Last month I discussed pressure ulcers so I will continue with the description of other types of wounds common to the Long Term Care facility (LTC). Wounds are classified based on cause and location. Ulcers can be venous, arterial and diabetic/neuropathic. Fungal dermatitis is common in obese residents and can become ulcerative if left untreated. Various surgical wounds and stomas can also be cause for concern.
Ulcers are usually caused by circulatory insufficiency, both arterial and venous. In arterial insufficiency, blood supply to the lower extremities is greatly diminished. These ulcers usually occur in the distal areas of the lower extremity including the toes, top of the foot and the outside edges of the foot. However, they may also occur in the heel and ankle.
Residents with a history of atherosclerosis, peripheral vascular disease (PVD), heart attack or stroke are very susceptible to arterial insufficiency ulcers. The wound bed is usually dry, pale, deep based and painful. The pale color is due to lack of oxygen. The surrounding skin is dry, shiny, pale and without hair. Pedal pulses are frequently non palpable.
Venous ulcers usually occur in the lower and back portion of the leg. They are caused by circulatory insufficiency. When the one-way valves in the veins do not function properly, there is an accumulation of the breakdown products of hemoglobin due to the venous stasis. The wound bed is usually superficial, red in color and moist. The edges are irregular and the surrounding skin shows induration and edema. Drainage can be variable based on the amount of edema and the presence of infection. Dilated varicose veins may also be present. Symptoms of venous ulcers can be relieved with elevation, but not eliminated.
Diabetic/Neuropathic Ulcers: Longstanding diabetes mellitus, especially if poorly controlled, has severe consequences for the lower extremities which often result in ulcer formation.There are changes to the microvasculature and accompanying nerve damage (neuropathy). They often occur in the sole of the foot in areas of constant repetitive pressure and because of the neuropathy, they are often painless. The wound bed can be covered with fibrotic tissue called callus. The ulcer can be deep and can penetrate the bone resulting in osteomyelitis (bone infection) adding to the prolongation of the healing process.
When a resident is admitted to the LTC facility with an existing wound, obtaining a good medical history is of the utmost importance. Details of how the wound started, how long it has been present, treatments used and the resident’s response to the intervention should be obtained and documented. If non compliance with care has been an issue, the cause should be identified if possible. As information is gathered, nurses should never be judgemental about the patient’s actions or inactions.
Wound healing can occur by two possible mechanisms. Scar tissue formation and regeneration. The depth of the wound will determine which mechanism will occur. Wounds also heal by primary and secondary intention. Those healed by primary intention are surgically closed. With secondary intention wounds are left open and heal by granulation, contracture and epithelialization. It takes much longer for a deep wound to heal than a superficial one.
Wound cleansing is very important as it removes non-adherent debris from the wound bed. This prevents infection and promotes healing. Follow the physician’s orders for products to use but normal saline at room temperature can be very effective. During cleansing the surrounding tissue should be protected from trauma.
Wound treatments should be performed at a time of the day when the resident is least fatigued (get the treatment done before the resident goes to therapy). Pain assessment should also be done prior to dressing change and pain medication should be administered at least 20 minutes prior to commencing the treatment.
Debridement is very important and there are many methods to this procedure. Necrotic tissue can adhere to the wound bed causing delay in the healing process. This is more common when the moisture level of the wound decreases (It is important to keep the resident well hydrated). Debridement is necessary to allow healing to continue. The type of debridement is determined by the amount of necrotic tissue present, the location of the wound and the general condition of the resident.
Autolytic debridement occurs when the body’s own physiological process removes the necrotic tissue. To enable this to occur, it is important to utilize the proper dressing. Hydrogel dressings are most often used. Amorphous hydrogels are effective in digesting the necrotic tissue. Hydrocolloids are also beneficial in their ability to absorb drainage while keeping the wound bed moist.
Enzymatic debridement involves the application of concentrated, commercially prepared enzymes to the necrotic tissue. These do not harm healthy tissue.
Mechanical debridement is achieved by applying wet to dry gauze dressings to the wound, usually with normal saline. Studies have shown that healthy viable tissue can be removed as well as the necrotic tissue. Whirlpool therapy can also be used for this type of debridement.
Chemical debridement involves the use of chemical agents. Dakin’s solution in a 0.25% strength is most often prescribed. I have also seen Iodine in use but appears to have a drying effect on the wound bed. Surgical debridement is rarely an option for LTC residents as due to their compromised state, they are not good candidates for such invasive procedures.
Wound dressings can be divided into two categories: those placed inside the wound and those placed as a cover over the wound. Dressings protect the wound from the environment, provide a barrier to prevent infection, maintain moisture to the wound bed, curtail fluid from areas of tunneling and absorb drainage. Dressings that add moisture to the wound bed are referred to as hydrating and those that remove excess exudate from the surface of the wound are absorptive.
Hydrocolloid dressings are an occlusive dressing that prevents secondary infections. They are used for wounds with a large amount of drainage. After absorption they become gel. They are comfortable but must be secured with another dressing.
Hydrogel dressings are usually applied to superficial wounds with limited drainage. They have a hydrating quality which promotes healing.
Foam dressings protect wounds at risk to further damage from shear and can be used with topical treatments. Foam provides thermal insulation, conforms to body shape and leaves no residue in the wound.
Silver Impregnated dressings are a treatment option for infected or heavily colonized wounds. They have an antimicrobial effect and have shown to reduce bacterial count in wounds. They do not adversely affect healthy tissue.
Calcium Alginate dressings are very highly absorptive. They are a good choice for bleeding wounds as the aid in hemostasis.
Composite dressings are a combination of more than one substance and fulfill many helpful functions in wound care. They have an effective barrier against bacteria and have an absorbent layer.They are comfortable and available in many shapes and sizes.
Gauze dressings are rarely used at present. They have poor absorptive qualities and are less effective in coping with drainage. They also have to be changed frequently.
Some dressings incorporate collagen which is an important protein involved in wound healing. They are absorptive while keeping the wound bed moist and are easily removed.
Failure of a wound to heal may be due to systemic issues, such as, ischemia, infection and continuation of the causative factors. These must be addressed first to achieve optimum wound healing.
Whatever type of dressing is prescribed, it is vitally important that the wound care nurse follows the manufacturer’s instructions explicitly. An evaluation of the products in use and the progression of the wound should be completed at each dressing change. Clinical signs of improvement should appear between two to four weeks.
Documentation of wounds should be frequent and concise. Only approved abbreviations should be used and all dates and times should be accurate, and the name of the clinician providing the care should be included.
(Last year I took a took a wonderful informative course on wound care provided by NetCE. I learned so much from it. It was a three part course, was reasonably priced and awarded 20 CEUs. I would recommend it to any nurse who is involved in wound care).
