A Trip to Cuba: A view of the island from the eyes of Christina Taylor, PhD

As a psychology resident on staff at the mental health center in Key West, Florida in the early 90s, my interest in Cuba was piqued by work with Cuban-American exiles who brought their vibrant Cuban culture to our most southern American city. This past March my dream of visiting Cuba came true on a tour focused on birding, people, and cultural exchange.

From the desk of PESI author Christina J. Taylor, Ph.D. pictured above with the President of the Cuban Society of Psychology, Dr. Alexis Lorenzo Ruiz.


For many of us of a certain age who lived through the Bay of Pigs invasion, the Cuban missile crisis, and the trade and travel embargo, the island of Cuba, only 90 miles away from US shores, has for too long been an intriguingly unavailable neighbor. As a psychology resident on staff at the mental health center in Key West, Florida in the early 90s, my interest in Cuba was piqued by work with Cuban-American exiles who brought their vibrant Cuban culture to our most southern American city. This past March – three weeks before Obama in fact – my dream of visiting Cuba came true on a tour focused on birding, people, and cultural exchange.

It was a completely fascinating and sometimes very difficult trip; conditions in the hotels in the countryside falling well below standards that would be considered budget lodging in the US. Sadly, the island is in a state of decay, buildings standing vacant and in disrepair. A formerly grand home, that is now a resort near a magnificent nature preserve, was reminiscent of Miss Havisham’s run down mansion in Dickens’ novel Great Expectations. The shower in our bathroom with the exposed light bulb, provided barely a trickle of cold water, necessitating creative maneuvering to get at least nominally washed and rinsed.

The Cuban people, on the other hand, possess an indomitable spirit in the face of truly difficult economic conditions. They engage in what our young Cuban guide called the struggle to make ends meet. While the average Cuban salary is about $24 a month, he explained that it really takes 10 times that amount to meet basic needs. Hence the need to find additional sources of income – alluding to making do by struggling to find jobs that pay under the table. If possible, many people seek out employment in the tourist industry – one cab driver explained that although he possessed a college degree in mechanical engineering, he could make more money in two hours driving a taxi than in one month working as an engineer. The irony is that there is free education, including up to the level of a Ph.D., for those who are qualified, but the downside is that there are many obstacles to earning an adequate income.

The deprivation that the Cubans are experiencing now is still not as bad as in the 1990’s following the collapse of the Soviet Union and the withdrawal of its economic support. Our guide told us that the average Cuban lost 30% of their body weight during that time because of severe food shortages. Fidel Castro labeled this period “the special period” because of the hardships faced by the Cuban nation. Food is certainly more plentiful now, but again, the restaurant quality in the countryside is generally not up to American standards. Stray cats and dogs are seen everywhere – sometimes to the point of their ribs showing through – leading some of us on the tour to regularly drop food onto the floor for them and to surreptitiously wrap up part of our meals for feeding other stray animals.

The long history of economic difficulties and hardships definitely accounts for why the Cuban people are so enthusiastic about the renewal of relations with the US. Everywhere we went, Cubans who initially thought we were Canadian, broke out into big, big smiles when they learned we were Americans. It is clear that they believe the normalization of relations with the US will have a positive effect on their lives.

To this point, people in the travel industry wore a pin with adjoining Cuban and American flags, and many taxi drivers displayed both flags on the dashboard of their vintage American cars. The cars are, of course, a hoot for all of us, especially for us baby boomers who rode around in them with our parents in the 50’s and 60’s. It was incredible to ride in a 1938 Oldsmobile that appeared to be right out of a Hollywood gangster movie, sans the tommy guns, of course! I also spoke to the owner of a 1958 yellow Rambler exactly like my father’s who told me that he had installed a Russian engine to keep it going. That is a testament to the ingenuity and perseverance of a people who have surmounted great obstacles. To this point, the drivers are excellent, adept, and by far more polite than those in the US! And for those who want to travel more frugally, cheaper taxi fares can be had by riding in the less glamorous non-vintage cars! And forget about seat belts and emission controls!

Despite the decay, pollution, deprivation (internet service is extremely scarce – available in some hotel lobbies for $4.50 an hour) and all the physical and social rehabilitation that needs to be done, Cuba is surreally enchanting. It is both weird and tranquil to look out over Havana harbor and see no boats except for one Russian cruise ship parked at a dock. And by the way, not one seagull! Outside of Havana, horse drawn carts are common and oxen are used to plough the fields.

