Wound Care Wound and Skin

Wound Care

Wound and Skin Care: A Critical Review

Initial treatment of medical conditions calls for immediate response such as diagnosis of chronic conditions, the performance of emergency services, an inductive investigation on the contextualizing conditions defining an individual patient's health scenario and the prescription of any medication, therapy or initial treatment which have thus been necessitated. However, the focus on modes of secondary treatment is often just as important in determining likely health outcomes. So is this the case where wound and skin care are concerned. The procedures and approaches which are adopted in this area may be central to the health outcomes experienced by such patient categories as the elderly, those with advanced diabetic conditions and victims of burns or serious accidents, all of whom will be impacted in their treatment consequences by the proficiency, cleanliness and attentiveness with which wound care is accomplished. An array of wound care responsibilities indicate the need for a process which is standardized; which employs up-to-date equipment and/or products; which is administered with compassion; which addresses the pain management realities associated with wound care; which responds to the specific realities created by certain categories of client who are vulnerable to wound development and/or recurrence; and which considers many of the improvements, reflections and innovations which are taking place in the area of wound care today. The research conducted hereafter seeks to consider these various aspects of wound care as a way of more fully understanding the connection between the way this secondary treatment aspect is approached and the impact which this has on health outcomes.

Methods:

The research is conducted here within the framework of a general literature review. This is designed to provide what might be used as an initial investigation of wound care as a specific aspect of healthcare provision. Specifically, the research proceeds from the perspective of the nursing professional, intending to approach the various areas of wound and skin care considered here with respect to the responsibilities and education needed by the nursing professional. Primarily, the articles selected for review were included for their relative currency and the academic credibility underlying them. The body of research intended here should help to promote the importance of proper wound care and to indicate the various practicalities which are implicated by wound care.

This would result in a consideration of such subject areas as the challenges specific to wound care, the role of nursing in proper wound care, the identification of those most vulnerable to severe wound formation or recurrence, the dangers of poor wound care, the steps needed to ensure proper wound care, the consideration of some peripheral areas of concern where treatment is concerned and the identification of some ongoing issues which continue to necessitate research in the field.

Presentation:

What are the challenges specific to wound care?

The field of wound care is defined by the need to help facilitate the healing of wounds, to reduce pain for the patient, the prevent the worsening of wounds and to prevent the recurrence of wounds. According to such research as that provided by Sibbald et al. (2000), this is particularly challenging because it requires the integrated efforts of all attending healthcare providers. Therefore, a key challenge is the establishment of consistency in key areas of wound care such as those relating to the maintenance of the treatment environment, the regularity of redressing, the sanitary state of this process and the humanitarian approach taken by healthcare providers. Accordingly, Sibbald et al. indicates that "successful diagnosis and treatment of patients with chronic wounds involve holistic care and a team approach. The integration of the work of an interdisciplinary care team that includes doctors, nurses, and allied health professionals with the patient, family, significant others, and caregivers offers an optimal formula for achieving wound resolution." (Sibbald et al., 14)

Here, we see that a primary challenge is the establishment of a proper organizational orientation toward proper wound care. As a subsequent section will demonstrate, the elderly are a specifically an example of a vulnerable demographic, with nursing homes often being required to establish proper standards for wound management. These standards are often a key indicators of the degree to which a long-term care facility has properly treated its patients or the degree to which it may be guilty of negligence in a more general capacity. Therefore, the research by Sibbald et al. remarks that the holistic and integrated treatment approach must center on the standardization of key treatment demands. The article reports that "such an approach challenges practitioners and everyone participating in wound care to integrate data and information that arise from a number of sources and mitigating factors. In this article, the authors define the changing paradigm that links treatment of the cause and focuses on three components of local wound care: debridement, wound-friendly moist interactive dressings, and bacterial balance." (Sibbald et al., 14)

What is the role of nursing in proper wound care?

The role of the nurse is one which has taken on increasing importance in all settings. A desire to see an improvement in general standards of nursing education and quality are manifested through a qualified health professional with the training in leadership and health practice to bring the latest knowledge, technique and ingenuity to the field. This is crucial with respect to the gaining awareness of long-term healthcare practitioners as to the need for proper wound care training and procedure. As the text by Ayello et al. (2007) notes that "for a wound to heal, it must have a mircoenvironment free from the nonviable tissue that serves as a bacterial culture medium to increase organism proliferation." (Ayello et al., 120)

This is to indicate that there are serious biological needs concerning wound care that impact the entire bodily system. What may in the past have been considered a matter of peripheral care is increasingly being accepted as a primary avenue for proper long-term care in which extensive training and knowledge are required. The team of nurses will be a defining source for both of these necessities, helping to establish an environment that is sanitary and appropriate for treatment as well as to establish a body of knowledge concerning the proper ways of identifying wound stages, determining treatment courses and executing treatment courses. Nurses with certification in wound specialization will also be equipped with the bedside manner to help improve the quality of life for patients with limited mobility, who are often especially vulnerable to bedsores and other such stagnant wounds.

