Since I began working in a reconstructive surgery clinic several years ago, I have been exposed to a myriad of complex acute and chronic wounds that require advanced treatment modalities, such as Negative Pressure Wound Therapy (NPWT), in order to heal. These devices were new to me, and I quickly realized that they can be a source of great anxiety for both patient and clinician. I decided I needed more information and education on the topic. In Part 1 of this blog series, I will discuss the basics of NPWT, what it is, how it works, as well as risks and benefits.
What is Negative Pressure Wound Therapy (NPWT)?
Also known as vacuum-assisted wound closure (VAC), NPWT is the distribution of negative pressure across a wound1. The therapy, which emerged in the early 1980’s, includes the placement of a dressing (foam or gauze) onto the wound and is connected to a vacuum pump via tubing1
. A clear occlusive dressing is placed on top, forming an air tight closed system. Gentle, controlled suction is applied pulling wound debris into a collection chamber. The Food and Drug Administration (FDA) approved the first device for NPWT in 1997. Currently, there are over a dozen FDA approved devices available on the market1, many of which are small and lightweight, allowing patients full mobility3
. Due to varying designs, it is important that you become familiar with the manufacturer instructions for the specific device in use.
Which types of wounds benefit most from NPWT?
How effective is NPWT?
- Surgical wounds, especially those which need to heal by secondary intention1
- Open abdominal incisions1
- Dehisced surgical wounds1
- Skin flaps and preparation for skin graft sites1
- Traumatic wounds1
- Chronic wounds, such as venous insufficiency ulcers, diabetic foot ulcers, and pressure ulcers1,4
- Wounds at high risk for infection4
- Wounds with copious drainage4
- Meshed grafts, to either secure the graft in place or improve epithelialization4
- Adjunct to skin graft/flap procedure4
Compared to traditional forms of wound therapy, advantages of NPWT include:
What are the factors that increase a patient’s risk for adverse events with NPWT:
- Improved healing of transplanted skin and decreased length of hospital stay for patients receiving split thickness skin grafts.4
- Decreased wound infections in patients following orthopedic trauma and open fractures.4
- Improved wound healing, shorter length of stay, lower hospital mortality in patients with mediastinitis and unsuccessful wound healing following sternotomy.4
- Improved wound healing in patients with diabetes mellitus and gangrene that might require amputation.4
Are there any contraindications for NPWT?
- Increased risk for bleeding and hemorrhage2,3
- Anticoagulant or platelet aggregation inhibitor therapy2,3
- Friable or infected blood vessels2,3
- Vascular anastomosis3
- Infected wounds3
- Spinal cord injury2
- Enteric fistulas2
- Exposed organs, vessels, nerves, tendons, and ligaments3
- Inadequately debrided wounds2
- Necrotic tissue with eschar
- Untreated osteomyelitis2,3
- Cancer in the wound2,3
- Untreated coagulopathy2
- Unexplored fistulas
- Exposed vasculature, nerves3, anastomotic site3, vital organs2
While great strides have been made to improve the safety of NPWT devices, serious adverse events may still occur. Clinicians should take time to review specific device instructions for use, indications, and contraindications and adequate staff training should be provided. Healthcare providers that understand the principles of NPWT can then collaborate to ensure that each patient is selected appropriately for therapy based on wound type, risk profile and care setting. In Part 2
of this series, I will review the procedure for applying a NPWT dressing, general patient care, and tips to trouble-shoot the device.
Myrna B. Schnur, RN, MSN
1. Centers for Medicare and Medicaid Services. (2014) Negative Pressure Wound Therapy Technologies for Chronic Wound Care in the Home Setting. Retrieved from the Centers for Medicare and Medicaid Services: https://www.cms.gov/Medicare/Coverage/DeterminationProcess/Downloads/id96ta.pdf
2. Rock, R. (2014). Guidelines for Safe Negative-Pressure Wound Therapy: Rule of Thumb: Assess Twice, Dress Once. Wound Care Advisor, 3(2), 29 – 33.
