The Best Type of Care - Literature review Example

?Running head: WOUND CARE Wound Care (school) Wound Care Introduction First of all, a wound is basically a break in the skin, particularly, the outer layer (epidermis) of the skin (Durkin, 2011). This is often caused by physical injuries including cuts, scrapes, and similar injuries. Wound care is part of the healing process which involves the different responses to injury for the wound and the processes which facilitate wound healing, including the following activities: stop bleeding, preventing infection, and promote healing (Durkin, 2011). These processes encompass the concept of wound care. Wound care is a crucial part of the medical practice. It prevents infection and blood loss, as well as further complications for the patient. There are various techniques which health professionals can apply in order to manage wounds. Such management strategies are supported by various studies and evidence in actual practice. This study shall consider literature and supporting researches in wound care, with particular attention given to patient preference and evidence-based practice. With the variety of applications which can be used for skin care, there is a need to consider the best type of care according to patient response and outcomes. Wound care All injuries trigger a series of events which are involved in healing, characterized by the arrival of platelets and inflammatory cells at the site of injury (Diegelmann and Evans, 2004). These cells also give off signals on the influx of connective tissue cells and on the increase of new blood. Chemical signals for these are the cytokines or growth factors. The fibroblasts are the connective tissues which mark collagen deposition essential for tissue injury (Diegelmann and Evans, 2004). In response to injury, platelets come into contact with exposed collagen. With platelet aggregation, clotting elements are released causing the formation of a fibrin clot at the injured area. The fibrin clot is considered the provisional matrix upon which healing is built on. Platelets facilitate clotting which helps control bleeding and loss of fluids and electrolytes. As well as releasing the cytokines, which initiate healing, these platelets also release the platelet-derived growth factor (PDGF) and transform growth factor-beta (TGF-B). Through the PDGF, chemotaxis of neutrophils, macrophages, smooth muscle cells, and fibroblasts is initiated (Diegelmann and Evans, 2004). These platelets also trigger the mitogenesis of the fibroblasts and smooth muscle cells. The TGF-B also triggers the healing cascade by drawing in the macrophages and prompting them to release more cytokines (including the fibroblast growth factor-FGF, PDGF, TNFa and the IL-1) (Diegelmann and Evans, 2004). The TGF-B supports the chemotaxis of the fibroblast and the smooth muscle cells; it also regulates collagen and collagenase expression (Diegelmann and Evans, 2004). The overall result of these signals is a strong response of the matrix which then supports the release of cells which help ensure rapid formation of new connective tissue at the injured area during the proliferative stage of healing which follows the inflammatory phase (Diegelmann and Evans, 2004). Within 24 hours of the injury neutrophils are the common markers in the injury site. This neutrophil removes foreign material and bacteria in the wound site. Bacteria send of chemical signals which attract neutrophils, ingesting these through phagocytosis. These neutrophils will fill themselves with bacteria and make up the laudable pus in the injury site (Diegelmann and Evans, 2004). The mast cell is a market cell crucial to wound healing. These cells give off granules made up of enzymes, histamine, and numerous other active amines; they are also responsible for the signs of inflammation seen around the wound. The active amines in the mast cells trigger nearby vessels to become leaky; this causes the easy passage of mononuclear cells in the injured area (Diegelmann and Evans, 2004). Fluids also gather at the wound site and with this, signs of inflammation arise. The signs of inflammation include rubor (redness), calor (heat), tumor (swelling), and dolor (pain) (Diegelmann and Evans, 2004). Within 48 hours following an injury, fixed tissue monocytes are stimulated and become wound macrophages. These macrophages are crucial cells in the healing process because inhibiting these cells causes delays in the healing process (Leibovich and Ross, 1975). These macrophages also trigger the release of PDGF and TGF-B which then attracts the fibroblasts and smooth muscle cells in the wound sites. Such phagocytic macrophages are there to eliminate nonfunctional host cells, including the neutrophils, foreign debris and other bacteria in the wound site (Diegelmann and Evans, 2004). The wound macrophages in the wound site signify the end of the inflammatory phase, and the onset of the proliferative phase. Lymphocytes gather in the wound area during the latter stages, but are not considered major inflammatory triggers (Diegelmann and Evans, 2004). There