Pressure Ulcer Healing Research Articles

Nutritional support in the treatment and prevention of pressure ulcers: An overview of studies with an arginine enriched Oral Nutritional Supplement

Under-nutrition, inadequate protein or poor protein and energy intake and unintended weight loss have been identified as independent risk factors for the development of pressure ulcers. Providing oral nutritional supplements (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. To examine the effect of nutritional intervention in pressure ulcer care, clinical studies performed with a specific ONS enriched with arginine, vitamin C and zinc were reviewed. Six clinical studies that were performed with the specific ONS, identified via electronic and conference databases, were included in the review. Four studies examined the effects of the specific ONS in patients with pressure ulcers, while two studies examined the effects of the specific ONS in patients at high risk of developing pressure ulcers. The reviewed practice-based studies with the specific ONS specifically developed for patients with pressure ulcers show positive effects of this ONS on pressure ulcer healing and the ONS might potentially reduce the risk of developing pressure ulcers.

Professional Practice-Restructuring in Healthcare Settings, Strategies for Survival

BACKGROUND: At our 524-bed, Level 1 Midwest Trauma Center, patients with complex wounds, new and/or challenging stomas, enterocutaneous fistulas and bowel and bladder incontinence populate all inpatient care units. The nosocomial pressure ulcer rate at our facility in 2005 was 7.6 %. In July of 2005, Memorial Ostomy and Wound Services developed a Unit Champion Program to address the aforementioned concerns. PURPOSE: To develop nursing expertise in the management of noncomplicated wound patients and routine ostomy patients. Implement strategies to decrease the occurrence of nosocomial pressure ulcers. METHODS: Unit champions are either self-identified or recruited, based on their interest in ostomies, skin and wound care. They serve as communication liaisons between the Nursing QI Committee, the Quality Practice Council, and nursing staff. Champions represent all acute care units and those services that provide direct patient care. Multiple job classifications are encouraged to participate with at least one RN unit representative. Dieticians, Clinical Nurse Specialists and nursing administration are also representatives. Champions attend monthly educational programs and receive contact hours for attendance. Course offerings include basic and advanced ostomy care, management of enteric fistulas, fecal incontinence, nutrition and wound healing, assessment, prevention and treatment of pressure ulcers and utilizing therapeutic support surfaces. Competencies in negative pressure wound therapy are offered. Contact hours received and committee membership is used for Clinical Ladders advancement. Champions assist with quarterly Prevalence and Incidence Studies and oversee unit-based product pilots. RESULTS: Since its inception our facility has received Magnet status. Nosocomial pressure ulcer incidence has decreased from 7.6% to 1%. A Unit Champion resource list is located on the facility's intranet. This allows for hospital-wide access to a Champion's expertise twenty-four hours a day.

Protein, Calories Essential To Pressure Ulcer Healing

Protein, Calories Essential To Pressure Ulcer Healing

Alcohol Neurolysis of the Sciatic and Femoral Nerves to Improve Pressure Ulcer Healing

Successful pressure ulcer treatment is challenging and is often plagued with prolonged hospitalizations, multiple surgeries, and high recurrence rates. Pressure ulcer secondary to spinal cord injury is further complicated by spasticity, which contributes to both ulcer continuance and healing. This report illustrates the use of neurolytic regional techniques for spasticity control and pressure ulcer healing. We present our experience with a paraplegic man who suffered from chronic right trochanteric and ischial pressure ulcers that failed to heal despite surgical and conservative treatment. We report the successful treatment of knee and hip flexor spasticity with a femoral and sciatic alcohol neuroablation technique. It was not until the successful control of his lower extremity spasticity that the pressure ulcers showed signs of healing. Neuroablation nay be considered for spasticity control when more conservative approaches fail or are not feasible.

Efficacy of pulsed electromagnetic field therapy in healing of pressure ulcers: A randomized control trial