3. Federal Drug Administration. (2009). FDA Preliminary Public Health Notification: Serious Complications Associated with Negative Pressure Wound Therapy Systems. Retrieved from the Federal Drug Administration: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm190658.htm#table1
4. Wound Care Centers. (2016) Negative Pressure Wound Therapy. Retrieved from Wound Care Centers: http://www.woundcarecenters.org/article/wound-therapies/negative-pressure-wound-therapy
This topic came up a couple of times recently – once, in a conversation with nurse faculty preparing courses for undergraduate students; the second, during the Keynote Address at the Dermatology Nurses’ Association Convention. The faculty members were questioning which term – patient or client – is appropriate for use in the academic setting. In her Keynote, Everyday Ethics for Nurses in Everyday Practice,
Leah Curtin, ScD(h), RN, FAAN touched on this topic and even dug deeper into the roots of each of the words, encouraging the audience to make their own decisions regarding the appropriateness of each term.
Here’s a closer look at the terms ‘patients’ and ‘clients.’
- Comes from the Latin word, patior, which means ‘to suffer’
- Defined as ‘one who suffers’
- Comes from the Latin word, clinare, which means ‘to lean’
- Defined as ‘one who is the recipient of a professional service’
Based on the word roots and definitions, some may feel that the term ‘patient’ indicates a hierarchical relationship, where the term ‘client’ signifies a more collaborative relationship. It’s interesting then that many authors, clinician and non-clinician, use the terms interchangeably or even simultaneously. For example, “patient or client self-report measures” or “patient/client safety” is often found in the literature. However, we know that the written word is not how we speak and I’ve yet to hear a colleague ask “Is the patient/client NPO?” or say “The patient/client needs a new IV inserted.”
I was surprised during a search on this topic, to find that this is not a new discussion. In a 1997 article
from the Canadian Medical Association, Peter C. Wing, MB, ChB found that use of the term “client” was documented as early as 1970. He also shares results from his survey of 101 people attending an ambulatory back-pain clinic; almost ¾ of those surveyed stated a preference for ‘patient’ rather than ‘client.’
Personally, I can’t imagine referring to a person in my care as a client. It just sounds unnatural to me. Which do you prefer?
For whom do you care – patients or clients?
Farlex, Inc. (2016, April 8). Retrieved from The Free Medical Dictionary: http://medical-dictionary.thefreedictionary.com/
Wing, P. (1997). Patient or client? If in doubt, ask. Canadian Medical Association, 287-289.
Posted: 4/13/2016 9:18:24 AM
Lisa Bonsall, MSN, RN, CRNP
| with 6 comments
Are you looking to advance your nursing career by either writing for a nursing journal or reviewing the work of other nurses? Medical publishing is a vast and growing industry, and we need experienced nurses who are looking to advance their own career and the nursing profession as a whole by creating content and evaluating the content of others.
Right now, Wolters Kluwer is seeking freelance clinical editors for Lippincott Procedures
and Lippincott Advisor
. Lippincott Procedures
hosts over 1,600 evidence-based procedures used by nurses and other health care personnel caring for patients in acute, long-term, and ambulatory care settings worldwide. Lippincott Advisor
houses a variety of entries in categories, such diseases, signs and symptoms, diagnostic tests, healthcare acquired conditions, sentinel events, and more. We need clinical editors to ensure that assigned product entries are current, accurate, and evidence based. Learn more about this opportunity and the application process.
Wolters Kluwer also publishes over 50 Lippincott nursing journals
seeking credible nurses to submit journal articles to be published. These journals, including American Journal of Nursing
, Computers Informatics Nursing
, and Nursing2016 Critical Care
, are interested in hearing from you and learning more about your ideas for upcoming journal issues. Read more about How to Write for Our Nursing Journals
Posted: 4/11/2016 2:24:53 PM
| with 0 comments
Categories: Education & Career
This March, I traveled to the 2016 NSNA Annual Convention
at the Disney Coronado Springs Resort in Orlando from March 30 – April 3. This was the first time NursingCenter attended this event, and I was really looking forward to all that the National Student Nurses Association (NSNA) had in store.
