobility, pain, unpleasant odor, sleep disturbances, social isolation and frustration, and inability to perform everyday duties. Among the most common psychological reactions to chronic diseases, including chronic wounds, are depression, anxiety, aggression and frustration. Psychological factors may not only be a consequence of delayed healing, but may also impact on wound healing. Anxiety and depression have direct influences on endocrine and immune function. About the impact of disease on quality of life and individuals' perceptions of illness, there are questionnaires and methods to analyze this, but the challenge is to move from a focus on wound management to understanding the specific needs of each individual within the context of their life.

[BASIC PRINCIPLES OF SURGICAL TREATMENT OF CHRONIC WOUNDS – SHARP DEBRIDEMENT]

The ever improving health standards in terms of quality and more efficient health care result in an increase in life expectancy, thus increasing the number of elderly people in the population. A higher level of activity in elderly population leads to greater incidence of injuries, and on the other hand, there is an increasing number of comorbidities. Circulatory disorders, diabetes mellitus, metabolic imbalances, etc. and a reduced biological potential of tissue regeneration result in an increased number of chronic wounds that pose a significant health, social and economic burden on the society. These conditions require significant involvement of medical and non-medical staff in pre-hospital institutions. Significant material and other health care resources are allocated for the treatment of chronic wounds. These conditions result in a lower quality of life of patients and their families and caregivers. Debridement is a crucial medical procedure for the treatment of acute and chronic wounds. The result of debridement is removal of all barriers within and around the wound that obstruct physiological processes of wound healing. Debridement is a repeating process when indicated. There are several types of debridement, each with its advantages and disadvantages. The method of debridement should be determined by the physician or other professional trained person on the basis of wound characteristics and in accordance with their expertise and capabilities. In the same wound, we can combine different types of debridement, all with the goal of faster and better wound healing.

[PRESSURE ULCER AS THE PRINCIPAL INDICATOR OF HEALTH CARE QUALITY AT NEUROLOGY DEPARTMENT]

According to the European Pressure Ulcer Advisory Panel (EPUAP) definition, pressure ulcer is a local skin or subcutaneous tissue damage due to the force of pressure or friction or their combination. Pressure ulcers have accompanied humans since the beginning and respective descriptions are found in the 19th century literature. Pressure ulcer is a major medical, social and health-economic problem because it is associated with a number of complications that require multidisciplinary approach in care and treatment. In affected patients, pressure ulcer causes quality of life reduction, discomforts, pain, emotional problems and social isolation. If the process of tissue decay is not halted, tissue damage will spread involving deep and wider structures, thus seriously compromising the patient general condition. Pressure ulcer usually develops at the sites of protrusions formed by lumbar spine, ischium, hip, ankle, knee or elbow, as well as in the areas with less developed adipose tissue. Any temporary or permanent immobility should be perceived as a milieu favoring the onset of pressure ulcer. Advances in medicine and standards of living in general have prolonged life expectancy, thus also increasing the population at risk of chronic diseases including pressure ulcer. The aim of the study was to determine the relationship between the length of bed-ridden condition and the occurrence of pressure ulcers in patients treated at Department of Cerebrovascular Diseases and Intensive Neurology from January 1, 2012 until December 31, 2015. The study included patients with pressure ulcer verified on admission and those having developed pressure ulcer during hospital stay. Clinical picture of severe stroke predominated in the majority of study patients. Patients were divided into groups according to health care requirements as classified by the Croatian Chamber of Nurses. Preliminary results indicated the length of bed-ridden condition to be associated with the occurrence of chronic wounds, and thus with increased cost and length of hospital treatment. Therefore, health care methods and procedures should be focused on reduction of pressure ulcer development, quality health care, implementation of preventive measures, and continuous education of health care professionals.

Why do patients develop severe pressure ulcers? A retrospective case study

OBJECTIVES

This study focuses on the ways in which the organisational context can influence the development of severe pressure ulcers. Severe pressure ulcers are important indicators of failures in the organisation and delivery of treatment and care. We have a good understanding of patients' risk factors, but a poor understanding of the role played by the organisational context in their development.

SETTING

The study was undertaken in six sites in Yorkshire, England. The settings were sampled in order to maximise diversity, and included patients' own homes, acute hospital medical and surgical wards, a community hospital and a nursing home during a period of respite care.

PARTICIPANTS

Data were collected about eight individuals who developed severe pressure ulcers, using a retrospective case study design. The data sources included interviews with individuals with severe pressure ulcers, and with staff who had treated and cared for them, and clinical notes.

