Wound Care Refresher for Retail Health Clinicians

Jenna Herman, DNP, APRN, FNP-BC
Thursday August 10, 2017
The skin is the largest organ in the human body and has many functions, including defending against bacterial invaders and maintaining thermal regulation. It also aids with recording sensations and controlling water content. The skin is the first line of defense against the external environment.11 However, sometimes an external force is enough to break the skin and cause damage or injury. One example is a wound that penetrates the skin or other tissues in the body in the form of scratches, scrapes, punctured skin, or cuts. Causes may include inadvertent injury, outcomes from stitches, surgery, and chronic disease. Wounds may be superficial or deep. Superficial wounds occur when the epidermis is damaged and are influenced by their reason and location. They may not be typically severe, but they must be kept clean to decrease infection risk. Deeper wounds inherently need additional treatment to prevent function loss and infection because of injury to underlying structures.8

The care of wounds and treatment plans are multifaceted procedures. Professionals who participate in wound care require specific knowledge,6 consisting of anatomy, assessment, and interventions.8 Anatomical knowledge is particularly crucial because of the rich vascular and connective tissue involvement in the extremities, which could have calamitous consequences if proper technique isn’t used.5

WOUND HEALING
The wound healing process is a well-designed series of biological phases11 and can be split into 3 stages. The first stage is called inflammatory or hemostatic, next is proliferative, and finally, remodeling. During the first 2 to 5 days after a wound is sustained, which encompasses the inflammatory phase, hemostasis happens with vasoconstriction, as well as aggregation of both platelets and thromboplastin to help create a clot. In addition, phagocytosis and vasodilation transpire as a result of inflammation. Through the next 5 to 21 days, during the proliferative phase, several processes occur. Fibroblasts generate a collagen bed, supplant the defect, and create capillaries at the injury site. Simultaneously, wound edges begin to contract, further decreasing the defect with epithelialization. During epithelialization, new epithelial cells travel to the site of injury from the undamaged epidermis around it. The final time frame, lasting from 3 weeks to 2 years is the remodeling phase. Fresh collagen appears to intensify the tensile strength, and formation of scar tissue starts, though it has only about three-quarters the strength of the initial tissue.9

The body naturally heals wounds through several stages, but further categorizations can be delineated through outside intervention. These consist of primary, secondary, or tertiary intention.8 When wound edges are closed surgically or approximated, it is known as healing by primary intention. Primary intention wounds have decreased infection risk and mend with the nominal formation of scars.8,9 Some examples include Steri-Strips, adhesives, and sutures.9 If wound edges are not approximated well, tissue decreases. The wound often goes open to allow permeation of healthy granulated tissue to increase the chances of healing. These steps encompass secondary intention mending. Secondary intention wounds have increased infection risk and repair with the formation of scars, compared with healing with primary intention. These types of wounds comprise severe lacerations, burns, and chronic wounds.8,9 Finally, open wounds are those defined by tertiary intention. Edges of these wounds are open, and granulated tissue forms to help in healing and may produce substantial scars. Compared with primary and secondary intention, these wounds have the highest infection risk and necessitate postponed closure. An example of a tertiary intention healing wound is an abdominal one that is kept open at first to drain and is later closed.8 Other types are bites, human or animal, or wounds for which the patient delayed seeking care.9

ACUTE VS. CHRONIC WOUNDS
Acute wounds encompass 2 main types: surgical and traumatic. In 2010, 53 million outpatient procedures and 45 million inpatient procedures were performed in the United States.2 Each time an incision is created, a wound is formed.1 Others include abrasions, punctures, and lacerations. More than 10 million acute wounds were treated in emergency departments in 2006.12

