Chronic Wound Care 4th Edition Excerpts
Section 5: Preparing the Wound Bed—Cleansing, Debridement, Infection, and
Therapeutic Modalities
Chapter 32
Infections in Chronic Wounds
Stephan Landis, MD, FRCPC; Siobhan Ryan, MD, FRCPC; Kevin Woo, RN, MSc, PhD(c), ACNP, GNC(C); R. Gary Sibbald, BSc, MD, FRCPC (Med Derm), ABIM DABD, MEd
Early recognition and management of increased bacterial burden and infection is vital during the ongoing care of a chronic wound. Bacterial damage will cause wound deterioration, delaying wound healing and increasing the risks of further morbidity and mortality. The appropriate use of antimicrobial agents is an ongoing challenge in this field.
Chapter 33
Infection Control Perspectives on Wound Care
Sue Crow, RN, MSN, CIC; P.J. Thompson, RN, CCRN, CIC
Without intact skin, the susceptible patient’s wound may become infected if the surrounding skin flora invades the devitalized tissue or if the wound is contaminated with organisms. Lavaging or irrigating the wound reduces the number of organisms. Debridement of necrotic tissue reduces the risk for infection, because necrotic debris in a wound provides an excellent medium for bacterial growth. Proactive practices, such as maintaining clean, intact skin, using standard precautions from the Centers for Disease Control and Prevention (CDC), and utilizing aseptic practices, reduce the risk of wound infection. These methods of infection prevention and cross-contamination prevention for both the patient and the healthcare provider will be discussed in this chapter.
Chapter 34
Wound Cleansing, Wound Irrigation, Wound Disinfection
George T. Rodeheaver, PhD; Catherine R. Ratliff, PhD, APRN-BC, CWOCN
Wound cleansing is one of the most important components of an effective wound management protocol. Optimal wound healing cannot occur until all pro-inflammatory material and foreign bodies have been removed from the wound. In its broadest sense, wound cleansing can encompass aggressive debridement of all devitalized tissue, extensive use of fluids for cleansing, and selective use of topical antimicrobial agents to control bacterial contamination and colonization. Each of these steps is essential for obtaining a clean, vital wound that has the greatest potential for healing at an optimal rate.
Chapter 35
Wound Debridement
Dot Weir, RN, CWON, CWS; Pamela Scarborough, PT, MS, CDE, CWS, CCWS; Jeffery A. Niezgoda, MD, FACHM, FACEP
Regardless of the type or technique used, effective wound debridement is paramount to achieving adequate wound-bed preparation and ultimately wound healing and has become a standard of care among wound care providers. Once the decision to debride is made, the methodology used is dependent upon the patient’s plan of care, the overall goals of therapy, the urgency of the need, the setting in which the care is being provided, the skill level of the care providers, and access to the modalities. Adequate wound debridement is essential for successful outcomes in the management of chronic wounds and is critically important to create a wound environment in which to achieve the desired benefits of modern advanced wound therapies, such as growth factors and bioengineered tissues.
Chapter 36
Growth Factors and Erythropoietin in Wound Healing
David Keast, MSc, MD, CCFP, FCFP
Conceptually, growth factors hold much promise in stimulating chronic wounds to heal. In practice, the theory has yet to be realized. Although many studies have been conducted in animal models and in humans, local application of growth factors to date in general has not proven to be more cost effective than best practice care, which identifies and remediates underlying causes, identifies and addresses patient-centered concerns, and provides good local wound care through adequate debridement, bacterial load management, and provision of appropriate moisture balance. Only 1 growth factor, rPDGF-BB, is currently approved for clinical use in North America. The future of growth factors will depend upon determining the appropriate timing and combinations of growth factors that can stimulate chronic wounds to close in a cost-effective manner.
Chapter 37
Surgical Repair in Advanced Wound Caring
Dean P. Kane, MD, FACS, CWS
Surgery, with the ultimate goal of hastened healing, pain reduction, durable repair, and less healthcare costs, is offered in those relatively few patients whose catabolic states have been reversed and whose wounds are of such size and clinical magnitude they otherwise would not heal. Advanced wound caring now includes compassionate patient management for those whose wounds will not heal. It is prudent for the modern wound care specialist to appreciate more global views of chronic wound healing. The human ecosystem survives within a galaxy of overlying environments.