On the first day of the exhibit hall opening, I could see a line of eager and excited nursing students around the convention center hall. With over 3,000 students in attendance, I knew this was going to be an exhilarating day.
As the doors to the hall opened, a flood of nurses entered the room and started making their way to the different booths. The NursingCenter team was ready with tons of free nursing tip cards
, black notebooks, pens, and flyers. Wolters Kluwer also hosted interactive events, including video interviews and their very own WKNurseEd Instagram
I loved getting to know the nursing students and discover how they use our site and our other Wolters Kluwer products, like Lippincott CoursePoint
, and our LWW nursing textbooks
After the exhibit hall closed, I was able to enjoy the Coronado resort
, which hosts a 22-acre lake (and even small alligators!), a giant pool with a 50-foot replica of a Mayan temple, and a number of hammocks to kick back in after a long day. I can’t wait to be back at this resort when I attend the National Conference for Nurse Practitioners
Are you attending any nursing conferences this year? Check out our Nursing Events Calendar
for an entire conference listing. Don't forget about NursingCenter's Tips & Timesavers for Conference Attendees
Posted: 4/8/2016 8:25:40 AM
| with 0 comments
Categories: Continuing Education
As National Nutrition Month comes to an end, I am reminded how nutrition isn’t just about cutting calories and eating healthy. There is so much more that we don’t think about on a regular basis, unless it affects the patients in our care or our personal lives.
I regularly visit an adolescent sports medicine facility with one of my children. The clinicians there deal with a variety of conditions and issues, ranging from orthopedic injuries and concussions to eating disorders and, in our case, impaired growth related to caloric expenditure through sport.
Some people may see a kid who is fit and active and think “Wow, he is so lucky!” I see a kid who is competitive to the point that his growth charts have taken some sharp declines during a critical adolescent growth period. While I’m proud of his commitment and determination, I also am concerned for his growth and development.
We are fortunate to have a great resource in our area that has helped us turn things around for my son. He is a swimmer and a runner who trains for hours each day, and to meet his nutritional needs for sport and catch-up growth, he must take in over 5,000 calories each day! Sounds easy, right? Actually, it is a challenge and requires quite a bit of hard work. I ask that you let this post serve as a reminder to be open to the struggles of others; sometimes the problems they face aren’t as simple as you may think.
For some related reading on this topic and more on nutrition, explore Nutrition Today
, a journal with articles written by “leading nutritionists and scientists who endorse scientifically sound food, diet, and nutritional practices,” including the following related to sports nutrition:
NursingCenter is celebrating Certified Nurses Day
, which happens every year on March 19th. Why March 19th? It happens to be the birthday of the pioneer and inspiration behind nurse certification, Margretta "Gretta" Madden Styles, RN, EdD, FAAN.
While we would have been beyond thrilled and honored to interview this innovator in the nursing profession, sadly, Styles passed in 2005 after a long, successful life and career. We thought we would adjust our ‘Nurse on the Move’ blog to feature one of the top ‘Nurses Who Moved’ and truly shaped the profession.
Life and Education
Styles was born in Pennsylvania in 1930. She was married to her husband for 47 years, Reverend Douglas Styles, and the couple had three children.
Styles attended Juanita College and earned undergraduate degrees in biology and chemistry. She went on to Yale University to earn her master’s degree in nursing and then on to the University of Florida, where she earned her doctorate in education.
Nurse educator, author, and innovator
Styles started teaching as an associate professor in 1967 at Duke University and then moved on to become the dean of nursing at various universities, including University of Texas Health Science Center at San Antonio, Wayne State University in Detroit, and the University of California, San Francisco.
Styles campaigned and advocated for stricter certification requirements and credentialing standards for nurses. She wrote at great length on this topic and later helped to create the American Nurses Credentialing Center (ANCC). Her influence on refining the nursing profession in the U.S., extended internationally, and, for a time, Styles also served as president of the Internal Council of Nurses.
While her legacy will always be tied to her role in the creation of the ANCC, her impact on the nursing profession is still widely prevalent. She is often quoted and referenced in medical publications and has had many awards and grants named in her honor. Styles was also inducted into the American Nurses Association hall of fame.
