NURS13127 Wound Care Principles and Practice

Introduction

Chronic wounds have been a significant issue in Australia. They are defined as wounds that cannot be healed, or can’t reach functional and anatomic integrity. The main categories of a chronic wound along with different etiologies include pressure injuries, venous ulcers of the leg, foot ulcers in diabetes, arterial ulcers. All these categories are common issues in Australia. Chronic wounds healthcare-related costing is considerable, which is equivalent to or more than AUD $ 3.5 billion, which is approximately 2 (%) of the total health-care national expenditure. These wounds have a negative effect on the quality of life (McCosker et al., 2019). It is an under-recognised problem in health-care system of Australia and can be under-considered in both public policies and research thereby receiving very little information and investments that can be compared with other chronic conditions. This study aims at discussing the effects of chronic wounds have on health-care system in Australia, etiology and pathophysiology of pressure injuries on the sacrum, diagnostic and therapeutic techniques for assessing the wounds, and various options for treatment for dressing the wound.

Effects of chronic wounds on the Health-Care System

400,000 people are affected in Australia with wounds that contribute to 2.1% of overall healthcare expenditure on a national level. The most common wound type include pressure injuries that comprise 84.1% (more than 400,000 cases estimated) for chronic wounds in residential care and hospital settings. In primary health care settings, venous leg and diabetic foot ulcers are amongst the most common types of chronic wounds (Weller et al., 2020).

Chronic wounds that cannot be healed, have shown to be an economic burden for the healthcare system, they affect the quality of life and affected people, they often show serious issues such as amputation of the limb and premature deaths (Gupta et al., 2021). Such burden has a huge impact on increasing the population in the elderly and an increase in life-style related disorders like diabetes and obesity (Järbrink et al., 2017). These wounds affect the quality of life which affects the overall health care system. It increases working capacity and also increases social isolation.

As the population in Australia ages and prevalence of vascular diseases increase, and Type II continues to increase which is proportional to the prevalence and incidences of chronic types of wounds in Australia. All such risk factors are responsible for the development of chronic wounds which are at high risk for developing serious complications if they get affected with Covid-19. Delay in wound healing remains to be a major challenge that is faced by the community and hospital nurses, presence of biofilms that are acknowledged as the main cause of delay in wound healing. The overusing of antibiotics alongside increasing antibiotic resistance also affect the quality/standard of life.

Aetiology of pressure injuries

Pressure injuries causes include pressure that cannot be relieved, that is applied with greater forces over a short duration (lesser force over a long time-period). It disrupts the blood supply towards a network of capillaries, impeding the blood flow and depriving tissues of nutrients and oxygen (Martinengo et al., 2019).

Pathophysiology of pressure injuries on sacrum

Many factors are contributing to the development of pressure injuries. These pressure ulcers result from constant pressures that are sufficient for impairing the local flow of blood towards soft tissues for an extended time-period. External pressures shall be greater than arterial capillary pressures for impairing the inflow of blood for an extended time-period (32 mm Hg). It shall be greater than venous-capillary closing pressure (8-12 mm Hg) for impeding the return of flow of blood for an extended time. Tissues that are capable and can withstand a lot of pressure for a brief time-period, still longer exposures to pressures that are slightly above the (capillary filling pressure) that initiates a descending spiral towards ulcers and tissue necrosis. The superficial dermis tolerates ischemia for two to eight hours before the breakdown happens. Deeper muscles, fat tissues and connective tissues, tolerate pressure for two hours or lesser (it may be because of an increase in oxygen demand and high metabolic requirements) More often there is adequate damage to the underlying tissues but the dermis and the epidermis remain intact (Elahad et al., 2018).

 Till the time ulceration is being present through the skin levels, adequate damage to the underlying muscles already occurs that makes the shape of that ulcer-like the inverted cone. The friction that is caused by rubbing the skin against the surfaces like bedding and clothing leads to the formation of ulcers by contributing to the breaks in the skin layer (superficial). Moisture caused ulcers and worsening of existing ulcers by a breakdown of tissues and maceration. The main features that contribute to such injuries involve the application of pressure. Soft tissues when they are compressed for a longer time between external surfaces and bony prominences tissue ischemia along with micro-vascular occlusion and hypoxia occur. The amount of pressure that exceeds normal capillary pressures (range of 12-32 mm Hg) results in the reduction of oxygenation and compromising microcirculation of affected tissues. If the compression does not get resolved, pressure ulcers develop in three to four hours (Labeau et al., 2021).

Wound Assessment: Diagnostic techniques

The major signs of a chronic wound causes inflammation, swelling, stiffness, pain in affected areas. The common methods that are used for accessing microbes that surround the wound include swab testing and biopsies. Complete blood count for assessing leucocytosis, thrombocytopenia, and anemia. The patient’s basic profile (metabolic) shall be analyzed and looked for electrolyte abnormalities and renal insufficiencies. Determination of transferrin, pre-albumin, albumin, serum proteins is important for assessing the nutritional status of the patient. To detect the abnormalities, deep wound excisions may be required. Wound tissue cultures are required for determining effective antibiotic therapy.

While doing initial and an ongoing assessment for wounds, clinical considerations shall be considered for allowing appropriate management in collaboration with the team that is treating. Wound type whether it is acute/chronic, etiology related to the development of wounds (burns, abrasion, pressure injury, surgical, ulcers, neoplastic), surrounding skin and location, loss of tissues, stages of healing, clinical look of a wound, wound edges, exudates, presence of any infection,  pain and wound management (previous history). In broader terms, degrees of tissue loss include superficial wound that involves the epidermis, partial wound that involves the epidermis and dermis, complete thickness wounds which involve dermis, subcutaneous tissues and extends to bones, muscles, and tendons (Frescos, 2018).

