Preventing, assessing and treating skin tears.

Skin tears are acute wounds caused by mechanical forces resulting in the separation of the skin's outer layers. Skin tears are more likely to occur in vulnerable people such as older people and people with neurodegenerative conditions. Rising life expectancy means that the number of patients with skin tears is expected to increase. This article describes the characteristics of skin tears, details the risk factors for skin tears and explains the importance of using a holistic, evidence-based and person-centred approach to skin tear prevention, assessment and treatment. The article outlines the crucial role of nurses as part of the multidisciplinary team in the management of skin tears.

Does in-shoe pressure analysis to assess and modify medical grade footwear improve patient adherence and understanding? A mixed methods study.

BACKGROUND: Medical grade footwear (MGF) with demonstrated plantar-pressure reducing effect is recommended to reduce the risk of diabetes-related foot ulceration (DFU). Efficacy of MGF relies on high adherence (≥ 80%). In-shoe pressure analysis (IPA) is used to assess and modify MGF, however, there is limited evidence for the impact on patient adherence and understanding of MGF. The primary aim of this study was to determine if self-reported adherence to MGF usage in patients with previous DFU improved following IPA compared to adherence measured prior. The secondary aim was to determine if patient understanding of MGF improved following in-shoe pressure analysis. METHODS: Patients with previous DFU fitted with MGF in the last 12 months were recruited. The first three participants were included in a pilot study to test procedures and questionnaires. MGF was assessed and modified at Week 0 based on findings from IPA using the Pedar system (Novel). Patients completed two questionnaires, one assessing patient adherence to MGF at Week 0 and Week 4, the other assessing patient understanding of MGF before and after IPA at week 0. Patient understanding was measured using a 5-point Likert scale (strongly disagree 1 to strongly agree 5). Patient experience was assessed via a telephone questionnaire administered between Weeks 0-1. RESULTS: Fifteen participants were recruited, and all completed the study. Adherence of ≥ 80% to MGF usage inside the home was 13.3% (n = 2) pre-IPA and 20.0% (n = 3) at Week 4. Outside the home, ≥ 80% adherence to MGF was 53.3% (n = 8) pre-IPA, and 80.0% (n = 12) at Week 4. Change in scores for understanding of MGF were small, however, all participants reported that undergoing the intervention was worthwhile and beneficial. CONCLUSIONS: Self-reported adherence inside the home demonstrated minimal improvement after 4 weeks, however, adherence of ≥ 80% outside the home increased by 27%, with 80% of all participants reporting high adherence at Week 4. Participants rated their learnings from the experience of IPA as beneficial.

A service evaluation to examine the use of compression strapping for the management of patients with retromalleolar leg ulcers in a specialist community setting.

Leg ulcers are costly to the NHS, and they have a significant impact on patients' physical, social, and psychological well-being. Compression therapy is traditionally the "gold-standard" treatment for the management of venous leg ulcers and can be beneficial for those individuals with mixed ulcer aetiology. Evidence suggests that the application of standard, strong, graduated compression bandaging does not apply therapeutic compression to the retromalleolar fossa. The addition of compression strapping has been found to increase sub-bandage pressure, promote healing, reduce pain and increase quality of life in patients with retromalleolar leg ulcers. This service evaluation aimed at evaluating the use of compression strapping with patients with retromalleolar leg ulcers. The service evaluation included 24 patients with 41 ulcers treated with compression strapping by a specialist team. Patients treated with CS had multiple comorbidities and shared common characteristics including foot and ankle oedema, previous ulceration, reduced mobility, and failure to heal despite the application of "gold-standard" compression therapy. Following application of compression strapping, 17 patients (n = 27/41 ulcers) healed, mean pain scores decreased, and mean quality of life scores increased. The compression strapping was tolerated well, and patients reported a positive experience. This service evaluation has contributed towards a growing evidence base that supports the use of CS for the management of patients with retromalleolar leg ulcers.

Evidence-based review of the effects of nutritional supplementation for pressure ulcer prevention.

