By: Mary Brennan, RN, MBA, CWON and Diane Krasner, PhD, RN, CWCN, CWS, MAPWCA, FAAN
By the WoundSource Editors
With aging populations facing increasingly complex comorbid medical conditions coupled with polypharmacy and multidrug-resistant organisms, wound healing can often feel like an uphill, never-ending battle. There are often elements that cannot be allayed, and some factors will always be outside the control of the patient and the practitioner. Barriers that can be eliminated should be, but sometimes compliance is a concern.
Compliance Versus Adherence
Health care providers and caregivers are often expected to be the change agents or catalyst to move the patient or family members from a state of non-compliance and stagnation to compliance and, hopefully, wound healing. Let's start with the word compliance. Compliance is an outdated term that insinuates the patient should comply with the decisions of the health care provider. Adherence really redefines the relationship and reflects a patient choice and the "freedom to decide whether to adopt the provider's recommendations and that failure to do so should not be a reason to focus blame."1
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Reasons for Non-adherence With Pressure Injury Prevention Plan
There may be a number of reasons a patient does not adhere to pressure injury prevention or treatment methods. Those who require assistance with turning and repositioning may resent the lack of autonomy and therefore refuse to allow a nurse to reposition them. As often as possible, explain to these patients the importance of turning and positioning for pressure injury prevention; always document such conversations. Those patients who have already developed a pressure injury may have trouble adhering to dressing changing schedules because of the associated pain. Again, document the patient's pain and any measures used to reduce pain at the dressing site.2 Wound care professionals have access to many different healing options. There are numerous skin substitutes, dressings, debridement options, and many advanced wound modalities to encourage wound healing. As wound specialists, we should outline options for the patients to allow them to choose one. As part of creating adherence, it is the wound clinician's job to suggest options from the worst to the best. It is the patient's job to pick an option, but note they don't have to pick the best option. Sometimes creating adherence means changing the goal. The goal may not always be to heal. Sometimes the goal is to prevent the wound from getting worse or just maintaining patient comfort.
Pressure Injury Education for Prevention
With regard to pressure injury education, prevention is best. One way to prevent pressure injuries is to keep the patient moving whenever possible. The more movement there is, the better the blood flow and the better the reduction in shearing or friction forces. Keeping skin clean, dry, and moisturized is a great way to keep skin healthy. Manage microclimate by allowing perspiration to evaporate or preventing incontinence from reaching the skin.
Investigating the Cause of a Pressure Injury
If a pressure injury has already developed, try to identify the precipitating factor. Is it from sitting in a wheelchair for too long? Perhaps the wheelchair cushion needs to be replaced or is not inflated to the proper level. Don't forget to evaluate the patient's overall clinical condition. Maybe they have had significant weight gain or loss. Maybe a metabolic condition is reducing the skin's ability to stay intact. If the patient spends a significant amount of time in bed, evaluate the mattress. If you can't see the mattress in person, perhaps the patient would take a photograph to review at their next visit.
With value-based care, patients are empowered to take the driver's seat while buying in to their health care. It is the job of the health care professional to help the driver navigate the medical road map that includes options for care, diagnosis, treatment, and even choosing a provider or specialist, should the need arise.3 The more our patients feel in control of their health, the more control they can take, which in turn ensures adherence to the treatment plan and collective goal established between patient and provider. Patients' desire to be in control of their health is a great pressure injury prevention strategy.
1. Hurlow J, Hensley L. Achieving patient adherence in the wound care clinic. Today's Wound Clinic. 2015;9(9). https://www.todayswoundclinic.com/articles/achieving-patient-adherence-w.... Accessed October 14, 2019.
2. Harvard Men’s Health Watch. Peripheral artery disease: leg pain and much more. Harvard Health Publishing Harvard Medical School. 2019. https://www.health.harvard.edu/heart-health/peripheral-artery-disease-le.... Accessed October 14, 2019.
3. Dart S. Putting the patient in the driver’s seat on the value-based care journey. MedCity News.com. 2018. https://medcitynews.com/2018/10/putting-the-patient-in-the-drivers-seat-.... Accessed October 14, 2019.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.