Beyond the bedsore: recognizing different wound types in long-term care

In the realm of wound management, pressure ulcers often command the most attention from long-term care providers. While diligence is undoubtedly necessary, given the prevalence of pressure ulcers and impact on morbidity and mortality, it’s vital providers don’t let their guard down on other types of wounds.

But, that’s precisely what’s happening, experts warn.

“I believe it’s happening quite a bit. In some cases, people aren’t aware of these other wounds. They may automatically assume that every wound is a pressure ulcer, which just is not the case,” says Dr. James Spahn, a retired head and neck surgeon who now serves as CEO/founder of EHOB Inc., an Indianapolis-based manufacturer of pressure ulcer prevention and treatment products.

Statistics reveal that the prevalence of non-pressure ulcer skin breakdown is indeed significant. Collectively, more than 600,000 new cases of leg ulcers are diagnosed each year across the general population, experts say.

Meanwhile, the prevalence of venous wounds in adults is 1% to 2% of the U.S. population and can be as high as 3.4% in those over age 80, according to the American College of Phlebology. The prevalence rate for arterial leg wounds can range from 0.12% to 1.8%, according to researchers, and those rates may be conservative because only 25% of Americans over age 65 who have peripheral arterial disease are treated for the condition.

Incontinence-related dermatitis, which affects at least 6% of long-term care residents, also must not be overlooked, along with the 1.5 million skin tears that occur in institutionalized adults each year, many of them stemming from wheelchair injuries, transfers and falls. Finally, with roughly 23% of those age 60 or older being diabetic (many of them undiagnosed), diabetic foot ulcers are another major concern. These wounds account for up to 25% of all diabetic hospital admissions in the United States. They also are credited for more than 60% of all non-traumatic lower limb amputations, according to the National Diabetes Education Program.

“Each type of wound can be a real challenge and requires careful attention. Prevention and early diagnosis is key, and neither will occur without proper training that elevates caregiver knowledge,” notes Chris Cashman, CEO of Sanuwave, Alpharetta, GA. Sanuwave is a manufacturer of regenerative wound healing technologies.

Stopping the bleeding

The first and perhaps most critical element of successful wound management and prevention is a comprehensive, proactive care plan that combines ongoing physiological and risk assessments.

“If we don’t take the time to really get to know each resident and their history, we won’t know the risk factors and won’t be able to prevent some of these wound problems in the first place,” Spahn stresses. “Regardless of the wound type, it does really come down to education. Without it, we’re in trouble.”

Effective wound management also requires a multidisciplinary approach to ensure that all aspects of a resident’s care are represented.

“You have to treat the whole [resident], not just the hole in the [resident],” Jackie Todd, RN, CWCN, clinical education specialist for Medline Industries Inc.’s Atlantic Division, reasons. “There are nine body systems and they all intertwine and affect each other. Everything has to be evaluated for impact on healing.”

Ideally, a multidisciplinary team should include a healthcare provider, such as a physician or advance practice nurse; administrator and bedside clinicians, dietitians, physical therapists, staff nurses, occupational therapists, infection control, and educators.

“All should have clearly defined roles,” adds Diane Maydick, director of clinical affairs, Derma Sciences, Princeton, NJ.

Asking the right questions also is essential, as is diligent documentation and communication to ensure that all members involved in resident care are well versed on risks, changes to physiological and cognitive status, and adjustments to medication and other treatment protocols.

Dodging disasters

Taking a proactive approach through detailed assessments, personalized care plans and a team approach also will reduce the likelihood for wound misdiagnosis—and subsequent mistreatment that can prove catastrophic.
One example might be a resident with recurrent venous stasis disease, bordering on lymphedema. Compression must never be applied without first ruling out arterial involvement and a history of congestive heart failure.
“If peripheral vascular disease exists, or if CHF is a possibility, compression could exacerbate [the condition] and possibly cause death,” Todd warns.

