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An integrated experimental‐computational study of the microclimate under dressings applied to intact weight‐bearing skin

Abstract

Pressure ulcers (PUs) are one of the most prevalent adverse events in acute and chronic care. The root aetiological cause of PUs is sustained cell and tissue deformations, which triggers a synergistic tissue damage cascade that accelerates over relatively short time periods. Changes in skin microclimate conditions are known to indirectly contribute to PU‐risk levels or to exacerbation of existing wounds. It is therefore surprising that information concerning heat accumulation under dressings is poor. Here, we aimed to investigate the effects of dressings on the microclimate of weight‐bearing buttocks skin in 1‐hour supine lying sessions. Using a novel and originally developed experimental‐computational approach, we compared the combined influence of the mechanical and thermal properties of a polymeric membrane dressing (PolyMem, Ferris Mfg. Corp., Fort Worth, TX) on skin microclimate under and near the dressings with those of a standard placebo foam dressing. We specifically identified the thermal conductivity properties of dressings as being highly important in the context of protective dressing performances, given its association with potential heat accumulation under dressings. Accordingly, this article highlights, for the first time in the literature, the relevance of thermal properties of a dressing in effectively mitigating the risk of developing PUs or aggravating an injury, and offers a systematic, methodological bioengineering process for assessing the thermal performances of dressings.

Human Amniotic Membrane: A New Option for Graft Donor Sites – Systematic Review and Meta‐analysis

Abstract

There are currently no standardised guidelines on the optimum dressing used for graft donor sites. The aim was to compare the outcomes of human amniotic membrane (HAM) vs routine dressings in split‐thickness skin graft (STSG) donor site healing. A systematic review and meta‐analysis was performed and a search of electronic information was conducted to identify all randomised controlled trials comparing the outcomes of HAM vs routine dressings in STSG donor sites. Wound healing and infection rate were primary outcome measures. Secondary outcome measures included severity of pain, discharge from donor site, the number of dressing changes, pruritus, and comfort. Fixed effect modelling was used for the analysis. Four studies enrolling 157 patients were identified. There was a significant difference between HAM and routine groups with wound healing time (P < .0001) and proportion of wounds healed by day 12 (P = .01). There was no significant difference between the two groups in infection rates (P = .27). For all secondary outcomes, HAM had improved results. HAM dressings are a superior option when compared with routine dressings used in current clinical practice for STSG donor sites as they improve wound healing and do not increase the infection rate.

Biological dermal templates with native collagen scaffolds provide guiding ridges for invading cells and may promote structured dermal wound healing

Abstract

Dermal substitutes are of major importance in treating full thickness skin defects. They come in a variety of materials manufactured into various forms, such as films, hydrocolloids, hydrogels, sponges, membranes, and electrospun micro‐ and nanofibers. Bioactive dermal substitutes act in wound healing either by delivery of bioactive compounds or by being constructed from materials having endogenous activity. The healing success rate is highly determined by cellular and physiological processes at the host‐biomaterial interface during crucial wound healing steps. Hence, it is important to design appropriate wound treatment strategies with the ability to work actively with tissues and cells to enhance healing. Therefore, in this study, we investigated biological dermal templates and their potential to stimulate natural cell adherence, guidance, and morphology. The most pronounced effect was observed in biomaterials with the highest content of native collagen networks. Cell attachment and proliferation were significantly enhanced on native collagen scaffolds. Cell morphology was more asymmetrical on such scaffolds, resembling native in vivo structures. Importantly, considerably lower expression of myofibroblast phenotype was observed on native collagen scaffolds. Our data suggest that this treatment strategy might be beneficial for the wound environment, with the potential to promote improved tissue regeneration and reduce abnormal scar formation.

Exploring the prevalence and management of wounds for people with dementia in long‐term care

Abstract

The prevalence of wounds and comorbidities such as dementia increase with age. With an ageing population, the likelihood of overlap of these conditions is strong. This study aimed to determine the prevalence of wound types and current management strategies of wound care for people with dementia in long‐term care (LTC). A scoping literature review, a cross‐sectional observational and chart audit study of residents in dementia specific facilities in LTC were conducted. The scoping review indicated that people with dementia/cognitive impairment are often excluded from wound related studies and of the nine studies included in this review, none looked at the prevalence of types of wounds other then pressure injuries. In the skin audit, skin tears were noted as the most common wound type with some evidence‐based practice strategies in place for residents. However, documentation of current wound occurred in less than a third of residents with wounds. This is the first study to note the prevalence of different wound types in people with dementia and current management strategies being used across two dementia‐specific facilities and a lack of research in this area limits evidence in guiding practice.

