Complex Wound Management

By Cathy L. Harmon, DNP, MSN, FNP-BC, CWON, CFCN

The impact of diabetic foot wounds is extensive. Diabetic foot ulcers (DFUs) are a major concern among those with diabetes. Research estimates that 25% of adults with diabetes may suffer a DFU sometime in their lifetime, with 20% of those requiring amputation.¹ It is also estimated that DFUs cost around $1.4 billion for inpatient care alone.¹

Vascular ulcers are wounds on the skin that form as the result of abnormal blood circulation in the body, including arterial and venous etiologies. Estimates suggest 3-5% of those over 65 in the United States have a vascular ulcer. Of those with peripheral arterial disease, approximately 20-70% have chronic wounds, according to data up to 2018. Since arterial ulcers may be underdiagnosed, certain experts theorize that the number of chronic wounds developed due to arterial insufficiency is higher in reality.

Severe burn wounds are among the most debilitating injuries because they can significantly affect the entire body. The body’s inflammatory response to a severe burn injury can lead to fluid loss, dangerously low blood pressure, and shock. The risk of infection is also elevated in patients with severe burn wounds. Therefore, prevention of these complications is a key component of care for these patients.

Surgical wounds originate when a surgeon cuts into tissue with a surgical tool, such as a scalpel. The size and placement of a surgical wound will depend entirely on the procedure performed due to varying incision requirements.

Regardless, most surgical interventions aim for wound closure with primary repair. Tissue edges are typically brought together and held in place by various modalities, such as sutures or staples. However, this result isn’t always the case, as some wounds may be left open to heal secondarily or may fail to heal primarily. This piece will discuss the surgical wound timeline, various complications of a surgical wound, signs/symptoms of infection, along with the recovery process for patients.

Acute wound: An alteration in skin integrity, such as a simple laceration or a surgical wound, that typically moves through the healing process and heals in a predictable timeframe without complication. An acute wound results from a documentable event with the assumption that it will progress normally through the 4 phases of wound healing.

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.

Wound management is a tremendous clinical challenge for many health care professionals. The World Health Organization has recognized that wound management is a worldwide public health issue best managed by an interprofessional team. This interdisciplinary approach has been shown to increase healing and decrease wound recurrence. However, it requires shared decision making with many clinicians to create an optimal care plan.

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.

Wounds have a significant negative impact on patients, including pain, decreased quality of life, and social isolation. Optimal wound healing can help patients and the health care system cope with the burden of chronic wounds. Wound management may not always be the priority in patients whose cases are complicated by severe comorbidities, palliative care, hospice care, surgery, chemotherapy, radiation, or management of a chronic condition.

Patients with wounds are frequently treated pharmacologically for both their wounds and their acute or chronic conditions. On a daily basis, patients usually take at least five drugs to treat multiple chronic conditions, and this level of drug use is termed polypharmacy. Polypharmacy can also be defined as the intake of more medications than are medically necessary for a particular problem or the continuation of intake after the initial problem has been resolved