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Ulcer and Wound Care: Getting to the Depth of the Tissue

Disclosures

Description

Author(s): Lydia Corum, RN, MSN, CWCN, Paralegal Civil and Criminal

The purpose and goal of this course are to educate healthcare professionals about how to recognize the phases of healing and types of pressure injuries and ulcers. The course describes ways to identify and document infection, intervene with new treatments, and choose the type of dressing that will promote healing.

Learning outcomes include the ability to:

1. Describe the four phases of the healing cycle and the essential characteristics of each phase;
2. differentiate among colonized or contaminated, critically colonized, and infected ulcers; and
3. accurately measure an ulcer's length, width, and depth.

Criteria for Successful Completion

After studying the course material, participants complete the online evaluation. Healthcare professionals with a Florida nursing license must complete the multiple-choice test online with a score of at least 70%. Upon completion of the requirements, participants may immediately print the continuing education (CE) certificate of completion.

Accreditation

• The National Center of Continuing Education, Inc., is accredited as a provider of nursing continuing professional development by the Commission on Accreditation of the American Nurses Credentialing Center (ANCC).
• California Board of Registered Nursing Provider No. CEP 1704
• Florida Board of Nursing No. 50-1408
• Kentucky Board of Nursing Provider No.7­0031-12-23
  5 Contact Hours displayed above use ANCC definition of a 60 minute hour, KY defines a contact hour as equivalent to 50 minutes of clock time. KY certificate of completion for this activity will display: 6.0 CE Hours

Conflicts of Interest

The planner(s), author(s) and/or editor(s) of this educational activity have attested to no relevant financial relationship(s) with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Expiration Date

This course expires on November 30, 2025.

About the Authors

Lydia Corum, RN, MSN, CWCN, is a Certified Wound Care Nurse and Wound Care Coordinator. She has been working with wounds for more than 22 years. Ms. Corum has extensive knowledge of wound care, diagnoses that affect wound healing, and a passion for healing patients. Her guiding philosophy is, “It is not the importance of healing the wound but healing the patient.” Ms. Corum developed her outlook from classes, hands-on experience, research, and doctors’ influence. She has worked in various healthcare settings, including home healthcare, extended care facilities, wound clinics, hospitals, and the National Institutes of Health. Ms. Corum gained expertise in healthcare costs and budgets while working as a supply manager for a home healthcare agency. She is a passionate advocate and educator to improve wound care costs, ensure patients receive better healing and care and retire from the bedside. In June 2022, Ms. Corum received Paralegal certification. She is now pursuing her dream working in the legal field to leverage her expertise, experience and passion make life better for patients and clients.

Shelda L. Hudson, RN, BSN, PHN, Director of Healthcare Information, completed her baccalaureate degree in Nursing and public health certificate at Azusa Pacific University. Ms. Hudson [has over 21 years of extensive experience publishing courses in continuing education for healthcare professionals through the National Center of Continuing Education.

Purpose and Goals

The purpose of this course is to gain an understanding of the current treatments for a variety of ulcers and pressure injuries. The goal is for the nurse and other healthcare professionals to recognize the phases of healing, the types of ulcers, and the stages of pressure injuries. The professional will be able to identify and document infection and intervene with new treatments. With an accurate assessment of the ulcer or pressure injury, the professional can choose the type of dressing that will promote healing.

Learning Outcomes

At the end of this course, the participant should be able to:

1. Describe the four phases of the healing cycle and the essential characteristics of each phase.
2. Differentiate among colonized or contaminated, critically colonized, and infected ulcers.
3. Outline the characteristics of infected ulcers.
4. Differentiate among the types of ulcers and risk factors involved in prevention.
5. Outline a complete assessment of the patient with skin assessment emphasized.
6. Explain how to measure an ulcer's length, width, and depth accurately.
7. Choose the type of dressing that will promote moist wound healing.

Introduction

Trying to understand ulcer healing traces back to ancient times and continues today. Interest grew in the 1900s. By 1960, it was understood that appropriate dressings could halve the amount of time it would take an ulcer to heal. Since then, there has been an ongoing expansion in the understanding of the vast array of intrinsic and extrinsic factors of ulcer healing and the intracellular, extracellular, molecular, and biochemical processes and interactions that facilitate healing.

With today’s aging population, an estimated 2.5% will be affected by changes in the quality of life that chronic wounds create. Increasing costs of health care, an aging population, recognition of difficult-to-treat infection threats such as biofilms, and the continued threat of diabetes and obesity worldwide make chronic wounds a substantial clinical, social, and economic challenge.

Of Medicare/Medicaid beneficiaries in 2014, 14.5% were diagnosed with at least one type of wound or wound-related infection at a cost of $28.1 to $96.8 billion. The associated cost for healing chronic wounds for hospital outpatients was estimated to be $9.9 to $35.8 billion, and for inpatient wound care, $5.0 to $24.3 billion. Of all types of wounds, the largest categories and most spending were for treatment of surgical ulcers followed by diabetic foot ulcers. (Nussbaum et al, 2017)

There is a shift in how and where patients are being treated. For severe wounds, from 2016 to 2018 there was a 7% decrease in the inpatient use of long-term care hospitals, and an increase in stays at acute care facilities and inpatient rehabilitation facilities, with most Medicare/Medicaid patients being treated within 10 miles of their home address. The COVID pandemic then disrupted the continuum of care and changed delivery with establishing the widespread use of telehealth including coaching patients remotely on how to change and monitor their dressings. Studies indicate that incorporation of telehealth for wound care increases compliance, patient satisfaction and outcomes. (Sen, 2021).

In this course and professionally, the terms “ulcer” and “wound” are often used interchangeably without regard to etiology (cause). Depending on its etiology, the open area in the skin is an ulcer, wound, or injury. In 2016, the then named National Pressure Ulcer Advisory Panel (named National Pressure Injury Advisory Panel in 2019) changed its preferred terminology from pressure ulcer to pressure injury to reflect injuries with intact skin and ulcerated skin. The International Statistical Classification of Diseases and Related Health Problems (ICD) uses “ulcer” if its etiology is not an instrument (scalpel, knife, gun, etc.). With the terminology changes, the importance of advanced ulcer care is still the assessment of the physical, financial, and social issues that encompass the ulcer dynamic.

Each ulcer and patient is different in terms of need and healing process. As with all health care today, evidence-based care must include a patient's plan. The ulcer does not heal itself; the person heals the ulcer.

Ulcer healing is a continuation, communication, and collaboration of care. The 3 Cs start when the patient is admitted with the wound, and they continue until the ulcer heals. All disciplines communicate and interact with the patient and caregivers to ensure the care plan is understood and accepted. Jean Watson, nursing theorist and nursing professor, states, “Unknowns can also lead to illness; the unknown can only be known by experience and may require inner searching to find meaning.” The healing comes from the person and knowledge of the disease process, and healing becomes problematic when the person is not informed or left unsure about how the ulcer is progressing or what the care plan is. Though patients want healing to occur, many patients find adding in elements of care that differ from their normal routine difficult to incorporate into their life. Therefore, it is essential to assess the ulcer and the person each time the patient is seen. This routine assures the patient of quality care for which the patient has control.

“Society needs the caring professions, and nursing, in particular, to help to restore humanity and nourish the human heart and soul in an age of technology, loneliness, rapid change, and stresses, ….” Dr. Jean Watson

Basic Types of Ulcers

Abrasions result when skin is rubbed or scraped off. Rope burns, rug burns, and skinned knees or elbows are typical abrasions. This kind of wound can become infected quickly because of the embedding of dirt and germs into the tissues. Abrasions are classified by full and partial thickness.