And, of course, the profession will continue to honor Styles’ work and accomplishments on her birthday every March 19th for Certified Nurses Day.
Happy Birthday, Gretta and Happy Certified Nurses Day! Be sure to check our Certified Nurses Day
page on March 19th for lots of great resources and deals to honor this special day.
By Kim Fryling-Resare
Posted: 3/14/2016 8:07:11 AM
| with 1 comments
Last month, new definitions for sepsis and septic shock (Sepsis-3) were released and published in the Journal of the American Medical Association (JAMA). The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)
is the work of a consensus panel of experts from the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. There have been multiple revisions and evolutions to the definitions of sepsis and treatment strategies over the years as we continue to increase our understanding of the complex biology of sepsis and the physiologic effects of sepsis on the body. We are constantly adapting this knowledge to clinical practice. Despite advances in our understanding of sepsis biology, it remains a condition associated with high morbidity and mortality worldwide. Despite constant advances in pharmacologic treatments and organ support devices (i.e. mechanical ventilation, renal replacement therapies, etc.) early identification and treatment of patients with sepsis remains the cornerstone of improving survival. The new definitions simplify the classification of sepsis and provide tools to identify those with suspected infection that are at risk of developing complications of sepsis by utilizing the Sequential (sepsis-related) Organ Failure Assessment (SOFA)
and qSOFA scores.
The new definitions and risk assessment scores take the focus off inflammation and place it on the organ dysfunction related to the dysregulated host response that is sepsis. In fact, Sepsis-3 defines sepsis as “Life-threatening organ dysfunction caused by a dysregulated host response to infection (Singer et al. 2016).” A lay term definition is also provided in the article describing sepsis as “a life-threatening condition that arises when the body’s response to infection injures its own tissues and organs” (Singer et al. 2016). This provides helpful terminology in speaking with families about the complex and complicated condition.
Why the change?
Prior to the release of Sepsis-3, healthcare providers generally referred to four different levels of sepsis: systemic inflammatory response syndrome (SIRS), sepsis
(SIRS in response to a confirmed infectious process), severe sepsis
(sepsis plus organ dysfunction as evidenced by hypotension or hypoperfusion to one or more organs), and septic shock
(sepsis with persisting arterial hypotension or hypoperfusion despite adequate fluid resuscitation).
Over the years, there has been much controversy over the SIRS criteria, as they are considered to have poor specificity and sensitivity for predicting the development of sepsis. The SIRS criteria – fever, tachycardia, tachypnea, leukopenia/leukocytosis – are present in many conditions, both in chronic medical illness and in acute reactions to infection. A patient with acute bacterial pharyngitis with dehydration from poor intake and tachycardia from dehydration and fever can be treated outpatient and is at very low risk of progressing to septic shock despite meeting SIRS criteria. Furthermore, the “levels” of sepsis infers there is a continuum or spectrum that a patient with sepsis follows in the course of illness and this is not the case.
In a nutshell, the focus of the new definitions as described above is defining sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection. The Sequential (sepsis-related) Organ Failure Assessment (SOFA)
is presented as a tool to identify organ dysfunction and the risk of a patient with infection in developing sepsis. SIRS has been eliminated from sepsis vocabulary, as has severe sepsis, which was considered redundant. So now we have:
- Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction is measured by changes in the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score of two points or more. In a patient with unknown baseline, the beginning score is zero.
- Septic shock: a subset of sepsis with vasopressor requirement to maintain MAP >65 and serum lactate > 2 mmol/L in the absence of hypovolemia (i.e. after a patient has received adequate fluid resuscitation).
The SOFA Score (Vincent et. al 1996) provides clinical measures to identify organ dysfunction; these criteria identify infected patients most likely to develop sepsis. Organ dysfunction is identified as an acute change in SOFA score of greater than or equal to two. These clinical variables include PaO2/FiO2 ratio, platelet count, bilirubin, MAP with and without the presence of vasoactive agents, Glascow Coma Scale, creatinine and urine output.