The objective of this evidence-based review was to explore whether the evidence supports the use of nutritional supplements in pressure ulcer (PU) prevention strategies. Several electronic databases, including Ovid MEDLINE (1946 to May week 32 019), Ovid EMBASE (1947 to May 28, 2019), EBSCO CINAHL (until June 13, 2019), Scopus (until July 9, 2019), and the Web of Science (until June 13, 2019) were searched. No limitation was placed on the year of publication. Studies considered for inclusion were those with adult populations, and only English language texts with available full text were reviewed. AMSTAR (a measurement tool to assess systematic reviews) was used to evaluate the quality of the studies included in the systematic review. The Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 Levels of Evidence was used to assess the level of evidence. Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) was used to assess guideline article, and Appraisal tool for Cross-Sectional Studies (AXIS) was also used for cross-sectional studies. The search identified 1761 studies. After the application of inclusion and exclusion criteria, 24 studies were retained of various designs, including 10 systematic reviews, five clinical reviews, three randomised controlled trials, two observational studies, one quasi-experimental study, one cross-sectional study, one cohort study, and one Clinical Guideline. Two were rated as high-quality reviews, 14 were rated as moderate-quality reviews, five were rated as low-quality reviews, and three were rated as critically low-quality reviews. The majority of the reviewed studies were of low-to-moderate quality because of biases in the study design and incomplete data reporting, which did not fulfil the reporting criteria of the appraisal tools. However, the majority of the studies showed a reduction in PU incidence after nutritional supplement though not significant. Whether the use of pharmacological appraisal tools to assess non-pharmacological studies is appropriate is unclear. Regardless of the low-to-moderate quality of the studies in this review, nutritional supplements appear to play a role in PU prevention.

The measurement properties of assessment tools for chronic wounds: A systematic review.

BACKGROUND: Chronic wounds are an increasing problem in the aging population, patients experience a lower health-related quality of life and the care for these patients is associated with high costs. Thorough wound assessments facilitate objective monitoring of wound status and progress. A wound assessment tool can guide clinicians in these wound assessments and in recording wound progress or deterioration. OBJECTIVE: Systematically identify assessment tools for chronic wounds, investigate their measurement properties, and summarize the data per assessment tool. DESIGN: Systematic review METHODS: The databases Medline (PubMed interface), Embase, CINAHL, and CENTRAL were systematically searched until May 2020 (updated in February 2021). Studies reporting the development and/or the evaluation of measurement properties of assessment tools for chronic wounds were included. The "Consensus-based Standards for the selection of health Measurement Instruments" risk of Bias checklist was applied to evaluate the methodological quality of the included studies. Each reported measurement property was rated against criteria for good measurement properties. The evidence was summarized and the quality of the evidence was graded using a modified Grades of Recommendation, Assessment, Development, and Evaluation approach. Study selection, data extraction and quality appraisal were conducted independently by two reviewers and double-checked by a third reviewer. RESULTS: Twenty-seven studies describing the measurement properties of fourteen assessment tools for chronic wounds were included. None of the studies reported a content validity evaluation by a relevance study or a comprehensiveness study in professionals. Six articles reported the development or revision of an existing assessment tool. The reported measurement properties included: structural validity (5 studies), reliability (18 studies), hypotheses testing for construct validity (18 studies) and responsiveness (7 studies). Internal consistency, cross-cultural validity / measurement invariance and measurement error were not reported. If criterion validity was assessed, the results were allocated to hypotheses testing for construct validity as no 'gold standard' is available. CONCLUSIONS: Fourteen assessment tools for chronic wounds were identified. Construct validity (by hypotheses testing) and responsiveness of the Pressure Ulcer Scale for Healing version 3.0 were supported by sufficient ratings based on moderate to high level quality of evidence. Reliability of the (Revised) Photographic Wound Assessment Tool had a sufficient rating based on moderate quality of evidence. The ratings of the measurement properties of the other wound assessment tools were either insufficient or indeterminate, or a sufficient result was supported by low to very low quality of evidence. Registration number in PROSPERO: CRD42020183920 Tweetable abstract: A systematic review giving a clear overview of the measurement properties of available assessment tools for chronic wounds.

Periwound skin care considerations for older adults.

