With appropriate treatment, most venous leg ulcers heal within 3 to 4 months. Show Treatment should always be carried out by a healthcare professional trained in compression therapy for leg ulcers. Usually, this will be a practice or district nurse. Cleaning and dressing the ulcerThe first step is to remove any debris or dead tissue from the ulcer and apply an appropriate dressing. This provides the best conditions for the ulcer to heal. A simple, non-sticky dressing will be used to dress your ulcer. This usually needs to be changed once a week. Many people find they can manage cleaning and dressing their own ulcer under the supervision of a nurse. CompressionTo improve vein circulation in your legs and treat swelling, your nurse will apply a firm compression bandage over the affected leg. These bandages are designed to squeeze your legs and encourage blood to flow upwards, towards your heart. There are many different types of bandage or elastic stockings used to treat venous leg ulcers, which may be made in 2, 3 or 4 different layers. The application of a compression bandage is a skilled procedure and they should only be applied by trained healthcare staff. The bandage is changed once a week, when the dressing is changed. When compression bandages are first applied to an unhealthy ulcer, it's usually painful. Ideally, you should have paracetamol or an alternative painkiller prescribed by your GP. The pain will lessen once the ulcer starts to heal, but this can take up to 10-12 days. It's important to wear your compression bandage exactly as instructed. If you have any problems, it's usually best to contact your nurse, instead of trying to remove it yourself. If the compression bandage feels a little too tight and is uncomfortable in bed at night, getting up for a short walk will usually help. However, you'll need to cut the bandage off if:
Once you remove the bandage, make sure you keep your leg highly elevated and contact your doctor or nurse as soon as possible. In some clinics, specialist teams are using new alternatives to compression bandages, such as special stockings or other compressive devices. These may not be available in every clinic but could change the way ulcers are treated in future. Your specialist will be able to advise you whether a different approach may help you. Treating associated symptomsSwelling in the legs and anklesVenous leg ulcers are often accompanied by swelling of your feet and ankles (oedema), which is caused by fluid. This can be controlled by compression bandages. Keeping your leg elevated whenever possible, ideally with your toes at the same level as your eyes, will also help ease swelling. You should put a suitcase, sofa cushion or foam wedge under the bottom of your mattress, to help keep your legs raised while you sleep. You should also keep as active as possible and aim to continue with your normal activities. Regular exercise, such as a daily walk, will help reduce leg swelling. However, you should avoid standing or sitting still with your feet down. You should elevate your feet at least every hour. Itchy skinSome people with venous leg ulcers develop rashes with scaly and itchy skin. This is often due to varicose eczema, which can be treated with a moisturiser (emollient) and occasionally a mild corticosteroid cream or ointment. In rare cases, you may need to be referred to a dermatologist (skin specialist) for treatment. Itchy skin can also sometimes be caused by an allergic reaction to the dressings or creams applied by your nurse. If this happens, you may need to be tested for allergies. It's important to avoid scratching your legs if they feel itchy, because this damages the skin and may lead to further ulcers. Looking after yourself during treatmentTo help your ulcer heal more quickly, follow the advice below:
You may also find it helpful to attend a local healthy leg club, such as those provided by the Lindsay Leg Club Foundation, for support and advice. Treating an infected ulcerAn ulcer sometimes produces a large amount of discharge and becomes more painful. There may also be redness around the ulcer. These symptoms and feeling unwell are signs of infection. If your ulcer becomes infected, it should be cleaned and dressed as usual. You should also elevate your leg most of the time and you'll be prescribed a 7-day course of antibiotics. The aim of antibiotic treatment is to clear the infection. However, antibiotics don't heal ulcers and should only be used in short courses to treat infected ulcers. Follow-upYou should visit your nurse once a week to have your dressings and compression bandages changed. They'll also monitor the ulcer to see how well it's healing. Once your ulcer is healing well, your nurse will see you less often. After the ulcer has healedOnce you've had a venous leg ulcer, another ulcer could develop within months or years. The most effective method of preventing this is to wear compression stockings at all times when you're out of bed. Your nurse will help you find a stocking that fits correctly and that you can manage yourself. Various accessories are available to help you put them on and take them off. Read more about preventing venous leg ulcers. Damage or disruption of living tissue's cellular, anatomical, and/or functional continuum defines a wound. Before treatment, the exact cause, location, and type of wound must be assessed to provide appropriate care. Each clinician will have widely differing and distinct opinions on wound therapy depending on prior experiences. Given that non-healing wounds affect millions of people in the United States impacting a significant percentage of persons 65 years and older, minimizing wound complications is essential in the current healthcare environment. This activity addresses protocol for wound assessment for the interprofessional team during initial and subsequent wound assessments to best classify and treat a wound to enhance outcomes. Objectives:
