Article Archive
November/December 2015

Comprehensive Wound Care Review
By Mary Cardy Weaver, ARNP, WOC nurse, CWCN, and Kathy Wright, MSN, CWOCN-AP, ACHRN
Today's Geriatric Medicine
Vol. 8 No. 6 P. 16

Because wound etiologies are multifactorial, clinicians must recognize the need for a comprehensive and individualized plan of care to ensure successful wound healing.

Clinicians caring for individuals with wounds recognize the need for a comprehensive and individualized plan of care designed to assess and manage risk factors and wound etiologies. Other factors to be considered in comprehensive wound management include comorbidities that can impede wound healing and increase the risk for complications, the needs of the wound's microenvironment to facilitate the healing cascade, and lifestyle choices that contribute to the wound's incidence and may prevent healing.

This article provides a global review of wound care principles as well as nationally recognized resources to provide some guidelines for wound management clinical pathways and practices. Key to success in this area is the education of your staff and continuous performance improvement audits, along with measures to improve practice and outcomes.

There are too many wound etiologies to do justice to each in the context of this article. Therefore, the following list includes only some of them and the article briefly discusses some of the most frequently occurring wounds:

• arterial insufficiency;
• venous stasis;
• lymphedema;
• neuropathic/diabetic or nondiabetic;
• pressure ulcers;
• skin tears;
• acute trauma;
• surgical;
• burn;
• malignancy; and
• atypical (vasculitis, pyoderma gangrenosum, bullous pemphigoid, infectious).

It is common for wound etiologies to be multifactorial; therefore, it is advised that all avenues be explored and addressed in the plan of care. Common etiologies to be assessed include vascular ulcerations such as arterial, venous, lymphedema, and neuropathic ulcerations. This is certainly an area where the comprehensive assessment and treatment of all factors is imperative. A referral to a vascular consultant would be beneficial. In general, the assessment and interventions for consideration would include the following:

Vascular Ulcerations
• Arterial insufficiency: Consider diagnostic tests to measure tissue oxygenation (TCPO2 measurement) and tissue ischemia (ankle brachial index, arterial Doppler/duplex). Interventions might include revascularization, stent placement, or medications to improve circulation when revascularization is not possible. Limb salvage is directly related to a patient's life expectancy, quality of life, and productivity.

• Venous insufficiency: This condition should be evaluated via physical assessment and venous studies to rule out the presence of deep vein thrombosis, which, if identified, requires treatment. Interventions for venous insufficiency might include implementation of pharmaceutical therapy and use of compression therapy after it has been determined through arterial studies that the compression therapy will not compromise the arterial circulation. Identification of the location of the reflux will help to determine the best option for the type of compression. The clinician will determine whether the reflux is superficial, deep, or in the perforators. Laser or radio-frequency ablation of the affected vessels may also be considered.

• Neuropathy: When arterial disease or diabetes is the etiology or a contributing factor, the patient should be assessed for sensory, motor, and autonomic neuropathy. Consider a consultation with a neurologist and a specialist for orthotics and offloading.

Other Wounds
Pressure ulcers require pressure reduction or relief. It's important to become familiar with and consider implementing the prevention and management guidelines of the Agency for Health Care Research and Quality (AHRQ). Research into the available support surfaces and their indications/effectiveness is an important aspect of prevention and treatment. Establishing guidelines for use of support surfaces and offloading devices is an important aspect of care. A reliable thorough risk assessment tool validated for interrater reliability and predictability such as the Braden or Norton Tool, as well as incident audits, should be a part of the wound care protocol. The tool(s) should not be altered. Clinicians should ensure that the primary goals of all health care providers are prevention, early detection, aggressive intervention, and the prevention of complications.

Diabetic ulcerations require aggressive assessment and management of the diabetes. A patient with diabetes who develops a wound will be at risk for poor glucose control and poor healing. This population requires close assessment for arterial and neuropathic involvement. Offloading by contact casting or the use of other devices is an important consideration.