are various types of problem wounds, the common ones include: diabetic foot ulcers, pressure ulcers, and the venous stasis ulcer (de la Torre, 2008). First of all, diabetic foot ulcers are the most common causes for foot and leg amputations in the US. Diabetic patients suffer from this disease at a rate of 2% per year. This is mainly caused by the nerve impairment of muskoskeletal balance, including immune compromise from leukocyte dysfunction and peripheral vascular disease which cause more complications of infected wounds (de la Torre, 2008). This type of wound has a high level of growth factors, hence the slower speed of healing for these types of injuries. The second type of problems wounds are pressure ulcers which are caused by ischemia triggered by the prolonged exposure over bony protrusions in the skin. They are usually seen in paralyzed or comatose patients or any other patient with limited mobility that are often confined to their beds or chairs for prolonged periods at a time (Philips, et.al., 1994). Venous stasis ulcers are caused by lack of oxygen in areas where there is venous congestion, most especially in the lower extremities. The thick perivascular fibrin cuffs prevent oxygen from infiltrating surrounding areas. In some instances, growth factors are trapped by the macromolecules which are leaking into the perivascular tissue trap (de la Torre, 2008). In other instances, the leukocytes which are passing through the capillaries in a slower speed trap the growth factors and are activates in the vascular endothelium, thereby causing damage to the region (de la Torre, 2008). There are varied emerging concepts in chronic wound management. Since the incidents of chronic wounds increased in recent years and their cost of treatment also increased, various concepts have been considered in their management. For one, clinicians now understand the importance of support from the clinical effectiveness team and the clinical audit departments (Stevens, 2008). These teams assist in the data analysis and interpretation and in the establishment of clear and encompassing management methods. The importance of medical and surgical teams in wound assessment and management has also been established in the current practice (Stevens, 2008). In the current practice, more training and expert skills are now needed in order to adequately manage chronic wounds. Wound care teams must also be made available in each hospital or health institution in order to ensure that expert wound care is available for patients at all times and in most health care institutions (Stevens, 2008). The concept of patient-centered care is also an important consideration in wound care. With the variety of means now available in chronic wound management, there is a need to focus on what works best for individual patients, and not what works in general to different patients. The concept of mandatory staff training in wound assessment and management has also been acknowledged as an important part of wound care (Stevens, 2008). Staff training would help ensure that chronic wounds are adequately managed and are prevented altogether. The importance of providing support for wound care is also an important concept in chronic wound care. Research needs to catch up with chronic wound care in order to ensure that appropriate wound care methods are in place in the clinical setting. Main body Evidence-Based Practice Evidence-based practice refers to “the integration of best research evidence with clinical expertise and patient values to facilitate clinical decision-making” (Sacket, et.al., as cited by Melnyck and Fineout-Overholt, 2010, p. 242). This practice can be carried out with the use of results of research to the extent that they display effectiveness. It also involves the process of monitoring and assessment of practice in each case, most especially in the use of single system designs (Deming, n.d). It also includes the skills and commitment to learn and to search for new ways to serve clients. In essence, evidence-based practice involves the commitment in words and deeds to the different values of the helping professions, such deeds includes sensitivity, caring and concern “for the well-being, rights, and dignity of clients and consumers” (Deming, n.d). This study shall consider the case of a healthy 42-year old male who underwent an emergency operation under general anesthesia following a crush injury to his left a year ago. The surgical wound failed to heal after 6 months of dehisce and multiple infections. During such time, the wound was being dressed by the district nurse three times a week with Allevyn Gentle Border foam dressing, and other dressings, including Sorbsan Ribbon, were used based on the condition of the skin. Since the wound was clean and red, with little sign of new granulation occurring, and with the patient being fit and healthy with a good diet, the district nurse found it difficult to understand why it did not heal. The patient was then referred to the Tissue Viability Nurse. After the initial assessment, clinical signs indicated that the