Arterial ulcers result from a lack of blood flow to the lower extremities. These ulcers are dry and necrotic. Many have black eschar present. Problems in healing arise from a lack of circulation, thus increasing blood flow to the area is an important component of healing. Arterial ulcers are generally classified as full-thickness wounds, painful, and dry.

Diabetic ulcers are located below the ankle and are related to neuropathy or deformed feet from arterial and venous blood flow. Diabetic ulcers are classified by full or partial thickness.

Incisions, commonly called cuts, are wounds made by sharp instruments, such as knives, razors, scalpels, and broken glass. Incisions tend to bleed freely. With an incision, there is a smooth cut to blood vessels. As a result, there is little damage to the surrounding tissues. Of all classes of wounds, incisions are the least likely to become infected since the free flow of blood washes out many of the microorganisms that cause infection. Incisions are classified by full and partial thickness.

Lacerations are torn rather than cut. They have ragged, irregular edges and masses of torn tissue underneath. Blunt rather than sharp objects usually make these wounds. An injury produced by a dull knife, for instance, is more likely to be a laceration than an incision. Bomb fragments often cause lacerations. Many of the wounds caused by accidents with machinery are lacerations. Lacerations that crush tissue will complicate the area. Many materials contaminate lacerations, including dirt, grease, or other material that can be ground into the tissue, causing infection. Lacerations are classified by full or partial thickness.

Pressure injuries occur due to the loss of blood flow over a bony skin area. Pressure injuries do not include the buttock unless the patient is in surgery or a supine position for greater than three hours. Pressure injuries are staged from 1 to 4, with unstageable and deep tissue injuries.

Punctures are from objects that. penetrate the tissues while leaving a small surface opening. Wounds made by nails, needles, wire, and bullets are usually punctures. As a rule, minor puncture wounds do not bleed freely; however, large puncture wounds may cause severe internal bleeding. The possibility of infection is great in all puncture wounds, especially if the penetrating object has tetanus bacteria. Often, to prevent anaerobic infections puncture wounds are not surgically closed. Puncture wounds are classified by full and partial thickness.

Venous insufficiency wounds are related to the lack of blood flow returning to the heart. These wounds are a result of incompetent perforators, and typically seen in lower extremities. These wounds have a tremendous amount of drainage and are typically partial thickness. Four or three-layer compression is the goal standard for healing. Before compression, invasive or non-invasive vascular studies must be done to ensure good arterial flow. Do not compress extremities of diabetic patients unless completion of invasive examinations assure good arterial flow. Venous insufficiency wounds include the classification of partial and full thickness wounds.

Healing Cycle

Wound healing is an intricate, complex, and dynamic process in which the skin or another organ tissue repairs itself after injury. It is a series of events that occurs from the time of injury and continues with the wound closing. The body must complete this process to prevent infection and repair the area of damage. The healing process occurs in phases. Although different, the main steps often overlap from one phase to the next. For example, the difference between a chronic and an acute wound is the time from opening to closing. In addition, the causes for delayed healing are related to comorbidities, infection, and improper care of the healing tissue. As our understanding of wound healing progresses, further phases and subphases may be delineated. Therefore, it is essential to understand what the body does as the wound goes through the phases.

Phase 1 - Hemostasis Phase

When damage has occurred during a natural disaster, it takes a team with specific jobs to rebuild the community. So too, with wound healing.

First responders, with specialized skills, take care of the most crucial situations, sealing off dangerous areas. In the healing cycle, platelets in the blood are cell fragments that act as the “first responders,” sealing off the damaged blood vessels. The fibrin clot formed by the platelets creates the foundation for cells to move across. The many reactions of hemostasis are as follows:

• Invasion of normal bacteria from the skin into the wound causes the body to produce white blood cells.
• Fibrinolysis - the breakdown of the fibrin clot to further cell migration and move to the next phase of wound healing.

Phase 2 - Inflammatory Phase

In the wound healing analogy, the next job to be done once the “dangerous areas are sealed” is to clean up the debris. The body assigns this job to the “clean-up crew.” These are the neutrophils or PMNs (polymorphonucleocytes).

The inflammatory response causes the blood vessels to become leaky, releasing plasma and PMNs into the surrounding tissue. The neutrophils “eat” debris which includes bacteria and dead cells. Mast cells in the blood assist with this process.

With the breakdown of the fibrin part of this “clean-up,” the degradation products attract the next cell. The task of rebuilding a community is complex and requires someone to direct this activity, like a military commander. The macrophage is the cell that acts as “commander in charge” in wound healing. Macrophages can eat bacteria and provide a second line of defense. This phase shows increased warmth, redness, and edema. The symptoms are not to be confused with the first signs of infection.

To identify infection is to know the signs and symptoms. Pain is an important factor, along with warmth, redness, erythema, edema, changes in drainage, and wound measurement, to name a few. During this time of wound healing, the following takes place:

• The body increases the amount of fluid in the area, causing the breaking down of the fibrin clot and increasing the permeability of vessels, which in turn activates the complement system.
• The complement system continues the destruction of bacteria by working with the white cells.
• The release of cytokines bolsters the repair process by increasing cell proliferation, migration, matrix synthesis, and inflammatory response.

Phase 3 - Proliferation/Repair Phase

In the wound healing analogy, builders move in to construct the new community after clearing the site of debris under the commander's direction. Other team members can now install new infrastructure. Fibroblasts secrete the collagen frame and further dermal regeneration. In this phase of wound healing, there is the formation of granulation tissue and filling in of the wound bed, from the base to the top. During this phase, the surgical patient is at a high risk of dehiscence. The following is happening during this time of wound healing:

• The Type III collagen created by fibroblasts decreases the tensile strength.
• Protein need increases the need for the creation of growth factors and angiogenic factors. Angiogenesis is the formation of new capillaries and the repair of injured capillaries.
• The formation of granulation tissue uses the formation of the extracellular matrix to move from one side of the wound edges to the other side.
• Epithelialization, which is the migration of cells across the extracellular matrix.
• Wound contraction is the movement of the wound edges closer using fibroblasts and myofibroblasts.

Phase 4 - Remodeling/Maturation Phase

Once completing the basic structure, the interior structure may begin. So too, in wound repair. The healing process involves remodeling. In this phase, the wound is moving to finish closure and rebuilding of tissue inside of the wound bed. This phase can take up to one year to complete, and the damage will remain weaker than the original tissue.

• There is a replacement of granulation tissue, made up of fibroblasts and myofibroblasts, with collagen tissue which increases tensile strength.
• Scar formation that is neither vascular nor cellular, is made of collagen and used to increase tensile strength.
• Remodeling will increase the tensile strength to only 70%-80% of the original tissue when completed.

Although the definition of categories of wound healing can vary, the ultimate outcome of the healing process is the repair of damaged tissue.

Key Points

The definition of an acute and chronic wound has changed many times over the years. Recent research defines acute as progressing in an orderly, rapid, uncomplicated, and organized fashion. Chronic would be the opposite, including an increased chance of infection, the buildup of bioburden, and the resulting financial drain on the healthcare system and the patient’s quality of life. Knowledge of each phase of wound care and the changes that must occur is key to decreasing the cost of healing and increasing the quality of life for the patient.

Phase 1 is essential to stop the body from continually bleeding and to bring in the white cells to fight bacteria that have entered the outer skin. In addition, it is necessary to maintain homeostasis and start the wound healing continuum.

Phase 2 is a continuation and the start of the inflammatory phase. This phase is when the white cells control the number of bacteria in the wound. In this phase, observation of the wound for differences between normal signs and symptoms and signs and symptoms of infection is vital. For example, the increase in pain, a noted fever, and an increase in the size or no changes in the wound would indicate an infection.

