| Continued from Page 1
| Alternative treatments |
There are a number of alternative treatments available for chronic wounds that do not respond to regular therapy. Three types currently in use are oxygen therapy, ultrasound treatment, and electrical stimulation.
Oxygen Therapy — Brief exposure to oxygen has been shown to improve healing rates of hard-to-heal wounds. In one study, more than two-thirds of the wounds healed when treated only with oxygen.1 Topical oxygen treatment was delivered with an inflatable bag that adhered to the skin and fastened securely around the wound. The oxygen was administered for 90 minutes a day for four days, followed by three days of rest. This cycle was repeated for as long as the wound appeared to be healing — treatment duration lasted from 24 days to eight months.
Ultrasound Treatment — Ultrasound can be used to produce chemotaxis within the wound. This plays a role in attracting neutrophils and monocytes during the inflammatory phase of wound healing. It also stimulates fibroblasts in their production of collagen.
Electrical Stimulation — In 1994, the Agency for Health Care Policy and Research (AHCPR) issued a panel statement confirming that electrical stimulation is an acceptable complementary therapy for treating pressure ulcers. It suggested that electrical stimulation could be used successfully when combined with moist healing treatment.
An electrode covered in gel is placed on the skin near the wound or in the wound. A low-level of electricity with short pulse durations transfers energy to the wound. This current helps to attract fibroblasts and to stimulate granulation tissue growth.
— Heather Lewin, health care
editor and writer
Source: Kalliainen LK, Gordillo GM, Schlanger R, Sen CK. Topical oxygen as an adjunct to wound healing: A clinical case series. Pathophysiol. 2003;9(2):81-87. |
For more serious wounds, mechanical or surgical debridement is necessary. Mechanical debridement occurs when moist gauze is placed within the wound. As it dries, the necrotic tissue adheres to the gauze and is removed when the dressing is changed. Unfortunately, this type of debridement is nonselective, removing healthy as well as devitalized tissue. Surgical or sharps debridement occurs when the wound is dissected with scalpel or scissors and is the preferred method for quick debridement.
Treat the slow-to-heal wounds
In some cases, chemical enzymes, zinc wrap compression, or oxygen therapy (see sidebar, “Alternative treatments”) may be applied to hasten the healing process. A moist wound environment is also conducive to healing. And sometimes certain procedures are appropriate to certain situations. For example, if there is edema in the site of a lower extremity wound, clinicians have found success in using Unna Boot Zinc compression. Wounds do not heal in the presence of edema.
The following describes a system of wound care therapy for stage III or IV pressure ulcers and for lower extremity ulcers. Nurses should remember to begin treatment after consulting with a physician.
- Assess: Access laboratory data and medical history to determine whether the patient has diabetes, osteomyelitis, or other systemic issues. Review the patient’s medications since there are meds that will retard a patient’s healing potential, such as steroids, anticoagulants, and certain cardiac meds. Assess the patient’s ankle-brachial index (systolic ankle pressure/systolic brachial pressure) to determine PAD status if it’s a leg ulcer.
- Clean: Normal saline should be used to clean the wound. Apply warm saline compress as indicated and as tolerated. If there is MRSA, begin systemic antibiotic therapy. As per physician, apply a local antibiotic such as mupirocin (Bactroban®); cream-based antibiotics are recommended rather than those with oil bases. The many silver-based products on the market are also useful in combating infected and heavily colonized wounds.
- Debride: Irrigate to remove eschar. Use papain-urea topical (Accuzyme® or Gladase®). Cover peri-eschar tissue with papain-urea-chlorophyllin (Panafil®).
- Cover: Cover the wound with a thin hydrocellular dressing. If it’s a leg ulcer and edema is present, apply compression using an Unna Boot® with zinc oxide dressing. The compression helps to prevent further injury to the tissue by enhancing venous return.
- Reassess: Remove the dressing after four days and reassess the wound. As healing progresses, continue to apply the treatment. Change dressing every three to four days and continue treatment for 14 days. The wound should begin to show marked signs of healing, depending on the stage [status] of the wound and the patient’s underlying morbidity.
For patients with wounds on the leg, elevate the leg as often as physically possible. Nutrition should be monitored according to dietary protocol. Protocol support surface for stages III and IV wounds should include dynamic (alternating pressure), air fluidized (high air loss), or low air loss pressure devices, as appropriate.
Healing chronic wounds can be a difficult and long process. Patients should be monitored for infection and nutrition and reassessed to ensure that the care approach is successful.
| Nutrition in wound healing |
Although there is no direct cause-effect relationship between nutritional status and the development of pressure ulcers, nutrition intervention remains a major focus in prevention strategies. Poor nutritional status has been associated with an increased risk for the development of pressure ulcers. Reduced body mass index, low body weight, the inability to eat independently, reduced food intake, and low dietary intake of protein can affect the development and healing of pressure ulcers.
Protein-calorie malnutrition and deficiencies of vitamins A and C and zinc impair normal wound-healing mechanisms. If a patient who has a chronic wound also has untreated malnutrition, the healing process may be even more difficult. Protein is needed for tissue regeneration and repair. A protein deficiency can delay wound healing by exacerbating the inflammatory phase of the wound. There is also a connection between zinc and the body’s ability to synthesize protein and collagen, which is necessary for wound healing. Zinc is essential for cell division and protein synthesis.
Vitamins also play a part in wound healing. One study suggests that vitamin A can benefit wound healing by enhancing the early inflammatory phase and increasing the number of macrophages at the wound site. It also could improve the stimulation of the immune response. Vitamin C enhances neutrophil production, increases angiogenesis, acts as an antioxidant, and helps in the production of collagen.
Lymphocyte counts are also an indicator of malnourishment. A count of less than 800 indicates severe malnourishment; nutritional supplementation is suggested when the lymphocyte count is 1,800.
Patients’ nutritional needs must be assessed and treated, either by increasing intake of foods that are high in calories and protein, supplementing meals with commercially prepared oral supplements, or providing GI feedings. — Heather Lewin, health care editor and writer
Source: MacKay D, Miller AL. Nutritional support for wound healing. Altern Med Rev. 2003; 8(4):359-377. |
Joy Lindsay-Garvey, RN, MEd, is a wound care specialist at Morningside House Nursing Home, Bronx, N.Y.
References
1. Wound healing, growth factors. Rosenberg L, de la Torre J. Available at: http://www.emedicine.com/plastic/topic457.htm#target3. Accessed October 19, 2004.
2. Appendix E: Managing wounds due to surgery, injury, or pressure. Milliman Care Guidelines: Inpatient and Surgical Care. 8th Edition. Available at: www.intra.ccgh.com/CareSource8th/isc/isc_ape1.htm. Accessed October 19, 2004.
3. AHCPR supported clinical practice guidelines. Executive summary. Available at: www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.section.4502. Accessed May 5, 2005.
4. MacLean DS. Preventing & managing pressure sores. Caring for the Ages. American Medical Directors Association. March 2003. Available at: www.amda.com/caring/march2003/policies.htm#refs. Accessed October 26, 2004.
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