(Quick SOFA) Criteria is an additional tool highlighted in Sepsis-3. The clinical variables of the qSOFA are:
- Respiratory rate > 22
- Altered mentation (GCS < 15)
- Systolic blood pressure ≤ 100
The presence of any two of these criteria (qSOFA) in a patient with a known infection should prompt further evaluation for organ dysfunction. This tool can be utilized by the bedside nurse.
Nursing implications of Sepsis-3
While these definitions will not change how we treat patients with sepsis or presumed sepsis, they do provide more straightforward terminology, as well as a bedside tool to evaluate a patient with infection, potentially allowing us to both identify at-risk patients sooner and treat earlier. The presence of the qSOFA criteria in a patient with infection should prompt further evaluation of the patient and possible measurement of the more detailed SOFA criteria to evaluate for organ dysfunction. As a nurse, awareness and understanding of the most up-to-date terminology surrounding sepsis improves care of our patients and allows for better communication of patient information to colleagues in a consistent manner. Nurses are in a key position at the bedside to monitor and identify patient in the early stages of clinical decline and have the potential to positively impact patient outcomes by facilitating early interventions and treatment of the septic patient.
With this information, we can improve our communication. In the past, we might have said, “I am very concerned about Mr. X. He was admitted to the floor for treatment of a urinary tract infection. I just have a feeling this patient is declining; he looks like he might be septic.” Now, with our new definitions, we can say, “I am very concerned about Mr. X. He was admitted to the floor for treatment of a urinary tract infection. Since admission, he has deteriorated clinically; his qSOFA score is two, he has a respiratory rate of 30 and his systolic blood pressure is 80. When he arrived in the ED, his SOFA score was one due to a creatinine of 1.5. Now his urine output is down to 15 mL/hr, and his MAP is 60. I think we need to order more labs and have someone come re-evaluate the patient for possible transfer to the ICU.” As nurses, we often know when something is changing and our patient’s clinical condition is headed in the wrong direction. Familiarization with these tools provides us with more objective data to present and support our concerns.
It has now been several weeks since the release of Sepsis-3. In reviewing medical commentary, there are varying supports and criticisms of both the new definitions and on the utility of the SOFA and qSOFA scores. True, qSOFA and SOFA are not diagnostic of sepsis or septic shock, the SOFA is a predictor of mortality; but they provide objective data points that can be easily measured in the hospital setting. What remains unchanged is our goal of early identification and early treatment to reduce overall morbidity and mortality related to sepsis. Sepsis is a complex condition; in addition to overt symptomatology, there is complex biochemical, genetic and endogenous factors involved in the pathobiology of sepsis. Some pathways are well understood while others are only on the brink of being understood.
I am personally happy with the new definitions and the simplicity of the diagnostic terms of sepsis vs. septic shock. I am looking forward to the improved dialogue and communication using the SOFA criteria. As with any changes in medicine, there is typically a lag time from publication to implementation. At my hospital, in particular in the ICU, there has certainly been a lot of buzz and support for the new terminology. I would love to hear how other hospitals and facilities have reacted to Sepsis-3!
Megan Doble, MSN, RN, CRNP
Singer M, Deutschman CS, Seymour C, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. doi:10.1001/jama.2016.0287.
Vincent JL, Moreno R, Takala J, et al; Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med. 1996;22(7):707-710.
Carolyn Ackerman Ed.D MS RN CHPN, is from Arvada, Colo., and has almost 40 years of experience in home health and hospice. She actually discovered our Nurse On the Move
feature in a recent Home Healthcare Now journal article, Nurse on the Move: Lisa Gorski
, and thought to herself, “Well…why not [me]?”
I had the opportunity to speak to her over the phone to discover why she thought she would make a good candidate, and I am so glad she reached out to us at NursingCenter. Not only is Ackerman a registered nurse, but she is also an assistant professor at Regis University in Denver, and she is very involved in end-of-life interdisciplinary simulation.
Ackerman recently graduated from Creighton University with her Ed.D in interdisciplinary education. She created an end-of-life board game called The Path of Life: The Journey of Living at the End-of-Life © game
, where participants assume the role of the patient as they make decisions related to their terminal disease.
