Delayed wound healing: how did it start, what are we doing to prevent delay, and what could we be doing differently when delay is noted?

If you have worked in wound care a long time, there are those wounds we recall that were a real puzzle. Why wouldn't they heal when we were doing everything right? Sometimes it is as simple as finding out that the client has been sleeping in a recliner instead of a bed, in which case edema and sacral wounds will suffer. Or perhaps that the patient has resumed smoking now that their mobility allowed getting outdoors. A Symposium on Advanced Wound Care (SAWC) event that has been a favorite of mine is "CSI for Wounds". A rule of thumb advocated in this session and in other sources is that if the wound hasn't healed in 6 months, biopsy.

Investigating Why Wounds Won't Heal

So when I have a new client with a long-standing wound, what I can do depends on the setting that I am working in. If it is a wound clinic, then obviously we can direct where and when the wound investigation goes. Right now I am in an inpatient rehab facility. Most patients are here for reasons other than their long-standing wound. I look at the wound from a new perspective and discuss with client and family what has been tried in the past, who has been treating the wound, lifestyle, activities, sleeping habits, pain, health history, pets, work, and when the wound started.

The start:
Many times I find that a change in the patient's life can lead to the wound onset. Perhaps a new job means more sitting or walking. Edema from sitting more can lead to wounds if not just the edema itself. Further questions about health procedures, injuries or family history can tease out a possible lymphedema or venous stasis diagnosis. Doppler studies can rule out an acute DVT adding on to the edema/wound. Wounds on the feet lead me to look at shoes and foot contours. New or non-adherent patient's with diabetes may not be taking care of their feet or have adequate knowledge of foot care. Surprisingly, this rehab setting may be the first time patients have been told or are ready to listen to the need for good foot care (seeing individuals with amputations in the rehab gym can do that…) Providing offloading shoes and podiatric referral on discharge can set them off in the right direction. A foot wound that becomes markedly worse in a few days has led to arterial studies on more than a few occasions and a diagnosis of arterial versus acquired pressure ulcer.

What we are doing:
My patients mostly come from acute care hospitals with or without wound orders. Preventing wound infection or dehiscence as well as pressure ulcers are main goals here. So is the wound draining too much and at increased risk of infection or dehiscence? A negative pressure wound therapy device with some silver tossed in could prevent a sad future and unhappy surgeon. Is the brace or splint not fitting well and putting excessive pressure on boney areas? An orthotic consult or visit to the surgeon may be in order. Some well-placed padding in the splint may be all that is needed to offload the area. Weak hip flexors may require floating heels or a podus boot if the ankle is too weak to prevent heel pressure ulcers. Fragile skin from age or a lifetime of prednisone leads to daily moisturization, sleeves and long pants to prevent hard-to-heal skin tears.

What could be done differently:
Knowing when to change what is being done for an incision or wound is also key. Sometimes the moist wound healing needs some help to jump to the next stage if a stall happens. Talking to the dietitian may get more protein added to the diet. The nurse may indicate that blood pressure or glucose has been fragile. An undiagnosed adhesive allergy or reaction to the staples needs a change in direction. Adding collagen to the wound can be just the boost a wound with healing delay needs. Most of all, it seems if everyone in the facility is on-board—physician, nurse, therapists, patient care technician, patient, dietitian—the wound does better.

About the Author
Janet Wolfson is a wound care and lymphedema educator with ILWTI, and Lymphedema and Wound Care Coordinator at Health South of Ocala with over 30 years of field experience.