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Evaluating patient satisfaction in the care of ulcerating metastatic skin lesions Upright, Cheryl Ann 1990

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EVALUATING PATIENT SATISFACTION IN THE CARE OF ULCERATING METASTATIC SKIN  LESIONS  by CHERYL ANN UPRIGHT B.S.N.,  The U n i v e r s i t y o f  A THESIS  British  Columbia,  1983  SUBMITTED IN PARTIAL FULFILLMENT OF  THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE  IN NURSING  in THE FACULTY OF GRADUATE STUDIES School  We a c c e p t t h i s to  the  of  Nursing  thesis  required  as  conforming  standard  THE UNIVERSITY OF BRITISH September, (5)  Cheryl  COLUMBIA  1990  Ann U p r i g h t ,  1990  In  presenting  degree freely  at  this  the  available  copying  of  department publication  of  in  partial  fulfilment  University  of  British  Columbia,  for  this or  thesis  reference  thesis by  this  for  his thesis  and  scholarly  or for  her  Department The University of British Columbia Vancouver, Canada  I  I further  purposes  gain  the  shall  requirements  agree  that  agree  may  representatives.  financial  permission.  DE-6 (2/88)  study.  of  be  It not  that  the  Library  by  understood be  an  advanced  shall  permission for  granted  is  for  allowed  the  make  extensive  head  that  without  it  of  copying my  my or  written  ABSTRACT The p u r p o s e o f t h i s develop a Patient patient  patient  Satisfaction  satisfaction  ulcerating  metastatic  satisfaction  dressings:  thesis  was t w o - f o l d :  Q u e s t i o n n a i r e which  with dressings skin  lesions;  and p a t i e n t  Mesalt dressings  first,  reflects  used i n the  care  and s e c o n d ,  to  preference  to  of  evaluate  w i t h two t y p e s  and c o n t i n u o u s wet  of  saline  dressings. The P a t i e n t measure  patient  Satisfaction satisfaction  Patients  with ulcerating  identify  important  satisfaction  metastatic skin  characteristics  clarity  s c a l e was u s e d as t h e  for  performance.  l e s i o n s were a s k e d  evaluating  These q u e s t i o n s  by t h e  response  patients. scale.  to  patient  were  validated  A visual  Testing for  to  analogue reliability  limited. Mesalt dressings  dressings  The c r i t e r i a  application dressing  were  compared t o  by e v a l u a t i n g p a t i e n t  criteria.  for  and r e m o v a l ,  changes,  control  one d r e s s i n g  for  Although  10 were  statistically  were  evaluation  of odor,  14 p a t i e n t s  excluded because  each  satisfaction  treatment.  saline  with pre-defined  i n c l u d e d ease  and p a t i e n t  of  between preference.  d e s i g n i n which each p a t i e n t  a month and t h e  month.  c o n t i n u o u s wet  d i s c o m f o r t d u r i n g and  The s t u d y u s e d a c r o s s - o v e r  of  with dressing  with dressings.  and r e v i e w e d f o r  was  Q u e s t i o n n a i r e was d e v e l o p e d  other  were  analyzed.  dressing f o r the  involved i n the  The r e m a i n i n g f o u r  t h e y were u n a b l e t o  complete  study,  used next only  patients a portion  Two m a j o r Patient  f i n d i n g s were i d e n t i f i e d .  Satisfaction  metastatic skin be asked t o  lesions  evaluate  They c o n s i d e r e d t h e and t h e  questions  important  Questionnaire,  patients  had numerous  patient  ideas  satisfaction  questionnaire to  generated  First,  by t h e  regarding  with  ulcerating  a b o u t what s h o u l d with  dressings.  be an a p p r o p r i a t e  investigator  to  format  be b o t h  and u n d e r s t a n d a b l e .  Second,  the  Mesalt dressings  f i n d i n g s of the received  study i n d i c a t e d that  application  and o d o r c o n t r o l .  s i g n i f i c a n t l y preferred to  Mesalt dressings  c o n t i n u o u s wet s a l i n e  The k n o w l e d g e g a i n e d t h r o u g h t h i s d e c i d e which d r e s s i n g s  ulcerating  metastatic skin  appears  be a f a v o r a b l e  to  application  the  s i g n i f i c a n t l y more p o s i t i v e  when compared w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s  patients  the  study  to  use  lesions. choice,  and o d o r c o n t r o l  is  ratings  for  were  ease  of  also  dressings.  i s u s e f u l when h e l p i n g i n the  care  of  The M e s a l t d r e s s i n g  p a r t i c u l a r l y when e a s e important.  of  TABLE OF CONTENTS  Page ABSTRACT  ii  TABLE OF CONTENTS  iv  L I S T OF TABLES  vii  L I S T OF FIGURES  viii  ACKNOWLEDGEMENTS  ix  CHAPTER 1.  INTRODUCTION Background of t h e Study C o n c e p t u a l Framework, 1 S t a t e m e n t o f t h e P r o b l e m and P u r p o s e Hypotheses D e f i n i t i o n o f Terms Patient, 6 Ulcerating metastatic skin lesion, Satisfaction, 6 Preference, 7 A s s u m p t i o n s and L i m i t a t i o n s Assumptions, 7 Limitations, 8 Summary.  2.  1 .  3 5 6  6 7 8  REVIEW OF RELEVANT LITERATURE Introduction Incidence of U l c e r a t i n g M e t a s t a t i c Skin Lesions M e d i c a l Treatment of U l c e r a t i n g M e t a s t a t i c Skin Lesions Care of U l c e r a t i n g M e t a s t a t i c S k i n L e s i o n s Cleansing, 11 Bleeding, 14 C l i n i c a l Infection, 15 Odor, 15 Drainage, 17 C o n t i n u o u s Wet S a l i n e D r e s s i n g s Mesalt Dressings. Patient Satisfaction Summary iv  9 9 10 11  18 18 22 26  Page 3.  METHODOLOGY Introduction Development of t h e P a t i e n t S a t i s f a c t i o n Questionnaire Sample f o r P a t i e n t S a t i s f a c t i o n Questionnaire, 28 Procedure f o r Q u e s t i o n n a i r e Development, 29 Content I d e n t i f i c a t i o n , 29 Content V a l i d i t y V e r i f i c a t i o n , 29 R e l i a b i l i t y T e s t i n g , 30 Study Methodology Study Design, 31 Study Group, 32 Study Procedure, 33 A c c r u a l , 33 Procedure, 33 E v a l u a t i o n Tools, 35 S t a t i s t i c a l A n a l y s i s , 36 Sample S i z e , 36 S t a t i s t i c a l Procedures, 36 Withdrawals, 39 E t h i c s , 39 Summary  4.  27 28  31  39  PRESENTATION AND DISCUSSION OF FINDINGS Introduction Patient S a t i s f a c t i o n Questionnaire Content I d e n t i f i c a t i o n , 41 C h a r a c t e r i s t i c s o f t h e Sample, 41 R e s u l t s o f t h e Interviews, 42 Development o f t h e P r e l i m i n a r y Q u e s t i o n n a i r e , 44 Content V a l i d i t y V e r i f i c a t i o n , 45 C h a r a c t e r i s t i c s of t h e Sample, 46 R e s u l t s o f t h e T e s t i n g , 47 Development of t h e P i l o t Q u e s t i o n n a i r e , R e l i a b i l i t y T e s t i n g , 48 C h a r a c t e r i s t i c s of t h e Sample, 49 R e s u l t s of t h e T e s t i n g , 49 The P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e , D i s c u s s i o n of t h e F i n d i n g s , 53  v  41 41  48  52  Page Study F i n d i n g s C h a r a c t e r i s t i c s o f t h e S a m p l e , 55 Study Completeness, 57 Overall Evaluation Scale, 58 Comments a b o u t t h e A n a l y s i s , 60 Comments a b o u t t h e O v e r a l l E v a l u a t i o n Scale, 61 D i s c u s s i o n o f F i n d i n g s , 62 Preference Scale, 64 Comments a b o u t t h e A n a l y s i s , 65 Revisions to the Preference Scale, 65 A n a l y s i s o f t h e O p e n - E n d e d Q u e s t i o n , 66 Comments a b o u t t h e P r e f e r e n c e S c a l e , 67 D i s c u s s i o n o f t h e F i n d i n g s , 67 G e n e r a l Comments a b o u t t h e S t u d y , 69 Comments a b o u t t h e S t u d y D e s i g n , 69 Comments a b o u t t h e P a t i e n t s , 70 P a t i e n t s ' Comments and P o s t - S t u d y Consultation, 74 Summary 5.  55  75  CONCLUSION AND RECOMMENDATIONS Introduction Major C o n c l u s i o n s D e r i v e d from the Implications for Nursing Recommendations f o r F u r t h e r S t u d y Summary  76 76 77 80 81  Results  REFERENCES  83  APPENDIXES A. B. C. D. E. F. G. H. I. J. K. L.  Patient Satisfaction Questionnaire Interview Guide Preliminary Questionnaire L e t t e r of Introduction P i l o t Questionnaire Medical History P r o t o c o l f o r Wound C a r e ! Overall Evaluation Scale Preference Scale Preference Scale (Revised) P a t i e n t I n f o r m a t i o n and C o n s e n t Form C o n t e n t I d e n t i f i c a t i o n Summary  vi  • • • • ..  90 95 97 103 105 112 114 116 118 120 122 125  LIST OF TABLES Table  Page  1.  P a t i e n t Randomisation t o F i r s t D r e s s i n g  58  2.  Frequency D i s t r i b u t i o n of P a t i e n t P r e f e r e n c e s . . .  64  vii  LIST OF FIGURES Figure 1.  Page Histogram d e p i c t i n g t h e average d i f f e r e n c e s between t h e 1st and 2nd t e s t f o r t h e 25 questions on the P i l o t Q u e s t i o n n a i r e  viii  50  ACKNOWLEDGEMENTS I would l i k e t o metastatic skin inspiration  thank the  patients  with  ulcerating  l e s i o n s who have p r o v i d e d t h e  for this  thesis.  e x p r e s s my a p p r e c i a t i o n t o  In a d d i t i o n ,  the  staff  at  the  energy  I would  patients  were  accrued  to  the  study.  encouragement  from the  Chris  D r . M i c h e l e Deschamps,  Salton,  Maher,  my r e s e a r c h Nursing care  (BCCA);  in ensuring the  BCCA s t u d y :  J o a n Murphy,  Maureen  O t h e r p e o p l e who h a v e  L e s l i e Bradley,  is  supported  Assistant Director  and S h a r o n B r i d g e r and Penny B i c k e r t o n ,  of wound  specialists. The  thesis  author  committee  Finally, were  include:  of the  to  Columbia  Also appreciated  co-investigators  and D r . F r e d R o b e r t s .  like  British  C a n c e r A g e n c y (BCCA) who h a v e b e e n v e r y h e l p f u l  and  is  grateful  members:  f o r the Carol  I a c k n o w l e d g e my f a m i l y ,  invaluable.  ix  guidance received  from the  J i l l i n g s and J u d y Mogan. whose p a t i e n c e  and  support  CHAPTER 1 Introduction Background o f t h e Study L i v i n g with cancer significant expectancy to  as t e c h n o l o g i c a l  produce odors,  and t h e i r  lesions.  deformities,  1985,  manifestations  p.  103),  they  health care providers.  dressings  chosen  Conceptual  some of  l e s i o n s may or  intolerable and b l e e d i n g " difficult  f o r the patient,  these  even y e a r s  needs  and t h e i r  f a m i l y and  the dressing.  l e s i o n s may be (Andreev,  1978).  t o be p a i d t o t h e t y p e s  affect  on p a t i e n t  present  of  comfort.  Framework  Satisfaction satisfaction  chronic,  In a d d i t i o n  a r e among t h e most  i s uncommon,  attention  As t h e s e  t h e l e s i o n and change  o r i n some c a s e s  Consequently,  life  Compounding t h e s e d i f f i c u l t i e s a r e t h e  to regularly cleanse  months  more  with cancer,  with drainage  o f advanced cancer  Although occurrence  1982).  unsightly sores,  a n d may p l a g u e t h e p a t i e n t  (Billings,  needs  for living  the  f a m i l i e s h a v e t h e added s t r e s s e s  metastatic skin  "gross  increase  (Rosenbaum,  d e v e l o p i n g new c o p i n g s k i l l s  ulcerating  of  advances  of cancer patients  individuals  for  i s a phenomenon t h a t h a s become  with health  with l i f e  care  or q u a l i t y of l i f e ,  long-term care s i t u a t i o n s  Satisfaction  is a positive  compared t o o n e ' s  i s an i m p o r t a n t  (McMillan,  especially in 1987).  judgment o f a p r o d u c t  own e x p e c t a t i o n s 1  (McMillan).  component  or  service,  Because  patients will  a r e consumers o f h e a l t h c a r e ,  be r e f e r r e d t o as p a t i e n t Efforts  are  to evaluate  consumer  satisfaction  satisfaction.  patient  satisfaction  in health  care  b e i n g e m p h a s i z e d as an i m p o r t a n t a s p e c t o f q u a l i t y -  a s s u r a n c e programs and p a t i e n t quality  satisfaction  1985).  Although q u a l i t y of care  are often related,  the presence of  c a r e d o e s n o t n e c e s s a r i l y mean t h e p a t i e n t  satisfied services without  (Black,  (Oberst, using  input  Patient recent years  1984).  clinical  Therefore,  evaluating health  and economic c r i t e r i a  from t h e p a t i e n t  is  ( L o c k e r 8s D u n t ,  s a t i s f a c t i o n has been g a i n i n g for a variety  of reasons.  is  inadequate  1978).  importance i n  Not o n l y  ethically  important t o s a t i s f y the p a t i e n t ,  countries  s u c h as t h e U n i t e d S t a t e s ,  it  b u t i n some  i t is also  requirement f o r the i n s t i t u t i o n ' s success  is  a  financial  (McMillan,  1987).  Emphasizing the a c c o u n t a b i l i t y of h e a l t h care p r o f e s s i o n a l s provide e f f e c t i v e patient patient the  satisfaction  effects  care also necessitates  (Black,  of p a t i e n t  1985;  McMillan).  evaluating  Concern about  d i s s a t i s f a c t i o n on c o m p l i a n c e w i t h  recommended h e a l t h c a r e r e g i m e n s h a s a l s o importance of e v a l u a t i n g p a t i e n t Rootman,  to  increased the  satisfaction  (Larsen &  1976).  The consumer movement h a s c o n t r i b u t e d t o t h e s i g n i f i c a n c e of p a t i e n t  satisfaction.  consumer's  right to  his  health,  involved  Canadians have d e c l a r e d t h e  "participate  i n d e c i s i o n making  affecting  w i t h t h e h e a l t h p r o f e s s i o n a l s and p e r s o n n e l  in his direct  health care"  2  (Consumers' A s s o c i a t i o n of  Canada,  1974 p .  1).  A study of cancer patients  51% t o 87% p r e f e r r e d their  treatment  1980).  National  i n making d e c i s i o n s  Zupkis,  H e a l t h and W e l f a r e  health  input i s not only a goal;  (1986).  for participating  time,  Canada's  contacts with health  skin  lesions  care professionals.  preferences  related  to  Statement  literature  i n the care of  No s p e c i f i c  s a t i s f a c t i o n and  metastatic skin  ( I v e t i c & Lyne,  1990).  i s l i m i t e d and t h e recommended c a r e experiences.  To d a t e ,  The e v a l u a t i o n  no t o o l s  i n the literature,  specifically  to evaluate  lesions.  Patient  also  satisfaction  i s based mainly  dressings  is have  also been  n o r have any been d e v e l o p e d  dressings  satisfaction  evaluate  lesions  The a v a i l a b l e  of dressings  which e v a l u a t e  in ulcerating  satisfaction  3  metastatic  i n the evaluation of  has n o t been c o n s i d e r e d .  tools  individual  o f t h e P r o b l e m and P u r p o s e  established  on p e r s o n a l  about  dressings.  The d r e s s i n g c a r e o f u l c e r a t i n g not well  care  have a g r e a t e r  is limited to  i s a v a i l a b l e about p a t i e n t  dressings  is a  patients'  with dressings  information  skin  health  and m a k i n g d e c i s i o n s  knowledge about  and s a t i s f a c t i o n  ulcerating metastatic  reported  it  care.  expectations  limited.  about  S u t t o n - S m i t h & March,  i s c h a n g i n g t o a s y s t e m where consumers  At the present  is  that  as p r o c l a i m e d b y t h e H o n o r a b l e J a k e E p p , M i n i s t e r o f  responsibility their  (Cassileth,  The n e e d f o r p a t i e n t  certainty  system  to participate  revealed  Most  patient  w i t h c a r e o n l y from a  broad  perspective. No known s t u d i e s  have  in the care of u l c e r a t i n g the  patient's  formally evaluated metastatic skin  perspectives  C o l u m b i a C a n c e r A g e n c y (BCCA)  centers  across  used,  Canada r e v e a l s  wet s a l i n e  personal  dressings  communication,  that  and/or  c l o t h i n g t o become w e t .  bleeding.  moisture,  However,  maintain moistness especially  they  which  1986;  infected  a feasible  visits  fewer d r e s s i n g  changes.  they  and t h e r e f o r e report  additional  resist  resulting  from b r e a s t  of t h i s  Ruth,  which,  1986).  As  a r e removed when  considerably  metastatic skin  lesion  1988).  consequently,  b a s e d on p a t i e n t 4  1979)  s t i c k i n g t o t h e wound.  (Spencer,  thesis,  gauze  ulcers  found t h a t Mesalt d r e s s i n g s  t h e o d o r o f an u l c e r a t i n g  an e v a l u a t i o n t o o l  1982;  Nurses.  a r e e a s y t o a p p l y and r e q u i r e  decreased  One p u r p o s e  dressing  b y t h e Home C a r e  Mesalt dressings  cancer  to  option,  (Jagelman & Spencer,  Mesalt dressings  One a n e c d o t a l  where  Gross & Gerner,  dry dressings,  are moist  changes r e q u i r e d  i s a dry, saline-impregnated  lesions  Salton,  do n o t  i n t h e c a r e o f l e g and d e c u b i t u s  (Gallant & Sibbald, and i n o p e n ,  dressings  and may c a u s e b e d l i n e n  dressing  i n t h e community s e t t i n g  is useful  cancer  c a n c a u s e p r o b l e m s w i t h p a i n and  a r e n o t always  The M e s a l t d r e s s i n g  A  C o n t i n u o u s wet  If the dressings  the frequent  c h a n g e s r e q u i r e more f r e q u e n t  examined  common ( C h r i s  1988).  c a n be u n c o m f o r t a b l e  used  of the dressings.  of the various  November 14,  dressings  or  s u r v e y o f major  were t h e most  saline  maintain t h e i r  lesions,  on t h e c o m f o r t  British  dressings  was t o  input,  develop  measures t h e  patient's  satisfaction  ulcerating  with dressings  metastatic skin  patient  by t h e  preference  dressings  B.C.  with continuous  metastatic skin  lesions  wet  spent  for  infection,  care of the  Scale  performance, dressings,  including  discomfort  control  of odor.  patient  preference.  satisfaction as  part  patients  of the  ulcerating  satisfaction preference,  changes,  measure  time materials.  patient  The O v e r a l l satisfaction  Evaluation  with  dressing  a p p l i c a t i o n and r e m o v a l  Scale  dressing  However,  thesis  due b o t h t o  metastatic skin  the and  evaluate  patient would a l s o  be u s e d  low numbers  lesions  was d e v e l o p e d b u t n o t  of  changes,  was u s e d t o  was hoped t h a t t h e  developed f o r t h i s  tool  in  conducted Mesalt  of d r e s s i n g  d u r i n g and between  study.  the  and n u r s e  patient  ease of  It  compared  patient  and c o s t  satisfaction  study  dressings  preference.  with ulcerating  constraints,  saline  The P r e f e r e n c e  tool  a larger  The s t u d y  were u s e d t o  evaluate  of  patient  number o f d r e s s i n g  and p a t i e n t  was u s e d t o  of  patient  lesion,  Two p r e - d e v e l o p e d t o o l s satisfaction  the  by e v a l u a t i n g  with d r e s s i n g performance, occurrence of  evaluate  components  BCCA i n V a n c o u v e r ,  care  lesions.  A n o t h e r p u r p o s e was t o and  i n the  and t o  of time  used.  Hypotheses The 1.  hypotheses  are:  Mesalt dressings continuous  wet  satisfaction  will  saline  receive  a more p o s i t i v e  dressings  with dressing  with respect to  performance.  5  rating  than  patient  2.  Mesalt dressings  will  be p r e f e r r e d  c o n t i n u o u s wet s a l i n e  "ulcerating metastatic "preference"  to  dressings.  Definition For the purposes  by p a t i e n t s  of t h i s skin  are defined.  o f Terms  study,  lesion,"  t h e terms  "patient,"  " s a t i s f a c t i o n " and  "Satisfaction"  and " p r e f e r e n c e "  o p e r a t i o n a l l y d e f i n e d s o as t o more a c c u r a t e l y  reflect  are  their  use w i t h i n t h e s t u d y . Patient The p a t i e n t  i s an i n d i v i d u a l  18 y e a r s  confirmed diagnosis  of cancer,  requiring dressings  f o r an u l c e r a t i n g  Ulcerating metastatic  skin  registered  cancerous  l e s i o n may r e s u l t  with a  w i t h t h e BCCA, and  metastatic  skin  lesion.  lesion  An u l c e r a t i n g m e t a s t a t i c s k i n draining  or older,  l e s i o n i s an open and  l e s i o n w i t h i n the dermis of the s k i n . from a metastasis t o t h e s k i n  tumor o r f r o m a tumor  in a distant  site  from a  (Rosenberg,  This local  1977).  Satisfaction Satisfaction service, 1987).  compared t o h i s / h e r It  is a subjective,  which cannot varies  i s the patient's  be d i r e c t l y  judgment o f a p r o d u c t  own e x p e c t a t i o n s evaluative  rating  observed by o t h e r s .  from a very n e g a t i v e  (McMillan, on a c o n t i n u u m Satisfaction  judgment t o a v e r y  positive  judgment. Measures  of s a t i s f a c t i o n  were 6  or  incorporated  into the  Patient Patients  Satisfaction  i d e n t i f i e d f a c t o r s which they  dressings, the  and t h e  dressings  Evaluation  Scale  removal, control  scale  allowed the  to  find  patients  was a l s o m e a s u r e d u s i n g t h e as  and c o n t i n u o u s wet evaluate  response  expected  thesis. in to  the  part  of the  e v a l u a t i o n of Mesalt  saline dressings.  dressings  Overall  i n terms of  The p a t i e n t s  dressings  were  asked  e a s e o f a p p l i c a t i o n and  d i s c o m f o r t d u r i n g and between d r e s s i n g c h a n g e s , of  rate  on a c o n t i n u u m .  Satisfaction  to  Questionnaire developed i n t h i s  and  odor.  Preference Preference chooses other  a particular  dressing  1983). Patients  i s d e t e r m i n e d when t h e  were  d r e s s i n g which he/she  (Avis,  Preference  patient  is  asked t o  Drysdale, Gregg, a general indicate  e v a l u a t i o n of Mesalt dressings  subjectively  favors  Neufeldt,  e v a l u a t i o n of a preference  over  the  & Scargill,  satisfaction. as p a r t  and c o n t i n u o u s wet  of  the  saline  dressings. Assumptions  and L i m i t a t i o n s  Assumptions There are 1.  Patients skin  t h r e e major  r e c e i v i n g care f o r t h e i r  l e s i o n s h a v e an i n t e r e s t  regarding the 2.  assumptions  Patients  are  dressings able to  in this  study:  ulcerating  metastatic  in decision-making  being used.  evaluate  7  the  performance  of  dressings 3.  Changes are  and make d e c i s i o n s  i n the  regarding  preference.  c l i n i c a l wound c o n d i t i o n d u r i n g t h e  primarily a result  of the  study  d r e s s i n g being used.  Limitations There are 1.  two m a j o r  The P a t i e n t the  limitations  Satisfaction  s t u d y has  in this  study:  Questionnaire developed during  had l i m i t e d t e s t i n g  for  r e l i a b i l i t y and  validity. 2.  The O v e r a l l  E v a l u a t i o n S c a l e measures t h e  satisfaction the  with pre-determined  evaluation to  caring  for ulcerating  this  i n p u t was n o t  tool  development.  criteria,  those p a r t i c u l a r  were i d e n t i f i e d f r o m p r e v i o u s  patients' thus  criteria.  contacts with  metastatic  skin  The  criteria  patients  lesions.  formally obtained for the  limiting  However,  purposes  of  Summary In  this  chapter,  the  conceptual  and  purpose of the  the  background of the  framework,  has  been p r e s e n t e d ;  s t u d y h a v e been  literature lesions  recognised. relevant  and t h e  of  the  presents  care of u l c e r a t i n g of p a t i e n t  and c o n c l u s i o n and  8  problem  hypotheses and  the  metastatic  skin  satisfaction.  i n c l u d e the methodology,  findings,  The  and a s s u m p t i o n s  The n e x t c h a p t e r  evaluation  Subsequent chapters discussion  to  including  and t h e  introduced.  have been i d e n t i f i e d , terms d e f i n e d , limitations  study,  presentation  and  recommendations.  CHAPTER 2 Review o f R e l e v a n t  Literature  Introduction Presented  in this  on t h e i n c i d e n c e , metastatic skin  are discussed  documentation  metastases e x i s t s . metastases lesions.  account It  of  agreed  with breast  cancer.  Skin metastases  Sweeney,  i n 7.3  or neck  s k i n m e t a s t a s e s a r e most  occur  lung,  (Rosenberg, 1986).  results 9  with  to  breast  i n m a l i g n a n t lymphoma;  uterus,  i n f i l t r a t i o n o f a tumor,  Skin ulceration  skin  cancer and, according  can a l s o  o f t h e stomach, head,  that  1980).  