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Abstracts from the First Training Course for Nursing Home Staff
Journal of Tissue Viability 1996 Vol6 No 3
85
ABSTRACTS FROM THE FIRST TRAINING COURSE FOR NURSING HOME STAFF Derby 20 March 1996 Physiology of the Skin and Wound Healing Dr Kate Springett, Department of Podiatry, University of Brighton It is useful to know about the structure and function of the
skin, as it helps to understand what happens as wounds heal. The process of wound healing is complex but it is worthwhile knowing about this in simple terms to understand what may go wrong and why some wounds, like ulcers, take a long time to improve and heal. The skin is composed of two main layers. The surface layer is the epidermis and the deeper is the dermis. The soles of feet and palms of hands have a slightly different structure to that of hairy skin. A most important function of the skin is that it is a barrier to the environment. It protects the body from damage (eg heat, mechanical trauma, sunlight, bacterial invasion). Skin abnormality means it is not able to function as efficiently as normal skin and wounds may develop more readily. There are a variety of reasons for skin abnormality. These include: Medical disorders (eg diabetes, rheumatoid arthritis, malabsorption syndromes) Poor nutrition (low nutrient value of food) A peripheral problem in the legs (eg reduced blood supply, swelling, skin complaints such as eczema) Lack of mobility Psychosocial status A combination of such factors puts one at risk of developing a chronic wound (an ulcer). A lot has still to be learnt about what causes ulcers to form. The amount and quality of blood flow ( oxygen and nutrients, waste product removal) is important, as well as the mechanical damage to the cells of the skin and deeper tissue. The length of time the body is placed in one position (duration of contact) is important as well as how much mechanical stress (ie pressure, shear, friction, torsion and tension) is put on one spot of the skin. Whatever the process of ulcer induction, the end result is damage to the skin and deeper tissues. Once damaged, healthy body tissues start the healing process. The healing process is divided into types and stages according to the nature of the damage. If the type of wound is a cut or caused by a surgical incision it heals by first intention. Second intention healing takes place in the type of wounds where skin and soft tissue have been scooped out by accident or intentionally, leaving a hollow or cavity. Ulcers (chronic wounds) heal by second intention but the time for each stage is variable, can run over into the next stage, or not occur at all. Chronic wound healing is therefore often unpredictable.
Healing by first intention in healthy tissue - clinical features: at first, there is very little to see except for the incision site and a small surface clot. The injured area may be sore or just itchy. After 2-8 days there may be some redness around the wound edges which turn slightly blue-red/purple as time progresses. The scab will lift off and itchiness will subside. The healing process continues but if infection occurs, there will be pain, a marked inflammatory response, and healing will be delayed. Healing by second intention in healthy tissue - clinical features: the scoop-out of tissue will be obvious at first, with a blood clot on top. Between 0-8 days the surrounding tissue will be red, warm, painful, swollen. The base of the defect/wound will have exudate (fluid from blood and tissues) in the base perhaps with some pus. As time progresses (3-20 days) the surrounding tissue will become less swollen, less painful, the redness will subside to normal but perhaps looking a little purple and the wound base will be covered in red tissue (granulation tissue full of blood vessels). Anytime from day 12 onwards, the wound cavity will fill in with tissue, become covered with new epidermis and return to normal colour. Swelling subsides and the wound/scar flattens out. With infection, inflammation will be marked and healing delayed. The stages of healing have a variety of different descriptions given to them which can be confusing; however, usually 4 stages are given. Only one of these variations is described here (adapted from The Wound Programme, University of Dundee). The stages are noted in italics. In healthy tissue, the first event after injury is a blood clot (immediate), after which the damaged tissues release chemicals causing more blood and cells involved in the healing process to arrive at the damage site (inflammation). The next stage (proliferation) involves debris removal, formation of new blood vessels and reduction in the size of the wound. New fibrous tissue is laid down and epidermis begins to grow over the wound surface. In the maturation stage, the epidermis covers the wound, the number of blood vessels reduces, the cavity is filled and the wound site/scar flattens. The causes of ulcers are many but they also influence the rate and quality of healing. It is important to recognise the stages of ulcer development and to identify the people who are at risk of forming ulcers so that they can be prevented.
