Kneading healing
Deidre Wipke-Tevis
When Deidre Wipke-Tevis was a young nurse, new to the profession, she went to work on a vascular surgery floor at a Veterans Affairs hospital in Kansas City. One of her major responsibilities was to take care of patients who had stubborn wounds that resisted healing. Over and over again, Wipke-Tevis saw the same types of cases. For five years she worked to ease her patients’ suffering and encourage healing, but the experience was frustrating.
“I realized that wound-care practices and technology were not changing,” she says. “I knew that I wanted to go to graduate school and decided that my interest area and focus would be wound healing in patients with cardiovascular disease.” Thus, a researcher was born.
Wipke-Tevis earned her master’s degree and doctorate at the University of California-San Francisco where she worked with both nursing and medical researchers who specialized in wound healing. By delving into the literature on the subject, she became interested in venous ulcers, which are chronic, recurring wounds that present a particular treatment challenge.
Venous ulcers, the most frequent type of leg ulcer, are the result of a condition known as “chronic venous insufficiency (CVI),” which is caused by recurrent blood clots in the veins of the leg that lead to problems with the venous valves and allow a backflow of blood in the legs.
Obesity and diabetes are two major contributors to these recurrent blood clots. As many as 1 million people in the United States, most of them elderly, suffer from venous ulcers of the legs or feet as the result of severe CVI. Recent studies in Missouri suggest that individuals who are admitted to nursing homes have more than twice the number of venous ulcers as do those in the general population.
Now an associate professor at the MU Sinclair School of Nursing, Wipke-Tevis is in the final year of an almost $1 million, National Institute of Nursing Research-funded project titled, “Venous Ulcers: Testing Effects of Compression and Position.”
She says that the primary aim of her research program is to develop and test treatments delivered by nurses that will improve the quality of care provided to patients with chronic wounds. Her research collaborators include nursing school colleagues Donna Williams and Jane Armer, a general surgeon who has expertise in the care of chronic wounds, a geriatrician, a nurse gerontologist and a biostatistician.
“Each of these individuals play an important role in the success of our work,” Wipke-Tevis says. “In my previous work, I performed a series of wound and microcirculation studies that laid the groundwork for my current project.”
To date, her most significant research achievement has been the discovery of important relationships between the levels of oxygen, carbon dioxide and blood perfusion in the skin that occur in response to changes in the leg or body position of patients who have venous ulcers.
With the completion of her American Heart Association (AHA) grant , Wipke-Tevis is now confident in her approach to research design, planning, implementation, analysis and publication.
“My previous work has allowed me to refine my skills in both qualitative and quantitative data collection and analysis as well as developing expertise in measuring wound healing, evaluating nutritional status and noninvasive assessment of skin microcirculation,” she says.
The AHA grant allowed Wipke-Tevis to examine the effect of leg elevation and compression bandaging on young and old healthy adults.
The treatment of venous ulcers is an issue for advanced-practice and staff nurses in outpatient clinics (especially those who work for vascular surgeons, dermatologists, family practitioners and wound-care specialists), home health-care nurses and enterostomal therapy nurses (also known as wound, ostomy or continence nurses).
Hospital-based nurses also may see serious cases of infected venous ulcers or instances where the ulcer is so chronic that surgical treatment in the form of vein stripping or skin grafts is needed.
Wipke-Tevis says that if venous ulcers could be more effectively treated, the results would include fewer hospital admissions, lower health-care costs and better outcomes for patients who even risk amputation if venous ulcers do not respond to standard treatments.
One study reports that the average cost to heal one venous ulcer is $1,950, but the cost can be as high as $6,449 in some cases.
“The total annual cost nationally is between $9.75 million and $1.95 billion,” Wipke-Tevis says. “Furthermore, once a venous ulcer heals, approximately 60 to 70 percent recur. I have cared for some venous ulcer patients who have had the same venous ulcer for nearly 20 years!”
Not surprisingly, individuals who live with venous ulcers for weeks, months or years report a higher than normal degree of fatigue, sleep disturbances, pain, fear, emotional distress, anxiety, depression, anger and hostility. They often experience periods of prolonged activity restriction, impaired mobility and functional disability, and significant reductions in social and leisure activities.
“Nurses are often the ones who assist the venous ulcer patients in coping with the symptoms associated with living with a venous ulcer,” Wipke-Tevis points out.
For more than 100 years, venous ulcers have been treated in essentially the same way. The most common treatment approaches involve elastic compression bandaging and leg elevation.
Wipke-Tevis explains that the rationale for this approach has been that compression and elevation therapy increase the amount of oxygen and blood perfusion in the skin, decrease swelling, promote healing and prevent recurrence.
However, her recent research indicates that leg elevation actually decreases blood perfusion in the skin near the ulcer. So while swelling may decrease due to leg elevation, the practice does not optimize oxygen delivery to the area via blood flow. It is still not known how compression bandaging combined with leg elevation affects skin microcirculation.
Wipke-Tevis plans to find out. She notes that venous ulcer patients already have altered microcirculation, as evidenced by their low levels of oxygen and blood perfusion in the skin.
“It’s possible that elastic compression bandaging in concert with leg elevation may further decrease skin perfusion,” she adds. “In addition, since as many as 20 percent of patients with venous ulcers also have arterial insufficiency, it is important to understand the possible interactions between compression, leg/body position changes and skin microcirculation.”
Elderly people, in particular, may be affected by wearing tight compression bandages on a continual basis because data show that elevating an extremity while increasing tissue pressure through compression can cause notable changes in circulation.
“These issues must be resolved in order to develop and test a nursing intervention that prescribes optimal leg/body position and compression combinations and maximizes healing,” Wipke-Tevis says.
She is recruiting 64 people who have venous ulcers to compare to 64 people who do not. The subjects will have their levels of oxygen, carbon dioxide and blood perfusion in the skin measured while lying down, lying with their legs elevated and standing. The measurements will be taken both with and without compression bandages on the legs.
In 2006, when Wipke-Tevis completes her study, she anticipates that her findings will allow medical professionals to have a better understanding of the effects of position and compression on the skin’s microcirculation so that more effective wound healing treatment protocols can be developed. And look for her to be one of the first to do just that.