2.7% o f a l l m e t a s t a t i c  kidney, 1977;  ovary,  Watson,  A m a l i g n a n t growth or a metastatic  o f e m b o l i z a t i o n t h r o u g h l y m p h a t i c s and b l o o d (Rosenberg).  is  ulcerated  estimates that  - 31.9% o f a l l p a t i e n t s  McGregor, & S l e i g h ,  from a l o c a l  Lesions  about t h e o c c u r r e n c e  f o r approximately  occur  bladder,  Skin  expanded.  (Rosen,  A n d r e e v (1978)  Andreev,  colon,  is  problem i s a v a i l a b l e  is generally  commonly a s s o c i a t e d  or carcinoma  satisfaction  and t h e  L i t t l e documentation t o determine the  frequency of t h i s less  i n more d e t a i l ,  of s k i n metastases without u l c e r a t i o n  r e l a t i v e l y uncommon.  Even  and c a r e o f u l c e r a t i n g  of Ulcerating Metastatic  The o c c u r r e n c e  literature  C o n t i n u o u s wet s a l i n e d r e s s i n g s and  framework o f p a t i e n t  Incidence  exact  are a review of the  medical treatment,  lesions.  Mesalt dressings conceptual  chapter  occurs  process  vessels  when p r o l i f e r a t i n g and  infiltrating The  ulcerating  cavity, or  metastatic skin  a n o d u l a r growth  The  Rosen,  1989,  aggressive  lesions  skin  nodules,  of the skin  i n patients  i d e n t i f i c a t i o n of patients  were i d e n t i f i e d w i t h  by BCCA  1988  -  ulcerating  which d i d n o t respond e a s i l y  to  A t t h e end o f December  The 66 r e m a i n i n g l e s i o n s  death.  o f p r e s e n c e was 9 . 3  1989,  either  1989,  O f t h e 66 l e s i o n s , months,  Treatment  were s t i l l  o r were p r e s e n t  21  present  at the time  the average  of  duration  w i t h a r a n g e o f 1 week t o  The m e d i a n d u r a t i o n was 6 . 5 Medical  was d e t e r m i n e d  had e v e n t u a l l y h e a l e d w i t h m e d i c a l  t h e end o f December  months.  of the skin,  from t h e s u r f a c e  medical treatment.  patient's  (Andreev).  During the p e r i o d January  87 p a t i e n t s  o f t h e 87 l e s i o n s treatment.  tissue  l e s i o n may t a k e t h e f o r m o f a  lesions  through  reviews.  metastatic skin  the  extending  frequency of these  and c h a r t  December  at  destroy  1980).  the investigator  staff  cancer c e l l s  an open a r e a on t h e s u r f a c e  (Andreev;  by  malignant  60.5  months.  of Ulcerating  Metastatic  Skin L e s i o n s Medical treatment focuses malignant  cells,  on d e s t r o y i n g  or s t a b i l i z i n g t h e i r  intention of healing the ulceration its  complications  Controversy exists,  (Billings, however,  which t h e malignancy e f f e c t s lesion  (Irvin,  1981).  1985;  or removing t h e  growth w i t h t h e  or at Borg,  least Rubin,  as t o t h e d e g r e e  controlling & DeWys,  to  the healing potential  Medical treatments 10  of the  for localized  1983)  ulcerations  may i n c l u d e r a d i a t i o n  debridement, breast  excision  lesions,  treatments  (Billings),  chemomasteetomy  s u c h as c h e m o t h e r a p y  involved  i n addition to,  (Petrek,  Glenn,  related  1983;  (Goncalves,  of,  Systemic  Wood,  may b e  therapy  1980).  Unfortunately,  o r no l o n g e r  p a l l i a t i v e care of the l e s i o n focuses  on m i n i m i s i n g  problems.  established,  investigated relating  metastatic skin  and few s t u d i e s  the efficacy  Skin  have  of d i f f e r e n t  often  clinical  includes  infection,  containing drainage, (Folta,  1980;  patient  comfort  little  lesions  cleansing  preventing  the lesion,  odor, possible  The p r o m o t i o n o f  may b e t h e p r i m a r y o b j e c t i v e  o r no p o t e n t i a l  skin  and managing  and p r o m o t i n g h e a l i n g where 1987).  Literature  metastatic  c o n t r o l l i n g and p r e v e n t i n g  Sims & F i t s g e r a l d ' ,  i s not  treatments.  i n f o r m a t i o n about  and p r e v e n t i n g b l e e d i n g ,  Lesions  systematically  t o t h e wound c a r e o f u l c e r a t i n g  controlling  has  1987).  local  are inappropriate  The c a r e o f u l c e r a t i n g  lesions  i n some  o r hormonal t h e r a p y  Care of U l c e r a t i n g M e t a s t a t i c  well  surgical  o r more r e c e n t l y  or instead  & Cramer,  when t h e s e m o d a l i t i e s effective,  therapy,  where t h e l e s i o n  for healing.  Cleansing Traditionally, the  many s o l u t i o n s  cleansing process:  peroxide,  normal s a l i n e  povidone i o d i n e ,  Sims & F i t z g e r a l d ,  h a v e b e e n recommended i n  1987).  solution,  and h e x a - c h l o r o p h e n e Recent  studies,  hydrogen (Folta,  however,  1980;  indicate  t h a t the t r a d i t i o n a l use of a n t i s e p t i c s longer  appropriate  interfere 1988;  other the  are detrimental  w i t h wound h e a l i n g  Rodeheaver,  solution  as t h e y  1988).  (Alvares,  Except  and t h e s o l u t i o n  or the c e l l s  orchestrate healing antiseptics  1985;  Van F u r t h ,  (Alvares  acetic  Lineaweaver  1982).  that  acid,  wound, b u t a l s o t o i n c r e a s e Viljanto,  (Lineaweaver has a l s o  p r o m o t i n g wound h e a l i n g  and/or  ensymatic  little  solution),  Van d e n B r o e k ,  Further,  potential  speculation such as non-toxic  et a l . ,  recommended d e b r i d e m e n t  to  1980).  Folts  In  suggests  saline  for. h e a l i n g s i n c e  that  dressings,  s u c h as D a k i n ' s  may be q u e s t i o n a b l e  solution.  i n wounds  i t may i n f a c t  e x a c e r b a t e p r o b l e m s w i t h b l e e d i n g and d r a i n a g e . 12  1982).  i s considered v i t a l i n  1990).  or o x i d i s i n g agents however,  is  in diluted,  e t a l . ; Rodeheaver  (Stotts,  damage  of i n f e c t i o n  there  o f t h e wound ( F o l t s ,  Buys, &  of  of a n t i s e p t i c s  i n v o l v e the use of wet-to-dry  A c t i v e debridement, with  1980).  debridement o f dead t i s s u e  debridement  (Dakin's  the occurrence  effectiveness  maintain the cleanliness general,  These  and p o v i d o n e i o d i n e ( B r e n n a n &  i o d i n e and hydrogen p e r o x i d e  The l i t e r a t u r e  and/or  and 5% h a s b e e n f o u n d n o t o n l y t o  about t h e b a c t e r i c i d a l  concentrations  on e i t h e r  Povidone i o d i n e i n concentrations  the  povidone  effects  most  eliminate bacteria  e t a l . , 1985;  (full-strength)  1986;  saline  et a l . ; Rodeheaver).  10%  (Becker,  & Wiseman,  f o r t h e normal  i n c l u d e sodium h y p o c h l o r i t e  hydrogen p e r o x i d e , Leaper,  Rosint,  have t o x i c  i s no  t o t h e wound a n d  "Shur C l e n s " (Rodeheaver),  commonly u s e d a n t i s e p t i c s  wound t i s s u e  i n wound c a r e  Wet-to-dry  saline  dressings  stick  of the u l c e r a t i n g  t o t h e wound a n d o f t e n  metastatic  a recent study discourages  skin  cause b l e e d i n g  l e s i o n when removed.  using wet-to-dry  dressings  removing t h e d r e s s i n g d i s t u r b s  the crusts  wound b e d , t h e r e b y  interfering  i n wound h e a l i n g  Eaglstein,  A l t h o u g h D a k i n ' s s o l u t i o n has been  1984).  extensively, "safe"  concentration  (Kozol, also  a recent  Gillies,  contains  Association, metastatic Elase,  study levels,  Salwa,  Travase,  attached t o the  that  Mezinc,  properties  Dakin's solution  (American  prone t o b l e e d i n g .  as w e l l as p a p a y a ,  No l i t e r a t u r e  these agents'  u s e i n m e t a s t a t i c wounds.  was f o u n d ,  of autolysis  slower  but less  using  occlusive  1984)  or Mezinc,  environment. not  be u s e d  completely  harmful process. dressings  Products  A less  aggressive  and  i n wounds  et a l . ,  itself  1988).  through  a  T h i s may be a c h i e v e d b y  s u c h as DuoDerm ( F r i e d m a n & S u ,  however,  occlusive  warm dressings  should  i n a c l i n i c a l l y i n f e c t e d wound where t h e d r e s s i n g occludes  t h e wound ( A l v a r e z  et a l . ) .  a c c e p t a b l e method o f r e m o v i n g s l o u g h i n g t i s s u e g r e a t harm t o t h e wound i s t h r o u g h m e c h a n i c a l continuous  s u c h as  regarding  a l l o f which p r o v i d e a moist,  Importantly,  in a  however,  (Alvarez  T h i s method c a u s e s t h e wound t o d e b r i d e  Medical  have been used f o r  more uncommon method o f r e m o v i n g d e a d t i s s u e the process  used  as t h e r e a r e no  1988).  debridement.  involves  (Alvarez &  w h i c h may p o t e n t i a t e p r o b l e m s  lesion already  because  i t s u s e s h o u l d be d i s c o n t i n u e d  & Elgebaly,  anticoagulant 1986)  indicates  Also,  wet s a l i n e  dressings. 13  A still without  means;  causing  using  Bleeding Bleeding  c a n be c o n t r o l l e d b y t h e a p p l i c a t i o n o f a  topical  hemostatic  gelatin  s p o n g e s u c h as G e l f o a m  focal  p r o d u c t s u c h as K a l t o s t a t  bleeding points,  (Foltz,  these products  o r an a b s o r b a b l e  1980).  Applied  are l e f t  to  i n place  until  absorbed. D r e s s i n g s w h i c h s t i c k t o t h e wound n o t o n l y irritation  and b l e e d i n g , b u t a l s o  interfere  i n wound h e a l i n g .  Designed t o prevent  s t i c k i n g are the f o l l o w i n g :  dry dressings  ETE d r e s s i n g ) ;  (e.g.  creams/ointments  sulfadiazine  (Flamazine));  as  (e.g.  a barrier  to  some d r e s s i n g s  healing  Despite  or type of drainage.  i f they prevent  nevertheless  silver moisture  or  do s t i c k factors  s u c h as t h e amount,  D r e s s i n g s a l s o d e l a y wound  organisms which support h e a l i n g from  m o v i n g a c r o s s t h e wound ( A l v a r e z e t a l . , 1988; 1985).  Little  process  o f gauze d r e s s i n g s  emulsion.  or  their  There i s a l a c k o f i n f o r m a t i o n about  w h i c h may c a u s e a d r e s s i n g t o s t i c k , consistency,  (e.g.  which promote  s u c h as DuoDerm).  intentions,  t h e wound.  which a c t as b a r r i e r s or dressings  dressings  (e.g. Adaptic,  c o n t i n u o u s wet s a l i n e d r e s s i n g s ,  hydrocolloid dressings non-adherent  non-adherent  impregnated gauze  b e t w e e n t h e wound and t h e a b s o r b e n t d r e s s i n g Jelonet);  promote  i s known a b o u t t h e e f f e c t s  May & S t i l l ,  on t h e wound h e a l i n g  impregnated w i t h p a r a f f i n o r an o i l  D r e s s i n g s w h i c h c o m p l e t e l y o c c l u d e t h e wound,  as  hydrocolloid dressings,  to  prevent  a r e v i e w e d as t h e s a f e s t  such  dressings  s t i c k i n g t o t h e wound and t o p r o m o t e wound h e a l i n g .  14  Clinical  Infection  A c l i n i c a l i n f e c t i o n may i n v o l v e a l o c a l infection.  A l o c a l wound i n f e c t i o n i n c l u d e s s i g n s  purulent drainage, tenderness includes (e.g.  redness  (Westaby  signs  systemic  and s w e l l i n g ,  & White,  of a fever  > 10,000).  infection  and/or  1985).  involving  and i n c r e a s e d  A systemic  a local  or a  a physician.  i n f e c t i o n s may r e q u i r e  infection  systemic  a n t i b i o t i c therapy,  a n t i b i o t i c therapy.  count  B o t h l o c a l and  p o s s i b l e h o s p i t a l i z a t i o n f o r wound management intravenous  s u c h as  and a h i g h w h i t e b l o o d c e l l  Managing e i t h e r  requires  systemic  The t y p e s  with  and/or  of dressings  used  during a c l i n i c a l i n f e c t i o n are s i m i l a r t o those described i n t h e upcoming s e c t i o n Wound c u l t u r e s lesions  almost  However, is  on o d o r . taken  from u l c e r a t i n g m e t a s t a t i c  always demonstrate  without the signs  a colonization of  of a c l i n i c a l i n f e c t i o n ,  n o t c o n s i d e r e d t o be i n f e c t e d and t h e r e f o r e  require  any f u r t h e r  problems.  attention  it  bacteria. t h e wound  does n o t  i s causing  odor  P r e v e n t i n g c l i n i c a l i n f e c t i o n i n v o l v e s p r o v i d i n g an  environment which promotes risk  unless  skin  cleanliness,  thus  decreasing  the  o f wound c o n t a m i n a t i o n .  Odor Ulcerating metastatic  skin  lesions  are often  malodorous,  due m o s t l y t o t h e p r e s e n c e o f a n a e r o b e s o r as a r e s u l t necrosis  of t i s s u e  Sparrow,  Minton,  cells  Rubens,  (Ashford, Plant, Simmons, 15  & Maher,  & Aubrey,  1980).  of the  1984;  Traditionally,  bactericidal  decrease b a c t e r i a However,  solutions  (Ellerhorst-Ryan,  Gauze i m p r e g n a t e d  reevaluation  with antimicrobial  t o x i c t o t h e wound may a l s o wound ( A l v a r e z  have  e t a l . , 1988;  May & S t i l l ,  creams/ointments well  1987;  Foltz,  1985).  dressing  antimicrobial  agents  1980).  Topical  creams/ointments  considered effect  Mertz,  indications general  (Alvarez  a local  infection  the  some  such as F l a m a z i n e ,  Polysporin,  their  but also  e t a l . ; Geronemus e t a l . , 1 9 7 9 ) .  for using antimicrobial  about  as  absorbent  h a s shown t h a t  wound c a r e a r e n o t e n t i r e l y  controversy  on t h e  & Eaglstein,  and N e o s p o r i n a r e n o t o n l y s a f e t o u s e i n wounds, healing  t o be  antimicrobial  which prevents  Research  in  practice.  a detrimental  may be u s e d t o t r e a t  from s t i c k i n g .  of t h i s  Geronemus,  as t o p r o v i d e a b a r r i e r  promote  to  b o t h t h e i n j u r y t o t h e wound b e d and i n t e r f e r e n c e  wound h e a l i n g a r e c a u s i n g  1979;  have b e e n u s e d  creams/ointments clear  effectiveness  as t h e r e  The  in is  and t h e d e v e l o p m e n t  of  resistance. Metronidazole effective  deodorant  metastatic  e t a l . , 1980). products  effectively  (Foltz,  skin  o r a l l y was f o u n d t o be  infection lesions  F o r odor c o n t r o l ,  of dressings  1980).  c h a n g e s may a l s o  s a t u r a t e d w i t h odorous  and odor  (Ashford,  l i k e N i l o d o r , Hexon,  applied to the outside  dressing  taken  i n c o n t r o l l i n g both  of u l c e r a t i n g Sparrow,  (Flagyl)  in a  et a l . ,  and B a n i s h h a v e  16  been  used  the frequency  decrease the exposure t o  drainage.  1984;  traditional  and a r e s t i l l  Increasing  variety  of  dressings  Hydrocolloid dressings  such  as  DuoDerm may d e c r e a s e t h e  necessary,  thereby  Although charcoal odor are  (Beckett, expensive  and h o s p i t a l s  decreasing dressings  Coombs,  the  have  Frost,  and t h e r e f o r e to  number o f d r e s s i n g patient's also  changes  exposure  been used t o  McLeish,  odor.  control  & Thompson,  d i f f i c u l t for  to  1980),  patients  to  they  obtain  justify.  Drainage After to  manage  cleansing the bleeding,  be c o n t a i n e d .  l e s i o n and c o n s i d e r i n g what  infection,  and o d o r ,  The i n n e r d r e s s i n g s  chosen  in direct  c o n t a c t w i t h the. wound ( e . g .  cream,  continuous  or  dressing,  covering  dressing. amount  the  infection,  may be u s e d dressings  require  dressing  stick, is  they  fewer d r e s s i n g  are  considerable,  secure the  However,  d r e s s i n g depends  on  minimal drainage  and no  and s i a e s  s u c h as  the  DuoDerm  Hydrocolloid  c h a n g e s t h a n do most they  often  of the  a l l that  is  cannot  ulcerating  required.  a wound d r a i n a g e  outer  Tape,  dressings.  17  or  of  adapt  the to  the  metastatic  I n c a s e s where  collector  netting  are  outer  In some c a s e s where d r y g a u s e d r e s s i n g s  p o u c h may be u s e f u l . to  is  to  usually a dry  o f an i n n e r d r e s s i n g .  types.  lesions.  there  needs  Flamaaine  The  a hydrocolloid dressing  in place  many u n u s u a l s h a p e s skin  If  is  needed  those which  Adaptic,  inner dressing, outer  drainage  are  saline dressings).  The s i a e o f t h e  of drainage.  clinical  other  wet  the  is  s u c h as  an  c l o t h i n g may be  do  not  drainage ostomy used  C o n t i n u o u s Wet S a l i n e Wet s a l i n e an i s o t o n i c water)  are d r y gauze d r e s s i n g s  "normal s a l i n e "  and a r e o f t e n  ulcerating wet  dressings  solution  recommended  metastatic  saline dressings  skin  lesions  preventing  (0.9% s o d i u m c h l o r i d e i n  (Stair,  moist,  decreasing  p r o b l e m s w i t h p a i n and b l e e d i n g  skin  lesions  (Greenberg,  adherence  dressing  t o t h e l e s i o n and (Cusaell,  for ulcerating  frequent  continuous  dressing  wet s a l i n e  dressings  mentioned p r e v i o u s l y ,  this  increased  i s economically undesirable  care s i t u a t i o n ,  as w e l l  changing h i s / h e r continuous  viable tissue (Cuszell,  metastatic  uncomfortable,  frequency  own d r e s s i n g s .  and may i n c r e a s e Third,  A second  As  of dressing  f o r the  patient  consideration  may r e s u l t  i n maceration  bacterial  proliferation  continuous  moist,  i n t h e Home N u r s i n g  as more b o t h e r s o m e  wet d r e s s i n g s  1985).  often  changes t o keep t h e d r e s s i n g  t h a t has s a t u r a t e d t h r o u g h .  that  1985).  1978).  o r t o remove d r a i n a g e  changes  Continuous  b e c a u s e a d h e s i o n t o t h e l e s i o n i s n o t recommended  Unfortunately, require  1986).  e x u d a t e a n d k e e p t h e wound  constantly  They p r o v i d e an a p p r o p r i a t e  soaked i n  i n the treatment of  d i l u t e viscous  thus  Dressings  wet d r e s s i n g s  a n d may c a u s e b e d l i n e n  and/or  is of  can be  clothing  to  become w e t . Mesalt Mesalt dressings  Dressings  a r e made o f b l e a c h e d  impregnated with c r y s t a l l i n e  100% c o t t o n  sodium c h l o r i d e 18  (Sancella,  gauze  pamphlet). hospital  T h e y a r e f r e q u e n t l y u s e d i n b o t h community and  settings.  When M e s a l t d r e s s i n g s  h y p e r t o n i c environment and r e m o v i n g e x c e s s (Sancella, in place  fluid,  pamphlet).  decreasing  Applied dry, Mesalt dressings  to large  To be  edema  are  are moist,  base  Mesalt  thereby  f o r s t i c k i n g t o t h e wound.  decreasing  Also suggested  t h a t the h y p e r t o n i c environment decreases t h e p o t e n t i a l bacterial the  growth  (Sancella,  c l i n i c a l setting  noted, case  substantiates  Mesalt dressings  involving  from b r e a s t  booklet).  (Spencer,  metastatic skin 1988).  for  odor  lesion  Additionally,  i n one resulting since  a r e d r y , t h e p r o b l e m s o f wet c l o t h i n g / b e d  linen  w i t h wet d r e s s i n g s  To d a t e f o u r s t u d i e s , non-cancerous All  skin  lesions,  of these studies  are minimised.  a l l o f them d e a l i n g w i t h have e v a l u a t e d  measurement  however,  arterial  wound,  used.  study evaluated wounds,  and a l a r g e  dressings.  o f c o l l e c t i n g d a t a and  O f t h e two s t u d i e s  o n l y one h a s been t r a n s l a t e d  The f i r s t with  tools  Mesalt  used a d e s c r i p t i v e d e s i g n w i t h l i m i t e d  i n f o r m a t i o n a b o u t t h e s p e c i f i c methods the  in  As p r e v i o u s l y  Mesalt dressings associated  is  no r e s e a r c h  effect.  considerably decreased  an u l c e r a t i n g  cancer  However,  this  left  effective,  amount o f d r a i n a g e .  a r e removed when t h e y  potential  interstitial  must b e i n c o n t a c t w i t h a m o i s t u l c e r  which has a moderate  their  thus  a  s t i m u l a t i n g wound c l e a n s i n g  t o become m o i s t e n e d b y d r a i n a g e .  Mesalt dressings  dressings  i s created,  are applied,  pressure  into  English.  Mesalt dressings wounds,  i n 17  an i n f e c t e d  a m p u t a t i o n wound ( R u t h , 19  published,  1979).  patients  venous Results  showed t h a t M e s a l t d r e s s i n g s , saline dressings, ulcers.  were t h e most  Mesalt dressings,  saline dressings  because  of d r e s s i n g changes, maceration  c o m p a r a b l e t o t r a d i t i o n a l wet effective  though,  they decreased  were  easier  paraplegic  patients  1985).  cleanliness dressings  Mesalt dressings  As w e l l ,  Mesalt dressings ulcers  changes  having leg ulcers  were e a s y t o a p p l y ,  Mesalt dressings  comparisons  (Gallant & Sibbald,  comparisons,  one o f t h e u l c e r s  Mesalt dressings,  1986).  suitable  completely within  In t h e p a i r e d comparisons,  improvement o f b o t h u l c e r s ,  2)  comparable  treated 2 to  only with  14 experienced  and i n t h e t h i r d p a t i e n t  1) t h e h e a l i n g p r o p e r t i e s to those of other  that Mesalt dressings  and/or Bard g e l .  two p a t i e n t s  a f a i l u r e t o show any s i g n i f i c a n t r e s p o n s e . concluded that  for paired  was t r e a t e d w i t h M e s a l t  10 o f t h e 14 u l c e r s  healed  venous  Of the p a i r e d  with benzoyl peroxide  indicated that  w i t h 16  secondary t o p e r i p h e r a l  t h r e e o f them h a v i n g l e s i o n s  the other  These  t h a n d i d wet s a l i n e  deficiency,  were  i n promoting  time.  The t h i r d s t u d y e v a l u a t e d  weeks.  among 21  (Gross & Gerner,  were b e n e f i c i a l  Mesalt dressings  r e d u c i n g d r e s s i n g change  Results  frequency  t o h a n d l e and d i d n o t c a u s e  with decubitus  r e q u i r e d fewer  dressings,  the required  o f t h e wound, g r a n u l a t i o n a n d h e a l i n g .  dressings.  patients  f a v o r e d o v e r wet  a t t h e wound e d g e s .  The s e c o n d s t u d y e v a l u a t e d  1982,  were  with decubitus  The a u t h o r s  of Mesalt  dressings  e s t a b l i s h e d m o d a l i t i e s and  were s i g n i f i c a n t l y l e s s 20  t h e r e was  expensive  t h a n most o t h e r t h e r a p i e s preferred  used  Mesalt dressings  were s i m p l e and r e q u i r e d The l a s t  study  w i t h open i n f e c t e d Evaluation dressings  ease of  A l l patients  including  a variety  "Representative  treatment,  The a u t h o r s  the  apply,  during the  changes d e c r e a s e d .  material  and n u r s i n g s t a f f  dressing  is  conclusions  must be c o n s i d e r e d  the  a proper  absence of  the  indicate  changes.  and  while not Mesalt  hasten  increase  dressings  more  and t h e  cost  to  adversely  frequency  related  of  to  that the  lesions.  with caution  of the  control 21  Mesalt  w h i c h c o u l d be u s e d  metastatic skin  limitations  and d u r i n g  appeared  appeared  changes,  a promising dressing  methodological  to  to  was m i n i m i s e d .  these r e s u l t s  care of u l c e r a t i n g  care plan  wound edema,  patients  Thus,  surrounding  with respect  In a d d i t i o n ,  dressing  dressing  In g e n e r a l ,  the  to  modalities.  formation,  surrounding skin. to  ability  of Mesalt d r e s s i n g  tissue  patients  Mesalt  on t h e  lesion prior  reduce  they  1986).  of  a structured  of the  wound h e a l i n g ,  were c o n v e n i e n t comfortable  of  other treatment  and f r e q u e n c y  r a t e of g r a n u l a t i o n  affecting  and e f f e c t  concluded that Mesalt dressings  and s t i m u l a t e the  were p a r t  size  i n 27  and r e m o v a l ,  c a s e s " were d e s c r i b e d  treatment protocols, the  performance  lesion,  staff  change.  (Jagelman & Spencer,  application  of  to  Nursing  because  Mesalt dressings  overall  c l e a n s e and d e b r i d e t h e skin.  less time  lesions  clinic.  other dressings  evaluated  included the for  to  in their  studies,  group.  in  the  However,  these  because of  the  and i n  particular,  Patient, Patient i n the  satisfaction  literature  study are  is  (Oberst,  presented  gatisfaction i n f r e q u e n t l y or u n c l e a r l y d e f i n e d  1984).  