Efficacy of gel containing organic extra virgin olive oil for peristomal skin hygiene: A pilot randomised controlled trial.

AIM: To assess the efficacy and safety of the application, during stoma hygiene, of a pH-neutral gel containing organic EVOO (oEVOO) for the maintenance of peristomal skin integrity. METHOD: Patients with a colostomy or ileostomy were enrolled in a pilot randomized controlled trial and assigned treatment with a pH-neutral gel made from natural products including oEVOO or usual stoma hygiene gel. The primary outcome was three domains of abnormal peristomal skin: Discolouration, Erosion and Tissue overgrowth. Secondary outcomes that were evaluated included skin moisture; oiliness; skin elasticity; water-oil balance; patients' perceptions; difficulty inserting and removing the pouching system; pain, any other chemical, infectious, mechanical, or immunological complications of concern. The intervention lasted 8 weeks. RESULTS: Twenty-one patients were recruited for the trial and randomly assigned to either the experimental group (n = 12) or the control group (n = 9). The groups did not differ significantly in terms of patient characteristics. No significant differences between groups were identified either at baseline (p = 0.203) or at the end of the intervention (p = 0.397). In the experimental group, domains of abnormal peristomal skin improved after the intervention. The difference observed before and after the intervention was statistically significant (p = 0.031). CONCLUSION: The use of a gel containing oEVOO has shown similar levels of efficacy and safety to other gels commonly used for peristomal skin hygiene. It is also relevant to highlight that a significant improvement in skin condition was observed in the experimental group before and after the intervention.

Skin injuries associated with severe life-threatening situations: A new conceptual framework.

PURPOSE: To create a conceptual framework for skin injuries developing in patients whose lives are severely compromised or who are expected to die within a short period of time. To name and classify these types of skin injuries. To describe the clinical features of the different types of skin injuries that may occur in terminally ill and/or dying patients. DESIGN: A sequential design with several different phases (a literature review, a nominal group, and a consensus conference) was used. METHODS: Six experts with extensive knowledge of these types of injuries were selected for the nominal group. The traditional eight-phase nominal group technique was followed. The consensus conference consisted of participants voting on different options based on the statements elaborated with the expert panel summarizing the best scientific evidence available. FINDINGS: Using all these elements, a conceptual framework was constructed to identify skin injuries associated with severe life-threatening situations (SI-SLTSs), defined as unpredictable and therefore unpreventable injuries indicating a serious threat to life or even imminent death. These injuries can occur in two forms: (a) as skin injuries associated with multiple organ dysfunction syndrome (SI-MODSs) or (b) as skin injuries associated with severe vasoconstriction (SI-ESVs). SI-MODSs develop very quickly and suddenly. They progress from superficial to deep stages abruptly, even within hours. The severity of the injuries does not reflect the care provided to the patient. Individuals suffering from these injuries have an irreversible clinical condition. SI-ESVs also appear in individuals who are in a very critical, even terminal, clinical condition. They are frequently treated in the ICU and may exhibit severe vasoconstriction due to their disease process (e.g., shock), sometimes exacerbated by vasoconstriction caused by various drugs (e.g., noradrenaline). CONCLUSIONS: We have developed a conceptual framework for skin injuries developing in patients whose lives are severely compromised or who are expected to die within a short period of time and have named them SI-SLTSs, distinguishing between SI-MODSs and SI-ESVs. CLINICAL RELEVANCE: This new conceptual framework may help clinicians understand the mechanisms and the pathophysiology of skin injuries that develop in terminally ill and/or dying patients associated with multi-organ failure. Through this new framework these injuries can be identified and differentiated from pressure injuries or other dependence-related skin lesions.

Conceptual Framework for Incontinence-Associated Dermatitis Based on Scoping Review and Expert Consensus Process.

Incontinence-associated dermatitis (IAD) has been studied over the last decades, but gaps in the knowledge related to its identification, etiological agents, and risk factors remain. We carried out a scoping review about IAD that included systematic reviews, experimental, and observational studies about IAD and its potential risk factors. We retrieved 24 articles that described 100 potential risk factors and which were synthesized by the authors and proposed to a panel of experts. Panelists used a structured process of consensus development to create a conceptual framework of factors associated with IAD. This framework proposes that liquid fecal material, when combined with exposure to urine and stool, and bacterial contaminated urine are etiological factors for development of IAD. The framework also proposes 2 pathophysiological mechanisms and 8 main risk factors for IAD development. The proposed model could improve the quality of care for patients with or at risk of IAD, assisting healthcare professionals to identify at-risk patients, diagnose the type of lesion, and establish adequate and effective prevention and treatment measures.

