by Holly M. Hovan MSN, APRN, ACNS-BC, CWOCN-AP
By Martin D. Vera, LVN, CWS
We hear this all too often, but it is so true: it takes a village to heal a wound. A village that's on the same page, with a thorough understanding of gaining progress and obtaining positive outcomes for the patient and removing the barriers to wound healing.
As mentioned in my previous post on skin anatomy, patients over their 6th decade of life are already experiencing the changes in skin structure that happen naturally as we age. With that alone, we are already swimming against the current. Now, factor in a patient with a history of a stage 3 sacral pressure injury that has since healed. The skin tensile returns to, per research, only as high as 80%. If that same area re-injures with another stage 3 or 4 pressure injury, once it completely heals the skin tensile strength is even lower.
So, factor in the changes in skin with age and the higher risk of re-injury due to lower skin tensile strength after initial injury. That is just one scenario. Clinicians understand this ongoing battle. There are systemic and local factors that affect healing. Let's look at the different types of factors, how they affect or impede healing, and how we can—with the village or SWAT team—identify them, manage them, and hopefully break through barriers to achieve closure of chronic wounds.
Local Factors Affecting Wound Healing
First, let's examine the local and systemic factors that create wound healing barriers. Once we've covered the differences between local and systemic factors, only then can we discuss how to manage them. There are no "easy to manage" factors. They all come with challenges. Yet, as savvy wound clinicians (with the help of the SWAT team), we will be able to identify various factors and work to manage them to prevent any further delay in wound healing.
Local factors are those that directly influence the characteristics of the wound itself:
- Pressure: Unrelieved pressure results in tissue damage over bony prominences or non-pressure areas by an external force. Implement turning schedules, instruct the patient, family, and staff on proper use of pillows, and assess for external sources of pressure such as Foley catheters, monitors, remote controls, spoons, forks, etc.
- Dry environment: The research of Dr. George Winter suggests that moist wound healing is 50% faster than that of a dry environment. Use moisture retentive dressings to maintain wound moisture and enhance cell migration. Evaluate products every 2 weeks to prevent maceration and or desiccation.
- Incontinence: Patients with incontinence should be provided proper skin care and education. Moisture barriers must be in place and evaluated with daily use. Due to difference in pH balance and content, urine and fecal matter will alter skin integrity.
- Edema: Uncontrolled edema is secondary to venous or arterial insufficiency. Perform a vascular consult and assess circulation. Is the patient and appropriate candidate for compression garments?
- Non-viable tissue: Non-viable tissue harbors bacteria, so assess for the proper form of debridement and consult the SWAT team. Wounds must be cleansed with the proper PSI. Research indicates 4-15 PSI is appropriate to cleanse a wound from local debris without harming healthy tissue. Forms of debridement include: autolytic, mechanical, enzymatic, conservative sharps, surgical, and biological (among others). Determine which form better suits the patient (and will be most tolerable).
- Temperature: Wounds must be kept at a constant temperature. When providing wound care, removing the dressing, cleansing the wound etc., we expose the wound to ambient temperature. Vasoconstriction occurs and wound healing is delayed, taking up to 4 hours and even longer after covering the wound again for wound to reach body temperature and wound healing process to continue. Assess need of dressing changes, assess for proper dressing selection.
- Poor blood supply: When blood supply is abnormal, wounds are deprived from proper nutrients, affecting cell activity and resulting in further wound healing delay.
- Poor oxygen supply (hypoxia): Decreased oxygen results in delayed healing as well. Cells become senescent or sluggish. Proper oxygen and blood flow play a huge part in wound healing.
- Foot deformities: Paraplegia, hemiplegia, quadriplegia, or presence of Charcot foot may cause undesired pressure to affected areas. Assess for proper offloading and use of orthotics if possible.
- Alcohol consumption: Alcohol consumption impairs wound healing and increases the incidence of infection, not to mention that over half of ER trauma cases are related to acute or chronic alcohol abuse.
- Smoking: Smoking causes vasoconstriction, resulting in delayed healing. Encourage the patient to quit—which is ideal—and at least assist in weaning down the amount of cigarettes smoked per day.
Systemic Factors Affecting Wound Healing
Systemic factors include the overall health and disease processes of the individual that affect his or her ability to heal properly.
- Age: Skin changes as we age. Healing is slower and skin injures easier.
- Bioburden: All wounds are contaminated, and as such, should stay in that state for proper wound healing to occur. If bioburden is present and untreated from contamination, wounds go to colonization, then critical colonization. Wounds become sluggish, regression may happen, and wound healing is delayed. Use of antimicrobials is instrumental at this stage to try and control bioburden before systemic infection sits in. Review the need and use of antimicrobials as cleansers and primary dressings with the SWAT team. Remove antimicrobials once bioburden has been controlled and the wound is back to contamination state.
- Infection: The presence of infection results in changes in wound exudate, edema, or erythema – all of which contribute to delayed healing. Full-thickness wounds near bone must be properly assessed and reported, as bone infection (osteomyelitis) may be a possibility. A proper tissue biopsy, fluid aspiration, or DNA sequencing test must be performed for an effective antibiotic to be prescribed.