or d e s c r i b i n g the  Satisfaction  is  a subjective  an e v a l u a t i v e  o b s e r v e d by o t h e r s as  the  patient's  compared t o 1987;  product than  or  service  is  characteristics  1975;  be  it.  care  directly  c a n be v i e w e d  received,  or standards  (McMillan,  when  be l o w e r i n  satisfaction  s u c h as  the  performance  have  general  1987;  and  examined  practitioner,  hospital services,  personal  (Lemke,  studies  those of the  and o u t - p a t i e n t  Satisfaction  actual  perceived to  patient  measure  Satisfaction  D i s s a t i s f a c t i o n occurs  i n f l u e n c e of various  studied  1981).  a  (McMillan).  services  in-patient  used t o  of  on a c o n t i n u u m t h a t  own e x p e c t a t i o n s  Numerous p a t i e n t medical  rating  judgment o f t h e  Ware).  expected  criteria  component w h i c h c a n n o t  (Ware,  his/her  Oberst;  results  and a n a l y z e d w i t h o u t d e f i n i n g  satisfaction  includes  Often the  and  the  institutional  L o c k e r & Dunt,  1978).  w i t h t h e d e l i v e r y o f n u r s i n g c a r e has  (Derdiarian,  Ventura,  Fox,  1990; Corley,  studies  have e v a l u a t e d  studies  include the  (Sidi,  Reddy,  bridge  (Hoogstraten  measuring p a t i e n t  8s M e r c u i r o ,  s p e c i f i c treatments  1988)  and t h e  8s L a m e r s ,  been  Risser,  O n l y a few  or products. for  These  impotence  implantation of a  dental  1987).  i s no g e n e r a l l y  satisfaction  1982;  1982).  e v a l u a t i o n of a treatment  8s Chen,  Although there  H i n s h a w & Atwood,  also  accepted  (McMillan, 22  method  1987),  the  for most  commonly u s e d t o o l hospital  studies  i s the questionnaire  either  (Ware,  have d e v e l o p e d t h e i r  1981).  Most  own q u e s t i o n n a i r e  or have used a q u e s t i o n n a i r e p r e v i o u s l y d e v e l o p e d (Abramowits, Cote, to  & Berry,  1987).  The q u e s t i o n n a i r e was e i t h e r  discharged patients,  patient, a l . )..  delivered to the s t i l l - h o s p i t a l i s e d  o r u s e d as f o r m a t  f o r an i n t e r v i e w ( A b r a m o w i t s  As m a i l i n g s o f t e n r e s u l t  contact with patients  mailed out  i n low r e t u r n  through interviews  rates,  et  direct  is preferred  (French,  1981). W h i l e most q u e s t i o n n a i r e s some c o m b i n e s t r u c t u r e d Dunt, the  1978).  items  use only s t r u c t u r e d  and u n s t r u c t u r e d  questions,  questions  (Locker &  G e n e r a l l y , t h e q u e s t i o n n a i r e h a s two p a r t s :  t o be e v a l u a t e d  and 2)  the response  scales  1)  (Ware,  1981). Numerous p r o b l e m s e x i s t evaluate 1978;  patient  Oberst,  satisfaction  1984;  o f t h e measurement al.,  1978).  perspective,  r e g a r d i n g t h e methodology used t o  Ware, tool  Davies,  1981;  & Stewart,  i s a major concern  Many s t u d i e s sometimes  (French,  measure  (Oberst;  as a s i n g l e q u e s t i o n .  be i n s e n s i t i v e t o d i f f e r e n c e s  care received  (Locker & Dunt).  H e n l e y and D a v i s  consumer s a t i s f a c t i o n satisfaction  measure  (1967)  Patients  the results  aspect 23  et  may be tend  of the do n o t  satisfaction  suggest  that  b e e v a l u a t e d u s i n g two t o o l s : f o r each  Ware  from a broad  i n s p e c i f i c aspects Further,  Validity  and t h e r e s u l t s  i n d i c a t e how c a r e may be c h a n g e d t o i m p r o v e (Locker & Dunt).  1978).  satisfaction  a s k e d how s a t i s f i e d t h e y a r e i n g e n e r a l , to  L o c k e r & Dunt,  first,  of the i n d i v i d u a l ' s  a  care;  and s e c o n d ,  a general  evaluation  Not c l e a r l y d e f i n i n g what problem i n e v a l u a t i n g p a t i e n t this  problem e x i s t .  developed  First,  i s b e i n g measured satisfaction.  (1975).  However,  have  Satisfaction  Snyder,  care received,  aspects  of the care  they  (Oberst,  Instrument  are not s e n s i t i v e 1984).  Second,  topics.  o f t e n measure  The q u e s t i o n s  want t h e p a t i e n t for  measurements validity  to  tool  obtained  studies  particular  there  is a itself.  assume  (Oberst).  is  important  Without  patient  the v a l i d i t y of the  is questionable because  (Oberst).  the majority  do n o t i n d i c a t e p a t i e n t  The l a c k o f of  patient  involvement i n  development. Other problems  whether  i n v o l v e the format  of the questions,  u s e d i n an i n t e r v i e w o r a q u e s t i o n n a i r e .  rendered useless to  only  b a s e d on p r e - d e t e r m i n e d  o r what t h e y  satisfaction  concern  measure  r e l a t e t o what t h e r e s e a r c h e r s  i n t o o l development,  i s a major  satisfaction  often  to evaluate  evaluating patient  involvement  satisfaction  (Ware,  by R i s s e r  problem w i t h t h e development o f t h e q u e s t i o n n a i r e Researchers  Patient  & Wright  as b o t h o f t h e s e q u e s t i o n n a i r e s  general  been  with the intention  These i n c l u d e t h e  Q u e s t i o n n a i r e b y Ware,  and t h e P a t i e n t  i s a major  Two a s p e c t s o f  environments  o f b e i n g more u n i v e r s a l l y u s e d .  1981)  received.  some q u e s t i o n n a i r e s  f o r use i n h o s p i t a l  Satisfaction  of the care  as t h e y  a r e ambiguous,  i d e n t i f y or misrepresent  patients'  Some a r e  b a d l y worded,  attitudes  or  fail  (French,  1981). A common p r o b l e m i n m e a s u r i n g consumer 24  satisfaction  is  that  satisfaction  ratings  T h i s may be a r e s u l t measure  scale  A visual horizontal  t h e words (e.g.  the s e n s i t i v i t y of the  analogue s c a l e  (VAS) c o n s i s t s  end o f t h e l i n e  indicate polar opposites  (Reading,  with respect  corresponds  a mark,  to his/her  t h e two e x t r e m e s  obtained.  score  to  (Jensen, studies,  variations  scale  (Price,  on i n t e n s i t y  (Oberst,  1984).  The VAS i s s h o r t , Karoly,  patient the  t o meaning The  The d i s t a n c e  and e a s y  & Braver,  1986).  from t h e  to  first  in millimeters  t o a d m i n i s t e r and Used e x t e n s i v e l y i n  i t h a s b e e n shown t o be r e l i a b l e and s e n s i t i v e (Seymour, McGrath,  levels.  some s u b j e c t s  (Stewart,  Each of  f e e l i n g s on t h e c o n t i n u u m r e l a t i v e  1982). Rafii,  important c h a r a c t e r i s t i c  that  1980).  with  a p o i n t on t h e l i n e w h i c h  a n c h o r word t o t h e mark i s m e a s u r e d a n d a s c o r e  pain  i n length)  not uncomfortable at a l l , very uncomfortable).  respondent places  is  responses.  of a s i n g l e  ( c o n v e n t i o n a l l y 10 c e n t i m e t e r s  a n c h o r words a t e a c h  1984).  O b e r s t recommends u s i n g a v i s u a l  to increase  line  (Oberst,  of t h e i n s e n s i t i v i t y of t h e t o o l used t o  satisfaction.  analogue  are frequently high  1977).  I n a d d i t i o n , VAS i s a & Buckingham,  enables  1983).  the quantitative  A potential  ratio  This expression  l i m i t a t i o n of t h i s  have d i f f i c u l t y u n d e r s t a n d i n g t h e  scale  is  task  T h i s may be overcome b y e n s u r i n g t h a t t h e  c l e a r l y understands the task  prior to using  scale. The few s t u d i e s  t h a t have e v a l u a t e d  t r e a t m e n t do n o t a p p e a r t o h a v e developing the questionnaire,  a particular  involved the patient  and t h e e v a l u a t i o n s 25  of  in patient  s a t i s f a c t i o n v a r y from s p e c i f i c responses  t o an o v e r a l l  ( H o o g s t r a t e n & Lamers,  & Chen,  1987;  Sidi,  Reddy,  No q u e s t i o n n a i r e i s a v a i l a b l e t o measure p a t i e n t  rating  1988). satisfaction  with r e s p e c t t o t h e type of d r e s s i n g s used i n t h e care of ulcerating metastatic skin includes  lesions,  nor i s there  one w h i c h  t h e development p r i n c i p l e s Oberst suggested  (1984).  Summary In summary, lesions  the care of u l c e r a t i n g metastatic  i s neither well  researched.  established i n the l i t e r a t u r e nor  Though c o n t i n u o u s wet s a l i n e d r e s s i n g s  commonly u s e d ,  some i n c o n v e n i e n c e s a n d p a t i e n t  do n o t make them i d e a l a good a l t e r n a t i v e .  choices.  are  discomfort  M e s a l t d r e s s i n g s may p r o v i d e  They a r e d r y , and s t u d i e s h a v e shown  them t o be c o n v e n i e n t and r e q u i r e f e w e r d r e s s i n g thus,  skin  they decrease the nurse's  changes;  w o r k l o a d and i n c r e a s e  patient  comfort. Using patient dressings  s a t i s f a c t i o n to s p e c i f i c a l l y evaluate  i s u n i q u e s i n c e most p a t i e n t  a broad focus.  Most p a t i e n t  developed without patient  satisfaction tools  satisfaction tools  involvement.  not  for ulcerating metastatic skin  discusses  seem t o b e  No e v a l u a t i o n  have been d e v e l o p e d f o r e v a l u a t i n g d r e s s i n g s , lesions.  The n e x t  using patient  indicator.  26  satisfaction  chapter  Satisfaction  a n d t o compare M e s a l t d r e s s i n g s w i t h  wet s a l i n e d r e s s i n g s ,  tools  and s p e c i f i c a l l y  t h e methods u s e d t o d e v e l o p t h e P a t i e n t  Questionnaire,  have  continuous  as an  CHAPTER 3 Methodology  Introduction The  research  c o n d u c t e d by t h e  for this BCCA,  thesis  satisfaction preference, changes,  focus  because  the  a Patient  infection,  part  number o f  of d r e s s i n g  evaluating  due t o  to  time constraints  the  study,  the  instruments.  For  were  preference.  important and  first,  often Therefore,  to  develop  patient  care of  ulcerating  compare  Mesalt  dressings. and t h e  Patient  Q u e s t i o n n a i r e was n o t u s e d d u r i n g t h e data  be  were t w o - f o l d :  w i t h c o n t i n u o u s wet s a l i n e  satisfaction  patient  own d r e s s i n g s  and s e c o n d ,  nurse  materials.  and p a t i e n t  used i n the  patient  dressing  Q u e s t i o n n a i r e which r e f l e c t s  lesions;  to  and  a c o n s i d e r a b l e p e r i o d of time.  with dressings  accrued  with  ulcerating  patient  was c o n s i d e r e d t o  thesis  study  study evaluated:  and c o s t  change t h e i r  Satisfaction  Unfortunately, patients  patient  of t h i s  metastatic skin  of a larger  care of  with d r e s s i n g performance  lesion for  satisfaction  dressings  of  f o c u s e d on t h e  on t h e  purposes  The l a r g e r  lesion,  many p a t i e n t s  have t h e  i n the  with d r e s s i n g performance,  care of the  satisfaction The  lesions.  occurrence  This thesis  part  comparing M e s a l t d r e s s i n g s  c o n t i n u o u s wet s a l i n e d r e s s i n g s metastatic skin  is  study.  low numbers  of  Satisfaction Instead  patient  o b t a i n e d u s i n g two p r e - d e v e l o p e d BCCA  clarity  i n discussing the  27  m e t h o d o l o g y and  study findings, component o f t h e  "study" w i l l larger  Two h y p o t h e s e s receive  refer  only to  the  thesis  BCCA s t u d y .  were t e s t e d :  first,  Mesalt dressings  a more p o s i t i v e r a t i n g t h a n c o n t i n u o u s wet  dressings  with respect to patient  performance; patients  to  and s e c o n d ,  satisfaction  Mesalt dressings w i l l  c o n t i n u o u s wet s a l i n e d r e s s i n g s .  will  saline  with dressing be p r e f e r r e d by This  chapter  r e v i e w s t h e m e t h o d o l o g y and a n a l y s i s u s e d b o t h f o r d e v e l o p i n g the t o o l  and e v a l u a t i n g t h e d r e s s i n g s  Development o f t h e P a t i e n t The P a t i e n t measure  S a t i s f a c t i o n Q u e s t i o n n a i r e was d e v e l o p e d  satisfaction  the  response  with d r e s s i n g performance  scales.  Patients i n the  formed t h e  m a j o r i t y of the  as  to  be  evaluated were  support from the  response  scale.  develop  were s e e n as  Subjects  l e s i o n s who were  o f t h e BCCA V a n c o u v e r  sample used t o  A few p a t i e n t s  s p e a k and r e a d E n g l i s h .  in the  (Appendix A ) .  be e v a l u a t e d  with ulcerating metastatic skin  BCCA V a n c o u v e r C l i n i c .  criteria  items  to  Satisfaction Questionnaire  Ambulatory Care U n i t  questionnaire.  the  as w e l l  The VAS was u s e d as t h e  Sample f o r P a t i e n t  seen  1)  Items t o  d e v e l o p e d f r o m i n p u t by p a t i e n t s literature.  study.  Satisfaction Questionnaire  The q u e s t i o n n a i r e has two p a r t s : and 2)  during the  the  in-patients  were r e q u i r e d t o  A l l those patients  28  at  the  understand,  who f i t  the  were a p p r o a c h e d and t h o s e who c o n s e n t e d were  sample.  Clinic  included  Procedure  f o r Q u e s t i o n n a i r e Development  The q u e s t i o n n a i r e content  was d e v e l o p e d t h r o u g h a p r o c e s s  identification,  reliability  content v a l i d i t y v e r i f i c a t i o n ,  Identification.  questionnaire interviews,  was  A total  metastatic skin  Content  for  literature,  of eight  lesions  and  patients  ( A p p e n d i x B)  be c o n s i d e r e d when e v a l u a t i n g  i n t r o d u c t i o n was w r i t t e n questionnaire  with  ulcerating  (Appendix C). to  explain the  and g i v e an example  investigator  to determine patient  The d a t a o b t a i n e d was u s e d t o  Preliminary Questionnaire  patient  personal  were i n t e r v i e w e d b y t h e  who u s e d an i n t e r v i e w g u i d e  with dressings.  the  i d e n t i f i e d through a combination of  review of the  experiences.  to  and  testing.  Content  factors  of  those  satisfaction  develop  A letter purpose  q u e s t i o n and  the  of  of  the  response  (Appendix D). Content V a l i d i t y V e r i f i c a t i o n . the  extent to  relevant  which the  and c o m p l e t e  administered the (not  items  included i n the  (Nunnally,  completeness importance responses  of the  to  first  determine  questionnaire, of the  items  five patients  questionnaire. from the  lesions  of each of  1978).  The o t h e r  step) the  identified.  three patients  study because they  appeared 29  is are  investigator  to  eight  with  clarity Only  refine had t o  patients  ulcerating  relevance  and t h e  were u s e d t o  scale  The  preliminary questionnaire  p r e v i o u s l y involved i n the  metastatic skin  Content v a l i d i t y  and and the  the be  eliminated  slightly disoriented  and  o f t e n were u n a b l e t o great deal  of  assistance.  meaning o f t h e the  questions  questionnaire.  calculated. were k e p t ,  Comments a b o u t were c o n s i d e r e d  each  These r e s u l t s  for  Testing.  metastatic skin  i n the  first  three of the  second t e s t  were d e p i c t e d  correlation  investigator,  greater  less  than  develop the  50%  Pilot  was  method.  The  with previously  One week l a t e r  four patients.  enough t o  it  was  However,  complete  coefficient  The a n a l y s i s  sum o f t h e  between t h e  i n the  r e c o g n i s i n g the  average responses  to  the  one  second  each  was d e t e r m i n e d b y  consistency.  Homogeneity of t h e  s p l i t - h a l f method:  to  each  were f u r t h e r  dividing questions. 30  and  the  first  tested  The  small  sum o f  test,  question  questions the  1)  for  the  the  of such a  question of the  The r e s u l t s  test  form of a h i s t o g r a m .  involved correlating  average responses  by a l t e r n a t i n g  first  limitations  second t e s t .  groups  of  was  testing.  The a v e r a g e d i f f e r e n c e s  the  50% o r  (who were n o t  two s t e p s ) .  feeling well  was n o t  of the  revising  importance  four patients  lesions  patient  the  of  test/re-test  was a d m i n i s t e r e d t o  to  sample.  average  The P i l o t Q u e s t i o n n a i r e  re-administered  Pearson  the  a  w o r d i n g and  and u s e d f o r  were u s e d t o  r e l i a b i l i t y using the  questionnaire  part  item,  the  without  (Appendix E ) .  Reliability  involved  questionnaire  w h i l e t h o s e w i t h an a v e r a g e r a t i n g  Questionnaire  ulcerating  For  the  Items w i t h an a v e r a g e r a t i n g  were d e l e t e d .  tested  complete  the  with  for  2)  the  internal  was a s s e s s e d u s i n g  questions  into  The two g r o u p s  two  were  then  r e - t e s t e d using the The  final  Satisfaction the  study.  correlation  of the  tool  coefficient.  d e v e l o p m e n t was t h e  Q u e s t i o n n a i r e w h i c h was made a v a i l a b l e  this  due t o  patients  outcome  Unfortunately,  administer study,  Pearson  f o r use  t h e r e was a l a c k o f o p p o r t u n i t y  questionnaire  time  Patient  constraints  with patients and t h e  still  in  low numbers  in to  the  of  involved.  Study Methodology Study Design The  study used a c r o s s - o v e r  dressings  with continuous  cross-over patient the  design  order  "within-patient"  of design patient  is  The  i n which  one f o l l o w i n g  appropriate  preferences  b e s t s u i t e d where  i n terms of d i s e a s e short-term  each  another,  for  each  and t h e  with  their  d e v e l o p e d by t h e  i n comparing  is  treatment  (Pocock).  relatively is  stable  relatively in this  subject:  first  first  1 month f o r t h e second.  Patients  31  of  were r a n d o m l y  of Epidemiology, Biometry  BCCA.  study  arm  treatment using a randomisation  Division  Occupational Oncology,  sample  1983).  The d u r a t i o n o f t r e a t m e n t  t r e a t m e n t and 1 month f o r t h e to  f o r use  f o r two t r e a t m e n t s  a patient  state,  (Pocock).  was 2 months  assigned  study  Mesalt  of treatments b e i n g d e c i d e d randomly (Pocock,  individual is  a  compare  saline dressings.  r e c e i v e s two t r e a t m e n t s ,  This type  It  is  wet  design to  and  table  Study Group Fourteen patients  were a c c r u e d t o  t i m e p e r i o d c o v e r e d by t h i s registered homecare  BCCA p a t i e n t s :  patients.  thesis.  the  inpatients,  lesion.  satisfy 1.  the  To be e l i g i b l e f o r t h e  following  BCCA r e g i s t e r e d  study,  from  and  were e x c l u d e d i f t h e y  u n d e r g o i n g r a d i a t i o n or chemotherapy a f f e c t i n g t h e of the  the  T h e y were s e l e c t e d  outpatients,  Patients  study during  were condition  patients  had  to  criteria:  patient,  18 y e a r s  or over,  w i t h no u p p e r  limit. 2.  R e s i d e n t o f t h e G r e a t e r V a n c o u v e r Lower M a i n l a n d  3.  Ulcerating metastatic skin  l e s i o n secondary to  area.  a confirmed  cancer. 4.  Ulcerating metastatic skin at  5.  least  Free  of  lesion with discharge requiring  two d r e s s i n g c h a n g e s clinical  p e r 24  hours.  and m i c r o b i o l o g i c a l e v i d e n c e  of  infection. 6.  Survival  7.  Stable disease  8.  Competent t o with the  9.  expectancy  one month p r i o r t o  answer  questions  therapeutic  Consenting to the  g r e a t e r t h a n 3 months.  consent  entry.  and w i l l i n g  to  be c o m p l i a n t  protocol.  p a r t i c i p a t i n g i n the  s t u d y and h a v i n g s i g n e d  form.  The s a m p l e u s e d f o r t h i s convenience.  study  Many o f t h e  s t u d y was a s a m p l e  patients  were n o t  of  e l i g i b l e for  the  s t u d y as t h e y were f r o m o u t s i d e t h e G r e a t e r V a n c o u v e r Lower Mainland,  were r e c e i v i n g c h e m o t h e r a p y o r 32  radiation  therapy  w h i c h was e f f e c t i n g t h e i r of t h e i r  disease,  instances, increase the It  it  treatment  o r had t o o  was n o t  their  was t h u s d i f f i c u l t  changes.  During the  participate  of the Study  visits  f o r the  Home C a r e N u r s e s  study patients  accrue patients  study,  and t h e  who were  five patients  m o s t l y due t o  need t o  the  of  to  who were  on  dressings. completely * dressing  decided  not  inconvenience  follow a protocol.  i n the  contacted the  N u r s e s and p h y s i c i a n s a t community, the  patient  was e l i g i b l e , study to  participating  i n the  further  explain the  patient  patient's  was n o t  the  them.  study,  to  the If the  determine nurse the  investigator  the  patient  actively  b e i n g seen  at  study,  Greater  contacted  However,  d i d not  this  i n an a t t e m p t t o  result  i n the  was  interested  was c o n t a c t e d  the  BCCA,  contact the  i n the  M a i n l a n d were  patients  i n more d e t a i l .  regarding h i s or her p a r t i c i p a t i o n i n the  study  or p h y s i c i a n b r i e f l y  study to  hospitals  and  eligibility.  patient  BCCA p h y s i c i a n was a s k e d t o  a l l of the  BCCA,  identified potential  investigator  explained the  the  In a number  c o n t i n u o u s wet s a l i n e  study period,  stages  Procedure  nurses  the  terminal  Home N u r s i n g c a r e p r o g r a m f o r t h e i r  i n the  Accrual.  If  to  i n the  drainage.  accomodate  arm u s i n g t h e  on t h e  and  to  were  little  feasible  visits  dependent  to  lesion,  study.  If  the  patient 33  If  patient Later  in  the  V a n c o u v e r Lower  promote  accrual  consented  to  the  accrual.  o f any p a t i e n t s  study. Procedure.  in  to  the  study,  to  the  investigator  study. the  took  a medical h i s t o r y  The f a m i l y p h y s i c i a n s  s t u d y were i n f o r m e d a t  O n l y one p a t i e n t infection,  ( A p p e n d i x F)  of a l l the  the  patients  prior  to  involved in  b e g i n n i n g and end o f t h e  study.  had c l i n i c a l and m i c r o b i o l o g i c a l e v i d e n c e  and e n t e r e d  the  study a f t e r  resolution  of  of  the  infection. The l e s i o n was (Appendix G ) .  the  of  lesions,  dressings. the  patient  c a r e was t h e  investigator  to  a standard  were i n d e p e n d e n t  protocol in  the  i n some c a s e s Home C a r e N u r s e  Staff  Prior to  according to  patients  but  community o r t h e  oriented  for  Most o f t h e  care of t h e i r in the  cared  Nurse i n the  entering the  the  .investigator  wound c a r e p r o t o c o l .  The p r o g r a m  protocol  study,  changed  the  same f o r b o t h t y p e s  monitored the  hospital  of treatments. compliance  The  on a w e e k l y  basis. The s t u d y t o o k p l a c e However, at  the  once  three patients  BCCA t o  o r more  treatment  for  see  p r i m a r i l y i n the  were v i s i t e d once  a physician;  in a hospital complications  while they  The O v e r a l l E v a l u a t i o n S c a l e  arm. the  first  t r e a t m e n t arm and t h e  The P r e f e r e n c e second treatment  Scale  of the  was  34  at  receiving  wound.  Home  patients.  administered  was a d m i n i s t e r e d  arm.  while  were  study  end o f t h e  homes.  were v i s i t e d  involving their  Care Nurses r e g u l a r l y v i s i t e d seven  of the  or twice  four patients  setting not  patients'  at  second the  the  end  treatment  end  of  Study  assessments: Beginning of Study  End o f first treatment arm  Weekly  End o f second treatment arm  Medical History  X  Assessment of Compliance  X  Overall Evaluation Scale Preference Scale Evaluation  X  X Tools  The s t u d y u s e d two measurement for the  BCCA s t u d y .  Scale,"  used a q u e s t i o n n a i r e  The f i r s t  was a s k e d f i v e q u e s t i o n s , response  scale  identified  i n the  format  and e a c h  metastatic skin  However,  lesion.  p r e v i o u s l y developed "Overall  Evaluation  (Appendix H). q u e s t i o n was  of previous i n the  format.  the  patient  f o l l o w e d by a Each  contacts with  care of t h e i r  The  question  patients  ulcerating  questions  d i d not  f o r v a l i d i t y or r e l i a b i l i t y p r i o r t o  use  study.  