Contact with Wet Cement-A Preventable Cause of Chemical Burn: Case Report and Discussion.

GENERAL PURPOSE: To review the management of a patient with a chemical burn from wet cement. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and registered nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Recognize the clinical presentation of a patient with a chemical burn from contact with wet cement.2. Describe features related to the pathophysiology of alkali burns from wet cement.3. Select the proper decontamination procedure after exposure to wet cement.4. Identify steps in the treatment of a patient with a chemical burn from contact with wet cement.

Alkali burn from wet cement is an often unrecognized and completely preventable chemical injury. The prevalence of cement burns is likely underestimated because of a lack of awareness and knowledge among both individuals who work with cement and healthcare providers. Chemical injuries have important differences compared with thermal burns: they are usually produced by longer exposure to noxious agents as opposed to short-term exposure that is quickly stopped. As a result, first aid approaches are different. Chemical burns from cement can be avoided with adequate skin and eye protection as well as immediate first aid if contact occurs. Manufacturers of bagged cement place warning notices on packaging, but these can be small and go unnoticed by consumers. Construction workers and amateur do-it-yourselfers should avoid direct contact with cement for any prolonged amount of time. Watertight boots, gloves, and clothing will prevent contact, and any accidental splash on exposed skin should be immediately washed away. Education and awareness of the consequences of cement burns are the best prevention.

Wound Care Consultation in Postacute/Long-term Care: Characteristics and Practice Implications.

OBJECTIVE: To study the characteristics of residents in postacute (PA)/long-term care (LTC) facilities with wounds and prevalence of wound types other than pressure injuries (PIs). METHODS: The authors conducted a retrospective review of all wound care consultations over 1 year at The New Jewish Home, a 514-bed academically affiliated facility in an urban setting. Investigators analyzed residents by age, sex, type of wound, presence of infection, and whether the resident was PA or LTC. Authors designated PIs as facility acquired or present on admission. RESULTS: During the study period, 190 wound care consultations were requested; 74.7% of consults were for those in PA care. The average patient age was 76.3 years, and there were 1.7 wounds per resident receiving consultation. Of studied wounds, 53.2% were PIs, 15.8% surgical, 6.8% arterial, 6.3% soft tissue injury, 5.8% venous, 2.6% malignant wounds, and 2.1% diabetic ulcers; however, 11.6% of residents receiving consults had more than one wound type. In this sample, 13.2% of residents had infected wounds, and 76.2% of PIs were present on admission. CONCLUSIONS: The wide variety of wounds in this sample reflects the medical complexity of this population. The transformation of LTC into a PA environment has altered the epidemiology of chronic wounds and increased demand for wound care expertise. These results challenge traditional perceptions of wound care centered on PIs. Given its importance, a wound care skill set should be required of all PA/LTC providers.

Medical Device-Related Pressure Injury to the Ear from a Mask.

ABSTRACT: Mask wearing is now ubiquitous because of the COVID-19 pandemic and has given rise to medical device-related pressure injuries in persons at risk of skin breakdown. The ear has unique anatomy that is particularly susceptible to injury from pressure. In this time of mandatory personal protective equipment requirements in healthcare facilities, protection and assessment of skin in the vulnerable postauricular area are needed. This article presents a case report of a pressure injury on the ear, reviews the anatomy of the ear, and provides strategies for assessment and treatment of pressure injuries in this often overlooked anatomic region.

Clinical Aspects of Aging Skin: Considerations for the Wound Care Practitioner.

GENERAL PURPOSE: To provide information about changes associated with aging skin and the implications for wound care practitioners. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Describe proposed biologic theories of aging and the biology of aging skin.2. Discuss the clinical consequences of aging skin and the implications for wound care practitioners. ABSTRACT: Aging is a complex phenomenon manifested by macromolecular damage, adverse changes to the genome, blunted immunologic function, alterations in body composition, and decreased adaptation to stress. Understanding the changes that skin undergoes with age is essential for wound care practitioners. Accordingly, this article will introduce the reader to theories of aging, the biologic changes associated with aging skin, and clinical considerations for the wound care practitioner, including the concepts of skin failure, Skin Changes At Life's End, and frailty.

