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Nursing research: PICOT statement with resources

Molly F. Keller

Grand Canyon University

NRS-433V-0504

Professor Cherryl Llanos

February 24, 2019

Nursing research: PICOT statement with resources

In Elderly patients ages 65 and older, with venous stasis, how effective are compression devises such as compression socks, versus compression wraps such as Unna boot therapy, 2 way or 3-way compression, to combat against venous stasis leading to lower extremity edema, wounds, Deep vein thrombosis and infection and work for patients comfort and functionality.

Venous stasis effects millions of people every year. The older we get combined with medical problems many face, add to decreased blood flow and leave patients with decreased circulation. This leads to edema in the lower extremities, leaving patients uncomfortable, vulnerable to venous stasis ulcers, deep vein thrombosis and infection. Through compression therapy patients can find relief by increasing the movement of fluid out of the lower extremities, decrease their risk of developing a DVT, and lower their risk for ulcers and infections.

There are multiple styles and forms of compression therapy in use today. Elderly patients often find applying compression socks hard to do but find other compression methods such as compression wraps uncomfortable. Others prefer one over the other, while some are not able to afford one compression system over another. In this you also have to account for providers preferring one compression over another. The question is which compression do patients tolerate better, which compression works the best, and is there a happy medium providers can use to achieve a worthy result. One of the main concerns I have are what system with work for a patient to use daily and be functional within their lives.

References

Resource:

Onuigbo, M. A. C. (2010). Bilateral Lower Extremity Sequential Compression Devices (SCDs): A Novel Approach to the Management of Intra-Dialytic Hypotension in the Outpatient Setting—Report of a Case Series. Renal Failure, 32(1), 32–35. https://doi-org.lopes.idm.oclc.org/10.3109/08860220903367478

Abstract:

Aim

Intra-dialytic hypotension (IDH) affects as many as 15–50% of patients during hemodialysis. Several treatment approaches and preventative methods are available. These therapeutic options are often ineffective and cumbersome, and some of the causative factors such as poor cardiac reserve is commonly not amenable to any therapy.

Background/Method

Enhanced external counter pulsation (EECP) is increasingly being utilized by cardiology services as an adjunct to the long-term management of chronic congestive heart failure as well as in the management of otherwise refractory angina. EECP works by mechanistically improving venous return, enhancing peripheral resistance, and ultimately improving the cardiac index. We speculated that bilateral lower extremity sequential compression devices (SCDs), commonly used in the inpatient setting for DVT prophylaxis, could indeed serve as mini-EECP devices.

Method

We carried out an outpatient pilot study of its use to prevent IDH in three patients who otherwise had failed other treatment approaches. The SCDs were effective, convenient, and safe.

Results

We were able to achieve ultrafiltration (UF) goals of 1–3 kg during hemodialysis sessions in all three patients, consistently, for months, a feat that was not possible previously.

Conclusion

This novel modality of managing IDH is complementary to other standard therapies. Larger multi-center studies are warranted. [ABSTRACT FROM AUTHOR]

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Resource:

Wu, S. C., Crews, R. T., Skratsky, M., Overstreet, J., Yalla, S. V., Winder, M., … Andersen, C. A. (2017). Control of lower extremity edema in patients with diabetes: Double blind randomized controlled trial assessing the efficacy of mild compression diabetic socks. Diabetes Research and Clinical Practice, 127, 35–43. https://doi-org.lopes.idm.oclc.org/10.1016/j.diabres.2017.02.025

Abstract:

Aim

Mild compression may be effectively and safely used in diabetes patients with LE edema.•Mild-compression diabetic socks significantly decreased calf and ankle circumferences.•Lower extremity circulation well maintained throughout the study.

Background

Persons with diabetes frequently present with lower extremity (LE) edema; however, compression therapy is generally avoided for fear of compromising arterial circulation in a population with a high prevalence of peripheral arterial disease. This double blind randomized controlled trial (RCT) assessed whether diabetic socks with mild compression could reduce LE edema in patients with diabetes without negatively impacting vascularity.

Method

Eighty subjects with LE edema and diabetes were randomized to receive either mild-compression knee high diabetic socks (18–25mmHg) or non-compression knee high diabetic socks. Subjects were instructed to wear the socks during all waking hours. Follow-up visits occurred weekly for four consecutive weeks. Edema was quantified through midfoot, ankle, and calf circumferences and cutaneous fluid measurements. Vascular status was tracked via ankle brachial index (ABI), toe brachial index (TBI), and skin perfusion pressure (SPP).