Kennedy terminal ulcer and other skin wounds at the end of life: An integrative review.

AIMS: To undertake an integrative literature review to identify, analyse and synthesize current literature on the Kennedy terminal ulcer (KTU) and other unavoidable skin injuries that appear at the end of life regardless of the healthcare context in which they occur. METHODS: Integrative review following the Whittemore and Knafl methodology. The search was carried out in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus. It was limited to articles in English, French, Portuguese and Spanish. As there is little scientific production on the subject, no restrictions were applied regarding publication date. RESULTS: Only 17 articles met the inclusion criteria. These articles were reviewed and analysed. Four relevant issues emerged: Skin failure, SCALE, Kennedy Terminal Ulcer, Trombley-Brennan: different names for the same problem; the defining characteristics and physiopathology of KTU; the differences between KTU and other injuries; and the care approach for KTU and other unavoidable injuries at the end of life. CONCLUSIONS: We identified gaps regarding the physiopathology of KTU since the current knowledge is based only on hypotheses. There is also a large gap in the knowledge about care approaches, perhaps because care plans are not recorded. Despite this, it is clear that the main objective in this situation at the end of life would be to prioritize patient comfort and quality of life.

The Effectiveness of Advanced Practice Nurses with Respect to Complex Chronic Wounds in the Management of Venous Ulcers.

This study aims to evaluate the effectiveness of advanced practice nurses with respect to complex chronic wounds (APN-CCWs) in the care of patients with venous ulcers. A multicentric, quasi-experimental pre-post study was conducted without a control group in the sanitary management areas where the APN-CCW program is being piloted. The intervention consisted of a mass training of clinical nurses from the participating districts on the proper management of injuries and the use of compression therapy. The data were collected through a specifically constructed questionnaire with questions regarding descriptive variables of injuries and their treatment. A total of 643 professionals responded (response rate of 89.1%), attending to a total population of 707,814 inhabitants. An increase in multilayer bandage use by 15.67%, an increase in elastic bandage use by 13.24%, and a significant decrease in the referral of patients to consultation with hospital specialists was achieved, from 21.08% to 12.34%. The number of patients referred to the APNs was 13.25%, which implied a resolution rate of 94.08% of their injuries. In conclusion, the coordination by the APN-CCWs in patients with venous ulcers was effective in improving the continuity of care, in the optimization of resources, and in their care role.

The advanced practice nurse in the adequacy of chronic, complex wound care. / La enfermera de práctica avanzada en la adecuación de los tratamientos de las heridas crónicas complejas.

AIM: To determine the impact of advanced practice nurses in chronic wound care in the adequacy of treatments for patients with chronic wounds and the consumption of dressings in the districts where they have been implemented. METHOD: A quasi-experimental pre-poststudy without a control group with 3measurements: pre-implementation in 2015, one year after implementation in 2016, and 2years post-implementation in 2017, in the health districts (HD) where the role of the advanced practice nurse in chronic wound care was piloted in Andalusia. The main variables were trained professionals, consultancies, prevalence of chronic wounds, adequacy of treatments and economic cost in materials for the participating HD. RESULTS: The training of a total of 2,717 health teams with a total of 95,095 teaching hours was achieved. In addition, a total of 3,871 consultancies were performed. The prevalence of patients with injuries in the home care (HC) programme and in care homes diminished significantly, to almost half. The adequacy of the treatments increased to 90% and savings of more than 250,000€ in dressings were achieved in just 2years. CONCLUSION: The prevalence of chronic wounds during the 2years of implementation decreased by almost half. Adequacy of training and consultancy was achieved, rationalising health expenditure and ensuring efficient care for patients with chronic wounds.

Pressure ulcers' incidence, preventive measures, and risk factors in neonatal intensive care and intermediate care units.