wound was stuck in the inflammatory stage and was non-healing. For three weeks the wound was treated with hydrofibre with a foam secondary dressing for exudate control. The peri-wound area was then treated with a combination of steroid ointment and Cavilon Barrier. The dressing was changed to Activon honey with Eclypse adherent dressing for two weeks. After two weeks, no improvement in the wound depth was seen. The wound appeared to be clean and manifested no signs of further infection and slough, however, exudates decreased. After further assessment, treatment with Promogran Prism and a foam secondary dressing was started. After four weeks a big improvement was seen and was followed by complete wound closure. From this experience the major question to arise in relation to evidence-based practice is on whether or not Promogran Prisma was the best available method of quick and effective chronic wound healing treatment. Consequently the following review of literature discusses the evidence relating to healing chronic wounds based on practice evidence. In a study by Lanzara, et.al., (2008), the authors set out to compare the use of the Pormogran Prisma compression versus the best standard treatment. The study was carried out as a randomized prospective controlled trial covering a population of 30 patient respondents with venous leg ulcers. The study revealed that patients were 4 times more prone to heal after treatment with Promogran Prisma with a more significant reduction in wound size seen in patients having been treated with Promogran Prisma, as compared to those being treated with the best standard treatment. In a similar study, Gottrup, et.al., (2010) sought to compare the use of Promogran Prisma and the best standard of care for 14 weeks. Their study was carried out as a randomized prospective controlled study with about 40 patients with diabetic foot ulcers. The study revealed that Promogran Prisma facilitated wound healing and protected the wound from any infection. To a more significant extent, wounds being treated with Promogran showed a clear reduction in size as compared to the wounds being treated with other standards of wound care. In effect, more wounds were infected in the control group and no wounds incurred infection in the Promogran Prisma group (Gottrup, et.al., 2010). In the paper by Cullen, et.al., (2009), the authors set out to study the effect of Promogran Prisma therapy on healing and wound biochemistry. The study was a clinical research assessing healing and wound biochemistry on patients with venous leg ulcers. The study revealed that as a result of Promogran Prisma therapy the inflammatory cytokines and protease levels were decreased after treatment and as the wound started to progress into the healing process (Cullen, et.al., 2009). The above studies provide support for the use of the Promogran Prisma, with most of the studies indicating faster and improved reduction of size of the wounds and facilitation of healing in the patient respondents undergoing Promogram therapy as compared to other patient treatments for other patients. Other wound healing options included in the study included the use of the Cavilon No Sting barrier cream. This cream was appropriately used for this patient because it “acts as a barrier against irritation from body fluids, protecting intact or damaged skin from urine and/or fecal incontinence, digestive juices, and wound drainage” (Twycross and Wilcock, 2001, p. 318). The cream prevented the area from wound drainage and irritation from the body fluids. In a study by Schuren, et.al., (2005) the authors set out to undertake a systematic review on the clinical performance and cost-effectiveness of film-forming liquid acrylate in protecting chronic ulcer peri-wound skin. The study established that using the acrylate Cavilon no-sting barrier film was safe and effective in protecting the peri-wound area of chronic ulcers. Compared with no treatment and placebo groups, those applied with Cavilon barrier creams experienced better integrity of the peri-wound skin. Moreover, benefits were seen in pain control and patient comfort due to lesser nursing time (Schuren, et.al., 2005). In yet another study on the use of the Cavilon barrier cream, Coutts, et.al., (2010) sought to compare the protective function of a protective acrylate skin barrier film. This was carried out as an open-labeled case series study which the patients being used as control in a split wound model. The authors compared the use of the Cavilon barrier cream and the traditional oxide ointment (Coutts, et.al., 2010). These products were assessed based on the following chronic wounds: venous stasis ulcers, diabetic foot ulcers, and pressure ulcers. The study revealed that all preparations had similar efficacy with the Cavilon barrier proving to be more effective as a skin barrier product. It was also more patient friendly, it allowed the visualization of the wound edges, and it was easier to apply in the actual practice (Coutts, et.al., 2010). The Activon honey with Eclypse adherent dressing was also used. It is a “low-adherent