Results

Seventy-seven subjects (39 controls and 38 mild-compression subjects) successfully completed the study. No statistical differences between the two groups in terms of age, body mass index, gender, and ethnicity. Repeated measures analysis of variance and Sidak corrections for multiple comparisons were used for data analyses. Subjects randomized to mild-compression diabetic socks demonstrated significant decreases in calf and ankle circumferences at the end of treatment as compared to baseline. LE circulation did not diminish throughout the study with no significant decreases in ABI, TBI or SPP for either group.

Conclusion

Results of this RCT suggest that mild compression diabetic socks may be effectively and safely used in patients with diabetes and LE edema

Resource:

Eze, A. R., Comerota, A. J., Cisek, P. L., Holland, B. S., Kerr, R. P., Veeramasuneni, R., & Comerota, J. A. J. (1996). Intermittent calf and foot compression increase lower extremity blood flow. The American Journal of Surgery, 172, 130–135. https://doi-org.lopes.idm.oclc.org/10.1016/S0002-9610(96)00134-1

Abstract:

Aim

Purpose Although foot compression increases foot skin perfusion and calf compression increases popliteal artery blood flow, these compression techniques have not been evaluated in combination.

Background

The purpose of this study was to evaluate whether calf and foot compression applied separately and simultaneously increase popliteal artery blood flow and/or foot skin perfusion, and to assess the relative merits of compression in patients with superficial femoral artery occlusion.

Method

Twenty-two legs from 12 normal volunteers with ankle/brachial indices (ABIs) > 0.96, and 10 legs from 7 claudicator patients with angiographically documented superficial femoral artery (SFA) occlusion and patent popliteal arteries with ABIs <0.8 were studied in the sitting position. Calf and foot cuffs connected to a rapidly inflating and deflating timed-pressure pump (Art-Assist-AA 1000; ACI Medical Inc., San Marcos, California) were applied to the subject in the sitting position. Skin blood flow of the great toe was measured with a laser doppler (Laserflo model BPM 403A; TSI Inc., St. Paul, Minnesota), and popliteal artery blood flow was measured using duplex ultrasonography (ATL-Ultramark 9; Advanced Tech Laboratory, Bothell, Washington). Foot and calf compression was applied separately and simultaneously at 120 mm Hg pressure, with a 10-second inflation and 20-second deflation cycle. Popliteal artery blood flow and foot skin perfusion were recorded and the mean of 6 cycles calculated.

Results

Precompression popliteal artery blood flow (mL/min) for volunteers was 38.86±3.94, and for patients was 86.30±14.55 (P=0.001). Precompression foot skin perfusion (mL/min/ 100/g tissue) for volunteers was 1.67±0.29, and for patients was 4.00±0.92 (P= 0.01). With the application of calf, foot, and simultaneous calf and foot compression, the popliteal artery blood flow increased in volunteers by 124%, 54%, and 173%, respectively, and in patients by 76%, 13%, and 50%. Foot skin perfusion increased in volunteers by 260%, 500%, and 328%, respectively, and in patients by 116%, 246%, and 188%. Relative increases in popliteal artery blood flow and foot skin perfusion were higher in volunteers compared with patients during compression; however, the absolute values for foot skin perfusion and popliteal artery blood flow were consistently higher in patients.

Conclusion

Measured in the sitting position, the resting popliteal artery blood flow and foot skin perfusion are greater in patients with SFA occlusion compared with normal volunteers. Following compression, popliteal artery blood flow and foot skin perfusion increased in both groups, but relatively more in volunteers. Increases in popliteal artery blood flow are significantly higher with calf compression than with foot compression for both groups. A patent SFA allows for additive increases in popliteal artery blood flow with simultaneous foot and calf compression in normal persons, whereas this is not observed in patients. However, the increases in foot skin perfusion in patients with an occluded SFA parallel the increases shown in normal volunteers, with separate and simultaneous foot and calf compression

Resource:

Demczyszak, I., Sutkowska, E., Jasiak, M., Fortuna, M., & Mazurek, J. (2017). The impact of compression garments on the quality of life in patients with chronic venous disease. Physiotherapy / Fizjoterapia, 24(2), 19–22. Retrieved from https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=124301098&site=eds-live&scope=site

Abstract:

Aim

Introduction. Assessment of quality of life in patients suffering from chronic venous disease of the lower extremity who were treated with compression garments.

