Atypical and Complex Wounds

By Cathy L. Harmon, DNP, MSN, FNP-BC, CWON, CFCN

The impact of diabetic foot wounds is extensive. Diabetic foot ulcers (DFUs) are a major concern among those with diabetes. Research estimates that 25% of adults with diabetes may suffer a DFU sometime in their lifetime, with 20% of those requiring amputation.¹ It is also estimated that DFUs cost around $1.4 billion for inpatient care alone.¹

By Lauren Lazarevski, RN, BSN, CWOCN

Up here in Western New York, we are still “digging out” – literally and metaphorically - from the historic blizzards and freezing temperatures that have hit our area. While we are no strangers to snow and subzero temperatures, the rapid deterioration seen in our recent storm posed a swift and formidable risk to the many residents who quickly found themselves stranded. Predictably, we still are seeing an increase in frostbite cases related to the weather event. I’ve summarized the guiding principles we’ve used to develop treatment guidelines for our patients suffering from the unfortunate effects of frostbite, but first, below is some background on this condition.

The presence of more than one chronic condition in an individual is often referred to as comorbidity. Various comorbidities can interfere with, or inhibit, wound healing processes. These conditions are associated with complex management, economic burden, and poor outcomes. Some of these obstacles to healing include nutritional abnormalities, aging, diabetes, and infection to name a few. The prevalence of such comorbidities in patients with complex wounds reinforces the importance of identifying these conditions and finding ways to mitigate the risks they pose to wound healing.

Vascular ulcers are wounds on the skin that form as the result of abnormal blood circulation in the body, including arterial and venous etiologies. Estimates suggest 3-5% of those over 65 in the United States have a vascular ulcer. Of those with peripheral arterial disease, approximately 20-70% have chronic wounds, according to data up to 2018. Since arterial ulcers may be underdiagnosed, certain experts theorize that the number of chronic wounds developed due to arterial insufficiency is higher in reality.

Severe burn wounds are among the most debilitating injuries because they can significantly affect the entire body. The body’s inflammatory response to a severe burn injury can lead to fluid loss, dangerously low blood pressure, and shock. The risk of infection is also elevated in patients with severe burn wounds. Therefore, prevention of these complications is a key component of care for these patients.

Surgical wounds originate when a surgeon cuts into tissue with a surgical tool, such as a scalpel. The size and placement of a surgical wound will depend entirely on the procedure performed due to varying incision requirements.

Regardless, most surgical interventions aim for wound closure with primary repair. Tissue edges are typically brought together and held in place by various modalities, such as sutures or staples. However, this result isn’t always the case, as some wounds may be left open to heal secondarily or may fail to heal primarily. This piece will discuss the surgical wound timeline, various complications of a surgical wound, signs/symptoms of infection, along with the recovery process for patients.

Acute wound: An alteration in skin integrity, such as a simple laceration or a surgical wound, that typically moves through the healing process and heals in a predictable timeframe without complication. An acute wound results from a documentable event with the assumption that it will progress normally through the 4 phases of wound healing.

Jeffrey M. Levine, MD, AGSF

I was asked to perform a wound consult on a newly admitted resident to a post-acute unit of a nursing home. She rested quietly with a barely touched breakfast on her bedside table. Her aide had tried to feed her, but she accepted only small spoonfuls of oatmeal and a sip of orange juice. She came to our facility after a long hospitalization for COVID-19–related complications, including pneumonia, kidney failure, and septic shock that required pressor agents. While in the ICU on a ventilator, she developed a pressure injury. At 86 years old, her transfer papers revealed feeding tube refusal and a do-not-resuscitate (DNR) order.

Bioburden: Normally defined as the number of bacteria living on a surface that has not been sterilized. The term is most often used in the context of bioburden testing, also known as microbial limit testing, which is a quality control test performed on medical devices and pharmaceutical products.

Wound healing is a complicated process that restores the skin's barrier function to prevent further damage or infection. The healing process normally progresses through 4 phases: hemostasis, inflammation, proliferation, and remodeling. However, a chronic wound may result when a wound fails to progress through the normal phases of healing.