Today's wound care: a review.

Making sure that nursing home staff is up-to-speed

While wounds heal readily in healthy, active people, risk factors that interfere with the healing process are a given in the skilled nursing facility, where early detection and intervention are essential.

Thorough and regular examination remains the most effective way to detect wounds. For example, the immobilized stroke patient must be turned regularly and examined completely to avoid missing a forming decubitus ulcer. While some nursing homes have designated specific staff to detect and monitor all skin wounds, all members of the health care team should be taught to be careful observers.

Once a wound is identified it should be classified according to stage as follows: stage I - previous decubitus ulcer; stage II-reddened area only (no break in skin); stage III - reddened area with skin break, excoriation or blisters; stage IV - full-thickness loss of skin also involving subcutaneous tissue; stage V - full-thickness loss of skin involving deeper tissues (bone, muscle, tendon or ligament).

A written record of all observations, changes and events is mandatory, including the type of wound, location, any underlying chronic and/or acute medical problems, and the resident's overall hydration and nutritional status. Once a wound is classified, a system for regular monitoring must be instituted to help determine the rate and degree of progression or regression, development of infection, and indications for specialized treatments.

Wound assessment and systematic reassessment require a comprehensive evaluation of multiple parameters in addition to wound stage. These parameters, outlined in Table 1, provide a systematic approach for routine assessment of initial and ongoing risk and the development of new risk factors, along with a scheme for following the effectiveness of interventions.

These risk factors contribute directly and in combination with other processes to skin breakdown. Medical conditions, including diabetes mellitus, peripheral vascular disease, congestive heart failure, cancer, stroke with any associated paresis and immobility, should be maximally assessed and controlled. Impairment of blood supply is a major risk factor for the development of skin breakdown, delayed healing and wound perpetuation. Neurological processes with loss of sensation and immobility are also predisposing risk factors.

It is reasonable to assume that all patients with stroke or spinal cord lesions who are immobilized will develop decubitus ulcers if not turned regularly. The sacral, hip, heel, and ankle areas must be inspected for early signs of breakdown or ulceration. Once an early change is found, steps must be quickly initiated to relieve pressure.

Decubitus ulcers due to constant, unrelieved pressure on the skin overlying bony protuberances are, of course, common in residents with limited mobility. In some cases sensation may be decreased due to neurological problems. Other patients, including those with diabetes mellitus, may have neuropathic complications that cause loss of sensation in the legs. Pressure ulcers on the plantar surface of the foot can occur as well; the patient is not immobilized, but has lost sensation and does not take steps to relieve constant pressure that may be exerted on the foot. Pressure applied for less than two hours is enough to start the process. The first sign is redness. If unrelieved, skin breakdown occurs next. This ulcer can eventually penetrate to bone if not discovered early and treated aggressively.

Key to prevention is nursing care with particular emphasis on turning the immobilized patient every two hours, and the use of special beds and other devices such as heel pads to minimize pressure. If a decubitus ulcer forms, it will require debridement of the dead tissue. In some cases in which infection is present, antibiotics are indicated.

Factors that prevent healing despite removal of pressure include infections of subcutaneous tissue and muscle due to inadequate debridement or chronic osteomyelitis due to the proximity of the wound infection to bone. Another major factor is poor nutrition. If the patient is not ingesting sufficient protein to synthesize new tissue, or is not receiving sufficient calories to allow for the utilization of this protein, the wound will not heal.

Wounds resulting from tissue ischemia (low oxygen levels) heal poorly or not at all. Evaluation and treatment of reversible causes, such as anemia and cardiac ventricular failure, are indicated. It is essential to assess the blood supply of any wound, especially in the legs of diabetic or other patients with peripheral vascular disease. Angiography should be considered if there is inadequate arterial vascular supply to the wound site. A bypassable arterial lesion should signal the need for vascular surgical consultation. When the blood supply cannot be restored, the patient becomes a possible candidate for amputation.

A chronically infected wound also compromises healing. Evaluation for an underlying cause requires thorough examination for a nidus of infection precipitated by a foreign body, necrotic tissue or fibrin. Wounds with retained necrotic tissue will persist until this tissue is adequately removed. Appropriate antibiotic therapy is also required.

If the wound is infected by aerobic and anaerobic bacteria, hyperbaric oxygen therapy (HBO) can be a useful adjunctive treatment: more oxygen is dissolved into the blood, and a greater amount is supplied to the injured tissue for healing. HBO is highly useful in treating bone, for example, a very poorly vascularized tissue which, once infected, is very slow to heal, even with adequate antibiotics and surgical treatment.

Nutritional status is a crucial, but often overlooked, factor in wound healing. Adequate oral intake of macro- and micronutrients is vital and decreased intake, especially in an at-risk patient or one with existing pressure ulcers, exacerbates skin breakdown.