The s e c o n d t o o l , patient  the  v i s u a l analogue  was a r e s u l t  u n d e r g o any t e s t i n g  tools  tool,  who were u s i n g d r e s s i n g s  in the  X  to  indicate  "second d r e s s i n g "  the  a preference  or  this  "Why?"  tool to  asked  "first  the  of t h i s degree  the  dressing",  (Appendix I).  As p a r t  measure 35  Scale,"  f o r the  "no p r e f e r e n c e "  open-ended q u e s t i o n asked VAS was added t o  "Preference  the  An thesis, of  a  preference  for  a dressing.  a preference  The q u e s t i o n u s e d was  i n d i c a t e d above,  The two e n d p o i n t s u s e d were strong.  As a r e s u l t  was e x p a n d e d t o above), scale  "If  dressings  the  and  "Why?" q u e s t i o n  you d i d have a p r e f e r e n c e the dressing?"  "Very  (indicated  The r e v i s e d  Previous  studies  using Mesalt  were m o s t l y c o n c e r n e d w i t h d e s c r i b i n g i t s  properties, calculate  sample s i z e .  Therefore,  A sample o f  a 75% p r e f e r e n c e  preference  the  s t u d y was b a s e d on t h e  preference.  determine  healing  and c o n s e q u e n t l y no d a t a were a v a i l a b l e  for this  .80.  question,  preference?"  Analysis  Sample S i z e .  patient  was y o u r  i n Appendix J .  Statistical  size  how s t r o n g  you d i d have  "Not v e r y s t r o n g "  of t h i s  why d i d y o u p r e f e r  is  "If  for neither  26  for the  calculation  to of  number n e e d e d t o patients  was  sample evaluate  required  M e s a l t d r e s s i n g compared  dressing with CX =  .05  and 1 -  ft  =  The s a m p l e s i z e was b a s e d on b i n o m i a l p r o b a b i l i t y  (Fleiss,  1981)  Epidemiology,  and was c a l c u l a t e d Biometry,  Unfortunately, completed, study.  at  the  BCCA D i v i s i o n  time that t h i s  only fourteen patients  Therefore,  by t h e  of  and O c c u p a t i o n a l O n c o l o g y . the  analysis  thesis  was  had been a c c r u e d  of the  results  has  to  the  some  limitations. Statistical  Procedures.  1.  Evaluation  Overall  Scale  The h y p o t h e s i s t e s t e d was 36  to  "Mesalt  dressings  to  will wet  receive  a more p o s i t i v e r a t i n g t h a n  saline dressings."  five  questions  were t e s t e d u s i n g t h e  signed-rank test OC  =  -05.  The r e s p o n s e s  to  the  Wilcoxon  using a one-tailed test  (Neave & W o r t h i n g t o n ,  of  w i t h an  1988).  T h e r e i s no d i f f e r e n c e i n t h e a v e r a g e r a t i n g s ( f o r each q u e s t i o n ) f o r M e s a l t d r e s s i n g s and f o r c o n t i n u o u s wet s a l i n e dressings.  Hi:  M e s a l t d r e s s i n g s w i l l r e c e i v e a more p o s i t i v e average r a t i n g ( f o r each q u e s t i o n ) t h a n c o n t i n u o u s wet s a l i n e d r e s s i n g s .  of the  "+"  the  negative  indicate  true,  the  sero.  If  a positive difference  Mesalt dressings  difference  saline dressings. average the  and " - "  in favor If  the  (median)  of d i f f e r e n c e s  differences  totalled. ranks  expected  For t h i s of negative to  ranked, test,  T i  Mesalt  and t h e  i f H i were  as  37  Hi is  be the  The  the  score  dressings dressings.  negative  T would  true.  rule: T critical,  is  will  " T " was d e f i n e d as  differences,  be s m a l l e r  Decision If  c o n t i n u o u s wet s a l i n e  were  wet  is true,  be p o s i t i v e .  score obtained with the  a  hypothesis)  d i f f e r e n c e was o b t a i n e d b y s u b t r a c t i n g  from the  favor  continuous  Hi (alternate hypothesis)  obtained with the  in  indicate  of the  Ho ( n u l l  t r u e average d i f f e r e n c e w i l l  of  each  Ho:  Let  The  continuous  supported.  scores the be  sum  Using the  statistical  Worthington,  2.  1988),  a decision  made.  Preference  Scale  tables the  The h y p o t h e s i s  T critical  t e s t e d was  be p r e f e r r e d  by p a t i e n t s  dressings."  This hypothesis  sign test .05  for this  (one-tailed)  to  test  was d e t e r m i n e d  "Mesalt dressings  continuous  wet  level  Preference continuous  Hi:  M e s a l t d r e s s i n g s a r e p r e f e r r e d more c o n t i n u o u s wet s a l i n e d r e s s i n g s . "+"  the  Mesalt dressings  If and Hi  for  number o f p r e f e r e n c e s  and " - "  signs  (the  indicate  continuous  Ho ( n u l l h y p o t h e s i s ) "-"  wet  alternate hypothesis)  No p r e f e r e n c e s it  was  large  is  number o f  were o m i t t e d  numbers o f t h e  "-"  defined  number o f  Decision  the  "-"  signs,  "-"  there  if  S _ 38  S  "+" if  would  and  signs.  test signs.  rule:  Hi tenable  of  Whereas,  signs  from the  the  for  number o f  true, "+"  and  dressings.  analysis.  e x p e c t e d t h a t t h e r e w o u l d be  as t h e  CxS =  than  number  saline  is true,  c o r r e s p o n d i n g l y few number o f  Since  the  w o u l d be r o u g h l y e q u a l .  be a r e l a t i v e l y  the  i s e q u a l between M e s a l t d r e s s i n g s wet s a l i n e d r e s s i n g s .  indicate  preferences  will  1988).  Ho:  Let  and  saline  was t e s t e d u s i n g  with a c r i t i c a l  (Neave & W o r t h i n g t o n ,  (Neave &  critical  smaller  statistic  "S"  was  Using the  statistical  Worthington,  1988),  tables  the  for this  S critical  test  (Weave &  was d e t e r m i n e d and  a d e c i s i on made. The using  open-ended q u e s t i o n r e s u l t s  a theme  from the  analysis  approach.  revised Preference  of preference Withdrawals.  were a l s o  Patients  analysis. by  The r e s u l t s  of the  reflecting  strength  evaluated. complete  omitted  at  least  from the  remaining patients  s u b - g r o u p s d e p e n d i n g on t h e  examined  The VAS r e s u l t s  Scale  who d i d n o t  one week o f b o t h s t u d y arms were  were  statistical were  analyzed  l e n g t h o f t i m e t h e y were  in  the  study. Ethics. procedures  Patients  of the  s t u d y as  inconvenience that were a l s o their  were  i n f o r m e d o f t h e p u r p o s e and well  could occur  informed t h a t t h e i r  refusal  as  the  potential  during the  study.  t r e a t m e n t and c a r e a t  signed a consent  form before  the  entering the  consent  form.  A l l the  under secure c o n d i t i o n s  data  Patients (Appendix K ) .  each  and c o d i n g f o r m s ,  forms u s e d i n t h e  i n the  not  BCCA. study  A u n i q u e s t u d y number was a s s i g n e d t o  the  Patients  s t u d y would  compromise t h e i r  on t h e  and  p a r t i c i p a t i o n was v o l u n t a r y and  or withdrawal from the  No name was w r i t t e n  benefits  Division  participant. except  s t u d y were  of Nursing,  for kept  BCCA.  Summary This used t o  chapter  has p r e s e n t e d  develop the  Patient  t h e m e t h o d o l o g y and  Satisfaction 39  analysis  Q u e s t i o n n a i r e as  well  as  to  compare M e s a l t d r e s s i n g s  dressings  as  presented  and d i s c u s s e d  chapter  part  of a l a r g e r  d e s c r i b i n g the  i n the  w i t h c o n t i n u o u s wet study.  The r e s u l t s  next chapter,  conclusions  40  and  saline are  f o l l o w e d by a  recommendations.  CHAPTER 4 Presentation  and D i s c u s s i o n o f F i n d i n g s Introduction  The f i n d i n g s a r e chapter.  to  is described  the  the  i n the  W i t h i n each  sample are  end o f  Patient first  two s t u d y h y p o t h e s e s  second s e c t i o n . of the  i n two s e c t i o n s  The d e v e l o p m e n t o f t h e  Questionnaire related  presented  each  section,  described.  Satisfaction  identification, testing.  d e s c r i b e d and t h e Content  section.  Findings  presented  in  the  the  characteristics discussed  at  content  Questionnaire involved three  results  steps:  validity verification,  The c h a r a c t e r i s t i c s  of the  and  sample  are  given.  Identification  Eight patients the  Satisfaction  The f i n d i n g s a r e  The q u e s t i o n n a i r e d e v e l o p m e n t  reliability  this  section.  Patient  content  are  in  were  interviewed to  Preliminary Questionnaire.  i d e n t i f y content  Additional  i d e n t i f i e d through a review of the  content  literature  for  was  and p e r s o n a l  experiences. Characteristics patients,  six  r a n g e d f r o m 35 m e d i a n o f 63  of the  were  females  to  78 y e a r s ,  years.  Sample.  Of t h e  eight  and two were m a l e s . w i t h an a v e r a g e 6 1 . 1  Their years,  The l e n g t h o f t i m e t h a t t h e y had 41  ages and a their  lesions 11.3  ranged  f r o m 1 week t o  33.5  months,  months and a m e d i a n o f 7 months.  result  of breast  melanoma. seven  c a n c e r and t h e  The l e s i o n s  instances, Results  and t h e  of the  leg  Interviews.  metastatic  skin  l e s i o n was due  breast  i n one  in  step i n  to  determine  the  patients factors  with  to  c o n s i d e r e d when e v a l u a t i n g p a t i e n t  satisfaction.  i n t e r v i e w g u i d e was w e l l  a l t h o u g h some p a t i e n t s  difficulty dressings.  articulating The p a t i e n t s  or had used a v a r i e t y to  their  l i k e s and d i s l i k e s  who had u s e d d r e s s i n g s  of d r e s s i n g s  found the  Also,  those patients  dressings  seemed t o  for  t h o s e who had t h e i r the  dressings  some  questions  i n the  time  easier  with own  questions  c h a n g e d by a n o t h e r  had  about  who c h a n g e d t h e i r  be more i n t e r e s t e d  be  The  answer t h a n d i d t h o s e w i t h l i m i t e d e x p e r i e n c e  dressings.  as  received,  a  to  or chest w a l l  interview eight  lesions  of  instance.  The f i r s t  q u e s t i o n n a i r e d e v e l o p m e n t was t o ulcerating  S e v e n l e s i o n s were  eighth  involved the  w i t h an a v e r a g e  person  than such  Home C a r e N u r s e .  The f i r s t  q u e s t i o n a s k e d was  have you used i n t h e included Telfa, dressing, ointment  "What t y p e s  c a r e o f y o u r open wound?"  Jelonet,  Sofratulle,  paraffin dressing, and d r y g a u s e ,  Unitulle,  Mesalt dressing,  and a v a r i e t y  of  dressings The  wet  responses saline  Vaseline  of p l a i n d r y gause  dressings. The s e c o n d q u e s t i o n a s k e d was each d r e s s i n g ? " f a c t that the  Four p a t i e n t s  d r e s s i n g d i d not  "What d i d y o u l i k e  about  responded t h a t they  liked  stick.  clarified  42  One p a t i e n t  the  that  if  it  d i d not  stick,  then  it  d i d not  cause b l e e d i n g .  A n o t h e r r e s p o n s e was t h a t t h e d r e s s i n g d r i e d t h e faster,  evidence to  In a d d i t i o n ,  the p a t i e n t  one p a t i e n t  d r e s s i n g was e a s y t o  t h a t the  considered  Dressings that  major d i s l i k e .  If  odor.  be t o o  one o f t h e d r e s s i n g s  was u n c o m f o r t a b l e Using a  "bother" as  it  at  to  cleanser One  s t i c k y and "gummy," and c a u s e d  night.  to  a  go  One. p a t i e n t  made t h e t u m o r  w o u l d c a u s e t h e tumor t o  wetter.  b r e a k down and  take  heal'.  dressing to do?"  or  would you c o n s i d e r was a d i f f i c u l t  important  question  instead.  leave t h i s  patients.  T h o s e who d i d r e s p o n d t h o u g h t  s h o u l d be t h a t  it  d i d not  identified  off,  usable without tape,  s h o u l d be a l s o  p r o m o t e h e a l i n g and i t  dressing  were t h a t  f i t t e d so  should not  43  This  Some  q u e s t i o n and answer t h e  characteristics absorbent,  of the  the  i n choosing a dressing?"  q u e s t i o n f o r many o f t h e  preferred to  characteristic  "What do y o u want  "What c h a r a c t e r i s t i c s  patients  It  it  a  as b e i n g i m p o r t a n t .  The f o u r t h q u e s t i o n a s k e d was  lint.  about  t h e wound were  Another d r e s s i n g caused t h e wetness  She t h o u g h t t h i s longer to  stuck to  lesion bleed.  o u t s i d e t h e d r e s s i n g and was a disliked  the  "What d i d y o u d i s l i k e  s t i n g was i d e n t i f i e d  d r e s s i n g was f o u n d t o "strange"  important that  the dressing stuck,  remove and c o u l d make t h e which d i d not  l e s i o n was h e a l i n g .  use.  The t h i r d q u e s t i o n a s k e d was each d r e s s i n g ? "  it  lesion  it  stick.  a  major  Other  s h o u l d be e a s y  non-abrasive, it  does not  allow the  fifth  to  take  and w i t h o u t  slip,  it  drainage to  should pass  through. The f i n a l  question  a s k e d was  i n f l u e n c e your s a t i s f a c t i o n describe  the  'perfect'  many p a t i e n t s who a n s w e r e d question.  sizes  the  easy to  but not  the  desirability  contoured  to  where y o u p u t  on one t h i n g -  answer  dressings  not  come i n  suggested open i t  and  adhere to  on t h e  this  which  sticky,  and f i t t e d  "just  Those  shape  the  of  the  different s u c h as  a  having a  spray  dressing  up and p u t  it  on  Band-Aid."  Considering the  Preliminary  characteristics  (summarised  (Appendix C ) .  questionnaire  was  questions  s c a l e used f o r  each  item to  Analogue Scale  (VAS).  Each anchor  comments  word r e p r e s e n t e d a great deal,  Questionnaire  words  at  large  The  was t h e  response  Visual  of a s i n g l e  e a c h end o f t h e  an e x t r e m e w i t h r e s p e c t not  44  at  all).  the  patients.  were i d e n t i f i e d . be e v a l u a t e d  of  from a  and a few  This scale consisted  l i n e w i t h anchor  (e.g.  Preliminary  previous  The w o r d i n g and f o r m a t  c a r e workers  28  horizontal  of  the  i n f l u e n c e d by t h e  number o f n o n - h e a l t h A total  Questionnaire.  i d e n t i f i e d i n the  i n Appendix L ) ,  was d e v e l o p e d  meaning  shape,  One p a t i e n t  Development of t h e  step  of having i t  adapt t o  off.  focused  question,  question.  and w h i c h w o u l d n o t  suggestions  "Can you  fourth  this  a p p l y and remove,  bulky;  Some o f t h e  a  L i k e the  or  fourth question u s u a l l y d i d not  foam w h i c h p e e l s  like  dressing?"  dressing?"  T h o s e who d i d r e s p o n d s u g g e s t e d  absorbent  bandage,  with the  had d i f f i c u l t y a n s w e r i n g  w o u l d be s o f t ,  wound.  "What f a c t o r s w o u l d  10  line. to  The p a t i e n t s  were  cm  asked t o  "place  extremes t o  a mark t h r o u g h t h e  i n d i c a t e the  The s e c o n d p a r t importance the  of the  question  of each  the  r a t i n g the  It  questions  of each  f e e d b a c k r e c e i v e d was t h a t t h e  questions  being asked. VAS, t h e  especially  Since the  initial  only questions  "yes"  or  "no" type  The w o r d i n g o f t h e difficult  as  w h i c h were  it  and o m i t q u e s t i o n s important. " to  describe  and r e i n f o r c e their  used t o  the  patient  it  of  somewhat  number  of  already  was greater  was e a s i e r  overall  to  used t o  hold the d r e s s i n g  importance  that the  d r e s s i n g and n o t t o in  g i v e an  The l e t t e r  remind p a t i e n t s  only to  own  experience  p e r c e i v e d as  purpose,  of  was  questions  "generally  l e t t e r was d e v e l o p e d  q u e s t i o n about  related  importance  by t h e i r  patient  experiences.  the  As i t  i d e n t i f y only those  questionnaire's  own p e r s o n a l  was a l s o  to  which the  that the  VAS was  question  question regarding  An i n t r o d u c t o r y the  subject  response.  attempted  important to  the  question.  which averaged  t h a n a 50% r a t i n g w o u l d be i n c l u d e d , use a  the  for the  i s s u e was compounded.  pre-determined that  asked about  I n i t i a l l y a VAS was  importance  and t i m e c o n s u m i n g ,  two  response."  was worded " I s  you?"  difficult  used the  between t h e  of your  of the  question.  important to  considered for However,  degree  line,  ( A p p e n d i x D) example, related  to  introduction  questions  were  tape or other  devices  place.  Content V a l i d i t y V e r i f i c a t i o n To d e t e r m i n e  the  v a l i d i t y of the 45  content,  the  Preliminary  Q u e s t i o n n a i r e was t e s t e d t o understandable easy to  fill  and i m p o r t a n t ,  complete  enough.  During the patients  unrelated to  were u s e d as t h e  sample.  excluded  73  into the  eight  as  19.5  and a m e d i a n o f  1.5  cancer.  breast  were  t h e y were n o t  verbal  feeling out  responses. the  questionnaire,  Some o f t h e  three  inappropriately and  their  only f i v e of the comments  from the  s a m p l e were u s e f u l and  of the  Sample.  The f i v e  and one m a l e .  months, months.  The l e s i o n s i t e s  patients three  were  patients  Their  ages ranged from  64  years,  and a m e d i a n o f  63  lesions  w i t h an a v e r a g e o f Four of the fifth  was due t o  The t y p e s  patients  of  ranged  months,  had  lesions  endometrial breast  or  chest  dressings  i n c l u d e d F l a g y l ointment  F l a m a z i n e cream and d r y g a u z e , 46  8.5  patients  included four of the  abdomen.  p r e v i o u s l y u s e d by t h e ETE d r e s s i n g ,  filled  patients  investigator,  Therefore,  c a n c e r and t h e  and one o f t h e  eight  q u e s t i o n n a i r e was f i l l e d  w i t h an a v e r a g e o f 6 8 . 6  f r o m 3 weeks t o  wall  patients  The l e n g t h o f t i m e t h a t t h e y had t h e i r  due t o  was  revisions.  four females  years,  years.  the  from the  Characteristics  to  were  questionnaire  r e s p o n d e d v a g u e l y and somewhat  s p a n was p o o r .  incorporated  questions  questionnaire to  using their  d i s c u s s i o n s with the  questions  included  questionnaire  investigator,  often  attention  the  three of the  For these three the  m o s t l y by the  patients  administered the  Unfortunately,  unable to  to  and i f t h e  remaining i n attendance while the  them o u t .  well  i f the  out.  The i n v e s t i g a t o r patients,  determine  and  Mesalt dressing,  Jelonet  and d r y g a u z e ,  and d r y g a u z e , and p l a i n  wet s a l i n e g a u z e ,  an unknown a n t i b i o t i c o i n t m e n t and d r y g a u z e ,  d r y gauze.  One o f t h e  five participants  h e a l e d one month p r i o r t o participant  had c o n s i d e r a b l e e x p e r i e n c e  recall  had u s e d ,  had a l e s i o n w h i c h had  being given the  t h e wound had been p r e s e n t easily  P o l y s p o r i n ointment  important  s h e was n o t  Results  of the  questionnaire.  with dressings  f o r a long time.  characteristics  of t h e  omitted from the  sample.  Testing.  Most o f t h e  using tape to  reminded t h a t the At times,  q u e s t i o n s were r e l a t e d  pain from the d r e s s i n g while i t  However,  a mark w h i c h r e f l e c t e d I n 27 the  subject  of the 28  o f 28 of the  q u e s t i o n was  questions;  and t o they  is  to  2 of the  found the  the  items,  the  two  a l l , " s h e wanted d e c i s i o n was t o  to place  occurrence.  The  a l l 5 participants  5 participants i n 1 o f 28  q u e s t i o n n a i r e easy t o The examples  fill  i n 6 of  given i n the  subject of  questions;  questions. out once  found  i n 21  28  be u s e f u l f o r e x p l a i n i n g t h e 47  be  experience  i m p o r t a n t t o them.  5 participants  i n t r o d u c t i o n proved to  Those  dressing.  3 o r more o f t h e p a r t i c i p a n t s  important to  4 of the  at  the  Given the  her f i n a l  average  questions  understood the process.  were  respond t o  "Do y o u  on?"  " a g r e a t d e a l " and " n o t  "sometimes."  she  were made.  only to  wanted t o  f r e q u e n c y o f t h e p r o b l e m : f o r example,  answer  she c o u l d  h o l d t h e d r e s s i n g i n p l a c e needed t o  one o f t h e p a r t i c i p a n t s  e x t r e m e s as  since  dressings  questions  e a s i l y u n d e r s t o o d and o n l y a few s u g g e s t i o n s patients  Because  This  Overall,  they letter scale.  of  Development o f t h e following the  revisions  Preliminary  Pilot  Questionnaire.  were made a f t e r  The  reviewing the  responses  to  Questionnaire:  From: Is t h e r e d i s c o m f o r t d u r i n g t h e d r e s s i n g c h a n g e ? To: Do y o u e x p e r i e n c e d i s c o m f o r t when t h e d r e s s i n g i s removed? From: Do y o u e x p e r i e n c e p a i n when t h e d r e s s i n g i s c h a n g e d ? To: Do y o u e x p e r i e n c e p a i n when t h e d r e s s i n g i s removed? From: Does t h e d r e s s i n g s t i c k t o t h e wound? To: Does t h e d r e s s i n g s t i c k t o t h e wound when i t removed? From: To:  is  being  Is  d r e s s i n g f i b r e l e f t i n t h e wound when d r e s s i n g i s removed? A r e t h e r e d r e s s i n g f i b r e s l e f t i n t h e wound when d r e s s i n g i s removed?  the  From: Does t h e d r e s s i n g r u b r o u g h l y a g a i n s t t h e wound? To: Does t h e d r e s s i n g r u b r o u g h l y a g a i n s t t h e wound w h i l e i t i s on? From: To:  Can y o u u s e t h e d r e s s i n g w i t h o u t t a p e o r o t h e r d e v i c e s which h o l d the d r e s s i n g i n p l a c e ? Can y o u u s e t h e d r e s s i n g WITHOUT t a p e , n e t t i n g o r o t h e r d e v i c e s which h o l d the d r e s s i n g i n p l a c e ?  Delete: Does t h e d r e s s i n g Does t h e d r e s s i n g Does t h e d r e s s i n g t h e wound? Given the questionnaire general  format  This then  was  revisions  revised  was t h e  became t h e  Reliability  to  i n c l u d e 25  same as  Pilot  and q u e s t i o n d e l e t i o n s ,  the  questions.  Preliminary  Questionnaire  the  The  Questionnaire.  (Appendix  E).  Testing  The P i l o t method.  above  c a u s e t h e wound t o e n l a r g e ? c a u s e a "gummy" f e e l i n g ? cause i t c h i n e s s t o the s k i n surrounding  Q u e s t i o n n a i r e was t e s t e d u s i n g t h e  The q u e s t i o n n a i r e  was  administered  48  to  test/re-test  four  patients;  and r e - a d m i n i s t e r e d one week l a t e r patients. the  One p a t i e n t  second p a r t  of the  Characteristics  to  57  years,  years.  t h r e e of the  was n o t f e e l i n g w e l l  enough t o  Sample.  The t h r e e  and one m a l e .  Their  ages r a n g e d f r o m 50  w i t h an a v e r a g e o f 53 y e a r s ,  11.5  months,  m e d i a n o f 5 months.  and a m e d i a n o f  w i t h an a v e r a g e o f 6.8  and one was a r e s u l t  lesion  sites  Telfa,  lesions months,  Two l e s i o n s were a r e s u l t  cancer  The t y p e s  included the  of dressings  complete  patients  The l e n g t h o f t i m e t h a t t h e y had t h e i r  from 4 t o  four  testing.  of the  i n c l u d e d two f e m a l e s  to  of  of a neck cancer.  chest wall,  ranged and a  breast  The t h r e e  the neck,  and t h e  u s e d i n c l u d e d wet s a l i n e ,  F l a m a z i n e cream and d r y g a u z e ,  arm.  Mesalt,  and p l a i n d r y  gauze.  One p a t i e n t  who p a r t i c i p a t e d was n o t u s i n g a d r e s s i n g a t  time of the  testing  as  s h e was u n d e r g o i n g r a d i a t i o n  When c o m p l e t i n g b o t h q u e s t i o n n a i r e s , t h e d r e s s i n g s h e had r e c e n t l y Results period,  the  stable. in the  of the  Testing.  l e s i o n s of each  The p a t i e n t s instance  been  she t h e r e f o r e  d r e s s i n g while completing both  use the  25  histogram  refer  1).  The s e c o n d t e s t  result  remained  to  first  the  and s e c o n d form of  The marks made by t h e p a t i e n t s  10 cm VAS were m e a s u r e d t o  to  or same  questionnaires.  q u e s t i o n s have been d e p i c t e d i n t h e (Figure  referred  same d r e s s i n g ,  continued to  The a v e r a g e d i f f e r e n c e between t h e for the  treatment.  one week  of the three p a t i e n t s  o f one p a t i e n t ,  the  using.  