Wound care: Not open and shut
Wound care: Not open and shut
Over time, nearly all professionals build a unique arsenal of tools and tips that helps them hone their craft and deliver on-the-job success.
Wound care professionals are certainly no exception. They consistently tap their go-to solutions and strategies to treat and prevent wounds, and speed healing — and often share these tips with peers and other healthcare workers. It's an approach that builds a more effective wound care team, experts say, and encourages staff to be more creative in their resident care and wound management approach.
“Wound care is an art and you must consider all the options in the toolbox,” says Marcy A. Turkos, PT, DPT, CWS, clinical field manager for Derma Sciences Inc. “It's important to try to think outside the box and think about what your approach can do for that wound and that [resident].”
Given the high incidence of wounds in the long-term care setting, and their associated risks, it's understandable why providers are sharpening their focus on effective wound management and prevention. Roughly 6.5 million people are affected by chronic wounds. An estimated $25 billion is spent annually in the United States on treating them.
“Skills and knowledge are most valuable when shared and used to empower others,” stresses Derma Sciences clinical specialist Sonya Dick, PT, MSPT, CWS, FACCWS. “The whole team will be stronger.”
Dress for success
Some of the most enlightening, if not surprising, wound care tips revolve around wound cleaning.
The greatest “aha!” moment for Toufic Rizk, MD, FACS, RVT, medical director for Unity Wound Care Center in Rochester, NY, came when he “realized the power of weekly debridements in hastening wound healing.”
Even if caregivers are cleaning wounds frequently, they're often not doing it as thoroughly or aggressively as they should, added another expert.
“You really need to be thorough and slightly aggressive when cleaning the wound, especially if you're trying to remove necrotic tissue,” notes Terri Fain, RN, BSN, a clinical specialist for Derma Sciences.
Necrotic tissue promotes bacterial growth and impairs wound healing, and it should be debrided until eschar is removed and granulation tissue is present.
Effective debridement doesn't require expensive pharmaceutical-grade products, either, experts assure. Medical-grade manuka honey, for example, has proven effective in debriding wounds, stimulating chronic wounds, reducing wound pH, and managing bioburden, says Jeri Lundgren, RN, BSN, PHN, CWS, CWCN, the director of clinical service at Pathway Health Services & Gulf South Medical Supply.
“Previously, there was only one topical enzymatic debriding agent on the market, which is a prescription and expensive,” Lundgren explains. “Manuka honey is not a prescription and it's not expensive. Plus, it's not harmful to granulation tissue and can also decrease bacterial loads.”
One widely used product that isn't always golden is topical silver. While silver wound dressings do have their place in wound care and numerous studies demonstrate their effectiveness, medical evidence also shows that using silver for extended periods — greater than two weeks at a time — offers little clinical benefit, Turkos asserts.
“Yet, we often see patients with silver dressings for months on end,” she said.
Warming cleaning solutions and ointments before they come in contact with the skin is another simple, yet underutilized strategy that not only makes wound care more comfortable for the resident, but also speeds healing. Unfortunately, many people aren't aware of this, so they're using ambient-temperature solutions — or even colder, sources note.
Studies underscore the benefits of warming solutions to 37 to 42 degrees Celsius. One 2005 study published in the Journal of Wound Care revealed that maintaining optimal wound temperature increases blood flow to the wound bed, enhances wound tensile strength and increases oxygen tension, all of which aid wound repair.
Additional key wound treatment strategies that Rizk found extremely effective include keeping wounds clean and wrapped at all times; following wound care specialists' instructions precisely; and following up with the specialist at regular, preferably weekly, intervals.
“These strategies have been time-tested and have consistently healed chronic and complex wounds,” he explains. Most of these practices were developed with the help of practical, evidence-based protocols currently in use in most wound care centers nationally, he added.
