Chronic wounds are a rising challenge for long-term caregivers and, of course, a scourge for residents. They can easily lead to extended stays, costly care and complications that neither caregivers nor residents would prefer to deal with. In this special “How To” article, experts offer tips on how to best deliver optimal chronic wound care.
One of the biggest mistakes has several variations on the same theme: Don't treat all wounds the same.
“Vary your treatment based upon the specific cause and presentation of each wound,” says Mark Richards, MS, PT, CEEAA, vice president of clinical education for Accelerated Care Plus. “If you are using a good, specifically tailored wound treatment approach and you are not observing significant healing, do something different.”
Continually assess and evaluate, adds Nancy M. Cote, RN, BSN, CWCN, a clinical specialist with RecoverCare LLC.
“I think we [as a profession] get stuck in doing just the ordered treatment, day after day and lose focus,” she says.
A critical eye is always handy when dealing with wounds, chronic or otherwise, notes Diane Heasley, RN, CWCN, WCC, DAPWCA, vice president of clinical services for DermaRite Industries.
“Do not assume all the right things have been done,” she emphasizes. “Many venous insufficient legs can develop arterial insufficiency over a period of time. Diabetics are famous for this. The person who has undergone compression for a long period of time needs to be checked periodically for vascular competence.
Richards recommends using whatever means a provider can — autolytic, mechanical and/or chemical — to heal persistent wounds.
“For chronic wounds, jump-start the inflammatory phase of healing by using a physical agent modality – electrical stimulation, shortwave diathermy or ultrasound,” he says. “These treatments stimulate the cells and chemical mediators that do the healing.”
He also advocates employing an interdisciplinary team—comprising nursing, dietary and therapy representatives, for example—to address the factors causing and contributing to chronic wounds “Involve therapy in chronic wound treatment and have them use High Volt Pulsed Current electrical stimulation,” he says.
Richards and numerous others caution to watch for the presence infection.
“The classic signs of wound infection are frequently absent in the elderly who are often immune compromised,” adds RecoverCare's Gail R. Hebert, RN, MS, WCC, CWCN, LNHA.
“Chronic wounds may or may not exhibit signs of infection but be in a stagnant phase of wound healing, and this may indicate critical colonization that could progress to infection,” observes Pat Cropley, clinical support specialist for Ferris Manufacturing Crop.
Heasley emphasizes asking for cultures.
“If a wound is six months or older and all of the ‘right' critical pathways have been followed, consider critical colonization as a culprit,” she observes.
She also recommends vascular studies, as warranted: “Remember that arterial Dopplers and indices do not measure vascular competence in a diabetic. They need toe pressures and/or more invasive testing.”
Pain is a “huge problem that may interfere with healing,” Heasley notes.“Compliance, mobility, appetite and overall mental wellness relies heavily on comfort. We tend to under-medicate,” she believes. The use of antidepressants adjunctively also helps enhance lower doses of pain meds.”
Setting objectives that are realistic for the specific wound and condition of a resident is “crucial,” says Rosalyn S. Jordan, RN, BSN, MSc, CWOCN, WCC, of RecoverCare.
“Of course, that is the ultimate goal of all wound care, but with chronic wounds, objectives should be based on the general patient condition. For example, if the wound is malodorous, the primary objective could be to ‘reduce and contain odor to promote a comfortable environment for the patient.' On the other hand, if the patient is terminal, comfort would take precedence.”
Mistakes to avoid
-Not being vigilant for changes that could prolong a wound's healing.
-Not being flexible or creative. If something's not working, it's time to change your approach.
-Setting unrealistic expectations for either the wound or the patient.