Journals Watch 2002

This section features a regularly updated list of recently published articles relevant to nurse prescribing.

Abstracts of the papers are included and users are encouraged to submit their views about published papers through the feedback section.

Please note: In this section of the website we aim to cover articles on areas where nurses do prescribe. However, not all the treatments or appliances mentioned are prescribable by nurses. For that reason, nurses should check the up-to-date versions of the Nurse Prescribers’ Formulary for District Nurses and Health Visitors (NPF) and the Nurse Prescribers’ Extended Formulary (NPEF) and Drug tariff if they are in any doubt. Alternatively contact your Regional Nurse Prescribing Lead for clarification.

Click here to visit the 2001 archive of Wound and leg ulcer care

Wound and leg ulcer care
Click on the article titles below to read the summaries.

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  • Short-stretch bandages for venous leg ulcers

Adderley U and Nelson A. Know how: applying short-stretch bandages. Nursing Times 2002; 98(1): 40-41

Although widely used in Europe, short-stretch bandaging for venous leg ulcers is less well known in the UK. The idea is that, during exercise these bandages resist the expansion of the calf muscle, so that the muscle supports the deep veins. They exert a low resting pressure, which may have safety advantages.

The authors look at the possible advantages and explain how these bandages should be applied. They point out that although research comparing short-stretch bandaging and four-layer bandaging is lacking, the widespread use of the former in Europe does suggest clinical acceptance and efficacy.

Website: www.nursingtimes.net

 

  • January 2002 wound care supplement

Nursing Times 2002; 98(2): 47-67

This wound care supplement includes an article describing the nurse-led development of a wound care formulary, aimed at raising nursing standards. The dissemination of the formulary and its implementation are also discussed. Other articles cover the preparation of the wound bed, flexible approaches to leg ulcer care, how to manage wound sinuses, and a scan of recent research.

Website: www.nursingtimes.net


  • Compression bandaging for venous leg ulceration

Finnie A. Bandages and bandaging techniques for compression therapy. British Journal of Community Nursing 2002; 7(3): 134-143

This article examines the use of compression bandaging for venous leg ulcers, and highlights the importance of applying the correct bandage with the correct technique. The choice of bandage is discussed and the different techniques described. Pressure necrosis can result from incorrect application.

  • Tissue viability supplement: April

Nursing Standard 2002; 16(30): 51-80

This supplement contains articles on foot ulcers, pressure-relieving equipment and diabetes and wound management.

Website: www.nursing-standard.co.uk/

  • Chronic skin ulcers and atopic dermatitis in the NPEF

Courtenay M. Nursing Times 2002; 98(14): 52-54

After a review of the history of nurse prescribing, the author examines the treatment and management of chronic skin ulcers and atopic dermatitis under the extended formulary for independent nurse prescribers.

The use of compression bandaging and hosiery for chronic skin ulcers during and after healing is discussed. Available preparations for their treatment include silver sulfadiazine 1% cream and metronidazole gel 0.075% and 0.8%.

For atopic dermatitis, the use of emollients and corticosteroids is discussed along with other aspects of managing this condition.

Website: www.nursingtimes.net

 

  • Exuding wounds and their management

Fletcher J. Exudate theory and the clinical management of exuding wounds. Professional Nurse 2002; 17(8): 475-478
Although exudate has a valuable role in the wound-healing process, it can cause over-hydration and chemical damage. Thorough assessment and management of wounds with exudate has clinical benefits, according to the author of this article.

After examining the composition of exudate in different situations, and how it can cause over-hydration, the author discusses how exudate can be assessed by measuring its levels and noting its colour and consistency.

Management plans can include measures to address oedema, wound infection, hydrostatic pressure, and other factors that can influence exudate production. Absorbent dressing products such as foams and alginates are perhaps the most commonly used management method. It is difficult to compare absorbency levels objectively and the author looks at the different factors that can influence choice of dressing, including patients’ wishes. In some cases of wounds with high exudate levels, it may be better to allow the exudate to drain freely.


  • Preparation of the wound bed

Pudner R. Wound bed preparation. Journal of Community Nursing 2002; 16(5): 35

This is a report of a symposium sponsored by Smith and Nephew Healthcare about the new concept of wound bed preparation. This is said to allows maximum benefits to be obtained from advanced wound care products. Guidelines for wound bed preparation should focus on wound debridement, reduction of bacterial burden in the wound and controlling wound exudate.