RESULTS

4 accounts indicated that specific actions by clinicians contributed to the development of severe pressure ulcers. Seven of the 8 accounts indicated that they developed in organisational contexts where (1) clinicians failed to listen and respond to the patients' or carers' observations about their risks or the quality of their treatment and care, (2) clinicians failed to recognise and respond to clear signs that a patient had a pressure ulcer or was at risk of developing one and (3) services were not effectively coordinated.

CONCLUSIONS

Patient accounts could only be partially explained in terms of specific events or sequences of events. The findings support the conclusion that there was general acceptance of suboptimal clinical practices in 7 of the 8 contexts where patients developed severe pressure ulcers.

Practice sensitive quality indicators in RAI-MDS 2.0 nursing home data

BACKGROUND

In recent years, improving the quality of care for nursing home residents has generated a considerable amount of attention. In response, quality indicators (QIs), based on available evidence and expert consensus, have been identified within the Resident Assessment Instrument-Minimum Data Set 2.0 (RAI-MDS 2.0), and validated as proxy measures for quality of nursing home care. We sought to identify practice sensitive QIs; that is, those QIs believed to be the most sensitive to clinical practice.

METHOD

We enlisted two experts to review a list of 35 validated QIs and to select those that they believed to be the most sensitive to practice. We then asked separate groups of practicing physicians, nurses, and policy makers to (1) rank the items on the list for overall "practice sensitivity" and then, (2) to identify the domain to which the QI was most sensitive (nursing care, physician care, or policy maker).

RESULTS

After combining results of all three groups, pressure ulcers were identified as the most practice sensitive QI followed by worsening pain, physical restraint use, the use of antipsychotic medications without a diagnosis of psychosis, and indwelling catheters. When stratified by informant group, although the top five QIs stayed the same, the ranking of the 13 QIs differed by group.

CONCLUSIONS

In addition to identifying a reduced and manageable set of QIs for regular reporting, we believe that focusing on these 13 practice sensitive QIs provides both the greatest potential for improving resident function and slowing the trajectory of decline that most residents experience.

Development and validation of a new patient-reported outcome measure for patients with pressure ulcers: the PU-QOL instrument

BACKGROUND

Patient-reported outcome (PRO) data are integral to patient care, policy decision making and healthcare delivery. PRO assessment in pressure ulcers is in its infancy, with few studies including PROs as study outcomes. Further, there are no pressure ulcer PRO instruments available.

METHODS

We used gold-standard methods to develop and evaluate a new PRO instrument for people with pressure ulcers (the PU-QOL instrument). Firstly a conceptual framework was developed forming the basis of PU-QOL scales. Next an exhaustive item pool was used to produce a draft instrument that was pretested using mixed methods (cognitive interviews and Rasch Measurement Theory). Finally, we undertook psychometric evaluation in two parts. This first part was item reduction, using PU-QOL data from 227 patients. The second part was reliability and validity evaluation of the item-reduced version using both Traditional and Rasch methods, on PU-QOL data from 229 patients.

RESULTS

The final PU-QOL contains 10 scales for measuring symptoms, physical functioning, psychological well-being and social participation specific to pressure ulcers. It is intended for administration and patients rate the amount of "bother" attributed during the past week on a 3-point response scale. Scale scores are generated by summing items, with lower scores indicating better outcome. The PU-QOL instrument was found to be acceptable, reliable (Cronbach's alpha values ranging 0.89-0.97) and valid (hypothesised correlations between PU-QOL and SF-12 scores (r>0.30) and PU-QOL scales and sociodemographic variables (r<0.30) were consistent with predictions).

CONCLUSIONS

The PU-QOL instrument provides a standardised method for assessing PROs, reflecting the domains in a pressure ulcer-specific conceptual framework. It is intended for evaluating patient orientated differences between interventions and in particular the impact from the perspective of patients.

Cumulative life course impairment in chronic wounds

Chronic wounds such as leg ulcers, diabetic or ischemic foot ulcers and pressure ulcers are a heterogeneous group of chronic tissue defects which share the stagnation of wound healing due to an underlying disease. Most patients suffer from marked reductions of quality of life, including pain, physical discomfort, functional limitations, social burden as well as psychological distress. In some countries, a negative socioeconomic impact for the patients is another strain. Most patients complain about the additional burden due to treatment. Given the long period of disease and the even longer-lasting comorbidity, chronic wounds can be associated with marked cumulative life course impairments. It is thus essential to detect any early signs of wound disease and psychosocial burden in patients at risk of chronic wounds. Though specific instruments have not yet been developed for the detection of cumulative life course impairment in chronic wounds, patients at risk can be identified by using validated disease-specific instruments for quality of life. Moreover, in specific situations, psychological instruments can be of additional diagnostic help.