Aging is a complex phenomenon manifested by macromolecular damage, adverse changes to the genome, blunted immunologic function, alterations in body composition, and decreased adaptation to stress. Understanding the changes that skin undergoes with age is essential for wound care practitioners. Accordingly, this article will introduce the reader to theories of aging, the biologic changes associated with aging skin, and clinical considerations for the wound care practitioner, including the concepts of skin failure, Skin Changes At Life's End, and frailty.

Wounds Related to Malignancy in Postacute and Long-term Care: A Case Series.

OBJECTIVE: To study the epidemiology and characteristics of wounds related to malignancy in a large, academically affiliated postacute/long-term care (PALTC) facility. DESIGN: Retrospective case series of 1 year of wound care consultations. Inclusion criteria included a cancer diagnosis with wounds related to malignancy or complications from cancer-related debility and/or treatment. SETTING: Academically affiliated 514-bed PALTC facility. PARTICIPANTS: Of 190 consults, 27 residents (14.2%) met the inclusion criteria. Of these, 20 (74.1%) were female, and 7 (25.9%) were male. The average age of residents with a cancer diagnosis and wounds was 69.5 years (range, 48.1-86.7 years), and 25 (92.6%) were on the postacute service. RESULTS: The most common reasons for consultation included pressure injuries (44.4%), surgical wounds (21.4%), and malignant wounds (14.8%). Seventy-six percent of pressure injuries were present on admission. Breast (29.6%), gastrointestinal (25.9%), and gynecologic (11.1%) malignancies were most common. Of the studied residents, 14 (51.9%) had metastases, and 13 (92.9%) had pressure injuries. CONCLUSIONS: These findings begin to fill a gap in understanding the spectrum of wounds in PALTC residents with cancer and reinforce the importance of the wound care skill set, including pressure injury prevention. Quality cancer care for older adults must anticipate severe skin complications not only from the tumor and its treatment, but also from the sequelae of immobility, immune compromise, malnutrition, and skin failure. The close association of metastatic disease with pressure injury raises issues of unavoidability and casts new doubt upon the use of pressure injuries for quality measurement.

Do cognitive and neuropsychological functioning deficits coincide with hippocampal alteration during first-psychotic episode?

BACKGROUND: Numerous studies shown that structural hippocampal alterations are present in subjects at high risk of developing psychosis or schizophrenia. These findings indicate that in a subset of patients undergoing first-psychosis episode (FPE), hippocampal volume alterations are accompanied by associated cognitive and neuropsychological deficits. The combination of psychological deficits and neuroanatomical alterations, in turn, appears to increase treatment complexity and worsen clinical outcomes. OBJECTIVE: We aim to determine whether cognitive and neuropsychological functioning deficits precede or follow hippocampal alterations during early onset psychosis. METHODS: This cross-sectional study describes 3 case-studies of adolescent subjects, ages 16-17, admitted at the child and adolescent inpatient psychiatric unit in lieu of first psychotic episode. We conducted detailed structured clinical psychiatric interviews, anatomical-structural magnetic resonance imaging (MRI), sleep-deprived electroencephalogram (EEG) recordings, laboratory testing, and a comprehensive battery of psychological testing to better understand their clinical pictures. RESULTS: Psychological testing in each patient demonstrated the presence of low to borderline intellectual functioning coupled with neuropsychological deficits in different psychiatric domains. Interestingly, these changes coincided with structural MRI alterations in the hippocampal area. CONCLUSIONS: Our case report adds to the armamentarium of literature signifying that radiologically detectable alterations of the hippocampus may occur either concomitantly or closely following the development of early cognitive deficits in patients with FPE.

Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries.

