European Pressure Ulcer Advisory Panel

Recognition of infection in chronic wounds by Dutch nursing home physicians

Armand Rondas¹, Jos M.G.A. Schols²

1. Nursing Home ‘Beukenrode’, Zorggroep Noord-en Middennnnn-Limburg, p/a Beukenlaan 1, 5802 CJ Venray, The Netherlands (Research is done in partial fulfilment of the degree of MSc in Wound Healing and Tissue Repair at the WHRU, Cardiff University);
2. Faculty of Health, Medicine and Life Sciences, dept. General Practice (section nursing home medicine) Maastricht University, The Netherlands.

Chronicity of wound healing can be related to infection. Chronic wounds tend to be a particular problem in Dutch nursing homes because of their frail elderly residents. Identification of wound infection provides a challenge and is mainly based on clinical signs and symptoms.

The aim of this study was to identify the treated number of chronic pressure ulcers, chronic post traumatic wound, chronic venous ulcers, chronic arterial and diabetic ulcers by Dutch nursing home physicians and the number considered infected. For different types of chronic wounds Dutch nursing home physicians were asked to rank their top five of symptoms of infection. Subsequently their ranking was compared with the choice of an international multidisciplinary group of wound experts in 2005.

Necessary information in this study was gathered by using a postal survey. One hundred and thirty-nine (38.5%) out of three hundred and sixty-one Dutch nursing home physicians returned the questionnaire of which hundred and twenty-one (33.5%) were adequately completed.

The results indicate that 93% (or 109 of 117) of the Dutch nursing home physicians treated currently < 5 pressure ulcers. 27% (or 31 of 117) did not treat any pressure ulcer at all. 32% (or 37 of 117) scored < 2 chronic post-surgical wounds, whereas 68% (80 of 117) treated no chronic post surgical wound. A prevalence of 20 per 1000 of chronic venous leg ulcers could be estimated. Chronic arterial and diabetic ulcers scored both infrequently.

Fifty-three percent of the Dutch nursing home physicians considered none of the pressure ulcers they treated infected. The number for other chronic wounds was comparable and scored over eighty percent.

In contrast to a group of wound experts (EWMA Position paper on Infection) Dutch nursing home physicians use ‘traditional’ criteria such as ‘pus/abscess’ and ‘malodour’ to diagnose infection and do not differentiate their criteria by chronic wound type.

Pressure ulcer healing with a specific oral nutritional supplement in long-term care residents

Hilde Heyman¹, Dirk E. J. Van De Looverbosch², Erwin P. Meijer³ and Jos M.G.A. Schols⁴

1. OCMW Antwerpen, Belgium;
2. Dept of Geriatrics, Antwerp University, Belgium;
3. Danone Research - Centre for Specialised Nutrition, Wageningen, The Netherlands;
4. Dept of General Practice, Maastricht University, The Netherlands.

Background

Under-nutrition and protein-energy malnutrition are seen at alarmingly high rates in institutionalized elderly and in patients admitted to hospitals. Malnutrition is an independent risk factor for development of pressure ulcers. Providing oral nutritional supplement (ONS) in addition to regular food intake seems a logical way to replenish body shortages of macro- and micronutrients as well as to supply extra nutrients for the preservation of skin tissue, strengthening of tissue resistance, and promoting tissue repair. The aim of this study was therefore to investigate the effects of a high protein ONS enriched with arginine, vitamin C and zinc on the healing of pressure ulcers in long-term care residents.

Methods

245 patients with grade II, III or IV pressure ulcers were enrolled into this open intervention multi-center trial at 61 long-term-care facilities in Belgium and Luxembourg. Residents received ONS (Cubitan(r), Nutricia) daily for nine weeks. 67 Patients had been previously treated with the ONS. The ONS provided 250 kcal, 20g protein of which 3g arginine, 250mg vitamin C, 38mg vitamin E and 9mg zinc, and other micronutrients per 200ml serving. Pressure ulcer area and the pressure ulcer condition were assessed after three weeks and after nine weeks. Data are expressed as mean ± SD. The data were analyzed by using ANOVA.