Music is everywhere and marvelous. Even in the small restaurants and hotels in the countryside, the local bands and singers serenaded us with the beat and sounds of salsa. The live music that reverberates all throughout the country is an anthem to the passion and soulfulness of a people who have endured.

As an American, I am hopeful that the renewal of relations between the countries will be positive for both peoples. The Americans I encountered in Cuba all expressed gratitude that we had the opportunity to visit the island before the anticipated onslaught of American tourists. Most expressed reservations about the negative effects that mass American tourism may have on this island nation stuck in time. Hopefully, the transition unfolding before us will work out in the end for both Cuba and the US. It is inevitable that something will be lost and gained.

At the end of my tour I had the opportunity to meet with the President of the Cuban Society of Psychology, Dr. Alexis Lorenzo Ruiz. I was able to contact him prior to my trip about my wish to meet and to share with him my recently published book on OCD. With that, he cordially invited me to meet him in his home (his day off from campus at the University of Havana).

We spent an hour and a half together talking about our respective careers and work as psychologists, finding out that we shared many commonalities. He has a background in social and clinical psychology, which I do as well. We both teach courses in Psychopathology and he is currently authoring a book on Psychopathology. Dr. Ruiz is a trauma specialist and knowledgeable about current evidence based treatments, including cognitive behavior therapy (CBT), Exposure and Response Prevention, and Acceptance and Commitment therapy (ACT). He spoke about the epidemiology of OCD, the importance of using ERP for treating OCD, and cited a case of a young man whose treatment was complicated by a co-morbid condition. He was truly delighted to receive my book as well as the one I donated to the University.

Dr. Ruiz was trained as a psychologist in the Soviet Union and speaks several languages. Following the Chernobyl disaster, he spent significant time in the Ukraine treating people suffering trauma from the disaster. His English has suffered as a result of his multi-linguistic experiences, and he is now interested in finding a post-doctoral position in the USA to perfect his English language skills. His lovely daughter, who is studying to become a physician, served as our translator. He is a brilliant, knowledgeable, and warm man who welcomed me into his home despite his busy schedule – working to finish his book by June! At his home, I met his two daughters, Aleli and Azucena, their grandmothers, and their new puppy, Lassie! His wife, Alma, is a physician and was away at work.

We parted with the understanding that we will hopefully meet again — with invitations to come to one another’s homes — Mi casa es su casa!


Christina J. Taylor, Ph.D., specializes in Cognitive Behavioral Therapy for Anxiety Disorders, including Obsessive Compulsive Disorder, Panic Disorder, Agoraphobia, Social Phobia, Generalized Anxiety Disorder, and specific phobias. Dr. Taylor lectures widely on anxiety disorders and provides training workshops for mental health professionals. She is an Associate Professor of Psychology at Sacred Heart University in Fairfield, Connecticut.

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Sexual Honesty: You Don’t Have to Fake It

What happens when you’ve been faking orgasm, and your sex life is not fulfilling? It is possible to turn a page and write a new script. Learn how from modern relationship expert Esther Perel, MA, LMFT.

From the desk of Esther Perel, MA, LMFT, and modern relationship expert.


“When we first started dating, we partied and drank a lot. And when I drink, I don’t orgasm, so I got into the habit of faking it. We got married and I stopped pretending, but I never told him. And now, he can’t understand why I don’t orgasm in five minutes any more. He married this hot, young thing who was crazy for sex but essentially, I lied. I want a fulfilling sex life with my husband. How do I turn things around? Do I tell the truth?”

— Sarah, 32

It’s old news that women lie about their pleasure (or lack-thereof). When sex was primarily a woman’s marital duty, and it was all for him, she often faked orgasm to get it over with. But what are we to make of the fact that so many women in our “liberated” Western society still feel compelled to play the same game? One would think that an increased level of sexual freedom is correlated to increased honesty. Not so. Now that her orgasm is an important affirmation of his sexual prowess, women have a new reason to keep pretending. Her pleasure is proof of his masculinity and how adept he is in bed.

I see ‘faking orgasm’ as part of longstanding gender dynamics, traditional power structures, poor sexual education, and persistent myths and stereotypes about sexual performance. Chief among them, that reaching the finish line signals the deed is done. Orgasm is not just that moment of climax; it’s a full body pleasure, not just one event. Nobody is served when partners lie about their needs, preferences, and dislikes. The result is a dissatisfying sexual experience for both.