Wounds of undetermined etiology or that fail to respond to the comprehensive plan of care should be assessed to determine whether there is an atypical etiology or malignancy. An atypical location, appearance, or response to therapy warrants suspicion. Although the initial thought might be to perform a biopsy, it is wise to refer the patient to a wound care specialist, as in some cases (such as pyoderma gangrenosum) a biopsy or debridement of tissue may exacerbate the condition.

Skin tears are wounds that occur as acute traumas that are largely preventable. The International Skin Care Consensus Panel was created in 2011. The goal of this group is to identify the prevalence and severity of skin tears, develop prevention and treatment guidelines, and establish a universal protocol for the classification of skin tears that demonstrates interrater reliability.

Wound Assessment
All systemic comorbidities should be identified and the management of these conditions included in the plan of care. Of particular concern would be endocrine disorders such as diabetes, circulatory impairment, anemia, pulmonary disease, a compromised immune system, neuropathy, poor nutrition, and/or dehydration. Pain management is also key to the plan of care as stress, lack of sleep, and uncontrolled pain all contribute to poor healing.

Local factors that prevent the body's ability to heal include, but are not limited to the following:

• Necrotic tissue: Eschar, slough, and friable granulation tissue are all considered necrotic, nonviable tissue. The presence of necrosis in the wound bed provides a "feast" for microorganisms. In addition, the wound is locked into a continuous state of inflammation, preventing the transition to the proliferative phase of wound healing. In an infected wound with necrosis, the AHRQ recommends consideration of a surgical consult. The implementation of a combination of debridement measures including sharp, chemical, autolytic, and/or mechanical debridement may enhance outcomes. The use of "wet to dry" gauze debridement is no longer considered an appropriate course of treatment as it may cause trauma to the wound and patient, does not provide thermal insulation or gaseous exchange, and doesn't prevent cross-contamination.

• Matrix metalloproteinases (MMPs): MMPs secreted by the fibroblasts during the inflammatory phase of wound healing degrade the nonviable collagen within the wound. Tissue inhibitor of metalloproteinase (TIMP) inhibits the MMPs to ensure the level of activity remains at the optimal level but does not result in unnecessary degradation and chronic inflammation. There is a need for a delicate balance between MMPs and TIMP. Extensive and chronic inflammation may be due to the excessive presence and activity of MMPs and result in degradation of healthy tissue. Collagen treatments with extracellular matrix will minimize the tissue degradation and donate external cellular matrix to the wound bed.

• Soft tissue infection: Assess for soft tissue infection any nonhealing wounds, wounds that present with odor, wounds displaying new onset necrosis, dark friable tissue, peripheral edema, induration, or erythema, and any wound with new onset or increased intensity of pain. It's important to determine the type of culture to be obtained which may be a swab, aspiration of wound drainage, or a tissue biopsy. Cleanse the wound prior to culture and avoid culturing necrotic tissue. The objective is to identify the presence of infection, gas gangrene, and/or necrotizing infection. Then determine the appropriate treatment and route of administration. Given the complexity of the patient and wound, a consultation with an infectious disease specialist may be warranted. A consultation with a pharmacist may also be advisable to determine the best option and route of administration.

• Osteomyelitis: Osteomyelitis may be primary or refractory (ie, failed antibiotic therapy with positive results on follow-up diagnostics). All wounds should be assessed for the presence of bone and, if present, suspect osteomyelitis. Diagnostics may include biopsy, triple phase bone scan, or MRI. In cases of refractory osteomyelitis, hyperbaric oxygen therapy may be an effective adjunctive therapy.

Tests and Procedures
Laboratory procedures to assess patients with wounds may include complete blood count, sedimentation rate, glycosolated hemoglobin (diabetic), prealbumin (albumin), basic metabolic panel or comprehensive metabolic panel, C-reactive protein noncardiac, prothrombin time/partial thromboplastin time, hypercoagulable panel, tissue or swab culture, tissue biopsy, or bone biopsy.