GENERAL PURPOSE: To synthesize the literature regarding skin injuries that are found in patients at the end of life and to clarify the terms used to describe these conditions. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After completing this continuing education activity, you should be better able to:1. Define the terms used to describe pressure injuries and skin changes at the end of life.2. Discuss the concept of skin failure as applied to end-of-life skin injuries and implications for practice. ABSTRACT: This article synthesizes the literature regarding the concepts of "terminal" skin injuries that are found in patients at the end of life, including Kennedy terminal ulcers, Skin Changes At Life's End, Trombley-Brennan terminal tissue injuries, and skin failure. Also included is a discussion of avoidable and unavoidable pressure injuries as defined and differentiated by the Centers for Medicare & Medicaid Services and the National Pressure Ulcer Advisory Panel. To help clarify the controversy among these terms, a unifying concept of "skin failure" that may occur with an acute illness, chronic illness, or as part of the dying process is proposed. This proposed concept of skin failure is etiologically different than a pressure injury, although pressure injury and skin failure can occur concomitantly. These proposed concepts require further research and validated diagnostic criteria. Consensus around appropriate terminology is essential to reduce confusion among stakeholders and ensure appropriate patient care.

100 Years of Bedsores: How Much Have We Learned?

Just over 100 years ago, an article was published describing a plan to treat decubitus ulcers that can shed light upon medical progress and current practices. Key prevention and treatment elements included a dedicated ward, staff continuity, frequent position changes and special surfaces, cleanliness, disinfectants, and dressing changes. The necessity of resource allocation and interdisciplinary collaboration was acknowledged. This article sheds light on not only how much we have learned, but also how far we have to go.

The Effect of Oral Medication on Wound Healing.

GENERAL PURPOSE: The purpose of this learning activity is to provide information about the effects of oral medications on wound healing. TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant should be better able to:1. Identify oral medications that aid in wound healing.2. Recognize oral medications that interfere with wound healing. ABSTRACT: Given the accelerated medical discoveries of recent decades, there is a surprising lack of oral medications that directly improve wound healing. Of the oral medications available, most target ancillary aspects of wound care such as pain management, infection mitigation, and nutrition. This article describes oral pharmacologic agents intended to build new tissue and aid in wound healing, as well as an introduction to oral medications that interfere with wound healing. This review will not discuss the pharmacology of pain management or treatment of infection, nor will it address nutritional supplements.

The VCU Pressure Ulcer Summit: The Search for a Clearer Understanding and More Precise Clinical Definition of the Unavoidable Pressure Injury.

This article reports the findings of the Unavoidable Pressure Ulcer Committee (of the VCU Pressure Ulcer Summit) that was tasked with addressing key issues associated with pressure injuries that are unavoidable or unpreventable. Our goals were (1) to clarify nomenclature and descriptions surrounding "terminal ulceration," (2) to describe the medical complications and comorbid conditions that can lead to skin failure and/or terminal ulceration, (3) to describe the variable possible causes of unavoidable pressure injuries, and (4) to present clinical cases to exemplify pressure injuries considered to be unavoidable.

Secondary analysis of office of inspector general's pressure ulcer data: incidence, avoidability, and level of harm.