Website: www.jcn.co.uk


  • Wound products: Telfa Clear

Edwards J. Product Focus. Telfa Clear. Journal of Community Nursing 2002; 16(5): 36-37

Telfa Clear appears to have all the benefits of more expensive low-adherent dressings but at half the cost, according to the conclusion of this article which examines the use of this dressing and the evidence for its efficacy.

Website: www.jcn.co.uk

 

  • Pretibial lacerations: treatment in the community

Ball C. The management of pretibial lacerations in the community. Journal of Community Nursing 2002; 16(6): 37-42

Although perceived by some patients as a minor injury, pretibial lacerations can be difficult to treat and can develop into leg ulcers. A conservative approach carried out in the community provides an alternative to surgery, avoiding the upheaval and other disadvantages of hospital admission. Most pretibial lacerations occur in women over 50.

Healing times associated with the more conservative approaches that are possible in the community are comparable to those for surgical methods. Assessment is, as ever, an important part of the nurse’s role in deciding which course is appropriate.

The author discusses the choice of dressing, which should provide a moist, warm environment. Non-adherent dressings are recommended and the different options are discussed. These wounds need to be seen early on, accurately assessed, and managed appropriately to achieve effective healing.

Website: www.jcn.co.uk

 

  • Choosing wound dressings for children

Casey G. Primary Health Care 2002; 12(5): 41-47

Choosing the most appropriate dressing for chronic wounds in children can be difficult because of the increasing number and complexity of dressings available to nurses and the lack of guidelines about their use in children.

This article looks at the four areas that nurses must understand to treat a wound:

  • the emotional and psychological impact of the wound on the child and parents
  • what caused the wound
  • the underlying factors that can contribute to delayed healing
  • how dressings can help maintain an ideal wound environment

Wounds resulting from minor injuries and surgical procedures are normally quick to heal and dressing selection is straightforward. A more complex challenge for the nurse is presented by wounds resulting from major injuries and chronic wounds associated with, for example, meningococcal septicaemia, immune deficiency, extravasation injuries or pressure sores.

After reviewing the features of an ideal wound environment, the author points out that an ideal dressing should:

  • remove excess exudate while maintaining high humidity
  • provide thermal insulation
  • be impermeable to pathogens
  • allow trauma-free removal
  • be cost-effective

Despite the importance of the wound environment, factors relating to the child and the location of the wound may ultimately determine choice of dressing.

Woven dressings, thin polyurethane films, hydrocolloids, alginates, polyurethane foams, hydrogels and other dressings are all described and their ability to protect, debride and absorb described.

Practitioners need to be able to assess claims made about particular dressings. Assessing clinical research can be difficult in practice and, in any case, there are few studies that look at wound healing in children. Dressing manufacturers will try to present their products in the most favourable light. Tissue viability specialist nurses can be extremely helpful in wound care decision-making.

It is extremely important that the wound and rate of healing are assessed regularly, as the treatment regime and type of dressing may need altering. All decisions should be well documented, particularly for really chronic wounds so that the child and parents are not always repeating information to health professionals.

The ultimate choice should based on a joint decision between child, parents and nurse. If one dressing is not satisfactory, another should be considered. The acceptability of a dressing to a child or parents may be as or more important than itAs performance in wound healing.

Website: www.primaryhealthcare.net

  • Tissue viability nursing and nurse prescribing

LayFlurrie K. The impact of prescribing in wound care on nurses and patients. Professional Nurse 2002; 17(11):661-664

Specialist nurses such as tissue viability nurses now have an opportunity to influence the education and support given to nurse prescribers as well as to use their own prescribing skills, according to the conclusion of this article looking at the impact of nurse prescribing initiatives on wound care.
Tissue viability nurses could adopt roles of educators, policy-makers and researchers, ensuring that evidence-based care is implemented and that nurses prescribing wound management products can assess a patient holistically, identify any factors that will delay healing and appreciate quality-of-life issues.
There is evidence that nurses turn to colleagues, product literature or company representatives when choosing wound management products instead of research-based evidence or clinical practice guidelines. New products will be added to the formulary, further complicating the choice. Tissue viability nurses have a role in developing and maintaining educational programmes for prescribers.

 

  • Wound care supplement: June

Nursing Times 2002: 98(25): 47-64

This supplement concentrates on the issue of leg ulcers, with articles about the Leg Ulcer Forum, prevention of heel pressure ulcers, leg ulcers and sickle cell, assessing the use of sterile dressing packs in the community, and health care in Nagorno Karabakh.