Diagnostic procedures for lower extremities may include arterial duplex Doppler, venous duplex Doppler with reflux and perforators, aortogram with runoff, arteriogram, X-ray, MRI, triphasic bone scan, and transcutaneous oxygen measurement (with or without elevation; with or without air challenge).

Consultations are an important aspect of the assessment and management of patients with wounds. There are many aspects of care that can benefit significantly from the expertise of an interdisciplinary approach to care. Some suggested consultations include infectious disease, vascular specialist, cardiology, endocrinology, surgery, podiatry, orthotics, physical therapist/occupational therapist, nutritional consultant, speech therapy for swallow studies, wound care nurse, pharmacy, social services/case management/navigator.

Thorough wound assessment should be completed according to a set schedule. It is important for all clinicians to use the same methods, terminology, and format to ensure accuracy and clearly identify whether the wound status is static, is improved, or has deteriorated. Factors identified in the wound assessment should include its anatomical location; size/volume (length, width, depth, undermining); exudate (viscosity, amount, odor, and color); the color and type of wound tissue; condition of the wound edges and periwound skin; pain (intensity, aggravating and/or relieving factors); signs of infection and/or inflammation; and overall status of the wound (unchanged, improved, worsened).

Wound Dressings
Topical wound care includes wound cleansing with a noncytotoxic cleanser, removal of necrotic tissue, management of bioburden infection and chronic inflammation, and protection of the tissues within and surrounding the wound.

The myriad types of wound dressings can make it puzzling to choose the best option. In general, one needs to consider the etiology of the wound, the desired wear time, ease of application, availability, and cost. It is a humbling fact that we do not heal wounds. The opportunity we have is to identify what the microenvironment of the wound is lacking so we can choose the best topical treatment that will support the body's cascade of events in wound healing. This "missing factor" can be referred to as the DEBT of the wound, acronym that stands for the following:

• Depth, including undermining and tunneling. The goal is to ensure that the primary dressing makes contact with the entire wound surface and provides support to the structure of the wound.

• Exudate, including the amount, viscosity, odor, and color. The goal is to ensure that the primary dressing allows for the appropriate level of moisture and absorbs excess exudate.

• Bioburden, including characteristics of the exudate, tissue, erythema, edema, induration, and other characteristics of bioburden or infection. The goal is to ensure that in the event an antimicrobial agent is necessary, it addresses the appropriate organisms of concern, exhibits a long-acting safe delivery system, and will not result in cytotoxicity or contribute to the development of resistant bacterial strains.

• Tissue, or the condition of the tissue within the wound, at the edges, and in the surrounding area. Differentiate healthy healing tissue from necrosis or unhealthy granulation tissue. Ensure that the chosen treatment supports the healthy healing of the wound and is appropriate to the stage of the wound healing process.

All topical and secondary dressings should ensure thermal insulation, gaseous exchange, appropriate moisture level, a bacterial barrier, comfort, and ease of application.

In general, the DEBT of a wound by etiology includes the following:

Pressure Ulcer
D: Depth varies from shallow to deep, depending on location and extent of tissue damage. Include undermining and tunneling.

E: Exudate varies from moderate to copious, depending on the extent of tissue damage and level of bioburden.

B: Bioburden may vary; however, patient is usually at high risk as is the wound. Contaminations from external sources are especially concerning (eg, excrement).

T: Tissue may vary and include granulation and/or necrotic tissue (eg, eschar and/or slough).

Skin Tears
D: Depth is typically shallow; however, may include full thickness.

E: Exudate typically minimal to small; occasionally large if edema or significant tissue damage exists.

B: Contaminated; however, not at high risk for infection if protected; normal flora can be helpful for regeneration of epidermis.

T: Tissue is typically not necrotic, but epidermis. If the wound is deep, there may be some granulation tissue or even necrosis. Note: the hair follicle is lined with epidermis and, if intact, one may observe "island epidermis" within the base of the wound.