Tensile Strength Proliferation Inflation
Maturation ~-------------
Days
7
14
21
-- --
-------- --
L-=======-~=============--
100
86 Journal of Tissue Viability 1996 Vol6 No 3 Wound Assessment Clare Williams, Clinical Nurse Specialist - Tissue Viability, Maelor Hospital NHS Trust, Wrexham
Before assessment of a wound can take place it is important for the healthcare professional to have a certain level of knowledge to enhance their assessment. It is important, for example, to understand how the four stages of healing affect the appearance of the wound, the principles of moist wound healing and the factors that can affect the healing process.
Wound assessment can be enhanced by taking a holistic approach. A nursing model, such as Roper, Logan and Tierney's Activities of Daily Living may be a useful tool. The clinical appearance of the wound itself is commonly colour coded. The colour code includes black for necrotic tissue, green for infected wounds, yellow for slough, red for granulating tissue and pink for epithelial tissue. A thorough wound assessment should also include the location of the wound, the associated pain, the state of the surrounding skin, a measurement of wound size, the level of exudate and odour. A wound assessment chart can be a useful tool to improve documentation and communication. The advantages of wound assessment therefore are that you are able to monitor the progress of wound healing, evaluate the treatment and improve the morale of the patient and staff. It also provides a useful teaching tool for students.
The chronicity of a wound may also be due to the inability to optimise the body's potential for healing itself. The potential for healing can be maximised by providing the wound bed with a warm moist environment and removing any non-viable tissue. Trauma to the wound bed should be minimised by eliminating the use of chemicals and dressings that are used for cleaning/dressing the wound. Smoking, malnutrition and infection all play a role in delaying the wound healing process in both acute and chronic wounds.
References 1. Bryant R. Acute and Chronic Wounds: Nursing Management. StLouis: Mosby, 1992. 2. Dealey C. The Care of Wounds. Oxford: Blackwell Sciences, 1995. 3. Thomas S. Wound Management and Dressings. London: The Pharmaceutical Press, 1990.
The Importance of Good Nutrition in the Prevention and Treatment of Pressure Sores Mrs Gail Methven, Senior Dietitian, Wirral Community Health Care Trust, St Catherine's Hospital, Sheffield.
'Nutrition plays such an important part in recovery that the ability of a wound to heal may be determined by the nutritional status of the individual.' 1 • In other words good nutrition, or the food that is provided to residents in nursing homes, is vitally important in the prevention and treatment of pressure sores.
Acute v Chronic Wounds Trudie Young, Lecturer in Nursing Studies, University ofWales, Bangor
Wounds are classified as either acute or chronic. The factors that influence the classification are the cause of the wound and the amount of time it takes the wound to heal. Wounds that fall into the acute category include surgical wounds, traumatic wounds and bums 1• Leg ulcers, pressure sores and fungating wounds fall into the chronic category2 • Acute wounds will heal uneventfully and have been described by Bryant 3 as 'healing themselves'. Chronic wounds require assistance to heal and do not pass smoothly through the stages of the wound healing process. Instead they have a sporadic progression in which they appear to become fixed within a certain stage and unable to achieve complete healing. Previously this was thought to be due to a lack of activity at the wound bed but recently the opposite has been proposed as the reason for the lack of progression in chronic wounds.
If residents are unable to eat for any length of time, then they are at risk from malnutrition. Malnutrition leads to delayed wound healing as well as the increased risk of pressure sores. Therefore, it is important that residents who appear to be at risk are recognised early. To help identify those at risk a nutritional scoring system may be useful. Important factors in the treatment of residents with pressure sores include adequate calories (30-40 Kcals per kilogram per day), adequate protein (1.2-2.0 grams per kilogram per day), various vitamins and minerals (most importantly, Vitamin C, Vitamin A, Iron and Zinc) and adequate fluid (30-35 mls per kilogram per day) is also vital. Putting these principals into practice can be difficult if the resident has a poor appetite and, in such cases, fortifying foods and supplementary products can be very useful.
