Reducing the Pressure: Holistic Methods for Effective Wound Care Management

The most cost-effective wound is no wound at all. Although many third party payers resist reimbursement for prevention activities, studies prove that prevention of pressure ulcers over treatment saves money. Beyond the fact that less funds are spent for expensive therapies, advanced dressings, adjunctive treatments and clinicians' time, unmeasurables such as pain and suffering, time away from work and secondary complications like osteomyelitis are prevented.

Low or no-cost preventative options, that are easy to incorporate into a plan of care include: a comprehensive skin care program with use of a good quality moisturizer and protective barrier ointment if incontinence or exudate are problems, scheduled and posted turning and repositioning schedules that family and caregivers can carry out. These repositioning schedules can include frequent skin checks and assessment for areas that are nonblanchable, use of a preventative group I (pressure reducing) support surface in the form of an overlay or mattress replacement and using the 30-degree lateral position to allow for better pressure distribution in a side-lying patient.

Know the patient and the risks.

With typical home care clients returning to their residences quicker and sicker, knowing each patient's risk is crucial to bypassing the scorn of pressure ulcers.

. A risk assessment score that coincides with a well thought out clinical practice guideline, protocol or plan is an indispensable tool that can alert the clinician to potential problems before they occur.
Simple and regular assessment of patient risk with a validated risk assessment tool such as the Braden Scale can alert the clinician to potential development of ischemia. Risk does not necessarily predict pressure ulcer occurrence, in fact, a risk assessment score by itself is rather useless. However, a risk assessment score that coincides with a well thought out clinical practice guideline, protocol or plan is an indispensable tool that can alert the clinician to potential problems before they occur.

The basic risk categories assessed by the Braden Scale include sensory perception, moisture, activity, mobility, nutrition, friction and shear. A program of prevention guided by risk assessment can simultaneously reduce the incidence of pressure ulcers by as much as 60 percent and ultimately reduce the costs of prevention.

Evaluate cause carefully.

Pressure alone doesn't cause pressure ulcers, but lack of blow flow or ischemia does. Extrinsically, peak pressure, shear, superficial friction and moisture all can contribute to pressure ulcer evolution. A complete history, including details regarding a person's activities of daily living (ADLs); mobility status and ability to perform a weight shift or turn; skin care practices; use of pressure distributing devices such as cushions and other support surfaces; whether or not the patient or their family routinely inspect their skin; what type of clothing a person wears; all can be important in pinpointing the cause and formulating the treatment plan. Getting to know a patient, what he or she does for a living and how he or she spends a typical day, is paramount in determining cause.

Case in point, a 16-year-old spinal cord injured client who I recently consulted with had a chronic pressure ulcer on one of his ischial tuberosities. He insisted in a phone interview that he was performing all the health-related practices of prevention, sitting on a therapeutic cushion, keeping his skin free of moisture, eating well and performing frequent weight shifts. I was pleasantly surprised by his interest and knowledge at such a young age. It wasn't until I pressure mapped him that I found that his effective weight shifts were nothing more than straightening out his scoliotic spine. Without cause, we cannot define a practical treatment plan.

Assess patients holistically.

The following are questions you should ask yourself in order to assess patients holistically.

*How is the patient's overall health?

*Does he or she suffer from any chronic disease processes?

*Does the wound have an adequate blood supply and sufficient host factors for healing?

*What medications is the patient taking? How about vitamins, minerals or herbs?

A risk assessment score that coincides with a well thought out clinical practice guideline, protocol or plan is an indispensable tool that can alert the clinician to potential problems before they occur.
Excess ingestion of vitamin E, for instance, can actually delay wound healing.

*Does the client take part in any unhealthy practices such as smoking or abusing alcohol? *Is there a history of pressure ulcers?

*Any dependent edema around the wound site?

*How about social, psychological and cultural issues or potential barriers?

*What is the patient's living situation? If planning for discharge to home, has the residence been assessed? Where will the patient sleep; is there a clean environment for dressing changes?

Global health, not just wound health, produces better outcomes overall. I often see orders written for complete bed rest for clients who have full-thickness pressure ulcers. Although I understand the theory as a whole, the patient suffers. I generally recommend that patients get out of bed and sit upright-even if the wound is on the seated surface-if only for five to 15 minutes, two to three times per day. The effects of this simple measure can mean the difference between developing pneumonia, a deep vein thrombosis, battling depression or remaining healthy overall. If a high-quality therapeutic cushion is in use, there is usually little or no negative influence on the healing wound.

Develop measurable and attainable goals.

Just as we wouldn't expect our geriatric patient who is beginning to walk after a stroke to run a marathon, granulation and epithelialization to closure is not always possible in an extensive full-thickness wound. Take for example the palliative care patient who is currently cared for by the home care hospice team. The primary goal may be to keep the patient comfortable, keep the wound free of infection and odor and minimize dressing changes, not to actually witness complete wound closure.

Follow the progress or decline of a wound, at least weekly with a comprehensive assessment, measurement and possibly photography re-evaluating the care plan as goals are met or not met. Progress toward healing should begin within two to four weeks of initiation of treatment.