Listen for the whole interview…
For inquiries around Ackerman’s board game and other work, email firstname.lastname@example.org
*Do you know a great candidate to be featured for Nurses On the Move? We want to know about the nurses who are advancing the profession and inspiring others to do the same. Email your submissions to ClinicalEditor@NursingCenter.com
Posted: 3/9/2016 7:51:01 AM
| with 0 comments
By Kim Fryling-Resare
I was going to put together a collection of information and statistics to share about multiple sclerosis, but as I started to write, it became more about what I personally do to raise MS awareness. My hope is that my story will give insight and shed some light onto a patient’s perspective. I feel like understanding is one of the keys to better support and care for patients living with a chronic illness.
March is MS Awareness Month
– a topic near and dear to my heart. I’ve been living with relapse-remitting multiple sclerosis since 2003 and I try to live my life every day as if it is “MS Awareness Day.”
Unfortunately, I’m not a scientist who will discover a cure. I’m not a neurologist or a nurse who will treat patients. And lastly, I’m not fortunate enough to be rolling in money that I could fund clinical trials or research studies. So what can I do to raise awareness about MS?
I can SUPPORT.
Whenever I hear about someone who is newly-diagnosed, or someone who may be struggling with the disease, I’m always ready to hand out my phone number or email address. I know all too well that it can be a continuous struggle, but I want them to know they are not alone. There is hope, and they will get through this battle learning strategies to improve life and ultimately discovering how truly strong they are.
I can stay POSITIVE.
I went through all of the typical emotions after my MS diagnosis, and I had to go through the grieving process and let go of my life, or at least my perceived life, before MS. Now, I’m actually thankful for MS. I have let go of a lot of toxic people and negativity, and I try not to sweat the small stuff. I have chosen to take the path where I value life and take little to nothing for granted.
I can EDUCATE.
I have always been very open about living with multiple sclerosis. I love shocking people with the fact that I have MS. I encourage questions and enjoy sharing my experiences and knowledge. There is a lot of misinformation out there and people tend to have such misconceptions about what MS looks like, and what it means to live with MS. It is such a varying disease that presents so differently and affects people in so many different ways.
I can LIVE fully.
I live the best life that I can with MS, and along the way, I try to educate others on what MS is and what it means to people battling it every day, every month, every year. Raising awareness for MS and living fully is my way of advocating and giving back to the MS community.
I will never give up HOPE.
I have this silly personal belief that if I say something, or believe something long enough, it will manifest and become reality. So…There will be a cure for MS. There will be a cure for MS. There will be a cure for MS…
To continue raising awareness, I’m marking my 13th year living with MS by participating in my first half marathon this summer. 13 years, 13.1 miles! Never give up!
Please use these free resources on NursingCenter to learn more about MS and to help spread awareness by sharing with your colleagues, patients, and the public.
The Journal of Neuroscience Nursing
and the Journal of Infusion Nursing
are both honoring MS Awareness Month by offering subscription discounts in March. Enter promotion code, WFS115GN, and take 40% off the subscription price for either journal.
During these busy days, time management is a challenge for many people. If you have a career where your schedule is frequently changing, the challenge becomes even more pronounced. Maybe you even flip-flop your nights and days sometimes or juggle teaching or taking classes on top of your already busy schedule. The point is, time management skills are essential to keep us rested, healthy, and productive!
Here are some top tips to help you manage your time effectively.
- Write it down. Use a calendar – paper or electronic – to keep track of all your appointments and responsibilities in one place.
- Stay focused. When at work, focus on work. When at home, focus on home.
- Break it down. Divide large tasks into smaller items that are more manageable.
- Declutter. Clear your work area. Whether it’s a desk, medication cart, or bedside table, don’t let excess clutter take your attention away from what you are doing.
- Delegate. Proper delegation and teamwork are time management wins for you and your colleagues.
- Set aside time to answer messages. Answer phone calls, texts, and emails at convenient times, rather than allowing those rings and beeps to distract from your current task.
What other time management tips would you add to this list?
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Posted: 2/29/2016 8:44:39 AM
Lisa Bonsall, MSN, RN, CRNP
| with 2 comments