Chronic wounds, by comparison, involve about 6.5 million patients in the United States.1 The mean age of these affected patients is higher than 62, and nearly three-quarters are Caucasian.7 Population estimates of 1% to 2% will have a chronic wound in developed countries in their lifetime.1,7 Specific types of chronic wounds such as pressure, diabetic, and venous ulcers have been further studied in times of their cost. Venous ulcers on the leg are near $10,000 for each episode and cost the US health care system between $2.5 billion and $3 billion. Diabetic ulcers are costlier, at $8000 to $20,000 each time and signify 1 of 5 hospitalizations related to diabetes. Nearly $10 billion is paid out each year related to diabetic ulcers. The most expensive are pressure ulcers, which may cost up to $70,000 to treat each time and $11 billion annually. Chronic wound treatment expenses vary in total, but estimates conclude more than $25 billion to $50 billion is spent annually. This cost is expected to rise quickly because of burdens such as an aging population, health care expenditures, and a worldwide increase in diabetes and obesity. Aside from the cost, many patients reported decreased activities related to daily living, sleep disturbance, mood swings, and pain.1

RISK FACTORS
Acute wounds most often can be traced back to a surgical procedure or a traumatic event. Several well-known risk factors exist for the development of chronic wounds, including advancing age and comorbidities such as obesity, diabetes, coronary artery disease, and peripheral vascular disease.1,6 Patients with chronic wounds have on average 2 comorbidities.6 Unfortunately, 70% of Americans are overweight or obese, and about 23 million, or 8%, are diabetic. About a quarter of individuals who are diabetic are unaware that they have diabetes. There is the lifetime chance that those with diabetes will acquire a foot ulcer.1

Other general risk factors for chronic wounds include anemia, lymphadenopathy, poor nutrition, peripheral edema, radiation therapy, friction and shear, and taking some medications such as immunosuppressants and steroids.5,8,9 Poor nutritional intake may consist of decreased protein and ascorbic acid (vitamin C) intake. Connective tissue disorders such as scleroderma and Marfan syndrome may also increase risk.9 Friction and/or shear in conjunction with pressure increase the risk of a pressure ulcer. In addition to the risk factors above, pressure ulcers are increased in bedridden or wheelchair-bound individuals, or those with reduced sensation or mobility.1

CLINICAL PRESENTATION
Wound treatment begins with a thorough history and examination. The history of present illness should include elements that consist of the injury mechanism and time, the amount of wound contamination, and involved materials during the time of injury such as shattered glass, shredded metal, or wood splinters.9 The history of present illness may be accomplished with one of the well-known mnemonics such as OLD CARTS (onset, location, duration, character, aggravating factors, relieving factors, and severity) or PQRST (provocative or palliative, quality or quantity, region or radiation, severity, timing).13 Other important and pertinent history comprises tetanus immunization status, allergies (principally to antibiotics, local anesthetics, or latex), and medical conditions.9,11 The review of systems should focus on wound symptoms of infection such as fever, chills, pain, odor, color changes, and inflammation.5

Physical examination (PE) should include a focused assessment of the skin; vascular, musculoskeletal, and neurological systems; and lymph nodes. Wound assessment needs to involve its location, the degree of tissue damage (whether partial or full-thickness tissue loss), size (width, length, and depth), a narrative of wound bed character, and exudate description of the amount/type.3,5,9 In addition, PE of the wound should also evaluate for vessel, tendon, nerve, and joint association. Assessment of the vascular system should incorporate capillary refill, skin color, and distal pulse palpation. Musculoskeletal examination needs to consider a movement assessment to define any possible harm that transpired during the injury and potential foreign body (FB) insertion.9 Surrounding lymph nodes must be assessed for any infection signs such as enlargement or tenderness.10 Finally, a neurological exam requires testing of both proximal and distal nerves as well as evaluating two-point discrimination.9

LAB TESTS/IMAGING STUDIES/CONSULTATION
Lab testing is not usually necessary. Swabbing of the wound is not always required, even if the wound is suspected to be infected.5 For severely ill patients, lab tests such as electrolytes, urea, and a complete blood count could be considered.10

Contemplate x-rays to rule out osteomyelitis, and search for a FB as needed.10 Plain radiography detects glass FBs in about 75% of cases, metal in 99%, and wood in 7%. If a FB is suspected and plain radiography did not find it, consider an ultrasound or a computed tomography scan.11

When an injury occurs to underlying structures, such as tendons, nerves, vessels, bones, and/or joints, it may be prudent to keep the wound open at the time of assessment. Consultation with a surgical specialist may be necessary.9