dressing which is impregnated with manuka honey” (Dealey, 2005, p. 103). Manuka, according to studies has antiseptic and antibacterial qualities and this antibiotic qualities is even greater compared to other types of honey (Rees, et.al., 2009). In effect, this Activon honey adherent dressing is more effective as compared to other wound dressings in preventing infection and in facilitating the healing process. Studies support the use of Activon honey. In a recent study by Rossiter, et.al., (2010) the authors set out to evaluate the possible impact of honey on angiogenesis, using in vitro analogues of angiogenesis and endothelial proliferation assay. The study revealed that all honey preparations assister in pseudotubule formation. Among the honeys tested, the manuka honey supported Activon was able to reduce infection as compared to other types of honey. The authors concluded that the use of Activon honey supports the use of honey in wound dressing which helps prevent the penetration of the active elements of infection (Rossiter, et.al., 2010). The use of maggots has also been considered for chronic wound debridement. In a review of studies by Chan, et.al., (2007) the authors established that the use of maggot debridement therapy has been safe and effective in chronic wound management. There are however various limitations in its applicability. Future developments in its use have been recommended by the authors. Hofman-Wellenhof, et.al., (2006) have also considered the use of teledermatology in wound management for patients having chronic leg ulcers. About forty-one chronic leg ulcers from 14 different patients were examined. The experts set forth wound assessment and various therapeutic recommendations. The study revealed a significant decrease in the visits to general physicians in the wound care centers. Patients favored the teledermatology, home-care nurses as well as wound experts also favored this process (Hofman-Wellenhof, et.al., 2006). All in all, the study revealed that teledermatology has a significant potential for chronic wound care and can be well accepted among patients and health care workers. Wolcott and Rhoads (2008) set out to assess the frequency of complete healing among subjects with chronic wound in a limb with critical limb ischemia managed with biofilm-based wound care (BBWC). The study revealed that out of 190 subjects with critical limb ischemia, about 146 or 77% healed completely and 23% were described as non-healing. The authors concluded that when healing patients with CLI, the use of BBWC is significantly more effective. These results indicate that managing the biofilm in chronic wounds is a crucial element in order to transform non-healable wounds to healable ones (Wolcott and Rhoads, 2008). In a study by Vuerstaek, et.al., (2006) the authors set out to compare vacuum-assisted closure with modern wound dressings. The study revealed that the average complete healing time for the wound was at 29 days in the vacuum-assisted group and 45 days for the control group. Wound bed preparation was shorter also for the vacuum assisted therapy group. Costs for wound care also registered at lesser numbers for VAC as compared to traditional healing methods (Vuerstaek, et.al., 2006). All in all the authors concluded that VAC must be used as the preferred method of healing for chronic leg ulcers and conventional methods of healing must be discarded because they cost more and take up more healing time for patients. The above studies indicate varying methods of treatment for chronic wounds. These approaches present evidence and options for treatment which are beyond the conventional methods of chronic wound treatment. These studies exemplify how their goals are geared towards shortening the healing process and ensuring that infection does not occur in the course of treatment. The studies also venture towards alternative and complementary medicine with the introduction of maggot debridement and with the use of honey as a means of easing the healing process. These alternative forms of treatment show much support from various researches with its thorough application in the different types of wounds and injuries. These research studies underwent clear and appropriate research methods with their application of statistics and specific research processes including analysis and data presentation. The questions raised were very much relevant issues in wound care and chronic wound treatment. The studies above were also able to present the available diverse methods of wound healing. They bring sharp focus to the fact that the conventional methods of treatment need to be updated and there are various available methods of treatment which health practitioners can consider. The research processes undertaken for the studies were based on logical and well-supported results found in the tables and statistical figures. The authors specified their methodology and ensured that ethical processes were followed while conducting their research. In comparing these researches with each other, the studies indicate strong support for the