Pressure ulcers are one of the most common complications in health care settings. Still there are no optimal protocols to manage the pressure ulcers. To assess the effectiveness of pulsed electromagnetic field therapy (PEMF) in healing of pressure ulcers in patients with neurological disorders. Randomized double blind control trial. Neurological rehabilitation department in a university research hospital. Twelve patients (M:F, 9:3) having neurological disorders, with age between 12-50 years (mean 30.166 +/- 11.32 yrs) and 24 pressure ulcers. Six patients with 13 ulcers received PEMF therapy and the remaining 6 patients with 11 ulcers received sham treatment, for 30 sessions (45 minutes each) using the equipment 'Pulsatron'. The frequency of PEMF was set at 1 Hz with sine waves and current intensity of 30 mili ampere. Whole body exposure was given in both the groups. Bates-Jensen wound assessment tool (BJWAT) score was used as main outcome measure and scores at the end of session were compared with initial scores and analyzed. Similarly National Pressure Ulcer Advisory Panel (NPUAP) scores were compared and analyzed as secondary outcome measure. Thirteen ulcers were in stage IV and 11 were in stage III at the start of the study. Significant healing of ulcers was noted, BJWAT scores, in both the treatment and sham groups (P < 0.001 and 0.003 respectively) at the completion of the study. However, when comparing between the groups, healing was not significant (P = 0.361). Similarly trend was noted with NPUAP scores with no significant difference between the treatment and sham groups (P = 0.649) at the completion of study. No significant difference in pressure ulcer healing was observed between PEMF treatment and sham group in this study.

Benefits of an oral nutritional supplement on pressure ulcer healing in long-term care

To investigate the effects of an oral nutritional supplement (ONS) plus standard care on the healing of pressure ulcers in long-term nursing home residents in addition to standard care. The ONS (Cubitan, Nutricia Advanced Medical Nutrition) was high in energy and protein, and enriched with arginine, vitamin C and zinc. A total of 245 patients with grade II-IV pressure ulcers were enrolled into this open study at 61 long-term-care facilities, which reflect the nursing-home population of Luxembourg and Belgium. Residents received the ONS daily for nine weeks, along with their normal diet or enteral feed and standard pressure care. Pressure ulcer area (mm2) and condition were assessed after three and nine weeks. Data were analysed using ANOVA and expressed as mean +/- SD. The patients' age was 82.2 +/- 10.1 years. Sixty-seven patients (27%) had been previously treated with the ONS. The majority of pressure ulcers were located at the sacrum (54%) and heel (32%). The average intake of the 200 ml ONS was 2.3 +/- 0.56 servings daily, which corresponds to 46 g protein, 6.9 g arginine, 575 mg vitamin C, 87 mg vitamin E and 21 mg zinc. After nine weeks' nutritional support, the average pressure ulcer area reduced significantly from 1580 +/- 3743 mm2 to 743 +/- 1809 mm2, which is a reduction of 53% (p<0.0001). Complete wound closure occurred after three and nine weeks in 7% and 20% of the pressure ulcers respectively. The amount of exudation (assessed subjectively) also decreased after specialised nutritional support (p<0.0001). A high-protein ONS enriched with arginine, vitamin C, vitamin E and zinc, when used with standard pressure ulcer care, significantly reduced the mean pressure ulcer area of long-term nursing home residents.

Review: evidence of the effectiveness of hydrocolloids for healing pressure ulcers is limited

A Heyneman Mr A Heyneman, Ghent University, Ghent, Belgium; alexander.heyneman@ugent.be Are hydrocolloids effective for healing pressure ulcers? Studies selected evaluated hydrocolloids for management of pressure ulcers. Outcomes included pressure ulcer...

Using the Case Mix of Pressure Ulcer Healing to Evaluate Nursing Home Performance

Pressure ulcer healing is an important quality measure for nursing homes, but the factors that predict healing have not been well studied. Using the Minimum Data Set, the authors identified candidate variables for a logistic regression, risk-adjustment model to predict ulcer healing. The authors then assessed model discrimination and calibration. Finally, the authors compared unadjusted with risk-adjusted performance for the individual facilities within a nursing home chain. Significant predictors of healing included mobility in bed, presence of a stage 2 ulcer (compared with a stage 4 ulcer), absence of paraplegia and quadriplegia, and absence of end-stage illness. The model C statistic was 0.67, and the calibration was acceptable. Judgments about nursing performance varied in 2 cases depending upon whether unadjusted or risk-adjusted performance was used. The model that the authors developed contains credible predictors of healing. Pressure ulcer healing may be one of many indicators used to evaluate nursing home quality.