Chapter 38
Postoperative Care of Skin Grafts, Donor Sites, and Musculocutaneous Flaps
Cecilia Rund, BSN, CWOCN; Dean P. Kane, MD, FACS, CWS
Standardized best practices for postoperative care and management of skin grafts, donor sites, and flap procedures can enhance consistency of care, decrease confusion, increase adherence, and provide a basis for measuring patient outcomes. Guidelines can either be general or detailed and should provide standards of care based upon patient/surgical specific needs. They should also assist the caregiver in identifying complications and reportable complications. The best practices discussed in this chapter cover a wide range of patient issues. Wound care is complex, and wound healing and management are dependent on intrinsic and extrinsic host factors (medical condition, healhty diet, mobility, psychosocial issues, caregiver skill set, and patient environment). This chapter begins with a general discussion regarding factors that affect postoperative wound repair then progresses to preoperative patient preparation and patient selection for skin graft and flap operative procedures. Postoperative complications, interventions, and patient education concerns are also covered.
Chapter 39
The Physical Therapist’s Role in Wound Management
Pamela G. Unger, PT, CWS, FCCWS
According to Moffat, physical therapists have been “healing the generations…tending to the needs of those afflicted with disease, disability, loss of function, and pain; and preventing physical problems confronting our citizenry.” Today, physical therapists in clinical practice have diverse, complicated, and specialized roles. Since the beginning of the practice of physical therapy, physical therapists have been involved in chronic wound care, primarily thorough the use of whirlpool. In the 21st century, the physical therapists that are involved in wound care and frequently certified as wound specialists must consider the effect that skin impairments have on the various systems of the body as well as how wounds lead to disability and disability leads to wounds. Physical therapists possess a wealth of knowledge that may be employed to enhance wound healing. Their expertise includes knowledge and competence in the use of exercise, mobility assessment, wheelchair assessment, gait training, therapeutic modalities, debridement, and the use of topical agents.
Chapter 40
The Role of the Podiatric Physician in Wound Care
Vickie R. Driver, MS, DPM, FACFAS, FAPWCA; Catherine Griffis, MA
Podiatric physicians and surgeons are licensed in all 50 states, the District of Colombia, and Puerto Rico, staffing many of the nation’s hospitals and long-term care facilities. A podiatric physician and surgeon’s scope of practice varies by state law but is defined by the American Podiatric Medical Association as the diagnosis and treatment of the human foot and ankle and their governing and related structures, including the local manifestations of systemic conditions by any system or means. Based on this definition, the podiatric physician and surgeon is uniquely situated to recognize and treat diabetic foot pathologies and play a vital role in preventing lower-extremity amputation.
Chapter 41
The Role of the Hyperbaric Medicine Team in Chronic Wound Care
Robert A. Warriner, III, MD, ABPM/UHM, FCCP, FCCWS; Terry Beard, RN, RRT, CHT, ACHRN
A basic pathway to nonhealing of wounds is the interplay between tissue hypoperfusion, resulting hypoxia, and infection. Chronic hypoxia within the wound and in the periwound environment impedes wound healing by numerous mechanisms that act in a concurrent fashion. A challenge wound care clinicians face is identifying the extent to which local hypoxia is contributing to the abnormal healing response in a specific wound and then correcting that hypoxia as much as possible. During the past 30 years, a large body of research and clinical evidence has been accumulated demonstrating that intermittent oxygenation of hypoperfused wound beds, a process that is achievable only by exposing patients to hyperbaric oxygen (HBO), mitigates many of these impediments and sets in motion a cascade of responses that contributes to wound healing. The role of the hyperbaric medicine team is to select and safely treat those patients that will most likely benefit from this therapeutic intervention and integrate this component of care into the interprofessional care plan for those patients.
Chapter 42
Therapeutic Modalities in the Treatment of Chronic Recalcitrant Wounds
Pamela E. Houghton, BScPT, PhD; Karen E. Campbell, RN, MScN, NP/CNC
Candidates for therapeutic modalities include patients with chronic wounds who have failed to respond to optimal standard wound care, who have any pre-existing medical conditions that are associated with impaired wound healing (diabetes mellitus, etc.), and/or who prefer a conservative nonsurgical option to accelerate wound closure. Acceleration of wound closure is particularly important in individuals whose wounds significantly interfere with their ability to perform activities of daily living or result in immobilization for a prolonged period of time. A more conservative, nonsurgical wound management program is often preferred by the patient, since the majority of individuals who develop chronic wounds are elderly and frequently have several co-existing medical conditions that would contraindicate general anesthesia. The primary care provider is a key person that must be able to identify if the patient is a candidate for a therapeutic modality. However, all members of the wound care team have an ethical and legal obligation to review all of the second line treatment options with the patient who has a chronic wound.