 |
References |
Pressure ulcer references
This month's pressure ulcer references cover publications in MEDLINE that investigate pain, comfort or quality of life in people with, or vulnerable to pressure ulcers.
Abbas, S. Q. (2004). "Diamorphine-Intrasite dressings for painful pressure ulcers." Journal of Pain & Symptom Management 28(6): 532-4.
Amione, P., E. Ricci, et al. (2005). "Comparison of Allevyn Adhesive and Biatain Adhesive in the management of pressure ulcers.[see comment]." Journal of Wound Care 14(8): 365-70.
OBJECTIVE: The primary objective was to assess dressing delamination and the ensuing potential consequences during wear and/or removal, as well as the effect of residue remaining in the ulcer following foam breakdown. METHOD: In this prospective multicentre study, 32 patients with a grade II or III pressure ulcer were randomised to receive either Allevyn Adhesive or Biatain Adhesive dressing. The performance of the dressings was assessed over seven dressing changes or a maximum of six weeks. The primary efficacy variable was the proportion of patients with at least one delaminated dressing (delamination being defined as the falling apart of a dressing during wear or removal, or the presence of residue from the dressing in the ulcer). RESULTS: Allevyn Adhesive was significantly less likely to delaminate than Biatain Adhesive: 83% of patients given Biatain Adhesive had a dressing that delaminated compared with 14% for Allevyn Adhesive (p = 0.014). Furthermore, a greater proportion of the Biatain Adhesive dressings delaminated compared with the Allevyn Adhesive dressings: 50% versus 4% (p < 0.001). Allevyn Adhesive performed significantly better in the following parameters: handling exudate (p = 0.044), comfort (p = 0.007), ease of application (p = 0.004), conformability during application (p = 0.003) and removal (p < 0.0001), and adherence to the skin during application (p = 0.003) and prior to removal (p = 0.011). Three patients given Allevyn Adhesive (21%) reported three adverse events; six patients given Biatain Adhesive (33%) reported eight adverse events. CONCLUSION: Allevyn Adhesive is effective and well tolerated in the management of pressure ulcers and less likely to delaminate than Biatain Adhesive.
Anson, C. A. and C. Shepherd (1996). "Incidence of secondary complications in spinal cord injury." International Journal of Rehabilitation Research 19(1): 55-66.
In order to document the incidence of secondary complications following spinal cord injury (SCI), data were collected from 348 patients with post-acute SCI. More than 95% of these patients reported at least one secondary problem, and more than half (58%) reported three or more. Statistical analyses indicated that, in general, the number and severity of complications varied with the time since injury. Obesity, pain, spasticity, urinary tract infections, and pressure sores were common. Issues of social integration were also identified. The results suggest that improvement is needed in practices related to prevention and follow-up.
Ashfield, T. (2005). "The use of topical opioids to relieve pressure ulcer pain." Nursing Standard 19(45): 90-2.
This article provides an overview of the use of topical opioids to relieve pain associated with pressure ulcers in patients receiving palliative care. Morphine and diamorphine-infused gel have been used effectively to relieve pain and promote comfort in this group of patients. [References: 17]
Bale, S., C. Dealey, et al. (2007). "The experience of living with a pressure ulcer." Nursing Times 103(15): 42-3.
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).
Ballard, K. (1997). "Pressure-relief mattresses and patient comfort." Professional Nurse 13(1): 27-32.
The ideal pressure-relieving support system is comfortable, relieves pressure and prevents tissue damage. In order to ensure patient compliance with the choice of mattress, patient comfort and quality of sleep should be among the most important factors involved in the decision-making process.
Brink, P., T. F. Smith, et al. (2006). "Factors associated with pressure ulcers in palliative home care." Journal of Palliative Medicine 9(6): 1369-75.
BACKGROUND: Studies have identified factors associated with pressure ulcers in many health care settings including acute care, complex continuing care, long-term care, and home care. OBJECTIVE: The purpose of this study was to identify factors associated with pressure ulcers among palliative home care clients. Identifying associations specific to each setting is important for ulcer prevention and has implications for clients overall well-being and quality of life. METHODS: The study included all palliative home care clients diagnosed with terminal cancer from one palliative home care agency in Ontario. Information on health was gathered using the interRAI instrument for palliative care. RESULTS: The study found male gender, the inability to lie flat because of shortness of breath, catheter, or ostomy care, and a reduced ability to perform activities of daily living to be associated with pressure ulcers. SIGNIFICANCE OF RESULTS: In some instances, treatment and prevention of pressure ulcers is the primary goal of care. However, pressure ulcers are also suggestive of deterioration and considered as a part of the disease trajectory. Sometimes the primary goal of care of treatment and prevention is displaced by a greater need for comfort.
Bush, C. (2002). "Investigating the effects of living with a pressure ulcer." Nursing Times 98(36): 34-6.
Chang, K. W., S. Alsagoff, et al. (1998). "Pressure ulcers--randomised controlled trial comparing hydrocolloid and saline gauze dressings." Medical Journal of Malaysia 53(4): 428-31.
An open comparative randomised study comparing the performance of hydrocolloid dressings (DuoDERM CGF) to saline gauze dressings in the treatment of pressure ulcers was done to evaluate the overall dressing performance, wound healing and cost effectiveness. Thirty-four subjects were enrolled at the University Hospital, Kuala Lumpur over a 643 days period. Inclusion criteria were Stage II or III pressure ulcers, at least 18 years of age and written informed consent. Only one pressure ulcer per subject was enrolled in the study. Patients with infected pressure ulcers, diabetes mellitus, an immuno-compromised status and known sensitivity to the study dressings were excluded. Subjects who met the enrollment criteria were randomised to one of the two dressing regimes. They were expected to participate in the study for a maximum of eight weeks or until the pressure ulcer healed, which ever occurred first. Overall subject age averaged 58 years and the mean duration of pressure ulcer existence was about 1 month. Twenty-one of the thirty-four ulcers enrolled were stage II and thirteen were stage III. The majority of the ulcers (88%) were located in the sacral area and seventeen subjects (50%) were incontinent. In the evaluation of dressing performance in terms of adherence to wound bed, exudate handling ability, overall comfort and pain during dressing removal; all favoured the hydrocolloid dressing by a statistically significant margin (p < 0.001). Subjects assigned the hydrocolloid dressing experienced a mean 34% reduction from their baseline surface area measurement compared to a mean 9% increase by subjects assigned gauze dressings. This was not statistically significant (p = 0.2318). In cost evaluation of the study products, there was no statistical significance in the total cost of wound management per subject. When only labour time and cost was evaluated, there was a statistically significant advantage towards hydrocolloid dressings.
Charlifue, S., D. P. Lammertse, et al. (2004). "Aging with spinal cord injury: changes in selected health indices and life satisfaction." Archives of Physical Medicine & Rehabilitation 85(11): 1848-53.
OBJECTIVES: To document the impact of age, age at injury, years postinjury, and injury severity on changes over time in selected physical and psychosocial outcomes of people aging with spinal cord injury (SCI), and to identify the best predictors of these outcomes. DESIGN: Retrospective cross-sectional and longitudinal examination of people with SCI. SETTING: Follow-up of people who received initial rehabilitation in a regional Model Spinal Cord Injury System. PARTICIPANTS: People who meet the inclusion criteria for the National Spinal Cord Injury Database were studied at 5, 10, 15, 20, and 25 years postinjury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Number of pressure ulcers, number of times rehospitalized, number of days rehospitalized, perceived health status, satisfaction with life, and pain during the most recent follow-up year. RESULTS: The number of days rehospitalized and frequency of rehospitalizations decreased and the number of pressure ulcers increased as time passed. For the variables of pressure ulcers, poor perceived health, the perception of pain and lower life satisfaction, the best predictor of each outcome was the previous existence or poor rating of that same outcome. CONCLUSIONS: Common complications of SCI often herald the recurrence of those same complications at a later point in time, highlighting the importance of early intervention to prevent future health and psychosocial difficulties.
Chen, M.-L. and H.-K. Chang (2004). "Physical symptom profiles of depressed and nondepressed patients with cancer." Palliative Medicine 18(8): 712-8.