Pay Attention to Topical Care

Assess and monitor the physical characteristics of the wound, its location, stage, size, base or wound bed, exudate, periwound skin, any undermining of the wound' edges or tunneling. Document consistently, with as much detail as possible. Obtain consent for photography and take photos at regular intervals-the newer digital cameras make sending photos to payer sources and other professionals easy. Determine the condition of the wound bed. Is there any nonviable material present? If so, debride the necrotic tissue, a major roadblock to healing.

Cleanse the wound with every dressing change. This is easily accomplished with normal saline solution (0.9 percent NaCl). Assess the wound for signs and symptoms of superficial or deep infection. Beware the use of topical antiseptics such as povidone iodine, acetic acid and Dakin's solution which are cytotoxic and delay healing. They should only be used for a short period of time or if the wound is deemed nonhealable. Select appropriate topical dressings based on the needs of the wound, the amount of exudate, the presence of devitalized material and the ability to stimulate granulation tissue and epitheliatlization. Evaluation of the treatment regimen to determine effectiveness is imperative and may have to be altered as the wound progresses.

Continuity of Care: Think outside of the box.

Before becoming a wound care specialist, my background was caring for critically ill patients in the ICU. I prided myself on giving exemplary care, often witnessing dramatic recoveries and subsequent discharges to step-down units and eventually, home care. Despite the use of preventative mattress overlays and replacements on every patient, I failed to address the need for a pressure reducing cushion when my rehabilitating clients were up and out of bed. Patients sat on upholstered hospital chairs or a pillows, if they were lucky. Back then, I sent my patients on their way, never to know that they often developed a pressure ulcer on their sacrum or ischial tuberosities by the time they returned home.

Sixty-six percent of pressure ulcers occur on the pelvis with nearly half of those due to the seated posture. Since approximately 70 percent of a person's weight is shifted from recumbency-offering greater surface area to distribute weight-to an upright sitting position, chances are even greater that peak pressure over the bony prominences of the pelvis can cause ischemia and lead to a pressure ulcer. Not to be forgotten are the heels and ankles that account for approximately 15 percent of breakdown. If your patient is covered by Medicare B for instance, a full support surface may not be covered for those with calcaneous or malleolus breakdown. Consider highly therapeutic heel and ankle protectors that distribute pressure and alleviate friction and shear.

Don't underestimate nutrition.

Without adequate food, fluid and vitamin intake, patients not only are more vulnerable to development of a pressure ulcer, but also healing an existing pressure ulcer can be next to impossible. Many of our elderly patients, especially those who live alone, are prone to malnutrition and chronic dehydration. Every home care patient at risk should undergo a nutritional assessment. Such a screening, in its most basic form, should consist of height and weight (both present weight and usual weight to account for fluid imbalances); a serum albumin level which is a common indicator of a patient's protein stores; a thorough clinical exam for signs and symptoms of dietary deficiencies; a dietary history; and an estimation of nutritional needs such as calories, protein and fluid intake. Consultation by a registered dietitian may be necessary for nutritionally deficient patients. Such consultations can be invaluable in designing a plan for nutritional intervention and supplementation. Generally, I recommend a 100 percent R.D.A. multi-vitamin and mineral supplement to all of my chronic wound patients unless there is history of liver disease or other reasons that would preclude the use of supplementation.

Work with a multidisciplinary team.

Make certain that the right professionals are involved in the care of a patient with a chronic wound. Many health care providers lack knowledge of chronic wound management and view these wounds as troublesome or with disinterest and therefore treat the ulcers with antiquated and often unsuccessful measures. These clients tend to slip through the cracks or get passed from one provider to the next. In order to provide comprehensive chronic wound management, it is oftentimes beneficial to use a team model which includes multidisciplinary involvement from physicians, nurses, physical and occupational therapists, dietary, social service and manufacturers, distributors and home care equipment providers. The team should gain leadership from a dedicated wound care professional such as an enterostomal therapy nurse or certified wound specialist.

Educate everyone involved.

The successful clinician or provider is a perpetual student and teacher. The study of advanced wound care is still fairly young and each day new findings allow health care providers to provide excellent care to clients often saving time, money and discomfort. Seek out the wound care specialists within your facility or community. A wound management professional such as the ones mentioned above can offer worthwhile assistance with education, protocol development, chronic wound evaluation as well as help with comprehensive clinical practice guidelines.

Read pertinent journals that keep you current on chronic wound management, and attend seminars, workshops and continuing education programs dealing with pressure ulcers and other chronic wounds. Offer to take part in clinical trials and case studies, go on-line to learn about new products, and seek out appropriate training materials for patients and their families. As providers and life-long adult learners, it is our duty to acquire and pass knowledge on to one another. Head up a committee, get involved in the community wound care team, join a clinical chat room, or perform a basic inservice for your staff.

Lastly, in the home health care arena, our main partners are our patients and their support systems: family, friends, significant others and the community. These people rely on us to be more than just providers of medical equipment and care; they require us to be problem solvers. Educating these key people can mean the difference between wound success and failure and is an essential component of fortuitous wound care. Our primary skills, which often provide us with the best outcomes, are listening and collaboration.

This article originally appeared in the May 2002 issue of HME Business.


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