Damage or disruption of living tissue's cellular, anatomical, and/or functional integrity defines a wound.[1] Acute and chronic wounds are technically categorized by the time interval from the index injury and, more importantly, by the evidence of physiological impairment.[2] Accordingly, specific treatments, including biofilms, would be planned to address the management of chronic wounds with an impaired physiological outcome.[1] Before treatment, the exact cause, location, and type of wound must be assessed to provide appropriate care. Each clinician will have widely differing and distinct opinions on wound therapy depending on prior experiences. An ostomy nurse will have a completely different approach to wound care than an orthopedic surgeon dealing with an open fracture during a trauma. Both will be far different from a dermatologist who treats burn victims. Nevertheless, each of these healthcare providers is performing wound care. Since non-healing wounds affect millions of people in the United States, impacting a significant percentage of persons 65 years and older, minimizing wound complications is essential in the current healthcare environment.[3] As non-healing wounds constituted a multi-billion dollar industry of hospital admissions, antibiotics, and local wound care and were called a silent epidemic, this topic will be presented with an emphasis on clinical quality and optimization of patient safety.[4][5][6] Moreover, the 0.3 to 0.4 % rate for wound diagnosis has been reported in the general European population.[6][7] Almost all wounds are colonized with a spectrum of microbes. However, only some of them are considered infected wounds.[8] Community nurses usually manage patients with chronic wounds. Chronic wounds are identified as wounds persisting for greater than six weeks.[9] Considering the complexity of the patients' health needs and the wound, on the other hand, this is a complicated, perplexing task for the nurse. Accordingly, wound assessment tools are designed to support all qualified nurses in the wound management field in delivering safe and appropriate wound care. The wound assessment tool, TIME, has been recently revised to TIMERS (Tissue, Infection/Inflammation, Moisture, Wound edge, Repair/Regeneration, Social).[10] At the very premise of gaining a thorough understanding of wounds is acquiring solid foundational knowledge in skin anatomy, physiology, and the biological cascade of normal wound healing.
The series of events associated with wound healing instantaneously begins at the moment of injury. Each of the potential underlying causes must be addressed and optimized for the wound to progress successfully through a complex biological healing procession of hemostasis, inflammation, proliferation, and remodeling. All four highly integrated and overlapping physiological phases must occur in the proper sequence and time frame for wound healing success.
Clinicians perform wound assessments to determine the appropriate treatment for extremely diverse disease processes. How do professionals then approach wound assessment when the causes are so diverse? Below are some basic questions for the interprofessional team during initial and subsequent wound assessments to best classify and treat a wound to optimize outcomes. The initial assessment is crucial.[21] It should begin with the following:
All of these factors significantly impact the treatment plan moving forward. While there are many excellent biologics, skin grafts, and other options available, without the proper understanding of the nature of the wound, the chances of healing will decline significantly.[23][24] While some wounds are simple, the majority of encountered wounds are caused by or become complicated by confounding patient-related issues. Examples
Universal Principles of Management
Considering this rational algorithm, in total, is the core of successful wound healing. Similarly, there is no one-to-one correlation between a given wound and specific treatment. A spectrum of options must be considered for every wound encountered; selecting the best option for each patient remains challenging. Before determining the underlying cause, it is essential to establish what type of wound the patient has. These subclassifications can be acute or chronic. Types of Wounds Acute Clinicians assess acute wounds by the method of injury and resultant damage to soft tissues and bony structures. For example, in crush or high impact injuries, there is an area of demarcation which is not fully recognized until sometimes as much as a week or two later. For this reason, it is important to determine the method of injury and to keep in mind that the wound seen is not necessarily the entirety of the wound which will be present in a week. In these cases, the patient and their family should be educated on this progression to prevent frustration and misunderstanding. For all acute types of wounds, it is important to determine the length of time since injury (days or hours), the involvement of neurovascular supply, muscle, tendon, ligament, and bony structures, and the likelihood of contaminants in the wound. Also important is when the patient had their last tetanus vaccine/booster dose. Clinicians should start antibiotics if the wound is severely contaminated or if it has been longer than 3 hours since the injury. All underlying tissue should be repaired, and the wound should be irrigated to remove contaminants and bacteria. In cases of traumatic/open fracture, the most used classification system is Gustillo-Anderson:
Chronic If a wound becomes arrested during normal stages of inflammation and healing, this classifies a chronic wound; deemed such at an untimely three months of non-progression. They often stall in the inflammatory phase.[34][35][36] Numerous factors and disease conditions impair the wound healing process, resulting in chronic, non-healing wounds. The most important concept is a persistent pro-inflammatory condition that propagates an unstable wound environment, recalcitrant to healing. Persistent hyper-inflammation is the ubiquitous pathophysiological characteristic of chronic wounds, and macrophage malfunction significantly contributes to the altered normal course. In the chronic setting, the main goal is to identify why the wound is not healing and alleviate these obstacles. Chronic wound causalities can be categorized as follows, and the related questions should be responded to accordingly.
