Chronic Wounds

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.

By Becky Naughton, RN, MSN, FNP-C, WCC

In Part 1 of this series on recalcitrant wounds, we started our discussion on some factors on why wounds may seem to stall or stop healing. It can be very difficult in trying to treat a wound that seems to resist all efforts to get it to heal. In Part 1, we discussed some signs of a recalcitrant wound, exploring alternative etiologies behind a wound and how dressings can impact a wound’s ability to heal. In Part 2, we will discuss other possible factors that can cause a recalcitrant wound, including, infection, prolonged or chronic inflammation, the presence of necrotic tissue, the edge effect, nutrition as well as socio-economic factors. We must also bring up the fact that, due to underlying comorbidities or complications, some wounds may never heal and how to start a conversation about this.

Holly Hovan MSN, GERO-BC, APRN, CWOCN-AP

Pain has been a prevalent health care challenge in the United States for some time, with data from the Centers for Disease Control and Prevention showing that approximately 16% of men and 20% of women experience pain on most days or even every day.

Advanced therapeutic devices in wound care can be among your greatest tools for encouraging wound closure. However, it can be disappointing when you may have an advanced modality in mind, but it is denied by the patient’s insurance plan. Or it is simply too expensive to have the patient pay out of pocket. One type of healing device that has a tremendous positive impact on wound healing is negative pressure wound therapy (NPWT). If it is not reimbursed properly, however, the patient may be looking at a shocking expense of thousands of dollars. What’s a wound care clinician to do? Having a few knowledge tools in your pocket may help you to navigate some of the complexities of ordering an NPWT system.

When working with a person who has been living with a chronic wound, it can be frustrating to try to figure out why the wound isn’t closing as the wound healing model would predict. Not all patients follow the “traditional” timeline. The wound may not progress neatly through the four phases of wound healing as expected. There may be an underlying issue that is preventing the wound from healing. How, as clinicians, can we address this? Can we actually expect closure of this wound based on the specific patient’s condition, or should we consider a palliative approach?

The last year and a half have proven to be an extreme challenge for many, especially health care providers. There have been lockdowns, quarantine, medical office closures, staffing shortages, and the overall concern of an unknown virus. The fallout from the last year and a half will likely be ongoing for many years, and although it’s still too soon to truly know all the effects of what has happened, it is an interesting point of reflection on how the field of wound care has been impacted.

Managing chronic wounds can be difficult and often includes multiple treatment strategies. Management techniques can vary depending on the size of the wound, comorbidities of the patient, and the underlying etiology. However, many chronic wounds benefit from the application of negative pressure wound therapy (NPWT). This treatment is known for improving healing conditions across a wide range of acute and chronic wounds.

Advanced treatment modalities: Wound care interventions that are typically applied when standard of care treatments have failed to lead to significant wound closure progress. Treatments include collagen products, cellular and/or tissue-based products, negative pressure wound therapy, hyperbaric oxygen therapy, and others.

Full-thickness wound: Tissue damage involving total loss of epidermis and dermis and extending, at the minimum, into the subcutaneous tissue and possibly through the fascia, muscle, or bone.

Granulation tissue: Tissue found in wounds beginning to heal. It is marked by pink or red tissue and may appear moist or shiny with an irregular or granular surface. Granulation tissue contains new vessels, tissue, fibroblasts, and inflammatory cells.

It is well known that chronic and hard-to-heal wounds have created a global crisis. Delayed healing in these wounds is often associated with biofilm, and antimicrobial dressings can be effective in managing bioburden in chronic wounds. For the use of antimicrobial advanced wound care dressings to be successful in chronic wound care, however, clinicians must have practical knowledge of dressing formats and options, dressing indications and applications, the principles of antimicrobial stewardship, and care planning for specific wound types.

Of all the types of chronic wounds in lower extremities, venous leg ulcers are the most common, and they account for up to 70% of lower leg ulcers. Infection is a common complication in these wounds, however, and may contribute to chronicity. Biofilm is another common complicating factor. Preventing infection, removing unhealthy tissue from the wound, providing dressings that manage exudate, and using advanced modalities can help heal these chronic wound types and prevent a recurrence.