Stage 2 Pressure Ulcer Healing in Nursing Homes

To identify resident and wound characteristics associated with Stage 2 pressure ulcer (PrU) healing time in nursing home residents. Retrospective cohort study with convenience sampling. One hundred two nursing homes participating in the National Pressure Ulcer Long-Term Care Study (NPULS) in the United States. Seven hundred seventy-four residents aged 21 and older with length of stay of 14 days or longer who had at least one initial Stage 2 (hereafter Stage 2) PrU. Data collected for each resident over a 12-week period included resident characteristics and PrU characteristics, including area when first reached Stage 2. Data were obtained from medical records and logbooks. There were 1,241 initial Stage 2 PrUs on 774 residents; 563 (45.4%) healed. Median time to heal was 46 days. Initial area was significantly associated with days to heal. Using Kaplan-Meier survival analyses, median days to heal was 33 for small (<or=1 cm(2)), 53 days for medium (>1 to <or=4 cm(2)), and 73 days for large (>4 cm(2)) ulcers. Using Cox proportional hazard regression models to examine effects of multiple variables simultaneously, small and medium ulcers and ulcers on residents with agitation and those who had oral eating problem healed more quickly, whereas ulcers on residents who required extensive assistance with seven to eight activities of daily living (ADLs), who temporarily left the facility for the emergency department (ED) or hospital, or whose PrU was on an extremity healed more slowly. PrUs on residents with agitation or with oral eating problems were associated with faster healing time. PrUs located on extremities, on residents who went temporarily to the ED or hospital, and on residents with high ADL disabilities were associated with slower healing time. Interaction between PrU size and place of onset was also associated with healing time. For PrU onset before or after admission to the facility, smaller size was associated with faster healing time.

170 Laser Doppler Perfusion Imaging for the Assessment of Healing in Pressure Ulcers

170 Laser Doppler Perfusion Imaging for the Assessment of Healing in Pressure Ulcers

Urethral Reconstruction in Patients With Neurogenic Bladder Dysfunction

There is limited literature examining urethral reconstruction in patients with neurogenic bladder dysfunction. We describe our experience of urethral reconstruction in men with concurrent neurogenic bladder. A prospectively maintained database of all urethral reconstruction procedures performed by 1 surgeon was analyzed for patients with neurogenic bladder dysfunction. Patient characteristics including the etiology of neurogenic bladder, urethral pathology, urethral reconstructive technique, complications and recurrences were evaluated. A total of 23 patients were included in the analysis. Urethral pathology included erosions (10), strictures (7), diverticula (3), urethrocutaneous fistulas (2), and a combination of diverticular and stricture disease (1). Median length of the urethral pathology was 5.0 cm (range 2.0 to 10.0). Overall urethral reconstruction was successful in 16 of 23 patients (69.6%) at a mean followup of 24.7 months (range 2 to 79). Success rates differed among the types of pathology with 60% for urethral erosions, 85.7% for urethral strictures, and 66.6% for urethral diverticula and fistulas. Of those cases of recurrence 4 of 7 (57%) were after urethral erosion repair. There was 1 (4.3%) postoperative complication and no patient underwent urinary diversion after recurrence. When identified at an early stage, urethral reconstruction in patients with neurogenic bladder dysfunction offers acceptable outcomes with limited morbidity. Men undergoing reconstruction for urethral erosion had inferior outcomes compared to those with other urethral pathology.

Prospective clinical study of a new adhesive gelling foam dressing in pressure ulcers

This prospective, non comparative study evaluated the safety and effectiveness of an adhesive gelling foam dressing in pressure ulcer management. Twenty-three subjects with exuding pressure ulcers were recruited from seven centres in the USA and Canada. Study treatment included an adhesive gelling foam dressing, optional tape/roll bandaging and mandatory pressure-reducing/relieving devices. Subjects were followed until ulcer healing, for up to 28 days, or on patient withdrawal from the study, whichever came first. Dressings were changed at least once every 7 days. Mean percentage change in ulcer area from baseline to final measurement was -13%. Investigators reported healing or subjective improvement of ulcer condition in 61% of patients. Mean dressing wear time was 4.2 days. Subjects found the dressing was comfortable, soothing and cushioning in situ at 80%, 64% and 70% of dressing changes, respectively. Subjects reported pain severity of none or mild for every dressing change. Fourteen subjects experienced adverse events, including seven subjects with study-related maceration, erythema, wound enlargement, blister or infection. A regimen including an adhesive gelling foam dressing proved to be safe and effective for managing exudate, protecting the surrounding skin, minimising pain and supporting healing of pressure ulcers with exudate.

Escarres et dénutrition - Dépistage et évaluation de l´état nutritionnel

Acquired pressure ulcer is associated with significant human, economic and functional consequences. Its prevalence varies between 3 and 23% in a community hospital and between 7 and 54% in an elderly home residency. Pressure ulcer healing is a complex process which involves numerous cellular and molecular mechanisms. An altered nutritional status is a contributing factor in the development of pressure ulcers and the delay in pressure ulcer healing. The key to management of undernutrition is screening and early intervention. According to the gravity of undernutrition, various degrees of intervention will be required. Systematic oral supplementation with various nutrients may provide benefit in the prevention of pressure ulcers, but further studies have to be completed in human subjects prior to being recommended for the treatment of pressure ulcers.

