Chronic Wounds

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By Holly M. Hovan MSN, APRN, GERO-BC, CWOCN-AP

Chronic wounds impact more than 8 million Americans in a multitude of ways ranging from affecting quality of life along to creating a significant economic burden, with the estimated cost of care in the United States currently at 30 billion dollars. As technology and medicine continue to advance, our aging population continues to grow, and those impacted by chronic wounds are likely to increase. This blog will take it back to the basics—using our senses to guide wound assessment and management—while incorporating technology/telemedicine and wound photography to guide treatment and track progress.

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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.

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Wound healing typically progresses through four phases: hemostasis, inflammation, cell proliferation or granulation and repair, and epithelialization and remodeling of scar tissue. Clinicians should achieve wound closure through a standardized framework such as the TIMERS (tissue management, infection or inflammation, moisture balance, edge or epithelialization, regeneration, and social factors) tool, which provides a comprehensive approach to wound management and optimizes the wound bed and conditions to support progression of wounds through the healing process.

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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.

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The term chronic wound is frequently used when discussing challenges in wound care, and it is widely recognized as a wound state that presents a formidable public health challenge. Although this term has been used since the 1950s to describe wounds that are difficult to heal or those that do not follow the normal healing process, there has been uncertainty since that time about what conditions actually make a wound chronic.

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When a wound fails to progress through the phases of healing in a timely fashion despite the standard of care wound treatment provided, advanced therapies may be warranted. Wound care often needs a multifaceted approach that involves the treatment of entire patient, not just the wound. Clinicians should obtain a comprehensive medical history of the patient and conduct a thorough skin and wound assessment of the patient. This medical history and assessment will lay the foundation of initial treatment.

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Chronic and complex wounds present a formidable challenge in health care. Nonhealing wounds impact approximately 1% of the world's population yet account for more than 2% to 4% of health care expenses. Wounds that require additional clinical efforts often include those that are chronic and resistant to therapy, those with increased risk, and those that reduce the patient's quality of life.

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The management of wounds, especially complex and chronic wounds, is a daunting clinical challenge. Achieving progress toward wound closure often depends on the right selection of treatment modalities for the wound and acknowledgment of any other underlying clinical considerations that present barriers to healing. However, before treatment selection, a full and accurate wound assessment must be completed. Without analyzing all variables that impact wound healing, clinicians may be unable to identify the proper treatment course.

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Alex M. Aningalan, MSN, RN, CWON, WCC

Chronic wound conditions are prevalent across health care systems globally and often result in economic and humanistic burdens on clinicians and patients.1 Moreover, pressure injuries, among of the more common types of chronic wounds, affect an estimated 2.5 million people in the United States annually, resulting in a staggering 60,000 preventable deaths.2 In addition, the Centers for Medicare & Medicaid Service reported that the United States spends about $9.1 to $11.6 billion annually as payment for the burden imposed by pressure injuries.2

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Wound care is complex. Even professionals who have worked as wound care specialists for decades are still learning as researchers discover more about the healing process and barriers that impede healing. Additionally, the medical professionals who may work with a patient with a complex or chronic wound can include clinicians with varying expertise, such as nurses, physical therapists, surgeons, dietitians, and so on. Fortunately, several national organizations are committed to enhancing the quality of wound care for both wound care professionals and patients alike.