Chronic wounds represent a devastating health care problem with significant clinical, physical and social implications. Evidence suggests that consistent, meticulous and skilled care provides the primary means by which successful wound care and healing is promoted. The occurrence of wounds has plagued humankind throughout recorded history and remains a major source of morbidity and mortality in several disciplines of clinical medicine. Within this thesis, an effort will be made to address the basics of appropriate and potentially successful nursing in wound care and the promotion of healing. Section 1 will provide introductory information on the problem of wound care. In Section 2, the relevant literature will be reviewed while Section 3 will present the research methodology used within the thesis. In Section 4, the results of the thesis will be provided, offering a framework that can be used for insuring that the essential basics in wound care are provided by nurses. Section 5 will offer conclusions based on the thesis.
Basic principles of wound care have been established that serve as a model for managing wound and delivering wound care services and treatment (Dickerson, Purdue & Hunt, 1999). These principles include adherence to a wound care strategy that recognizes that as with any injury, priorities are given to life-threatening conditions, which are managed accordingly. As well, as outlined by Dickerson et al., all patients should be considered to have potential risk for communicable diseases with Universal Precautions taken when providing direct patient care.
As suggested by Dickerson et al. (1999), initially it is important to note the depth of injury, as determined by loss of function of the injured part as well as injury to underlying nerves, blood vessels, tendons, bones, and joints. As well, knowledge of the duration of the time that has elapsed since the injury occurred is also critically important. According to Dickerson et al., an overall assessment should be completed including nutritional status as well as general medical condition, with particular attention given to systemic factors such as diabetes mellitus, peripheral vascular disease, bleeding disorders, and immunotherapy or steroid therapy that alter the body's capability to respond to injury and may impede wound healing.
As explained by Dickerson et al. (1999), wound care efforts are directed at methods and techniques which prevent infection, facilitate wound healing, promote comfort, and at the same time, maintain optimal function and minimize deformities.
The basic types of wound care injuries include soft tissue injuries can be roughly divided into simple open wounds with minimal soft tissue damage and wounds with major soft tissue damage. Wounds with major soft tissue damage are burn wounds, avulsive injuries, crush injuries, and amputations. As well, cecrotizing infections also create wounds with extensive skin loss, which fall into the category of major tissue damage.
As explained by Dickerson et al. (1999), models of wound care management are based on a strategy for the practical management of wounds, implemented and based on knowledge of the nature of the injury, functional anatomy, and the wound healing process. According to Dickerson et al., understanding the mechanism of injury helps explain the type of wound, determine the nature and extent of damage, identify common injury combinations, and predict eventual outcome.
According to Fishman (2003), important to a model of would management is a recognition that the entire wound healing process is a complex series of events that begins at the moment of injury and can continue for months to years. The wound healing phases as identified by Fishman include the following:
I. Inflammatory Phase
A) Immediate to 2-5 days
Thromboplastin makes clot
II. Proliferative Phase
A) 2 days to 3 weeks
Fibroblasts lay bed of collagen
Fills defect and produces new capillaries
Wound edges pull together to reduce defect
Crosses moist surface
Cell travel about 3 cm from point of origin in all directions
III. Remodeling Phase
A) 3 weeks to 2 years
B) New collagen forms which increases tensile strength to wounds
C) Scar tissue is only 80% as strong as original tissue
Recent estimates suggest that 1% of the total health care dollar is spent on wound care in the U.S. (Lane, 1995). While this figure seems relatively small and inconsequential, many of individual costs associated with wound care are massive.
Approximately $1.36 billion is spent on pressure ulcer treatment (U.S. Department of Health and Human Services [USDHHS], 1994). Similar estimates have also suggested that the average cost to heal a single pressure ulcer ranges from $1,951 for a leg ulcer to $29,373 for a diabetic ulcer (Bolton, Van Rijswijk, & Shaffer, 1996). Foot ulcers are the number one reason for hospitalization of diabetic patients and are the major cause of non-traumatic amputations. Diabetic amputations average 67,000 procedures per year at a cost of $98 billion in health care dollars (Burdette-Taylor, 1999; USDHHS Diabetes Surveillance, 1997).