Phase 3 is when the wound continues to fill in and begins true healing. There is movement from the base of the wound to the top. There is a filling with granulation tissue and collagen matrix to complete the healing process. There is an increase in protein needed during this phase to help with the building of the matrix.

Phase 4 completes the healing cycle with scar formation and exchanging fibroblasts for myofibroblasts. The importance in this phase is regrowth, increasing tensile strength, and completion of wound healing.

Identification of Infected Wounds

Our skin has many microorganisms creating colonization of natural flora. When the skin breaks, the microorganisms can enter deeper areas of tissue and multiply. Therefore, each dressing change should monitor the wound to ensure no progression from colonization to infection. If the wound becomes critically colonized or infected, it is often necessary to address the problem and bring the wound back to the colonized level. Controlling microorganisms is essential using dressings and antibiotics. When there is a definite indication of deep tissue infection, the standard of care is to culture the wound bed. The best practice of wound cultures is to be sure the wound is well cleansed, free of necrotic tissue, and performed to collect only the wound bed.

In a colonized infection, there is a movement of bacteria into the wound bed with some microorganisms starting to multiply without overt signs of infection. The wound bed shows no signs of infection or interruption in healing. An analogy would be: People happily living together without one person being more potent than another.

In a critically colonized infection, the number of microorganisms has increased, causing the body to respond by returning to the immune phase. The microbes in the wound are growing faster than they are dying, thus delaying healing. This type of wound lacks clinical signs of infection, despite supporting a bacteria level close to the maximum level the patient can tolerate. The patient’s immune defenses are simply not strong enough to prevent the wound from moving from one stage to the next.

“The critically colonized stage is the calm before the storm. By recognizing trouble now, you can initiate appropriate treatment before the balance is tipped further and deeper tissue infection occurs” – Connie Sarvis, RN, CON(C), CWD, IIWCC, MN, FCCWS

There is no need for an oral antibiotic as much as the use of an antimicrobial dressing to help support the continuation of wound healing. One of the indications of infection present is the lack of wound progression.

The mnemonic NERDS by Baranoski & Ayello, 2012 explains the best signs and symptoms to monitor:

N = non-healing wound.

E = exudative wound or change in the exudate coming from the wound by amount and color.

R = red and bleeding wounds or a change in the tissue in the wound bed, where the wound bed bleeds easily.

D = debris found in the wound bed, or necrotic tissue.

S = smell/odor emanating from the wound that is not related to the type of dressing. When these symptoms occur, the wound is a local infection, and the patient is NOT symptomatic.

An infected wound is present when the number of microorganisms causes tissue damage and often a systemic reaction by the body. The systemic reactions include an increase in skin temperature and body temperature.

The mnemonic STONES by Baranoski & Ayello, 2012 is as follows:

S = size is bigger.

T= temperature increase in the patient and area surrounding the wound.

O = osteomyelitis; that is, one can probe to the bone, see exposed bone, or feel bone in the wound.

N = new areas of breakdown.

E = exudate, erythema, edema present surrounding the wound and coming from the wound.

S = smell not associated with the dressing.

When there is a systemic or deep tissue infection, the wound must be addressed with antibiotics therapy and can also include an anti-microbial dressing. Culturing the wound bed will ensure the antibiotic chosen will kill the bacteria present.

Cultures should be done on cleaned wound beds only and in a Z-pattern, ensuring to cover the whole wound bed. An infected wound identified, with a detailed assessment, will determine the extent of the problem and get to the depth of the issue.

Pressure Injuries

The National Pressure Injury Advisory Panel (NPIAP) defines a pressure injury as localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to medical or other devices. Medical devices include oxygen tubing, catheters, and casts. The damage occurs due to a lack of oxygen and blood flow to tissue, causing cells to die and breakdown to occur. That is why off-loading is very important for preventing and curing pressure injuries.

Pressure injuries are a significant cause of increased mortality and morbidity, physical disfigurement, and prolonged hospitalizations. These injuries are one of the costliest preventable problems for long-term care residents. More than 3 million people in the United States each year develop pressure injuries. Immobile people are at the highest risk of developing pressure injuries.

The cost of pressure injury treatment and chronic wound care in the United States is estimated to be in the tens of billions of dollars annually. In a research study reported in 2019 in the International Wound Journal, estimations show that 8.3% of acute care patients develop hospital-acquired pressure injuries (HAPI) at an incremental cost to hospitals of $10,708 per patient. (Padula & Delarmente, 2019)

Study results show a wide variability of statistics. A recent report states that in acute care settings in the United States, the incidence of pressure injuries is 0.4% to 38%; within long-term care, it is 2.2% to 23.9%, and in-home care, it is 0% to 17%.

The Braden Scale for Predicting Pressure Injury Risk which will be described in detail later in the course is the assessment tool most often used in home healthcare, nursing homes, and hospitals. The Braden Scale assesses the patient for the following six areas: sensory/cognitive perception, moisture, activity, mobility, nutrition, and friction and shear.

Prevention Plan

The essential part of any pressure ulcer prevention program is not to base it on only one dressing or wound bed. Instead, the program should utilize staff input, patients’ statistics, and accurate analysis of problems on an ongoing basis in conjunction with advances in medicine.

The Agency for Healthcare Research and Quality (AHRQ) offers a Pressure Injury Prevention in Hospitals Training Program to help support staff trainers with implementation of their Preventing Pressure Ulcers in Hospitals Toolkit. Training materials and resources include a more than six-hour curriculum broken up into five modules covering such topics as the rationale for change, best practices in prevention, how to implement a program and measure rates.

This program was piloted in 11 hospitals for a two-year period and showed a sustained reduction in stage 2 hospital acquired pressure injury rates The website (https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressure-injury/index.html)contains links to all program materials including fully scripted slide presentations.

Risk Factors

Anyone with limited mobility is at risk of developing pressure injuries. Immobility may be due to:

• Generally poor health or weakness
• Paralysis
• Injury/illness that requires bed rest or wheelchair use
• Sedation
• Recovery after surgery
• Coma

Additional Risk Factors

Age. The skin of older adults is generally more fragile, thinner, less elastic, and drier than the skin of younger adults. Also, reproducing new skin cells is a slow process. All of these conditions of the skin make it more vulnerable to damage.

Lack of sensory perception. Spinal cord injuries, neurological disorders, and other conditions can result in a loss of sensation. For example, an inability to feel pain or discomfort can result in not being aware of bedsores or the need to change position.

Weight loss. Weight loss occurs during prolonged illnesses, and muscle atrophy and wasting are common in people living with paralysis. The loss of fat and muscle results in less cushioning between bones and a bed or wheelchair.

Poor nutrition and hydration. An adequate amount of fluids, calories, protein, vitamins, and minerals in the daily diet are essential for maintaining healthy skin and preventing the breakdown of tissues.

Urinary or fecal incontinence. Problems with bladder control can significantly increase the risk of pressure sores because the skin may frequently be moist, making it more likely to break down. In addition, bacteria from fecal matter can cause serious local infections and life-threatening infections affecting the body.

Excess moisture or dryness. Skin moist from sweat, or excessively dry is more likely to be injured in general and increases the friction between the skin and clothing or bedding.

Medical conditions affecting circulation. Because specific health problems, such as diabetes and vascular disease, affect circulation, parts of the body may not receive adequate blood flow, increasing the risk of tissue damage.

Smoking. Smoking impairs circulation and reduces the amount of oxygen in the blood. Therefore, smokers tend to develop more severe wounds, and their wounds heal more slowly.

Decreased mental awareness. People with a diminished mental understanding of their disease, trauma, or medications are often less able to take the actions needed to prevent or care for pressure sores.

Muscle spasms. People with muscle spasms or other involuntary muscle movements may have an increased risk of wounds from frequent friction or shearing.