A pilot randomised controlled trial of negative pressure wound therapy to treat grade III/IV pressure ulcers [ISRCTN69032034]

BACKGROUND

Negative pressure wound therapy (NPWT) is widely promoted as a treatment for full thickness wounds; however, there is a lack of high-quality research evidence regarding its clinical and cost effectiveness. A trial of NPWT for the treatment of grade III/IV pressure ulcers would be worthwhile but premature without assessing whether such a trial is feasible. The aim of this pilot randomised controlled trial was to assess the feasibility of conducting a future full trial of NPWT for the treatment of grade III and IV pressure ulcers and to pilot all aspects of the trial.

METHODS

This was a two-centre (acute and community), pilot randomised controlled trial. Eligible participants were randomised to receive either NPWT or standard care (SC) (spun hydrocolloid, alginate or foam dressings). Outcome measures were time to healing of the reference pressure ulcer, recruitment rates, frequency of treatment visits, resources used and duration of follow-up.

RESULTS

Three hundred and twelve patients were screened for eligibility into this trial over a 12-month recruitment period and 12/312 participants (3.8%) were randomised: 6 to NPWT and 6 to SC. Only one reference pressure ulcer healed (NPWT group) during follow-up (time to healing 79 days). The mean number of treatment visits per week was 3.1 (NPWT) and 5.7 (SC); 6/6 NPWT and 1/6 SC participants withdrew from their allocated trial treatment. The mean duration of follow-up was 3.8 (NPWT) and 5.0 (SC) months.

CONCLUSIONS

This pilot trial yielded vital information for the planning of a future full study including projected recruitment rate, required duration of follow-up and extent of research nurse support required. Data were also used to inform the cost-effectiveness and value of information analyses, which were conducted alongside the pilot trial.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN69032034.

Health status utilities and the impact of pressure ulcers in long-term care residents in Ontario

Purpose

To estimate health status utilities in long-term care (LTC) residents in Ontario, both with and without pressure ulcers (PUs), and to determine the impact of PU on health-related quality of life (HRQOL).

Methods

A retrospective population-based study was carried out using Minimum Data Set (MDS) health assessment data among all residents in 89 LTC homes in Ontario who had a full MDS assessment between May 2004 and November 2007. The Minimum Data Set-Health Status Index (MDS-HSI) was used to measure HRQOL. A stepwise regression was used to determine the impact of PU on MDS-HSI scores.

Results

A total of 1,498 (9%) of 16,531 LTC residents had at least one stage II PU or higher. The mean ± SD MDS-HSI scores of LTC residents without PU and those with PU were 0.36 ± 0.17 and 0.26 ± 0.13, respectively (p < 0.001). Factors associated with lower MDS-HSI scores included: older age; being female; having a PU; recent hip fracture; multiple comorbid conditions; bedfast; incontinence; Changes in Health, End-stage disease and Symptoms and Signs; clinically important depression; treated with a turning/repositioning program; taking antipsychotic medications; and use of restraints.

Conclusions

LTC residents with PU had slightly though statistically significantly lower HRQOL than those without PU. Comorbidity contributed substantially to the low HRQOL in these populations. Community-weighted MDS-HSI utilities for LTC residents are useful for cost-effectiveness analyses and help guide health policy development.

Setting priorities for research: a practical application of 'payback' and expected value of information

BACKGROUND

Setting priorities for research using economic in addition to scientific criteria can ensure that resources are spent efficiently and equitably.

OBJECTIVE

This study applies two priority setting methods 'payback' and expected value of information (EVI) to two research areas (osteoporosis and pressure ulcers) and where appropriate to four clinical trials: the Record Trial, the Vitamin D and Calcium Trial and the Hip Protector Trial (osteoporosis), and the Pressure Trial (wound care).

METHODS

Two decision-analytic models were developed. For 'payback', the PATHS model was used to estimate the expected net benefits of conducting the four clinical trials. An EVI framework was applied to estimate the cost-effectiveness of conducting further research in the two disease areas investigated.

RESULTS

The application of 'payback' suggests that the Record Trial and the Vitamin D and Calcium Trial would be cost-effective. The Hip Protector and the Pressure Ulcer Trial are cost-effective under certain assumptions concerning the likelihood of obtaining positive, negative or inconclusive results. The EVI method suggests that research would be potentially cost-effective in these areas in the populations considered.

CONCLUSION

EVI provides strategic information for setting priorities for research between disease areas and study populations. 'Payback' provides information on the cost-effectiveness of specific research designs. However, further work in this area, particularly concerning the issue of implementation of research, is required.