Similarly, lengthy hospital stays are often experienced by patients with pressure ulcers who frequently remain hospitalized for more than 35 days (O'Brien, Gahtan, Wind, & Kerstein, 1999). Chronic non-healing wounds, most often associated with inadequate blood flow, are suffered by an estimated five million people in the U.S. (Liang, 1999). The number of those affected by chronic wounds is increasing at an annual rate of 10%. Venous ulcers account for 80% to 90% of all lower extremity ulcers (Neil, & Munjas, 2000). On the basis of available Medicare data, more than $20,000 is spent per patient, per ulcer episode, including at least one hospital stay and home visits (Liang, 1999). An estimated $5 billion to $7 billion is spent on chronic wound treatment annually in the U.S. (Morgan, & Hoelscher, 2000).
As evidenced within the literature, on wound care, estimates such as the above only represent the costs that are most widely visible. Such estimates fail to account for the hidden costs that patients and families must endure, including loss of work and self-esteem, social isolation, depression, increased stress, and adaptation to demands of daily living. As well, the costs associated with caregiving are also extensive as this type of care is not only time-consuming, but emotionally and physically draining. The cost to nursing staff can lead to increased stress, frustration, and burnout due to the chronic nature of many wounds. As the estimates of incidence and prevalence of pressure ulcers become more widely known, the costs of care also become more readily observable. As reported by Dwyer and Keeler (1997), currently, rates for pressure ulcers in skilled care and nursing home facilities approach 23%. It has also been documented that critical care patients represent a large proportion of hospitalized patients with pressure ulcers: 33% incidence and 41% prevalence (Beitz, Fey, & O'Brien, 1998). According to Carlson, Kemp and Short (1999), the prevalence of pressure ulcers is 3% to 30% in the general population and 17% to 56% in critically-ill patients (Carlson, Kemp, & Short, 1999). As indicated by Larson (1993), the costs associated with nursing care escalate substantially once pressure ulcers develop, with 50% more nursing time required to care for the patient. Iatrogenic ulcers have resulted in up to $92 million in malpractice awards (Larson, 1993).
The Joint Commission of Accreditation of Hospital Organizations (JCAHO) has established that pressure ulcers are an indicator of quality care (Larson, 1993). However, as explained by Larson, pressure ulcers must continue to be viewed within the context of the overall health of the patient. Pressure ulcers do not necessarily point to inferior quality-of-care, but rather to the complexity of the patient's condition. While not all pressure ulcers are preventable or curable (Larson, 1993), accepting ownership of pressure ulcers places hospitals and nursing homes in jeopardy of punitive action from Medicare and state regulatory agencies. Lawsuits claiming personal injury negligence related to the development of pressure ulcers have significantly increased since the introduction of the Omnibus Budget Reconciliation Act of 1987. Between 1977 and 1997, the median settlement related to pressure ulcers in federal and state appellate cases was $250,000 (Bennett, O'Sullivan, Devito, & Remsburg, 2000).
The magnitude of the wound problem has been well documented. It is estimated that more than 5 million patients in the United States have chronic wounds (American Hospital Association, 2003), with 1.1 to 1.8 million people developing new pressure ulcers each year (Maklebust & Siggreen, 1991). The elderly and persons with spinal cord injury are two groups well-known to be at risk for pressure ulcer development (Young, Burns, Bowen & McCutchen, 1982; Stover & Fine, 1986; Allman, 1989). Data gathered on the prevalence of pressure ulcers have suggested a rate ranging from 4.7% (Allman, Larade & Noel, 1986) to 9.2% (Meehan, 1990), with other estimates suggesting a range of 3% to 14% in hospitalized patients to 25% in nursing home residents (Allman et al., 1986; Guralnik, Harris & White, 1988).
Pressure ulcers and other chronic wounds constitute an expensive and debilitating health care problem with significant clinical and social implications. These wounds are an expense to society in…