Background/Method

Patients of both sexes aged 30-75 years with chronic venous disease and at least varices, but without active ulceration, were qualified for the study. To assess the quality of life, the CIVIQ-20 questionnaire was used before and after 4 weeks of compression therapy with second class compression.

Results

The combined results of the CIVIQ scale rose from 61.49% before compression to 75.17% after 4 weeks of compression therapy (p 0.01). No correlation was found between sex, age, career status or type of work and the averaged CIVIQ score.

Conclusion

Compression therapy with special garments significantly improves the quality of life in patients with chronic venous disease. Larger studies are still needed in this field. ABSTRACT FROM AUTHOR

Resource:

Wu, S. C., Crews, R. T., Skratsky, M., Overstreet, J., Yalla, S. V., Winder, M., … Andersen, C. A. (2017). Control of lower extremity edema in patients with diabetes: Double blind randomized controlled trial assessing the efficacy of mild compression diabetic socks. Diabetes Research & Clinical Practice, 127, 35–43. https://doi-org.lopes.idm.oclc.org/10.1016/j.diabres.2017.02.025

Abstract:

Aim

Persons with diabetes frequently present with lower extremity (LE) edema; however, compression therapy is generally avoided for fear of compromising arterial circulation in a population with a high prevalence of peripheral arterial disease.

Background

This double blind randomized controlled trial (RCT) assessed whether diabetic socks with mild compression could reduce LE edema in patients with diabetes without negatively impacting vascularity.Methods: Eighty subjects with LE edema and diabetes were randomized to receive either mild-compression knee high diabetic socks (18-25mmHg) or non-compression knee high diabetic socks.

Method

Subjects were instructed to wear the socks during all waking hours. Follow-up visits occurred weekly for four consecutive weeks. Edema was quantified through midfoot, ankle, and calf circumferences and cutaneous fluid measurements. Vascular status was tracked via ankle brachial index (ABI), toe brachial index (TBI), and skin perfusion pressure (SPP).

Results

Seventy-seven subjects (39 controls and 38 mild-compression subjects) successfully completed the study. No statistical differences between the two groups in terms of age, body mass index, gender, and ethnicity. Repeated measures analysis of variance and Sidak corrections for multiple comparisons were used for data analyses. Subjects randomized to mild-compression diabetic socks demonstrated significant decreases in calf and ankle circumferences at the end of treatment as compared to baseline. LE circulation did not diminish throughout the study with no significant decreases in ABI, TBI or SPP for either group.

Conclusion

Results of this RCT suggest that mild compression diabetic socks may be effectively and safely used in patients with diabetes and LE edema.

Resource:

de Lima, E. L., SalomÃ, , G. M., de Brito Rocha, M. J. A., & Ferreira, L. M. (2013). The impact of compression therapy with Unna’s boot on the functional status of VLU patients...Venous Leg Ulcer. Journal of Wound Care, 22(10), 558–561. Retrieved from https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=104146416&site=eds-live&scope=site

Abstract:

Aim

Objective: To assess disability in patients with venous leg ulcers treated with compression therapy with Unna's boot.

Background/Method

A descriptive analytic case control study was conducted from June 2010 to May 2011 in an outpatient wound care clinic in interior Brazil. Fifty patients of both sexes, aged 18 years or above, who had had a venous leg ulcer for more than 1 year and a Doppler ankle-brachial index of 0.8-1.0 were selected for the study. Patients were treated with wound dressings and Unna's boot. Disability was assessed using the 20-item Stanford Health Assessment Disability Scale (HAQ-20). Statistical analysis was performed using the Student's t-test, the Kruskal-Wallis test and the chi-square test of independence, all at a significance level of 0.05 (p<0.05).

Results

The mean overall HAQ score at inclusion (baseline) was 2.98, indicating impaired functional capacity. After 8 and 12 months of compression treatment with Unna's boot, the mean overall HAQ scores were 1.35 and 1.0, respectively, indicating good functional capacity.

Conclusion

Patients with venous leg ulcer reported severe difficulty or serious disability in their daily functioning at baseline; after 8 months of treatment with Unna's boot, these patients were able to perform activities of daily living.

Resource:

Salome, G. M., de Brito, M. J. A., & Ferreira, L. M. (2014). Impact of compression therapy using Unna’s boot on the self-esteem of patients with venous leg ulcers. Journal of Wound Care, 23(9), 442–446. Retrieved from https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=103916638&site=eds-live&scope=site

Abstract:

Aim

To assess self-esteem in patients with venous leg ulcers treated with Unna’s boot.