The effects of polarized light therapy in pressure ulcer healing

Neglecting polarized light as an adjuvant therapy for pressure ulcers and methodology distinctions in the trials engaging polarized light are the reasons for many dilemmas and contradictions. The aim of this study was to establish the effects of polarized light therapy in pressure ulcer healing. This prospective randomized single-blind study involved 40 patients with stage I-III of pressure ulcer. The patients in the experimental group (E) were subjected, besides polarized light therapy, to standard wound cleaning and dressing. Standard wound cleaning and dressing were the only treatment used in the control group (C). A polarized light source was a Bioptron lamp. Polarized light therapy was applied for six min daily, five times a week, four weeks. The Pressure Ulcer Scale for Healing (PUSH) was used in the assessment of outcome. Statistic analysis included Mann Whitney Test, Fisher Exact Test, Wilcoxon Signed Rank test. There were significant differences between the groups at the end of the treatment regarding the surface of pressure ulcer (E: 10.80 +/- 19.18; C: 22,97 +/- 25,47; p = 0.0005), rank of pressure ulcer (E: 5.90 +/- 2.48; C: 8.6 +/- 1.05; p = 0.0005) and total PUSH score (E: 7.35 +/- 3.17; C: 11.85 +/- 2.35; p = 0,0003). The patients in the experimental group had significantly better values of the parameters monitored than the patients in the control group. After a four-week polarized light therapy 20 patients with stage I-III ulcer had significant improvement in pressure ulcer healing, so it could be useful to apply polarized light in the treatment of pressure ulcers.

Malnutrition as a risk factor for the development of pressure ulcers

Malnutrition - as a fundamental aspect both in genesis as in healing of pressure ulcers - is the object of this update paper. Countless studies point out that malnutrition, immune function alterations, hypoalbuminemia, low hemoglobin levels, as well as low diet intake, as responsible for an increase in the risk of developing these lesions. Therefore, it is essential to include the assessment of the nutrition status - monitoring of the calorie-protein intake and the difficulties to use the nutrients - in the prevention and treatment protocols of this type of chronic wound.

Ozonated Olive Oil Enhances the Growth of Granulation Tissue in a Mouse Model of Pressure Ulcer

The curative effect of ozonated olive oil was evaluated using mouse models of cut wounds and pressure ulcers (decubitus or bedsores). Although ozonated olive oil did not significantly accelerate or decelerate wound contraction in either model, some histological modifications were observed. Ozonated olive oil induced blood coagulation in the hypodermis and cell infiltration in the dermis 1 day after its application. Moreover, it enhanced the formation of granulation tissue 10 days after application. These results indicate that ozonated olive oil promotes granulation tissue formation and is effective in the healing of wounds and pressure ulcers.

A diet enriched in eicosapentanoic acid, gamma-linolenic acid and antioxidants in the prevention of new pressure ulcer formation in critically ill patients with acute lung injury: A randomized, prospective, controlled study

Pressure ulcers are a significant burden in the ICU. Many factors have found to be associated with pressure ulcers including malnutrition. While it has been recognized that high protein diets decrease the incidence of pressure ulcers, the role of lipids as well as vitamins and antioxidants remains unclear. The aim of this study was to evaluate the preventive and healing effects of an enteral diet enriched in eicosapentanoic acid (EPA) and gamma-linolenic acid (GLA) and vitamins (vitamins A, C and E) on pressure ulcers. One hundred patients with acute lung injury were included in a larger study evaluating the effects of lipids and vitamins on respiratory function. A secondary end point, occurrence and healing of pressure ulcers was included. A diet enriched in lipids (EPA, GLA) and vitamins (vitamins A, C and E) was compared with a diet similar in macronutrient composition. The occurrence and healing of pressure ulcers was evaluated according to the National Pressure Ulcer Panel. Nutritional assessment included calorie intake, resting energy expenditure, levels of serum prealbumin, albumin, vitamins A and E, zinc and copper. C-reactive protein and procalcitonin were also measured. Patient's age, severity of disease and gender distribution were similar in the two groups. The study group had a higher body mass index. At baseline, the pressure ulcer score was similar in the two groups A significantly lower rate of occurrence of new pressure ulcers was observed in the study group compared to the control group (p<0.05). No difference was observed in the healing of existing pressure ulcers in the study as opposed to the control group. There was no significant difference in the nutritional parameters between the two groups. A diet enriched with EPA, GLA and vitamins A, C and E is associated with a significantly lower occurrence of new pressure ulcers in critically ill patients with acute lung injury.