Epidemiological studies on pressure ulcers (PUs) in hospitalised infants are scarce. Spain lacks comprehensive research studies providing data on the prevalence or incidence in this population. This work was developed to determine the incidence of PUs in hospitalised infants admitted to intensive and intermediate care units, along with relevant risk factors and preventive measures. A prospective study appraising the incidence of PUs in infants was performed. The risk factors and preventive measures were evaluated using a multivariate logistic regression model. A sample of 268 infants was included. The cumulative incidence of PUs was 12.70% (95% confidence interval, CI95% = [8.95%-17.28%]). The cumulative incidence in the intermediate care units was 1.90% (CI95% = [0.39%-5.45%]), while it was 28.18% (CI95% = [20.02%-37.56%]) in the intensive care units. The PUs were categorised as stage I, 57.10%; stage II, 31.70%; and stage III, 11.10%. The multivariate analysis found the following to be risk factors: low scores in the Spanish version of the Neonatal Skin Risk Assessment Scale (e-NSRAS) (Relative Risk (RR) 0.80; CI95% = [0.66-0.97]), the use of non-invasive mechanical ventilation (RR 12.24; CI95% = [4.02-37.32]), and the length of stay (RR 1.08; CI95% = [1.02-1.15]), suggesting a direct impact of these factors on PU development in infants. Kangaroo care influenced the prevention of PUs (RR 0.26; CI95% = [0.09-0.71]). The infants admitted in intermediate care units suffered PUs. In the case of intensive care units, the incidence is even higher. The risk increases with the length of stay, while the presence of medical devices, particularly non-invasive mechanical ventilation, is the main causal relationship. Kangaroo care has been shown to be an important preventive measure.

[Incidence of dependence-related lesions in a population of critical patients]. / Incidencia de lesiones relacionadas con la dependencia en una población de pacientes críticos.

AIM: To determine the incidence of various types of dependence-related lesions (DRL) on a population of critically ill patients. METHOD: Descriptive, longitudinal and prospective study in an Intensive Care Unit from January 2014 to January 2015. Adult patients who did not present DRL at the moment of admission were included. Those with brain death and/or stay at the unit for more than two days were excluded. Patients were studied till they developed DRL, were exitus, discharged or stayed for more than 14 days. Each patient was evaluated daily till DRL did develop or was excluded from the study. If DRL did develop it was photographed and related data were recorded. The comparison between quantitative variables of normal distribution was done with the t de Student. The Mann-Whitney U was used to compare the other variables. Qualitative variables were compared through Pearson's chi square. In both cases p≤.05 was considered significant. RESULTS: 295 patients were included, 27.45% of them developed DRL. The density of incidence was 41 DRL/1,000 days at risk. 50.62% of DRL were categorized as PU. 17.28% were moisture injuries, 13.58% were due to friction and the rest were combined injuries. The risk according to EMINA and Braden scale was significantly different in the group of patients with lesions compared to the group without them. CONCLUSIONS: Not all injuries were caused by pressure. Specific prevention strategies based on different causal mechanisms are required.

Predictive capacity of risk assessment scales and clinical judgment for pressure ulcers: a meta-analysis.

A systematic review with meta-analysis was completed to determine the capacity of risk assessment scales and nurses' clinical judgment to predict pressure ulcer (PU) development. Electronic databases were searched for prospective studies on the validity and predictive capacity of PUs risk assessment scales published between 1962 and 2010 in English, Spanish, Portuguese, Korean, German, and Greek. We excluded gray literature sources, integrative review articles, and retrospective or cross-sectional studies. The methodological quality of the studies was assessed according to the guidelines of the Critical Appraisal Skills Program. Predictive capacity was measured as relative risk (RR) with 95% confidence intervals. When 2 or more valid original studies were found, a meta-analysis was conducted using a random-effect model and sensitivity analysis. We identified 57 studies, including 31 that included a validation study. We also retrieved 4 studies that tested clinical judgment as a risk prediction factor. Meta-analysis produced the following pooled predictive capacity indicators: Braden (RR = 4.26); Norton (RR = 3.69); Waterlow (RR = 2.66); Cubbin-Jackson (RR = 8.63); EMINA (RR = 6.17); Pressure Sore Predictor Scale (RR = 21.4); and clinical judgment (RR = 1.89). Pooled analysis of 11 studies found adequate risk prediction capacity in various clinical settings; the Braden, Norton, EMINA (mEntal state, Mobility, Incontinence, Nutrition, Activity), Waterlow, and Cubbin-Jackson scales showed the highest predictive capacity. The clinical judgment of nurses was found to achieve inadequate predictive capacity when used alone, and should be used in combination with a validated scale.

A new theoretical model for the development of pressure ulcers and other dependence-related lesions.