Another word to the wise, says Derma Sciences' Dick: Avoid throwing too many wound treatments and products at the problem at once. “Overuse of ineffective treatments and products is one of the biggest mistakes. Wound care clinicians tend to get a recipe and stick to it, or they want to try everything under the sun and usually can't tell which ingredient is more effective than another.”
Make your mark
Lundgren recommends caregivers use a cheat sheet to ensure proper risk factor identification and intervention.
Caregivers also must understand that even the most seemingly healthy and ambulatory residents are still at risk for pressure ulcers and other wounds.
“Although frail elderly with mobility issues are at greater risk for wounds, you can't assume that those who are ambulatory aren't at risk,” reasons Pamela Braun, MSW, LCSW, C-ASWCM, LF, president of Geriatric Assessment, Management & Solutions LLC. She stressed the importance of diligent, daily skin assessments, and urged staff to pay close attention to bottoms of feet and between toes — areas prone to pressure and friction. “The bath or shower is one of the best places to do skin assessments, and this should be done every day.”
Closely examining all areas of skin, including ear tips and under breasts, is also prudent, as opposed to focusing solely on high pressure points, she continues. To relieve ear pressure, she's seen facilities successfully use special pillows with a hole cut out for the ear.
Providers also shouldn't forget to audit dressings and wound prevention practices, such as offloading and repositioning, urges Braun. As a licensed social worker and fiduciary, Braun has seen instances where caregivers initialed that they turned the resident or changed a dressing but never actually did.
“Most may do a good job, but you can't just assume or automatically trust that all are,” she said.
One wound care nurse who posted anonymously on an online nursing forum noted that one of the best tips she learned from a veteran nurse was to always print your name, date and time on a piece of tape before applying the final gauze. That way, when a nurse says she changed a dressing, the proof is under the gauze.
Another wound care expert shared advice for dressing a sacral wound, a notoriously problematic area for caregivers.
“Turn the dressing so the corner of the dressing is in the gluteal fold — corner down, so to speak,” explains Derma Sciences clinical specialist Ann Avery, RN, CWCN, LNC. “This will allow the dressing to stay on longer as the seal stays more intact and doesn't allow incontinency to travel up the gluteal fold under to the dressing to contaminate the wound bed.”
Inaccurate wound measurement is another obstacle facilities can't afford to overlook. If you're using a ruler with both inches and centimeters, you are giving clinicians a 50/50 chance to confuse the measurement.
“Eliminate the inches, decrease the confusion and only measure that wound in centimeters,” urges Margaret Falconio-West, BSN, RN, APN/CNS/CWOCN, senior vice president of clinical education for Medline Industries. “Whatever you do, make it difficult to do the wrong thing.”
Back to basics
Experts' consensus is that there are no quick fixes to comprehensive wound management.
“The consistent delivery and execution of effective services is key. When it comes to wound care, it's more important that the basic, proven, data-driven approaches, such as assessments, early identification and referrals — which we already know to be effective — are taught and that these core basics are reaching more people,” says Ameet Vohra, M.D., founder and president of Vohra Wound Physicians.
Building a more dynamic, multidisciplinary wound care team is another key way to ensure that staff members are adhering to wound care basics and contributing to quality resident care. Teams should have representation from a wide range of caregivers and specialties.
Having a crew that's been educated on wound assessments, detection and care can go a long way, particularly when a dedicated wound nurse is unavailable or spread too thin.
“Many new admits come in late on Friday and if the wound nurse is not there, they may wait until Monday for the assessment,” says Lundgren. “No one nurse can do it all. If the wound nurse goes on vacation, is sick or leaves the facility, your weekly wound assessment will continue — if the floor nurses know exactly how wounds are assessed.”
Fostering a relationship with a dedicated wound care center also is good practice, and is especially helpful for facilities dealing with more challenging, hard-to-heal wounds, adds Braun.
“Sometimes, despite your best efforts, wounds don't heal. Sometimes, getting expert help from the outside may be one of the best things you can do for the resident.”