What else is wrong with this charade? Clearly, she’s not fulfilled, and lying to protect his ego maintains the status quo. He has no way of knowing that she’s isn’t fulfilled and the conversation on how to please isn’t happening. She may think her lying shields him, but in effect he remains clueless and she, frustrated as the opportunity for him to do better is squandered. Sarah and Damian are stuck in a cycle of displeasure.

If this sounds familiar, here are a few ways you can enter into a mature era of sexual connection.

Establish the Conversation
Simply state that honesty is important to you, and that your partner’s pleasure truly matters. And ask the right questions. For example:

  • What do you like?
  • What do you not like?
  • Are there certain things that I do that you like more than others? And why?
  • Are there certain things you don’t enjoy doing to me?
  • Is there something we have not yet tried that you are interested in?

When Sarah is able to speak truthfully about her experience, she may not discover immediate orgasm, but she will feel liberated from the pretense, and from lying. She doesn’t have to keep it up anymore. That in itself makes her feel safer, more trusting and more open to exploring her sexuality.

Shift the focus: there is a whole person, not just genitals.
Practice giving and receiving touch in less obvious parts of the body. For example, caress the neck, arms, back of the knees or curve of the spine. The clitoris is just the tip of the volcano; women have a largely unknown network of structures responsible for arousal and orgasm. All the body parts you’ll never see focused on in porn. You can also play with energetic touch, by touching me without touching me. Let your hand just hover over the other’s body. Lastly, try having the slowest sex you’ve ever had. No matter how slow you think you are, you could probably still go slower. The point being, you are not aiming for any outcome, you are simply exploring each other’s bodies.Pleasure is the measuresays Emily Nagoski in the highly recommended book Come as You Are.

Give active feedback.
Tell him that you want to be able to take the time you need to become aroused or to climax without worrying that it’s taking too long or that he’s getting bored. Most men, once they know, and see the pleasure you experience, are more than motivated to do it again.

I can’t express to you enough how many women have told me that the “coming out” conversation about her lying is such a turning point in her relationship and in her sexual development. And if her partner is chronically defensive and responds with counter attack, i.e. what’s wrong with you, then perhaps a therapist may be helpful, or if not, it is a sign that her partner is not ready for a mature sexual intimacy. Sarah may need to seek new arms.

Have you ever had to start a tough conversation about sex with your partner? Share your thoughts on the best way to initiate those discussions in the comments.

Warmly,
Esther


Esther Perel is a master trainer and an acknowledged international authority on couples, culture, and sexuality. She’s the author of the international bestseller Mating in Captivity: Unlocking Erotic Intelligence.

 

Cognitive Conceptualization: Don’t get stuck in therapy again

With the Cognitive Conceptualization Diagram, you can develop a road map for your clients that shows them where their problems came from and sets them on a path to success.

It’s difficult to do good therapy without having an accurate case conceptualization. Jeff Riggenbach, PhD, LPC, says, “It’s like getting lost hiking on a mountain trail with no map. You don’t know where you’ve come from, and you don’t know where you’re going.”

But with the Cognitive Conceptualization Diagram, you can develop a road map for your clients that shows them where their problems came from to set them on a path to success.

Download the worksheet below, and watch this short video to learn how to use this tool effectively with your clients.


Download the Worksheet: Cognitive Conceptualization Diagram


Jeff Riggenbach, Ph.D., LPC, is one of the most sought after trainers in North America in the area of CBT and personality disorders. Over the past 15 years he has developed and overseen CBT based Mood Disorder, Anxiety Disorder, Borderline Personality Disorder treatment programs at two different psychiatric hospitals serving over 3,000 clients at multiple levels of care. Dr. Riggenbach trained at the Beck Institute of Cognitive Therapy and Research in Philadelphia, is a Diplomat of the Academy of Cognitive Therapy, and has presented in all 50 United States, Mexico, and Canada on topics related to CBT, DBT and Personality Dysfunction.


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Wound Care Challenges: Physical Therapy Strategies to Support Healing

Four questions may guide you in assigning etiology of areas of the trunk where moisture may be a contributing factor. Do you know what they are?