COMPLICATIONS
Wound complications are common and costly. Recurrence rates of wounds can be high. With diabetic ulcers, the recurrence rate is nearly 70%. With each diabetic ulcer recurrence, the risk of amputation increases. Just over 10% of patients with a foot ulcer need amputation of some sort.1

Every wound has the possibility of becoming contaminated9 and developing an infection. Wound infections are one of the costliest consequences after surgery and are the basis for bacteria that increase acquired infections at many hospitals.1,5 Signs and symptoms of wound infection may include discoloration, easily bleeding tissue, slow healing, a strong smell, unexpected pain or tenderness, wound base pocketing, and a breakdown of the wound.5,8 If a FB is retained, it needs to be recognized and withdrawn.9

Another difficulty is the potential of scarring from wound healing, as there can be intense visual and functional outcomes. This drives a $12 billion annual market in the United States.1

Finally, litigation has increased in the past 10 years from wounds such as pressure ulcers. Pressure ulcers can be a major infection source, leading to consequences such as osteomyelitis, septicemia, and even death. The Centers for Medicare & Medicaid Services decreases reimbursement to facilitates for pressures ulcers acquired in hospitals.1

TREATMENT
Acute wounds heal quickly, an average of days to a few weeks. Wounds that develop into chronic ones take more time to mend. In an analysis of data from the US Wound Registry, the mean wound surface area was 19.5 cm2 , about two-thirds of wounds took 15 weeks to heal, and 10% of wounds took 8 months or more.7

Usually wound cleansing uses solution to eliminate superficial debris, microbes, and remnants of dressing materials from the wound bed as well as the surrounding skin on occasion.5 Wound cleansing helps to create an atmosphere favorable for healing.5,9

Dressings remain the foundation of patient management for wounds. A plethora of dressings exist for treatment. The basis for selection is factored according to several elements: a detailed history and PE, desired intervention outcomes, cost, and patient inclination. Wound dressings also support an advantageous mending environment through support of the body’s natural restorative processes. Continuing frequent assessment of both the wound itself and treatment procedure is necessary to determine effectiveness in wound healing.4,5

Debridement is one of the most important interventions in wound care.11 It is defined as the removal of fibrin, foreign material, or infected or devitalized tissue. The body can remove debris and dead tissue through its natural processes, but eliminating too much may slow healing and increase infection risk. Many methods of debridement require specialized techniques and should be done only by an expert practitioner.5

Pharmacological treatment is often unnecessary. Localized infection may require antibiotic treatment for 7 to 10 days. Stronger antibiotics are likely needed for systemic infection.5 Analgesics such as acetaminophen or nonsteroidal anti-inflammatory drugs are often enough to treat pain.10 Nonpharmacological treatments may include nutritional supplementation, timed toileting to help with incontinence, and skin protection with barrier cream.3

For wounds that are unresponsive to the above treatments, hyperbaric oxygen therapy treatment (HBOT) may be helpful. It permits exposure of the entire body to oxygen under increased atmospheric pressure, which increases delivery of oxygen to the wound, allowing quicker healing. HBOT is the preferred treatment for wounds such as soft tissue infections, severe diabetic ulcers, radiation injuries, chronic osteomyelitis, and compromised flaps.8

CONCLUSION
The skin and the human body have many natural processes to reduce and prevent wounds. On occasion, there is an external force such as trauma or surgery that is great enough to cause injury and subsequently an acute wound. Chronic wounds often result from an underlying process such as a disease like diabetes or obesity. A careful look at the patient’s history and a thorough physical assessment are essential with wound examination. Taking care of wounds is dynamic and complex because many treatment choices exist and the plan of care should be as individualized as the patient.


Jenna Herman, DNP, APRN, FNPBC, is the family nurse practitioner program coordinator and an assistant professor at the University of Mary in Bismarck, North Dakota. Her clinical practice includes the emergency department at a level II trauma center, correctional medicine, and locum tenens in primary care clinics, nursing homes, and hospitals across rural North Dakota.

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