Wound Care in Advanced Illness: Application of Palliative Care Principles

1159 EVEN THOUGH Alvarez et al.1 defines palliative wound care as “the incorporation of strategies that prioritize symptomatic relief and wound improvement ahead of wound healing,” their review article illustrates that these two goals are not mutually exclusive. The paper points out that these strategies intended to provide comfort also lead to healing even in the context of advanced disease. In fact, good palliation, by improving patient care, increases the likelihood of healing the wound. The goals of palliative wound care promote wound healing: controlling pain, managing infection, odor, bleeding, and exudate, and maintaining a good quality of life for the patient and caregiver.2 First, improving mobility is central to preventing/treating pressure ulcers. A primary reason for the lack of mobility, however, is pain. Good pain management improves mobility and thus can lead to decreased pressure on the ulcer, increasing the opportunity for healing.3 Second, management of the infection that causes the odor and exudates is also one of the fundamental tenets to healing a pressure ulcer.4 Third, recent data suggest a relationship between wound healing and psychosocial factors. For example, a national pressure ulcer study showed that administration of an antidepressant correlates positively to pressure ulcer healing.5 Finally, treating the family and caregivers is an integral part of treating the chronic wound.6 Assisting and supporting the caregiver who does the dressing changes improves the wound care. On the flip side of the same coin, curative measures may provide the best palliation for a wound that impairs quality of life. Restoring the blood flow through balloon angioplasty not only provides wound healing but also improves the patients’ pain while salvaging the limb.7 Medicated compression wraps for venous stasis ulcers serve a dual purpose of palliating the discomfort and drainage from the wound and promote healing. Our communication to patients and families should reflect our understanding of this dual purpose of wound management in palliative care. Just as we speak about “hoping for the best and planning for the worse” when breaking bad news,8 so we ought to speak of treatment of the wound as an integration of palliative and curative modalities. The goal is to decrease the burden of the wound, while simultaneously hoping that the interventions will promote healing. Discussion using such a parallel mindset avoids unrealistic expectations. Such unrealistically high expectations may be the reason why pressure ulcers are the number one cause of lawsuits against facilities.9 Effective communication may decrease these lawsuits.10 Like palliative care, wound care is a growing field in which evidence about effective treatments is just beginning to accumulate. As palliative care doctors, we look forward to learning more about how we can integrate this information into our therapeutic arsenal.

Treatment Protocol Aids Pressure Ulcer Healing

Treatment Protocol Aids Pressure Ulcer Healing

Nutrition Status and Pressure Ulcer: What We Need for Nutrition Screening

Pressure ulcers (PU) and malnutrition exist in elderly hospitalized patients as a significant and costly problem. The aim of the study was to compare different screening tools to assess nutrition status and to verify them for usage in clinical routine. Nutrition status (body mass index [BMI], Mini Nutritional Assessment [MNA], weight loss) was determined in 484 (326 female/158 male) multimorbid elderly patients with mean age of 79.6 +/- 7.6 (80.9 +/- 7.4 female/76.9 +/- 7.4 male) years. Bioelectrical impedance analysis (BIA; Nutrigard 2,000-M) was used for evaluation of body composition. Activities of daily living (ADL) were measured with the Barthel Index. PUs were divided into stages I-IV (European Pressure Ulcer Advisory Panel [EPUAP]) and were assessed by the Norton scale. The prevalence of PU was 16.7%, with a median Norton scale of 20 (range, 17-24). According to MNA, 39.5% of the PU patients were malnourished, and 2.5% were well nourished. By contrast, 16.6% of the non-PU patients were malnourished, and 23.6% were well nourished. BMI decreased significantly in PU patients (p < .008). BIA resulted in no significant resistance and reactance but in a significant reduction of phase angle in PU. According to a significantly reduced body cell mass and lean body mass in PU patients, the ADL decreased in these patients, too. Furthermore, we analyzed a significant effect of age, ADL, MNA, BMI, phase angle, and body cell mass on the Norton scale. The MNA as a screening and assessment tool is easy to use to determine the nutrition status in multimorbid geriatric patients with PU. Further studies are needed to show an improved outcome of PU healing if evaluation of nutrition status is part of routine clinical practice in multimorbid elderly risk patients within the first day after admission.