use of the Promogran Prisma. Other researches also break away from the use of conventional methods of healing for chronic wounds. Instead, they strongly support the use of honey, maggot debridement, and vacuum-assisted closures to ease the healing process. Based on the above analysis, the more effective method of healing may indeed be Promogran Prisma. The studies included in this research indicate a strong support for Promogran Prisma. The studies were able to specify the benefits of Promogran Prisma and they were able to evaluate its use in the actual clinical setting. This indicates a strong-support for evidence-based clinical practice in terms of chronic wound healing. Recommendation for future practice For the future practice, based on the above discussion, there is a strong support for the application of combined methods of chronic wound healing. The use of Promogran Prisma, and later the application of the Activon honey on the wound indicated much progress in the healing process for the wound. The various studies evaluated in this research also suggest different methods of wound healing. These methods of wound healing apply to different patients based on particular circumstances. It is therefore important to consider specific patient qualities before any particular method for treatment for the wound can be applied. This is the essence of evidence-based practice. Applied treatment methods must be supported by research. According to the above studies, the conventional methods of treatment, while they are relatively effective in treating chronic wounds, are no longer the only means of treatment available. There are now better and more effective means of treating, methods which heal chronic wounds in shorter lengths of time and which eventually do not cost as much for the patient. In the future practice, these methods of treatment must be instructed on all practitioners and in all health care settings. Trainings for wound care experts must be carried out in order to introduce these methods of healing. Most institutions must adapt adjustments in their methods of practice in order to ensure that these methods of healing are accommodated and incorporated into the health care setting. These are essential changes which must be gradually introduced into hospitals and other health institutions. Without these adjustments, the conventional methods of treatment would likely remain and would likely not improve wound healing. Wound healing must be taken seriously because it can potentially progress into more difficult areas of the practice, and it can affect the protection and treatment of patients. Works Cited Chan, D., Fong, D., Leung, J., Patil, P., & Leung, G. (2007). Maggot debridement therapy in chronic wound care. Hong Kong Med J., volume 13(5), pp. 382-386. Coutts, P., Queen, D., & Sibbald, G. (2010). Peri-wound Skin Protection: A Comparison of a New Skin Barrier vs. Traditional Therapies in Wound Management. Canadian Association of Wound Care. Retrieved 11 July 2011 from http://www.cawc.net/images/uploads/resources/Peri-wound_Skin_Protection.pdf Cullen, B. et al. (2009). PROMOGRAN PRISMA® therapy examining effect on healing and wound biochemistry. SAWC. Dealey, C. (2005). The care of wounds: a guide for nurses. Mississippi: Wiley-Blackwell. De la Torre, J. (2008). Wound Healing, Chronic Wounds. eMedicine. Retrieved 11 July 2011 from http://emedicine.medscape.com/article/1298452-overview#a30 Deming, W. (n.d). Evidence-Based Practice. Lyceum Books. Retrieved 11 July 2011 from http://www.lyceumbooks.com/pdf/Toward_Evidence-Based_Chapter_21.pdf Diegelmann, R. & Evans, M. (2004). Wound healing: an overview of acute, fibrotic, and delayed healing. Frontiers in Bioscience, volume 9, pp. 283-289. Durkin, W. (2011). Wound Care. eMedicine. Retrieved 11 July 2011 from http://www.emedicinehealth.com/wound_care/article_em.htm Gottrup F, et al. (2010). PROMOGRAN PRISMA® vs best standard of care for 14 weeks. EWMA. Lanzara, et.al. (2008). PROMOGRAN PRISMA® + compression vs best standard treatment (moist wound healing + compression) for 12 weeks. EWMA Hofmann-Wellenhof, R., Salmholder, W., Binder, B., Okcu, A., Kerl, H., & Soyer, H. (2006). Feasibility and acceptance of telemedicine for wound care in patients with chronic leg ulcers. 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Stevens, J. (2008). Chronic Wound Management-Clinical Need, Efficiency, Effectiveness, Financial planning. NHS Hounslow & West Middlesex University Hospital. Retrieved 11 July 2011 from http://www.arjohuntleigh.dk/admin/files/20081017131356.pdf Twycross, R. & Wilcock, A. (2001). Symptom management in advanced cancer. London: Radcliffe Publishing. Vuerstaek, J., Vainas, T., Wuite, J., Nelemans, P., Neumann, M. & Veraart, J. (2006). State-of- the-art treatment of chronic leg ulcers: A randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings. Journal of Vascular Surgery, volume 44(5), pp. 1029-1037. Wolcott, R. & Rhoads, D. (2008). A study of biofilm-based wound management in subjects with critical limb ischaemia. J Wound Care., volume 17(4): pp. 145-8. Read More