OBJECTIVE: To review the risk factors included in pressure ulcer risk assessment scales and construct a theoretical model for identifying the etiological factors of skin ulcers, excluding those of systemic origin (e.g., venous, arterial, and neuropathic). METHODS: Consensus study with expert panel (Delphi Method) based on a structured review of the literature. A search was conducted of the main databases between 1962 and 2009 with no language limitations. All descriptive or validation studies were included, but the grey literature was excluded. After identifying the risk factors in each scale, they were grouped into risk dimensions as a basis for constructing a new theoretical model. RESULTS: Eighty-three risk factors were identified in the 56 scales reviewed, and the risk factors were then classified by the expert panel into 23 risk dimensions. These dimensions were used to construct a new theoretical model (middle-range theory) for chronic wound development that explains the production mechanism of seven types of lesion: moisture, pressure, friction, combined pressure-moisture, combined pressure-friction, multifactorial lesions, and coadjuvant factors. These lesions were generically defined as dependence-related injuries. CONCLUSIONS: Based on the classification of risk factors from the different scales into risk dimensions, a new middle-range theory was constructed that explains the production mechanism of seven dependence-related lesions considered to date as pressure ulcers. CLINICAL RELEVANCE: The prevention and treatment of these lesions requires a correct diagnosis and differentiation of their cause and management of the risk dimensions involved. The type of lesion also influences the selection of local approach.

Guía de práctica clínica sobre terapia intravenosa con dispositivos no permanentes en adultos / Clinical practice guideline on intravenous therapy with temporary devices in adults

El objetivo principal de la guía es proporcionar a los profesionales sanitarios una herramienta que les permita tomar decisiones basadas en evidencia sobre aspectos de la atención al paciente adulto con indicación de terapia intravenosa con dispositivos no permanentes. Además, se señalan los objetivos secundarios siguientes: aumentar la calidad de las intervenciones, evitar complicaciones relacionadas con la terapia intravenosa y reducir la variabilidad existente entre los profesionales sanitarios.

The guideline includes recommendations for taking care of adult patients with intravenous therapy who are at primary care centres, hospitals and homes.

Effectiveness of the 'sleep enhancement' nursing intervention in hospitalized mental health patients.

AIM: To determine the effectiveness of the 'sleep enhancement' nursing intervention (Nursing Interventions Classification) in patients hospitalized with mental illness and having a disturbed sleep pattern and to identify the possible effect of psycho-active medications on this disturbed sleep pattern. DESIGN: A quasi-experimental pretest-posttest type study without control group. METHOD: The study was conducted in all patients admitted to the mental health inpatient unit of University Hospital of Spain from 1 March 2007-31 May 2008. The effectiveness of the 'sleep enhancement' nursing intervention was measured using the Oviedo Sleep Questionnaire score and Nursing Outcome Classification sleep scores at admission and discharge. Psycho-active medication was considered an intervening variable and data were analysed by multivariate analysis of variance for repeated measures. RESULTS: The study included 291 patients. Consumption of psycho-active medications did not change between admission and discharge and was not statistically significantly different in the multivariate analysis of variance. Oviedo Sleep Questionnaire and Nursing Outcome Classification sleep scores at admission and discharge demonstrated significant sleep improvement after the nursing intervention. CONCLUSION: This nursing intervention could be implemented in patients admitted to a mental health inpatient unit with disturbed sleep pattern, regardless of their consumption of psycho-active medications.

[Compilation of historical anecdotes about chronic wounds. Well-known people who have suffered from them]. / Anecdotario histórico de las heridas crónicas. Personajes ilustres que las han padecido.

Throughout the course of human history many people have been affected by the presence of chronic wounds. Millions of anonymous people have suffered bed sores, varicose ulcers, arterial ulcers or neuropathic ulcers. But there have been some famous people who, from time to time, remove these lesions from their cloak of invisibility In our day and age, every time a famous person suffers from these wounds, we observe how the means of communication publicize this health problem. However famous people also suffered from these wounds in the past. In this article, the authors will review historical figures who died due to these feared sores. Kings or saints have been affected by this problem. Specifically the authors will focus on six historical figures: three kings, one composer and two saints,; the authors shall analyze the influence of chronic wounds as a cause of their deaths. This article was submitted at the VII National Symposium on Bed Sores and Chronic Wounds and at the First Latin American Congress on Ulcers and Wounds.