Reference The wounds that fall into the chronic category are often the visible aspect of an underlying disease, eg Venous Hypertension, Malignancy, Tissue Ischaemia and Diabetes Mellitus. The wound will remain in a chronic non-healing state until the underlying disease processes are addressed.
1. Edward Wallace. Feeding the wound - nutrition and wound care. British Journal of Nursing, 1994; 3(13): 662-667.
Journal of Tissue Viability 1996 Vol6 No 3 Selecting Wound Management Products Mrs Mair Fear Price Deputy Matron Thornhill Nursing Home, Gwent.
There continues to be uncertainty among some practitioners in the selection of appropriate dressing materials. Each product comes supported with a wealth of literature which provides the reader with very sound resons of why they should select that particular product. Moreover the dilemma escalates as the industry rises to the demands of clinicians for 'a bigger dressing, a more absorbent dressing or a different shaped dressing'. The company representatives too have a wealth of knowledge and also influence our choice by providing samples, or telling us that some clinical nurse specialist is having wondrous results with that particular product!! We are not always aware that our clinical decision making is being influenced by factors such as the recency of our experience with a particular product or the condition we are treating. The amount of our experience, or the profoundness of those experiences can also affect our clinical reasoning and the decision making process. Suggested further reading: l. Davis A et al. The Wound Programme. Singapore: Centre for Medical Education, 1992. 2. Thomas S. Wound Management and Dressings. London: The Pharmaceutical Press, 1990. 3. Thomas S. Handbook of Wound Dressings. London: Journal of Wound Care, 1994. 4. Dealey C. The Care of Wounds. Oxford: Blackwell Scientific Publications, 1994. The 30" Tilt Positioning Technique Mr William Haughton, CNS Tissue Viability, Wirral Hospital NHS Trust, Merseyside.
The management of people at risk of developing pressure sores is time consuming and labour intensive. The 'traditional' technique of turning the patient frequently from one lateral position to the other serves several purposes: Pressure relief. Comfort. To allow regular observation of the skin. However, this traditional approach can present a number of problems. It disrupts the patient's rest periods and activities, and may be painful and distressing. It may increase disorientation in susceptible individuals, and may increase the risk of skin trauma through friction and shear forces, despite efforts to ensure correct handling techniques are used. It increases the risk of back injuries to carers, and it is impractical and unrealistic to expect carers in the home to continue the practice throughout 24 hours, 7 days a week. While there is no doubt that pressure relieving support systems can be extremely effective in assisting in the prevention
87
ano management of pressure sores, these are not always readily available in the nursing home or community setting. The 30" tilt technique can provide a useful alternative system of repositioning, which in may cases obviates the need for specialised equipment, and may be readily adopted in the community setting, nursing homes and residential homes. The advantages of such a technique are that it: - allows a greater area of contact between the patient and the support surface, thereby reducing interface pressures. -minimises disruption of the patient's rest and activity periods. -reduces the likelihood of disorientation, as the patient's field of view remains much the same after repositioning. The risk of friction and shear injuries is significantly less, and the amount of handling is reduced, decreasing the risk of back injuries to carers. The technique is easily learned and performed by home carers, and requires no special equipment. In many cases, the frequency of repositioning can be reduced without compromising the patient's skin condition. There is no 'ideal' repositioning technique which is suitable for all patients and circumstances. However, the 30° tilt technique offers a simple, effective and inexpensive alternative for many patients, and can be particularly useful in a community setting. Further reading 1. Preston KW. Positioning for comfort and pressure relief: the 30 degree alternative. CARE - Science and Jlractice 1988; 6 (4): 116-119.
2. Seiler WO, Allen S, Stahelin HB. Influence of the 30 degree laterally inclined position and 'Supersoft' 3 piece mattress on skin oxygen tension on areas of maximum pressure implications for pressure sore prevention. Gerontology 1986; 32: 158-166.