Depression and symptom severity are predictive of survival in cancer patients, but are often correlated with each other. This paper compares the physical symptom profiles of depressed and nondepressed cancer patients and further examines the predictive ability of multiple symptoms on depressive status. Data were collected from 121 hospitalized patients with breast, oesophageal and head and neck cancer. Patients were categorized as depressed (n = 30) or nondepressed (n = 91) using the Hospital Anxiety and Depression Scale. Occurrence of symptoms was evaluated with the Patient Disease Symptom/Sign Assessment Scale. The most prevalent symptom in the total sample was insomnia (occurrence rate = 67%). Insomnia, pain, anorexia, fatigue, and wound or pressure sore occurred significantly more often in depressed patients, with no difference in occurrence rates of nausea/vomiting and dyspnoea. Significantly more symptoms were observed in depressed than in nondepressed patients (mean = 3.77 versus 2.52). Both groups showed similar rankings of symptom occurrence rates. Patients simultaneously experiencing insomnia, pain, anorexia and fatigue had a higher risk of depression (odds ratio = 5.03).
Cornu, A., A. Bidzouta, et al. (1996). "[Comfort and quality of care. Using anti-bedsore mattresses in a long-term care service]." Soins Gerontologie.(4): 33-4.
Dauterive, R. (2006). "Was my patient fortunate or forsaken?[see comment]." Journal of Clinical Ethics 17(1): 90-3.
de Laat, E. H. E. W., W. J. Scholte op Reimer, et al. (2005). "Pressure ulcers: diagnostics and interventions aimed at wound-related complaints: a review of the literature." Journal of Clinical Nursing 14(4): 464-72.
AIMS AND OBJECTIVES: To describe the current scientific evidence in the field of diagnostics and treatment of pain, malodour and exudate from pressure ulcers and to give recommendations for practice, based on these findings. BACKGROUND: Patients with pressure ulcers are confronted with symptoms of chronic wounds and impaired wound healing. Assessment and treatment of these symptoms have received very little attention. DESIGN: Systematic literature review. METHODS: Medline, CINAHL, and Cochrane, were searched for studies on pain, malodour and exudate in patients with pressure ulcers. RESULTS: The McGill Pain Questionnaire, the Visual Analogue Scale and the Faces Rating Scale are useful instruments to assess pressure ulcer related pain. Strong evidence was found to support a positive effect of (dia)morphine. Some evidence was found to support a positive effect of benzydamine gel and Eutectic Mixture of Local Anaesthetic-cream. Wound malodour is subjectively assessed. In a laboratory study, it is proved that activated charcoal is capable of absorbing gas molecules causing malodour. At present, no studies are available on the odour-absorbing capacity of activated charcoal dressings in pressure ulcer patients. Exudate is a symptom of impaired wound healing. The Pressure Sore Status Tool is a valid and reliable instrument for assessing the wound healing process. There is a possible indication that hydrocolloid positively influences healing time because the absorption of exudates is more effective. CONCLUSION: Little sound research has been performed on wound-related complaints in patients with pressure ulcers. Nevertheless several recommendations could be made on the present state of the art. RELEVANCE TO CLINICAL PRACTICE: Regarding pressure ulcer related pain, this review supports the intervention of local pain relieve in patients with pressure ulcers. Regarding pressure ulcer related odour and exudates, this study identifies the gaps in evidence and research. [References: 28]
DeLegge, M. H., S. A. McClave, et al. (2005). "Ethical and medicolegal aspects of PEG-tube placement and provision of artificial nutritional therapy.[see comment]." Gastrointestinal Endoscopy 62(6): 952-9.
Dukich, J. and D. O'Connor (2001). "Impact of practice guidelines on support surface selection, incidence of pressure ulcers, and fiscal dollars." Ostomy Wound Management 47(3): 44-53.
Predicated on a need to control overall hospital costs and to integrate a Level 1 trauma center (Campus A) with a family practice based tertiary care hospital system (Campus B), expenditures associated with rental support surfaces were evaluated. Consistency and appropriateness of support surface selection is necessary to promote positive clinical outcomes, patient comfort, and a healthier bottom line, despite increasing costs. Clinical practice guidelines for therapeutic support surfaces were developed to decrease support surface expenditures and maintain prevalence rates below national averages. Utilizing the Agency for Health Care Policy and Research algorithm for managing tissue loads, along with other guidelines, criteria for prevention, comfort, and treatment were developed to assist nurses and physicians in support surface selections. A prevalence study was conducted before these criteria were implemented and repeated 1 year later. Expenditures for all rental support surfaces were assessed quarterly. Campus A, with a history of higher financial expenditures, was monitored weekly to assess whether support surfaces selections met guideline recommendations. Nursing staff reviewed hospital protocol regarding guidelines before implementation, and a self-administered review test was required during the first year post-implementation. One year later, a modest decrease in annual expenditures for rental support surfaces was noted. Campus A had a decrease in nosocomial pressure ulcers, while Campus B had an increased prevalence rate. Staff selection of support surfaces, within guideline recommendations, improved to 75% on medical/surgical units, and 98.8% in ICUs on Campus A. Although implementing support surface selection guidelines did not result in a significant reduction in cost, it created a framework for monitoring future related decisions.
Egner, A., V. L. Phillips, et al. (2003). "Depression, fatigue, and health-related quality of life among people with advanced multiple sclerosis: results from an exploratory telerehabilitation study." Neurorehabilitation 18(2): 125-33.
This study reports on secondary data, depression, fatigue and health-related quality of life (HRQOL), collected on people with advanced multiple sclerosis (MS) as part of a larger study of the impact of a telerehabilitation intervention on people with severe mobility impairment. People with spinal cord injuries (SCIs) (n=111) and the prevention of pressure sores were the primary group of interest of the project. The focus here is on data collected from people with advanced MS (n=27), who were included as an exploratory cohort, as they experience increased risk of pressure ulcer development as their level of mobility declines. The study consisted of a nine-week intervention with three randomized groups: video, telephone, and standard care. Aside from information on pressure sores, data were also collected on fatigue, depression, and HRQOL for a two-year follow-up period. For the video group HRQOL scores trended higher and fatigue and depression scores lower for 24 months. Fatigue scores were significantly lower for the video group at month six, 12, and 18. In the sample overall, fatigue symptoms were far more prominent than depressive symptoms and affected 100% higher rates of depression than women. At baseline, controlling for Extended Disability Status Score (EDSS), depression and fatigue were correlated. However, contrary to indications from previous cross-sectional studies, no consistent relationship was observed over time between the two. Telerehabilitation interventions for people with advanced MS warrant further investigation. Findings here suggest that such interventions may be beneficial, although the results need affirmation through larger samples. In addition, the higher prevalence of male depression merits serious attention.
Eisenberger, A. and J. Zeleznik (2003). "Pressure ulcer prevention and treatment in hospices: a qualitative analysis.[see comment]." Journal of Palliative Care 19(1): 9-14.
There has been little research into pressure ulcer prevention and treatment in hospices. In this study, interviews with hospice directors of clinical services and direct-care nurses were analyzed using qualitative methods. Several general themes were found. Both pressure ulcer prevention and treatment can be painful to hospice patients. Comfort may supersede prevention and wound care when patients are actively dying or have conditions causing them to have a single position of comfort. Family caregivers must face additional burdens when a pressure ulcer develops. In conclusion, hospice providers, patients, and family caregivers together must balance patient comfort with pressure ulcer prevention and treatment, which often leads to decisions to accept death with a pressure ulcer. Future studies should clarify how these parties can best work together, especially to identify when prevention or treatment has become futile.
Ferguson-Pare, M., E. Bourret, et al. (2000). "Best practices in the care of elderly persons in hospital." Hospital Quarterly 3(4): 30-7.
Findlay, D. (1533). "Practical management of pressure ulcers." American Family Physician 54(5): 1519-28.
The use of wound dressings that are based on the principles of moist wound healing has recently changed the management of pressure ulcers. These products may improve healing rates but also offer improved comfort to the patient, reduced dressing time and improved cosmesis. However, healing is unlikely to be achieved unless the factors that contribute to ulcer formation are addressed. Principles of management include the elimination or reduction of pressure and other contributing factors, treatment of infection, appropriate wound management, involvement and education of the patient and caregivers, and maintenance of healed tissue. It is estimated that 95 percent of all pressure ulcers are preventable. Prevention rather than mere treatment of established ulcers remains a top priority in the effort to reduce the incidence of this common, complex and difficult problem. Use of assessment tools that quantify the primary risk factors for the development of pressure ulcers is helpful in predicting and preventing compromise of tissue. [References: 22]
Fleurence, R. L. (2005). "Measuring quality of life in patients with pressure ulcers to include in economic evaluations." Journal of Wound Care 14(3): 129-31.