Incidence and prevalence of pressure ulcers in cancer patients admitted to hospice: A multicentre prospective cohort study

Abstract

Pressure ulcers lead to discomfort for patients and may have an important impact on a patient's quality of life. Measure the incidence and prevalence of pressure ulcers in a Hospice environment; evaluate the risk factors associated with pressure ulcers; and calculate the incidence of Kennedy Terminal Pressure Ulcers. This multicentre prospective cohort study enrolled 440 cancer patients in advanced phase, consecutively admitted to five hospices of the AUSL della Romagna (Italy), during a period of 1 year. Five hundred more patients were excluded from the study because of inability to sign the consent form or refusal to participate. All patients were adults above 18 years of age. The National Pressure Advisory Panel Classification System was used to evaluate the pressure ulcers. Potential risk predictors were evaluated through the Braden Scale, the Numerical Scale, and the Pain Assessment in Advanced Dementia Scale. Starting in September 2016, 214 (48.6%) females and 226 (51.4%) males were analysed. The incidence of pressure ulcers in the total population was 17.3%. The risk factors that influence the development of pressure ulcers were age, proximity to death, and duration of stay in Hospice. The incidence of Kennedy Terminal Pressure Ulcers was 2.7%. This study demonstrates that 17.3% of all patients admitted to a hospice setting developed a pressure ulcer. The longer the patients stay in hospice and the clinical condition deteriorates, the higher the risk of developing a pressure ulcer.

Use of home negative pressure wound therapy in peripheral artery disease and diabetic limb salvage

Abstract

Use of negative pressure wound therapy (NPWT) in peripheral artery disease (PAD) and diabetic limb salvage (DLS) improves wound healing by providing moist wound conditions, reducing exudate, controlling wound‐bed infection, and stimulating granulation. NPWT duration may take several weeks, and home‐based NPWT allows patient to recover in the community while minimising risks of prolonged hospitalisation. The aim of this study is to review the use and outcomes of home NPWT in PAD and DLS. The methodology is the retrospective review of patients who were discharged with home NPWT after in‐patient PAD revascularisation and DLS debridement or minor amputations. The results included a total of 118 patients who received home NPWT between January 2017 and December 2017. The mean age was 62.8 years with 66% male and 34% female patients. The study population comprised 25% smokers, 98% patients with diabetics, 35% with ischemic heart disease, and 21% with end‐stage renal failure (ESRF). Of which, 56% of patients required revascularisation while 31% of patients underwent foot debridement, 48% underwent toe amputations, and 20% underwent forefoot amputations. All patients received in‐patient NPWT for a week before being discharged on home NPWT for 4 weeks. Then, 62% received targeted antibiotics regime while 36% received empirical antibiotics on discharge; 60% of patients achieved wound healing on home NPWT, with 9% requiring split‐thickness skin graft; 4% required further surgical debridement, 16% required further minor amputation while 20% required major amputation. 9% required further home NPWT extension, with a mean length of 7.1 ± 4.7 weeks' extension. Overall survival of 1 year was 89%. Risk factors that predict the failure of home NPWT includes subjects with a background of ESRF and wet gangrene on presentation. Home NPWT is a useful adjunct in the management of PAD and DLS foot wounds.

A novel measurement instrument for pressure‐injury risk assessment competence: Theoretical procedures, simulation, and psychometric quality

Abstract

This study developed a measuring instrument of pressure‐injury risk assessment competence for nursing education adopting theoretical procedures based on competence structuration to support the psychometric quality. The objective of this study is testing the psychometric properties of the instrument using simulation strategy and to determine the instrument's standardisation and normalisation. A methodological study was designed. The instrument was developed by a content‐validated theoretical construct administered to 155 undergraduate nursing students from universities in the northeast and south of Brazil using simulation. The instrument was applied over three phases: before the lecture on pressure‐injury risk assessment competence, after scenario of simulation experience, and after debriefing experience. The instrument comprised 32 items. The factorial analysis found that three domains explained 64.6% and 62.18% of the total variance in post‐scenario and debriefing cases. The perfect and very high discrimination index of the instrument indicated minimal differences in measured latent trait levels. It also found that reliability was excellent (0.973 and 0.967). Moreover, an equation applicable to instruments using study's theoretical procedure was proposed. The instrument was found to be a valid, accurate, and reliable educational tool for pressure‐injury risk assessment competence.

