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The challenges of managing the nonhealing wound

Ruth Ropper
BA RGN
Tissue Viability Nurse Specialist
NHS Lothian
West Lothian

Most chronic wounds are managed by community and district nurses who report spending upwards of 50% of their time on them.2 Nurses come across a wide range of wounds throughout their career, ranging from surgical wounds to pressure ulcers, traumatic wounds to leg ulcers, burns and scalds to fungating wounds and diabetic ulcers to infected wounds of all descriptions. The wounds are found across all age groups, from babies to older people.

Defining a nonhealing wound
So, what can we do when wounds are nonhealing and how do we know when this is the case?

Wound healing is highly complex, involving many cellular and biochemical processes. It is when these processes do not occur as expected that the wound can become chronic or nonhealing. A clear definition of the nonhealing wound is given by Boyd et al as: "A wound (treated or not) that has not exhibited, during the first two or three weeks, signs of progression from the inflammatory to proliferative stage of healing that could be considered to be demonstrating chronicity".2

To be able to assess if this progression is happening we need to be aware of the phases of wound healing and the tissue type in the wound (see Box 1) as well as whether or not infection is affecting the wound. In other words, it is important to undertake a full and accurate assessment of the wound and to review this regularly to see if progress is being made.

[[Box 1 wounds]]

A logical process needs to be followed in assessing the wound and this can be done using a wound assessment chart or a tool such as TIME (see Box 2). TIME was developed by the European Wound Management Association (EWMA) to aid in assessing the factors that can cause a wound to become slow to heal and to help prepare the wound bed for healing.3 Any assessment process should include the dimensions of the wound, the type or cause of the wound, tissue type present and whether infection is present (see Box 3). By reviewing the changes in the wound over time we can see if it is moving towards healing. "A percentage reduction of over 40% in the first two to three weeks of treatment indicates that the wound is healing."4

[[Box 2 wounds]]

[[Box 3 wounds]]
 
Deciding on the correct treatment plan
One of the causes of a nonhealing wound can be incorrect treatment and this can occur for a number of reasons. It may be that the wrong combinations of products are being used. For example, when rehydrating necrotic tissue using a hydrogel, if the correct secondary dressing is not used the hydrogel will evaporate and the necrosis will remain dry.

To ensure rehydration it is important to keep the wound moist. Use of a semipermeable film over the hydrogel will allow the moisture to be donated to the necrosis rather than soaked into an absorbent pad. As the necrosis softens and the wound starts to exudate, the secondary dressing should be changed to a foam (or equivalent) dressing with a film backing to manage the exudate while still promoting autolysis of the dead tissue.

Being aware of the tissue type and exudate levels in the wound will allow correct decisions to be made about which products to use. If we remember that we want to add moisture to a dry wound and use absorbent dressings, such as alginates or hydrofibre, on a wet wound, then this should help in deciding on correct treatment. The aim is to promote autolysis of dead tissue and by keeping the wound moist you will achieve this. An alginate or hydrofibre once moistened by wound exudate will create that moist environment we are looking for without adding extra moisture into the equation.

Another issue can relate to sensitivities or reactions to components of the dressing. This is a particular problem with patients who have had a wound for a long time where delayed sensitivities can occur.

It is important to check that it is a true reaction to the dressing and not a reaction to the proteolytic enzymes within their own exudate. One way to do this is to look at the dressing on removal from the wound. If the exudate covers the whole surface of the dressing and the skin is inflamed to the same size as the dressing then it is likely to be a reaction to the exudate. However, if there is only exudate over a portion of the dressing but the redness is in the shape of the dressing then it is more likely to be sensitivity to a component within the dressing. If a patient appears to be experiencing multiple sensitivities, referral to a dermatology department for patch testing is recommended.

Conflict between nurses' opinions can cause inappropriate changes to the dressing type or regimen. This needs to be addressed within the nursing team so that a consistent approach is used to promote healing. If dressings are not used for a long enough period of time progress may not be seen (see Case study 1).

[[Case study 1 wounds]]

A suggested time frame of two to three weeks and then a review would allow for a proper evaluation of the product and the nurses would be able to assess if progress was being made in the wound  healing process.

Impact of underlying medical conditions on healing
As well as a full assessment of the wound and correct product use, it is important to look at the impact any underlying medical conditions may have on healing, particularly in older people, in whom the concurrent disease processes can delay healing.5

There are many medical conditions that can impact on the wound healing process to a greater or lesser extent (see Table 1). Circulatory disorders can affect the volume of blood and the nutrients at the wound bed, which slows down cell division. Both circulatory and respiratory diseases will affect the amount of oxygen available at the wound bed, slowing down the action of the cells within the wound.

[[Table 1 wounds]]

Malabsorption disorders will reduce the nutrients available for wound healing. Immune deficiency disorders tend to cause a prolonged inflammatory phase of healing and disorders of mobility and sensation impact on the circulation to an area and increase the risk of damage from trauma. In metabolic disorders, toxins can build up in the system and the body's ability to deal with infection is compromised.

General factors impacting on healing
Issues such as nutrition and hydration apply to all patients with wounds. There is an increased need for proteins and calories, as well as specific nutrients such as vitamin C and zinc to aid in healing. If there is a decrease in fluids in the body this can lead to an electrolyte imbalance, creating the wrong environment for cell growth.