When the albumin level is lower than normal but above 2.5 gm/dl, wound repair is difficult. When the albumin is lower than 2.5 gm/dl, the wound will not heal. Once a patient is deemed malnourished or at risk for malnutrition by serum albumin level, prealbumin level, transferrin level and/or skin fold assessment, calorie and protein intake must be improved.

Inadequate caloric intake causing weight loss also leads to a reduction in subcutaneous tissue, thus allowing bony prominences to compress and restrict circulation to the skin. A large, draining pressure ulcer can produce a loss of up to 30 grams of protein per day. Table 2 outlines the risk factors in the elderly with nutritional and other implications for skin breakdown.

Nutritional intervention for a healthy person at risk for pressure ulcers, but with no skin breakdown, is a significant preventive approach. This should consist of helping to maintain a diet adequate for age and appropriate body weight and, when necessary, should include special supportive care (e.g., mechanical soft diet, dysphagia diet). The patient with an existing pressure ulcer experiences metabolic stress. In this case protein should be provided at 1.5 to 2.5 gm/kgm of ideal body weight. Caloric and carbohydrate intake should be maintained at 25 to 35 kcal/kgm of current body weight.

The diabetic patient presents a particular challenge, since poor blood glucose control contributes to impaired wound healing. For the obese patient, it is important that protein requirements are met while caloric intake is kept in check. Micronutrients (zinc, iron, magnesium, folic acid, etc) should be provided in amounts equivalent to the RDA or supplemented if a deficiency is suspected. When nutrient requirements aren't being met through oral intake, intensive nutritional support using tube feeding or peripheral or central parenteral modalities is indicated. The efficacy of nutritional care must be carefully monitored and nutrient needs reassessed by a dietitian.

Another important factor influencing wound healing is the status of the patient's skin. Skin that is continually exposed to urine and/or feces is much more apt to develop lesions than skin that is kept dry and clean.

Prevention, early detection and rapid, effective intervention are the hallmarks of a cost-effective wound care program in an at-risk and elderly population. Paramount to this is an optimally educated team of trained observers, educated in patient-focused care, with quality of care and quality of life as the prime objectives.

Table 1. Wound Assessment and Risk

General Health Status

Good Fair Poor Moribund

Underlying Medical Conditions

None Slight Contribution Moderate Contribution Severe Contribution

Mental Status

Oriented Lethargic Confused-Disoriented Comatose-Stuporous

Activity-Mobility

Ambulatory-independent Ambulates with assistance Chair-bound/assistance to position Bedfast/Chair-fast, immobile

Nutrition-Fluid Status

Food-fluid Intake [less than] 50%; Weight WNL; Adequate output Eats if fed, [less than]50%; Slightly under/over weight; Adequate output Inadequate food-fluid intake; Eats 30-50%; Moderately underweight or tube-fed None to very poor intake; 0-30% consumed; Cachectic; Obese

Incontinence Status

Rarely moist skin; Usually dry Occasionally moist; Requires [less than] 2 changes per 24 hrs. Skin often moist; Requires [less than] 2 changes per 24 hrs. No control; Wet every time checked

Skin Status

Normal Fair Poor Lesions Presents

Wound Stage

Stage O Stage I/II Stage III Stage IV/V

Table 2. Skin Breakdown Risk Factors

* Immobility

* Sensorium Impairment (Coma, Lethargy, Disorientation)

* Neurological Disease (Dementia, Stroke)

* Difficulty Chewing Due To Inadequate Dentition 

* Difficulty Swallowing

* Pain On Eating

* Gastrointestinal Discomfort That Cannot Be Expressed Due To Dementia or Aphasia

* Gastrointestinal Diseases (Malabsorption, Pernicious Anemia)

* Diabetes mellitus

* Poor Nutritional Status Due To Chronic Illness

* Poor Skin Status

* Low Body Weight

* Lack Of Nutritional Intervention Or Recognition Of Malnutrition

* Inadequate Protein And Caloric Intake

Jack E. Rubin, MD is Attending Physician, Daniel Freeman Memorial Hospital Wound Care Center, Inglewood, CA, and is a Wound Care and Hyperbaric Medicine Consultant with Medical Horizons Unlimited[TM], San Antonio, TX. David D. Madorksy, MD, MPH is Director, Long Term Health Care, Home Health Care and Hospice Programs Division, and a Dermatology Consultant, Medical Horizons Unlimited. Carol S. Ireton-Jones, PhD, RD/LD is Vice President, Preferred Nutrition Therapists, Richardson, TX and Co-Director, Nutrition Programs Division, Medical Horizons Unlimited. Saul B. Wilen, MD is CEO, Medical Horizons Unlimited, a national medical educational consulting firm supporting the long-term care industry through clinical educational programs and courses.