Pressure Ulcers: A Role for Thymosin beta4

Pressure ulcers occur in up to 14% of acute hospitalizations. They cause pain, decreased quality of life, increased morbidity, and prolonged hospitalizations. Treatment includes pain control, nutritional support, relieving pressure, removing devitalized tissue, and by using dressings and medications, providing an environment in which healing can occur. Even with optimal treatment, pressure ulcers may take months to heal. Thymosin beta4 is being investigated as a treatment for pressure ulcers. Thymosin beta4 has wound healing and anti-inflammatory properties. It is thought to exert its therapeutic effect through promotion of keratinocyte and endothelial cell migration, increased collagen deposition, and stimulation of angiogenesis. A study in a rat full-thickness wound model showed that treatment with thymosin beta4 increased collagen deposition and angiogenesis and stimulated keratinocyte migration and reepithelialization. If thymosin beta4 decreases healing time, this would represent a significant advance in the treatment of pressure ulcers.

The experience of living with a pressure ulcer

This short paper presents a qualitative study, reported in detail elsewhere (Hopkins et al, 2006) that investigated the experience of older people with pressure ulcers. The researchers were surprised to find how significant pain associated with the pressure ulcer was to patients or the impact it had on their lives. All quotes from the participants are taken from Hopkins et al (2006).

Pressure ulcers and their treatment and effects on quality of life: hospital inpatient perspectives

AIM

This paper reports a study exploring patients' perceptions and experiences of the impact of a pressure ulcer and its treatment on their health and quality of life.

BACKGROUND

Pressure ulcers are a significant health problem, and their prevention and management in primary and secondary care is high on the clinical and policy agenda. However, patients' perspectives and experiences of the impact of pressure ulcers on health and quality of life is not understood.

METHOD

Qualitative semi-structured interviews were carried out from 2002 to 2004 with a purposive sample of 23 hospital inpatients (five men, 18 women: aged 33-92 years) with a pressure ulcer (graded 2-5) at various anatomical sites and with varied reasons for hospital admission. Data were analysed thematically.

FINDINGS

The majority of participants (91%; n = 21) indicated that the pressure ulcer and its treatment affected their lives emotionally, mentally, physically and socially. They presented their perspectives on the causes of their pressure ulcer and descriptions of pain (experienced by 91%), appearance, smell and fluid leakage. Patients described amounts and quality of care they received, including levels of comfort of dressings and pressure relieving equipment and the timing of interventions. They were largely dependent on others to treat, manage and care for their ulcer, but indicated that the pain, discomfort and distress of pressure ulcers was not acknowledged by nursing staff. The pressure ulcers could be pivotal in preventing full recovery, were perceived to increase hospital stays and resulted in ongoing treatments.

CONCLUSION

Healthcare professionals can learn from these patients' experiences about the management of dressings, providing information (in particular about realistic time expectations for healing), providing preventative interventions and understanding the importance of comfort and positioning for patients. The study highlights the complexities of evaluating the impact of pressure ulceration.

Data-based models of how pressure ulcers develop in daily-living contexts of adults with spinal cord injury

OBJECTIVE

To examine the daily-lifestyle influences on the development of pressure ulcers in adults with spinal cord injury (SCI).

DESIGN

Qualitative investigation using in-depth interviewing and participant observation.

SETTING

Participants were studied in their homes and other naturalistic contexts.

PARTICIPANTS

Twenty men and women of diverse ethnicities with paraplegia or tetraplegia who were recruited at a pressure ulcer management clinic in a large rehabilitation facility.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Detailed descriptive information pertaining to the development of recurring pressure ulcers in relation to participants' daily routine and activity, personal choices, motivating influences, lifestyle challenges, and prevention techniques and strategies.

RESULTS

The daily-lifestyle influences on pressure ulcer development in adults with SCI can be described through various models that vary in complexity, depending on whether they incorporate individualization, interrelations among modeled elements, situational specificity, and/or temporal comprehensiveness. Ulcers are most likely to develop when a person with a relatively high-risk background profile is exposed to an equilibrium-disrupting change event that culminates in a specific pressure ulcer risk episode.

CONCLUSIONS

The results underscore the significant degree of complexity and individualization that characterize the emergence of pressure ulcers in daily-life contexts. Prevention efforts should therefore incorporate attention to the unique constellation of circumstances that comprise a person's everyday life.

Patient stories of living with a pressure ulcer

AIM

This paper reports the findings of a pilot study exploring the experience of older people living with pressure ulcers.

BACKGROUND

Pressure ulcers are known to be a significant health burden, but little is known of the impact on the quality of life of the sufferer. They mainly affect older people, and this is a neglected group in previous studies of this topic.

METHODS

A Heideggerian phenomenological approach was used and patients were recruited if they were over 65 years of age and had a grade 3 or 4 pressure ulcer that had been present for more than a month. Patients were recruited from multiple centres but the data were analysed centrally. The study took place in 2003-2004.