Causes

Three different tissue forces likely cause pressure injuries:

1. Pressure, or the compression of tissues and/or destruction of muscle cells. The force of bone against a surface causes a reduction in blood flow. When a patient remains in a single position for a lengthy time, this results in compression. After an extended amount of time with decreased tissue perfusion, ischemia can lead to tissue necrosis if left untreated. External devices can cause pressure, such as medical devices, braces, and wheelchairs.
2. Shearing, or the force created when a patient's skin stays in one place. The deep fascia and skeletal muscle slide down with gravity and cause the pinching off of blood vessels, which may lead to ischemia and tissue necrosis. Friction is related to shearing but is considered less important in causing pressure injuries.
3. Microclimate factors, including the temperature and moisture of the skin in contact with the surface of the bed or wheelchair. Moisture on the skin causes the skin to lose the dry outer layer and reduces the skin's tolerance for pressure and shearing. The aggravating situations include other conditions**,** such as excess moisture from incontinence, perspiration, or exudate. Over time, this excess moisture may cause the bonds between epithelial cells to weaken, thus resulting in the maceration of the epidermis. Therefore, the temperature is also a significant factor.

Pathophysiology of Pressure Injuries

Source: Used with permission of the National Pressure Ulcer Advisory Panel 11/2013 © NPUAP

Figure 1

Pressure injuries may be caused by inadequate blood supply and reperfusion injury when blood re-enters tissue. A simple example of a mild pressure injury may be experienced by healthy individuals while sitting in the same position for extended periods of time: the dull ache experienced is indicative of impeded blood flow to affected areas. Within two hours, a shortage of blood supply (ischemia) may lead to tissue damage and cell death. The injury will initially start as a red, painful area. The other process of pressure injury development is seen when pressure is high enough to damage the cell membrane of muscle cells. This is the deep tissue injury form of pressure ulcers and begins as purple intact skin.

Staging of Pressure Injuries

NOTE: Staging is only for pressure injuries. All other ulcers (wounds) are classified as partial or full thickness, including incontinence-associated damage.

A pressure injury that is not off-loaded will not heal properly. Not compressing a venous stasis wound decreases the ability of the body to rid the area of extra fluid. The excess fluid slows down the wound from moving through the healing cycle. As a result, the venous wound will increase in number and size. An arterial wound that lacks blood flow does not have enough oxygen to promote proper wound healing.

With this in mind, the stages of wounds are as follows:

Other Types of Ulcers

Arterial insufficiency ulcers are severe and difficult to heal. Thorough health history of the patient should include skin itching and the location of the pain. On assessment, these ulcers are on the lower part of the legs and feet. Arterial ulcers happen as a result of trauma or infection. Arterial wounds are generally pale in color, have distinctive borders, and are pale gray or yellow in the base. Often these ulcers are deep, showing tendons, bones, fascia, muscles, and joint structures in the ulcer. With ischemia present, the ulcer cannot heal well or completely. In addition, these ulcers can lead to gangrene or tissue necrosis. Testing needs to be complete with the assessment to include the following: capillary refill, bringing the leg to 45 degrees equals ischemia, loss of hair on legs and feet, and thickening of nails. Often these patients need to have follow-up studies done, to assess the possibility of increasing blood flow to the area.

The following are three examples of arterial insufficiency ulcers:

Venous insufficiency is related to the inability of the venous system to return blood to the heart. Superficial veins communicate with the deep veins via perforator veins. If you imagine the two legs of the letter “H,” the perforator vein is the connection between the two legs of the letter “H.” That connection, a perforator vein, is the part that perforates the muscle fascia and connects the deep veins with the superficial veins. With incompetent perforators, the pathway and flow from the superficial veins to the deep veins is compromised. Incompetent perforators, decreased muscle strength and enlarged veins are the reasons for the insufficient venous return.

With venous insufficiency there is an increased chance of infection and skin breakdown. The slightest injury to the skin and/or increased pressure on the skin surface will create a wound that will not heal appropriately. The physical assessment should include the appearance of hemosiderin, edema, varicose veins, and lipodermatosclerosis. The assessment of these ulcers also needs to include the lymphatic and arterial systems. In healing venous ulcers, compression is the gold standard with determining use by assessment of arterial blood flow, to ensure compression will not affect the arterial system. The focus on non-invasive studies is essential unless the patient has diabetes. For diabetic patients, an invasive vascular study can be used to assess blood flow and increase blood flow.

The following are three examples of venous insufficiency wounds located on the pretibial and medial supra-areolar areas of the ankle:

Diabetic foot ulcers are more severe and can lead to an increased chance of amputation. Most often, the causes of open areas are improper shoes, walking barefoot, and accidents. The risks include loss of blood flow to the feet, neuropathy, and uncontrolled blood sugar. People with diabetes often have foot deformities, including Charcot foot, which is the widening of the foot, including misshaping from the breakdown of bones. It is essential to teach these patients never to go barefoot and check their feet daily. Diabetic patients can become septic with infection quickly. People with diabetes rarely run a fever with a diabetic foot ulcer, but they will have increased blood sugar readings if there is an infection. An exposed bone will often equal osteomyelitis and should not mean amputation.

The following are three examples of diabetic foot ulcers:

Traumatic wounds include wounds that occur due to cuts, burns, abrasions, motor vehicle accidents, gunshots, or animal bites. Some trauma wounds are superficial lacerations and will heal by primary intention depending on location and type, such as can be the case with skin tears when edges can be realigned to the normal position and skin flaps reused. Extensive lacerations need debridement and sometimes multiple debridement’s to reach the healthy tissue. Wounds not closed after six hours of injury are considered contaminated and will not heal by primary intention. The importance of traumatic wounds is a complete patient assessment to assure knowledge of how the trauma occurred and how best to promote healing.

The following are three examples of traumatic wounds:

Surgical wounds are described as wounds that have not healed by primary intention. Because of extrinsic and intrinsic causes, these surgical incisions need to heal by secondary or tertiary intention. The assessment of a surgical wound needs to include why the patient had the surgery and the patient's comorbidities. The evaluation of an incision line should ensure that the incision has healed properly, checking the incision for any indication it did not heal from the base to the surface. The dehiscence of the surgical line is a full-thickness wound since most surgery involves all layers of the skin. Partial-thickness wounds would only include the first two layers of skin.

The following are two examples of surgical wounds:

Assessing Vascular System and Arterial Status

Non-invasive and invasive vascular assessments are used to evaluate blood flow for healing and to indicate the appropriateness of compression.

The Ankle Brachial Index (ABI) is a measure of ankle blood pressure divided by arm blood pressure specifically: divide the higher dorsalis pedis or posterior tibial systolic by the higher of left or right brachial pressure. A result of less than 1 suggests vascular disease. Compression therapy can be considered for patients with 0.8 -1.0 range. It is contraindicated with an ABI of less than 0.7. Test results may be less reliable for diabetic patients and for those with stiff blood vessels and calcifications.

An ABI assessment needs practicing before performing. This technique takes training on how to listen to the doppler sounds. The ABI will not locate an occlusion or stenosis. More studies may be needed if the assessment shows arterial insufficiency.

Problems to watch for are:

• Increased pain with compression.
• Increased size of the wound.

Be sure to inform the doctor immediately.

This video below by the Stanford University School of Medicine shows a doctor performing the test and includes audible pulses.

Source: https://www.youtube.com/watch?v=KnJDrmfIXGw

Figure 2

The Toe Brachial Index (TBI) is useful to assess perfusion for patients with vascular stiffness, since toe blood vessels are less susceptible to stiffness.

For diabetic patients with known arterial disease (PAD) or vascular calcifications, assessing arterial status is best done by use of an angiogram, especially when there is a foot wound related to the compromise of minor arterials.