During the  continued to  53  the nearest tenth  was s u b t r a c t e d 49  of  from the  a  test  a on  the  centimeter.  first  test  6-r  Frequency of Questions  3  A v e r a g e Differences b e t w e e n 1st a n d 2 n d test (in centimetres)  Figure  1.  between t h e Pilot  Histogram d e p i c t i n g the 1st  and 2nd t e s t  average  for the  Questionnaire.  50  25  differences  questions  on  the  result  f o r each p a t i e n t .  three patients  were t h e n a v e r a g e d  average d i f f e r e n c e s 2.0  cm t o  for  each  f o r each  a p o s i t i v e 2.5 0.5  tended t o the  be r a t e d  for  obtained for  each  question.  q u e s t i o n ranged from a  cm.  cm d i f f e r e n c e .  T h e r e were one t o  first  the The  negative  six  A g r e a t e r number o f  more p o s i t i v e l y on t h e  questions  questions t e s t t h a n on  second. Using the Pearson  correlation  of  results  administration quite strong internal first  correlation  coefficient,  between t h e  first  at  .75.  Using the  consistency,  t h e two s u b s e t s  a correlation  Regarding the  This  of  questions'  one o f t h e  other.  of  patient  This  f o r the  were a n a l y z e d . .63,  importance,  q u e s t i o n s was  important  o c c u r r e d w i t h one p a t i e n t  also  occurred  questions  dressing while i t  is  s h a p e o f t h e wound?"  on?"  and t h e  to  testing The  second  some  patients  one week and n o t for the  question  b l e e d when i t  i n two q u e s t i o n s w i t h  "Do y o u e x p e r i e n c e  pain  is another  from the  and "Does t h e d r e s s i n g a d a p t  One p a t i e n t  d i d not f i n d the  to  important  either  question  The same p a t i e n t  the d r e s s i n g cause a and a n o t h e r not  patient  important the  'strange' found t h i s  other  time.  d i d not f i n d the odor?"  important e i t h e r  question important  the  question  "Does t h e d r e s s i n g c a u s e a s t i n g i n g s e n s a t i o n ? " time.  be  .75.  "Does t h e d r e s s i n g c a u s e t h e wound t o removed?"  and s e c o n d  s p l i t - h a l f method f o r  group r e v e a l e d a c o r r e l a t i o n  thought  the  o f t h e P i l o t Q u e s t i o n n a i r e was c a l c u l a t e d  group r e v e a l e d  the  The d i f f e r e n c e s  "Does  time,  one t i m e and  In t h e each time,  it  enough t o patients  s i t u a t i o n where t h e  were n o t  unable to 25  consistent  that their  carry  them o v e r  important both times. importance  different. to  Patient  steps  reliability.  remark. it  pain.  response  is  strong  Where it  may be they  Overall,  by a l l t h r e e p a t i e n t s  to  a l l of the  over the  content  A f t e r c o n s i d e r i n g the  important  The  final  result  and t e s t i n g  responses  is  t o p i c was  " s t i n g i n g " or  patients,  question  "Do y o u  o n ? " was a  f o r the p a t i e n t  i n d i r e c t l y covered  "burning"  i n the  q u e s t i o n was d e l e t e d w h i l e t h e  remained unchanged,  forming the  to  Questionnaire.  52  sensation,  r e m a i n i n g 24  valid  determine  questionnaire.  Patient  the  of the  s i n c e t h e r e were q u e s t i o n s w h i c h r e l a t e d  causing a  of  the  was t h e d r e s s i n g o r t h e wound w h i c h was c a u s i n g Also,  about  one week p e r i o d .  comment a b o u t t h e  was o f t e n d i f f i c u l t  of  questions being  Satisfaction Questionnaire.  of d e v e l o p i n g the  19  be  two q u e s t i o n s were n o t  opinion  were  c h a n g e d h i s / h e r mind  p a i n from the d r e s s i n g w h i l e i t  It  dressing  this  a one week p e r i o d .  felt  was d e t e r m i n e d t h a t t h e  experience  if  opinion,  S a t i s f a c t i o n Q u e s t i o n n a i r e was t h e  previous  it  in their  Each p a t i e n t  h i m and m a i n t a i n e d t h i s The P a t i e n t  opinion  a one week p e r i o d .  o f one q u e s t i o n -  One p a t i e n t  same  o p i n i o n s were weaker b e c a u s e  q u e s t i o n s were t h o u g h t  the  had t h e  may be i n t e r p r e t e d t h a t h i s  be m a i n t a i n e d o v e r  interpreted  patient  the to  the  the  Therefore,  questions  Satisfaction  Discussion  of the Findings  During t h e development o f t h e P a t i e n t Questionnaire,  many c h a r a c t e r i s t i c s  were  i m p o r t a n t when e v a l u a t i n g s a t i s f a c t i o n individuals  repeated  difficult  being caused reason,  scale.  were  also to  Some p a t i e n t s  to use.  This d i f f i c u l t y  when u s i n g t h e VAS ( G i f t ,  However,  t o h a v e boxes  t o check  had a l s o 1989;  patients  a few p a t i e n t s  was u s e f u l  i n that  questionnaire's VAS. useful  making i t e a s i e r  Berman,  & Keller,  instead  teaching,  study  i n an example (Lorig,  (Guyatt  found t h e that  f o r the  scales patients  (Guyatt,  The i n t r o d u c t o r y  letter  understand the of using the  a l t h o u g h t i m e c o n s u m i n g , was et a l . ) ,  and t h e d e t a i l e d  f o r m was p r e v i o u s l y r e c o g n i z e d  1984).  For t h i s 53  been  of a l i n e to  p u r p o s e a n d g a v e them an example  i n a previous  effective  1987).  first  Stewart,  indicated  to administer  i t helped patients  Pre-questionnaire  instructions  was  had d i f f i c u l t y w i t h i t a t  f o u n d t h a t t h e L i k e r t s c a l e was e a s i e r  Townsend,  it  For t h i s  A s t u d y comparing L i k e r t and v i s u a l a n a l o g u e  understand,  being  found  were n o t f a m i l i a r w i t h t h e VAS a s a  by others  they preferred mark.  patients  A f t e r c o m p l e t i n g a few q u e s t i o n s ,  VAS e a s i e r  v a l i d i t y and  deleted.  and r e q u i r e d some e x p l a n a t i o n .  1977).  f o r content  Many  importance  b y t h e d r e s s i n g o r t h e wound i t s e l f .  Most p a t i e n t s  experienced  Their  i f the undesirable characteristic  some q u e s t i o n s  response  with a dressing.  F o r some c h a r a c t e r i s t i c s ,  to decide  i d e n t i f i e d as b e i n g  these c h a r a c t e r i s t i c s .  was r e i n f o r c e d d u r i n g t h e t e s t i n g reliability.  Satisfaction  thesis,  as  instructions  were p l a c e d a t was f e l t the  the  t h a t due t o  VAS, e i t h e r  letter  top  of  the  e a c h page difficulty  pre-questionnaire  at  the  top  of each  patients  one was w i t h r e g a r d wanted t o  second d i f f i c u l t y experienced  the  all"  the  to  sensation  VAS.  Therefore,  anchor word,  results  three patients the  questions  patients than  first  were  second.  they  questions  "an a v e r a g e . "  Patients  in  The not  this  available to  the  v e r y end o f t h e test/re-test  limited interpretation  "not  at  line. method since  The a v e r a g e d i f f e r e n c e s  r e s p o n d more p o s i t i v e l y on t h e The P e a r s o n  suggested  format and  correlation  correlation  The t e s t i n g  t h a t the  consistency.  questionnaire's understandable  the  cases  where t h e p e r s o n had  using the  involved.  second t e s t .  also  good i n t e r n a l  i n as  which  In t h o s e  responded c l o s e  at  showed a f a i r l y s t r o n g  and t h e  it  occurred.  only  for  were d e p i c t e d w i t h a h i s t o g r a m and showed t h a t  tended to  on t h e  results  which have  brief  questions  " n o , " an o p t i o n n o t  but r a r e l y  the  those questions  fill  The r e l i a b i l i t y t e s t i n g revealed  to  the  asked about.  respond  explanatory  page.  was w i t h q u e s t i o n s  s i t u a t i o n wanted t o using  o r an  answer w i t h " s o m e t i m e s . "  t h e y needed encouragement  It  had i n c o m p l e t i n g  additional to  Two d i f f i c u l t i e s i n r e s p o n d i n g t o The f i r s t  questionnaire.  patients  teaching  w i t h an example was n e e d e d ,  instructions  of the  and f o u n d t h e  54  test  coefficient  of  .75  between  f o r homogeneity  the  of  q u e s t i o n n a i r e had f a i r l y  Overall,  important.  first  the  patients  questions  to  liked  the  be b o t h  Study F i n d i n g s The r e s u l t s this  section.  of the  Fourteen patients  The c h a r a c t e r i s t i c s Evaluation  hypothesis t e s t i n g  Scale  ( A p p e n d i x I)  of the  presented  patients  discontinued the  the  was s t a t i s t i c a l l y  data  findings  of the  about t h e  Of t h e were  analysis  study are  Characteristics  of the  10.25  patients,  study,  dressing All  some o f  the  much o f  i n t h r e e subgroups.  breast the  The  comments  were  f r o m 45  to  ranged  months,  from 3  cancer  ovary  chest wall  Of the  67  85 years.  to  and a m e d i a n  from b r e a s t and t h e  or  13  and a m e d i a n o f  lesions  11.8  study,  in 1  i n 10  groin in 1 instance,  remaining instance. 7 patients  i n the  ages ranged  years,  in 2 patients,  neck i n 2 i n s t a n c e s ,  the  Their  had t h e i r  involved the  i n the  Because  than planned,  who p a r t i c i p a t e d  The l e s i o n r e s u l t e d neck  Overall  Scale  d i s c u s s e d and g e n e r a l  w i t h an a v e r a g e o f  the  The l e s i o n s  to  are  of the  Preference  study e a r l i e r  w i t h an a v e r a g e o f 6 5 . 6  months.  scalp  and t h e  study.  Sample  14 p a t i e n t s  months,  results  in  made.  The l e n g t h o f t i m e t h e y 33.5  the  analysed  described  involved i n the  and d i s c u s s e d .  f e m a l e and 1 was m a l e .  years,  the  sample,  (Appendix H),  are  were  are  in  of 11  patient. instances,  and  14 p a t i e n t s  the accrued  e q u a l l y randomised i n t o  each  arm. patients  Mainland, During the  and were study,  were  living  living  at  two o f t h e  i n the home a t patients 55  Greater the  V a n c o u v e r Lower  start  were  of the  admitted to  study. the  hospital  due t o  disease  complications,  unrelated  to  their  wounds. Many t y p e s i n t o the  of dressings  study.  They i n c l u d e d S o f r a t u l l e  F l a m a z i n e and d r y g a u z e , V a s e l i n e ointment ointment  were b e i n g u s e d p r i o r t o  continuous  and d r y g a u z e ,  and d r y g a u z e ,  (sodium h y p o c h l o r i t e ) J e l o n e t & d r y gause,  Kleenex to diapers.  s o l u t i o n and g a u s e ,  all  No p a t i e n t  drainage,  Hygeol  ETE d r e s s i n g , With the  other  remaining patients.  absorb the  dressings,  C i c a t r i n powder & T e l f a ,  and p l a i n d r y g a u s e .  of the  o n l y one o f t h e  saline  gauze,  an unknown a n t i b i o t i c  o f J e l o n e t u s e d by t h r e e p a t i e n t s , used by each  wet  and d r y  entry  exception  dressings  One p a t i e n t  while another  was  were  was  using  using  had p r e v i o u s l y u s e d M e s a l t d r e s s i n g s  patients  had u s e d c o n t i n u o u s  wet  and  saline  dressings. Of t h e normal  solutions  saline  Two p a t i e n t s  solution, d i d not  patients  had s c a n t  entering  the  control  pills  for  patients  study,  through the  experienced  cleanse t h e i r  or  of the  wounds,  six  used  and one u s e d  wounds.  Seven o f  Hygeol. the  a s m a l l amount o f b l e e d i n g p r i o r  to  and two o t h e r s had b l e e d i n g w h i c h r e q u i r e d occasional  odor c o n t r o l , had no  cleanse the  f i v e used water,  some d e g r e e o f  use  odor,  p r i o r to  of Gelfoam.  Eight  patients  and f o u r were t a k i n g F l a g y l entry  into the  study.  Six  odor.  Seven p a t i e n t s start  used t o  study.  were r e c e i v i n g m e d i c a l t r e a t m e n t S i x were on hormones  undergoing chemotherapy.  None o f t h e  56  and one  treatments  was were  at  the  a f f e c t i n g the enter the  condition of the  study u n t i l  the  lesion.  One p a t i e n t  d i d not  c l i n i c a l i n f e c t i o n o f h e r wound was  resolved. Study  Completeness Not a l l  of the  patients  Therefore,  both the O v e r a l l  Preference  Scale  o f 6,  8,  completed the  Evaluation Scale  have been s t a t i s t i c a l l y  and 10 p a t i e n t s ,  entire and  study. the  a n a l y z e d by groupings  d e p e n d i n g on t h e  extent of  study  completion. The f i r s t  analysis  c o m p l e t e d b o t h arms identified patients: arm,  as  of the  study;  s u b g r o u p A.  one p a t i e n t  and one p a t i e n t  who c o m p l e t e d two weeks  other;-  these patients  analyzed.  Four the or  as  less  third  was on t h e  d i d not  of  each  study  o f one s t u d y  arm  i d e n t i f i e d as  completed f o u r  s e c o n d arm;  Two d i s c o n t i n u e d t h e  first  switch to  arm,  the  first  change t o  d i s c o n t i n u e d the  s e c o n d arm f o r  completed the  added two  are  to weeks  these patients  o r i g i n a l fourteen patients  and d i d n o t w i s h t o  patient  are  are  s u b g r o u p C.  of the  analysis.  who  added two more p a t i e n t s  These p a t i e n t s  o f one arm and one week o f t h e identified  these patients  The s e c o n d a n a l y s i s  The t h i r d a n a l y s i s  those already  six patients  who c o m p l e t e d f o u r weeks  and two weeks o f t h e s u b g r o u p B.  included the  first  the  s e c o n d arm. 57  the  omitted  arm w i t h i n  For the  The  one week and  The f o u r t h disease  from  one week  s e c o n d arm.  arm w i t h i n  o n l y one week. b u t due t o  were  patient  progression  patients  included  i n the  analysis,  indicated  the  i n Table  randomization to  the  first  dressing  is  1.  Table.1 P a t i e n t Randomization to  First  Dressing  Subgroups Patient's  First  Dressing  Mesalt dressings C o n t i n u o u s wet  Overall  saline  Evaluation  The f i r s t  dressings  hypothesis  dressings  performance.  the  questions  the  dressing?"  W i t h n = 5, supported  and T c r i t i c a l was s u p p o r t  4  4  5  2  4  5  than  patient  question  a s k e d was  From s u b g r o u p A ,  the  continuous satisfaction  wet with  was t e s t e d by a s k i n g  Evaluation  Scale  Wilcoxon  "How i s  (Appendix  signed-rank  null  = 0,  between  the  58  null  dressings  hypothesis  for Mesalt dressings  the  application  f i v e r e s p o n s e s were  r e s p o n s e s were a n a l y s e d . = 2,  dressings  1988).  T = 2 and T c r i t i c a l  six  C  r e s u l t s u s i n g the  and no d i f f e r e n c e  s u b g r o u p B,  rating  Overall  (Neave 8s W o r t h i n g t o n , The f i r s t  B  This hypothesis  i n the  H) and a n a l y s i n g t h e test  A  t e s t e d was t h a t M e s a l t  with respect to  dressing five  Patients  Scale  w o u l d r e c e i v e a more p o s i t i v e saline  of  found.  W i t h n = 6, was  analyzed.  hypothesis was  rejected  of  was From  T = 2 and  h a v i n g a more p o s i t i v e  there rating  using  a one-tailed  eight  responses  critical  = 5,  test  and an O x £ = . 0 5 .  were a n a l y s e d .  the n u l l  support  rating  using a one-tailed question  = 0,  and an 0 < £ =  the n u l l  hypothesis  between d r e s s i n g s  .05.  W i t h n = 5,  were  T = 10.5  obtained five  and T c r i t i c a l  was s u p p o r t e d and no d i f f e r e n c e  was f o u n d .  From s u b g r o u p C, e i g h t  W i t h n = 8,  null  was s u p p o r t e d and no d i f f e r e n c e  dressings  of the  From s u b g r o u p B,  were a n a l y s e d . hypothesis  positive  a s k e d was "How i s t h e r e m o v a l  for analysis.  were a n a l y s e d .  and t h e r e was  h a v i n g a more  From s u b g r o u p A, f o u r r e s p o n s e s  w h i c h were i n a d e q u a t e responses  test  T = 3 and T  was r e j e c t e d  f o r Mesalt dressings  The s e c o n d dressing?"  W i t h n = 8,  hypothesis  strong  From s u b g r o u p C ,  T = 10.5  and T c r i t i c a l  responses = 3,  between  was f o u n d .  The t h i r d q u e s t i o n a s k e d was "How much d i s c o m f o r t experience four  when t h e d r e s s i n g  responses  analysis. n = 6,  i s removed?"  From s u b g r o u p B,  s i x responses = 2,  the n u l l  s u b g r o u p C, e i g h t  were a n a l y s e d .  difference  = 5,  the n u l l  hypothesis  between d r e s s i n g s  was f o u n d .  The f o u r t h q u e s t i o n  responses 0,  between  dressing  were a n a l y s e d .  the n u l l  hypothesis  was f o u n d .  W i t h n = 8,  was s u p p o r t e d  a s k e d was "How c o m f o r t a b l e changes?" W i t h n = 5,  From T = 17  and no  i s the  From s u b g r o u p A ,  five  T = 1 and T c r i t i c a l  was s u p p o r t e d and n o d i f f e r e n c e 59  With  h y p o t h e s i s was  between d r e s s i n g s  and T c r i t i c a l  for  were a n a l y s e d .  s u p p o r t e d and no d i f f e r e n c e responses  do y o u  From s u b g r o u p A ,  were o b t a i n e d w h i c h were i n a d e q u a t e  T = 13 and T c r i t i c a l  dressing  the  =  between  dressings  was f o u n d .  From s u b g r o u p B,  analyzed.  W i t h n = 7,  hypothesis  was s u p p o r t e d  T = 6 and T c r i t i c a l and no d i f f e r e n c e  was f o u n d .  From s u b g r o u p C,  W i t h n = 8,  T = 6 and T c r i t i c a l  s u p p o r t e d and no d i f f e r e n c e Despite the almost  eight  = 5,  Mesalt  q u e s t i o n a s k e d was  i n c o n t r o l l i n g odor?"  for  analyzed.  W i t h n = 5,  hypothesis dressings test  analysis.  was  CxC  =  entire  to  changes,  VAS.  responses  was a l s o  in  Analysis.  each  of  were  is  the were  inadequate  f i v e responses = 0,  the  for  using a  In some  were  null  Mesalt  one-tailed  d i d not  The a n a l y s i s affected two,  the  the  removal.  questions  of the by t h e  three, 60  already  their relating  In one c a s e ,  A l t h o u g h she was a b l e complete  the  questionnaire  one  f o u r and f i v e ,  the  to  s m a l l numbers  d e l e t i o n of  the  patients  involved in doing  complete  i l l .  complete  In two c a s e s ,  s h e was u n a b l e t o  questions,  cases,  s t u d y were u n a b l e t o  As t h e y were n o t  became t e r m i n a l l y  using the  ratings  .05.  they  respond v e r b a l l y ,  was  found.  and p r o v i d e d  rating  e a s e o f a p p l i c a t i o n and e a s e o f  patient  the  "How e f f e c t i v e  Overall Evaluation Scale.  dressing  hypothesis was  and t h e r e was s u p p o r t  involved with the  were h o s p i t a l i z e d .  were a n a l y z e d .  null  T = 0 and T c r i t i c a l  Comments a b o u t t h e patients  dressings  dressings.  From s u b g r o u p C,  rejected  were null  Only three responses  h a v i n g a more p o s i t i v e  and an  the  the  between  results  o b t a i n e d f o r b o t h s u b g r o u p s A and B, numbers  = 3,  between d r e s s i n g s  more p o s i t i v e w i t h t h e  dressing  responses  responses  absence of s i g n i f i c a n t  The f i f t h  seven  as  of  difference the  difference  was e q u a l t o  0.  B e c a u s e some p a t i e n t s entire  study,  odor.  The a n a l y s i s  experienced  they d i d not  respond to  of t h i s  question  who h a d u s e d M e s a l t d r e s s i n g s but n o t i c e d  a difference  was u n a b l e t o unable to  complete  smell.  investigator difference  to wet  the  the  of the  and i n b o t h  between  sometimes  procedure example  the the  f o r using the  therefore  I n one response  patient.  mark t h e  subgroups  the  the  B and  randomised  continuous  low numbers  only questions  instances  analysis  of  one and  four  showed no  Overall Evaluation Scale. d i f f i c u l t to  VAS.  understand  Explanations  evaluation VAS w i t h an  m o d i f i e d from " . . . p u t  on t h e  already  The i n v e s t i g a t o r  completion of a l l to  the  any  f o u r were f i r s t two t o  was  the be  for this  she  dressings.  found i t  was g i v e n .  patients  seem t o  other  g r o u p s u b g r o u p A,  Comments a b o u t patient  Due t o  patient  o d o r as  Home C a r e N u r s e and  and t h e  about patients  One  were r a n d o m i s e d e q u a l l y i n t o  saline dressings.  were a f f e c t e d ;  a /  q u e s t i o n about  two d r e s s i n g s  Mesalt dressings  difference  i n c l u d e d two  noted t h a t there d i d not  between  question  of odor.  S u b g r o u p A was u n b a l a n c e d s i n c e  responses  the  the  the  the  a p e r i o d o f o n l y one week  in control  Both the  The p a t i e n t s C.  for  no o d o r d u r i n g  was  the  were made and an  i n attendance during  scales. "X."  The  It  was d i f f i c u l t  The i n s t r u c t i o n s  a X on t h e  line..."  to  for  were "...put  line. instance,  given t r u l y  the  investigator  reflected  the  61  was n o t  patient's  sure that  feelings.  the For  example,  one p a t i e n t  indicated that  she had q u i t e  d i s c o m f o r t when a n s w e r i n g t h e q u e s t i o n a b o u t dressing  removal.  As t h i s  made b y t h e i n v e s t i g a t o r , The p a t i e n t discomfort about  with a l l dressing  appropriate related  the  Mesalt dressings  she  felt  was d e l e t e d  question  remained  Discussion  t o the continuous  during dressing  1986;  response,  Except  each  f o r the  of the other  expected.  control  There i s agreement  (1988).  two d r e s s i n g s  1982,  The r e s u l t s  with Mesalt dressings  by Spencer  patients'  The f i n d i n g t h a t M e s a l t  Gross & Gerner,  1979).  uncertainty  between  o b s e r v e d d u r i n g t h e s t u d y and t h e  of the analysis.  Ruth,  for that  unchanged.  were g e n e r a l l y  1986;  When t h i s  the results  easy t o a p p l y i s s u p p o r t e d by p r e v i o u s  Sibbald,  dressings,  t h e same w i t h  removal.  from t h e a n a l y s i s ,  what t h e i n v e s t i g a t o r  are  In comparing  wet s a l i n e  were a b o u t  of Findings.  o f one p a t i e n t ' s  other  she i n d i c a t e d t h a t t h e d i s c o m f o r t  t h a t both dressings  response  After using the  r e m o v a l was n o t t o o b a d .  to discomfort  findings  c h a n g e s and n o t p a r t i c u l a r l y  "removal."  f o r f o u r weeks,  responses  her  e v e n when i t was e m p h a s i s e d t h a t t h e q u e s t i o n  during the dressing  regard  reflected  further.  She m a i n t a i n e d t h a t h e r r e s p o n s e was  to the dressing  dressing  during  observations  was q u e s t i o n e d  c l a r i f i e d t h a t her response  the removal.  discomfort  c o n f l i c t e d with the the patient  a l o t of  research  (Gallant &  Jagelman  & Spencer,  indicating greater  substantiate  L i t t l e difference  with regard  1985;  odor  the e a r l i e r  was n o t e d between  t o ease of d r e s s i n g 62  dressings  finding the  r e m o v a l and  discomfort during the that the  significant  wear,  and f u r t h e r  i s the  comparison of  Evaluation Scale  Satisfaction  and t h o s e  Questionnaire.  Evaluation Scale  patients  are  Although the  more  dressings  a s k e d on  r e c o g n i z e d as  from  f i v e of the  the  Patient the  questions  Satisfaction  Patient  questions  Satisfaction  questions,  being pertinent  the for  five evaluating  satisfaction.  The e v a l u a t i o n o f t h e referring  to  the  investigators shown t o difficult  the to  patient,  study.  have t h e  effective  method was  the  easier  the  dressing.  results (Gift,  1989).  to  Another approach  r a t e both dressings  Mesalt dressings  were  at  the  have would  same t i m e .  found t o  be  a p p l y and s i g n i f i c a n t l y more  There appeared t o 63  is  regarding  i n c o n t r o l l i n g o d o r compared w i t h c o n t i n u o u s  saline dressings.  It  w o u l d h a v e had any  one i n s t a n c e  in place.  