FINDINGS

Analysis of the transcripts revealed three main themes, all with associated subthemes: pressure ulcers produce endless pain; pressure ulcers produce a restricted life; coping with a pressure ulcer. The endless pain theme had four subthemes: constant presence, keeping still, equipment pain and treatment pain. Some patients found that keeping still reduced their pain. Several patients also reported that pain was exacerbated by their pressure relieving equipment and at dressing change. There were three subthemes for the restricted life theme: impact on self, impact on others and consequences. Patients found that the pressure ulcer restricted their activities and had an impact on their families. In addition, for some, the restrictions delayed their rehabilitation. To cope with their pressure ulcers, patients developed ways of accepting their situation or comparing themselves with others.

CONCLUSIONS

Although a pilot, this study has produced a wealth of data that demonstrates the impact of pressure ulcers on people. While a larger study is required to obtain a European perspective, it is still reasonable to conclude that the issues of pain and restrictions should be considered in the development of pressure ulcer treatment and prevention guidelines.

When the goal is palliative care

OBJECTIVE

An analysis of the literature regarding palliative care of patients with wounds.

DATA SOURCES

Health care literature, including national and international reports, focusing on enhancing quality of life for individuals with wounds who are receiving palliative care.

CONCLUSION

The literature on palliative care of patients with wounds is limited. Integration of palliative care concepts and chronic wound management is challenging; however, palliative care, which focuses on comfort and symptom management for quality of life, can provide the best quality care within the parameters of disease and individual patient wishes.

How can we make pressure ulcer prevention and management truly multiprofessional?

There is scope for allied health professionals to become more involved in pressure ulcer management. This can be achieved by giving them more say in the running of wound-care organisations and by encouraging more dialogue between professions.

Patterns of recurrent pressure ulcers after spinal cord injury: Identification of risk and protective factors 5 or more years after onset11No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated

OBJECTIVES

To identify risk and protective factors associated with a history of recurrent pressure ulcers among participants with spinal cord injury (SCI).

DESIGN

A mail survey was used to identify factors associated with the presence or absence of recurrent pressure ulcers.

SETTING

A large specialty hospital in the southeastern United States.

PARTICIPANTS

All participants had traumatic SCI, were nonambulatory, 18 years or older, and had been injured at least 5 years. A total of 826 subjects participated, 633 of whom reported a pressure ulcer history that could be classified as to whether they did or did not have a history of recurrent pressure ulcers.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

History of pressure ulcers was measured by a single item that required participants to classify their history into 1 of 5 options, ranging from never having any pressure ulcers to having almost continuous pressure ulcers, often requiring hospitalization. Those who either never had a pressure ulcer or had them mostly for a short period after SCI onset were classified as nonrecurrent, whereas those who reported at least 1 per year were classified as recurrent.

RESULTS

Seventy percent of the participants failed to report recurrent pressure ulcers (never had any or had them only immediately after SCI onset), whereas 13% reported a clear pattern of recurring pressure ulcers of 1 or more per year. Logistic regression analyses suggested several general behaviors were protective for recurrent pressure ulcers, including lifestyle, exercise, and diet. Yet none of the behaviors generally recommended during inpatient rehabilitation specifically to prevent pressure ulcers (eg, skin checks weight shifts) were associated with pressure ulcer history. Only 2 risk behaviors were identified (number of cigarettes smoked, use of medication for sleep), although several proxy variables were related to pressure ulcer history.

CONCLUSIONS

Pressure ulcer history is a more viable measure of pressure ulcer outcomes than measures taken at a single point in time (current), over a brief period (eg, 1y), or those relying on critical events occurring at any time since SCI onset (ie, surgeries to repair pressure ulcers). A healthy lifestyle appears to be strongly associated with avoiding pressure ulcers, whereas the efficacy of specific prevention behaviors was not demonstrated. Problem solving and coping strategies should be targets for further research.

Internal consistency and responsiveness of the Skin Management Needs Assessment Checklist post-spinal cord injury

OBJECTIVE

To evaluate the internal consistency and sensitivity to change of the Skin Management needs assessment checklist (SMnac), a measure specifically developed for the spinal cord injury (SCI) population to assess skin management ability and equip individuals with the skills they need to prevent pressure ulcer development.

STUDY DESIGN

Consecutive series, psychometric evaluation study.

SETTING

Spinal Cord Injuries Rehabilitation Unit, United Kingdom.

PARTICIPANTS

317 participants with traumatic or nontraumatic SCI.

MEASURE

This study used the SMnac, which assesses the ability to perform skin checking, pressure relief, and the prevention of skin insults based on the individual's perception of his or her ability to independently undertake skin management activities.

RESULTS

Assessment of internal consistency produced a Cronbach's alpha for this scale of 0.85. A paired-samples t test was used to evaluate the SMnac's sensitivity to change. There was a significant difference between the first and second SMnac scores (t = - 24.38, df = 186, P < 0.001).

