Innovations in wound care


 
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Wound care

From a pathological view, a wound specifically refers to a sharp injury which damages the dermis of the human skin. Wound is a type of physical trauma, where, the skin layers are torn, cut or punctured (Haley et.al, 1985). This trauma can either cause an open wound or a closed wound. An open wound always runs a risk of blood loss and high chance of bacterial infections. Bacterial infections of the wounds cause pus and damage to the underlying tissues. Untreated infections lead to septicemia and even death. A closed wound is as dangerous as open wounds (Salcido, 2005).

Healing of infected wounds is important in terms of the existence of multiple drug resistant bacteria and immunocompramised status of patients due to factors like HIV. Staphylococcal pyogenic lesions are common wound infections in man. Pseudomonas species contribute to nosocomial wound infections. 'Blue pus' is a common post operative entity caused by these bacteria. Pseudomonas infections are also common in bedsores and burns (AHC, 1964). The process of healing involves clinical diagnosis substantiated by the evidence of laboratory diagnosis followed by appropriate therapy. Although specific antimicrobial therapy constitutes the main aspect of healing of infected wounds, tests to determine the best antibiotic regimen, treatment of the underlying causes and appropriate supportive therapy has drawn attention in the process of healing of wounds today.

Wound assessment

It is important to recognize the importance of thorough wound assessment and to identify the technologies to measure and document wounds in wound care. The efficacy and prognostic value of simple wound measurements using computer-based planimetry as evidenced by complete healing outcome suggest that wound measurements can be used as predictors of healing in the clinical setting (Kantor et.al, 1998). Wound assessment includes the documentation of the uni-dimensional quantities, such as length, width, and depth of the wound. While the Wound length and width can be easily assessed with a ruler, tape measure, or calliper, the depth of a wound can be estimated by inserting a sterile cotton swab or curette into the deepest point in the wound (Maklebust, 1997). Most commercial wound documentation systems report physical quantities calculated from 2-dimensional data, such as digital photographs (Korber et.al, 2006). Recent progress in wound measurement technology allows utilization of the full 3-dimensional shape of the lesion (Ahn and Salcido, 2008).

Skin Substitutes

Skin substitutes are a heterogeneous group of substances that aid in the temporary or permanent closure of many types of wounds (Shores et.al, 2007). Xenograft innovations include Permacol and OASIS Wound Matrix (Niezgoda et.al, 2007) that promote wound healing by absorbing, retaining, and protecting bioactive molecules from the wound environment (Nihsen et.al, 2007). Study results have shown that treatment with OASIS is effective in healing full-thickness diabetic foot ulcers by 12 weeks (Niezgoda et.al, 2007).  Autograft innovations include autologous cultured keratinocyte products indicated for deep partial- and full-thickness burns of total body surface area like Epicel (Carsin et.al, 2000), autogenous keratinocytes cultured and seeded onto laser microperforated esterified hyaluronic acid membrane and cultured skin substitute (Harriger et.al, 1995). Allografts include human amniotic membrane (Colocho et.al, 1974), Acellular dermal allografts and more recent composite allograft products (Trent et.al, 1998). The use of Apligraf, a ready-to-use living fibroblast and keratinocyte bilayer to heal complicated surgical and nonsurgical wounds has also been evaluated in a sample of 16 patients and has been proved effective with ninety four percent of the sample showing complete healing (Shealy and DeLoach, 2006).

Ultrasound Technology Ultrasound Technology has a number of uses in wound care (Hanson et.al, 2008). The use of high-resolution ultrasound to detect soft tissue damage and edema before visible clinical signs helps understanding of the pathogenesis of pressure ulcers (Quintavalle et.al, 2006). MIST ultrasound therapy, low-frequency, noncontact ultrasound device has been shown to be clinically effective for the healing of diabetic foot ulcers in a recently published randomized controlled trial (Ennis et.al, 2005).

Hyperbaric Oxygen Therapy

The role of Hyperbaric Oxygen Therapy (HBOT) in wound healing has been elucidated recently (Wood, 2002). HBOT, although, not a common method of wound management, offers another avenue to healing recalcitrant wounds. It has been explained that increasing the availability of oxygen does not stimulate the healing process, but the pressure at which the oxygen is delivered seems to be the stimulus. In this context, the effect of supplemental oxygen on the incidence of surgical-wound infection in 500 patients undergoing major elective colorectal surgery has also been elucidated (Greif et.al, 2000). A recent study has shown a significant increase in local wound NO levels as evidenced by NOx measurements after successful HBOT suggesting that this mechanism may be an important factor in promoting enhanced wound healing and wound closure associated with this therapy (Boykin and Baylis, 2007).

