Application of holistic, evidence-based care

Living with a chronic wound is soul destroying for people. The relentless pain together with wound related factors such as malodour, wet dressings/ bandages and infection impacts significantly on quality of life. This can lead to depression and anxiety and social isolation.

For many of my patients this had been their life for years and they had given up all hope of ever leading a ‘normal’ life again and even after 12 years as a Tissue Viability specialist nurse I am still moved by the plight of these people. To me, they are the invisible, silent sufferers with an acceptance that this is as good as it gets!

I do not accept this and always try to give my patients and their families hope. I agree, wound healing can be difficult, particularly when patients have underlying health conditions, but it does not mean that healing is impossible. Most wounds should heal without complication given the right conditions and treatment. To achieve this, a thorough, holistic assessment should be undertaken that will help identify any factors that may impact on healing and allow early intervention of strategies to manage these potential complications.

Holistic assessment

Holistic assessment one of the cornerstones of my role as a Tissue Viability nurse and I have found this part of the treatment process extremely rewarding. I was able to give my patients time without appearing pressurised, I spent time asking about ‘them’, gathering useful biographical information which helped me connect better with their lives and how living with a wound was impacting on them as a person.  This was often an emotional experience for patients who, being given the time to do so, offloaded stories, frustrations and sometimes anger about their wound experience.

The skill of listening

The skill of listening is so powerful – many of us think we listen when in fact we haven’t actively done so. We often are thinking about solutions or the next question to ask when the patient is still talking. That ‘little voice’ in our head is interfering with our ability to fully understand and interpret what is being said. To assure our patients that we have correctly heard what they have said we should summarise the conversation with them and check this is an accurate reflection. Doing this reinforces that we place an importance on what is being said and on them as a person. This approach helps build trust and is essential for the development of a positive patient/ clinician partnership. Without this, negotiating the pathways required for treating the presenting problem can be problematic.

The giving of information

My role was to share my assessment findings with my patients and to offer the treatment options available to them. We should never assume that patients want to hear what you want to share. Some may feel overwhelmed by their wound experience and cannot cope with the barrage of information, your treatment suggestions may not be what they were expecting or there may be an element of denial. For care to be effective, patients need to be in a position of change physically and mentally, if they are not ready for this then I would always negotiate another date and time to re-visit the treatment options. This Motivational interviewing technique is useful to use when assessing patients as it will help to set goals that are realistic and flexible to any resistance and will support self – efficacy and optimism. I find this topic fascinating and have taught both locally and nationally on how to apply motivational interviewing when assessing patients with wounds.

Application of therapeutic interventions

I feel strongly that nursing is both an art and a science. It is essential that we have the empirical knowledge base to support our decision making but it is equally important that our skill set is finely tuned in terms of competence if our care is to be effective. As we know, its not just about the dressing, its ensuring that we optimise the health of the wound bed and the peri-wound skin and to manage the underlying conditions that have caused the wound to develop in the first place. In terms of leg ulceration this is likely to be associated with venous disease and therefore there is a need for high compression therapy. I love bandaging – I do see it as a nursing art when applied correctly, but more importantly I never fail to be excited when I see the positive impact it has on a person’s lower limb condition. The lives I have managed to change because of compression is phenomenal – from pain reduction, improving mobility, enabling people to wear normal shoes or a normal pair of trousers, reducing cellulitis episodes and of course healing! Compression must be applied correctly though if it is to work. It has been my role to teach nurses the skills of compression bandaging and to try and give them the confidence to compress. We need to challenge the routine application of reduced compression when full compression is required.

There has been the need to be more ‘creative’ with my bandaging over the years when faced with complex cases. This may have been when people have had significant oedema in their legs, often up to the thigh or when they presented with retro-malleolar ulcers or when people were very tall or had very long lower limbs. All these factors increase complexity and can impact on healing or infection risk.

I was fortunate to attend an ‘Advanced Practice in Lower Limb Ulceration’ course run by Accelerate CIC which has helped me develop additional skills when managing people with complex leg ulceration. This brilliant 1-day course explored the factors that makes lower limb wounds complex. How the biomechanics of mobility and gait need to be considered as part of your assessment if healing is to be optimised, when to use higher levels of compression (compression that exceeds the standard 40mmHg level) and the advanced skills/ techniques including strapping that can be used to manage complex oedema and retro malleolus ulcers.

Wound Debridement

Wound debridement has been an essential skill in my role as a Tissue Viability Nurse. Chronic wounds are frequently filled with devitalised tissue that increases the risk of wound infection and non-healing. Having the skills to sharp debride has enabled me to revert the wound to a healthier status without the need for a hospital visit and therefore optimising the potential for healing more quickly.