CONCLUSION

The SMnac has high internal consistency and sensitivity to change. The SMnac provides constructive assessment of skin management, specifying problems for individuals with SCI, standardizing the critical inputs required to meet rehabilitation targets, and measuring the effects of those inputs and their relationship to other mediating variables and expected outcome.

Provision of alternating air-pressure mattresses in the community

The presence of pressure ulcers is seen as a key indicator of quality (Department of Health, 1993) and they are both costly to the patient (Franks, 2001) and the NHS. It is important that resources are directed towards prevention rather than treatment, which makes the provision of pressure-relieving equipment an integral part of any strategy for the prevention and management of pressure ulcers.

Social problem solving abilities and psychosocial impairment among individuals recuperating from surgical repair for severe pressure sores

BACKGROUND/OBJECTIVES

The relationship of social problem solving abilities, health locus of control beliefs, and psychosocial impairment were examined among individuals with spinal cord injuries who were hospitalized following surgical repair of severe pressure sores.

METHODS

Individuals were approached after surgical repair and completed measures of problem solving, health locus of control beliefs, and psychosocial impairment after admission to the rehabilitation hospital.

RESULTS

The sample reported greater psychosocial impairment than observed in comparative data, but they did not differ from another sample in terms of health locus of control beliefs. Correlational analyses revealed that a negative orientation toward problem solving was significantly predictive of psychosocial impairment, consistent with prior research. However, a second study found persons assigned to a brief problem solving intervention did not differ on any measure from participants in a control group.

DISCUSSION

Implications of these results are discussed from theoretical and clinical perspectives. Although social problem solving abilities were predictive of psychosocial impairment in a predicted direction, the lack of effects for the intervention suggests greater precision is needed to understand individual needs and to develop individualized intervention protocols.

Death anxiety as a predictor of future time orientation among individuals with spinal cord injuries

PURPOSE

The purpose of this study was to examine the relationship between death anxiety and future time orientation among individuals who sustained spinal cord injuries (SCI).

METHODS

Participants were 317 individuals with SCI, of whom 57.4% were US veterans. Data were obtained by means of mailed questionnaires and included responses to the Death Anxiety Scale (DAS), the Future Time Orientation (FTOS) measure, as well as information on participants' personal and disability-related characteristics.

RESULTS

A hierarchical multiple regression analysis was conducted to examine the influence of a set of demographic variables, followed by a set of disability-related variables, and finally two factorially-derived measures of death anxiety (denial of death and distressed awareness of death) on future time orientation. Two disability-related variables (pain level and existence of pressure ulcers) and one of the two death anxiety measures (distressed awareness of death) significantly predicted future time orientation. A post-hoc analysis, adding depression as a predictor, was also significant, indicating that an increased level of depression uniquely contributed to a truncated future time orientation.

CONCLUSIONS

Distressed anxiety and depression may be important factors affecting goals and plans of people with SCI. Future research should attempt to clarify the intricate relationships among negative affectivity, future time orientation, and psychosocial adaptation to SCI.

Stress responses, pressure ulcer development and adaptation

This case study explores the possible psychosocial concepts underpinning a spinal cord-injured patients' pressure ulcer development, his response to the treatment offered and subsequent self-discharge. By examining both the physiological and psychological reactions of stress through conceptual models, it was possible to depict that there is a close relationship between autonomic responses and an individual's emotional and appraisal attributes. The effect of stress on the immune system was reviewed, with particular focus placed on the wound-healing process and the inflammatory phase. This identified a probable correlation between emotional stress and pressure ulcer development. An individual's reaction to emotional stressors is frequently associated with his/her unique coping strategies and their interplay with social support mechanisms. This case study will depict both positive and negative coping strategies and how the lack of social support influenced the final outcome. Through the provision of an anonymous patient history, investigation will be made into the effects of stress experienced by a patient. Models of stress and the patient's related physiological and psychological reactions will be discussed. Examination will be made into how the use of social support could have influenced the patient's coping mechanisms.

Let's own up to the real cost of pressure ulcers

I'm hoping someone can enlighten me. How do our advisory groups get the attention of the government, the NHS and the public to highlight the monetary and emotional costs of pressure ulcers in the UK? Well, they could follow the lead of Courtney Lyder, immediate past-president of the National Pressure Ulcer Advisory Panel in the US, who when trying to argue against using blanching erythema as a defining factor of grade I pressure ulcers, dropped his trousers and invited those present to ‘make his melanin-enriched skin blanch’.