Anti-inflammatory drugs will prolong the inflammatory phase of healing and immune suppressants can lead to an increased risk of infection. As people age, processes in the body slow down, including circulation and cell division, leading to a longer time to healing for the older patient. Psychological influences need to be remembered as stress can lead to a 40% slower healing rate.6

It is important to identify and correct as many of these factors as possible to give the wound the best chance of healing (see Case study 2). Not all wounds will progress to healing and it may be that "controlling exudate, minimising or eliminating odour, preventing infection or relieving pain should be considered as legitimate non-healing endpoints".7

[[Case study 2 wounds]]

Treatment options
It is important to be familiar with the dressings on the local formulary and their actions, as well as keeping up to date with new developments so that if formulary products are not appropriate alternatives can be considered. It may be that other wound treatments and therapies need to be considered (see Box 4).

[[Box 4 wounds]]

Topical antimicrobials are effective in reducing bacterial load, particularly in patients with compromised circulation. Honey is an antimicrobial, and also debrides wounds, stimulates fibroblasts and changes the pH of the wound to promote healing. Surfactant cleansers are thought to be effective in removing bio-films and lowering the bacterial load of the wound by their cleansing action. Maggot therapy promotes quick debridement of sloughy wounds.8 Protease modulating matrix aids in rebalancing the wound bed, reducing the action of enzymes and promoting the action of growth factors.

Collagen, growth factors and extracellular matrix add back into the wound some of the building blocks used in healing and can be useful when a patient is deficient in these. pH-balancing products promote the correct pH in the wound, encouraging growth of cells and reducing bacterial growth.

Compression therapy is one of the simplest and most effective  ways of improving outcomes for lower leg wounds and should be considered for any wound of the lower limb that has not healed within six weeks. Full assessment with Doppler Ankle Brachial Pressure Index (ABPI) and application by a competent practitioner are essential. Topical negative pressure can be effective for larger, deeper wounds to stimulate and improve granulation tissue to reduce time to healing. Other therapies such as skin grafts, skin substitutes, laser or light therapy and biostimulation may be available in certain healthcare settings and may be considered when full assessment of the patient and the wound have been taken into account.

When should I refer and to whom?
We need to be realistic about what we can do and this will depend on our experience, knowledge and the clinical setting where we work. Nonhealing wounds are complex multifactorial problems that often require a multidisciplinary approach to management.9 If, after reviewing the patient and wound, there is no progress or if you have identified specialist needs you do not have the skills to deal with, that is the time to refer on to another professional (see Box 5).

[[Box 5 wounds]]

A tissue viability nurse will often deal with complex wounds and can guide you to other therapies, treatments or specialties to promote healing. Urgent vascular referral is important for patients with Doppler ABPI

Recurrent skin reactions or the need for a biopsy to assess for malignancy or unusual conditions would benefit from referral to dermatology. Complex diabetic foot ulcers should always be referred to the diabetic podiatrist to ensure speedy diagnosis of underlying problems.

On occasion, complex wounds will require surgical debridement or reconstruction by a plastic surgeon. Your area of work will determine whether or not you have access to other specialist services, such as lymphoedema or leg ulcer clinics. Find out what is available in your area and how to access these services if necessary.

Conclusion
"It is important to identify as early as possible when a wound is likely to be slow and/or hard to heal."10 To ensure this, it is important to undertake a full assessment of the wound and the patient including any medical conditions that may influence the healing process. Nurses need to know what dressings and treatment options are available to them as well as understanding their own knowledge level and limitations. Knowing when and where to refer to if progress is not being made is essential in ensuring we give our patients the best chance of healing. We also need to remain realistic that for some patients healing may not be the endpoint and in these cases we need to be clear in deciding, with the patient, what outcomes we are aiming for.

Despite medical advances, chronic ulceration remains a significant problem in our society.11 As nurses we can help improve healing for our patients by keeping ourselves informed and up to date with new developments, as well as working together to find effective solutions.

References
1. Harding KG, Morris HL, Patel GK. Science, medicine and the future: healing chronic wounds. BMJ 2002; 324(7330):160–3.
2. Boyd G, Butcher M, Glover D, Kingsley A. Prevention of non-healing wounds through the predication of chronicity. J Wound Care 2004;13(7):265–6.
3. European Wound Management Association (EWMA). Wound Bed Preparation in Practice. London: MEP Ltd; 2004.
4. Flanagan M. Wound measurement: can it help us to monitor progression to healing? J Wound Care 2003;12(5):189–94.
5. Crooks A. How does ageing affect the wound healing process? J Wound Care 2005;14(5):222–3.
6. Glaser R, Kiecolt-Glaser JK, Marucha PT, MacCallum RC, Laskowski BF, Malarkey WB. Stress-related changes in proinflammatory cytokine production in wounds. Arch Gen Psychiatry 1999;56(5):450–6.
7. Enoch S, Price P. Should alternative endpoints be considered to evaluate outcomes in chronic recalcitrant wounds? Available from: http://www.worldwidewounds.com/2004/october/Enoch-Part2/Alternative-Enpo...
8. Dumville JC, Worthy G, Bland JM et al. Larval therapy for leg ulcers (VenUS II): randomised controlled trial. BMJ 2009;338:b773.
9. Medina A, Scott PG, Ghahary A, Tredget EE. Pathophysiology of chronic non-healing wounds. J Burn Care Rehabil 2005;26(4):306–19.
10. European Wound Management Association (EWMA). Hard-to-heal wounds: a holistic approach. London: MEP; 2008.
11. Enoch S, Price P. Cellular, molecular and biochemical differences in the pathophysiology of healing between acute wounds, chronic wounds and those in the aged. Available from: http://www.worldwidewounds.com/2004/august/Enoch/Pathophysiology-Of-Heal...

Resources
European Wound Management Association
W: www.ewma.org

University of Waikato
Waikato Honey Research Unit
W: http://bio.waikato.ac.nz/honey

World Wide Wounds
W: www.worldwidewounds.com