How patient migration in bed affects the sacral soft tissue loading and thereby the risk for a hospital‐acquired pressure injury

Abstract

Head‐of‐bed (HOB) elevation is a common clinical practice in hospitals causing the patient's body to slide down in bed because of gravity. This migration effect likely results in tissue shearing between the sacrum and the support surface, which increases the risk for pressure injuries. StayInPlace (HillRom Inc.) is a commercial migration‐reduction technology (MRT) incorporated in intensive care bedframes. Yet, the effects of migration‐reduction on tissue shear stresses during HOB elevation are unknown. We analysed relationships between migration and resulting sacral soft tissue stresses by combining motion analysis and three‐dimensional finite element modelling of the buttocks. Migration data were collected for 10 subjects, lying supine on two bedframe types with and without MRT, and at HOB elevations of 45°/65°. Migration data were used as displacement boundary conditions for the modelling to calculate tissue stress exposures. Migration values for the conventional bed were 1.75‐ and 1.6‐times greater than those for the migration‐reduction bed, for elevations of 45° and 65°, respectively (P < .001). The modelling showed that the farther the migration, the greater the tissue stress exposures. Internal stresses were 1.8‐fold greater than respective skin stresses. Our results, based on the novel integrated experimental‐computational method, point to clear biomechanical benefits in minimising migration using MRT.

Preparation of placental tissue transplants and their application in skin wound healing and chosen skin bullous diseases ‐ Stevens‐Johnson syndrome and toxic epidermal necrolysis treatment

Abstract

Unique properties of amniotic membrane make it a promising source for tissue engineering and a clinically useful alternative for patients suffering from chronic wounds including, for example, ulcers, burns, ocular surface damages and wounds occurring in the course of bullous diseases like stevens‐johnson syndrome and toxic epidermal necrolysis. Its use has many advantages over standard wound care, as it contains pluripotent cells, nutrients, anti‐fibrotic and anti‐inflammatory cytokines, growth factors and extracellular matrix (ECM) proteins. Placental tissues can be prepared as a medical component, an advanced therapy medicinal product or a tissue graft. In addition to basic preparation procedures such as washing, rinsing, cutting, drying and sterilisation, there are many optional steps such as perforation, crosslinking and decellularisation. Finally, transplants should be properly stored—in cryopreserved or dehydrated form. In recent years, many studies including basic science and clinical trials have proven the potential to expand the use of amniotic membrane and amnion‐derived cells to the fields of orthopaedics, dentistry, surgery, urology, vascular tissue engineering and even oncology. In this review, we discuss the role of placental tissues in skin wound healing and in the treatment of various diseases, with particular emphasis on bullous diseases. We also describe some patented procedures for placental tissue grafts preparation.

Pressure injury data in Australian acute care settings: A comparison of three data sets

Abstract

Hospital‐acquired pressure injuries (HAPIs) represent a serious clinical and economic problem. The cost of treating HAPIs in Australian public hospitals was recently reported at AUS$983 million per annum. There are three main sources of data for documenting pressure injury (PI) occurrence in Australian hospitals: incident reporting, medical record coded data, and real‐time surveys of pressure injury. PI data reported at hospital level and to external agencies using these three different sources are variable. This reporting issue leads to inaccurate data interpretation and hinders improvement in accuracy of PI identification and PI prevention. This study involved a comparison of the three different data sources in selected Australian hospitals, to improve the accuracy and comparability of data. Findings from this study provide benchmark areas for improvement in PI documenting and reporting. Better understanding the agreement between the three data sets could lead to a more efficient and effective sharing of data sources.

Multiple subcutaneous haematomas of the legs causing skin necrosis in an elderly patient affected by corticosteroid‐induced skin atrophy: Case report and review of literature

Abstract

Corticosteroid‐induced skin atrophy (CISA) consists of a thinning of the skin and subcutaneous tissues, representing the natural consequence of a prolonged glucocorticosteroids use, both systemic as well as topical. It is characterised by the loss of elasticity and skin thickness, associated with an increased skin fragility leading to ecchymoses, haematomas, and steroid purpura. The management of CISA is a challenge for physicians, as the pathology is reversible in a minimal percentage of cases and only after a short topical steroid or low‐dose course therapy. Often wounds with large loss of substance represent the more common complication, after a surgical drainage which is often necessary. Skin necrosis with compartment syndrome of a leg is another potential risk for these patients. Here, we report a case of an elderly patient affected by multiple subcutaneous haematomas of the legs causing skin necrosis, arisen after the use of anticoagulants for a deep venous thrombosis. The patient was successfully treated with surgical drainage, negative pressure wound therapy (NPWT), and porcine xenograft with no complications. Finally, we discuss the evidence of the current literature on topic.