A Transcutaneous Oxygen Measurement (TCOM), also referred to as transcutaneous oximetry, is noninvasive and can be the first assessment by trained professionals to measure subcutaneous oxygen level near a wound. It is necessary to perform a TCOM assessment before performing hyperbaric oxygen therapy on a patient.

Skin perfusion pressure (SPP) can predict wound healing by detecting the circulation of subcutaneous tissue and its readings are not affected by vascular calcifications.

Key Points

The most common ulcers include pressure injuries, venous insufficiency, diabetes, and arterial and surgical ulcers. In addition, atypical wounds, though not common, do often occur. These wounds are related to uncommon location and appearance and do not respond to conventional therapy. These factors are essential when deciding what is best for the patient and healing the wound.

Pressure injuries are located over bony pressure areas and are related to the depth of the wound bed. Stages include the following:

• Stage 1 - a reddened area that does not go away immediately but will when off-loaded for 30 to 60 minutes.
• Stage 2 - first two layers of skin, superficial.
• Stage 3 - down to the fascia of the wound bed.
• Stage 4 - down to the bone and including the bone.
• Non-stageable – wound base cannot be visualized because of necrotic tissue. Deep tissue injury is a pressure-related injury to subcutaneous tissues UNDER intact skin with the potential for rapid deterioration.
• Deep tissue injury - purple to deep red, not open, with damage of the underlying soft tissue that can extend to the bone.
• Device-related pressure injury - includes injuries related to pressure from devices that include air tubing, CPAP masks, and catheters, to name a few.
• Mucosal pressure injury - over mucosal layers of skin, including the mouth and anal area, that is not staged and device-related.

Leg wounds can be caused by venous insufficiency, arterial insufficiency, or both. Venous insufficiency wounds located between the knee and the ankle have a lot of drainages, are ruddy, not painful, and irregular in shape. Arterial insufficiency wounds are located from the ankle to the foot, have little to no drainage, pale granulation, or pain, and are round in shape. With venous insufficiency, compression is the only way to increase healing, and three-to-four-layer compression is the gold standard. Before doing compression, arterial studies must be done to assure there is good blood flow. With arterial wounds there needs to be medical intervention to increase arterial flow, or the wounds will not heal.

Diabetic wounds are the most challenging wounds to heal. There are many problems with healing diabetic wounds such as possible arterial insufficiency, neuropathy, uncontrolled blood sugars, increased infection rate, and slow wound healing. The healthcare professional must focus on blood sugar control, arterial studies, and comorbidities along with the wound and diabetes and educate the patient. It is essential for the patient and their caregivers to learn the signs and symptoms of infection, especially with diabetes.

Traumatic wounds result from injury to the area, not to be confused with skin tears. Traumatic wounds can be complicated by comorbidities but not caused by them. For example, if a person with diabetes has a stab wound, it will heal more slowly due to uncontrolled blood sugar. A traumatic wound can result from gunshots, stabbing, burns, motor vehicle accidents, abrasions, and animal bites, to name a few. Often traumatic-wound patients need mental health support related to the trauma and support of both the emotional and physical aspects to heal the wounds. These wounds are either full thickness or partial thickness.

Surgical wounds are the result of an incision that did not heal correctly. This healing is complicated by infection or comorbidities. The total assessment of the wound for undermining and tunneling is essential to ensure that under the incision, no pockets of infected area are left. Most surgical wounds heal best using negative pressure wound therapy (NPWT). These wounds are either full thickness or partial thickness.

Wound Assessment

The first assessment needs to include a complete head-to-toe review, including how the patient views the wound and their quality of life. The assessment should include questions such as: “What is your plan for the future?”, “How do you feel about your wound? , “What do you view as important now?”, and “What do you see as the priority of your treatment and for your treatment at this time?”. Many professionals forget the patient assessment when assessing the wound.

Direct wound assessment is essential to indicate the progression of the wound, detrition of the wound, and support for the dressings. A visual evaluation, verbal subjective history from the patient, and complete assessment of the wound will assist with a positive outcome and aid in diagnosing the type of wound. In addition, it is essential to understand that wounds can be caused by pressure (most common), venous/arterial insufficiency, surgery, trauma, and diabetes.

Measuring and Assessing Ulcers and Wounds

An important aspect of measuring and assessing ulcers and wounds is documenting the progress of healing or lack of progress. Healthcare professionals measure wounds weekly and inform physicians of any changes. The assessments must contain the following information: type, anatomic location, age, size, shape, stage, sinus tract, tunneling, undermining, fistula, exudate, sepsis, surrounding skin, maceration, edges, epithelialization, necrotic tissue, tissue inside of the wound bed, and pain assessment. Medicare/Medicaid and other government health programs stress the need to do a complete evaluation so that the assessment supports a written plan of care.

When assessing the patient with or without a wound, it is essential to understand the patient’s risk of developing a pressure injury. In addition, with many changes in government regulations, it has become necessary for hospitals, skilled nursing home facilities, home care agencies, and transitional care companies to specifically and thoroughly document wound-healing progression.

The Braden Scale

The Braden Scale is the most widely used scale to assess the patient and the potential risks of developing a pressure injury. It is a summary rating scale made up of the following six subscales to accurately predict a patient’s risk for a pressure wound.

1. Sensory perception
2. Activity
3. Mobility
4. Moisture
5. Nutrition
6. Friction and shear

Subscale definitions and guidelines are as follows:

Sensory Perception	Skin Moisture
This is the patient’s ability to know not only their whereabouts but also the ability to feel their position or pain in the area. A score of 1 = Completely limited by answering these questions: Does the patient shift weight when sitting too long? Does the patient show any emotion related to pain? A score of 2 = Very limited Does the patient only respond to painful stimuli by moaning or becoming restless? Does the patient only feel half of their body? A score of 3 = Slightly limited Does the patient respond to verbal commands, but cannot always communicate discomfort or the need to turn? Do some sensory impairments limit the patient’s ability to feel in one or more extremities. A score of 4 = No impairment The patient has no problems with being aware of pain or discomfort of body parts.	This is the patient’s current way of staying dry. At present, is the patient incontinent, sweating a lot, or damp? A score of 1 = Patient is always moist/wet, unable to verbalize that he/she feels wet or in discomfort, and the linens are changed often throughout the shift. A score of 2 = Patient is often moist/wet, and linens are changed once per shift. A score of 3 = Patient is sometimes moist/wet, and linens are only changed once per day. A score of 4 = Patient is never moist/wet, and linens are not frequently changed.
Activity	Nutrition
This measures the patient’s ability to change position often without help from others. A score of 1 = The patient is bedfast. A score of 2 = The patient can move with help from the bed to a chair or wheelchair. A score of 3 = The patient can walk a moderate distance with a walker or help, or unassisted for short distances. A score of 4 = The patient has no problems walking around or getting her/himself out of bed.	This measures the patient’s ability to take in food and nutrients as a daily diet sufficient to satisfy everyday needs and healing needs. A score of 1 = The patient cannot eat or take in any nutrition, or is NPO (nothing by mouth) and/or on clear liquids or IV fluids for more than five days. A score of 2 = The patient is unable to take in more than half of the nutrients needed for daily calories. The patient is on a liquid diet or receiving tube feedings. A score of 3 = The patient can eat more than half of a meal and consumes most of the protein needed to heal the body. Alternatively, the patient is receiving TPN (total parenteral nutrition) or tube feedings that meet nutritional needs. A score of 4 = The patient has no problems taking in the calories and nutrients needed for metabolism or healing needs.
Mobility	Friction and Shear
This measures the patient’s ability to move in bed or change positions. A score of 1 = The patient is immobile, unable to move in bed. A score of 2 = The patient is limited in their ability to move and needs help repositioning and turning. A score of 3 = The patient makes frequent, but only slight changes in body position on their own without help or assistance. A score of 4 = The patient makes all changes in body positioning without problems or assistance.	This measures the patient’s ability to move themselves in bed while keeping themselves from sliding against sheets or decreasing the potential of harm related to sliding down in bed. A score of 1 = The patient cannot move themselves up in bed. Once sliding down in bed, the patient needs maximum help getting back up. Contractions, spasticity, or agitation lead to constant friction and increased breakdown in the skin. The patient is in restraints or other means that restrict the ability to move freely. A score of 2 = Patient requires some assistance and can keep position in chair or bed most of the time. A score of 3 = The patient has no problem with friction or shear. The patient can move independently in a chair or bed by lifting oneself up and can maintain a good position. By scoring these correctly, the interventions of keeping the patient from breakdown will be appropriate to help assure no skin breakdown or limited skin breakdown.