85
ABSTRACTS FROM THE FIRST TRAINING COURSE FOR NURSING HOME STAFF Derby 20 March 1996 Physiology of the Skin and Wound Healing Dr Kate Springett, Department of Podiatry, University of Brighton It is useful to know about the structure and function of the
skin, as it helps to understand what happens as wounds heal. The process of wound healing is complex but it is worthwhile knowing about this in simple terms to understand what may go wrong and why some wounds, like ulcers, take a long time to improve and heal. The skin is composed of two main layers. The surface layer is the epidermis and the deeper is the dermis. The soles of feet and palms of hands have a slightly different structure to that of hairy skin. A most important function of the skin is that it is a barrier to the environment. It protects the body from damage (eg heat, mechanical trauma, sunlight, bacterial invasion). Skin abnormality means it is not able to function as efficiently as normal skin and wounds may develop more readily. There are a variety of reasons for skin abnormality. These include: Medical disorders (eg diabetes, rheumatoid arthritis, malabsorption syndromes) Poor nutrition (low nutrient value of food) A peripheral problem in the legs (eg reduced blood supply, swelling, skin complaints such as eczema) Lack of mobility Psychosocial status A combination of such factors puts one at risk of developing a chronic wound (an ulcer). A lot has still to be learnt about what causes ulcers to form. The amount and quality of blood flow ( oxygen and nutrients, waste product removal) is important, as well as the mechanical damage to the cells of the skin and deeper tissue. The length of time the body is placed in one position (duration of contact) is important as well as how much mechanical stress (ie pressure, shear, friction, torsion and tension) is put on one spot of the skin. Whatever the process of ulcer induction, the end result is damage to the skin and deeper tissues. Once damaged, healthy body tissues start the healing process. The healing process is divided into types and stages according to the nature of the damage. If the type of wound is a cut or caused by a surgical incision it heals by first intention. Second intention healing takes place in the type of wounds where skin and soft tissue have been scooped out by accident or intentionally, leaving a hollow or cavity. Ulcers (chronic wounds) heal by second intention but the time for each stage is variable, can run over into the next stage, or not occur at all. Chronic wound healing is therefore often unpredictable.
Healing by first intention in healthy tissue - clinical features: at first, there is very little to see except for the incision site and a small surface clot. The injured area may be sore or just itchy. After 2-8 days there may be some redness around the wound edges which turn slightly blue-red/purple as time progresses. The scab will lift off and itchiness will subside. The healing process continues but if infection occurs, there will be pain, a marked inflammatory response, and healing will be delayed. Healing by second intention in healthy tissue - clinical features: the scoop-out of tissue will be obvious at first, with a blood clot on top. Between 0-8 days the surrounding tissue will be red, warm, painful, swollen. The base of the defect/wound will have exudate (fluid from blood and tissues) in the base perhaps with some pus. As time progresses (3-20 days) the surrounding tissue will become less swollen, less painful, the redness will subside to normal but perhaps looking a little purple and the wound base will be covered in red tissue (granulation tissue full of blood vessels). Anytime from day 12 onwards, the wound cavity will fill in with tissue, become covered with new epidermis and return to normal colour. Swelling subsides and the wound/scar flattens out. With infection, inflammation will be marked and healing delayed. The stages of healing have a variety of different descriptions given to them which can be confusing; however, usually 4 stages are given. Only one of these variations is described here (adapted from The Wound Programme, University of Dundee). The stages are noted in italics. In healthy tissue, the first event after injury is a blood clot (immediate), after which the damaged tissues release chemicals causing more blood and cells involved in the healing process to arrive at the damage site (inflammation). The next stage (proliferation) involves debris removal, formation of new blood vessels and reduction in the size of the wound. New fibrous tissue is laid down and epidermis begins to grow over the wound surface. In the maturation stage, the epidermis covers the wound, the number of blood vessels reduces, the cavity is filled and the wound site/scar flattens. The causes of ulcers are many but they also influence the rate and quality of healing. It is important to recognise the stages of ulcer development and to identify the people who are at risk of forming ulcers so that they can be prevented.