Some  s h o u l d be  d r e s s i n g change w o u l d p r o b a b l y n o t  patients  In summary,  do n o t  or not t h i s  However,  first  previous  while others  know w h e t h e r  i f this  significantly  given f o r the  recommend t h a t t h e  in this  occurred  s e c o n d d r e s s i n g was made w i t h o u t  responses  discomfort during the  be t o  of these  i d e n t i f i e d f o r the  Patient  i n c l u d e s many o t h e r  effect  may r e v e a l  questions  s i m i l a r to  Questionnaire are  quite  The f i v e q u e s t i o n s  i d e n t i f i e d f o r the  Questionnaire.  patient  research  felt  changes.  interest  Overall  were  findings regarding discomfort  between d r e s s i n g  Overall  Some p a t i e n t s  c o n t i n u o u s wet s a l i n e d r e s s i n g s  uncomfortable to  Of  d r e s s i n g change.  be no s i g n i f i c a n t  wet  d i f f e r e n c e between t h e  two d r e s s i n g s  with regard  to  r e m o v a l and d i s c o m f o r t d u r i n g and between d r e s s i n g The c h a r a c t e r i s t i c s important the  to  evaluated  measure  s t u d y were  when e v a l u a t i n g p a t i e n t  care of u l c e r a t i n g  Preference  i n the  metastatic skin  dressings." Preference  Patients  "first  alternatively,  divided  recognised  satisfaction  to  "Mesalt  c o n t i n u o u s wet  T h i s h y p o t h e s i s was t e s t e d b y u s e Scale.  between t h e  were a s k e d t o  d r e s s i n g , " the  "no p r e f e r e n c e . "  sign test patients  verbally.  changes.  of  the a  preference  "second d r e s s i n g , "  (Neave & W o r t h i n g t o n ,  responded t o  saline  choose  The r e s u l t s  this  were  or  analyzed  1988).  question,  two d o i n g s o  The f r e q u e n c y d i s t r i b u t i o n o f p r e f e r e n c e s  i n t o the  t h r e e subgroups  Frequency D i s t r i b u t i o n of P a t i e n t  i n Table  are  2.  Preferences  Subgroups o f  Mesalt  Preferences dressings  C o n t i n u o u s wet s a l i n e No  in  dressings  Table 2  Patient  as  Scale  w o u l d be p r e f e r r e d by p a t i e n t s  All  of  lesions.  The s e c o n d h y p o t h e s i s t e s t e d was t h a t  using the  ease  A  B  C  5  6  7  dressings  preference  1 1  64  Patients  2  2  O f s u b g r o u p A, had null  five preferred  no p r e f e r e n c e . hypothesis  W i t h n = 5,  was r e j e c t e d ,  saline dressings O f s u b g r o u p B,  no p r e f e r e n c e . hypothesis  were p r e f e r r e d  preferred  W i t h n = 6,  was r e j e c t e d ,  dressings  and t h e r e was s u p p o r t  test,  the  0<^  =  .05  and two had  = 0,  for  were p r e f e r r e d  the  continuous  Mesalt dressings  using a one-tailed  for  and an  S = 0 and S c r i t i c a l  conclusion that Mesalt dressings wet s a l i n e  test  to  one  = 0;  and t h e r e was s u p p o r t  using a one-tailed six  and  S = 0 and S c r i t i c a l  conclusion that Mesalt dressings wet  Mesalt dressings  the  null  the  to  continuous  w i t h an  Q*^  =  .05. O f s u b g r o u p C, no p r e f e r e n c e dressings.  seven p r e f e r r e d  and one p r e f e r r e d  W i t h n = 8,  hypothesis  was  rejected,  continuous  saline  dressings  wet  S = 1 and S c r i t i c a l  = 1,  the  for  were p r e f e r r e d  using a one-tailed  two had  saline  and t h e r e was s u p p o r t  conclusion that Mesalt dressings wet  Mesalt dressings,  to  null  the continuous  t e s t w i t h an  -  .05. Comments a b o u t t h e the  first  dressing  and  was u n b a l a n c e d  s u b g r o u p A.  It  was e q u a l in favor  However,  subgroup A appears two  for  group of the  The r a n d o m i z a t i o n subgroups  of the  was d i f f i c u l t  randomization of the obtained.  Analysis.  to six  affected  preference  consistent  B and C,  Mesalt dressings  determine  to  if  for  the  the  results  for Mesalt dressings  with the  analysis  of the  groups. Revisions to  the  Preference 65  Scale.  The  the  Preference  in other  S c a l e was r e v i s e d u s i n g a VAS i n an a t t e m p t strong the preference patient to K).  s i n c e t h e r e was no method f o r  i n d i c a t e the magnitude of t h e i r  The a n c h o r words were c h o s e n w i t h  non-health made,  care workers.  o n l y two p a t i e n t s  question.  Therefore,  responses  for  Analysis question if  was,  However, were  involved  was m o d i f i e d t o  r e v i s i o n was  i n completing the  "Why?" w i t h r e g a r d t o was i n d i c a t e d . "If  the  The o p e n - e n d e d patient's,  During the  the  same t i m e t h e  strength.  any a f f e c t  on t h e t y p e o f results  question  (indicated  This modification  VAS was added t o  determine  The m o d i f i c a t i o n d i d n o t seem t o responses  using  received.  a theme a p p r o a c h was  No one common theme a p p e a r e d due t o involved.  preference,  study the  you d i d have a p r e f e r e n c e  why d i d y o u p r e f e r t h e d r e s s i n g ? "  analyse the  f r o m a number o f  t h e r e was an i n a d e q u a t e number o f  preference  patients  the  of t h e Open-Ended Q u e s t i o n .  asked  occurred at  response (Appendix  input  after  the  analysis.  a preference  above),  t o measure how  Therefore,  the  have  Attempting to difficult.  s m a l l number o f  e a c h r e s p o n s e was  considered  individually. The r e s p o n s e to  c l a r i f y the  received to  patient's  i n f o r m a t i o n t h a t was n o t Scale.  to  added  e v a l u a t e d on t h e O v e r a l l E v a l u a t i o n  Mesalt dressings  d r e s s i n g s were e a s i e r  open-ended q u e s t i o n helped  c h o i c e and sometimes  In t h e g r o u p o f 6,  preferring  the  the  responses  included the  from the  66  patients  comments t h a t  a p p l y and manage,  d i d n o t d r a i n t h r o u g h so q u i c k l y .  5  and t h a t t h e  In one c a s e t h e  the fluid  drainage  was  less,  the  perceived to  wound was c l e a n e r ,  be v e r y e f f e c t i v e b e c a u s e  m o i s t u r e i n t h e wound. because messy, the  and t h e d r e s s i n g was  One p a t i e n t  t h e y were q u i c k e r t o  apply,  and t h e r e was m i n i m a l o d o r .  the p a t i e n t Of t h e individual  i r r i t a t i o n at  the  preferred Mesalt dressings the process  was n o t  This patient  times.  who d i d n o t h a v e a  as  d i d not  w i t h no p r e f e r e n c e  it  Of t h e  i n t h e g r o u p o f 8,  indicated that  s c a b f o r m a t i o n on t h e  final  3 patients  i n the group of  and no comment.  10,  The p a t i e n t  one  the Mesalt dressing  that  decreased.  In a d d i t i o n ,  the  dressings  " d r y t h e wound q u i t e a b i t . "  h a v e no d i f f i c u l t y  preference. preference  case."  t h e d r e s s i n g was q u i t e c o m f o r t a b l e and  Comments a b o u t t h e P r e f e r e n c e seemed t o  found  " v e r y d i s t r e s s i n g f o r my p a r t i c u l a r  a couple of days,  seemed t o  she  who p r e f e r r e d t h e M e s a l t d r e s s i n g s f o u n d  o d o r was g r e a t l y  patient  who p r e f e r r e d  c o n t i n u o u s wet s a l i n e d r e s s i n g s d i d s o b e c a u s e  after  ulcer  be d r i e r .  had no p r e f e r e n c e  The p a t i e n t  the  The r e s p o n s e  who p r e f e r r e d M e s a l t d r e s s i n g s  to  felt  T h e r e was no comment f r o m  had no comment.  the Mesalt d r e s s i n g caused l e s s and c a u s e d  like  preference.  additional 2 patients  from the p a t i e n t  the  decreased  c o n t i n u o u s wet s a l i n e d r e s s i n g s b e c a u s e t h e y a l w a y s  wet and c a u s e d  the  it  The a d d i t i o n  Scale.  completing the  o f t h e VAS t o  Patients q u e s t i o n about  determine strength  required a d d i t i o n a l explanation with  an e x a m p l e ,  o r d e r t o be e a s i l y c o m p l e t e d . Discussion  of Findings.  The a n a l y s i s r e v e a l e d 67  that  of in  t h e r e were  statistically  Mesalt dressings dressings.  significant results  being preferred to  The p r e f e r e n c e s  patients'  d i d n o t have a p r e f e r e n c e ,  comments  study,  dressing in her  the  response  dressings. decreased  the  study.  if  The s e c o n d p a t i e n t  tissue,  resulting  caused  she f e l t  characteristic  dressings  had caused h e r t o of t h i s patient  overall  e v a l u a t i o n of the over the  odor.  wound.  to  know what  dressings  However,  cleanliness  dressings  dressing  she had t o by t h e  of the  as  of  wound was saline  Unfortunately,  the  bleeding.  a problem,  i n her  she d i d not p r e f e r  one  other.  regarding the Some o f t h e  r e v e a l e d more  rationale  comments 68  specific  for preferring  were n o t  dead  spend  end  c o n t i n u o u s wet  increased  d i d not view t h i s  continuous  of s l o u g h i n g of  Thus,  c l e a n more.  The o p e n - e n d e d q u e s t i o n s information  Mesalt  She f o u n d t h a t t h e  c l e a n i n g caused  the  had been  s h e was n o t i n v o l v e d  is d i f f i c u l t  and t h a t t h e  Because  favorable  entering the  a great deal  that the  important  vigorousness  made more  found Mesalt  i n increased  much more t i m e c l e a n i n g t h e f o u r weeks,  to  patients  unexpected.  were u n c o m f o r t a b l e between  and t h a t t h e y  the  s h e had been c h a n g i n g h e r own  odor q u i t e a b i t .  changes  dressing.  It  were  One p a t i e n t  As a r e s u l t ,  own d r e s s i n g s .  wet s a l i n e d r e s s i n g s  dressing  responses  h o s p i t a l concurrent  w o u l d h a v e been  the  saline  Where t h e two  Mesalt dressings.  arm o f t h e  changing her  study.  both of these p a t i e n t s  about the  admitted to  c o n t i n u o u s wet  g i v e n were s u p p o r t e d by  comments d u r i n g t h e  During the  which support  reflected  the in  the  an  Overall  Evaluation Scale.  satisfaction only the  were  with dressings  questions  interest,  This  most  i n the  of the  indicated that the  was n o t t o t a l l y  Overall  responses  to  open-ended  In summary,  results  o b t a i n e d showed a  evaluated. specific  f o r the  Mesalt dressings  Answers t o  the  Of question  Questionnaire. significant  when compared w i t h  even w i t h t h e  small  open-ended questions  i n f o r m a t i o n about  using  patients'  reasons  the  sample  added more  for  preferring  dressings.  General  Comments a b o u t t h e  Comments A b o u t t h e  dressings. weeks,  method f o r  For those patients  no c a r r y - o v e r  dressings  effects  Study  Study Design.  d e s i g n was an a p p r o p r i a t e  were  evaluated.  the  a desirable  situation  1989;  The c o n c e r n design because arms.  (Beck,  Pocock,  The p a t i e n t s  f o r using the  four  when  carry-over first throughout  cross-over  1983). d r o p p i n g out  was a r e a l i s t i c  many p a t i e n t s  the  wounds r e m a i n e d s t a b l e  about p a t i e n t s  1989)  were a p p a r e n t  randomization to  the  (Beck,  two  The p o s s i b i l i t y o f  In g e n e r a l ,  design  cross-over  comparing the  or r e s i d u a l e f f e c t s  was m i n i m i z e d by t h e  study,  The  who u s e d e a c h d r e s s i n g f o r  dressing.  the  the  Satisfaction  c o n t i n u o u s wet s a l i n e d r e s s i n g s ,  the  Evaluation Scale.  Patient  preference  the  evaluated  i n c l u d e d i n the the  patient's  were u n a b l e t o  of the  problem i n t h i s fully  who d i s c o n t i n u e d t h e  complete  study a f t e r  s e c o n d d r e s s i n g f o r o n l y one week f o u n d t h e 69  cross-over study both  study  b e i n g on  one week  period  adequate  patient  enough t o  evaluate  who u s e d b o t h d r e s s i n g s use the  to  The d i f f i c u l t y  them.  time needed f o r were a b l e t o others  adjustment  fully  adjust  t o o k more t i m e .  dressing control patients the  noticed  require  less  time to  i n the  study  It  purposes  of comparison.  been r e c o g n i z e d  generally  dressings  Some  a few d a y s  were  i n the  of u s i n g  intolerable  comments  Patients. study.  patients'  like  for  (Carlsson, patients  during the  Most o f t h e Clinically, lesions.  for  some the  i n remembering  i n d i c a t e d by t h e  t o l e r a t e the  the  than d i d the  has  1983). were  study.  patients there  None o f  were the  d e v e l o p e d a c l i n i c a l i n f e c t i o n w h i l e on t h e  Many p a t i e n t s  variables  four-week time p e r i o d  The d i f f i c u l t y  preferences  m i n i m a l changes patients  dressing  itself.  s u p p o r t e d by t h e i r  able to  while  d r e s s i n g or d i s c o n t i n u e d  i n a previous study  Comments A b o u t t h e were  of  patients  between d r e s s i n g s .  use of the  remember what t h e  the  a  was a l o n g p e r i o d o f t i m e f o r  to  However,  order  quickly,  determine  a great difference within  patients  also  Some  In some c a s e s t h e d i f f e r e n c e was s o  s t u d y arm.  in  arose i n the d e c i s i o n  dressings  A n o t h e r p r o b l e m was w i t h t h e each  that  o f s t u d y d e p e n d s on t h e  comfort  that they discontinued the participation  felt  f o u r weeks  the dressings. the  type  o d o r and t h e  dressing.  for  The  The e a s e o f a p p l i c a t i o n and r e m o v a l o f  seemed t o of  to  variables.  The l e n g t h o f t i m e t h a t  s h o u l d be u s e d f o r t h i s being evaluated.  dressings  to  of the  f o r two weeks a l s o  he d i d n o t n e e d t o evaluate  all  study.  had a s c a n t o r s m a l l amount o f b l e e d i n g p r i o r 70  to  the  study,  and t h i s  d i d not  i n b l e e d i n g was n o t e d dressings,  but t h i s  saline dressings. some c a s e s t h e dressings not w e l l  change  i n some s i t u a t i o n s  also  occurred  Despite the  the  wound s l i g h t l y .  s t i n g i n g from the  Out o f t h e  13 p a t i e n t s  10 d i d n o t  experience  stinging,  she d i d n o t  on t h e  dressings  the  the  somewhat  wet  in  saline  occurred  patients  caused the felt  is  remained unchanged f o r t h e Most o f t h e s t u d y were started  treatments  patients  on t h e  decreased  appeared t o  dressings,  entire  d r y out  In one  the All  case  dressing  cases the  drainage  study p e r i o d .  treatment f o r the during the  have a f f e c t e d  71  Mesalt  or s h r i n k .  require  i n most  cases  In f i v e c a s e s  on m e d i c a l t r e a t m e n t a t  lesions.  arm.  in only three  was b e n e f i c i a l .  However,  some  Mesalt dressing  I n one c a s e t h e  wound t o  chemotherapy  concern.  stinging diminished  the drainage.  that this  f i v e months.  a  study  Three d i d experience  wound c o m p l e t e l y d r i e d and d i d n o t for  of the  Mesalt dressing treatment  drainage  increased  start  d i d not use the  Mesalt dressings.  Mesalt dressings  patient  wet  dressings,  s t u d y who u s e d M e s a l t  any s t i n g i n g .  switch to  while using the  the  the  M e s a l t d r e s s i n g as  One p a t i e n t  Of i n t e r e s t ,  changes  of the  Why t h i s  and i n one o f t h e s e c a s e s t h e  w i t h i n two weeks.  the  Mesalt  understood.  identified  of the  increase  continuous  and c o n t i n u o u s  A number o f Home C a r e N u r s e s a t  as  A slight  using the  with the  moistness  Mesalt dressings  stuck to  greatly.  the  the  start  study duration. study.  None o f  c o n d i t i o n of  One the the  of  For the  patients  s t u d y no d i f f i c u l t y protocol.  who f u l l y  occurred  In one c a s e ,  after  and s e n s i t i v i t y ,  patient.  The p a t i e n t  any m e d i c a t i o n s  situation,  the  patient  n o r n o t i c e d any change  patient's  responses  each p a t i e n t .  about  early  as  l o n g enough t o  dressings  early  the  assess  the  it  or  felt  study.  length  varied  continuous  he had u s e d try  discontinued the  dressings  f o u n d them t o o u n c o m f o r t a b l e t o  wet  reasons.  feeling.  the  the  Mesalt the  patient  In saline  continue. analysis  F o r one p a t i e n t , 72  do  continue with  who u s e d c o n t i n u o u s wet  excluded from the  for  Mesalt  Another  i r r i t a t i n g " to exact  of  preference.  wound d r i e d u p . "too  In  the  two weeks when  one o t h e r  study f o r various  take  infection  study e a r l y  contrast,  the  any o f  the  the  increased  and wanted t o  had g r e a t d i f f i c u l t y d e s c r i b i n g t h e patient  and  to  p h y s i c i a n was p l a n n i n g t o  The p a t i e n t  who f o u n d M e s a l t d r e s s i n g s  The f o u r p a t i e n t s  for  discontinued the  One p a t i e n t  because  antibiotics  affect  He d i s c o n t i n u e d t h e s e a f t e r  wound was d e b r i d e d .  for  had a c l i n i c a l  satisfaction  This  swab r e s u l t  was on t h e  This  to  of f o u r .  w i t h odor,  for discontinuing the  some wound d e b r i d e m e n t .  dressings.  appear t o  One p a t i e n t  saline dressings  odor.  wound c a r e  s h e was n o t  patient  neither  i n the  study d i d not  The r e a s o n s  dressing  that the  that  the  was a s k e d  instead  and o r d e r e d o r a l  t h a t might i n t e r f e r e  the  patient  f i v e weeks  had f o r g o t t e n  p h y s i c i a n had f o r g o t t e n  t i m e on t h e  the  the p h y s i c i a n received the  culture  this  in tolerating  however,  r e m a i n on one d r e s s i n g f o r occurred  c o m p l e t e d b o t h arras o f  discontinued several  factors  contributed to  condition;  the  the  withdrawal:  Home C a r e N u r s e s '  a gravely  i n a b i l i t y to  deteriorated  increase  visits  f o r the  c o n t i n u o u s wet s a l i n e d r e s s i n g arm o f  study;  and t h e  Home C a r e N u r s e s '  reluctance  f a m i l y w i t h c o m p l i c a t e d d r e s s i n g changes. discontinued the one week o r  less.  the  Mesalt dressing;  One p a t i e n t and t h e  Two o t h e r  experienced  other  c o n t i n u o u s wet s a l i n e d r e s s i n g s  patient,  finding  patients  dressings  the  d i d not wish  The f o u r t h  b u t was more c o m f o r t a b l e  the  s t i n g i n g with  uncomfortable,  h a v e them changed more t h a n once p e r d a y . both dressings  the  involve  s t u d y a f t e r u s i n g o n l y one o f t h e  for  tried  to  their  to  patient  with a dressing  she had used p r e v i o u s l y . Another d i f f i c u l t y regard  to  maintaining protocol  those patients effort  who were  was n e e d e d t o  The s t a f f  encountered  ensure  It  was a l s o  compliance with p a t i e n t s Nursing  care f o r t h e i r  d e p e n d e d more on t h e rather than the major  concern with the  and p r e v e n t  to  however,  were  very  maintain  protocol  c o m p l e t e l y dependent The d r e s s i n g  have  it  on a r e g u l a r  sticking to  73  on Home changes  Home C a r e N u r s e changed.  T h i s was  c o n t i n u o u s wet s a l i n e d r e s s i n g s  r e q u i r e d d r e s s i n g changes moistness  was f o l l o w e d .  a v a i l a b i l i t y of the need t o  with  protocol  involved,  who were  occurred  Considerable  that the  difficult  This  hospital.  d r e s s i n g changes.  patient's  s t u d y was w i t h  compliance.  admitted to  i n both h o s p i t a l s  supportive.  i n the  basis  t h e wound.  to  as  maintain  a  they  P a t i e n t s * Comments and P o s t - S t u d y In g e n e r a l involved about  the  i n the  patients  study.  had p o s i t i v e  They a p p r e c i a t e d  how t h e y were c a r i n g  weekly v i s i t s .  Consultation  for their  One p a t i e n t  feelings receiving  nevertheless  became  patients  to  afford after  at  the  end o f t h e  Consultation the  about  (50  lesion,  the  care of the This  preventing  o d o r and c o n t a i n i n g d r a i n a g e .  were d i s c u s s e d ,  obtain the  regarding  strongly  encouraged  to  them t o however,  found the  continue wish to  Those p a t i e n t s  after  wish t o  were f a c t o r s  become  received  study v i s i t s  do t h e i r  the  encountered  cost,  places  P a t i e n t s were  so h e l p f u l  that  own d r e s s i n g s  lesion.  she  wanted  She d i d  Home N u r s i n g c a r e study v i s i t s  also  l o c a l Home  own c a r e o f t h e  s t u d y was c o m p l e t e d .  who a p p r e c i a t e d  dressing  p r e v i o u s l y from  involved with the  monitor t h e i r  the  s u c h as  be i n v o l v e d w i t h Home N u r s i n g c a r e .  who were n o t  offered  c o n t r o l l i n g and  Various  of d r e s s i n g s .  be i n v o l v e d i n t h e  those quite able to  l e s i o n was  infection,  and comments  comfort  N u r s i n g c a r e program t o One p a t i e n t  as  dressings,  patients  Mesalt  c o n t r o l l i n g and p r e v e n t i n g b l e e d i n g ,  and managing c l i n i c a l  to  of the  All  involved discussing  preventing  options  s t u d y w h i c h was  study.  s t u d y was c o m p l e t e d .  cleansing the  gause)  the  discouraged  s t u d y was c o m p l e t e d .  were o f f e r e d two b o x e s  dressings  after  the  being  feedback  wounds and welcomed  when he f o u n d a d r e s s i n g he l i k e d w h i l e on t h e difficult  about  the  not,  program.  most  were  and who d i d n o t Those  patients  r e c e i v i n g Home N u r s i n g c a r e h a d p r e v i o u s l y many d i f f i c u l t i e s .  These d i f f i c u l t i e s i n c l u d e d 74  deciding  on d r e s s i n g s  and k n o w i n g where t o d i d not  purchase  Furthermore,  these patients  provided the  i n f o r m a t i o n and r e a s s u r a n c e t h a t  them.  find that their  physician  they  required.  Summary The r e s u l t s  of both the  development of the  Satisfaction  Questionnaire,  satisfaction  with Mesalt dressings  wet s a l i n e d r e s s i n g s , Patients  and t h e  evaluation of compared w i t h  have been p r e s e n t e d  with u l c e r a t i n g metastatic skin  questionnaire's understandable  format  and f o u n d t h e  and i m p o r t a n t .  Questionnaire s o l i c i t e d development,  it  has  Patient  questions  liked  to  Patient  i n p u t from p a t i e n t s  had l i m i t e d t e s t i n g  continuous  and d i s c u s s e d . lesions  Though t h e  patient  in  the  be b o t h Satisfaction  its  f o r v a l i d i t y and  reliability. In t h e  study,  however,  Mesalt dressings  s i g n i f i c a n t l y more p o s i t i v e r a t i n g s when compared w i t h c o n t i n u o u s wet  i n a group of  e a s e o f a p p l i c a t i o n and o d o r c o n t r o l .  to  evaluate  satisfaction  appropriate  since  the  Satisfaction  Patient  preferred  i n the  t h e y were s i m i l a r t o Questionnaire.  with u l c e r a t i n g metastatic skin Mesalt dressings  to  10  saline dressings  to  patient  received  lesions  with  The q u e s t i o n s s t u d y were  those  regard used  considered  identified for  Notably,  patients  significantly  c o n t i n u o u s wet s a l i n e  75  patients  dressings.  CHAPTER 5 Conclusion  and Recommendations  Introduction The l i m i t e d k n o w l e d g e r e l a t e d metastatic skin Patient input,  lesions  is  to  addressed  the  care of  in this  thesis.  S a t i s f a c t i o n Q u e s t i o n n a i r e was d e v e l o p e d , to  lesions.  evaluate Also,  dressings  used i n the  care of  an e v a l u a t i o n o f p a t i e n t  was c o m p l e t e d .  i n the  Major c o n c l u s i o n s ,  and r e c o m m e n d a t i o n s  for  further  A  with  patient  these  satisfaction  d r e s s i n g performance comparing Mesalt d r e s s i n g s c o n t i n u o u s wet s a l i n e d r e s s i n g s  ulcerating  with  with  same t y p e s  of  lesions  implications for nursing  study are  presented  in  this  chapter. Ma.ior C o n c l u s i o n s D e r i v e d f r o m t h e T o o l development i n v o l v e d c o n s i d e r a b l e patients patients* ideas  with ulcerating metastatic skin having used d r e s s i n g s  for  a b o u t what s h o u l d be a s k e d t o  satisfaction  with dressings  The q u e s t i o n n a i r e many p a t i e n t s some t e s t i n g  felt  i n p u t from  lesions.  