Scoring

Total scores range from 6- 23. A lower Braden Scale score indicates lower levels of functioning and, therefore, a higher risk for pressure ulcer development.

The subscales measure the functional capabilities of the patient that contribute to either higher intensity and duration of pressure or lower tissue tolerance for pressure.

Each functional category is rated a subscale on a scale of 1 to 4 (excluding the “friction and shear” category rated on a 1-3 scale). The score combines for a possible total of 23 points, with a higher score meaning a lower risk of developing a pressure ulcer and vice-versa. A score of 23 means there is no risk for developing a pressure ulcer, while the lowest possible score of 6 points represents the severest risk for developing a pressure ulcer.

The Braden Scale assessment score scale:

• Very High Risk: Total Score 9 or less
• High Risk: Total Score 10-12
• Moderate Risk: Total Score 13-14
• Mild Risk: Total Score 15-18
• No Risk: Total Score 19-23

A note on The Braden Scale: A commercial entity purchased the Braden Scale in 2021 and on Sept. 27, 2022 announced the release of the Braden Scale II^© and Toolkit, with enhancements and more modern language.

Anatomic Wound Location

It is important to note the exact location of the wound rather than general locations such as hip or buttock.

Include the following information for wound location:

• Superior - above a wound or anatomic location
• Inferior - below a wound or anatomic location
• Lateral - outside part of the body
• Medial - toward the middle part of the body
• Interior - front part of the body
• Posterior - the back part of the body

Measuring Wounds

Wound measurement must include the shape and size of the wound. The method for measurement must be consistent each time a measurement is made. Measurements are in centimeters.

Figure 3

The most common measurement method is the Clock Method, which considers the wound as the face of the clock. The wound positioning should be aligned with the standard anatomical positioning of the patient (arms down by the side, palms facing anteriorly, with thumbs facing away from the body), the head being 12:00, the feet at 6:00. For the feet, the heels are at 12:00, and the toes are at 6:00.

• Length – Head-to-toe measurement to include time on the clock. If not, at the exact 12:00 and 6:00 parts of the clock. Example: The wound length is measured from 1:00 to 7:00 and is 5cm.
• Width – Side-to-side measurement to include time on the clock, if not at the exact 3:00 and 9:00 parts of the clock. For example, the wound width measured from 4:00 to 10:00 is 10cm.
• Depth – Distance from the skin’s surface to the bottom of the wound.

Assess Drainage

The assessment of the amount of drainage is given in terms of the percentage of the dressing that has visible drainage on it. In other words, how much of the dressing has drainage on it. A rule of thumb is: ¼ or less means small or scant, ½ to ¼ is medium, and ½ or greater would be large. An increase in drainage could be one sign of infection. Check for other signs and symptoms of infection. Drainage is also documented using the following terminology.

• Serosanguineous is a combination of blood and serous drainage. The drainage would be thin watery, pale red, or pink in color.
• Serous is a clear fluid.
• Sanguineous is bloody flow.
• Purulent drainage is thin or thick and sometimes yellow or brown and may be malodorous. A wound is in the inflammatory stage of wound healing, or indicates infection. If infection is a concern, silver may be applied for a short time.

Assessment of Wound Bed

These tissue types and amounts need to be noted in the wound assessment and add up to 100%. Example: Black Eschar 10%, Yellow Slough 90%.

Granulation tissue in a wound is an indication of good healthy tissue. The tissue is red and will continue to move upward.

Hypergranulation tissue is red to pink in color and often rises above the wound bed. It appears bumpy and not like smooth granulation tissue. These signs indicate the cells have too much fluid, and the dressing is not pulling the fluid from the wound bed.

Slough tissue is yellow, fibrous, necrotic tissue that is nonviable. This tissue, from the inflammatory phase of healing. can sometimes be loose and easily removed, or adheres to the wound bed and is in need of debridement. Slough tissue is a collection of fibrin, bacteria, dead cells, and wound fluid.

Black eschar is black or brown tissue that is hard and non-viable. Eschar can be yellow slough that has dried out or tissue that has lost the blood supply to remain healthy. This tissue will inhibit wound closure. Removing this tissue is needed in most wound locations, except areas on the feet.

The feet are often the first to lose blood supply, and debridement will only create a deep wound that will be difficult to heal. When intact and hard, the eschar covers only with a dry dressing or using an agent that will promote dryness and anti-infecting qualities. The idea is to keep the area dry and intact until complete healing and the eschar falls off.

Assessment of Wound Edges

Attached edges are normal and indicate the presence of wound healing. The cells will continue across to form wound contraction.

Non-attached wound edges could indicate the wound bed is surrounding bone, a wound that has rolled or epibole, or a wound that is not healing correctly. Only by debridement of wound edges will the wound continue to heal.

Wound edges that are not distinct could indicate that the wound bed is at the same level as the edges, and epithelialization is occurring.

Calloused wound edges indicate rubbing or pressure close to the wound. The body is trying to protect the area. Debriding the edges ensures that the edges will continue to move toward healing.

Rolled or epibole edges often indicate that the wound has been kept dry, and the edges seek moisture to finish wound healing. Therefore, these edges need to be surgically re-opened so that the granulation tissue can continue to move across the wound bed and create an epithelized wound.

Macerated wound edges are soggy and white. This dressing is not controlling the drainage, and if not controlled, the edges will breakdown to promote an increase in wound size.

Surrounding Tissue Assessment

Hemosiderin staining - Chronic venous stasis changes the skin texture and elasticity, resulting in a brownish discoloration of the lower legs. This staining occurs when the pressure in the veins causes the red blood cells to break. When the red blood cells break, they leak out hemoglobin. Hemoglobin contains iron, leaking into the tissue and staining the skin. The staining is related to the venous system's decreased ability to remove the blood back to the heart. The skin around the ankle area can no longer adapt to swelling and breaks open and seeps, leading to a painful venous stasis ulcer.

Erythema - Warmth, increased pain, and increased drainage could indicate infection. Erythema is also present with the application and removal of three-to-four-layer compression dressing.

Induration - Indicates that the wound's edges have extra fluid around them. Induration could be related to the fluid collection or further breakdown of the edges. In addition, induration indicates that the wound has backtracked to phase 1, the inflammatory phase. Induration could be related to new trauma or a critically colonized wound. A silver dressing for 14 days can help to move the wound back to healing, after which time a regular dressing will continue the healing process. Silver dressings should not be the only type used throughout the healing process.

Scar tissue - May be slightly lighter to light pink surrounding, indicating past wounds that have healed recently or quite some time ago. Scar tissue is only 85% as strong as the original tissue.