Website: www.nursingtimes.net

 

  • Tissue viability supplement: July

Nursing Standard 2002: 49-76

This supplement contains an editorial urging a standardised approach to classifying common wounds and measuring the success of treatment. The articles cover adverse reactions to wound dressings and how to manage them, a risk assessment and prevention audit project, and nurses’ roles in wound bed preparation.

Website: Nursing Standard

 

Cutting KF and White RJ. Avoidance and management of peri-wound maceration of the skin. Professional Nurse 2002; 18(1): 33-36

Maceration may delay wound healing and lead to complications and most practitioners are advised to try to avoid it. The authors argue that there is no evidence that moist wound healing is related to the development of maceration. Wound exudate in the correct quantities and constituency is useful in the healing process. To avoid maceration and optimise healing, exudate levels should be assessed, suitable dressings chosen and wear time estimated for every wound at every dressing change.

Managing exudate production means achieving a balance between wound desiccation and wetness. Several factors should be considered in choosing a dressing and establishing wear time. Alginate, foam, hydrofibre or hydropolymer dressings may be appropriate for wounds that tend to be ‘wet’ wounds. Additional secondary dressings, or more frequent dressing changes, will be required for wounds producing copious exudate.

Although it has been suggested that occlusive dressings can lead to maceration, they are not inherently likely to when used correctly. Partially occlusive dressings that rely on absorbency and moisture vapour transmission rate (MVTR) for fluid-handling may have a lower risk of inducing maceration. Dressings with a high MVTR and containing a variety of absorptive materials have the potential to avoid maceration and have increased wear time.

The peri-wound skin can be protected from the enzymes in chronic wound exudate using, for example, liquid paraffin/soft paraffin (50/50) or zinc oxide cream or ointment BP.

Other methods for managing exudate include topical antiseptic preparations such as impregnated dressings, systemic antibiotics and leg elevation and compression as appropriate. The use of topical corticosteroids is controversial but for leg ulcers they seem to be of benefit on the peri-ulcer skin in the presence of wet eczema. There is currently no evidence to support their use on the wound bed.
 

NT Plus 2002; 98(36):31-49

This supplement, published with the Leg Ulcer Forum, includes a discussion of what it is like to have a pressure ulcer, a recommended management pathway for venous leg ulcers using compression therapy, and a description of the applications of larval therapy and the case for its inclusion in the Drug Tariff.

Website: Nursing Times

 

Dowsett C. Why wounds fail to heal. Practice Nurse 2002; 24(5): 54-58

This article considers the reasons for wounds to fail to heal, highlighting the importance of good patient assessment taking into account the patient’s perspective and quality of life.

Factors that can delay wound healing can be divided into patient factors (age, underlying disease, mobility, nutrition, medication and psychosocial issues) and wound bed factors (tissue type, bacteria and infection, site and size of the wound, exudate levels, biochemical imbalance and inappropriate wound management).

The focus of care should initially be on addressing the underlying cause of the wound and then on the wound itself.

 

  • Advanced dressing materials in wound repair

Casey G. Wound repair: advanced dressing materials. Nursing Standard 2002; 17(4): 49-54.

Pharmaceutical products are now being incorporated into wound dressings. Nurses need to be able to select and use these as appropriate on the basis of up-to-date evidence.

This article describes the processes that occur in wound healing and the main biological molecules involved. An example of an advanced wound dressing is one that combines with matrix metalloproteinases to remove them from the wound bed. Although it looks like a dressing and is applied like one, it acts as a treatment.

Careful criteria should be adopted for advanced wound care products, as they are expensive and inappropriate use would lead to the conclusion that they are ineffective. Preliminary criteria could include: the current dressing must meet certain standards; the patient must be able to co-operate with and participate in, the new dressing regimen; the underlying disease process must be identified and treated if possible; and there must be no infection, foreign contaminants or necrotic tissue.

The quality of the data supporting manufacturers’ claims for their efficacy also need scrutiny. This requires knowledge of statistical and scientific methods and the author discusses the type of research that can produce good evidence.

Website: www.nursing-standard.co.uk

 

  • New techniques in wound therapy

Benbow. M. Modern wound technology. Practice Nurse 2002; 24(7): 52-58.

This article examines modern wound technologies including topical negative pressure therapy, using silver, larval therapy, and honey. The types of wounds where these can be used are discussed, as are the methods of application, costs and benefits.
 