Diabetic/Neuropathic Ulcers
D: deep—covered by callous;

E: moderate to large;

B: risk for critical colonization and infection due to diabetes mellitus, poor circulation, and age of wound when diagnosed; and

T: tissue may appear as healthy granulation to tissue (eg, slough/eschar).

Venous Stasis Ulcers
D: Depth is usually moderately deep.

E: Moderate to copious (note: especially copious when using compression therapy with initial shift in fluids).

B: Patient and wound frequently at risk for critical colonization or infection due to edema/poor circulation and associated necrosis or comorbidities. Not uncommon for periphery of wound to exhibit contact/stasis dermatitis and/or cellulitis.

T: Not unlikely to exhibit necrosis (slough most commonly; however, eschar also possible).

Arterial Ulcer
D: typically shallow due to location (toes, top of foot, or lower leg);

E: exudate small to moderate;

B: high-risk patient and wound for critical colonization and/or infection due to poor circulation; and

T: tissue may be necrotic (eschar most common; slough possible) or granular.

D: typically shallow; blister;

E: large to copious from ulcers as well as skin;

B: patient at high risk for contact dermatitis; and

T: tissue typically not necrotic.

Surgical Wound
D: May vary from shallow (donor site) to deep depending on location and complications.

E: May vary from small to copious depending on cause complication, location, and type of surgical procedure.

B: Contamination, critical colonization, and infection common cause of surgical dehiscence or intentional closure by secondary or tertiary wound closure.

T: Tissue may include granulation and necrosis (eschar, slough).

There have been significant developments of new therapies for treating wounds. Clinicians are often challenged to stay current with the knowledge of the appropriate selection of topical dressings and advanced wound therapies, including negative pressure wound therapy, support surfaces, compression therapy (static and dynamic), contact casting, orthotics and offloading devices, skin and tissue therapies, and hyperbaric oxygen.

— Mary Cardy Weaver, ARNP, WOC nurse, CWCN, has been in clinical, managerial, and educational roles responsible for clinical practice in the acute, home, hospice, and long term care settings. Her passion and focus is geriatrics and wound care. Following her recent retirement, she currently consults for health care organizations in Merritt Island, Florida.

— Kathy Wright, MSN, CWOCN-AP, ACHRN, is a member of the Nanticoke Health Services Wound Care and Hyperbaric Medicine department in Seaford, Delaware. With extensive managerial and educational experience, she has a passion for wound care and hyperbaric medicine.

Additional Resources
1. Armstrong DG, Lavery LA. Clinical Care of the Diabetic Foot. 2nd ed. American Diabetes Association; 2010.

2. Bryant RA, Nix D. Acute and Chronic Wounds. Current Management Concepts. 4th ed. St. Louis, MO: Elsevier Mosby; 2011.

3. Hess CT. Clinical Guide Skin and Wound Care. 7th ed. Lippincott, Williams, & Wilkins; 2013.

4. LeBlanc K, Baranoski S, Skin Tear Consensus Panel Members. Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care. 2011;24(9 Suppl):2-15.


Professional Organizations
• Wound Ostomy and Continence Nurses Society (
• Symposium on Advanced Wound Care Network (
• Wound Healing Society (
• The Agency for Healthcare Research and Quality (
• National Pressure Ulcer Advisory Panel (
• National Board of Diving and Hyperbaric Medical Technology (
• International Skin Tear Consensus Panel (
• Clinical Symposium on Advances in Skin and Wound Care
• International Society of Limb Salvage (

Wound Care Management Guidelines
• Pressure Ulcer Risk Assessment (
• NPUAP Guidelines on Prevention and Management of Pressure Ulcers
• AHRQ Pain Management Guidelines

This article is designed as a helpful review to refresh wound care knowledge and practices. These resources are intended to be helpful in education and clinical practice. This is not a complete list nor is it intended to provide any endorsement.

— MCW and KW