Patient Assessment

Assessment of the whole person is as critical as wound assessment. Jean Watson states in her theory that nursing is an assessment of the entire person. In her theory of human caring, Jean Watson wrote, “The unity of human mind-body-soul as inseparable one whole.” Evidence-based care is based on both quality care and including the patient in creating a care plan for patient-centered care. Braden’s score uses some of this information to determine at-risk patients. The nurse doing the scoring must understand the importance of each section and how the scoring will help with prevention.

Age is not a specific score on the Braden assessment. Still, age affects wound healing in several ways: decrease in metabolism, decrease in blood flow, decrease in pain perception, and changes in skin composition. Older adult patients often have fewer fat cells, a reduction in skin elasticity, and a decrease in blood flow (especially in the lower legs). A reduction in fat cells increases the chance of pressure ulcers and suspected deep tissue injury. The decrease in skin elasticity creates an increased chance of skin tears and trauma wounds. With the reduction in pain perception, many patients cannot realize when they have touched hot objects or run into things. The decrease in blood flow increases the chance of venous and arterial insufficiency wounds. These patients must be encouraged to remain as active as possible, wear support hose**,** and eat a well-balanced diet. Age is also an indication of how quickly the wound will heal.

Mobility is an essential part of the Braden scale and accurate documentation. As discussed above, Braden assessment includes activity, mobility, and friction and shear. The degree of physical activity includes whether the patient is always in bed, confined to a chair, walks occasionally, or walks frequently. The Braden mobility assessment includes how well the patient can change and control body position. The scale range is entirely immobile, very limited, slightly limited, or no limitation. Finally, the assessment for friction and shear indicates a problem, potential problem, and no apparent problem. The assessment is essential to ensure the proper interventions are in place. For example, can a patient with venous insufficiency walk, put legs up, and exercise daily? A physical therapy referral will be important for helping to teach families and work with patients to ensure that the patient does activities which will help the patient to heal.

Nutritional status is an under-assessed yet essential factor in wound healing, which is why the Braden Scale also includes nutrition. The assessment needs intake: very poor, probably inadequate, adequate, and excellent. The healthcare professional must assess the patient’s nutrition by IV or TPN if the patient is NPO, for how long, and the type of supplemental nutrition. People may incorrectly assume an overweight or an obese patient does not require nutritional support. Regardless of weight, a patient who is not nutritionally sound will not heal and become very weak. Knowing the protein level is the most accurate way to assure good wound healing.

Labs need to include HbA1C to test blood glucose levels over the past three months, H&H (hemoglobin and hemocrit) to ensure enough blood cells to carry oxygen to the wound, and a white cell count to assess for the chance of infection. Another important lab is a comprehensive metabolic panel (CMP) to assess protein and albumin levels as well as kidney function. Protein and albumin are necessary to confirm that the wound has the essential elements to allow it to move through the phases. Every phase of wound healing requires protein to complete the healing process.

Comorbidities are essential factors in the assessment to ensure the whole picture of health is considered in the context of the healing cycle. For example, addressing the highs and lows of diabetic blood sugars will indicate healing, stress, and infection. Control of blood sugar levels will help wounds heal faster. Uncontrolled blood pressure or chronic heart failure causes increased leg fluid and decreased healing. A patient with a diagnosis of pneumonia, upper respiratory disease, and urinary tract infection, for example, is prone to have slower wound healing since the body is working on healing the widespread infection and cannot heal the wound. This information must be in the assessment to ensure an accurate picture of the patient. In addition, there needs to be an assessment of the medications since some medications interfere with wound healing.

Assessment of bowel and bladder control is critical and addressed in the Braden scale. It is important to note incontinence, even if that incontinence is temporary. A patient with C. difficile is going to have a stronger increase in breakdown than a patient who is incontinent of bowel and bladder. Diarrhea, especially C. difficile, is harsh to the skin.

Mental state and acceptance of the wound have an impact on how well a wound heals. The more stress and anxiety the patient feels, the greater the diminishment of the healing process. When a patient faces stress, it is a normal body response to go into fight or flight mode. Increased blood sugar pulls oxygen away from the legs and arms and increases mental alertness. The alertness will decrease the essential needs the wound has to move through the stages of healing. Therefore, monitoring depression and stress are elements to help assure homeostasis and proper healing.

Pain assessment is essential with each visit during wound care. An increase in pain would be an indication of infection. Pain with the dressing change would indicate the need to have medication. An increase in wound pain and an increase in a patient’s temperature warrants an immediate call to the physician.

Assessment of medications is essential since many pharmaceuticals can interfere with wound healing and others promote oxygenation to enhance wound healing. The effect of medicines on the body can either increase wound healing or decrease wound healing, depending on the drug interactions. Therefore, it is essential to understand what the drugs do in the body and how that will affect the healing process. For example:

• steroids and anti-inflammatories interfere with the immune response;
• anticoagulants decrease the body’s ability to produce fibrinogen;
• vasodilators increase blood flow; vasoconstrictors will decrease wound healing;
• antiseptics inhibit wound healing by reducing collagen formation; and

• vitamin C supports collagen formation.

Key Points

It is imperative to thoroughly assess both the wound and the patient on admission and throughout the healing process. Injuries are as complex and different as patients. The wound does not heal the patient, but the patient heals the wound. A description of the wound includes anatomic location using the clock time method, as well as shape, wound edges, and the patient’s pain level. Wound measurement must include the following: tunnels, undermining, depth, width, and length.

The wound assessment is not complete without a picture of the patient and the history of the wound. This includes comorbidities, medications, age, level of mobility, pain, mental status, and nutritional and spiritual status. A head-to-toe assessment ensures that the healthcare provider knows the patient—not just the wound. Use an assessment scale for predicting pressure injury risk. The Braden Scale, with its ease of use and inclusion of multiple risk factors and predictive validity is the most common assessment scale for predicting pressure ulcer risk.

Wound Dressing Choices

The proper dressing is difficult to choose at times. The first step is assessing the wound and the patient and understanding the dressing composition and how the dressing works. It is important to talk with the patient about any allergies and sensitivities to ensure that the chosen dressing does not contain anything that would cause an allergic reaction. Consider that while guidelines are helpful, the same dressing will not work on all patients. A dressing that provides optimal conditions for healing will promote faster healing. Moist wound healing is not just a slogan but is evidence-based care. The longer a dressing that maintains its integrity remains in place, the faster the wound heals.

The acronym MEASURES assists with the treatment decision and helps with the choice of dressing.

M = Minimize trauma.

E = Eliminate dead space.

A = Assess and manage exudate.

S = Support the tissue defenses.

U = Use nontoxic wound cleansers.

R = Remove infection, debris, and necrotic tissue.

E = Environmental factors such as humidity influence dressings and other aspects of the wound.

S = Surrounding tissue can be treated to decrease the chance of continued breakdown.

Many products in the market today promote wound healing within and through the phases of healing. There are also websites, organizations, and applications that enable communication with wound care professionals throughout the world. The array of available wound care products and published research evolves, so it is important to go beyond the basics and keep up to date. When possible**,** generic names should be used when writing dressing orders, and be sure the patient will have the ability to afford the dressing.

Primary dressings are those closest to the wound base. This dressing is responsible for creating the moist wound healing. The dressing will either give moisture to the wound or absorb the amount of drainage in the damage.