PURPOSE: To provide information about a secondary analysis of pressure ulcer data regarding incidence, avoidability, and level of harm. TARGET AUDIENCE: This continuing activity is intended for physicians and nurses with an interest in skin and wound care. OBJECTIVES: After participating in this educational activity, the participant should be better able to:1. Summarize the data provided in the Office of Inspector General (OIG) study regarding incidence of pressure ulcers (PrUs) found in hospitals and skilled nursing facilities (SNFs).2. Identify the classification systems used that designate levels of harm to patients and the avoidability of PrUs. OBJECTIVE: To investigate in greater detail the government data on pressure ulcer (PrU) incidence, avoidability, and level of harm. DESIGN: The authors performed a secondary analysis of PrU data published in 2 studies by the Office of Inspector General (OIG) on adverse events in hospitals and skilled nursing facilities (SNFs). SETTING: Acute care hospitals and Medicare-certified SNFs across the United States. PATIENTS: The hospital sample included 780 Medicare beneficiaries randomly selected from 999,645 discharges during October 2008. The SNF population included 653 Medicare beneficiaries randomly selected from 100,771 patients whose stay began within 1 day of hospital discharge, who had a length of stay of 35 days or less, and whose stay ended in August 2011. MAIN OUTCOME MEASURES: Pressure ulcer incidence with stage, location, avoidability, and level of harm using the Modified National Coordinating Council for Medication Errors Reporting and Prevention Index. MAIN RESULTS: The PrU incidence in hospitals was 2.9%, and the incidence in SNFs was 3.4%. Most PrUs were Stages I and II, with 78.3% in hospitals and 54.5% in SNFs. The avoidability of PrUs was similar in both locations, with 39.1% unavoidable in hospitals and 40.9% unavoidable in SNFs. All hospital-acquired PrUs and 90.9% of SNF-acquired PrUs were designated level E on the National Coordinating Council for Medication Errors Reporting and Prevention Index, indicating a temporary harm event. CONCLUSIONS: The OIG studies captured few Stage III PrUs and no Stage IV PrUs, and they underestimate the level of harm generated from PrUs in hospitals and SNFs. The studies offer a structured algorithm for avoidability determination, but lack measures of reliability and validity. Nonetheless, the high rate of unavoidable ulcers leads to questions on the reliability of PrUs as a quality indicator. There are several weaknesses in OIG methodology with regard to PrUs; however, its structured algorithm can be viewed as a starting point for future studies of PrU avoidability.

Pressure Injuries and Skin Failure.

Pressure injuries are a common chronic wound in the older adult. Care of pressure injuries is an interprofessional effort and involves physicians, nurses, registered dieticians, rehabilitation therapists, and surgical subspecialties. Numerous treatment modalities exist but have varying evidence to substantiate their efficacy. All primary and other care providers, particularly geriatricians, need to be aware of current evidence-based prevention and treatment standards. When healing is not expected, palliative care should be considered to avoid futile procedures and preserve dignity and quality of life.

Infectious Aspects of Chronic Wounds.

The treatment, maintenance, and suppression of infection in chronic wounds remain a challenge to all practitioners. From an infectious disease standpoint, knowing when a chronic wound has progressed from colonized to infected, when to use systemic antimicrobial therapy and when and how to culture such wounds can be daunting. With few standardized clinical guidelines for infections in chronic wounds, caring for them is an art form. However, there have been notable advances in the diagnosis, treatment, and management of infected wounds. This article will discuss the pathophysiology of infection in older adults, including specific infections such as cutaneous candidiasis, necrotizing soft tissue infection, osteomyelitis, and infections involving hardware.

Dakin's solution: past, present, and future.

Dakin's solution has been used for almost a century. It is a dilute solution of sodium hypochlorite, which is commonly known as household bleach. When properly applied, it can kill pathogenic microorganisms with minimum cytotoxicity. This article reviews its history and discusses how evolving technology might pave the way for a new role for this antiseptic.

Pressure ulcer knowledge in medical residents: an opportunity for improvement.

With the aging population and increasing complexity of patients with pressure ulcers (PrUs), as well as regulatory requirements, PrUs have become an important concern for physicians. Although there are some studies that measure nurses' knowledge of PrUs, there is a paucity of literature about physician knowledge of PrUs. Given that the Centers for Medicare & Medicaid Services is holding physicians accountable for documenting PrU status on admission to hospitals and the increased need for collaboration with revisions to long-term-care documentation MDS 3.0: Skin Condition, physicians' knowledge regarding PrUs takes on new urgency. This study reports on PrU knowledge of physicians using 2 tools: the Pieper Pressure Ulcer Knowledge Tool and a wound photograph test. Physicians' mean scores of 69% on the Pieper Tool were well below average scores of nurses' 76%. Physicians had greatest difficulty identifying suspected deep tissue injury and unstageable ulcers. Pressure ulcer content, including prevention, identification, staging, and treatment, needs to be included in physician education.