This article discusses the effects of ageing on the skin, particularly the main structural and functional changes that occur in the epidermis and dermis that make the skin more vulnerable to damage. Specific alterations that occur with ageing include slower epidermal turnover, flattening of the epidermal-dermal junction, loss of moisture and hydration as well as reduced immunity placing the skin at increased risk of damage. The discussion will also examine common periwound complications associated with ageing including; maceration, excoriation, dry skin, hyperkeratosis, callus, contact dermatitis and eczema. Strategies to manage these problems and interventions to reduce the risk of these complications include moisturising the skin to make it more resilient, debriding keratinised and callus tissue in the periwound area, appropriate choice of dressings to manage excessive exudate, careful removal of dressings as well as treating inflammatory conditions of the periwound skin.

Modified compression therapy in mixed arterial-venous leg ulcers: An integrative review.

Leg ulcers remain an increased burden to healthcare cost and morbidity in modern society. While most leg ulcers are venous in origin, recognition and prompt identification of concomitant arterial occlusive disease is critical to determine underlying aetiology and subsequent management. This integrative review presents the current evidence to establish the role of modified compression therapy (MCT) in treatment of mixed arterial venous leg ulcers (MAVLU). A literature search was conducted using the electronic databases CINAHL, MEDLINE, PUBMED, and Embase. Ten studies met the eligibility criteria and were subsequently analysed. Our review concludes that MCT, with compression pressures between 20 and 30 mmHg, can promote healing in MAVLU with moderate arterial insufficiency (0.5 ≤ ABPI ≤0.8). If ABPI is <0.5, MCT can be considered once restoration of acceptable ABPI is achieved. Intolerance, lack of response or further deterioration of disease within 3 months should prompt further arterial imaging and intervention. MCT is generally well tolerated with no adverse outcomes reported. A holistic yet individualised approach is vital in order to account for all factors influencing this patient-led decision-making process, ultimately ensuring effective treatment, which improves patient's quality of life and reduces socioeconomic burden of the disease.

Development and psychometric property testing of a skin tear knowledge assessment instrument (OASES) in 37 countries.

AIM: To develop and psychometrically evaluate a skin tear knowledge assessment instrument (OASES). DESIGN: Prospective psychometric instrument validation study. METHOD: The skin tear knowledge assessment instrument was developed based on a literature review and expert input (N = 19). Face and content validity were assessed in a two-round Delphi procedure by 10 international experts affiliated with the International Skin Tear Advisory Panel (ISTAP). The instrument was psychometrically tested in a convenience sample of 387 nurses in 37 countries (April-May 2020). Validity of the multiple-choice test items (item difficulty, discriminating index, quality of the response alternatives), construct validity, and test-retest reliability (stability) were analysed and evaluated in light of international reference standards. RESULTS: A 20-item instrument, covering six knowledge domains most relevant to skin tears, was designed. Content validity was established (CVI = 0.90-1.00). Item difficulty varied between 0.24 and 0.94 and the quality of the response alternatives between 0.01-0.52. The discriminating index was acceptable (0.19-0.77). Participants with a theoretically expected higher knowledge level had a significantly higher total score than participants with theoretically expected lower knowledge (p < .001). The 1-week test-retest intraclass correlation coefficient (ICC) was 0.83 (95% CI = 0.78-0.86) for the full instrument and varied between 0.72 (95% CI = 0.64-0.79) and 0.85 (95% CI = 0.81-0.89) for the domains. Cohen's Kappa coefficients of the individual items ranged between 0.21 and 0.74. CONCLUSION: The skin tear knowledge assessment instrument is supported by acceptable psychometric properties and can be applied in nursing education, research, and practice to assess knowledge of healthcare professionals about skin tears. IMPACT: Prevention and treatment of skin tears are a challenge for healthcare professionals. The provision of adequate care is based on profound and up-to-date knowledge. None of the existing instruments to assess skin tear knowledge is psychometrically tested, nor up-to-date. OASES can be used worldwide to identify education, practice, and research needs and priorities related to skin tears in clinical practice.

Maggot Therapy in Wound Healing: A Systematic Review.