Physical therapy modalities of ultrasound, E-stim, and sharp debridement allow for aggressive treatment of wounds. Some deficits may occur in etiology treatment of skin issues traditionally not managed by therapists, such as moisture-associated skin dermatitis.

Four questions may guide you in assigning etiology of areas of the trunk where moisture may be a contributing factor:

  1. Where is the wound located on the body?
  2. What is the appearance of skin/wound?
  3. What is the clinical history?
  4. What are the best treatment options?

Below are examples of the answers to these questions as well as treatment options per four etiologies of the trunk.

Incontinence-Associated Dermatitis

  1. Location
    • Perineal, buttocks, thighs
  2. Appearance
    • Superficial
    • With or without fungal component
  3. History
    • Persistent or recurrent incontinence
    • Fecal and/or urinary
  4. Treatment Options
    • Resolve incontinence when possible through toileting, thickening stool, eliminating aggravating factors
    • Contain incontinence through super absorbent polymer (SAP) briefs/pads
    • Protect/treat skin through emollients (lanolin, mineral oil, petroleum types) or crusting applications (copolymer powders & skin barrier wipes/sprays)

Intertriginous Dermatitis

  1. Location
    • Base of body fold
    • Opposing surfaces of body fold
  2. Appearance
    • Linear opening/break in the skin
    • Shallow kissing lesions
    • No ischemia
  3. History
    • Diaphoresis
    • Trapped moisture
  4. Treatment Options
    • Separate wet skin folds
    • Use wicking products for weeping skin folds
    • Drying powders or skin barrier wipes

Friction

  1. Location
    • Fleshy skin areas in contact with linens, bed, or chair
    • Heel or area that rubs against linen, etc.
  2. Appearance
    • Skin moist or fragile
    • Serous blister over heel
    • No ischemia
  3. History
    • Patient restless
    • Fragile skin
    • Frequent perineal cleansing
  4. Treatment Options
    • Manage moisture
    • Protect skin in agitated patients
    • Emollients or skin protectants for prevention/treatment
    • Early recognition

Pressure Ulcer

  1. Location
    • Over bony prominence
    • Under medical device
  2. Appearance
    • Defined edges
    • Tissue ischemia
  3. History
    • Periods of immobility
    • Compression by device
  4. Treatment Options
    • Redistribute pressure and envelopment within a surface
    • Moisture management via surface & wicking products
    • Debridement
    • Infection prevention/treatment
    • Nutrition

This blog was brought to life by PESI speaker and author Kim Saunders, MSN/ED, RN, CWON®, CFN. Kim Saunders has 18 years as a wound, ostomy, and continence expert in home health, acute care, hospice, and outpatient settings. Kim consults for patients related to wounds, ostomy, and incontinence-associated dermatitis. Her experience includes healthcare system-projects related to bed, stretcher, and wheelchair surfaces as well as system processes for skin and wound issues. She also is a co-owner of WOC Consulting, LLC.


Our new Intensive Skin and Wound Care Course will have you feeling confident treating patients regardless of where you’re practicing right now or where you might be practicing in the future.

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More Than Just Memory Loss: Not all dementia is created equal

By 2050 51% of adults aged 65 or older in the United States will have Alzheimer’s disease if we don’t find a cure. As a healthcare provider, this means that you will continue to see an increase in dementia cases in your practice. These patients are challenging and each case requires care tailored to your patients unique needs. Are you prepared to help them?

Dementia is not a specific disease. Instead, it’s a general term that describes a wide range of symptoms that affect the ABC’s of life: Activities of Daily Living (ADL’s), Behavior and Cognition. With the decline in memory, so too is there a decline in ADL’s. Behaviors are an unfortunate symptom that commonly accompanies the disease, but not all dementias are created equal. Knowing the type of dementia a patient has, can help in tailoring how the disease is treated. It also helps in understanding what types of functional or behavioral symptoms a patient may be expected to have.

Are you up-to-date with the most current dementia types? Are you familiar with what treatments may be the most effective for them? Do you know what medications are FDA approved for Alzheimer’s dementia? Answer the questions below to test your knowledge base.