Quality-of-life measures are increasingly being incorporated into economic evaluations of health-care interventions. But this review identified only two studies with empirical data on quality of life in patients with pressure ulceration. [References: 19]
Flock, P. (2003). "Pilot study to determine the effectiveness of diamorphine gel to control pressure ulcer pain." Journal of Pain & Symptom Management 25(6): 547-54.
Pressure ulcer pain, a common problem among palliative care patients, does not respond well to oral analgesics. There have been case reports in the medical literature describing the successful use of topical opioids for painful skin conditions. So far, these topical opioids have not been compared to placebo. To determine the effectiveness of diamorphine gel to control pressure ulcer pain and compare it with placebo, a randomized, double blind, placebo-controlled crossover trial was conducted in 13 patients with painful grade II or III pressure ulcers. Patients resided on the inpatient unit at St. Christopher's Hospice, London, UK. Seven patients completed the study and provided pain scores before and after diamorphine or placebo gel application. Pain scores improved significantly after diamorphine gel application compared with placebo (P < 0.05). Diamorphine gel appears to be an effective treatment for pain caused by stage II or III pressure ulcers. It is probably as safe as placebo in regards to side effects, but a larger study would be required to confirm these results.
Fowler, S. and L. Newton (2006). "Complementary and alternative therapies: the nurse's role." Journal of Neuroscience Nursing 38(4): 261-4.
One objective of Healthy People 2010 is to increase both quality and years of healthy life. Complementary and alternative medicine (CAM) encompasses strategies that can help individuals meet this goal. CAM includes therapies such as acupuncture, dietary supplements, reflexology, yoga, massage, chiropractic services, Reiki, and aromatherapy. Many CAM therapies focus on the concept of energy. The literature describes the use of CAM in individuals with neurological diseases such as dementias, multiple sclerosis, neuropathies, spinal cord injury, and epilepsy. Nurses have a unique opportunity to provide services that facilitate wholeness. They need to understand all aspects of CAM, including costs, patient knowledge, and drug interactions, if they are to promote holistic strategies for patients seeking to achieve a higher quality of life. [References: 31]
Fox, C. (2002). "Living with a pressure ulcer: a descriptive study of patients' experiences." British Journal of Community Nursing 7(6 Suppl): 10.
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.
Franks, P. J., H. Winterberg, et al. (2002). "Health-related quality of life and pressure ulceration assessment in patients treated in the community." Wound Repair & Regeneration 10(3): 133-40.
Little is known of the impact of pressure ulceration on adult patients' health-related quality of life. The purpose of this study was to determine the impact pressure ulceration has on pressure ulcer patients cared for in the community. A case control study design was used by drawing a random sample from patients receiving community nursing care, stratified by the presence of pressure ulceration. In all, 75 patients with pressure ulcers were compared with 100 controls without ulcers using the four-point ulcer grading scale described by United Kingdom consensus guidelines. Patients were interviewed using the Short Form-36 (SF-36) questionnaire and activities of daily living assessed using the modified Barthel scale. Patients with pressure ulcers had significantly poorer physical function (mean difference (d) = 37.6, 95% CI 28.6-46.6, p < 0.001) and social functioning (d = 33.9, 95 % CI 24.0-43.9, p < 0.001) than published age- and sex-matched normative data from the United Kingdom. The difference between cases and controls was much smaller in these domains, with neither approaching statistical significance. After adjustment for age and gender, scores for bodily pain were poorer in patients with no ulceration (d = -10.5, 95% CI - 20.6 to - 0.4, p = 0.042) indicating greater pain in these patients compared with the cases with ulceration. Activities of daily living determined by the modified Barthel scale showed reduced self-care (d = -7.6, 95% CI -12.5 to - 2.7, p = 0.010) and mobility (d = -9.2, 95% CI -14.6 to - 3.8, p = 0.001) in patients with pressure ulceration. The overall ability to perform these activities was also significantly poorer in this group (d = -16.3, 95% CI -27.3 to -5.3, p = 0.004). While patients with pressure ulceration experience some deficits in their health-related quality of life compared with a normal population, these differences are similar to those experienced by other patients receiving community nursing care.
Freedman, G., C. Cean, et al. (2003). "Pathogenesis and treatment of pain in patients with chronic wounds." Surgical Technology International 11: 168-79.
Pain must be managed during treatment of a patient with a chronic wound. Failure to do so will impair the patient's ability to heal significantly. Understanding the wound's etiology is essential for designing the wound-healing protocol and implementing its pain management regimen, of which a critical part is the chronic-wound patient's self-assessed scores of pain and functionality. In this report we present a paradigm for treating all chronic wounds, which was subsequently applied to 32 consecutive patients. Our integrated-team approach to managing the treatment of wounds includes accurate evaluation of the progression of patients' pain. Directors of the pain-management team and wound team have jointly managed hundreds of patients--either hospitalized or seen in both outpatient clinical practices. The three general categories for etiologies of the 10 most common types of chronic wounds are: ischemia, neuropathy, and direct tissue damage (e.g. pressure ulcers and venous stasis ulcers). Each of these are treated with unique analgesic regimens focused on surgical/medical management of the wound: oral and parenteral medications in combinations designed to facilitate specific additive analgesic effects and nerve blocks and implantable devices for correcting underlying wound pathophysiology. Successful treatment of pain generally results in increased functional independence and improvement of the patient's quality of life. We integrated wound-care pain-management team established guidelines that delineate the causes of chronic wounds and categorize treatment options for practical clinical use. The expectation is that all pain should be resolved in all patients if both the wound-healing and pain-healthcare providers use current technologies and drugs. [References: 61]
Fries, B. E., C. Hawes, et al. (1997). "Effect of the National Resident Assessment Instrument on selected health conditions and problems.[see comment]." Journal of the American Geriatrics Society 45(8): 994-1001.
OBJECTIVE: To evaluate the effect of the implementation of the National Resident Assessment Instrument (RAI) system on selected conditions representing outcomes for nursing home residents. DESIGN: Quasi-experimental, pre-/post-design, with assessments at baseline and 6-month follow-up. SAMPLE: Two thousand one hundred twenty-eight residents from 268 nursing homes in 10 states before RAI implementation, and 2,088 from 254 of the same nursing homes after implementation. MEASURES: From the full RAI Minimum Data Set, measures of dehydration, falls, decubitus, vision problems, stasis ulcer, pain, dental status (poor teeth), and malnutrition were examined at baseline and 6 months later. Poor nutrition was evaluated using a body mass index score below 20 and vision using a 4-level scale; other conditions were represented by their presence or absence. Decline and improvement were computed as the changes in level between baseline and follow-up, limiting the sample to those who could manifest each such change. MAIN RESULTS: Of eight health conditions representing poorer health status, dehydration and stasis ulcer had significantly lower prevalence after the implementation of the RAI (1993) compared with 1990. At the same time, there was an increase in the prevalence of daily pain. Fewer residents declined over 6 months in nutrition and vision after implementation. Although for these two conditions there were also significantly reduced rates of improvement, the net was an overall reduction in the 6-month rate of decline for all residents. Pain also demonstrated a decline in the postimplementation rate of improvement. The combined eight conditions showed reductions in the rates of both decline and improvement. CONCLUSIONS: Several outcomes for nursing home residents improved after implementation of the RAI. Of the four conditions for which there are significant declines in prevalence or outcome changes, three are specifically addressed in the care planning guidelines incorporated the RAI system (all except stasis ulcer, although there is a RAP for decubitus ulcer). Pain, the only other condition with a significant result --an increase in baseline prevalence--also has no RAP. Although the changes might be ascribed otherwise, they support the premise that the RAI has directly contributed to improved outcomes for nursing home residents.
Good, G. (2006). "Sick to death.[see comment]." Journal of Clinical Ethics 17(1): 80-2.
Gopalkrishnan, S. (2002). "Management of physical symptoms in terminal illness." Nursing Journal of India 93(11): 249-51.
Grindley, A. and J. Acres (1996). "Alternating pressure mattresses: comfort and quality of sleep." British Journal of Nursing 5(21): 1303-10.
Comfort is particularly important for patients with terminal illness where the priority is to maximize quality of life. Equally important is effective pressure area care, as such patients are at high risk of developing pressure sores because of their poor general condition (Bale and Regnard, 1995). The present randomized controlled study set in a hospice focused on the development of methodology for assessing patient comfort and quality of sleep and used this to compare two widely used, alternating air pressure mattresses (the Nimbus II and the Pegasus Airwave). The Nimbus II mattress performed consistently better than the Pegasus Airwave in terms of patient comfort and quality of sleep. Features of the Nimbus II that may explain its better performance include less extreme changes in pressure, lower peak inflation pressures and the ability to automatically vary the pressure to suit the patient's position and weight.