Results

Patients’ age was 82.2 ± 10.1 years. The majority of pressure ulcers were located at the sacrum (54%), heel (32%) and lower limb (6%). The average intake of ONS was approximately 2.3 ± 0.56 servings per day. After nine weeks of treatment, pressure ulcer area reduced significantly from 1580 ± 3743 mm2 to 743 ± 1809 mm2, which is a reduction of 53% (P < 0.0001; Figure 1, page 40). Post-hoc analysis demonstrated that patients who had not previously received ONS, showed a 60% reduction in pressure ulcer area. Complete wound closure occurred after three and nine weeks in 6.6% and 19.8% of the pressure ulcers. In addition, after the nutritional intervention the degree of exudation decreased (P < 0.0001; Mantel-Haenszel test).

Conclusions

A nutritional intervention with a specific ONS added to standard care resulted in a clinically significant reduction in pressure ulcer area of long-term-care residents.

What does a student need to learn in Nursing School about Pressure Ulcers? Contributions to a more effective Undergraduate Nursing Education Curriculum

Anas Paula Vasconcelos¹, Dulce Cabete²

1. Nursing Superior School, Azores University, Angra do Heroismo, Portugal;
2. ESS/IPS — Health Superior School of the Polytechnic Institute of Setubal, Setubal, Portugal.

Introduction

Undergraduate nursing education is the starting point of long life learning profession. In a short period of time students must develop a huge set of skills, namely the basics of wound care management. Considering that in Portugal almost all students at the end of the diploma will work in hospital settings¹ where Pressure Ulcer Treatment and prevention is a daily issue it would be expected that at the end of Nursing Education the young professional should have the basic skills to prevent, diagnose and treat pressure ulcers. However a National enquiry revealed that the medium time dedicated to wound management is short (from 4h to 18h²) despite wounds are almost ever present in all care settings. Nevertheless, we consider that the amount of hours in the theoretical part of the program is not the only relevant variable to develop skilled nursing students. All experiences (both theoretical and clinical teaching) are relevant. But are they effective? Do our students live school with the essentials? Thus the aim of this research is to identify strengths and weaknesses in our nursing education curriculum in order to propose more effective teaching strategies. And to achieve it we wanted to listen to final stage students.

Methods

To answer the question ‘In what extent do our final stage students feel prepared to care for patients with chronic wounds, namely pressure ulcers?’ qualitative research was undertaken focused on grounded theory approach. Participants were 25 students in their last clinical teaching period (end of the 4th year). The aim of the study was explained and the students were asked to report their experiences during the last clinical placement. Ethical considerations include confidentiality, free participation and no connection to the assessment process. One sheet having open ended guidance questions was delivered asking to describe relevant learning experiences at this stage. The students were free to return an unidentified written reply. Up to this moment nine participations were dropped. A content analysis was performed without prior framework.

Results

The results point to the following:

• Physiopathology could be more developed but is considered to be enough as with the basis students fill able to search for more;
• Students report insufficient theoretical knowledge regarding treatment;
• Students have trouble to deal with wounds’ odour and patients’ pain complains;
• Clinical placement facilitators often have practices opposite to school teaching and updated guidelines;
• To see a wound healing leads to students’ satisfaction;
• Students fill difficulties to act beyond the wound; this is aggravated by nurses’ focus on wounds instead of focusing on patients.

Conclusion

We may say that internal and external issues were found. Thus we should improve learning opportunities regarding treatment and pain relief in theoretical teaching and case discussion in clinical practice also because the ‘healing focus’ may not be always a goal. However there are issues related to clinical placement nurses’ practice that justify long life learning programs on wound management. This must be also a priority to Nursing Schools if we want good quality leaning experiences to undergraduate students, as the teacher is not always present.