Background/Method

A descriptive, analytic, clinical study was conducted from June 2010 to May 2011 in an outpatient wound care clinic in São Paulo, Brazil. Patients of both sexes, aged ≥18 years, who had had a venous leg ulcer for more than one year and a Doppler ankle brachial index ranging from 0.8–1.0 were consecutively selected for inclusion. Patients were treated with wound dressings and Unna’s boot. Self-esteem was assessed using the Brazilian version of the Rosenberg Self-Esteem Scale (RSE) at inclusion (baseline) and after 4, 8, and 12 months of compression therapy using Unna’s boot. The scale is reverse-scored; thus lower scores indicate higher levels of self-esteem.

Results

The patients showed a slight but significant improvement in self-esteem after 4 months of treatment (mean RSE score=17.12) compared with baseline (mean RSE score= 24.90). However, a marked and significant improvement in self-esteem was observed after 8 months (mean RSE score=7.40) and 12 months (mean RSE score=2.10) of compression therapy using Unna’s boot.

Conclusion

Patients with venous leg ulcers treated with Unna’s boot for 12 months showed a significant improvement in self-esteem.

Resource:

Schonfeld WH, Villa KF, Fastenau JM, Mazonson PD, & Falanga V. (2000). An economic assessment of APLIGRAF (Graftskin) for the treatment of hard-to-heal venous leg ulcers. Wound Repair & Regeneration, 8(4), 251–257. Retrieved from https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=106991999&site=eds-live&scope=site

Abstract:

Aim

Several recent advances in wound care may offer promise for the treatment of hard-to-heal venous leg ulcers. One such treatment is Apligraf (Graftskin), a bilayered, living human skin construct.

Background

To assess the economic impact of Graftskin, a model was constructed to compare the annual medical costs and cost-effectiveness of treating hard-to-heal venous leg ulcers with Graftskin vs. compression therapy using Unna's boot. A semi-Markov model was used to describe the pattern of ulcer treatment, healing, and recurrence among patients with venous leg ulcers.

Method

Patients received 1 of 2 treatment regimens, Graftskin or Unna's boot, and were followed in the model for a 12-month period. The analysis was done from the perspective of a commercial health plan; therefore, only direct medical costs were included. Health care resource use included the primary therapeutic intervention, additional compression dressings, physician office visits, home health visits, laboratory tests and procedures, management of adverse events, and hospitalizations.

Results

The model estimated the annual medical cost of managing patients with hard-to-heal venous leg ulcers to be $20,041 for those treated with Graftskin and $27,493 for those treated with Unna's boot. In addition, treatment with Graftskin led to approximately 3 more months in the healed state per person per year than did treatment with Unna's boot. Because patients treated with Graftskin experienced improved healing compared with those treated with compression therapy using Unna's boot, they required fewer months of treatment for unhealed ulcers.

Conclusion

As a result, the use of Graftskin for treating hard-to-heal venous leg ulcers resulted in lower overall treatment costs.

Resource:

Mullins, M., Bock, K., & Bhatia, A. (2017). Extremit-Ease compression garment: A review and cases. British Journal of Community Nursing, 22, S41–S47. https://doi-org.lopes.idm.oclc.org/10.12968/bjcn.2017.22.Sup12.S41

Abstract:

Aim

The rates of chronic oedema in the US continue to grow from multiple causative factors. One such factor is the skyrocketing rates of morbid obesity.

Background

There are about 40 million obese people in the US today. Among those people, the prevalence rate of lymphoedema is 74% (Fife and Carter, 2008).

Method

Treatment usually involves some type of compression for life, but that is easier said than done.

Results

Many patients with chronic oedema have dexterity issues or have limited abilities to put on tight compression options. This article explores a product that has just been recently launched on the market: the Extremit-Ease® compression garment.

Conclusion

This article also looks at five case studies involving the product to evaluate its effectiveness in the treatment of this growing condition. We explore the increasing problem of chronic oedema, specifically oedema caused by lymphoedema and venous stasis, and how Extremit-Ease compression garments could assist patient compliance with the gold standard treatment

Resource:

Macintyre, L., Kent, K., & McPhee, D. (2013). Do anti-embolism stockings fit our legs? Leg survey and data analysis. International Journal of Nursing Studies, 50(7), 914–923. https://doi-org.lopes.idm.oclc.org/10.1016/j.ijnurstu.2013.01.005

Abstract:

Aim

Anti-embolism stockings are commonly used worldwide to prevent the development of thrombosis in hospitalised patients. Patients are typically measured for, and fitted with, anti-embolism stockings during extended periods of non-ambulation. Anti-embolism stockings must critically fit the leg to achieve optimum blood flow and thus success of prophylaxis. Therefore, hospitals endeavour to maintain stock of antiembolism stockings that fit the majority of their patients.

background

The objective of this study was to establish whether popular styles/brands of anti-embolism stockings ''fitted'' the legs of convenience sampled volunteers.