Pressure ulcer care in Spain: nurses' knowledge and clinical practice.

AIM: This paper is a report of a study to determine: (a) Spanish nurses' level of knowledge of existing guidelines for pressure ulcer prevention and treatment, (b) the level of implementation of this knowledge in clinical practice and (c) the professional and educational factors that influence knowledge and practice. BACKGROUND: Improvement in pressure ulcer care depends both on the dissemination of knowledge and on its implementation in clinical practice. Studies carried out in several countries have demonstrated gaps in knowledge about recommendations for pressure ulcer care and deficiencies in their implementation. METHODS: A survey was carried out between September 2001 and June 2002, targeting a cluster randomized sample of 2006 Registered Nurses and Licensed Practice Nurses working at hospitals, primary healthcare centres and elder care centres in Andalusia (Spain). RESULTS: The response rate was 36.9% (n = 740). The level of knowledge of prevention interventions was 79.1%, while that of treatment interventions was 75.9%. The levels of implementation in clinical practice were notably lower: 68.1% for prevention, and 65.3% for treatment. Nurses holding a university degree obtained higher scores, and those who had received specific education in pressure ulcer care obtained higher scores both for knowledge and clinical practice. Taking part in research projects also improved knowledge implementation. CONCLUSION: Although most of the recommendations on pressure ulcer care found in guidelines are well known by nurses, there is a group of interventions about which they have insufficient knowledge and low implementation rates.

[Skin care and prevention of bed sores in bedridden patients]. / Cuidados de la piel y prevención de úlceras por presión en el paciente encamado.

The aging process and environmental aggressions will leave their imprints on the state of a person's skin, possibly compromising some of its functions. Age is a risk factor for the development of bed sores, but not the only factor nor the most important one; therefore, we need to develop prevention programs directed to all patients who spend long periods of time sedentary or bedridden. Prevention programs for bed sores must be based on the best evidence available and include a risk evaluation on these factors: suffering a lesion due to pressure, specific skin treatment, incontinence control, excessive humidity posture changes and the use of special surfaces to manage pressure during an increase in mobility or activity by the patient, local pressure reducing devices as well as paying attention to special situations. All of these care measures have to be developed based on a continuity of treatment among the institutions and caretakers involved with treating each patient.

Risk assessment scales for pressure ulcer prevention: a systematic review.

AIM: This paper reports a systematic review conducted to determine the effectiveness of the use of risk assessment scales for pressure ulcer prevention in clinical practice, degree of validation of risk assessment scales, and effectiveness of risk assessment scales as indicators of risk of developing a pressure ulcer. BACKGROUND: Pressure ulcers are an important health problem. The best strategy to avoid them is prevention. There are several risk assessment scales for pressure ulcer prevention which complement nurses' clinical judgement. However, some of these have not undergone proper validation. METHOD: A systematic bibliographical review was conducted, based on a search of 14 databases in four languages using the keywords pressure ulcer or pressure sore or decubitus ulcer and risk assessment. Reports of clinical trials or prospective studies of validation were included in the review. FINDINGS: Thirty-three studies were included in the review, three on clinical effectiveness and the rest on scale validation. There is no decrease in pressure ulcer incidence was found which might be attributed to use of an assessment scale. However, the use of scales increases the intensity and effectiveness of prevention interventions. The Braden Scale shows optimal validation and the best sensitivity/specificity balance (57.1%/67.5%, respectively); its score is a good pressure ulcer risk predictor (odds ratio = 4.08, CI 95% = 2.56-6.48). The Norton Scale has reasonable scores for sensitivity (46.8%), specificity (61.8%) and risk prediction (OR = 2.16, CI 95% = 1.03-4.54). The Waterlow Scale offers a high sensitivity score (82.4%), but low specificity (27.4%); with a good risk prediction score (OR = 2.05, CI 95% = 1.11-3.76). Nurses' clinical judgement (only considered in three studies) gives moderate scores for sensitivity (50.6%) and specificity (60.1%), but is not a good pressure ulcer risk predictor (OR = 1.69, CI 95% = 0.76-3.75). CONCLUSION: There is no evidence that the use of risk assessment scales decreases pressure ulcer incidence. The Braden Scale offers the best balance between sensitivity and specificity and the best risk estimate. Both the Braden and Norton Scales are more accurate than nurses' clinical judgement in predicting pressure ulcer risk.