Who is most vulnerable?

The elderly are most vulnerable to development of wounds, and may have specific limitations in healing capacity, according to the American Association of Dermatology. In the case of the nursing home patient in particular, the nurse will be assisted by a strong familiarity with each patient's background and support team, as these will be crucial features in helping to make informed referral and treatment decisions. Indeed, some patients will demonstrate a greater vulnerability to wounding such as those whose advanced age has compromised such features as skin elasticity. According to the American Academy of Dermatology (AAD), "as skin ages and loses its elasticity, the skin stops springing back to its line-free state, and these grooves become permanently etched on the face as fine lines and wrinkles." (AAD, 1) This makes the elderly especially susceptible to the formulation of wounds which can be caused by friction and movement during rest, during exercise or during health procedures. This is a serious issue in many long-term care facilities that have been criticized for failing to assure a high quality of life for the patience who reside there.

Nursing theories concerning the elderly, which are multifarious and even sometimes divergent from one another, still arise from the common point of interest which is preserving the well-being of individuals suffering from either fleeting or sustained health deficiencies. Another vulnerable group, and one with significant crossover to the elderly, is the demographic of diabetics. This group is particularly vulnerable to circulatory issues which result in wounding in the foot or heal. Poor or improper treatment in these cases, can have dire consequences.

What are the dangers of poor wound care?

As this discussion demonstrates, it is absolutely essential that organizational orientation reflect the heightened level of ethical consciousness implied. The demands placed upon the nursing home by these standards has created a socially responsible form of healthcare entrepreneurship that is highlighted by concerns over wound care. In long-term care facilities that lack the proper training in this area, wound care tends to function as a reflection both of the quality of healthcare and of the quality of life for patients. A recent article by Holleran (2009) highlights the importance of this issue, citing a case in which a "woman died after employees at an Illinois nursing home allowed her pressure sores to deteriorate, causing sepsis to flow throughout her blood." (Holleran, 1)

The story was invoked by a lawsuit claiming multiple acts of negligence against the facility in question, all of these prompted by a total absence of wound care standards, which allowed the woman's condition to go undetected and even to intensify and spread. This highlights the seriousness of the need for proper wound care in long-term care facilities, demonstrating the extent to which the nurse must define and provide oversight to standards in this area.

What steps should be taken to ensure proper wound care?

The first and most important aspect of ensuring that wound care is attended with proficiency is the provision of comprehensive training for nurse professionals. There are an array of strategies which can be applied to help hasten the process of healing or which can have the impact of lessening the likelihood or severity of recurrence. Indeed, the study by O'Meara et al. (2000) recognizes that such high risk individuals as diabetics are particularly vulnerable to recurrence and that 'secondary wound care' is a central part of reducing this likelihood. Accordingly, O'Meara et al. indicate that "the prevention and treatment of chronic wounds includes many strategies, including the use of various wound dressings, bandages, antimicrobial agents, footwear, physical therapies and educational strategies. This review is one of a series of reviews, and focuses on the prevention and treatment of diabetic foot ulcers and the role of antimicrobial agents in chronic wounds in general." (O'Meara, 237)

Using a set of electronic databases, including the Cochrane Library, the O'Meara source yields the best practices in preventative wound treatment based on trials conducted with diabetic foot-wound patients. Here, the measure of the success or effectiveness of certain measures would be determined by outcomes in health. These measured outcomes would include "(1) development or resolution of callus; (2) incidence of ulceration (for diabetic foot ulcer prevention studies); (3) incidence of pressure sores (pressure sore prevention studies); (4) any objective measure of wound healing (frequency of complete healing, change in wound size, time to healing, rate of healing); (5) ulcer recurrence rates; (6) side-effects; (7) amputation rates (diabetic foot ulcer treatment studies); (8) healing rates and recurrence of disease, among others, for pilonidal sinuses." (O'Meara, 237)

This range of measures for treatment success helps to provide some basic target points for nursing professionals whose primary training may be in other areas of treatment. The identification of wound dressing, redressing, cleaning and environmental maintenance are here recognized as direct determinants of health outcomes relating to the severity of diabetic wounds. Thus, the standardization of these in terms of timing, procedure and bedside manner all will be central in the predicting treatment outcomes. Beyond these standard secondary care measures, there is evidence that some of the most dire consequences of wound recurrence can be diminished by proper screening and prevention. Accordingly, O'Meara et al. find that "there is some evidence (1 large trial) that a screening and foot protection programme reduces the rate of major amputations." (O'Meara et al., 237) This helps to provide our research with the resolution that in addition to the procedures which are adopted to clean and dress wounds, those who have demonstrated specific medical or metabolic reasons for the emergence of wounds must also be entered into a screening and prevention program. Regular attention to vulnerable spots for the elderly or for diabetics can help to reduce the need for amputations or other extreme measures against the spread of wounds.