The contribution of microbial virulence to wound infection

This qualitative study explored the perceptions and feelings of patients with pressure ulcers. Five participants who had suffered from pressure ulcers extending into the subcutaneous tissue and deep fascia were interviewed. A semi-structured interview technique was used, in which participants were asked a series of open questions based on the reviewed literature and the author's clinical experience. Content analysis was used to analyse the interview transcripts. The following themes emerged: pain, exudate levels, loss of independence, emotional factors, worry about healing, relationships, body image and social isolation.

Perceptions of pressure ulcers among young men with a spinal injury

About 1000 younger people each year suffer a traumatic spinal cord injury that leaves them wholly or partly paralysed. The majority of these individuals are male. Paralysis leads to a host of physical and often psychological problems. Among the major challenges is the management of pressure and the maintenance of skin integrity. Long periods of immobility and loss of sensation make people with a spinal cord injury prone to developing pressure ulcers. While specialist spinal injury units have pioneered a holistic approach to the rehabilitation of those with spinal cord injuries, there has been little research conducted in the UK on the experiences and coping mechanisms of these patients. The study reported here sought to examine the perceptions and experiences of a sample of young men with a spinal cord injury in relation to pressure management and skin integrity, and their experiences of care. The results suggest that these men were knowledgeable about pressure management and highly motivated to look after themselves, but there was an over-reliance on the specialist unit for support.

[Scars of the soul--wounds of the body: plastic surgery and psychotherapy]

With the example of two case reports of chronic wounds the connection between somatic and psycho-social factors is shown on the basis of the biopsycho-social model of disease. Both in aetiology as well as in therapy the dilemma of "somatic OR psychic" can thereby be solved. The inclusion of psychotherapeutic interventions in conservative or surgical strategies increases the probability of healing.

Assessing the impact of pelvic obliquity in post-operative neuromuscular scoliosis

The goal of this pilot study was to explore the relationship between pelvic obliquity and patient pain, sitting tolerance, pressure sores, and function. Five neuromuscular patients who underwent spinal surgery 6-26 weeks prior to assessment took part in this on-going study (4F; 1M); age at surgery (14.6 +/- 2.6 years). Pelvic obliquity was measured from pre- and post-operative anterior-posterior radiographs. A force-sensing pad with a grid of sensors was placed on a flat surface and the weight distribution pattern was recorded. The pressures were divided into left and right sides and peak levels were noted on each side. The parents or caregivers completed a questionnaire on their child's pain, sitting tolerance, pressure sores, and functional abilities. Pelvic obliquity was reduced after surgery by approximately 50% depending on the method used to assess pelvic obliquity. The major curve was reduced from 64 degrees(10 degrees) to 39 degrees (10 degrees). Post operatively, the average pressure (left/right side) ranged from 1.2 to 2.0 (average 1.6). The peak pressure ratio ranged from 1.1 to 1.9 (average 1.4). The ratio of left/right pressure correlated with improvement in pelvic obliquity (r2=0.9). Pain was moderate/severe in the 2 patients with the least correction as measured with the Cobb angle from surgery; both improved following surgery. Two patients suffered pressure sores pre-operatively and one post-operatively. Only 3/5 felt sitting endurance had increased. All parents felt their child sat straighter after surgery. The outcome measures of pain, pressure sores, sitting tolerance, and function were not well related to the amount of pelvic obliquity. More candidates and a longer follow-up may shed light on the many relationships.

Improving pressure ulcer prevention through education

Pressure ulcers adversely affect the quality of life of many patients and cause anxiety and distress for their families. Pressure ulcer prevention and management is an integral part of nursing practice, but despite numerous policies and guidelines, research, and improvements in equipment, the incidence and prevalence of pressure ulcers have not fallen. In this article, the author examines issues involved in promoting more effective pressure ulcer management.

Chronic wound caring ... a long journey toward healing

Healthcare professionals use words like "frustrating," "expensive," and "time-consuming" to describe chronic wound care. Healing a wound that has been present for an extended period of time is difficult. Often the problem is not just the wound but also the "woundedness" of the individual with the wound. The patient's needs in chronic wound care often continue over months, years, or even a lifetime. This article addresses more than the wound--it offers healthcare professionals' accounts of patient stories and their active involvement in the long journey toward chronic wound healing.

Patients with pressure ulcers in Finnish hospitals

The purpose of this descriptive study was to produce knowledge of the degree of pressure ulcers, pressure ulcer patients' physical and psychological well-being and the association of these factors with pressure ulcers' severity. These patients were treated in Finland's capital area hospitals. The pressure ulcer patients' sampling was gathered during 1 day with two questionnaires, which was completed by nurses. The response rate was 94%, and data analysis was based on percentage distributions. Statistical association was tested with the chi2 test. The measurement identified 164 patients with a total of 257 pressure ulcers. Prevalence was 6.4%. Most of the ulcers (40%) were grade II ulcers. Fifty-six per cent of patients suffered poor general health, 63% of the patients were immobile, but psychological well-being was better with 29% of pressure ulcer patients being adequately motivated to follow treatment for their pressure ulcers. It is essential to identify high-risk patients in order to provide optimal care.