- Psychophysiological stress: Presence of pain and noise have been attributed to delayed healing when not properly managed, as both cause vasoconstriction. Team up with the patient's PCP or pain specialist if needed for proper pain management. Premedication prior to wound treatment has been documented as effective. Removing noise, using soothing sounds, and a comfortable environment will help (and not delay) healing.
- Chronic diseases: Research indicates wound healing delays with blood sugars over 180mg/dl, diabetes mellitus, hypertension, peripheral vascular disease (PVD), arterial insufficiency, cancer, collagen vascular diseases, psychosis, depression, and so on.
- Body build: Obese patients have a higher incidence of developing chronic wounds. Adipose tissue is poor in oxygen supply. Obese patients also have a higher incidence for wound dehiscence after surgery.
- Chemical stress: Some antiseptics and cleansing agents have been documented as cytotoxic to healthy tissue and fibroblasts, including povidone-iodine, hydrogen peroxide, acetic acid (vinegar), hypochlorite solution, alcohol, and iodophor. Assessment of the wound for its stage in the healing process, as well as the risk and/or presence of infection will help determine the most appropriate agents for cleansing and managing the wound. Become familiar with the types of cleansing and antiseptic agents available as there are many non-toxic and less cytotoxic available.
- Circulation: Peripheral vascular disease (PVD) and arterial insufficiency affect overall circulation. Assess circulation and involve the SWAT team. Assess use of medications if possible, or consider revascularization if appropriate for patient.
- Immunosuppressive disease: With HIV, AIDS, and other immunosuppressive diseases, the phases of wound healing are delayed, and the patient is at higher risk for infection.
- Malnutrition: Malnutrition has been associated with higher incidence of development of pressure injuries. Nutrition plays an intricate role in wound healing. Baseline labs are needed for assessment. Moving forward, include the SWAT team and a dietitian to evaluate nutritional needs.
- Medications: There are groups of medications that affect the healing cascade. Anticoagulants affect clotting and angiogenesis, anti-inflammatory meds prolong the inflammatory phase of wound healing, antibiotics may result in resistance and mask the symptoms of infection, and steroids have a negative impact on all phases of wound healing. Chemotherapeutic agents affect wound healing as well.
Other common complications that may impede wound healing include hemorrhage (internal or external), presence of or development of a fistula, dehiscence of a surgical wound, and evisceration (the protrusion of visceral organs through a wound).
"Wound care" refers to the act of performing a treatment. Reading the orders, following the steps (as ordered by MD) promptly; cleanse with this, pat dry with that, apply this product, cover with the ordered secondary or tape, and of course, repeat as ordered by MD.
My personal opinion is that, in reality, it wouldn't take a skilled professional to follow those orders. Basically anyone with a sense of direction, no knowledge deficits, and who is able to oblige what is written may perform these steps. In the post-acute setting, we do a lot of teaching. This includes instructions on wound care for family members, patients, and caregivers – all whom come into contact with the patient (including the patient), and are part of the sophisticated SWAT team (skin, wound assessment team).
"Wound management" refers to the study of wounds, including their etiology and characteristics. This also includes how to treat depending on type of wound, what phase of healing a patient is in, what tests to perform to rule out or confirm wound type or diagnosis, what barriers delay healing, and how we can manage those barriers.
It is critical to understand the phases of wound healing, layers of the skin, and how wounds heal, as well as the different types of tissues present on wounds. We learn to understand the importance of the SWAT team, and that this is not a one man or woman job. There is no single "super wound clinician" that can do all this by themselves. It takes a great team behind them and the support of MDs, DPMs, therapists, the patient, CNAs, family members, the environmental team, and basically anyone who comes into contact with the patient to heal a wound.
In order to achieve positive outcomes, wound clinicians must be ready for the task at hand. Know the possible complications, and understand the local and systemic factors. Consult with the SWAT team for proper plan of care, reevaluation, and education – and together, provide the tools necessary to be successful.
The information and education out there is overwhelming—believe me, I know! The work and dedication that wound clinicians bring to the table is unmatched by words. Working together as a team, being consistent, understanding standards of care, using best practices, using evidenced-based research, and being cost-effective are just some of the skills these individuals provide. Being a wound clinician is not something we do as a summer job, or for one year only—we are in it for the long haul. I speak for many clinicians when I say this: nursing is my calling, but wound management is my passion.
Continue the good fight, always put in your two clinical cents—they are extremely valuable. Always ask questions, and always refer to your guidelines for needed guidance.
Keep healing, my friends!
Hess CT. Clinical Guide to Wound Care. 4th ed. Springhouse, PA: Lippincott Williams & Wilkins; 2002: 9-12.
Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 3rd ed. Wayne, PA: HMP Communications; 2001: 265-71.
Shah JB, Sheffield PJ, Fife CE. Wound Care Certification Study Guide. Flagstaff, AZ: Best Publishing Company; 2011: 55-67.
The Wound Care Handbook. 2nd ed. Mundelein, IL: Medline Industries, Inc., 2008: 13-18.
About the Author
Martin Vera is a certified wound specialist with over 19 years of nursing experience, with a passion for wound management and patient-centered care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.