This must be instilled through example and explanation of nurse leaders in all processes, with wound care constituting one that arises daily in such a setting. In many ways, the nature of the ailment afflicting an individual will have a significant impact on the informational and theoretical conceptualization which the nurse will employ to make treatment decisions concerning the type of wound dressings used, the frequency of dressing changes, the debridement of necrotic skin tissue and the maintenance of bodily hygiene. This means that an effective wound care nurse will be capable of making such decisions on his or her feet, applying a proper interpretation of a patient's condition and needs, as well as the facility's treatment capacities, in order to determine the dressing and cleaning plan best suited to a case. It is therefore vital that the well-trained nurse working in the nursing home context be armed with a thorough understanding of the principles underlying the multitude of treatment theories in circulation and the ability to extend these principles to others. Such is to indicate that "nursing must have a comprehensive paradigm that honors the relational nature of the nurse-patient relationship, the critical influence of environment and the importance of biological factors." (Raingruber, 1) Given the opportunity to decide the best course of action for contending with any number of scenarios, a wound care nurse will find that possessing an awareness of the standards, practices and even the philosophies informing a variety of theoretical frameworks will enable him to approach a treatment dilemma with a compass that is dually empirical and humanistic in its nature.

What are some peripheral issues of relevance to wound care proficiency?

A major issue relating to the treatment and care of wounds is the management of pain. This is frequently an aspect of the patient's experience which is difficult to reign in simply through proper cleaning and dressing. Instead, pain management is often viewed as its own aspect of wound treatment, and has thus instigated its own body of research such as is demonstrated in the article by Hoffman et al. (2000). Here, pain management is the focus of more progressive treatment approaches which are designed to supplement more traditional drug treatments. The research article in question focuses on burn management, with burn wounds often generating the most extreme pain management demands. Quite to the point, Hoffman et al. argue that "for daily burn wound care procedures, opioid analgesics alone are often inadequate. Since most burn patients experience severe to excruciating pain during wound care, analgesics that can be used in addition to opioids are needed. This case report provides the first evidence that entering an immersive virtual environment can serve as a powerful adjunctive, nonpharmacologic analgesic. Two patients received virtual reality (VR) to distract them from high levels of pain during wound care." (Hoffman et al., 305)

The article by Hoffman et al. reports that patients who were psychologically immersed thusly experienced considerably less of the pain and discomfort which can be elicited by the necessary rigors of debridement, wound cleaning, dressing changing and in the case of the subjects studied for this research article, the removal of staples. The research reports findings in two study subjects, both teenage boys with extensive surface burns. The two subjects were asked to report on their levels of pain awareness during wound dressing and treatment procedures both on opioids alone and, subsequently, on opioids and immersed in virtual reality activities. Both subjects reported a significant decrease in measures of pain awareness during this latter experimental procedure. This would prompt the resolution of the research article endorsing further exploration of this experimental procedure. Accordingly, the research would report that "VR is a uniquely attention-capturing medium capable of maximizing the amount of attention drawn away from the 'real world', allowing patients to tolerate painful procedures. These preliminary results suggest that immersive VR merits more attention as a potentially viable form of treatment for acute pain." (Hoffman et al., 307)

The study's focus on two young subjects denotes that there is a need for a wider and more scientifically constructed sample for research. Moreover, its focus on young wound victims leaves some question with respect to the cultural viability of such methods for those who are older and may lack either the experience or even the psychological wherewithal to experiment with virtual reality methods of treatment. Therefore, in its current form, the research produced findings with little immediately applicability for the elderly subjects which dominate the research. However, as a point of more universal consideration, the focus here on methods of pain management for wound treatment which are psychological or psychosomatic in nature demonstrates the high level of opportunity for experimental treatment improvement that does focus on redirecting the mind's attention.

ONGOING RESEARCH:

One area in which research is today ongoing, and which thus might warrant further individual exploration subsequent to this review, is that relating wound care to telemedicine. With new technologies making it increasingly possible to perform critical diagnostic functions from remote locations, studies such as that by Braun et al. (2005) have considered the ramifications of wound care via such web-enabled video conferencing media. The study named here asserts that based on its trial studies, there is significant similarity in the diagnoses and treatment approaches determined by physicians conducting traditional wound care observation and by physicians taking web-mediated approaches to the same tasks. In the observation by Braun et al., "one physician performed the face-to-face consultation (gold standard), and 2 others performed the remote evaluation. The image was obtained with the mobile telephone and immediately sent via e-mail. To measure the agreement of the evaluation among the 3 physicians, we used Cohen {kappa} statistics. Overall, the agreement between the remote and face-to-face evaluations was very good, with {kappa} values of up to 0.94 the image quality was judged to be good in 36 cases (59%) and very good in 12 (20%)." (Braun et al., 254)