Tensile Strength Proliferation Inflation
Maturation ~-------------
Days
7
14
21
-- --
-------- --
L-=======-~=============--
100
86 Journal of Tissue Viability 1996 Vol6 No 3 Wound Assessment Clare Williams, Clinical Nurse Specialist - Tissue Viability, Maelor Hospital NHS Trust, Wrexham
Before assessment of a wound can take place it is important for the healthcare professional to have a certain level of knowledge to enhance their assessment. It is important, for example, to understand how the four stages of healing affect the appearance of the wound, the principles of moist wound healing and the factors that can affect the healing process.
Wound assessment can be enhanced by taking a holistic approach. A nursing model, such as Roper, Logan and Tierney's Activities of Daily Living may be a useful tool. The clinical appearance of the wound itself is commonly colour coded. The colour code includes black for necrotic tissue, green for infected wounds, yellow for slough, red for granulating tissue and pink for epithelial tissue. A thorough wound assessment should also include the location of the wound, the associated pain, the state of the surrounding skin, a measurement of wound size, the level of exudate and odour. A wound assessment chart can be a useful tool to improve documentation and communication. The advantages of wound assessment therefore are that you are able to monitor the progress of wound healing, evaluate the treatment and improve the morale of the patient and staff. It also provides a useful teaching tool for students.
The chronicity of a wound may also be due to the inability to optimise the body's potential for healing itself. The potential for healing can be maximised by providing the wound bed with a warm moist environment and removing any non-viable tissue. Trauma to the wound bed should be minimised by eliminating the use of chemicals and dressings that are used for cleaning/dressing the wound. Smoking, malnutrition and infection all play a role in delaying the wound healing process in both acute and chronic wounds.
References 1. Bryant R. Acute and Chronic Wounds: Nursing Management. StLouis: Mosby, 1992. 2. Dealey C. The Care of Wounds. Oxford: Blackwell Sciences, 1995. 3. Thomas S. Wound Management and Dressings. London: The Pharmaceutical Press, 1990.
The Importance of Good Nutrition in the Prevention and Treatment of Pressure Sores Mrs Gail Methven, Senior Dietitian, Wirral Community Health Care Trust, St Catherine's Hospital, Sheffield.
'Nutrition plays such an important part in recovery that the ability of a wound to heal may be determined by the nutritional status of the individual.' 1 • In other words good nutrition, or the food that is provided to residents in nursing homes, is vitally important in the prevention and treatment of pressure sores.
Acute v Chronic Wounds Trudie Young, Lecturer in Nursing Studies, University ofWales, Bangor
Wounds are classified as either acute or chronic. The factors that influence the classification are the cause of the wound and the amount of time it takes the wound to heal. Wounds that fall into the acute category include surgical wounds, traumatic wounds and bums 1• Leg ulcers, pressure sores and fungating wounds fall into the chronic category2 • Acute wounds will heal uneventfully and have been described by Bryant 3 as 'healing themselves'. Chronic wounds require assistance to heal and do not pass smoothly through the stages of the wound healing process. Instead they have a sporadic progression in which they appear to become fixed within a certain stage and unable to achieve complete healing. Previously this was thought to be due to a lack of activity at the wound bed but recently the opposite has been proposed as the reason for the lack of progression in chronic wounds.
If residents are unable to eat for any length of time, then they are at risk from malnutrition. Malnutrition leads to delayed wound healing as well as the increased risk of pressure sores. Therefore, it is important that residents who appear to be at risk are recognised early. To help identify those at risk a nutritional scoring system may be useful. Important factors in the treatment of residents with pressure sores include adequate calories (30-40 Kcals per kilogram per day), adequate protein (1.2-2.0 grams per kilogram per day), various vitamins and minerals (most importantly, Vitamin C, Vitamin A, Iron and Zinc) and adequate fluid (30-35 mls per kilogram per day) is also vital. Putting these principals into practice can be difficult if the resident has a poor appetite and, in such cases, fortifying foods and supplementary products can be very useful.