long p e r i o d s , evaluate  used i n the  incorporated t h e i r  Results  Many h a d numerous  patient  care of t h e i r  ideas  lesions.  i n t o a form which  was u n d e r s t a n d a b l e and i m p o r t a n t .  f o r v a l i d i t y and r e l i a b i l i t y was d o n e ,  Though it  was  limited. The s t u d y e v a l u a t e d p a t i e n t dressings  as  satisfaction  with Mesalt  compared w i t h c o n t i n u o u s wet s a l i n e d r e s s i n g s 76  in  the  care of u l c e r a t i n g  had a l i m i t e d a c c r u a l patients  study  o f 6,  8,  In t h e  study,  the  The r e s u l t s  of  conclusions  group of  odor 2.  In t h e  s m a l l e r group of  and c o n t i n u o u s  ease of  dressing  removal  changes.  ratings  regard 4.  extent  of  were  .05.  Mesalt dressings rating  eight  a more p o s i t i v e  dressings  the  study study  with respect to  received  than continuous  a  wet  ease of a p p l i c a t i o n  to  identified dressings  wet  in favor  and  The i n f o r m a t i o n o b t a i n e d can be u s e d i n v a r i o u s is  the  ways.  first  with  respect  between positive,  of Mesalt dressings  preference  the  Mesalt  significantly  with  changes.  f o r Mesalt dressings  i n comparison with continuous throughout  dressings  application.  d u r i n g and  between d r e s s i n g  overall  ease of  saline dressings  Although not  comfort  Mesalt  were f o u n d between  wet  was  saline  analyses.  Implications  Questionnaire  for  and d i s c o m f o r t  were h i g h  A significant  patients,  rating  No s i g n i f i c a n t d i f f e r e n c e s  to  were a n a l y z e d b y  control.  received 3.  the  were:  10 p a t i e n t s ,  dressings  study  all  d e p e n d i n g on t h e  =  more s i g n i f i c a n t l y p o s i t i v e saline  The  Because not  results  a n a l y z e d w i t h an  The m a j o r  lesions.  14 p a t i e n t s .  and 10 p a t i e n t s ,  completion.  statistically  1.  of  completed the  groupings  metastatic skin  for  Nursing  regarding patient The P a t i e n t  Satisfaction  known q u e s t i o n n a i r e 77  satisfaction  which attempts  to  evaluate  skin  dressings  lesions,  of p a t i e n t Directly  used  and i n p a r t i c u l a r ,  satisfaction  an e f f e c t i v e  approach,  input to  evaluation  is  now a v a i l a b l e  ulcerating  for  developing  tool  a tool  to  i n the  help patients help nurses  research  lesions.  Nurses can use t h e  choose  as  dressings.  dressings  used  lesions.  The e v a l u a t i o n  wet  i n the  saline dressings  care professionals satisfaction are  topics  known s t u d y t o  i n the  commonly u s e d and t h e i r  formally  and  i n f o r m a t i o n about  important.  health  C o n t i n u o u s wet s a l i n e performance  was r a t e d  was a new a p p l i c a t i o n o f a  are  The M e s a l t d r e s s i n g  in  dressings satisfactory  ulcerating frequently  appears  to  where e a s e o f a p p l i c a t i o n and c o n t r o l Application  e a s e may be p a r t i c u l a r l y 78  feel  patient  lesions  choice  further  skin  and  metastatic  positive  to  continuous  of Mesalt dressings  of d r e s s i n g .  may  metastatic  The u s e  used type  of  evaluate  i n many c a s e s . skin  care  which p a t i e n t s  provided both p a t i e n t s  with dressings.  for  for discussion  of Mesalt dressings  with useful  for  products.  care of u l c e r a t i n g  has  process  The q u e s t i o n n a i r e  s h o u l d be i n c l u d e d i n new d r e s s i n g first  of  characteristics  i d e n t i f y those c h a r a c t e r i s t i c s  T h i s was t h e  care  The t o o l  The method u s e d  used  proved  patients'  criteria.  i n the  dressings  questionnaire  evaluation  evaluate  the  may o u t l i n e an i n i t i a l evaluate  metastatic  perspective.  limiting  of pre-determined  further  the  important to  rather than  n o n - m a l i g n a n t wounds. identified  patient's  what was  metastatic skin  developing this  for ulcerating  incorporates  from the  asking patients  the  in caring  be of  a odor  important  if  the  patient  dressings.  is  having d i f f i c u l t y  Odor c o n t r o l  may be an added i m p o r t a n t  choosing Mesalt dressings, offensive  Mesalt dressings  s h r i n k some wounds, patient  is  where t h e patient  since  Mesalt dressings  d i d not  a factor  Overall,  a reasonable f o r the  Finally,  the  felt has of  the  option to  patients  the case the  time.  higher cost  some p a t i e n t s  Mesalt dressings saline  from  were  dressings,  often  metastatic  skin  lesions.  commented t h a t many h e a l t h  m o s t l y p h y s i c i a n s and n u r s e s , i n managing t h e i r  who i n d e p e n d e n t l y c a r e d  had  lesions.  for their  little  Although  lesions did  i n v o l v e d i n t h e Home N u r s i n g c a r e p r o g r a m ,  much k n o w l e d g e a b o u t t h e dressings  are  care required for t h e i r  o f t e n d i d not have care p r o f e s s i o n a l ;  dressings  and p l a c e s  recommended d r e s s i n g s  they  r e g u l a r l y c o n s u l t i n g a n u r s e who  These p a t i e n t s  f o l l o w - u p w i t h any h e a l t h  of  c o n s i d e r when c h o o s i n g  s p e c i a l i z e d knowledge o f t h e  of the  f o r some  c o n t i n u o u s wet  t h e y would a p p r e c i a t e  lesion.  or  In one  wound c o m p l e t e l y ,  w h i c h may d e t e r  because  knowledge or e x p e r i e n c e  be  are  d r y out  s t u d y was t h e  care of u l c e r a t i n g  care p r o f e s s i o n a l s ,  many p a t i e n t s  management  found t o  for  extremely  w i t h a d r i e r wound. d r i e d the  s i g n i f i c a n t l y preferred to  n o t want t o  also  addressed during the  u s i n g them.  dressings  were  its  r e q u i r e d r e s s i n g changes  Mesalt dressings,  are  for  reason  s o m e t h i n g w h i c h may be i m p o r t a n t , i f  more c o m f o r t a b l e  What was n o t  they  o d o r c a n become  and o n l y a few o p t i o n s  available.  c h a n g i n g h i s / h e r own  to  them.  quite expensive 79  regular nor d i d they  available to  purchase  type  them,  the  Many  and no  insurance  have cost  plan as  covers  the  the  less  costly  necessarily  the  recommended t h a t the  costs.  Patients  dressings  most  frustrated  and t o  It  are is  o b t a i n t h e most a p p r o p r i a t e  this  not therefore of  l e s i o n s be a v a i l a b l e  f o l l o w - u p on t h e  care of  f i n a n c i a l assistance should  these patients  by  a s p e c i a l i z e d knowledge  metastatic skin  In a d d i t i o n ,  a v a i l a b l e to  ones.  a n u r s e who has  consult with patients  often  t h e y must u s e ,  appropriate  care of u l c e r a t i n g  lesions.  are  their  be  i n o r d e r t h a t t h e y be a b l e dressing f o r the  to  care of  to  their  lesions. Recommendations Recommendations Satisfaction also  be o f  each  of the  ;  interest  dressings  to  i n the  greatly  of a l l dressings A systematic  of the  Patient  thesis.  rank the  It  importance  increased  the  patients  evaluation  with ulcerating  most h e a l t h  is  care of the  evaluation  to  crucial  would of  have  lesions.  of the  wet skin about  evaluation  be  completed.  since  metastatic skin  there  are  lesions,  limited It  dressings  c o o r d i n a t e d by a l i m i t e d group o f n u r s e s , 80  Further  needs  care professionals  managing t h e  metastatic  a v a i l a b l e knowledge  with the dressings.  approach to  recommended t h a t t h e  and c o n t i n u o u s  care of u l c e r a t i n g  available to  o n l y a few p a t i e n t s  experience  have p a t i e n t s  of Mesalt dressings  satisfaction  and s i n c e  testing  questions.  l e s i o n s has patient  include further  Study  Questionnaire developed f o r t h i s  The e v a l u a t i o n saline  for Further  is continue,  i n order to  provide  consistency.  An i n d i v i d u a l  u s e d may p r o v i d e h e l p f u l structured  e v a l u a t i o n of  information.  Given the to  remarks  it.  patients,  patients'  a more  would o f f e r  more  e v a l u a t i o n of the  dressings.  a two-week t r i a l  length of time t o  However,  effectiveness be  from the  be an a d e q u a t e  evaluate  However,  c o m p a r i s o n o f two d r e s s i n g s  i n f o r m a t i o n and a more s y s t e m a t i c  a dressing  adjust  to  the  seems  dressing  and  when s p e c i f i c a l l y c o m p a r i n g  on c o n t r o l  of odor,  the  time  limit  may n e e d  to  extended. The s t u d y p a r t i c i p a n t s  using  often  a d r e s s i n g that d i d not  e v i d e n t was t h a t but d i d not to simply to of the  reflect  the  drainage.  others.  stuck to  one p a t i e n t ' s  research  nor the  therefore  of  Also wound  T h i s phenomenon d i d n o t  amount o f d r a i n a g e  Further  importance  s t i c k when removed.  some d r e s s i n g s  those of  emphasized the  seem  consistency  i s needed  in  this  area. Summary The P a t i e n t a tool  to  evaluate  metastatic skin testing.  Satisfaction dressings  lesions,  Because  Q u e s t i o n n a i r e was d e v e l o p e d used i n c a r i n g  research is  related  lesions  two d r e s s i n g s :  Mesalt dressings  to  limited,  Mesalt dressings  the  this  care of  scored  ulcerating  s t u d y has  a more p o s i t i v e i n a group of  S i g n i f i c a n t numbers o f p a t i e n t s 81  further  and c o n t i n u o u s wet  e a s e o f a p p l i c a t i o n and o d o r c o n t r o l patients.  ulcerating  and i s now a v a i l a b l e f o r  metastatic skin  dressings.  for  as  involved  evaluated saline rating 10 in  the  for  study preferred dressings.  Mesalt dressings  over  continuous  T h i s k n o w l e d g e i s u s e f u l when h e l p i n g  d e c i d e which d r e s s i n g s metastatic skin  to  use  i n the  lesions.  82  care of  wet  saline  patients  ulcerating  References A b r a m o w i t z , S. , C o t e , A . A . , & B e r r y , E . (1987). Analyzing patient satisfaction: A m u I t i a n a l y t i c approach. Q u a l i t y R e v i e w B u l l e t i n . 13., 1 2 2 - 1 3 0 . A l v a r e z , 0 . , E a g l s t e i n , W. (1984). H e a l i n g wounds: or exposure. I n f e c t i o n s i n S u r g e r y . _ , 173-177,  Occlusion 181.  A l v a r e z , 0 . , R o z i n t , J . , & Wiseman, D. (1988). Moist e n v i r o n m e n t f o r wound h e a l i n g : Matching the dressing t h e wound. Ostomy/Wound Management. 21(Winter), 64-83.  to  American M e d i c a l A s s o c i a t i o n , Department o f Drugs, D i v i s i o n o f D r u g s and T e c h n o l o g y . (1986). Drug e v a l u a t i o n s (6th e d . ) . Philadelphia: W.B. S a u n d e r s Andreev, V. C. (1978). Current problems i n dermatology: Skin manifestations i n v i s c e r a l cancer. Basel, S w i t z e r l a n d : S. K a r g e r . A s h f o r d , R. , P l a n t , G . , Maher, J . , & T e a r e s , L . (1984). D o u b l e - b l i n d t r i a l o f m e t r o n i d a z o l e i n malodorous u l c e r a t i n g tumours. L a n c e t . 1. 1 2 3 2 - 1 2 3 3 . A v i s , W. S . , D r y s d a l e , P. D . , G r e g g , R. J . , N e u f e l d t , V . , & S c a r g i l l , M. H . (1983). Gage C a n a d i a n d i c t i o n a r y . Toronto: Gage P u b l i s h i n g . B e c k , S. (1989). The c r o s s o v e r research. Nursing Research.  design i n c l i n i c a l nursing 3J3, 2 9 1 - 2 9 3 .  B e c k e r , G . D. (1986). I d e n t i f i c a t i o n a n d management o f t h e p a t i e n t a t h i g h r i s k f o r wound i n f e c t i o n . Head & Neck S u r g e r y , 8_, 2 0 5 - 2 1 0 . B e c k e t t , R . , Coombs, T . J . , F r o s t , M. R . , M c L e i s h , J . , & Thompson, K. (1980). C h a r c o a l c l o t h s and m a l o d o r o u s wounds. L a n c e t . 2, 594. Billings, J. cancer.  A. (1985). O u t p a t i e n t management o f Philadelphia: J . B. L i p p i n c o t t C o .  advanced  B l a c k , M. K. ( 1 9 8 5 ) . The c o n s u m e r : Product of our e f f o r t s . In C . G . Meisenheimer ( E d . ) , Q u a l i t y assurance: A complete g u i d e t o e f f e c t i v e programs (pp. 2 9 5 - 3 i 4 ) . R o c k v i l l e , Maryland: Aspen. B o r g , S. A . , R u b i n , P . , & DeWys, W. D. (1983). Metastases and d i s s e m i n a t e d d i s e a s e . In P. Rubin ( E d . ) . , Clinical Oncology: A M u l t i d i s c i p l i n a r v Approach (6th e d . ) (pp. 498-513). New Y o r k : A m e r i c a n C a n c e r S o c i e t y . 83  B r e n n a n , S. S . , 8s L e a p e r , D . J . (1985). The e f f e c t s o f a n t i s e p t i c s on t h e h e a l i n g wound: A study using the r a b b i t e a r chamber. B r i t i s h J o u r n a l o f S u r g e r y . 22., 780-782. C a r l s s o n , A . M. ( 1 9 8 3 ) . Assessment o f c h r o n i c p a i n I: A s p e c t s o f t h e r e l i a b i l i t y and v a l i d i t y o f t h e v i s u a l analogue s c a l e . P a i n , 16, 8 7 - 1 0 1 . C a s s i l e t h , B. R . , Z u p k i s , R. V . , S u t t o n - S m i t h , K . , & March, V. (1980). I n f o r m a t i o n and p a r t i c i p a t i o n p r e f e r e n c e s among c a n c e r p a t i e n t s . Annals of Internal M e d i c i n e . 92, 8 3 2 - 8 3 6 . Consumers' A s s o c i a t i o n o f Canada. (1974). Consumer in health care. C a n a d i a n Consumer. 4 ( 2 ) , 1 - 3 . C u z z e l l , J . Z. (1985). to chronic problems. 162-166.  Wound c a r e f o r u m : American J o u r n a l  rights  Artful solutions o f N u r s i n g . 8J5_,  D e r d i a r i a n , A. K. (1990). Effects of using systematic a s s e s s m e n t i n s t r u m e n t s on p a t i e n t a n d n u r s e s a t i s f a c t i o n with nursing care. O n c o l o g y N u r s i n g Forum. 1 1 ( 1 ) , 95-101. E l l e r h o r s t - R y a n , J . (1987). Promoting s e l f - c a r e f o r ulcerating metastatic lesions. O n c o l o g y N u r s i n g Forum 1 4 ( 2 ) ( S u p p l . ) , 88. Epp,  J . (1986). A c h i e v i n g h e a l t h f o r a l l : A framework f o r health promotion. Canadian J o u r n a l o f P u b l i c H e a l t h . 11, 393-405.  Fleiss, J. L. (1981). S t a t i s t i c a l methods f o r r a t e s and p r o p o r t i o n s (2nd e d . ) . New Y o r k : Wiley Press. F o l t z , A. T. (1980). Nursing care of ulcerating metatstatic lesions. O n c o l o g y N u r s i n g Forum. 1 ( 2 ) , 8 - 1 3 . F r e n c h , K. (1981). Methodological considerations i n h o s p i t a l patient opinion surveys. International Journal o f N u r s i n g S t u d i e s . 18_, 1 7 - 3 2 . F r i e d m a n , S. J . , & S u , W. P. D. (1984). Management o f l e g ulcers with h y d r o c o l l o i d occlusive dressing. Archives o f D e r m a t o l o g y . 1 2 0 , 1329-1336. G a l l a n t , C . , 8s S i b b a l d , G . (1986). Mesalt dressings: An a l t e r n a t i v e therapy i n moist l e g u l c e r s . Unpublished manuscript a v a i l a b l e from S a n c e l l a I n c . , M i s s i s s a u g a , Ontario. 84  Geronemus, R. G . , M e r t z , P. M. , & E a g l s t e i n , W. H . (1979). The e f f e c t s o f t o p i c a l a n t i m i c r o b i a l a g e n t s . Archives of Dermatology. 1311-1314. G i f t , A. G. (1989). Visual o f s u b j e c t i v e phenomena. 286-288.  analogue s c a l e s : Nursing Research.  G o n c a l v e s , J . C. A . (1987). cancer. S k i n C a n c e r . 2.,  Chemomastectomy 49-68.  Measurement 38. for  advanced  Greenberg, E . (1978). Supportive care of patients with advanced b r e a s t c a n c e r . I n H . S. G a l l a g h e r , R . K . Snyderman, & J . A . U r b a n ( E d s . ) , The b r e a s t (pp. 409-418). S t . L o u i s : CV Mosby. Grosse,  W. ,  & Gerner,  H.J.  (1982).  Report  concerning  experience i n c o n n e c t i o n w i t h t e s t i n g o f Molnlycke  M e s a l t swabs i n d e c u b i t u s t r e a t m e n t o f p a r a p l e g i c patients. Unpublished manuscript a v a i l a b l e from S a n c e l l a Inc. , Mississauga, Ontario.  G r o s s e , W., & G e r n e r , H. J . (1985). M e s a l t - e i n e neue m o g l i c h k e i t d e r wundbehandlung b e i d e c u b i t u s . (Mesalt A n o v e l way o f t r e a t i n g d e c u b i t u s u l c e r s ) . Rehabilitation. 24, 100-102. (No t r a n s l a t i o n o f r e s u l t s a v a i l a b l e r e p o r t e d b y S a n c e l l a I n c . t o c o n t a i n same i n f o r m a t i o n as 1982 u n p u b l i s h e d m a n u s c r i p t ) . G u y a t t , G . H . , Townsend, M . , Berman, L . B . , & K e l l e r , J . L . (1987). A c o m p a r i s o n o f L i k e r t and v i s u a l a n a l o g u e s c a l e s f o r measuring change i n f u n c t i o n . Journal of Chronic D i s e a s e s . 4£>, 1 1 2 9 - 1 1 3 3 . H e n l e y , B . , & D a v i s , M. S. (1967). S a t i s f a c t i o n and dissatisfaction: A s t u d y o f t h e c h r o n i c a l l y - i l l aged patient. J o u r n a l o f H e a l t h and S o c i a l B e h a v i o r , fi, 6 5 - 7 5 . H i n s h a w , A . S . , & Atwood, J . R. (1982). A patient s a t i s f a c t i o n instrument: P r e c i s i o n by r e p l i c a t i o n . Nursing Research. 3_1, 170-175 Hoogstraten, J . , & L a m e r s , L . M. ( 1 9 8 7 ) . Patient s a t i s f a c t i o n a f t e r i n s e r t i o n o f an o s s e o i n t e g r a t e d implant bridge. J o u r n a l o f O r a l R e h a b i l i t a t i o n . 14., 481-487. I r v i n , T. T. practice.  (1981). Wound h e a l i n g : P r i n c i p l e s and England: Chapman & H a l l L t d .  85  I v e t i c , 0 . , & L y n e , P . A. (1990). F u n g a t i n g and u l c e r a t i n g malignant l e s i o n s : A review of the l i t e r a t u r e . Journal o f A d v a n c e d N u r s i n g . 15. 8 3 - 8 8 . J a g e l m a n , D. G . , & S p e n c e r , M. ( 1 9 8 6 ) . An e v a l u a t i o n o f M e s a l t s t e r i l e t o p i c a l wound t r e a t m e n t i n h o s p i t a l p a t i e n t s w i t h d r a i n i n g wounds. Unpublished manuscript. Cleveland C l i n i c Foundation, Cleveland, Ohio a v a i l a b l e from S a n c e l l a I n c . , M i s s i s s a u g a , O n t a r i o . J e n s e n , M. P . , K a r o l y , P . , & B r a v e r , S. (1986). The measurement o f c l i n i c a l p a i n i n t e n s i t y : A comparison of s i x methods. P a i n . 22, 1 1 7 - 1 2 6 . K o s o l , R. A . , G i l l i e s , C . , & E l g e b a l y , S. A . (1988). Effects o f s o d i u m h y p o c h l o r i t e ( D a k i n ' s s o l u t i o n ) on c e l l s o f t h e wound m o d u l e . A r c h i v e s o f Surgery, 123, 4 2 0 - 4 2 3 . L a r s e n , D. E . , 8s Rootman, I . (1976). Physician role p e r f o r m a n c e and p a t i e n t s a t i s f a c t i o n . S o c i a l Science M e d i c i n e . 10, 29-32. Lemke, R. W. (1987). I d e n t i f y i n g consumer satisfaction through p a t i e n t surveys. Health Progress. 68.(2), 56-58. L i n e a w e a v e r , W . , Howard, R . , S o u c y , D . , M c M o r r i s , S . , F r e e m a n , J . , C r a i n , C . , R o b e r t s o n , J . , 8s Rumley, T . (1985). T o p i c a l a n t i m i c r o b i a l t o x i c i t y . Archives of Surgery, 120.,  267-270.  L o c k e r D. , 8s D u n t , D. (1978). T h e o r e t i c a l and m e t h o d o l o g i c a l i s s u e s i n s o c i o l o g i c a l s t u d i e s o f consumer satisfaction with medical care. S o c i a l S c i e n c e 8s M e d i c i n e . 1 2 , 283-292. L o r i g , K. (1984). _ _ , 376. May,  R e : Measurement  of pain.  Nursing  Research.  S. R. , 8s S t i l l , J . M. ( 1 9 8 5 ) . C o n t e m p o r a r y wound management w i t h n a t u r a l and s y n t h e t i c d r e s s i n g s . Journal o f t h e M e d i c a l A s s o c i a t i o n o f G e o r g i a . 24, 5 6 4 - 5 7 0 .  M c M i l l a n , J . R. (1987). M e a s u r i n g consumer s a t i s f a c t i o n improve q u a l i t y o f c a r e . Health Progress. 68.(2), 54, 55, 78, 8s 80. . N e a v e , H . R. , 8s W o r t h i n g t o n , P . L . tests. London: Unwin Hyman.  (1988).  N u n n a l l y , J . C. (1978). Psychometric New Y o r k : McGraw H i l l . 86  theory  to  Distribution-free (2nd e d . ) .  O b e r s t , M. T . (1984). Patients perceptions Measurement o f q u a l i t y and s a t i s f a c t i o n . £ 3 J S u p p l . May 1 5 ) , 2 3 6 6 - 2 3 7 3 . P e t r e k , J . A . , G l e n n , P . D. , 8s C r a m e r , Ulcerated breast cancer: Patients The American Surgeon,, 49_, 1 8 7 - 1 9 1 . P o c o c k , S. J . approach.  of care: Cancer.  A . R. (1983). and outcome.  (1983). Clinical trials: A praotical Chichester: J o h n W i l e y 8s S o n s .  P r i c e , D . D. , M c G r a t h , P. A. , R a f i i , A . , 8s B u c k i n g h a m , B . (1983). The v a l i d a t i o n o f v i s u a l a n a l o g u e s c a l e as r a t i o s c a l e m e a s u r e s f o r c h r o n i c and e x p e r i m e n t a l p a i n . P a i n . 17. 4 5 - 5 6 . Reading, A. E. (1980). A comparison of p a i n r a t i n g J o u r n a l o f Psyehosomatip Research, 24, 1 1 9 - 1 2 4 .  scales.  R i s s e r , N. (1975). D e v e l o p m e n t o f an i n s t r u m e n t t o measure p a t i e n t s a t i s f a c t i o n w i t h n u r s e s and n u r s i n g c a r e i n a primary care s e t t i n g . N u r s i n g R e s e a r c h . 2A> 4 5 - 5 2 . Rodeheaver, G. management.  (1988). C o n t r o v e r s i e s i n t o p i c a l wound Ostomy/Wound Management. 2 X ( F a l l ) , 5 8 - 6 8 .  R o d e h e a v e r , G . , B e l l a m y , W. , Kody, M . , S p a t a f o r a , G . , F i t t o n , L . , L e y d e n , K. , 8s E d l i c h , R. (1982). B a c t e r i c i d a l a c t i v i t y and t o x i c i t y o f i o d i n e - c o n t a i n i n g s o l u t i o n s i n wounds. A r c h i v e s o f S u r g e r y . H Z , 181-185. Rosen, T. (1980). North America.  Cutaneous m e t a s t a s e s . 64, 8 8 5 - 9 0 0 .  Rosenbaum, E . H . ( 1 9 8 2 ) . C . V . Mosby C o . Rosenberg, F. internal  W. (1977). malignancy.  Medical  L i v i n g with cancer.  of  St L o u i s :  Cutaneous m a n i f e s t a t i o n s C u t i s . 20. 2 2 7 - 2 3 4 .  R u t h , M. ( 1 9 7 9 ) . " D r y " s o d i u m c h l o r i d e swabs therapy. OPUScula Medica. 24(2). Reprint o b t a i n e d from S a n c e l l a Inc.  Clinics  of  i n wound  S a n c e l l a Inc. Mesalt: How and why i t w o r k s . Booklet produced by S a n c e l l a I n c . , Mississauga, O n t a r i o . S a n c e l l a Inc. Treatment produced by S a n c e l l a  according t o phase. Pamphlet Inc., Mississauga, Ontario.  Seymour, R. A . (1982). The u s e o f p a i n s c a l e s i n a s s e s s i n g the e f f i c a c y of analgesics i n post-operative dental pain. E u r o p e a n J o u r n a l o f C l i n i c a l P h a r m a c o l o g y . 23., 4 4 1 - 4 4 4 . 87  S i d i , A . A . , Reddy, P. K . , & Chen, K. K. (1988). Patient a c c e p t a n c e o f and s a t i s f a c t i o n w i t h v a s o a c t i v e i n t r a c a v e r n o u s pharmacotherapy f o r impotence. The Journal Of U r o l o g y , MQ, 293-294. S i m s , R. , & F i t z g e r a l d , V . (1987). Wound c a r e : approach. Community O u t l o o k . ( N o v . ) , 16, 19,  A positive 8s 2 1 .  S p a r r o w , G . , M i n t o n , M. , R u b e n s , R. D. , Simmons, N . A . , 8s A u b r e y , C. (1980). M e t r o n i d a z o l e i n s m e l l y tumours. L a n c e t , 1 , 1185. S p e n c e r , M. (1988, M a r c h ) . An e v a l u a t i o n o f M e s a l t i n p a t i e n t s w i t h d r a i n i n g wounds: The C l e v e l a n d C l i n i c experience. P a p e r p r e s e n t e d a t t h e symposium " M e e t i n g t h e c h a l l e n g e o f t h e c h r o n i c wound: Clinical perspectives," Vancouver, B . C . S t a i r , J . C. (1986). S k i n i n t e g r i t y , impairment o f : R e l a t e d to malignant skin l e s i o n s . I n J . C . M c N a l l y , J . C . S t a i r , 8c E . T . Sommerville (Eds.), G u i d e l i n e s f o r cancer nursing p r a c t i c e (pp. 170-174). O r l a n d o : G r u n e 8s S t r a t t o n . S t e w a r t , M. L . (1977). Measurement o f c l i n i c a l p a i n . A . K . Jacox ( E d . ) , P a i n (pp. 107-137). Boston: L i t t l e , Brown and C o . S t o t t s , N. A . (1990). t h r e e - c o l o r concept 59-61.  