1. What are the medications that are FDA approved for Alzheimer’s dementia?

There are four different medications prescribed for Alzheimer’s dementia. They include:

  • Donepezil (Aricept)
  • Rivastigmine (Exelon)
  • Galantamine (Razadyne)
  • Memantine (Namenda)

2. Which dementia type is the most common: Alzheimer’s, Parkinson’s Disease Dementia, or Dementia with Lewy Bodies? 

Alzheimer’s dementia is the most common dementia affecting about 5.3 million Americans. Age is the most common risk factor to developing this disease. Alzheimer’s currently affects approximately 1 in 9 adults aged 65 and greater, but it affects 1 in 3 adults age 85 or older. Given older adults are the fastest growing population in the country, if a cure for Alzheimer’s is not found by 2050, 51% of adults aged 65 or older in the United States will have Alzheimer’s disease.

3. Do people with Parkinson’s Disease get dementia?

Approximately 20% of people with Parkinson’s Disease get dementia. It is rare for a Parkinson’s patient to get dementia. This disease is characterized by more of a movement disorder causing bradykinesia (slowness of movement), tremor, hypophonia (a weak and sometimes soft voice), a stooped posture and a mask-like face. Memory stays intact for a very long time though. Of all the dementia types, Parkinson’s Disease Dementia only accounts for approximately 5% of those with dementia.

4. Can you diagnose dementia with a memory screen? 

There is no single test that is routinely done to diagnose dementia. In fact, brain biopsy is still considered the gold standard for diagnosis of Alzheimer’s Disease. However, given the likelihood of complications by such an invasive procedure, most doctors will rely on a careful medical history, a through physical exam, lab tests, possibly request imaging studies, and discuss characteristic changes in thinking as well as day-to-day functional changes that may be occurring. A cognitive screen is just one of many tests that should be done in order to rule in dementia but as a screening tool alone, a “memory test” is a poor individual tool.

5. Do patients with Dementia with Lewy Bodies oftentimes hallucinate?

Patients suspected of having Dementia with Lewy Bodies nearly always hallucinate. Those hallucinations are oftentimes vivid and real enough that even practitioners can be fooled by how true they seem. And although other dementia types can cause hallucinations too, it is one of the most distinguishing features of this disease.

6. What risk factors increase your risk of getting Alzheimer’s Dementia?

Age is the biggest risk factor for developing Alzheimer’s Dementia and although genes do play a role in this disease, it is less significant than what a lot of people realize. Research has shown us that risk factors such as: controlling hypertension and cholesterol; cardiovascular factors; exercising and not smoking; physical factors; managing cholesterol and blood sugar; and maintaining a healthy diet have been shown to be powerfully influential for PREVENTING this disease.


This blog was brought to life by PESI speaker Steven Atkinson, PA-C,  MS.

Steven Atkinson is a Board Certified Physician Assistant specializing in geriatric internal medicine. In his work with older adults, he is directly involved with the unique pharmacological challenges faced by the geriatric population on a daily basis. In addition to patient care, Steven has been an educator at the University of Utah since 1994.His published works include the book, “Geriatric Pharmacology: The Principals of Practice & Clinical Recommendations” as well as materials in several regional publications promoting mental and physical health.


If older adults are routinely under your care, minimize your risk of escalating the problems associated with troublesome, often irrational behavior by viewing Challenging Geriatric Behaviors: A comprehensive and dignified approach to care.

$199.99 now $99 when you use promo code DEMENTIA0416 at checkout.

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*Offer valid through Saturday, April 30, 2016 at 11:59 pm (CST). Not valid on previous purchases or combined with other offers. Select product only. 

How Does the Brain with Autism Work?

Understanding the brain with autism is quite complex, as it is with understanding the brain of any individual, whether that individual is neurotypical or not. The more we know about the brain, the more we will know what interventions are the most effective in working with ASD.

Have you ever wondered how the brain of an individual with autism works? I love studying the brain. It is the most complex organ in the body. Everyone’s brain is different, whether you have autism or not. When it comes to autism spectrum disorders (ASD), we have learned a lot about the brain in the last 10 years. Numerous studies document how individuals with ASD have more neurons in their brains compared to neurotypical individuals. These neurons may be disrupted or impaired, causing overconnectivity or underconnectivity in different parts of the brain.

So what does this all mean?

Several researchers, including Nancy Minshew from University of Pittsburg, have described certain intact and impaired abilities that individuals with ASD have based on brain research. In talking with adults with autism, many have reported similar abilities or impairments.

Those abilities that have been described as Intact include the following:

Basic attention. Basic attention means the ability to attend to one thing at a time. For example, if I had four items on my desk, such as a phone, a pencil, a piece of paper, and an eraser, an individual with ASD would only be able to attend to one item at a time. If attending to the pencil, that individual with ASD would not be able to attend to the phone, paper, or eraser.