Haisma, J. A., L. H. van der Woude, et al. (2007). "Complications following spinal cord injury: occurrence and risk factors in a longitudinal study during and after inpatient rehabilitation." Journal of Rehabilitation Medicine 39(5): 393-8.
OBJECTIVE: To assess the occurrence and risk factors for complications following spinal cord injury during and after inpatient rehabilitation. DESIGN: Multicentre longitudinal study. SUBJECTS: A total of 212 persons with a spinal cord injury admitted to specialized rehabilitation centres. METHODS: Assessments at the start of active rehabilitation (n=212), 3 months later (n=143), at discharge (n=191) and 1 year after discharge (n=143). RESULTS: Multi-level random coefficient analyses revealed that complications were common following spinal cord injury. Most subjects reported neurogenic and musculoskeletal pain, or had spasticity at each assessment. During the year after discharge, complications remained common: urinary tract infections and pressure sores affected 49% and 36% of the population, respectively. The degree of pain decreased, whereas the degree of spasticity increased significantly during inpatient rehabilitation. Overall, increased age, increased body mass index, traumatic lesion, tetraplegia, and complete lesion all increased the risk of complications. CONCLUSION: Complications are common following spinal cord injury. They need specific attention after discharge from inpatient rehabilitation and within subpopulations.
Hamanami, K., A. Tokuhiro, et al. (2004). "Finding the optimal setting of inflated air pressure for a multi-cell air cushion for wheelchair patients with spinal cord injury." Acta Medica Okayama 58(1): 37-44.
Pressure distribution patterns of the seating interface on the multi-cell air cushion (ROHO High Profile) of 36 adults with spinal cord injury (SCI) (Neurological level Th3 -L1) were measured at different air pressure levels by a pressure mat measurement system. Stress distribution relative to the inflated air pressure in the air cushion on the patients' wheelchairs was analyzed to determine the appropriate inflated air pressure of the cushion for patients. The maximum pressure points in all subjects were at the areas of the ischial tuberosities (82 to 347 mmHg). The optimal reduction in interface pressure at the ischial tuberosities was obtained just before bottoming out. The cushion air pressure at that point was between 17 and 42 mmHg, and correlated well to body weight (r = 0.495, P = 0.0021). In contrast, the maximum pressure levels did not correlate to body weight or the Body Mass Index (BMI). Pressure at the ischial area could be reduced, but not eliminated, by adjusting the air pressure. The maximum pressure levels seemed to be related to the shape of the buttocks, especially the amount of soft tissue, and exceeded the defined threshold for pressure ulcers (> 80 g/cm2).
Hamon-Mekki, F. (2002). "[Heel decubitus ulcer]." Soins; La Revue de Reference Infirmiere(668): 57.
Hamon-Mekki, F. (2002). "[Sacral decubitus in a tetraplegic patient]." Soins; La Revue de Reference Infirmiere(670): 55.
Hansen, R., S. Tresse, et al. (2004). "Fewer accidents and better maintenance with active wheelchair check-ups: a randomized controlled clinical trial." Clinical Rehabilitation 18(6): 631-9.
OBJECTIVE: To investigate whether active intervention using a compiled checklist for wheelchair check-ups increases user satisfaction and/or decreases accidents, near accidents and pressure sores. DESIGN: A randomized controlled trial comparing active intervention versus standard intervention for prescribed, manually propelled wheelchairs. SETTING: Patients within primary health care of Boras and Bollebygd municipalities, a mixed urban and rural population. SUBJECTS: Users of manually propelled wheelchairs over 16 years of age. INTERVENTIONS: The accident rate, extent of pressure sores, number and extent of repairs, reconditioning, adjustments as well as user satisfaction were measured initially and at one year. In the standard intervention, the user and carer were encouraged to initiate contact when necessary. In the active intervention, an occupational therapist performed a scheduled, thorough check-up of the wheelchair, following a compiled checklist for safety, comfort and positioning, manoeuvrability and transportation. RESULTS: Of 253 registered wheelchair users, 216 were suitable and randomized. In the active intervention group, 99% (95% confidence interval 96-100%) of the inspected wheelchairs required maintenance. The incidence of accidents was unchanged in the standard intervention group, but decreased to 'no accidents' in the active intervention group (p = 0.03). User satisfaction was not affected by the active intervention. CONCLUSION: Most wheelchair users are unable to determine on their own when adjustments are needed. An active check-up on manually propelled wheelchairs seems to reduce accidents. More information is available at http://www.wheelchair.se
Hauswald, M. and T. McNally (2000). "Confusing extrication with immobilization: the inappropriate use of hard spine boards for interhospital transfers." Air Medical Journal 19(4): 126-7.
INTRODUCTION: To determine if air medical interhospital transport of patients with spinal injuries is done with techniques that minimize ischemic skin damage. METHODS: A formal telephone survey instrument was given to all U.S. flight services accredited by the Commission on Accreditation of Medical Transport Systems (CAMTS). RESULTS: Thirty-seven active services were listed by CAMTS; the author's service was excluded from the survey. One service did only scene responses; one was unreachable by phone; four were unwilling to complete the form, leaving 30 services for evaluation. Twenty-nine services used metal, plywood, or plastic "spine" boards for immobilization during interhospital transport. Eight services padded boards with blankets or cloth for patients immobilized for "extended periods." Eighteen services routinely reimmobilized all major trauma patients even if cleared by the sending physician, and four others reimmobilized patients not "cleared" by a radiologist. No service moved patients with known spinal injuries to softer, more conforming devices before transport. Only three services followed patients for complications throughout hospitalization. Two services reported cases of skin breakdown thought to be a result of prolonged immobilization. CONCLUSION: Air medical services often transport patients several hours after injury. Patients, particularly those unable to move because of their injuries, medication, or paralysis, are at risk for ischemic necroses of their skin. Decubitus ulcers are a major cause of morbidity and mortality, and preventing ulcers requires a very soft, conforming surface. Despite these facts, the highly select services surveyed continue to use hard, slippery boards designed for extrication at trauma scenes to immobilize patients for transport.
Herbert, R. A. (2003). "A personal story regarding pain control." Anesthesia & Analgesia 97(1): 291.
Hommel, A., K. Ulander, et al. (2003). "Improvements in pain relief, handling time and pressure ulcers through internal audits of hip fracture patients." Scandinavian Journal of Caring Sciences 17(1): 78-83.
The aim of this project was to improve the outcome of hip fracture patients by optimizing preoperative pain relief, diminishing the time from admission to operation and reducing the occurrence of pressure ulcers. A retrospective study of all medical records of hip fracture patients from the last 4 months in 1998 was compared with prospective registrations during the same period in 1999 and 2000 after the introduction of quality improvements. The number of patients who waited for more than 1 hour to get pain relief was almost halved after improvements. In 1998, close to half of the patients had to wait more than 24 hours for an operation. After attention was given to quality improvements, 36% of the patients in 1999 and 34% of the patients in 2000 had to wait more than 24 hours. In addition, 18% of the patients in 1999 and 24% of the patients in 2000 vs. 11% in 1998 were operated on within 12 had to wait more than 24 hours. Pressure ulcers were considerably reduced. In total, 19% of the patients in 1998, 8% in 1999 and 4.5% in 2000 had pressure ulcers at discharge from the hospital. The outcome for hip fracture patients was improved through attention to quality improvements with all staff involved and focused on these patients.
Hoogvliet, G. (2000). "['Decubitus' guideline of the Dutch College of Family Practice; response from family practice].[comment]." Nederlands Tijdschrift voor Geneeskunde 144(14): 644-5.
The guideline on pressure ulcers issued by the Dutch College of General Practitioners gives a lot of practical information for the family doctor and the practical nurse. The main thought is the treatment of decubitus in a moist environment. Furthermore this guideline will help the doctor to make the right choice in the chaos of supplies. It is of great interest that interdisciplinary collaboration will take place on this issue, for a well developed communication gives the best results of treatment. [References: 2]
Hopkins, A., C. Dealey, et al. (2006). "Patient stories of living with a pressure ulcer." Journal of Advanced Nursing 56(4): 345-53.
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.
Huebner, R. A., L. Bales, et al. (2003). "Tub benches for people with spinal cord injury: luxury or necessity?" Case Manager 14(1): 58-63.
Jay, R. (1997). "Other considerations in selecting a support surface." Advances in Wound Care 10(7): 37-42.