Method

Volunteer's legs were measured at ankle, calf and thigh following guidance from British nurses and in accordance with brand instructions. Leg measurements were subsequently compared to the size charts of 10 anti-embolism stocking styles made by 4 different manufacturers. ''Fit'' is defined as a volunteer's leg measurements matching any stocking size in a range at all measurement points. Settings: Volunteers were measured in different settings around Scotland, including private homes, work places and shopping centres. Participants: A convenience sample of 471 volunteers (283 female, 188 male) were recruited on the basis of willingness to participate and being over 16 years old. Volunteers ranged from 17 years to 82 years old with an average age of 35.

Results

The 10 different styles of anti-embolism stockings, made by 4 different brands, examined for this paper had a size match coefficient ranging from 0% to 100% for our volunteer's legs. The size match coefficient is strongly influenced by the Brand's sizing policy.

Conclusion

The proportion of legs that ''fit'' a particular brand of anti-embolism stockings can be increased through: (1) the reduction of the number of leg measurement points that need to be matched to the size chart of the stockings; (2) the use of open-ended size ranges; (3) the use of increased size range width and (4) the use of increased overlap between sizes. However, all but the last of these measures can have a potentially deleterious impact on the ability of the stocking to deliver the optimum graduated pressure profile to all legs that ''fit'' the stocking, resulting in important implications to the efficacy of prophylaxis.

Resource:

Cooper, K. L. (2011). Care of the Lower Extremities in Patients With Acute Decompensated Heart Failure. Critical Care Nurse, 31(4), 21–29. https://doi-org.lopes.idm.oclc.org/10.4037/ccn2011337

Abstract:

Aim

Patients with heart failure and pulmonary edema are often admitted to the critical care unit.

Background

Many of these patients have severe peripheral edema, which may be associated with exudates and wounds of the lower extremities and which present a challenge to critical care nurses. Little information is available on treatment of peripheral edema in the intensive care unit or in patients with unstable hemodynamic status.

Method

Nursing care is based on available evidence, findings on chest radiographs, and hemodynamic status. Medications that contribute to peripheral edema should be evaluated and discontinued if possible.

Result

An appropriate mattress surface with an underpad that promotes wicking away of moisture should be selected.

The patient's lower extremities should be elevated according to his or her current pulmonary status, and skin-protective interventions should be instituted.

Conclusion

Multilayer compression wraps should be avoided until the patient's hemodynamic status is stable and the patient can get out of bed.

Resource:

Vesna Karanikolic, Aleksandar Karanikolic, Dejan Petrovic, & Milenko Stanojevic. (2015). Prognostic factors related to delayed healing of venous leg ulcer treated with compression therapy. Zhōnghuá Pífūkē Yīxué Zázhì, Vol 33, Iss 4, Pp 206-209 (2015), (4), 206. https://doi-org.lopes.idm.oclc.org/10.1016/j.dsi.2015.04.005

Abstract:

Aims

The basic goal of this research was to determine and evaluate the prognostic factors related to the delay of venous ulcer healing in patients treated with multilayer compression bandage.

Background

The research involved a group of 100 patients of both sexes with venous ulcerations of the lower extremities.

Method

Patients were monitored for 24 weeks from the very beginning of the treatment. Ulcerations were treated with the use of multiple layer compression bandages. Results: Of the total number of tested patients, 58 (58%) were females and 42 (42%) were males. The average age of patients was 62.7 ± 6.53 years, where the male population was older.

Results

During the 24-week monitoring period, 25 patients (25%) did not heal completely. Lipodermosclerosis has a significant positive prognostic significance in healing chronic venous ulcers (p < 0.05). The infection proved to be the most important prognostic factor in the delay of ulcer healing (p < 0.01). The number and surface of ulcerative changes show a significant positive correlation with delay of venous ulcer healing (p < 0.001).

Conclusion

The results of this study show a significant positive correlation between the number and surface of ulcerative changes and the delay of venous ulcer healing. Further trials are necessary to identify the best treatment options, especially for nonhealing ulcers.