Wound Care
If you have a wound such as as a leg ulcer, pressure injury (pressure ulcer/sore), or slow-to-heal abdominal wound, read on. If you are a healthcare professional, there are downloadable resources at the bottom of this page.
Wounds heal by:
stopping any bleeding (forming a clot) if necessary,
reacting effectively to invasion of germs (inflammatory response),
laying down new proteins and growing new blood vessels (proliferation), and
remodelling.
Sometimes a wound may get stuck in the inflammatory part of the healing process and become a chronic wound that doesn't show any progress toward healing, even after 4 weeks.
Wound healing and moisture
Cells cannot produce proteins or divide in a dry environment. All biological processes need moisture. Look at how much life exists in a desert, compared to a moist and prolific rain forest. The other side of this delicate balance is a wound that is soggy and wet—just like a swamp, the biology within it is waterlogged and smelly. It is important to get the balance right, not always an easy task. Modern dressing products are designed to do this, but there can be an art to the choices made.
Wound care needs to start with efficient first aid to stop bleeding. Once this is done, there needs to be effective removal of dirt and debris, followed by stitches or adhesive strips to closely align the edges and prevent shearing. Some head wounds can be sealed by tying a few hairs from either side of the laceration together. There is a special sterile wound glue that rapidly sets, which can be used for minor cuts, providing they are not near the eyes.
Non-traumatic wounds are often termed chronic, even though some of them occur quickly and heal in a timely manner. Traumatic wounds can become chronic, particularly in people with diabetes. The word chronic in relationship to wound care means that whatever type of wound it is, there has been no progress toward healing within 4 weeks.
Examples of non-traumatic wounds are:
Leg ulcers caused by inadequate blood return from the legs,
Pressure injuries caused by pressure and/or shear,
Moisture lesions from incontinence,
Secondary skin infection (eczema, psoriasis, insect bites),
Cysts, abscesses and surgical excisions, and
Cancers.
Wound and skin assessment
An assessment should be done by someone who is knowledgeable about wound care. Knowing how a wound has occurred will help formulate a plan of care that will bring it to a timely closure. This is particularly important with pressure injuries, as merely addressing the wound care will not help. The pressure needs to be offloaded by regular position changes and use of redistribution surfaces and/or assistive devices. Some of the simplest items can assist with preventing pressure injuries—for example, a wall bar or side rail and a “slippy bag” (my favorite, see pressure injury prevention section). Issues relating to shear, moisture, nutrition, and mobility all need to be carefully examined.
Full lower-leg assessment for leg wounds is another example of the importance of a full and thorough assessment, as the most effective plan of care for wounds caused by venous disease is very different (and damaging) if the wound is due to lower extremity arterial disease or diabetes.
Skin lesions from dermatological conditions and cancers may require a more detailed assessment (biopsies) and medical interventions, rather than specific dressing choices.
Underlying conditions such as nutritional status, Crohn's disease, rheumatoid disease, and most of all diabetes can all impact both chronic and acute wounds, preventing them from healing and increasing the possibility of infection.
A wound assessment needs to look at where the wound is, the shape, and size. Having the person in the same position for measuring each time helps to ensure measurements taken reflect real changes. There are many ways to measure wounds; consistency is more important than exactly how.
The assessment should describe:
Severe infection of a previously small wound. The skin is red, hot, swollen, and painful. Note the dark purple area on the foot. This is a life-threatening necrotizing fasciitis. The patient will have severe pain, a high temperature, and become septic.
The presence of dirt, debris, foreign material, dead tissue, and structures such as tendon, bone, or new healthy granulation tissue within the open area
The amount, color, and odor of the exudate
Whether the edge of the wound is steep, flush, or proud
Whether the surrounding skin is healthy, or if it is painful, appearing red, angry, hot, inflamed, and swollen, indicating infection.
Culturing a wound
All open wounds will grow a mixture of bacteria, so wound swabs are of limited value. Where infection is suspected, the wound should be cleaned first and the reddest, most inflamed portion should have the swab applied very firmly in different directions within a 10 cm square.
How to plan a wound care regimen
The essential components of a wound care regimen are listed below, and each component should be considered for all chronic wounds, even though some may not need to be addressed.
Cleansing: Showering a wound may be appropriate, provided the water is OK and others using the shower are not at risk from contamination. Generally, wounds are cleaned with normal saline irrigation. Hydrogen peroxide damages healing tissue, as do many antiseptics and antibiotic creams.
Debridement: Getting rid of debris from within a wound is important as it harbors bacteria.
Addressing bioburden: Bacteria quickly colonize wounds, not necessarily causing any problems at all. However, an over-growth of bacteria may keep the wound off balance and delay healing. When this occurs, the wound may look shiny, delicate, and bleed easily. If bacteria really take hold, an active infection may occur (where the body launches a response, evident from increased pain, exudate, pus and a fever). Wound infection often will require a course of antibiotic, as the application of antibacterial dressings and even antibiotic ointments will not penetrate the invaded tissue.
Actively manage wound bed: There are some types of collagen and growth factors that are thought to enhance the healing process, that can be used on the wound bed. The wound has to be moist and mostly clear of debris for these products to work effectively.
Moisture balance: Dressings that donate moisture and hydrate wounds are usually amorphous (in a tube) gels or gel sheets. Dressings that are adhesive (and semi-occlusive) tend to keep a wound moist, and many are designed to absorb up to a moderate amount of exudate. Keeping the local wound conditions right for healing. Fluffy, absorbent materials and powders absorb excess exudate, but if covered with a semi-occlusive dressing, the wound may become macerated (soggy) if the exudate level is very high.
Negative Pressure Wound Therapy (NPWT) is an extremely effective way of maintaining the moisture balance of a wound that may also promote healing. When used by experienced professionals, problems associated with use are minimized.
Protect the skin around the wound: Exudate can cause skin irritation, as can some adhesives and Negative Pressure Wound Therapy systems.
Securing a dressing: Adhesive style dressings are best, provided the surrounding skin is OK and the wound not too wet. Generally, dressing should be fully secured, not just "picture framed.” Below the knee blood supply and venous drainage needs to be addressed.
Venous drainage (particularly in the legs) can be so poor that a wound won't heal. Mild to high compression wraps need to be considered for such wounds, provided there is no arterial disease. Elevation also reduces swelling and pain and will improve healing potential.
Other components of wound care are not related directly to the type of dressing, and these are: Infection, pain, nutrition, offloading pressure, educational needs, arterial blood supply, psychological issues and the affordability of the care needed.
Referrals that may be needed: Urgent surgical referral is needed if the wound is infected and/or with pain disproportionate to wound size. Dermatology will need consulting if it seems to be more of a skin issue (possible cancer, pemphigus, allergy). Vascular referral for arterial issues and podiatrist or orthotist for diabetic foot problems. Physical and occupational therapy have a big role to play and are part of the best case scenario where wound care clinics bring all the specialties together with nutritionists and wound care nurses in a multi-disciplinary team to optimize outcomes.
Some investigations that may need: Basic blood work, both as a baseline and to rule out infection, diabetes, and some other conditions, may be necessary. If the wound is on the leg, an Ankle Brachial pressure Index (ABI) indicates whether the optimal treatment of high compression, multilayer wraps can be utilized. Other vascular tests may be needed to show that blood supply to the area is sufficient.