Besides the seven basic support surface requirements for prevention and treatment of pressure ulcers, more than 30 additional factors should be considered by the clinician when selecting support surfaces to meet the needs of individual patients. These other considerations can be grouped into five categories: cost effectiveness; patient care; psychosocial issues, including patient comfort and clinician satisfaction; safety, reliability, and service issues; and equipment and logistical considerations. Future research on support surfaces should focus not only on wound outcomes, but also on these other factors. [References: 35]
Kalpakjian, C. Z., W. M. Scelza, et al. (2007). "Preliminary reliability and validity of a Spinal Cord Injury Secondary Conditions Scale." Journal of Spinal Cord Medicine 30(2): 131-9.
BACKGROUND/OBJECTIVE: Although the impact of secondary conditions after spinal cord injury (SCI) on health, well being, and financial burden have been studied, there are psychometrically sound scales of secondary conditions in the extant literature. The use of such scales allows for cross-sample comparison of secondary condition prevalence rates and associations with functional, medical, and psychosocial factors. Thus, the purpose of this study was to evaluate the preliminary reliability of a SCI secondary conditions scale. METHODS: The Spinal Cord Injury Secondary Conditions Scale (SCI-SCS) is a 16-item scale based on the Seekins Secondary Conditions Scale. Sixty-five individuals with SCI completed written surveys at 5 time-points over 2 years. RESULTS: Internal consistency across each of the time-points exceeded 0.76; test-retest reliability ranged from 0.569 to 0.805. Convergent validity was assessed with 6 physical functioning items from the SF-12. Spearman (coefficients were all statistically significant and ranged from 0.317 (accomplished less because of health problems) to 0.644 (pain). The most prevalent secondary conditions were chronic pain, joint and muscle pain, and sexual dysfunction. CONCLUSIONS: Preliminary testing of the SCI-SCS suggests that it is a reliable and valid scale, and further development (ie, factor analysis, item revision) and examination of validity are recommended with larger and more diverse SCI samples.
Kaufman, M. W. (2001). "The WOC nurse: economic, quality of life, and legal benefits." Dermatology Nursing 13(3): 215-9.
Patients who require treatment for complications stemming from skin and wound care conditions represent a significant and costly clinical problem in the health care arena. An innovative approach used to manage these patients is utilization and employment of the specialty trained wound, ostomy, and continence (WOC) nurse. A review of the literature supports the role of the WOC nurse in providing quality care, minimizing the expenditure of health care dollars, and overseeing the use of pressure ulcer and wound care guidelines so that litigious events may be avoided.
Klotz, R., P. A. Joseph, et al. (2002). "The Tetrafigap Survey on the long-term outcome of tetraplegic spinal cord injured persons: Part III. Medical complications and associated factors." Spinal Cord 40(9): 457-67.
STUDY DESIGN: To study the short- and long-term medical complications encountered in tetraplegic spinal cord injured persons (TSCI) and to give prominence to both the medical and socio-economic factors with which they are respectively associated. METHODS: The Tetrafigap Study is a multicentre epidemiological survey carried out using self-administered questionnaires studying the global long-term outcome of TSCI patients after the initial phase of rehabilitation. RESULTS: The data for 1668 patients were analyzed. The rate of rehospitalizations was 74.4% with on average three stays per patient and as reported causes, in descending order: urinary complications, systematic follow-up, pressure sores, respiratory complications, contractures, bowel complications, pains and secondary fractures of the lower limbs. At the time of the survey, 84.7% of patients mentioned awkward contractures, 73.8% pains, 55.9% embarrassing urinary leakage and 14.1% pressure sores. With regard to persons suffering from complete motor lesion, urinary complications and pressure sores were more frequently reported, whereas for persons suffering from incomplete motor lesions, awkward contractures and pains were more frequent. In the elderly, pains were more often mentioned, and pressure sores and pain were also the most common in patients coming from lower socio-professional status. Contractures and pain decreased with time. All these complications but pressure sores and pain are statistically interrelated. CONCLUSION: The medical complications of spinal cord injured persons are frequent, they are linked to biological, psychological and environmental factors, and are interrelated. Therefore, seeking mid- and long-term risk factors must be given priority in order to better adapt attempts at increasing secondary prevention.
Krasner, D. (1996). "Using a gentler hand: reflections on patients with pressure ulcers who experience pain." Ostomy Wound Management 42(3): 20-2.
Nurses who care for patients with pressure ulcers who experience pain were asked to reflect and write a story about this phenomenon. The objective of this study was to determine the meanings derived from nurse caregivers' reflections about patients' pressure ulcer pain. A Heideggerian hermeneutical approach was the methodology used for this inquiry. Stories from 42 participants, including nurse generalists and advanced practice nurses, were analyzed. Input was solicited from two qualitative research teams. Findings consist of three constitutive patterns and eight related themes: Nursing expertly (reading the pain, attending to the pain, and acknowledging and empathizing); Denying the pain (assuming it doesn't exist, not hearing the cries, and avoiding failure); Confronting the challenge of pain (coping with the frustrations and being with the patient). Lessons learned from this analysis are to stay connected with your patients; listen, attend ("be with") and comfort; and use a gentler hand.
Land, L., D. Evans, et al. (2000). "A clinical evaluation of an alternating-pressure mattress replacement system in hospital and residential care settings." Journal of Tissue Viability 10(1): 6-11.
An observational study was carried out to compare wound healing on alternating-pressure mattress replacement systems (APMRS) and other surfaces in an elderly population in acute and residential care settings. Subjects were assessed for the reduction in their pressure ulcers at approximately two weeks and per day, and a visual analogue scale was used to record the patients' comfort. Seven and ten subjects were allocated to the Nimbus III APMRS (Huntleigh Healthcare Ltd) in the hospital and residential care settings respectively. There was no significant difference in the healing of the subjects' sores in the two areas either at two weeks or per day. Five people were allocated to control surfaces in the hospital setting (mainly APMRS; Pegasus Airwave, Pegasus Egerton) and ten in the residential care setting (mainly alternating-pressure overlays; AlphaXcell, Huntleigh Healthcare Ltd). There was no significant difference in the healing of subjects' sores in the two areas, either at two weeks or per day. The trial APMRS was found to be equally comfortable in either setting, and in both settings the control surfaces were not regarded as significantly different in terms of comfort. These findings, from a small sample, promote discussion about the use of pressure-relieving equipment in settings where there are older people who may be at particular risk from pressure damage and where nursing interventions are less intensive and routine.
Langemo, D. K. (2006). "When the goal is palliative care." Advances in Skin & Wound Care 19(3): 148-54.
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. [References: 66]
Langemo, D. K., H. Melland, et al. (2000). "The lived experience of having a pressure ulcer: a qualitative analysis." Advances in Skin & Wound Care 13(5): 225-35.
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.
Lefebvre-Chapiro, S. and R. Sebag-Lanoe (1999). "[Palliative care of the aged]." Revue du Praticien 49(10): 1077-80.
Palliative care is no longer limited to patients with terminal cancer but now includes other diseases at terminal stage such as advanced Alzheimer disease. Accompanying the elderly at the end of life involves medical, psychological and social approaches. The expression of symptoms, and especially that of pain, can be atypical. Medical prescription should take into account both the change in drug metabolism and the more frequent occurrence of side effects in the elderly. Accompanying the patient at the end of life is an increasing part of care in geriatric institutions. Indispensable factors today are adapted personnel, training, specific support and social actualization.
Lyder, C. H. (2006). "Effective management of pressure ulcers. A review of proven strategies." Advance for Nurse Practitioners 14(7): 32-7; quiz 38.
Martz, E. and H. Livneh (2003). "Death anxiety as a predictor of future time orientation among individuals with spinal cord injuries." Disability & Rehabilitation 25(18): 1024-32.
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.
McDonald, A. and P. Lesage (2006). "Palliative management of pressure ulcers and malignant wounds in patients with advanced illness." Journal of Palliative Medicine 9(2): 285-95.