The Role of Temperature

The importance of temperature in the wound-healing process as a novel way to manipulate the wound-healing environment has been evaluated too (Khan et.al, 2004). The study, investigating the direct effect of Topical Radiant Heating (TRH), using a novel bandaging system on wound healing at a physiological and cellular level has shown excellent healing of infections with results showing increased local dermal blood flow and CD3 lymphocyte immunoreactivity.

Recent Trends  A nanocrystalline silver dressing combined with 4-layer bandaging has been proved successful in promoting healing associated with a reduction in wound bacteria and neutrophilic inflammation with a persistent or high lymphocyte count, as determined by wound biopsy (Sibbald et.al, 2007). Urgotul is a new class of non-adherent dressing useful in the healing process based on the lipidocolloid dressings. It is made up of an open weave polyester mesh impregnated with hydrocolloid polymers dispersed within petrolatum (Meaume et.al, 2002). Healing of pressure ulcers with a concentrated, fortified, collagen protein hydrolysate supplement has been evaluated recently in a randomized controlled trial and has been found effective (Lee et.al, 2006). Elevation is another important technique that has been proved successful in pressure ulcer prevention and treatment with enhanced tissue perfusion (Huber et.al, 2008). Activated polyacrylate dressings have been shown to facilitate wound debridement by retaining moisture while attracting and retaining proteins. Hydrogel is an effective, comfortable, easy to use and cost effective innovation that prevents wound surface hydration and has been proved effective in facilitating repair of pressure, diabetic, vascular, burn, and other wounds.

Conclusion

It is important to recognize the importance of wound care by wound assessment and utilization of modern technology. A wound is assumed healed when it achieves complete closure (Salcido, 2005). Factors that contribute to chronic wound healing failure include infection, abnormal blood flow and hypoxia, cellular failure, and trauma. Paying attention to one of these common factors frequently improves the other factors and significantly aids wound healing (Warriner et.al, 2005).