Guidelines for the management of wounds help in promoting a multidisciplinary approach towards care. Patient assessment at an initial stage is important and especially in those conditions where changes in condition are there. Considering psychological implications in a wound, they are relevant in child settings when they are related to the understanding of developmental stages and pain that may be associated with changes in dressing and wound. Determination of the goals of care and their expected results, respecting the fragile environment of the wound, maintaining a stable temperature of the wound, avoiding cold solution and exposure to wound, and maintaining acidic/neutral pH.  Allowing the wound to drain heavily, eliminating the dead spaces but packing the wound should not be very tight. Selection of appropriate dressing and methodology that is based on the assessment and evidence(scientific). Investigating apt adjunctive therapies for the wound. Such therapies include splinting, compression and pressure-redistribution equipment.

While determining the etiology of chronic wounds, addressing/controlling factors like presence of an infection, the appropriate selection for dressing, poor nutritional related status, presence of moisture in the wound environment. Selection of the dressing shall be based on the particular characteristics of the wound and referred to Stomal therapies shall be initiated for promoting optimum healing of wounds. Advancements in wound therapies might be required and can be utilized. Hyberbaric therapy, surgical debridement, and negative pressure dressing application (Gupta et al., 2017).

Treatment options

The first step is cleaning the wounds and covering it using bandages and dressings. If a wound has not healed for a long duration of time, despite the wound care. Treatments like skin grafts and vacuum-assisted grafts have been used.  A wound that has persisted for eight weeks or more without signs of healing, it is said to be a chronic wound. Such wounds arise because of blood circulation, weaker immune system or diabetes. Relieving the pain is important as well as treating the condition. Some people take psychological support also as a treatment option(Frykberg & Banks, 2015).

Cleaning of the wound

After the dressing is changed, the wound is cleaned, by using a saline solution (Kaur, Gondil & Chhibber, 2019).

Debridement

When the chronic wounds can be treated, nurses or doctors remove the dead/inflamed tissue. Tissues are removed by using instruments like curette, tweezers or use of scalpels. A wound is used by using a water jet (high-pressure). Local anaesthetics are used for numbing the wound before the hand /ointment use. General anesthetics help in cleaning wounds that are larger.

Wound dressings

After cleaning the wound, it is covered with help of dressings. Most of the wounds are kept with moist compress (Lennox et al., 2018). Type of dressings that are used includes guaze, films, hydrocolloid dressings, hydrogel dressings, foam dressings, Silver/alginates in dressings. The removal of excess fluid from wounds is done by the use of dressings and can get their protection from getting an infection.

They are placed on wounds for many days. These dressings can be changed if they are clear, as they cannot soak more secretions of the wound, in cases when fluid leakage is there out of a bandage. Some dressings also contain growth factors. Hormone-like substances help in the process of healing by promoting growth in cells of the body. Substances like honey are used in wound care (Weller, Team  & Sussman, 2020).

Compression stockings and bandages

If the chronic wound has been caused by deficient/poor blood supply, healing can be made faster by compression bandages/ stockings. This pressure from stockings can help veins in carrying blood towards the heart and improve circulation.

Antibiotics

Depending on the severity of an infection, antibiotics are needed. If bacteria is present, wounds cannot heal well. They are applied to wounds by using ointments/ placing the wound by using a compress (Kaur, Gondil & Chhibber, 2019).

Oxygen Hyperbaric therapy

In this treatment procedure, the patient is made to enter a special chamber so that he can breathe oxygen under high pressures. It improves the concentration of oxygen in the blood and improves the supply of blood to areas of the wound. Evidence states that this therapy improves healing of wounds who suffer from diabetes foot syndrome

Electromagnetic/Ultrasound therapy

Ultrasound involves the treatment of chronic wounds by using sound waves. These sound waves help in making the tissue warmer (Chang, Perry & Cross, 2017). Evidence show that this option doesn’t heal the wound that faster when compared to other treatment modalities. In electromagnetic therapies, weaker electromagnetic waves apply to the wound by using pillows/mats which have magnets in them (Munro, 2017).

Negative pressure therapy

Vacuum-assisted closures/VAC therapy, the wounds are covered, along with dressings that are airtight, which are connected to pumps by thin tubes.

Skin grafting

These are important treatment options / if a particular wound is larger in a way that it closes. In such type of a procedure, skin is utilized from some other part of a body, mostly from the thigh portion and is transplanted on top of the wound. These types of grafts are being made from synthetic products/ human cell products. Studies have shown that wounds/ chronic wounds heal at a faster rate after skin grafting than undergoing a standard treatment (Saleh et al., 2019).

Conclusion

Therefore from the above-mentioned discussion, it can be concluded that chronic wounds are a concern in Australia. It can be concluded that complex and chronic wounds are hard to heal. Various effects of chronic wounds on the overall health system in Australia is discussed in the above paper. It is shown that the commonest methods for detection include swabs and taking biopsies. Various other tests include complete blood count, guidelines for managing chronic wounds. Assessment of the patient in the initial stages is important. Cleaning, debridement, the ways by which the wounds are dressed, compression bandages and stockings are also discussed. The above discussion says that there are patients that take psychological treatments also. The use of antibiotics, Oxygen hyperbaric therapies, ultrasound/electromagnetic therapy are found to be effective treatment options for chronic wounds.

References

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