• Alginate dressings have fibers derived from brown seaweed or kelp. These dressings are available in a pad or a rope and can be impregnated with calcium, silver, or honey. The dressings become a gel when in contact with exudate. They are suitable for medium-to-high draining wounds and will provide hemostasis in bleeding wounds. Alginates are ideal for wounds with tunnels, undermining, and depth, and can be left in place from two to seven days.
• Collagen dressings are derived from bovine, equine, porcine, and/or avian sources. This dressing is a pad, sheet, particle, powder, and/or alginate and will sometimes have silver added. Collagen dressings are used with moderate-to-high drainage wounds. Collagen promotes granulation of undermining in wounds and are not suitable for wounds with greater than 1 cm depth. These dressings are designed to remain in place for a week and can be changed every three days if needed. Collagen will disappear into the wound bed.
• Hydrogel dressings (glycerin and water-based hydrogels) are available in gauzes, gels, and sheets. Hydrogels integrated with silver, collagen or medications are also available. These dressings are for dry wounds and can be used in place of a wet to dry dressing, since it can remain in place for two to three days.

Secondary dressings are responsible for protecting the wound from contamination when the primary dressing cannot. They support the primary dressing but do not come in touch with the wound directly.

Foam dressings are absorbent and can be a hydrophilic polyurethane or gel film-coated foam. The foam can be non-adherent, adhesive, absorbent, and silver coated. These dressings can remain in place for seven days, with the frequency of change dependent on the amount of drainage.

Advanced Therapies

This category includes dressings, procedures, and modalities used in wound care besides standard dressings.

• Tissue-engineered skin substitutes help wounds with epithelialization. These are expensive, fragile, and need protection throughout healing. They are usually applied by doctors in offices or wound clinics. The wound will require debridement to provide a good surface for granulation. A (non-adherent) contact layer will be placed over the skin substitute before adding padding and secondary dressing Use or lack thereof is often related to reimbursement issues and cost.
• Cellular and tissue-based products include nonviable, tissue-based human cells, tissue-based animal cells, and cultured and non-cultured viable human cells. The wound must be granulating and free from infection. Shelf life and storage requirements are key to the proper use of these products.
• Amnion-based graft products are cells created from the umbilical cord and amniotic sacs in the afterbirth of human birth. While traditionally used for burns, their use has expanded to include service in the wound bed of deep wounds. Proper directional placement of an amnion membrane’s stromal collagen layer facing the wound base is important.
• Negative-pressure wound therapy (NPWT or wound vac), also known as vacuum-assisted closure, is a technique that draws out liquid and promotes blood flow to the are by creating a vacuum and moist wound environment with the use of foam dressing and drape covering the area.
• Biophysical technologies include many modalities used in other healthcare settings: NPWT, hyperbaric oxygen therapy, kinetic therapies (including whirlpool, pulsatile lavage), electronic stimulation, electromagnetic field, phototherapy, and ultrasound (high and low frequency).
• Compression therapy includes three-layer and four-layer compression. Doctors use the treatment on legs primarily for venous insufficiency to treat venous leg ulcers (LVU). One needs to be very careful with the application and use of this type of therapy. Medically trained staff must assess arterial status before the application of compression dressings. Contraindications include uncontrolled congestive heart failure, abscesses, advanced peripheral neuropathy, and a brachial-ankle pressure index (ABI) of less than 0.8.

Key Points

Dressings are essential to wound healing. Through the healing phases, re-evaluating the wound and proper dressing choice helps to ensure effective wound management for each. individual patient. The patient also needs to be screened for allergies or sensitivities to ingredients used in dressings.

Conclusion

Wound healing represents the completion of the outcome of a large number of interrelated biological events in response to injury and its cellular environment. The immense economic and social impact of wounds in our society calls for allocating more research resources both to understand the biological mechanisms underlying the complexities noted in problem wounds, and to improve outcomes. In the US in an average year, more people die from hospital-acquired pressure injuries than from influenza or suicide. The five-year mortality rate for diabetic foot ulcers at 30.5% is comparable to the death rate from all cancers at 31%.

Glossary of Terms

Angiogenesis:

The process of producing blood vessels during the granulation phase of wound healing.

Autolysis:

The process of breaking down dead or devitalized tissue with enzymes.

Bioburden:

Dead cells and fluid that collect between dressing changes and need cleaning of the wound bed to allow healing.

Blanching:

The reddened area becomes white with pressure applied.

Cellulitis:

The inflammation or infection of skin cells causes redness, heat, pain, and edema.

Charcot:

A condition of peripheral neuropathy and diabetes. The bones in the feet dislocate, deform or fracture, causing the bottom of the foot to have the appearance of the boat's hull related to the arch collapsing. The rocker-bottom midfoot is at high-risk of developing an ulcer.

Collagen:

Protein is the main component of many major body parts and wound healing.

Contraction:

The process that brings together wound edges causing the wound size to become smaller. Measuring wounds over time will show healing or deterioration.

Detrition:

The mechanical process of wearing away by friction.

Epibole:

Non-healing wounds with closed rolled wound edges.

Exudate:

Fluid from the wound that can be serous, sanguineous, or purulent.

Fibrin:

A protein that is involved in the clotting process and is essential to the granulation phase of healing.

Fascia:

Connective tissue that covers muscles found throughout the body.

Fibroblast:

A critical cell in wound healing responsible for replacing fibrin with more substantial tissue.

Friable tissue:

Tissue that tears or bleeds easily; The existence can indicate infection.

Granulation tissue:

Red healthy tissue with good flow that will continue to heal.

Growth factors:

Upregulated proteins that bring cells to an area with tissue damage. The resulting cascade of effects facilitates wound healing.

Hemosiderin staining:

Discoloration of the lower leg caused by the release of iron from disintegrating red blood cells indicative of venous disease.

Intermittent claudication:

Pain related to poor or compromised blood supply. The pain is acute when walking and decreases with rest. An increase in pain often happens with leg elevation.

Ischemia:

The loss or deficiency of blood to an area.

Lipodermatosclerosis:

A skin and connective tissue disease that results in inflammation of the fat layer of the epidermis.

Maceration:

The whiteness and loss of intact skin around a wound caused by too much moisture. It occurs when a dressing is unable to pull or control excess fluid.

Necrotic tissue:

Dead tissue in the wound bed due to loss of blood flow. This tissue is usually black or brown and leathery.

Off-loading:

Removing the weight off an area to increase blood flow. Without off-loading, suspected deep tissue injury or chronic wound will occur.

Osteomyelitis:

Inflammation of the bone; bone infection.

Perforator veins:

Veins that form a pathway through muscle fascia to connect the superficial and deep venous systems of the legs.

Peri-wound:

Tissue surrounding the wound. This tissue needs to be assessed for warmth, color, or signs of discoloration, to indicate other problems.

Pink tissue:

Epithelial tissue can be shiny pink or white tissue.

Slough:

Yellow, stringy, dead cells that can adhere to the wound bed.

Tunneling:

Destruction of tissue around the infected area; a wound with channels extending from the central injury into the surrounding tissue, such as muscle and skin. These tunnels inhibit the wound’s healing.

Undermining:

The wound is spread out underneath the skin that surrounds the visible part of the wound. As a result, the wound is bigger than it appears at first glance.

References and Suggested Reading

American Professional Wound Care Association. (n.d). APWCA American Wound Care Association.https://www.apwca.org

Baranoski, S., & Ayello, E. A. (2020). Wound care essentials: Practice principles. (5th ed.) LWW.

Wound Care Advisor. (n.d.). Best practices.https://woundcareadvisor.com/best-practices/

Bryant, R. A., & Nix, D.P. (Eds.). (2016). Acute & chronic wounds: Current management concepts. (5^th ed.) Elservier.

Mometrix Media, LLC. (2021). CSOCN exam secrets study guide: CWOCN test review for the WOCNCB certified wound, ostomy, and continence nurse exam. (2^nd ed.). Mometrix Media, LLC.

Sen, C.K. (2021). Human wound and its burden: Updated 2020 compendium of estimates. Advances in wound care, 10(5), 281-292. https://doi.org/10.1089/wound.2021.0026

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National Pressure Injury Advisory Panel (NPIAP)https://npiap.com/

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