Reference The wounds that fall into the chronic category are often the visible aspect of an underlying disease, eg Venous Hypertension, Malignancy, Tissue Ischaemia and Diabetes Mellitus. The wound will remain in a chronic non-healing state until the underlying disease processes are addressed.
1. Edward Wallace. Feeding the wound - nutrition and wound care. British Journal of Nursing, 1994; 3(13): 662-667.
Journal of Tissue Viability 1996 Vol6 No 3 Selecting Wound Management Products Mrs Mair Fear Price Deputy Matron Thornhill Nursing Home, Gwent.
There continues to be uncertainty among some practitioners in the selection of appropriate dressing materials. Each product comes supported with a wealth of literature which provides the reader with very sound resons of why they should select that particular product. Moreover the dilemma escalates as the industry rises to the demands of clinicians for 'a bigger dressing, a more absorbent dressing or a different shaped dressing'. The company representatives too have a wealth of knowledge and also influence our choice by providing samples, or telling us that some clinical nurse specialist is having wondrous results with that particular product!! We are not always aware that our clinical decision making is being influenced by factors such as the recency of our experience with a particular product or the condition we are treating. The amount of our experience, or the profoundness of those experiences can also affect our clinical reasoning and the decision making process. Suggested further reading: l. Davis A et al. The Wound Programme. Singapore: Centre for Medical Education, 1992. 2. Thomas S. Wound Management and Dressings. London: The Pharmaceutical Press, 1990. 3. Thomas S. Handbook of Wound Dressings. London: Journal of Wound Care, 1994. 4. Dealey C. The Care of Wounds. Oxford: Blackwell Scientific Publications, 1994. The 30" Tilt Positioning Technique Mr William Haughton, CNS Tissue Viability, Wirral Hospital NHS Trust, Merseyside.
The management of people at risk of developing pressure sores is time consuming and labour intensive. The 'traditional' technique of turning the patient frequently from one lateral position to the other serves several purposes: Pressure relief. Comfort. To allow regular observation of the skin. However, this traditional approach can present a number of problems. It disrupts the patient's rest periods and activities, and may be painful and distressing. It may increase disorientation in susceptible individuals, and may increase the risk of skin trauma through friction and shear forces, despite efforts to ensure correct handling techniques are used. It increases the risk of back injuries to carers, and it is impractical and unrealistic to expect carers in the home to continue the practice throughout 24 hours, 7 days a week. While there is no doubt that pressure relieving support systems can be extremely effective in assisting in the prevention
87
ano management of pressure sores, these are not always readily available in the nursing home or community setting. The 30" tilt technique can provide a useful alternative system of repositioning, which in may cases obviates the need for specialised equipment, and may be readily adopted in the community setting, nursing homes and residential homes. The advantages of such a technique are that it: - allows a greater area of contact between the patient and the support surface, thereby reducing interface pressures. -minimises disruption of the patient's rest and activity periods. -reduces the likelihood of disorientation, as the patient's field of view remains much the same after repositioning. The risk of friction and shear injuries is significantly less, and the amount of handling is reduced, decreasing the risk of back injuries to carers. The technique is easily learned and performed by home carers, and requires no special equipment. In many cases, the frequency of repositioning can be reduced without compromising the patient's skin condition. There is no 'ideal' repositioning technique which is suitable for all patients and circumstances. However, the 30° tilt technique offers a simple, effective and inexpensive alternative for many patients, and can be particularly useful in a community setting. Further reading 1. Preston KW. Positioning for comfort and pressure relief: the 30 degree alternative. CARE - Science and Jlractice 1988; 6 (4): 116-119.
2. Seiler WO, Allen S, Stahelin HB. Influence of the 30 degree laterally inclined position and 'Supersoft' 3 piece mattress on skin oxygen tension on areas of maximum pressure implications for pressure sore prevention. Gerontology 1986; 32: 158-166.