Vivencias del duelo en niños y estrategias de abordaje

La pérdida de un ser querido es una de las situaciones más difíciles que deberá afrontar todo ser humano en algún momento de sus vidas. Cuando se produce el fallecimiento de un progenitor o un hermano en la etapa infantil, ocasiona una afectación mayor, debido a la pérdida de su rutina diaria y a una falta de información y entendimiento de las actuaciones que se llevan a cabo relacionadas con el luto y la despedida al ser querido. Metodología: Se lleva a cabo una revisión panorámica a través de una búsqueda sistemática de artículos originales en las principales bases de datos de ciencias de la salud: Cuiden, Scielo, Dialnet, Scopus, BVS, Psicodoc, Pubmed y CINAHL. Idiomas: español e inglés. Años 2008-2019. Resultados principales: Se localizan 12 artículos. Las respuestas de los niños ante el duelo más comunes son: el temor, la culpa y el absentismo escolar recurrente. Es de suma importancia el papel de los familiares más cercanos, personal sanitario y profesores en la superación del duelo, destacando como intervenciones principales: la comunicación de lo ocu-rrido al menor y la intervención grupal con niños en su misma situación. Conclusión principal: Las respuestas del niño ante la muerte de un familiar, variará según la edad. Entre las vivencias más comunes se encuentran la desprotección o la ansiedad. Además, se obtienen como resultado que el apoyo emocional por parte de los profesionales sanitarios y las familias es fundamental. La intervención más valorada es el counselling.

Colapso postnatal durante el contacto piel con piel: a propósito de un caso

Los recién nacidos sanos deben comenzar el contacto piel con piel tan pronto como sea posible después del nacimiento y continuarlo, al menos, durante una hora. Esta práctica muestra efectos positivos, pero también conlleva ciertos riesgos. Se presenta el caso de un neonato gemelar, de 35.3 semanas, que presentó una parada cardiorrespiratoria mientras estaba en contacto piel con piel con su ma-dre, transcurridos 95 minutos desde su nacimiento. Se estabilizó con reanimación cardiopulmonar avanzada, se inició hipotermia pasiva, se trasladó al hospital de referencia y a las 48 horas se realizó limitación del esfuerzo terapéutico. Con objeto de evitar nuevos casos, se constituyó un grupo multidisdiciplinar para realizar el análisis causa raíz del evento, poniéndose en marcha una serie de medidas correc-tivas inmediatas y un plan de acción para corregir o mejorar los factores contribuyentes identificados.

Intervenciones de enfermería a Recién Nacido Extremadamente Prematuro con Síndrome de Distrés Respiratorio

Introducción: La prematuridad y el bajo peso al nacer son factores predictivos asociados a la morbilidad y la mortalidad neonatal y, por lo tanto, dan lugar a complicaciones como el Síndrome de Dificultad Respiratoria (SDR), que es la principal complicación de los recién naci-dos que ingresan en la Unidad de Cuidados Intensivos Neonatales (UCIN). Objetivo: implementar cuidados integrales de enfermería especializados e individualizados al recién nacido extremadamente prematuro basados en recomendaciones de evidencia científica e intervenciones NIC. Presentamos la valoración integral de una persona recién nacida de 23 SDG con un peso de 500 g. más SDR remitidos desde un hospital comunitario básico a un hospital de tercer nivel de atención, donde se aplica el proceso de enfermería. Métodos: Se seleccionó un paciente a conveniencia de la UCIN, aplicando la metodología del proceso de enfermería, la evaluación integral a tra-vés de los 13 dominios de la NANDA, los datos se obtuvieron del expediente clínico, la entrevista con la madre y el examen físico del recién nacido Se identifican las principales respuestas humanas para analizar datos objetivos y subjetivos, se hacen juicios clínicos para implementar planes de atención bajo recomendaciones de guías de práctica clínica e intervenciones de NIC. Resultados: Se implementa-ron cinco planes de atención con diagnóstico priorizado de enfermería, cuatro reales y uno en riesgo, se identificaron los dominios más alterados: nutrición, eliminación/intercambio, crecimiento/desarrollo y seguridad/protección. Conclusiones: se realizaron intervenciones independientes e interdependientes observando mejoría en los dominios alterados, sin embargo, el recién nacido se mantuvo en una incubadora y permaneció en la UCIN para seguir los planes terapéuticos especializados, Esto implica que la UCIN debe contar con personal multidisciplinario altamente capacitado con conocimientos actualizados en atención neonatal.