BACKGROUND: Pressure ulcers and malignant wounds are prevalent in populations with advanced illness. In these populations, the goals of care may shift from a primary focus on healing to a focus on wound management, palliation and comfort. Many complications associated with these wounds must be palliated. OBJECTIVE: This review explores the palliative approach to managing pressure ulcers and malignant wounds in patients with advanced illness. DESIGN: A comprehensive search of MEDLINE, CINAHL, and Cochrane Databases for articles addressing wound management and palliation was performed. We also reviewed online wound care resources and textbooks related to the field. CONCLUSIONS: The key to good wound care is prevention if possible, ongoing wound assessment, correct choice of dressing and use of available adjuvant therapies. The ultimate goals of palliative wound care are to control pain, to manage infection, odor, bleeding, and exudate, and to maintain a good quality of life for the patient and caregiver. [References: 44]
McKinley, W. O., M. S. Gittler, et al. (2002). "Spinal cord injury medicine. 2. Medical complications after spinal cord injury: Identification and management." Archives of Physical Medicine & Rehabilitation 83(3 Suppl 1): S58-64.
This is a self-directed learning module that reviews medical complications associated with spinal cord injury (SCI). It is part of a chapter on SCI medicine in the Self-Directed Physiatric Educational Program for practitioners and trainees in physical medicine and rehabilitation. This article includes discussion of common medical complications that impact rehabilitation and long-term follow-up for individuals with SCI. Issues addressed include the rehabilitation approach to SCI individuals with pressure ulcers, unilateral lower-extremity swelling (deep venous thrombosis, heterotopic ossification, fractures), along with the pathophysiology, assessment, and treatment of spasticity, autonomic dysreflexia, orthostatic hypotension, and pain. OVERALL ARTICLE OBJECTIVE: To describe diagnostic and treatment approaches for medical complications common to individuals with SCI. Copyright 2002 by the American Academy of Physical Medicine and Rehabilitation [References: 79]
Meaume, S. (1999). "[Pain and decubitus ulcers in the aged]." Soins; La Revue de Reference Infirmiere(634 Suppl): suppl 11-2.
Meaume, S., Z. Ourabah, et al. (2007). "Optimizing wound care with a new lipido-colloid dressing (Urgotul Duo)." British Journal of Nursing 16(6): S4.
This non-comparative, multicentre clinical trial includes 43 patients whose acute or chronic wounds were treated with a new lipido-colloid dressing, Urgotul Duo, for at most 4 weeks, or until healing first occurred. The efficacy, tolerance and acceptability results obtained from this 'ready-for-use' dressing were similar to those reported for the Urgotul dressing in numerous previous clinical trials, and for all the different types of acute and chronic wounds. This well-tolerated new dressing greatly facilitates care operations in terms of execution (reduced use of supplementary gauzes for the secondary dressing) and duration (shorter nursing time), while improving patient comfort. This dressing is indicated for the local treatment of moderate exudative acute and chronic wounds in the granulation and epidermization phases.
Miller, P. S. J. (2004). "In economics as well as medicine prevention is better than cure.[comment]." Age & Ageing 33(3): 217-8.
Mingaila, S. and A. Kriscinas (2005). "[Influence of complications on independence of patients with spinal cord injury in early rehabilitation]." Medicina (Kaunas, Lithuania) 41(8): 649-54.
OBJECTIVE: To evaluate the influence of complications on independence of patients after spinal cord injury during rehabilitation. MATERIAL AND METHODS: Data were collected on 130 patients with spinal cord injury admitted to the Clinic of Rehabilitation, Kaunas University of Medicine Hospital in 1999-2004. The study population consisted of 94 (72.3%) males and 36 (27.7%) females. Their age ranged from 16 to 80 years. The functional improvement was determined in terms of progress in independence in twelve daily living skills using Functional Independence Measure scale. Neurological status was evaluated by Standard Neurological Classification of traumatic spinal cord injury. Also, during early rehabilitation period complications were evaluated. Patients were divided into two groups: patients with complications and patients without complications during rehabilitation. More passive occupational therapy procedures were applied to patients with complications in comparison with patients without complications. RESULTS AND CONCLUSIONS: The results of the study showed that 44 (33.8%) cases were without complications during rehabilitation and 86 (66.2%) patients had complications. The most frequent complications were chronic pain (55.8%), urinary infection (43%), spasticity (30.2%) and pressure ulcers (20.9%). No statistically significant dependence was found between the rate of complications and age, gender and level of injury (p>0.05). Statistically significant dependence has been observed only between the rate of complication and completeness of injury (p < 0.05). The change of the increased independence of patients without complications during rehabilitation was statistically significantly greater in comparison with patients who had complications (p < 0.05).
Newland, P. K., D. D. Wipke-Tevis, et al. (2005). "Impact of pain on outcomes in long-term care residents with and without multiple sclerosis." Journal of the American Geriatrics Society 53(9): 1490-6.
OBJECTIVES: To compare long-term care (LTC) residents with and without multiple sclerosis (MS); to compare admission status of pain, physical disability, pressure ulcers, depression, and cognitive performance in LTC residents with and without MS; and to examine the impact of MS and pain on outcomes 90 and 180 days after LTC admission. DESIGN: Retrospective analysis of a large data set. SETTING: LTC facilities in Missouri. PARTICIPANTS: Residents admitted to non-hospital-based LTC facilities. MEASUREMENTS: Minimum Data Set/Resident Assessment Instrument, Version 2.0; Activities of Daily Living Scale; Cognitive Performance Scale. RESULTS: Residents with and without MS had similar pain prevalence and intensity after admission, with daily pain more frequent in residents with MS (P=.03). On admission, residents with MS had more physical disability (P < .001) and a greater prevalence of pressure ulcers (P=.004) and depression (P < .001) than residents without MS. In all LTC residents, initial pain status was associated with physical disability (P < .001), pressure ulcers (P < .001), depression (P < .001), and cognitive performance (P < .001) 90 and 180 days after admission. A diagnosis of MS was associated with physical disability (P < .001) 90 and 180 days after admission and pressure ulcer development 180 days after admission (P=.02). CONCLUSION: Residents with MS were more physically disabled and had more frequent pain and a higher prevalence of pressure ulcers and depression on admission than residents without MS. Pain, or lack thereof, in residents with and without MS on admission may warn of problems that could occur within 6 months after admission to a LTC facility.
Norton, L. and R. G. Sibbald (2004). "Is bed rest an effective treatment modality for pressure ulcers?" Ostomy Wound Management 50(10): 40-2.
Despite the well-documented medical, physical, and psychological complications associated with this care management option, bed rest remains a frequently prescribed treatment modality for conditions such as pressure ulcers. Cognitive and psychosocial complications of bed rest include depression, learned helplessness, perceptual changes, and fatigue. Physically, complications can include contractures, muscle atrophy, osteoporosis, pathologic fractures, urinary tract infections, decreased cardiac reserve, decreased stroke volume, resting and post-exercise tachycardia, orthostatic hypotension, pulmonary embolism, deep venous thrombosis, pneumonia, anorexia, constipation, and bowel impaction. Furthermore, the literature does not contain evidence supporting the use of bed rest to facilitate healing of pressure ulcers. More suitable approaches to pressure ulcer care include limiting bed rest, initiating occupational therapy, integrating meaningful tasks into daily activities, increasing outside stimulation, involving patients in care decisions and addressing their concerns, optimizing nutritional status, and managing pressure and shear throughout daily activities. Recommendations for implementing alternatives to bed rest are addressed. [References: 44]
Okamoto, K., S. Iizuka, et al. (1997). "The effects of air mattress upon sleep and bed climate." Applied Human Science 16(3): 97-102.
The purpose of this study was to investigate the effects of an air mattress upon sleep and bed climate. This air mattress, which employs a pump and timer to increase or decrease the inflation pressure in order to cure and prevent decubitus was tested. Six healthy female volunteers, aged 18 to 23, served as subjects. The experiments were carried out under three conditions: using regular Futon (Futon), the air mattress with pump and timer activated (Air+) and the same mattress without pump and timer activated (Air-). Room temperature and relative humidity were controlled at 22-23 degrees C and RH 50-60% respectively. Subjects' sleep was monitored by using EEG machine throughout the night, and subject's body temperature and bed climate were also continuously checked. Subjective estimation of bed and sleep were obtained before and after the recording sessions. Sleep onset latency and wake after sleep onset tended to be reduced in Air+ compared to Futon and Air-. The time and percentage of Stage 3 was increased significantly in the middle one third of the night in Air+. A significant difference was observed in bed climate of the waist area. Temperature tended to be higher in Futon than in Air+ and Air-, while relative and absolute humidity were significantly higher in Air+ and Air-. Significant difference between Air+ and Air- was observed only during one hour after sleep recordings started. Thermal sensation in the morning was cooler and comfort sensation tended to be better in Air+ and Air-. Subjective sleep estimation was somewhat good under all conditions. These results suggest that although these air mattresses do not affect sleep, we have to be cautious in using these mattresses as relative and absolute humidity were kept higher than with Futon. Further study on materials and construction of these air mattresses to decrease the humidity is needed.