Elementary motor. Most individuals with ASD have intact elementary motor skills. Elementary motor is defined as performing one motor skill at a time. If they have any other impairments in motor abilities, this would likely be related to a separate motor disorder.

Sensory perception. Individuals with ASD have intact or even enhanced abilities when it comes to sensory perception. Each individual with ASD is different. Some individuals of ASD may be more sensitive to sounds than lights. Other individuals may be more sensitive to touch then smells.

Simple memory. Individuals with ASD have an intact or even enhanced simple memory. It is important to not confuse simple memory with complex memory. Simple memory can be detailed. Many individuals with ASD can tell me every specific detail of a situation. This is called simple detailed memory, meaning they are attending to one piece of information at a time.

Formal language. We also know that the phonological and grammatical elements of communication, are intact and may be enhanced. This is why some individuals with ASD may talk more formally than neurotypical individuals. If an individual with ASD is demonstrating other communication impairments such as articulation delays or an expressive or receptive language delay, this would be considered a communication disorder that is not related to ASD.

Rule-learning. The rule-learning aspects of the brain are intact or enhanced. This is typically why individuals with ASD are extremely focused on schedules or rules. When a schedule or rule is changed or not being followed, the part of the brain that allows them to be flexible does not work the same as a neurotypical individual.

Visuospatial processing. Most individuals with ASD have intact or even enhanced abilities in visual spatial processing. They are not only visualizing what they hear, but they are processing information visually and spatially. For most individuals with ASD, visual information is their primary language.

Those abilities that have been described as Impaired include:

Executive functioning. Many individuals with ASD have an impairment in the temporal and prefrontal cortex, which is responsible for executive functioning. This higher-level cognitive functioning may include difficulties with inhibition, flexible thinking, problem-solving, planning, impulse control, concept formation, abstract thinking and creativity.

Integrative processing. Any type of integrative or complex processing may be impaired. For example, complex sensory, motor, memory, or language skills are going to be difficult for an individual with ASD. This is because they are only able to attend to one skill or piece of information at a time. Have you ever wondered why techniques that use Applied Behavioral Analysis (ABA) work with the ASD population? ABA breaks down complex tasks into single parts. ABA techniques teach one basic skill at a time, thus setting up the child up for success.

Visuospatial facial recognition. Individuals with ASD have difficulties with facial recognition. If individuals with ASD are only able to attend to one piece of information at a time, they may only be able to attend to the individual’s nose or mouth. In fact, if you ask adults with ASD how they recognize another person, they will typically tell you by another characteristic, such as their hairstyle or their skin tone.

Concept formation. Concept or prototype formation is the ability to organize information into different categories. For example, a neurotypical developing child at the age of two may see a poodle, cocker spaniel, and shih tzu, and call all of them “dog.” In comparison, an individual with ASD might say, “That is a poodle, a cocker spaniel, and a shih tzu.” The ability to create the concept of “dog” does not work the same way in their brain.

Auditory processing. Many individuals with ASD appear to process auditory information in the right hemisphere (occipital lobe) instead of the left hemisphere, which means they are processing auditory information visually. I have heard many individuals with ASD say, “I see in pictures.” This now makes sense. If an individual’s primary language is visual then it would be helpful for us to talk less and use more visuals. That is why using techniques like the picture exchange communication system (PECs) is helpful in teaching individuals with ASD.

Understanding the brain with autism is quite complex, as it is with understanding the brain of any individual, whether that individual is neurotypical or not. The more we know about the brain, the more we will know what interventions are the most effective in working with ASD.


This blog was brought to life by PESI speaker and author Cara Marker Daily, PhD.

Cara Marker Daily, PhD, is a licensed pediatric psychologist with over 20 years of experience providing assessment and treatment for children with autism in the home, school, hospital, and community settings. Dr. Daily is the president and training director of Daily Behavioral Health, a leading behavioral health provider in northeast Ohio specializing in assessment, consultation, and treatment of autism, anxiety and disruptive behavior disorders. She is also the founder and executive director of the Building Behaviors Autism Center, a nonprofit organization that provides free and reduced cost applied behavioral analysis services to families of children with autism spectrum disorders.


