A vast percentage of wounds become chronically stalled because of mixed etiology and other underlying comorbid medical conditions. This means the wound is multifactorial, and using a singular approach won't be enough. Lower extremity wounds, for example, can have diabetes, venous and arterial issues, and pressure all as factors playing into the same wound. Chances are, all factors need to be addressed to obtain complete wound closure.¹ Looking at all the factors that may be impeding wound healing (including psychological and financial needs) often helps develop a goal for the patient that is both appropriate and realistic.

Compounding Factors That Lead to Complex Wounds

Just in the lower extremity, more than 25% of wounds have venous disease and arterial disease as compromising factors.² Someone with venous disease should elevate their legs and wear compression; however, if they have arterial disease with moderate to severe impairment, then elevating the legs is most likely painful. Adding compression may compromise whatever arterial blood flow is actually arriving to the lower extremity by acting instead as a tourniquet. How do you navigate successfully around so many barriers to assist the patient to heal or at least maintain their current wound?

Complex Wound Case Study

At an advanced wound center in Kansas City, a patient with a crush injury to the foot needed hyperbaric oxygen therapy twice a day for the first week or two to have any hope of limb salvage. Angiogenesis had to be created as quickly and efficiently as possible. The patient was a long-time two-pack-a-day smoker. It was quite possible he was going to lose his foot because of the injury. The attending clinicians sat down with the patient at the direction of his treating physician and explained that one cigarette, one, would negate the effects of the hyperbaric oxygen treatment. His treating physician would not order the treatment unless the patient agreed to stop smoking immediately while undergoing this therapy. The therapy cost more than $800 per day at the time.

The patient agreed, and his therapy was initiated using a monoplace chamber. On day four, the patient returned, and the clinician could smell cigarette smoke. The patient was asked whether he was smoking again. He admitted he had smoked a cigarette right before coming in for his treatment. The clinician reminded the patient that one cigarette negates the effects of hyperbaric treatment and each treatment was roughly $800. Additionally, by returning to smoking, it could also cost him his foot. The patient was in his mid-40s. He agreed to stop smoking and stay off the cigarettes until after his foot was healed, and he did. The patient kept his foot, and his injuries went on to heal just fine. The crush injury was preventing blood flow, but so was his smoking. By eliminating one barrier, the clinicians were able to create blood flow and salvage the foot.

Conclusion

Good wound care starts with a thorough evaluation of underlying clinical conditions along with risk factors. Does the patient smoke? How is their relationship with food? What is their financial status? Can they afford dressings? Are they able to attend appointments? Can they take time off from work (or are they currently taking time off)? Can they follow directions, and do they have the desire to follow the treatment plan? If surgical intervention is needed, are they a surgical candidate? Is the wound healable, or would maintenance or palliative goals be more appropriate and reasonable? Are they psychologically prepared to do what it takes to heal? Most patients with wounds do better when they understand they are in the driver's seat and they have options. By patients knowing which factors can be controlled and which factors are beyond control, they can be an important asset in clinical decisions. Patient education is a vital part of the wound healing process, especially when it comes to understanding and overcoming the factors that can contribute to a chronic wound.

References

1. Centers for Medicare and Medicaid Services. Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual. Version 1.16. M-6. Woodlawn, MD: Centers for Medicare and Medicaid Services; 2018 .

2. Hedayati NC, Carson JG, Chi YW, Link D. Management of mixed arterial venous lower extremity ulceration: a review. Vasc Med. 2015;20(5):479-486.