Reference

  • Aadil A Khan, Paul E Banwell, Martijn C Bakker, Patrick G Gillespie, Douglas A McGrouther and Anthony HN Roberts (2004). Topical Radiant Heating in Wound Healing: An Experimental Study in a Donor Site Wound Model. International Wound Journal. 1 (4); 233.
  • Ad Hoc Committee of the Committee on Trauma (1964). Division of Medical Sciences, National Academy of Sciences, National Research Council. Postoperative Wound Infections: The Influence of Ultraviolet Irradiation of the Operating Room and Various Other Factors. Ann Surg 160: Suppl: 1-192.
  • Carsin H, Ainaud P, Le Bever H, et al. (2000). Cultured Epithelial Autografts In Extensive Burn Coverage Of Severely Traumatized Patients: A Five Year Single-Center Experience With 30 Patients. Burns 26:379-87.
  • Chulhyun Ahn and Richard Salcido (2008). Advances in Wound Photography and Assessment Methods. Advances in Skin & Wound Care: The Journal for Prevention and Healing. 21(2); 85-93.
  • Darlene Hanson, Patricia Thompson, Diane Langemo, Susan Hunter and Julie Anderson (2008). Hidden Sounds and Busy Bubbles: Ultrasound Therapy and Applications for Wound Care. Advances in Skin & Wound Care: The Journal for Prevention and Healing. 21(1); 17-19.
  • Edith S. Nihsen, David A. Zopf, David M.J. Ernst, Abram D. Janis, Michael C. Hiles and Chad Johnson (2007). Absorption of Bioactive Molecules into OASIS Wound Matrix. Advances in Skin & Wound Care: The Journal for Prevention and Healing. 20(10); 541-548.
  • Fred G. Shealy and Ervin Daniel DeLoach (2006). Experience With The Use Of Apligraf To Heal Complicated Surgical And Nonsurgical Wounds In A Private Practice Setting. Advances in Skin & Wound Care: The Journal for Prevention and Healing. 19(6); 310-323.
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  • Jacqueline Huber, Raj Reddy, Tom Pitham, David Huber (2008). Increasing Heel Skin Perfusion by Elevation. Advances in Skin & Wound Care: The Journal for Prevention and Healing. 21(1); 37-41.
  • Jaimie T. Shores, Allen Gabriel and Subhas Gupta (2005). Skin Substitutes and Alternatives: A Review. Advances in Skin & Wound Care: The Journal for Prevention and Healing. 20(9); 493-508.
  • Jeffrey A. Niezgoda, Carl C. Van Gils, Robert G. Frykberg and Jason P. Hodde (2005). Randomized Clinical Trial Comparing OASIS Wound Matrix to Regranex Gel for Diabetic Ulcers. ? Advances in Skin & Wound Care: The Journal for Prevention and Healing. 18(5); 258 - 266.
  • Jonathan Kantor, David J. Margolis (1998). Efficacy and Prognostic Value of Simple Wound Measurements. Arch Dermatol. 134:1571-1574.
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  • Maklebust J (1997). Pressure Ulcer Assessment. Clin Geriatr Med .13(3):455-81.
  • Niezgoda JA, Van Gils CC, Frykberg RG, Hodde JP (2005). Randomized clinical trial comparing OASIS Wound Matrix to Regranex gel for diabetic ulcers. Adv Skin Wound Care 18(5 Pt 1):258-66.
  • Paul R. Quintavalle, Courtney H. Lyder, Philip J. Mertz, Connie Phillips-Jones and Mary Dyson (2006). Use of High-Resolution, High-Frequency Diagnostic Ultrasound to Investigate the Pathogenesis of Pressure Ulcer Development. Advances in Skin & Wound Care: The Journal for Prevention and Healing. 19(9); 498-505.
  • R. Gary Sibbald, Jose Contreras-Ruiz, Patricia Coutts, Marjorie Fierheller, Arthur Rothman and Kevin Woo (2007). Bacteriology, Inflammation, and Healing: A Study of Nanocrystalline Silver Dressings in Chronic Venous Leg Ulcers. Advances in Skin & Wound Care: The Journal for Prevention and Healing. 20(10); 549-558.
  • Richard Salcido (2005). When Is a Wound Really Healed? Advances in Skin & Wound Care: The Journal for Prevention and Healing. 18(5); 233 - 233.
  • Advances in Skin & Wound Care: The Journal for Prevention and Healing. 18(8); 2 -12.
  • S Meaume, P Senet, R Dumas, H Carsin, M Pannier, S Bohbot (2002). Urgotul®: A Novel Non-Adherent Lipidocolloid Dressing. British Journal of Nursing, 11(16; S42 - S50.
  • S. Kwon Lee, Mary Ellen Posthauer, Becky Dorner, Vicki Redovian and Mary Jane Maloney (2006). Pressure Ulcer Healing with a Concentrated, Fortified, Collagen Protein Hydrolysate Supplement: A Randomized Controlled Trial. Advances in Skin & Wound Care: The Journal for Prevention and Healing. 19(2); 92-96.
  • Trent JF, Kirsner RS (1998). Tissue Engineered Skin: Apligraf, a Bi-Layered Living Skin Equivalent. Int J Clin Pract 52:408-13.
  • William J. Ennis, Wesley Valdes, Marianne Gainer and Patricio Meneses (2006). Evaluation of Clinical Effectiveness of MIST Ultrasound Therapy for the Healing of Chronic Wounds. Advances in Skin & Wound Care: The Journal for Prevention and Healing. 19(8); 437-446.
  • Zoe Wood (2002). Hyperbaric Oxygen in the Management of Chronic Wounds. British Journal of Nursing, 11(16): S16 - S24.

Copyright 2008- American Society of Registered Nurses (ASRN.ORG)-All Rights Reserved


 
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Articles in this issue:

Masthead

  • Masthead

    Editor-in Chief:
    Kirsten Nicole

    Editorial Staff:
    Kirsten Nicole
    Stan Kenyon
    Robyn Bowman
    Kimberly McNabb
    Lisa Gordon
    Stephanie Robinson

    Contributors:
    Kirsten Nicole
    Stan Kenyon
    Liz Di Bernardo
    Cris Lobato
    Elisa Howard
    Susan Cramer

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