Pecile, A. and R. Zanotti (2002). "[Nursing research in Italy, 1998-2001]." Professioni Infermieristiche 55(3): 130-43.
Academic education and professional role, both enhancing status and opening new paths for further developments. Consequently, there is a wide a compulsory interest to develop scientific research in the nursing field and to increase the number of studies published in the nation each year. This study reviewed the areas of inquiry and characteristics of research articles published in Italian journals from 1998 throughout 2001. Phenomena of interest, research design, sampling, and internal consistency have been used as evaluation criteria. Of 64 articles identified, only 52 have been reviewed (81%) because matching the selection criteria. Of the reviewed studies, 73% focus on clinical aspects, 21.2% on management, and 5.8% on nursing education. The majority of the reviewed studies use cross or longitudinal observational design, correlational (3.8%), or quasiexperimental design (5.2%). Convenience selection was the most used sampling method when reported. Data analysis was mostly done using descriptive statistics with only few exceptions. The majority of the reviewed studied adopt a quantitative approach. A nurse was principal investigator only in 58% of the studies. [References: 61]
Popescu, A. and R. S. Salcido (2004). "Wound pain: a challenge for the patient and the wound care specialist." Advances in Skin & Wound Care 17(1): 14-20; quiz 21-2.
PURPOSE: To provide physicians and nurses with an overview of the mechanisms, pathophysiology, assessment, and treatment of pain related to pressure ulcers. TARGET AUDIENCE: This continuing education activity is intended for physicians and nurses with an interest in learning about management of patients with pressure ulcer-related pain. LEARNING OBJECTIVES: After reading the article and taking the test, the participant will be able to: 1. Describe the mechanisms and pathophysiology of pain related to pressure ulcers. 2. Identify assessment parameters and treatment options for pain related to pressure ulcers. [References: 37]
Prentice, W. M., L. J. Roth, et al. (2004). "Topical benzydamine cream and the relief of pressure pain." Palliative Medicine 18(6): 520-4.
OBJECTIVE: To determine whether topical benzydamine hydrochloride 3% cream is more effective than placebo in reducing pain related to pressure areas in palliative care patients. DESIGN: Randomized double-blind, placebo-controlled trial. SETTING: Three specialist palliative care units in the north of England, with local ethical committee approval for all sites. SUBJECTS: Hospice in-patients with pain related to pressure areas. INTERVENTIONS: A single application of either benzydamine hydrochloride 3% cream or placebo cream to the painful pressure area. MAIN OUTCOME MEASURES: Pain assessed using 100 mm VAS, an 11-point numerical pain score and a five-point pain relief score. RESULTS: There was no statistically significant difference between topical benzydamine hydrochloride 3% cream and placebo cream in reducing pain related to pressure areas in palliative care patients. CONCLUSIONS: This study does not demonstrate a statistically significant difference between the two treatments. However the study does provide reliable information with respect to the use of different pain measurement tools in late-stage palliative patients. It also provides information regarding the baseline characteristics of this group of patients which may be useful in the planning of any future similar studies.
Rantz, M. J., M. Zwygart-Stauffacher, et al. (2005). "Advances in measuring quality of care in nursing homes: a new tool for providers, consumers, regulators, and researchers." Journal of Nursing Care Quality 20(4): 293-6.
Rastinehad, D. (2006). "Pressure ulcer pain." Journal of Wound, Ostomy, & Continence Nursing 33(3): 252-7.
OBJECTIVE: To describe and interpret the complexities of the pain experienced by persons with painful pressure ulcers. DESIGN: Heideggerian hermeneutic phenomenology. SETTING AND SUBJECTS: Ten participants with pressure ulcers hospitalized in an acute-care community hospital were interviewed. METHODS: Multiple taped interviews, transcripts, and field notes were collected over an 8-month period. Data analysis occurred over a 16-month period and included an initial process of naming the text, identifying themes, and writing the interpretations of each participant's story. Secondary analysis comprised reading across the texts for commonalities and shared meanings. These data were related to other literature sources, shared with a team of researchers familiar with the Heideggerian hermeneutic phenomenology process, and with wound, ostomy, and continence nurses. RESULTS: A total of 22 themes and 1 constitutive pattern were identified. Participants with varying stages of pressure ulcers shared poignant stories about their pain. Many related their accounts and instances of actions by health personnel and the treatment interventions that were painful. Some related their accounts of communication failures that contributed to stress, tension, and anxiety. CONCLUSIONS: The findings of this study clearly indicate the need for increased attention to pain assessment and pain management in nursing education, nursing practice, and nursing research. The findings also suggest that the commonly used definition of pain is insufficient and needs revision.
Reddy, M., D. Keast, et al. (2003). "Pain in pressure ulcers." Ostomy Wound Management 49(4 Suppl): 30-5.
Integrating pain management into a treatment paradigm for pressure ulcers can lead to improved outcomes. An approach to wound bed preparation that addresses the cause and patient-centered concerns--as well as local wound care factors of moisture balance, debridement, and bacterial balance--can be integrated with the Krasner model of chronic wound pain. The risk factors for pressure ulcers are well known, but pain may be an important contributor to immobility and the development of pressure ulcers. Pain is also an important signal of wound-related infections. Strategies must be developed to control the cyclic acute pain of dressing changes and the noncyclic acute pain of wound debridement. Spinal cord injured and elderly, cognitively impaired patients with pressure ulcers present special challenges in pain management. [References: 27]
Rook, J. L. (1996). "Wound care pain management." Advances in Wound Care 9(6): 24-31.
Undertreatment of all types of acute and chronic pain is common, both in the United States and around the world. Moreover, a literature review of pressure ulcer pain and its management suggests that this area of pain medicine is truly in its infancy. This article includes a discussion of current literature, anatomy and physiology of pain related to pressure and ischemic ulcers and assessment methods. It also describes treatment modalities, including conservative measures, medication management and invasive procedures. Special emphasis is placed on the use of opioid analgesics in the management of severe acute and chronic wound pain. [References: 66]
Roth, R. S., J. C. Lowery, et al. (2004). "Assessing persistent pain and its relation to affective distress, depressive symptoms, and pain catastrophizing in patients with chronic wounds: a pilot study." American Journal of Physical Medicine & Rehabilitation 83(11): 827-34.
OBJECTIVE: The purpose of this study was to examine pain experience among patients with chronic wounds, assess the utility of pain assessment scales for chronic wound-related pain, and determine the relation of wound-related pain to wound stage, affective distress, depressive symptoms, and pain catastrophizing. DESIGN: In this cross-sectional study of patients with a mix of chronic wounds (n = 69) recruited for a study evaluating a telemedicine system for assessing chronic wounds, 19 men (12 with spinal cord injury) with wound-related pain were identified. Questionnaires included the Numerical Pain Rating Scale, McGill Pain Questionnaire, Brief Symptom Inventory, Center for Epidemiologic Studies Depression Scale, and the catastrophizing scale of the Coping Strategies Questionnaire. RESULTS: The McGill Pain Questionnaire was more sensitive to pain experience than a single rating of pain intensity. Wound stage was positively related to severity of pain. Pain catastrophizing was positively related to pain intensity and higher levels of affective distress and depressive symptoms. CONCLUSIONS: Pain associated with chronic wounds is a significant clinical challenge for both patients and health practitioners.
Sachs, G. A. (2003). "Research at the interface of palliative care and geriatrics.[comment]." Journal of Palliative Care 19(1): 5-6.
Saikkonen, J., P. Karppi, et al. (2004). "Life situation of spinal cord-injured persons in Central Finland." Spinal Cord 42(8): 459-65.