In  S e e i n g r e d and y e l l o w and b l a c k : The o f wound c a r e . Nursing90. £ 0 . ( 2 ) ,  Van Den B r o e k , P. J . , B u y s , F . M. , 8s V a n F u r t h , R. (1982). I n t e r a c t i o n o f p o v i d o n e - i o d i n e compounds, p h a g o c y t i c c e l l s , and m i c r o o r g a n i s m s . A n t i m i c r o b i a l Agents and C h e m o t h e r a p y . 22 > 5 9 3 - 5 9 7 . V e n t u r a , M. R. , F o x , R. N . , C o r l e y , M. C. , 8s M e r c u r i o , S. M. (1982). A p a t i e n t s a t i s f a c t i o n measure as a c r i t e r i o n to evaluate primary nursing. N u r s i n g R e s e a r c h . 3JL 226-230. Viljanto, J. (1980). D i s i n f e c t i o n o f s u r g i c a l wounds w i t h o u t i n h i b i t i o n o f n o r m a l wound h e a l i n g . Archives of Surgery. 115. 253-256. Ware, J . , D a v i e s - A v e r y , A . A . , 8s S t e w a r t , A . L . (1978). The measurement a n d m e a n i n g o f p a t i e n t satisfaction. H e a l t h 8s M e d i c a l C a r e S e r v i c e s R e v i e w . 1 ( 1 ) , 1, 3-1.5. Ware, J . E . (1981). Drug I n t e l l i g e n c e  How t o s u r v e y p a t i e n t and C l i n i c a l P h a r m a c y .  88  satisfaction. 15, 892-899.  W a t s o n , J . D . , Sweeney, G . , M c G r e g o r , I . A., & S l e i g h , J . D. (1986). P r o p h y l a x i s w i t h t i n i d a z o l e o f i n f e c t i o n i n major h e a d and n e c k s u r g e r y f o r m a l i g n a n t d i s e a s e . British J o u r n a l o f P l a s t i c S u r g e r y . 39, 526-529. Westaby, S . , & W h i t e , S. (1985). Wound i n f e c t i o n . S. Westaby ( E d . ) , W n 4 C a r e (PP. 7 0 - 8 3 ) . London: W i l l i a m Heinemann M e d i c a l Books L t d .  In  QU  Wood, D . K. (1980). The d r a i n i n g , m a l i g n a n t u l c e r a t i o n : P a l l i a t i v e management i n a d v a n c e d c a n c e r . Journal of the American M e d i c a l A s s o c i a t i o n , 244, 8 2 0 - 8 2 2 .  89  APPENDIX A Patient  Satisfaction  90  Questionnaire  PATIENT SATISFACTION QUESTIONNAIRE LETTER OF INTRODUCTION Dear  Participant,  Please f i n d enclosed a P a t i e n t S a t i s f a c t i o n Q u e s t i o n n a i r e which w h i c h e v a l u a t e s d r e s s i n g s u s e d i n t h e c a r e o f c a n c e r o u s wounds. E a c h q u e s t i o n r e f e r s o n l y t o t h e d r e s s i n g and d o e s n o t i n c l u d e tape or other d e v i c e s which h o l d the d r e s s i n g i n p l a c e . When y o u answer t h e q u e s t i o n s " P l e a s e p l a c e a mark t h r o u g h t h e l i n e , between t h e two e x t r e m e s t o i n d i c a t e t h e d e g r e e o f y o u r response." An example i s g i v e n b e l o w : Does t h e  weather  effect  y o u r mood?  A great deal  Thank y o u f o r y o u r  _/  coooperation.  91  Not a t  all  V  PATIENT SATISFACTION QUESTIONNAIRE PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE: 1.  Is  the  Not  2.  Is  3.  very  the  Not  dressing  apply?  easy  Very easy  dressing  very  easy t o  ID#  easy to  easy  How l o n g d o e s  remove?  ;  it  Very easy  take to  change y o u r  dressing? Not very long  A long time  4.  Do y o u e x p e r i e n c e d i s c o m f o r t  when t h e  dressing  is  removed?  A great deal  5.  Do y o u e x p e r i e n c e p a i n when t h e  dressing  is  Does t h e  dressing  stick  to  the  wound when i t  is  being  A great deal  7.  Does t h e  dressing  Are t h e r e d r e s s i n g removed? Quite  Not a t  all  removed? Not a t  cause the  wound t o  b l e e d when i t  is  A great deal  8.  all  removed?  A great deal  6.  Not a t  removed? Not a t  fibres  left  a few  i n the  wound when t h e  dressing None a t  92  all  all  is all  PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE: 9.  Does t h e  dressing  cause the  wound t o  dry  up?  A great deal  10.  Does t h e Not  11.  Is Not  12.  Is  Not at  dressing  keep t h e  dressing  very  the  Very well  soft  against your  skin?  soft  dressing  Very  comfortable  while i t  is  Does t h e  Very comfortable  dressing  cause a  "stinging"  sensation?  A great deal  14.  Does t h e  dressing  A great deal  15.  Does t h e  dressing  cause a  "burning"  •  cause a  "clammy"  Does t h e  dressing  all  Not a t  all  Not a t  all  feeling?  rub r o u g h l y a g a i n s t the  A great deal  Not a t  sensation?  A great deal  16.  soft  on?  Not v e r y comfortable  13.  all  wound c l e a n ?  very well  the  ID#  wound w h i l e i t  is  Not a t  93  on? all  PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE: 17.  Does t h e wound?  dressing  decrease the  odor  (if  there  ID#  is  any)  A great deal  18.  Does t h e  dressing  cause a  "strange"  Does t h e  dressing  absorb  all  of the  Does t h e d r e s s i n g p r e v e n t outside of the dressing?  Does t h e  dressing  drainage  from p a s s i n g  Does t h e  dressing  adapt to  the  shape  of the  Very well  have more b u l k t h a n  is  needed? Not at  Can y o u u s e t h e d r e s s i n g WITHOUT t a p e , which h o l d the d r e s s i n g i n p l a c e ?  Does t h e wound?  dressing  the  wound?  netting  Not v e r y w e l l 24.  all  Very well  A great deal  23.  Not at  through to  Not v e r y w e l l  22.  all  Very well  Not v e r y w e l l  21.  Not a t  drainage?  Not v e r y w e l l  20.  the  odor?  A great deal  19.  from  or  other  all  devices  Very well cause i r r i t a t i o n  A great deal  to  the  skin  surrounding  the  Not at  94  all  APPENDIX B Interview  95  Guide  INTERVIEW GUIDE 1.  What t y p e s  of dressings  have you used i n t h e  care  of  y o u r open wound? 2.  What d i d y o u l i k e  3.  What d i d y o u d i s l i k e  4.  What do y o u want t h e d r e s s i n g t o characteristics important  5.  about each  about each  the dressing?  dressing? d o ? o r What  o f t h e d r e s s i n g would you c o n s i d e r  i n choosing a  What f a c t o r s  dressing?  dressing?  would i n f l u e n c e y o u r s a t i s f a c t i o n o r Can y o u d e s c r i b e t h e  dressing?  96  "perfect"  with  APPENDIX C Preliminary  Questionnaire  97  PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE:  Is  the d r e s s i n g easy t o Not  Very  the  Is  the d r e s s i n g easy t o  Is  the  apply?  v e r y easy  Is  Not  ID#_  subject  of t h i s  q u e s t i o n important t o you?  Yes  How l o n g d o e s  Very of t h i s  it  take  question important to  to  change y o u r  you?  Yes  Is  the  Is  there discomfort during the d r e s s i n g  question important to  you?  Yes  the  subject  of t h i s  question important to  p a i n when t h e  dressing is  you?  Yes  subject  question important to  Does t h e d r e s s i n g s t i c k t o  the  you?  Yes  the  subject  No  Not of t h i s  all  wound?  A great deal Is  No  Not a t of t h i s  all  changed?  A great deal the  long  No  Not a t  Do y o u e x p e r i e n c e  Is  very  change?  A great deal Is  No  Not of t h i s  easy  dressing?  A long time subject  No  remove?  v e r y easy subject  easy  question important to  98  you?  Yes  at No  all  PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE?  Does t h e d r e s s i n g c a u s e t h e  wound t o  b l e e d when i t  is  ID#  removed?  A great deal subject  Not at  Is  the  of t h i s  Is  dressing fibre l e f t  question important to  i n the  you?  wound when t h e d r e s s i n g  Yes  is  A great deal Is  the  subject  Does t h e  the  of t h i s  question important to  d r e s s i n g cause the  subject  wound t o  you?  Yes  subject  Does t h e  of t h i s  question important to  you?  Yes  of t h i s  all  No  Not a t question important to  you?  Yes  all  No  d r e s s i n g k e e p t h e wound c l e a n ?  subject  .  Is  the  Is  the dressing s o f t  of t h i s  question important to  against  your  Very you?  Yes  subject  No  Very of t h i s  well  skin?  Not v e r y s o f t the  No  d r y up?  Not v e r y w e l l  Is  all  enlarge?  A great deal the  removed?  Not a t  Does t h e d r e s s i n g c a u s e t h e wound t o  Is  No  Not a t  A great deal Is  all  question important to  99  you?  Yes  No  soft  PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE:  Is  the d r e s s i n g comfortable while i t  is  on?  Not v e r y comfortable Is  the  subject  Very comfortable of t h i s  Do y o u e x p e r i e n c e  q u e s t i o n important t o you?  p a i n from the d r e s s i n g w h i l e i t  Yes  is  on?  A great deal Is  the  subject  Not a t of t h i s  question important to  Does t h e d r e s s i n g c a u s e a  "stinging"  you?  Yes  the  subject  Does t h e  q u e s t i o n important t o you?  d r e s s i n g cause a  "burning"  Yes  the  subject  question important to  Does t h e d r e s s i n g c a u s e a  "gummy"  you?  Yes  the  subject  Does t h e  q u e s t i o n important t o you?  d r e s s i n g cause a  "clammy"  Yes  the  subject  No  Not a t of t h i s  question important to  100  all  feeling?  A great deal Is  No  Not a t of t h i s  all  feeling?  A great deal Is  No  Not at of t h i s  all  sensation?  A great deal Is  No  Not a t of t h i s  all  sensation?  A great deal Is  No  you?  Yes  No  all  PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE:  Does t h e d r e s s i n g r u b r o u g h l y a g a i n s t  the  im.  wound?  A great deal Is  the  subject  Not a t of t h i s  question important to  Does t h e d r e s s i n g d e c r e a s e t h e  odor  (if  you?  there  is  Yes  any)  Is  the  subject  of t h i s  q u e s t i o n important t o you?  "strange"  Yes  subject  Does t h e  question important to  d r e s s i n g absorb a l l of the  Not v e r y w e l l Is  the  subject  you?  Yes  of t h i s  subject  Does t h e  question important to  you?  Yes  the  question important to  d r e s s i n g adapt t o  subject  the  Very of t h i s  the  you?  Yes  well  No  shape o f t h e wound? Very  of t h i s  well  No  from p a s s i n g through t o  Not v e r y w e l l Is  No  Very  Not v e r y w e l l the  all  drainage? ,  Does t h e d r e s s i n g p r e v e n t d r a i n a g e outside of the dressing?  Is  No  Not a t of t h i s  all  odor?  A great deal the  wound?  Not at  Does t h e d r e s s i n g c a u s e a  Is  No  from the  A great deal  all  question important to  101  you?  Yes  No  well  PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE?  Does t h e d r e s s i n g h a v e more b u l k t h a n  is  ID#.  needed?  A great deal Is  the  subject  Not a t of t h i s  question important to  you?  Can y o u u s e t h e d r e s s i n g w i t h o u t t a p e o r o t h e r dressing in place?  Yes  devices  the  subject  Very of t h i s  question important to  Does t h e d r e s s i n g c a u s e i r r i t a t i o n t o  the  you?  skin  Yes  the  subject  Does t h e d r e s s i n g c a u s e  question important to  itchiness  to  the  skin  you?  Yes  the  subject  No  No  Not at of t h i s  q u e s t i o n important t o you?  102  all  s u r r o u n d i n g t h e wound?  A great deal Is  well  Not a t of t h i s  the  s u r r o u n d i n g t h e wound?  A great deal Is  No  which h o l d  Not v e r y w e l l Is  all  Yes  No  all  \  APPENDIX D Letter  of  Introduction  103  APPENDIX E Pilot  Questionnaire  105  PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE:  Is  the d r e s s i n g easy Not  v e r y easy  the  Is  the d r e s s i n g easy t o  Is  the  apply?  ;  Is  Not  subject  to  of t h i s  Very question important to  Yes  subject  it  question important to  take to  change y o u r  you?  Yes  of t h i s  subject  question important to  you?  d i s c o m f o r t when t h e d r e s s i n g i s  Yes  of t h i s  question important to  p a i n when t h e  dressing is  subject  question important to  Does t h e d r e s s i n g s t i c k t o A great deal Is  the  subject  No  you?  Yes  t h e wound when i t  removed?  you?  is  being  Yes  No  Not a t  question important to  107  you?  all  removed?  : of t h i s  all  No  Not at of t h i s  long  removed?  A great deal the  very  Not a t  Do y o u e x p e r i e n c e  Is  No  Not  A great deal the  easy  dressing? .  Do y o u e x p e r i e n c e  Is  No  Very of t h i s  subject  easy  remove?  A long time the  you?  v e r y easy  How l o n g does  Is  im  Yes  No  all  PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE?  Does t h e  d r e s s i n g cause the  wound t o  b l e e d when i t  is  removed?  A great deal Is  the  subject  Not a t of t h i s  question important to  Are t h e r e d r e s s i n g f i b r e s removed?  left  you?  Yes  Is  the  subject  of t h i s  q u e s t i o n important t o you?  Yes  subject  question important to  Does t h e d r e s s i n g k e e p t h e  you?  Yes  the  Is  the d r e s s i n g s o f t  of t h i s  question important to  against  your  you?  Yes  Is  the  Is  the d r e s s i n g comfortable while i t  question important to  is  you?  Yes  the  subject  soft  No  on?  Not v e r y comfortable Is  No  Very of t h i s  well  skin?  Not v e r y s o f t subject  No  Very  Is  all  wound c l e a n ?  Not v e r y w e l l subject  No  Not a t of t h i s  all  d r y up?  A great deal the  is  None a t  Does t h e d r e s s i n g c a u s e t h e wound t o  Is  No  i n t h e wound when t h e d r e s s i n g  Q u i t e a few  all  Very comfortable of t h i s  question important to 108  you?  Yes  No  PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE:  Do y o u e x p e r i e n c e p a i n f r o m t h e  dressing  A great deal Is  the  subject  Does t h e  while i t  is  ID#.  on?  • of t h i s  dressing  question  cause a  Not a t  important  "stinging"  to  you?  Yes  the  subject  Does t h e  Not a t of t h i s  dressing  question  cause a  important  "burning"  to  you?  Yes  the  subject  Does t h e  dressing  question  cause a  important  "clammy"  to  you?  Yes  the  subject  Does t h e  dressing  question  important  rub r o u g h l y a g a i n s t the  to  you?  Yes  wound w h i l e i t  A great deal Is  the  subject  Does t h e  of t h i s  dressing  question  decrease the  important  odor  (if  to  there  you?  is  Yes  any)  the  subject  is  on?  question  important  109  to  you?  from the  Yes  all  No  Not a t of t h i s  all  No  Not at  A great deal Is  No  Not a t of t h i s  all  feeling?  A great deal Is  No  Not a t of t h i s  all  sensation?  A great deal Is  No  sensation?  A great deal Is  all  No  wound? all  PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE:  Does t h e d r e s s i n g c a u s e a  "strange"  ID#_  odor?  A great deal Is  the  subject  Does t h e  Not a t of t h i s  question important to  d r e s s i n g absorb a l l  of the  you?  Yes  the  subject  Very of t h i s  question important to  Does t h e d r e s s i n g p r e v e n t d r a i n a g e outside of the dressing?  you?  Yes  the  subject  Does t h e  question important to  d r e s s i n g adapt t o  the  you?  Yes  the  subject  question important to  Does t h e d r e s s i n g have more b u l k t h a n  is  you?  Yes  the  subject  of t h i s  question important to  you?  netting  Yes  or other  Not v e r y w e l l the  subject  No  Not at  Can y o u u s e t h e d r e s s i n g WITHOUT t a p e , hold the d r e s s i n g i n place?  Is  well  needed?  A great deal Is  No  Very of t h i s  well  s h a p e o f t h e wound?  Not v e r y w e l l Is  the  Very of t h i s  well  No  from p a s s i n g through t o  Not v e r y w e l l Is  No  drainage?  Not v e r y w e l l Is  q u e s t i o n important t o you?  110  Yes  all  No  d e v i c e s which Very  of t h i s  all  No  well  PLEASE PLACE A MARK THROUGH THE L I N E , BETWEEN THE TWO EXTREMES TO INDICATE THE DEGREE OF YOUR RESPONSE?  Does t h e  dressing  cause i r r i t a t i o n  to  the  skin  ID#  surrounding the  A great deal Is  the  subject  Not a t of t h i s  question  important  111  to  you?  Yes  No  wound? all  APPENDIX F Medical  History  112  MEDICAL HISTORY  DATE:  ID#  Day/Month/Year DIAGNOSIS:  DATE OF DIAGNOSIS:  History o f the Lesion  Date at Appearance: Day/Month/Year Ulceration:  •  No  •  Yes  Bleeding:  •  No  •  Yes  Infection:  •  No  •  Yes  Date: Day/Month/Year Date: Day/Month/Year Date: Day/Month/Year  CURRENT TREATMENT  Hormonal therapy  •  Yes -> When started  Type  I I No  Specify  CURRENT LESION CARE  A. B.  C. D. E. F.  When Started: Month/Year Dressings t y p e O N S •Dakins #dressings: #dressing changes/24 hours: Cleansing solution: Bleeding Control: Odor Control: Infection Control:  QDry  •Adaptic  •Other_  Q Y e s - O N S • H 2 0 2 QOther I I No • •  Specify  Yes ->QGelfoam • • Kalostat No  O Y e s - > • Flagyl • No  • Other  O Y e s - > • Antibiotic: • No Specify  113  •Other  Specify  Spec  APPENDIX G Protocol  f o r Wound C a r e  114  PROTOCOL FOR WOUND CARE  1. CLEANSING OF WOUND Solution: Cleanse wound with Normal Saline (N/S) solution 0.9%. Following consultation with the Research Nurse, may use 1/2 strength Hydrogen Peroxide and rinse with N/S i f indicated by the presence of crusting or dead tissue. Method: Cleanse wound using gauze soaked with solutions described above. May also use other methods i f gauze is inappropriate eg. cotton-tipped swabs, spray bottle, soft shower, squeeze from sponge over wound etc. *Use a gentle rubbing action unless tissue is friable, then NO rubbing. 2.  FREQUENCY OF CLEANING/DRESSING CHANGES To be determined by the Research Nurse depending on amount of drainage. Drainage which extends beyond the outer dressing (dry gauze dressing) indicates need for increase in dressing changes. Wet normal saline dressings will be changed every 4 to 6 hours depending on the dryness of the dressing. Mesalt will be changed when the area over the wound is saturated with drainage.  3.  CONTROL OF BLEEDING Apply Gelfoam or Kalostat to source of bleeding as required.  4.  DRESSING APPLICATION INNER DRESSINGS (1st layer - applied directly to wound) -  Mesalt or N/S soaked gauze (depending on study randomization) Apply dressing by laying gauze over top of wound For N/S soaked gauze, soak gauze in N/S solution so i t is moderately soaked.  OUTER DRESSINGS 2nd layer - Dry gauze over Mesalt or N/S soaked gauze 3rd layer - (optional) Abdominal padding SECUREMENT OF DRESSINGS Secure dressing with any of the following: - tape - Mefix - netting eg. fastonet - clothing eg. tube tops, camisoles, etc. For the purposes of the study, do not use: - creams, ointments, solutions, dressing materials, other than those specified - anything that effects bacterial growth or odor. 115  APPENDIX H Overall  Evaluation  116  Scale  OVERALL EVALUATION SCALE  (patient)  ID#_ Please put an X on the line to indicate: 1. How is the application of the dressing?  Very Difficult to apply  2.  Very easy to apply  How i s the removal of the dressing?  Very d i f f i c u l t to remove  3.  How much removed?  . " Very easy to remove  discomfort  do you experience when  the dressing is  A lot of discomfort  No discomfort  4. How comfortable is the dressing between dressing changes?  Very uncomfortable  5.  Very comfortable  How effective is the dressing in controlling odor?  Not effective at a l l  Very effective  117  APPENDIX I Preference  118  Scale  PREFERENCE SCALE ( p a t i e n t )  ID# Which dressing did you prefer? Q T h e f i r s t dressing Q T h e second dressing |  j No preference  Why?  119  APPENDIX Preference  Scale  120  J (Revised)  PREFERENCE SCALE ( p a t i e n t )  ID# Which dressing did you prefer? I I The f i r s t dressing | 1 The second dressing [Zl No preference If i you did have a preference (indicated above), how strong was your preference? (Please place a mark through the line, indicate the degree of your response)  Not very strong  between the two extremes  to  Very strong  If you did have a preference (indicated above), why did you the dressing?  121  prefer  APPENDIX K Patient  Information  122  and C o n s e n t Form  CCA BC Cancer Control Agency of British Columbia 600 West 10th Avenue Vancouver, B.C., Canada V5Z 4E6 (604) 877-6000 Telex 04-507648 Fax (604) 872-4596  EVALUATION OF DRY VS WET NORMAL SALINE DRESSINGS IN WOUND CARE  PATIENT INFORMATION AND CONSENT FORM The purpose of this study is to compare two types of dressings used in the care of open wounds related to cancer. The main focus of the study is to determine the convenience of both dressings. The study also examines the effects of the dressing on odor control and infection. Both types of dressings have been previously used in the care of open wounds and to date, there has been no evidence of side effects from either type of dressing. At the beginning of the study, the Research Nurse (a Registered Nurse assigned to the study) will see you either at the Cancer Control Agency of British Columbia or in your home. She will ask you questions about your wound and how you presently care for i t . She will then examine you for any signs of infection and use a cotton swab to take a specimen of the drainage from your wound. To compare these dressings, you will be randomly assigned to use one of the dressings for the f i r s t four weeks. This means that you will have an equal chance of being assigned to use either of the two dresssings. Then for the last four weeks you will use the other dressing. The study will therefore involve a total of eight weeks. The Research Nurse will instruct you about how to use each of these dressings. While you are on the study, the Research Nurse will v i s i t you once a week in your home to collect information about your wound and how you are managing with the dressings. During the time you are on the study, you will be asked not to use any ointments or solutions upon the wound other than those specified by the Research Nurse. Specimens of the drainage from your wound, using a cotton swab will be taken before switching to the second dressing, and again at the end of the study. If you are involved in changing the dressing you will be asked to record the number of dressing changes required per day and the time i t takes you to do the dressing. The study will require about 15 minutes per week of your time for the Research Nurse's v i s i t and 5-10 minutes for recording information about the dressing changes. Although there may be no direct benefit to you by participating in this study, the knowledge  123  APPENDIX L Content  Identification  125  Summary  CONTENT IDENTIFICATION SUMMARY C h a r a c t e r i s t i c s of i d e a l d r e s s i n g s from i n t e r v i e w s : - not uncomfortable - no s t r a n g e o d o r - n o t s t i c k i n g t o wound - d o e s n ' t cause b l e e d i n g - absorbent - d r a i n a g e d o e s n ' t pass through - soft - easy t o u s e / a p p l y - c o n t o u r s t o wound; d o e s n ' t s l i p - a d a p t a b l e - appropriate s i z e , not bulky - not gummy/sticky - not abrasive - no l i n t - d r i e s up wound - d o e s n ' t c a u s e wound t o b r e a k down - can use w i t h o u t tape - e a s y t o remove - h e a l s wound - not a bother - doesn't sting A d d i t i o n a l c h a r a c t e r i s t i c s from l i t e r a t u r e : - c o n t r o l of odor - controls drainage - controls bleeding - prevents i n f e c t i o n - c l e a n s wound - d r i e s wound - no p r u r i t i s o f s u r r o u n d i n g t i s s u e - no p a i n - wound - no d i s c o m f o r t - wound - comfortable - decreases s i a e of l e s i o n (shrinks) A d d i t i o n a l c h a r a c t e r i s t i c s f r o m own e x p e r i e n c e : - not i r r i t a t i n g / s t i n g i n g - wound - surrounding tissue - e a s y t o do d r e s s i n g - q u i c k t o change d r e s s i n g - k e e p s wound c l e a n - d o e s n ' t promote i n f e c t i o n - c o m f o r t " d u r i n g " d r e s s i n g change - n o t "clammy" - d e c r e a s e s odor  126  

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