Using therapies that increase microcirculation in residents who are misdiagnosed with vascular complications also is dangerous, adds Cashman. “You really need to know what you’re dealing with if you’re going to be increasing blood supply.”

Another line of caution when managing arterial wounds: Never raise the foot.

“About the worst thing you can do with an arterial wound is prop it up, which can cause the toes to rot,” and lead to amputation, Spahn explains.

Diabetic foot ulcers present their own set of challenges. In some cases, these are misdiagnosed as pressure ulcers—even though a prior diabetes diagnosis and location of the foot ulcer (typically on the plantar aspect of the metatarsal heads and the heel, and over the dorsal portion of the toes), serves as a reliable tip-off. In other cases, DFUs aren’t given the attention they deserve because caregivers may assume that they are unavoidable.

“In my opinion, it seems that many people just don’t understand how serious diabetic foot ulcers are, so they’re not being as serious about treating them,” says Dean Tozer, senior vice president, Advanced BioHealing Inc., Westport, CT. ABH manufacturers Dermagraft, a bio-engineered skin substitute for the treatment of diabetic foot ulcers.

And DFUs are serious. Diabetics who develop one have up to a 25% risk for lower limb amputation. There also is a 45% chance of death within five years, if not properly managed.

With a diabetic resident, it’s imperative not only to keep their blood sugar in check, but also to identify decreased sensation due to diabetic neuropathy and then take appropriate preventive measures to reduce the risk of diabetic-related ulcers. Such measures may include use of properly fitting stockings and shoes, and inspection of shoes for foreign objects or potential areas of pressure prior to the resident placing them on their feet, to prevent traumatic injury, explains Laura Popkes, clinical services manager for McKesson Medical-Surgical Extended Care Medimart, Minneapolis, MN.

Caregivers also must be aware that peripheral arterial occlusive disease is four times more prevalent in diabetics than in non-diabetics.

Paper power

Regardless of the type of skin ulcer being treated, detailed, ongoing documentation of risk factors, comorbidities, wound types, and care and treatment protocols becomes paramount.

“It is imperative to accurately document wound types and patient characteristics. Inaccurate documentation can lead to legal issues,” stresses Maydick.

Even more importantly, however, thorough documentation allows caregivers to better monitor wound care progress and make necessary care plan adjustments based on past treatment and prevention successes and failures. With a diabetic foot ulcer, for example, documentation creates a vital timeline to monitor standard therapies and determine when advanced modalities may be in order. Above all, documentation helps ensure that treatment and prevention are tailored to each resident.

“What works on one [resident] will not necessarily work for everyone, even if it is the same type of wound with basically the same underlying etiology and comorbid conditions,” Todd reasons.

Being fully aware of underlying conditions, additional risk factors and primary and secondary interventions–along with how long the interventions have been in place and their degree of effectiveness–will go a long way toward improving wound management.

“In order to achieve quality healed outcomes in the shortest amount of time, we have to step back, look from that 10,000-foot vantage point, and take a common sense approach to wound care,” Todd continues.

“Wound care is not rocket science and even though we may be given challenging wounds to deal with, we can achieve wound healing and not break the bank.”


W.O.U.N.D. protocol helps healing

To manage wounds effectively, Jackie Todd, RN, CWCN, clinical education specialist for Medline Industries Inc.’s Atlantic Division, recommends long-term care providers follow the W.O.U.N.D. protocol, which addresses the five principles of wound healing.

W  Is the wound healing?
      Yes – Continue with treatment and best practice
      No – Consider: other etiologies; comorbidities; other modalities; biochemical imbalance; bioburden; pain, etc.

O   Is there an optimal amount of moisture and is there an odor?

      Excessive moisture
      Moisture balance

U  Understand the peri-wound skin

     Adhesive effects
     Edges, etc.

N  Necrotic, senescent or viable tissue

     Necrotic (debride if debridement is consistent with overall patient goal)
     Senescent (consider debridement and antimicrobials)
     Viable and progressing (provide support )

D  Depth or dead space

     If deep, fill it
     If flat, cover it