Read more from Dr. Daily in her newly released book “The Key to Autism: An Evidence-based Workbook for Assessing and Treating Children & Adolescents“.

 

 

 

The 3 Most Important Questions When Treating a Wound

Assessing a wound is never just about the ‘Polaroid’ picture. The skin being the largest organ, doesn’t fail on its own. It is affected by other factors. Thus, when treating a wound, start with 3 important questions…

Assessing a wound is never just about the ‘Polaroid’ picture. The skin being the largest organ, doesn’t fail on its own. It is affected by other factors. Thus, when treating a wound, you need to start with 3 important questions:

1. What is the wound etiology? Four examples can occur on the perineal/sacral/trunk area of the body and can be confused when assigning etiology.

  • Pressure ulcers present as well-defined edges caused by an ischemic injury to the tissue over the bone or under a medical device. They are bottom up tissue injuries that usually take longer to heal than superficial top-down injuries.
  • Moisture-associated skin damage occurs peri-stomal, peri-wound, incontinence-associated, or intertriginous dermatitis (skin folds). This top-down, irregular-edge skin damage occurs from hyper-hydrated skin. Primary goals including moisture containment and prevention/treatment of skin.
  • Friction is top-down superficial skin damage caused by the skin rubbing against something else. It can present like a blister from a shoe, or it can present initially like a patchy, irregular-edge appearance on the fleshy part of the buttocks as they rub on the bed-sheet.
  • Shearing is bottom-up damage caused by blood vessel distortion. It presents with irregular edges, often linear in the direction of the damage, and is the culprit of undermining in pressure ulcers.

2. The next question should focus on the patient as a person: What are the ‘life goals’?

  • Is the patient palliative care or hospice? If so, your goals should focus on quality of life: minimize trauma, control odor, manage excess exudate, prevent deterioration & infection, and optimize pain management.
  • There are many topical wound products that can assist in this management to support any systemic medication needed.

3. Thirdly, what are the wound healing goals (comfort, maintenance, healing)?

  • Comfort is the usual goal at end of life. Focus on goals for palliative care, and keep wound care simple.
  • Maintenance is the goal when healing is unlikely because we are unable to correct the etiology. Focus on preventing infection and monitor wound presentation. Manage wound exudate. Use passive dressings such as alginates, foams, gels, etc.
  • Healing is the usual goal with a comprehensive approach of etiology, systemic support, and topical therapy per wound presentation. Measure weekly and consider active therapies that change the tissue, add a matrix, or promote angiogenesis if wound size doesn’t progress by 30-40% in 3-4 weeks.

Of course there are more questions in the assessment of a wound and the etiology work-up. However, these three questions are foundational in the next steps of diagnostics, topical and/or systemic treatment, and possible referrals.


CASE EXAMPLE:  A 76 year-old man with a sacral stage IV pressure ulcer is a full code. Diagnostics reveal he has sacral osteomyelitis. The patient does not desire surgery or antibiotics intravenously. He is not palliative care. His wound goals are maintenance because wound healing is unlikely due to the inability to correct/treat the osteomyelitis. Thus, our goals are to prevent symptomatic infection (pain, induration, fluctuance, odor) through passive dressings that manage drainage and address local bacterial count as needed (methylene blue/gentian violet dressings, silvers, manuka honey). Contraindicated active/adjunct therapies include negative pressure wound therapy (angiogenesis), bioengineered skin grafts, or collagen products (matrix and tissue changes). Monitor wound presentation and alter topical wound dressing as needed.


Always remember…

Skin and wound assessment can be challenging and rewarding at the same time. The wound bed and skin presentation will give you hints as to its needs; You just have to be able to interpret the presentation and know the products that will help you achieve wound bed homeostasis.


This blog was brought to life by PESI speaker and author Kim Saunders, MSN/ED, RN, CWON®, CFN. Kim Saunders has 18 years as a wound, ostomy, and continence expert in home health, acute care, hospice, and outpatient settings. Kim consults for patients related to wounds, ostomy, and incontinence-associated dermatitis. Her experience includes healthcare system-projects related to bed, stretcher, and wheelchair surfaces as well as system processes for skin and wound issues. She also is a co-owner of WOC Consulting, LLC.


Our new Intensive Skin and Wound Care Course will have you feeling confident treating patients regardless of where you’re practicing right now or where you might be practicing in the future.

LEARN MORE

WoundCourse