Nurses' Use and Ways of Understanding Web-Based National Guidelines for Child Healthcare

imageThe national Rikshandboken for child healthcare is both a Web-based guideline containing knowledge and methodological guidance and a national child healthcare program in the process of being implemented in Sweden. The aim of this study was to examine child healthcare nurses' use and ways of understanding the national Web-based Rikshandboken. A mixed-methods study with sequential explanatory design in two phases was used; a Web survey with descriptive statistics was followed with telephone interviews with phenomenographic analysis. The study showed variations in use and contributed deeper knowledge of child healthcare nurses' ways of understanding the unit Rikshandboken whose varied parts interact with each other. To be reliable, useful, and relevant for nurses in their specific contexts, Rikshandboken must be kept updated and involve the end users in the development process. With access to technical devices and optimal use of the possibilities of information and communication technology, Rikshandboken can be a resource for continuing learning, a tool in everyday work, and a possible determinant to equality in child healthcare. The study contributes valuable knowledge for the design of Web-based national guidelines for healthcare, making them useful and relevant for the end users.

Factors Affecting Patient Prioritization Decisions at Admission to Home Healthcare: A Predictive Study to Develop a Risk Screening Tool

imageThere is a lack of evidence on how to identify high-risk patients admitted to home healthcare. This study aimed (1) to identify which disease characteristics, medications, patient needs, social support characteristics, and other factors are associated with patient priority for the first home health nursing visit; and (2) to construct and validate a predictive model of patient priority for the first home health nursing visit. This was a predictive study of home health visit priority decisions made by 20 nurses for 519 older adults. The study found that nurses were more likely to prioritize patients who had wounds (odds ratio = 1.88), comorbid condition of depression (odds ratio = 1.73), limitation in current toileting status (odds ratio = 2.02), higher number of medications (increase in odds ratio for each medication = 1.04), and comorbid conditions (increase in odds ratio for each condition = 1.04). This study developed one of the first clinical decision support tools for home healthcare called “PREVENT”. (PRiority home health Visit Tool). Further work is needed to increase the specificity and generalizability of the tool and to test its effects on patient outcomes.

Promoting Emotional Well-being in Hospitalized Children and Adolescents With Virtual Reality: Usability and Acceptability of a Randomized Controlled Trial

imageThe aim of this study was to describe and compare small-sized preliminary data on the usability and acceptability of a randomized controlled trial. This study compares a one-to-one cognitive-behavioral treatment and a virtual reality treatment for children and adolescents hospitalized for long-term physical conditions. The final sample was composed of 19 children and adolescents with chronic illness who were hospitalized. The sample was randomly allocated to two intervention groups: cognitive-behavioral usual treatment and virtual reality–based treatment. Participants in the virtual reality group demonstrated higher perceived efficacy scores for every treatment component than for traditional treatment. Statistically significant differences were found for the total usability and acceptability scores. Participants in the virtual reality group show high acceptability of all the virtual environments. The components and environments of virtual reality were well accepted. The virtual reality program received high scores in immersion, feasibility of use, and sense of reality. Technology-based treatments, that is, virtual reality, can provide motivational benefits in relation to traditional treatments.

Exploring Family Nurse Practitioners' Practices in Recommending mHealth Apps to Patients

imagePatients frequently download mHealth apps, which can be used to support health promotion. It remains unclear, however, if family nurse practitioners are recommending apps to patients. This study identified family nurse practitioners' current practices of recommending apps to patients and described their use and intent to use mHealth apps for health promotion with their patients. Nearly 70% of the 303 participants surveyed recommended mHealth apps to their patients, with the most common types comprising patient portal, diet and nutrition, and fitness apps. However, the frequency with which apps were recommended was low. Participants reported that apps complement patient care, enable health promotion behaviors, are easy to use, and improve clarity of patient data. These factors facilitated their intent to recommend mHealth apps to patients. Healthcare organizational support influenced participants' intent to recommend apps, and access to trustworthy apps and electronic health records compatibility increased usage. Barriers to recommending involved patient-specific characteristics and provider concerns about reliability, privacy, and efficacy of apps. Family nurse practitioners must be supported in guiding patients to use reliable, safe, and HIPAA-compliant apps. To help engage patients, clinicians should be educated on methods to evaluate mHealth apps and how to incorporate them into patient care.
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