Chronic Wounds

By Janet Wolfson, PT, CLWT, CWS, CLT-LANA

Last spring, I encountered that specific type of patient we sometimes meet, the one who has been through the chronic wound care revolving door so many times that he or she sets out on his or her own path and refuses any byways diverting from it.

Ms. A had stage 3 lymphedema after a left knee replacement opened the hidden trap door of undiagnosed lymphedema several years before her admission to our inpatient rehab facility. Her reason for admission was debility from urinary tract infection (UTI). Comorbidities of obesity, severe arthritis of the right knee, diabetes, and chronic lymphedema wounds on both legs were exacerbating factors making discharge home difficult from the acute hospital.

by the WoundSource Editors

Successful utilization of the TIME model for wound bed preparation requires a working knowledge of chronic wound tissue types. In addition, building on this foundational knowledge is the development of accurate wound assessment skills. These components combined will assist the clinician in implementing the appropriate interventions for each wound.

by the WoundSource Editors

For wound healing to occur, a complex, well-defined cascade of events must take place in the body’s natural host processes. When this cascade of events is disturbed, a wound can fall into a state of non-healing or chronicity. In clinical practice, chronic wounds such as pressure ulcers, vascular ulcers, and neuropathic wounds behave differently and may be extremely slow to heal. A chronic wound, by definition, is a wound that has failed to progress through the “normal” healing process or is not responsive to management in a timely manner.

by the WoundSource Editors

Bioburden in chronic wounds can be a principal contributor to inflammation, clinical wound infection, and further delayed wound healing. Clinically diagnosing infection in chronic wounds can be problematic because most individuals susceptible to developing chronic wounds are subject to physiological states that often blunt typical infectious responses in various ways. These responses include pain, erythema, febrile state, leukocytosis, edema and increased wound exudate, wound odor, etc.

Chronic wounds are seen mainly in those individuals that are already patients (not healthy individuals). Ischemia involves lowered blood supply to the wound which decreases the amount of oxygen available to help the healing process. Peripheral vascular disease commonly causes Ischemia as well as Diabetes melllitus, renal failure, hypertension, and inflammatory diseases. Collagen dressings give structural support and promote granulation tissue formation. Proteolytic enzymes degrade ECM proteins (a major constituent of dermal ECM) thus slowing or stopping wound healing. Modified collagen gel (MCG) is used in the study to test its effects on wound angiogenesis with the porcine model of chronic ischemic wounds.

by The WoundSource Editors

To witness the normal wound healing process is extraordinary. However, the systematic process of healing is not always perfect. Chronic wounds are complex and present an immense burden in health care. Identifying the wound etiology is important, but an accurate wound assessment is just as important. The color, consistency, and texture of wound tissue will lead you to the most appropriate wound management plan.

by The WoundSource Editors

There are four stages of wound healing. This systematic process moves in a linear direction. The four stages of wound healing are: hemostasis, inflammation, proliferation, and maturation. It is imperative to remember that wound healing is not linear. It is possible for a patient to move forward or backward through the wound healing phases due to intrinsic and extrinsic forces.

by the WoundSource Editors

Calciphylaxis: A disorder, generally found in end stage renal disease, but not limited to renal patients, with widespread calcification of small and medium sized vessels, that leads to occlusion, thrombosis, and tissue necrosis. Extreme cases can be life-threatening.

by the WoundSource Editors

When developing the plan of care for the patient with a chronic wound, it is imperative first to look at the "whole" patient and not just the "hole" in the patient.1 As we do, we are able to review any medical conditions or disease states that may affect wound repair and healing. Millions of Americans are affected by chronic wounds each year. These wounds include causes such as diabetic foot ulcers, venous leg ulcers, arterial insufficiency, and pressure ulcers. Common comorbid conditions that can affect healing include diabetes, venous insufficiency, peripheral arterial disease, cardiopulmonary and oxygen transport conditions, immune deficiencies, and dementia.2 This discussion is focused on these conditions and factors that contribute to chronic wounds and their management.

by WoundSource Editors

Chronic wounds are any types of wounds that have failed to heal in 90 days. Identifying the cause of a chronic wound is most important in the healing process. We as clinicians must help bolster advanced wound care by sharing advances in education in evidence-based treatment, prevention, and wound assessment.