Necrotizing Soft Tissue Infections Necrotizing soft tissue infections (NSTIs)can induce and instigate widespread necrosis subsequent to their aggressive nature. Despite increased understanding of their disease processes, NSTI's rarity, complexity, and occasional ambiguity of symptomatology continue to pose diagnostic dilemmas.[41] A clear approach allows rapid identification, early administration of antimicrobial agents, and immediate surgical intervention, as they are limb- and life-threatening. Failure to recognize the underlying disease process and intervene expeditiously results in extremely high mortality.
In summary, successful treatment requires early initiation of broad-spectrum systemic antibiotic therapy, aggressive surgical debridement of all necrotic tissue, and supportive care (fluid resuscitation, organ, and critical care support) to maintain oxygenation and tissue perfusion. Delay of definitive debridement is the most critical risk factor for death. Early operative debridement is a significant determinant of success in NSTI treatment and an independent predictor of improved outcomes.[34][42][43] A wound ensues following a breach in epithelial integrity and may be accompanied by disruption of structure and/or function of underlying normal tissue. To restore the structure of the injured tissue, a complex signaling network of biomolecular interactions must occur in a precisely programmed fashion. Along each individual wound’s course of healing, repeated thorough assessments are necessary. Once a wound has been fully evaluated, treatment should be designed to address any modifiable cause for the wound and then to achieve specific targeted goals of (a) preventing complications resulting from the wound, (b) preserving or restoring critical functions, (c) achieving wound closure, and (d) restoration of aesthetics.[44] The current review provides a basic understanding of the common types of wounds and the underlying concerns. The takeaway is the need for appropriate assessment. Too often, wounds are not treated properly because of a lack of understanding of the underlying disease process. Most chronic wounds are complex and best managed by an interprofessional team coordinating care that includes a wound care nurse, general and/or vascular surgeon, podiatrist, plastic surgeon, hyperbaric specialist, infectious disease consultant, dietitian, and physical therapist. The key is first to find out the cause of wound breakdown. Without resolving the primary cause, wounds cannot heal. There are hundreds of wound care dressings and solutions, and for the most part, all work similarly with the same efficacy. The second point is to ensure that the wound is clean, has ample blood supply, and is regularly debrided. Other factors that play a role in wound healing include patient nutritional status, comorbidities, state of the immune system, age, degree of ambulation, presence of a foreign body, and infection. It is important to have a team of wound experts regularly assess the wound and the patient to achieve successful healing.[45] Evaluation Once the underlying issues and healing impediments are determined, a formal wound assessment is performed. The evaluation of patients with complex wounds is best approached systematically since wounds are rarely secondary to only one sole cause. Assessment of both local and systemic contributing factors within each portion of the work-up is critical. Generally, ongoing nursing and clinician assessments and monitoring of wounds are similar. Physical examination should be the primary criterion for the diagnosis of local wound infection:
Diagnostics
Prevention The preventative measures that should be taken for patients with open wounds depend on the setting.
Interventions After careful adherence to preventative measures and preservation of critical function, a strategy for wound closure can be formulated with respect to multidisciplinary decision-making.
Putting it All Together Taking the above information into consideration, walk through a formal wound evaluation. For instance:
While there are many factors to consider when approaching a wound, understanding the nature and underlying factors potentiating the wound in question will lead to successful evaluation and treatment. Wound checks are typically once per shift, but the clinician may vary this protocol based on concerns raised by the healthcare team. The care team must ensure that a patient with a wound does not develop complications from that wound or additional wounds from the same mechanism. This is particularly important in bedridden, obtunded, or paralyzed patients, in whom it should be possible to completely prevent pressure sores with proper care. Delays in wound healing can be perpetuated by clinicians who make poor treatment choices, fail to recognize complications, and/or do not seek timely advice. Improving patient outcomes requires a proactive method to care that includes accurate and timely assessment and reassessment, treatment of the underlying cause using a multidisciplinary team approach, and implementation of evidence-based practice and clinical judgment to develop an appropriate therapeutic plan. With such a broad array of possibilities, the entire interprofessional team, including all clinicians (MDs, DOs, NPs, and PAs), nurses, paramedics, and specialists, must all contribute from their specialty, document the patient's progress or lack thereof so all team members have the same patient data, and communicate any concerns to all appropriate team members so the team can implement therapeutic changes, if necessary. Utilizing this type of interprofessional paradigm will ensure that wound patients receive the best care leading to optimal outcomes. [Level 5] Review Questions1. Afonso AC, Oliveira D, Saavedra MJ, Borges A, Simões M. 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