STUDY DESIGN: Individual interview and questionnaire of a regional spinal cord-injured (SCI) population. OBJECTIVE: Local health care centres are mainly responsible for the SCI patients health care and rehabilitation after initial hospitalization in Finland. The purpose of the present study was to study aspects of the SCI patients life situation and their opinion of the health care services after 1 year since the injury. SETTING: Regional study in Central Finland. METHODS: Subjects were individually interviewed in their homes using a semi-structured questionnaire, the Functional Independence Measure (FIM) and the Beck Depression Inventory (BDI). RESULTS: The female/male ratio was 1:4. The mean age at the time of injury was 34 years in female and 40 in male. Traffic accidents accounted for 46% of the injuries. In all, 48 subjects (63%) used electrical or manual wheelchair or both. Most subjects regarded their living conditions as good having enough personal assistance in their everyday life. Only 10% of the subjects were employed. Half of the subjects had had out-patient physiotherapy, but no other therapies after 1 year since the injury. More than half of the subjects were dissatisfied with the current health care services. Many had experienced complications after the initial hospitalization, especially urinary tract infections, decubitus ulcers and neurogenic-type pain. FIM classified well according to the disability groups. The motor complete tetraplegic group had the lowest mean scores (63) and the recovered group the highest ones (122). There was no association between the FIM and the BDI results. There was a correlation between the BDI and the subject's age at the time of the injury and the year of the injury. The older the subjects were when injured, the higher were the BDI scores, that is, they had more depressive symptoms. Those injured in the 1990s had the highest BDI scores. Nearly one-third of the subjects had mild, moderate or severe depression. CONCLUSIONS: The reported medical complications, depression and dissatisfaction with the health care services support a life-long care for SCI patients in Jyvaskyla Central hospital, not in the local health care centres. The psychological services, for example, prevention and treatment of depression, in particular, require more attention.
Szor, J. K. and C. Bourguignon (1999). "Description of pressure ulcer pain at rest and at dressing change." Journal of Wound, Ostomy, & Continence Nursing 26(3): 115-20.
PURPOSE: To describe and compare the pain experienced by patients with stage II, III, and IV pressure ulcers both at rest and during dressing change. PATIENTS AND SETTING: Thirty-two subjects were recruited from acute, extended, and home care settings in the Midwest. The sample population ranged in age from 47 to 95 years (mean age 74.7 years, SD = 12.8), were white, and evenly divided between male and female patients. METHODS: Patients used the McGill Pain Questionnaire to rate their pressure ulcer pain at rest and again at dressing change. RESULTS: Twenty-eight subjects (87.5%) reported pain at dressing change and 27 (84.4%) experienced pain at rest, compared with 4 (12.5%) subjects who reported no pressure ulcer-related pain. Of the 28 reporting pain, 21 (75%) rated their pain as mild, discomforting, or distressing, and 5 (18%) described their pain as horrible or excruciating. Twelve (42%) reported their pain as continuous, occurring both at rest and during dressing changes. Despite these reports, only 2 (6%) subjects had received medication for their pressure ulcer pain. Although none of the hypotheses were statistically significant, we observed that patients with stage II, III, and IV pressure ulcers experienced pain. CONCLUSIONS: Within this study sample, the majority of patients had pressure ulcer-related pain, which for some was severe and constant. Therefore we conclude that the potential for pressure ulcer-related pain should be anticipated and assessed on a regular basis. In addition, further research is needed to increase our understanding of pressure ulcer pain and to find effective interventions for its relief.
Taylor, A. (2000). "Managing pressure ulcers: the need for pain assessment." Community Nurse 6(3): 45-6.
Thomas, J. M. (2001). "[Geriatric problems seen in general practice in patients in nursing homes]." Revue Medicale de Bruxelles 22(4): A310-3.
The general practitioner meets in long stay geriatrics polypathologic and frail patients. He is confronted with many problems: Staphylococcus aureus resistant to the methylpenicilline, ulcers of pressure, pain, depression, dementia, falls, etc. He will remain vigilant with ill-treat and the disorders of the nutrition. The communication will be improved by the use of validated scales. The nomination of a doctor coordinator will have to help to promote global geriatric assessment. The demography will involve the number of old patients. Sufficient financial means will have to be released in order to allow everyone to receive care of quality.
Thomas, S. and D. MacMahon (2004). "Parkinson's disease, palliative care and older people: Part 2." Nursing Older People 16(2): 22-6; quiz 28.
In the second of two articles on palliative care for people with Parkinson's disease, the authors consider other aspects of care relevant to this complex stage. They conclude that better understanding of its complexity, its innate variability and the roles extended team members can play help to improve the care given to patients. [References: 15]
Walter, J. S., J. Sacks, et al. (2002). "A database of self-reported secondary medical problems among VA spinal cord injury patients: its role in clinical care and management." Journal of Rehabilitation Research & Development 39(1): 53-61.
An interactive data management (IDM) system for the Spinal Cord Injury (SCI) Service was developed to collect self-reported patient data related to secondary medical complications and to provide feedback to the SCI rehabilitation team. The long-term objective is to improve clinical care through a process of staff review of current rehabilitation programs in the areas of prevalence, prevention, and management. Based on data from the first 99 SCI patients visiting the clinic and hospital after the installation of the IDM system, SCI patients reported high rates of current problems with spasticity (53 percent), pain (44 percent), and pressure ulcers (38 percent). Respiratory (12 percent) and bowel (14 percent) problems were less common current problems. The SCI staff questioned the reportedly high spasticity rates. They thought that the patients' answers might have indicated simply the occurrence of spasticity, rather than the more important issue of severe spasticity that interferes with daily activities. The staff suggested several additional spasticity questions to add to the study. In other areas, only a small percentage of patients wanted to talk with a therapist about prevention of pressure ulcers. Patients who had urinary problems consistently reported five urinary signs (e.g., cloudy urine). The clinical staff found these data informative and stated that they should continue to be collected.
Williams, C. (1997). "Pain in pressure sores." Community Nurse 2(11): 27-8.
Wilson, D. and D. Nix (2005). "Evaluation of a once-daily moisturizer used to treat xerosis in long-term care patients." Ostomy Wound Management 51(11): 52-60.
The pruritic, erythemic, dry, scaly, cracked, or fissured skin characteristic of xerosis is a result of the loss of natural moisturization factors and barrier abilities, as well as epidermal water loss. To determine if a new 24-hour moisturizer provides clinical benefit by reducing dry skin, scratching, and erythema, a 5-day prospective study was conducted that involved 16 residents (6 men, 10 women) with end-stage renal disease (average age 76 years) in a long-term care facility unit with an 18% prevalence of xerosis. Extent of xerosis was measured by evaluating each of the symptoms (dry scaly skin, erythema, and pruritus) using a four-point ordinal scale where 0 = absence of symptom and 3 = severe symptom. Photographs and patient comments were obtained at the time of the assessments on Day 1 (before the first product application) and on Day 5 (after four once-daily applications). One resident was discharged before the day 5 evaluation. Resulting data from the 15 patients completing the study were analyzed using a paired-sign test. Reduction in dry, scaly skin, erythema, and pruritus were statistically significant (P < 0.001, P < 0.001, and P = 0.016, respectively). Implementing a 24-hour moisturizer was found to significantly decrease symptoms of xerosis. Additional study to further validate use of the product in this and other settings where patients experience dry, red, itchy skin is warranted.
Wolski, C. A. (2004). "Kid-sized comfort." Rehab Management 17(2): 38-41.
Zeppetella, G., J. Paul, et al. (2003). "Analgesic efficacy of morphine applied topically to painful ulcers.[see comment]." Journal of Pain & Symptom Management 25(6): 555-8.
The analgesic effects of morphine applied topically to painful ulcers was assessed in a randomized, double-blind, placebo-controlled, crossover pilot study of five patients with painful sacral sores. Patients were treated for two days with either 10 mg morphine sulfate or placebo (water for injection) applied topically to the ulcer. After a two-day wash-out period, patients were crossed over for a further two days of the alternative treatment. Patients were asked to rate analgesia using a visual analogue scale (VAS) and to document any local or systemic adverse effects. All patients reported lower VAS scores with morphine compared to placebo and no local or systemic adverse events attributable to morphine were noted by either patients or nursing staff. This pilot study suggests that morphine applied topically is an effective method of producing local analgesia, well tolerated by patients, and not associated with systemic adverse effects.
Zidek, K. and R. Srinivasan (2003). "Rehabilitation of a child with a spinal cord injury." Seminars in Pediatric Neurology 10(2): 140-50.
The incidence and sex distribution of spinal cord injury (SCI) changes with age. Motor vehicle accidents, bicycle accidents, sports accidents, and violence are major causes in the pediatric population. Pulmonary complications may be severe and life-threatening in the acute phase. Chronically, the degree of ventilatory support needed depends on the level of the injury, with high cervical injuries typically requiring life-long ventilatory support. Deep venous thrombosis, autonomic dysreflexia, hypercalcemia, heterotopic ossification, spasticity, neurogenic bowel and bladder, scoliosis, and pain all may be secondary to SCI. Numerous orthotic aids are available for rehabilitation. An integrated rehabilitation program may also include spasticity management, a bowel and bladder program, and other features geared to the individual patient. [References: 62]
|
Download this newsletter in PDF format