Gray D. et al. Achieving value for money? Evaluation of two wound dressings. B J Community Nursing 2002; 7(10): 535-540

Nurses prescribing wound care products must achieve value for money, according to the authors of this article. Estimates of the annual cost of wound management products in the UK vary but it is clear that they represent a significant sum and one that has increased greatly in the last three decades. Although it is often assumed that the increased costs have been matched by improvements in clinical outcomes, there is not always evidence for this.

This study examines the use of superficial wound management products and secondary wound dressings. The authors propose a shortened list of seven criteria (usually 19) for a primary dressing for a superficial non-infected wound and a second list for a secondary dressing.

Using a series of 12 case studies, they conclude that selecting cheaper dressings over more expensive alternatives may offer cost savings while preserving high clinical standards. Although the cost savings were small on an individual basis, they would represent considerable savings projected across a primary care trust.
 

NT Plus 2002; 98(44): 43-63

This supplement, published in conjunction with the Leg Ulcer Forum, contains articles on bandaging technique for venous ulcers, compression bandaging, alleviating pain when changing wound dressings, neuropathic foot ulceration, assessing a problematic leg ulcer, best practice in leg ulcer assessment, and nutritional assessment in wound management.
 

Anderson I. Practical issues in the management of highly exuding wounds. Professional Nurse 2002; 18(3): 145-148

Highly exuding wounds can be difficult to manage and choosing the appropriate dressing crucial. Manufacturers are developing products that are more effective but it is important to recognize that dressings are only part of the story.
After looking at the implications of highly exuding wounds for professionals, patients and their carers, the author discusses the practical issues surrounding the use of dressings in these wounds. Nurses should understand how a particular product handles fluid so that it is not used inappropriately, with disappointing results.

Dressings are rarely accompanied by a precise figure for fluid capacity and determining this can be a subjective process. In any case, absorption will be influenced by, for example, clothes and bandages. The professional should be aware of the impact these factors may have on a particular dressing. The effect of applying tapes and additional dressings over primary dressings on moisture transmission is often underestimated.

Another common problem is the use of amorphous hydrogel dressings for heavily exuding wounds. Although these are indicated for sloughy or necrotic tissue, using them when the wound is also wet will add to the fluid levels. Applying creams or ointments to the wound bed or wound edges can block the passage of exudate into primary dressings.
Many primary dressings used to control fluid need a secondary dressing. Realistically, if the wound is very wet, this dressing will have to be changed frequently, even with an effective product. A balance between cost and additional fluid handling must therefore be sought, while protecting the surrounding skin. Other factors influencing choice of secondary dressing are considered.

The use of drainage pouches is then considered: there are more practical factors to consider here, such as the weight of the pouch when full, the patient’s circumstances and the size of the wound.

It would seem that cavity dressings are still sometimes packed tightly, despite instructions to the contrary. As the material absorbs fluid, it swells and tight packing inhibits this, reducing dressing capacity, causing pressure on the wound and allowing a fluid plug to build up behind the dressing material.

Choosing a size of a particular dressing and positioning it also requires the patient’s circumstances to be taken into account. The direction of flow of any leaked fluid will depend on the position and mobility of the patient.
Descriptive terms, such as wound dimensions, and how far fluid has travelled in a certain time, can be useful in capturing information about the exudate level and dressing performance, given the subjectiveness of exudate measurement in clinical practice.
 

Rees T. Use of compression therapy in venous leg ulceration. Nursing Standard 2002; 17(6): 51-56
Keywords: dressings, leg ulcers, patients: compliance

Compression bandaging has become the mainstay of treatment for patients with venous ulceration, but some patients are reluctant to comply with it or cannot tolerate the bandages. This article examines how compression therapy was adapted to suit the needs of a particular patient, establishing concordance, and leading to a satisfactory outcome.

Website: www.nursing-standard.co.uk

 

Collier M. Wound bed management: key principles for practice. Professional Nurse 2002; 18(4): 221-225
Keywords: bacterial burden, exudate, growth factors, oedema, necrotic tissues, well-vascularized wound bed, wound-bed preparation, wound-bed management, principles for practice.

The author explains the concept of wound bed management and argues that it should be considered for chronic wounds that are not progressing through a normal wound-healing process. Modern methods of promoting wound healing can be applied once the wound bed has been prepared. The relevant principles for practice are discussed and some of the techniques that can be used are examined.