Best practices for the prevention and treatment of pressure ulcers

In this article, the Canadian Association of Wound Care puts forward 12 recommendations for best practices in the prevention and treatment of pressure ulcers that focus on an interdisciplinary patient-centered approach. These recommendations are a synthesis of the Agency for Health Care Policy and Research guidelines, European guidelines, and current literature as interpreted by the Canadian experience and achieved through a national consensus panel. The article concludes that best practice guidelines must be fluid documents that respond to new evidence and experience.

Initial experiences with telerehabilitation and contingency management programs for the prevention and management of pressure ulceration in patients with spinal cord injuries

Two alternative treatment methods for preventive interventions for pressure ulcers, tele-rehabilitation and contingency management, are discussed. Telerehabilitation uses a videophone that transmits both audio and still images over a telephone line. Using this technology, the WOC nurse can interview a patient who cannot be present at a clinic because of physical condition or distance. Telerehabilitation allows the nurse to assess a patient's pressure ulcer, consult with appropriate caregivers, and make recommendations for treatment. Contingency management procedures are designed for patients with high rates of noncompliance in skin care. The patients are seen as outpatients and are compensated systematically for appropriate skin care (ie, the lack of pressure ulcers). Examples of each of these patient interventions is described, discussed, and contrasted.

The lived experience of having a pressure ulcer: a qualitative analysis

In this descriptive, qualitative, phenomenological study, the researchers explored the phenomena of the lived experience of having a pressure ulcer to determine the essential structure of the experience. The sample included 8 respondents: 4 individuals who currently had a pressure ulcer and 4 who previously had a pressure ulcer that had healed. Four respondents also had a spinal cord injury and 5 had surgical flap reconstruction. Respondents were asked to reflect and reply to the following statements: "Please describe your experience of having a pressure ulcer. Share all the thoughts, perceptions, and feelings you can recall until you have no more to say about this experience." From verbatim transcriptions of interviews, 7 themes evolved with related sub-themes. The themes that emerged were (1) perceived etiology of the pressure ulcer; (2) life impact and changes; (3) psychospiritual impact; (4) extreme painfulness associated with the pressure ulcer; (5) need for knowledge and understanding; (6) need for and effect of numerous, stressful treatments; and (7) the grieving process. In this paper, the essential nature of the experience of living with a pressure ulcer is presented. Pressure ulcers had a profound impact upon the subjects' lives, including physical, social, and financial status; change of body image; and/or loss of independence and control. Those with a Stage IV pressure ulcer and flap repair and/or those with a spinal cord injury experienced the grieving process in some form. Although the experience of having a pressure ulcer has similarities for each individual, each experiences it in a unique manner. Patients with a pressure ulcer with or without a spinal cord injury have significant needs in learning to cope and live with their condition.

Beyond the pressure ulcer blame game: reflections for the future

The concept of skin wounds caused primarily as a result of external physical forces has been the focus of many healthcare professionals for decades. Unfortunately, some of the choices made regarding the definition, description, and topical management of pressure ulcers hampers the appreciation of the complexity of issues that generally accompany the occurrence of these wounds. As the healthcare industry increasingly focuses on quality and accountability, industry watchdogs continue to develop metrics to evaluate quality of care while legal professionals demand more accountability for healthcare interventions. The management of pressure ulcers is often scrutinized and many healthcare providers are often unfairly accused of neglect. The occurrence of pressure ulcers, when viewed as a failure of the healthcare system, prevents the comprehensive and constructive attention this topic deserves. Therefore, as wound care providers, we must change the image of pressure ulcers and provide a more balanced portrayal of the influences, treatments, and likely outcomes of these wounds. We must separate fact from fiction and reality from the psychological reaction that pressure ulcers evoke. It is now time to recreate a dialogue for pressure ulcers that is productive, realistic, and likely to result in the advancement of care.

Consumer views of pressure sores: a preliminary survey

AIM

To obtain consumer views about pressure sore development, particularly in A&E departments.

METHOD

The local Patient and Carers Association received a freepost survey in the form of a simple fixed choice questionnaire.

RESULTS

Fewer than half the questionnaires were returned. Relatively few respondents were aware that pressure sores could be avoided, and few were aware that prolonged bed rest or lying on a hospital trolley could increase the risk.

CONCLUSION

The survey raised more questions than it managed to answer. More research is needed into the views of patients and carers before they can be involved in healthcare planning.