BACKGROUND: It is estimated that 2% of the population in developing countries suffer from a chronic wound, making it a hidden phenomenon that is increasing as populations age. The ease of access to maggot therapy has made it increasingly attractive for implementation. This study aimed to explore the effectiveness of maggot therapy as compared to hydrogel dressings in the healing of chronic wounds. METHODS: An electronic literature search until October 2019 was performed using Medline, Embase, and Cumulative Index of Nursing and Allied Health Literature. The eligibility criteria were chronic wound patients with an intervention that involved a comparison of any maggot species with hydrogel dressings. RESULTS: The full text of five studies, involving 580 patients with chronic wounds, was retrieved. Four studies used the Lucilia sericata species. The maggot therapy facilitated faster and more effective debridement of non-viable tissue. It enabled faster development of granulation tissue and increased reduction in the wound surface area compared to hydrogel dressings. Maggot therapy had no effect on disinfection or complete healing rate for the wound. CONCLUSION: Maggot therapy should be considered for faster wound debridement, granulation tissue development, and wound surface area reduction as well as in surgical contraindications. This review can be used as a guide to assist clinicians in identifying patients who may benefit from maggot therapy.

Validity and reliability of semi-quantitative wound swabs.

Wound infection is a common factor that delays wound healing. The diagnosis of wound infection should be based on clinical observations of the presence of classic signs of infection. There is also a role for microbiological investigation, for example, using semi-quantitative wound swabs, to help guide systemic treatment. However, there is still a debate about the most accurate method for taking a wound swab. This review explores the research evidence underpinning the use of semi-quantitative wound swabs, focusing on the validity and reliability of this method of assessment.

A clinimetric analysis of the Pressure Ulcer Risk Primary or Secondary Evaluation Tool: PURPOSE-T.

The assessment of patients' risk for developing pressure ulcers is a routine and fundamental nursing process undertaken to prevent avoidable harm to patients in all care settings. Many risk assessment tools are currently used in clinical practice, however no individual tool is recommended by advisory bodies such as the National Institute for Health and Care Excellence or the European Pressure Ulcer Advisory Panel. The evidence base on the value of structured risk assessment tools in reducing the incidence or severity of pressure ulcers is poor. This purpose of this article is to provide a clinimetric analysis of the recently developed Pressure Ulcer Risk Primary or Secondary Evaluation Tool (PURPOSE-T) and identify areas for future research to improve the utility of structured risk assessment in identifying patients at risk of developing pressure ulcers.

Skin tears: prevention and management.

Skin tears commonly occur at the extremes of age and are associated with skin changes in ageing skin. They are considered to be acute wounds caused by mechanical forces, such as blunt trauma. While the true prevalence and incidence of skin tears is unknown, the available evidence suggests that these wounds occur in all healthcare settings. Importantly, skin tears are preventable with the implementation of a risk-reduction programme, which includes twice-daily skin moisturisation. Where these injuries do occur, it is important to categorise the extent of damage as well as to choose the most appropriate dressing to avoid adding any risks for further trauma.

Skin considerations for older adults with wounds.

Ageing leads to a number of skin changes that not only place an older adult at risk of tissue damage, but can present as peri-wound problems for those with existing wounds, for example, incontinence-associated and moisture-associated dermatitis in individuals with pressure ulcers. Older adults with venous disease experience skin changes concomitant with venous hypertension, making the skin more at risk of breakdown, specifically the common complications of lipodermatosclerosis and venous eczema. In individuals with diabetic foot disease, skin changes related to autonomic neuropathy mean patients can experience dry skin that cracks easily, placing them at higher risk of infection. Common to all individuals with wounds requiring some sort of dressing is the risk of medical adhesive-related skin injury, where dressing application and removal need to be of the utmost priority to reduce the risk of injury. This article discusses some of the common peri-wound skin considerations in patients with chronic wounds.

A review of the effects of ageing on skin integrity and wound healing.

It is well known that advancing age is a factor that affects the normal course of wound healing. The population over the age of 65 years is increasing globally, and this may be accompanied by an increase in the number of individuals experiencing delayed wound healing. There is a breadth of research to show that age-related changes in the epidermis and dermis change the skin's ability to resist damage and injury. In particular, the dermoepidermal junction becomes flattened, which predisposes the tissue to shear and friction forces. Within the dermis, alterations in the amount and structure of collagen also mean that the tissue is much more rigid. Prompt assessment of the skin to identify existing conditions as well as preventive measures is therefore essential. This article discusses the anatomy of the skin and the effects of ageing on the tissues. It also offers some guidance on skin assessment and the basics of skin care.