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Wound Healing
Wound healing occurs in 3 stages: inflammatory, proliferative, and maturation.
A Critical Review of Natural Therapies in Wound Management
The use of natural medicine by both the general population and the nursing profession is increasing. Also referred to as unconventional, alternative, and complementary, these therapies often are derived from natural sources and facilitate improvements in health and well being by supporting innate healing processes of the body. Although the application of natural therapies in wound management is still in its infancy, several - honey, larval therapy, aromatherapy, herbal medicine, homeopathy, nutrition, and mind-body-spirit techniques - are demonstrating potential benefit in the management of acute and chronic wounds. Existing evidence of safety and effectiveness is predominantly based on the results of in vivo studies; confirmation from well-designed clinical trials is deficient. Consequently, clinical research is needed to examine these therapies to address the escalating incidence of chronic wounds in a climate of increasing healthcare costs.
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Pressure Ulcers and Other Chronic Wounds in Patients with and Patients without Cancer: A Retrospective, Comparative Analysis of Healing Patterns
Knowledge about wound healing patterns in patients with cancer is limited. To compare wound healing outcomes and patterns between persons with and persons without a diagnosis of cancer, a retrospective study was conducted using a convenience sample drawn from international chronic wound databases containing almost 36,000 standardized wound assessments (consisting of 13 anatomical wound characteristics). Based on the recorded chronic wound profiles, 18 patients who had cancer were matched with 18 who did not have cancer; their first assessment wound profiles were completely identical. It was hypothesized that, compared to patients without cancer, patients with cancer have 1) a greater percentage of non-healing wounds, 2) wounds that take longer to heal, and 3) more comorbidities that can delay healing. After a maximum treatment period of 24 weeks, 44% of wounds in patients with cancer compared to 78% of wounds in patients without cancer were healed (P = .018). Wounds that healed did so at the same pace regardless of cancer status (approximately 55 days [±41] for patients with cancer and 59 days [±48] for patients without cancer). Patients with cancer had more comorbidities and other factors that could impede wound healing [mean 4.72 (±1.09)] than patients without cancer [mean 1.50 (±0.39)]. Differential healing patterns between the two groups after 8 weeks suggest that alternative treatment and management practices may be warranted for cancer patients with non-healing wounds. KEYWORDS: cancer, chronic wounds, CuSum, retrospective, wound healing
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Topical Hyperbaric Oxygen and Electrical Stimulation: Exploring Potential Synergy
Treatment of chronic wounds involves interventions ranging from dressings to surgery. Modalities gaining popularity in clinical settings include topical hyperbaric oxygen and electrical stimulation. A prospective, uncontrolled study was conducted to obtain preliminary observations and data about the effects of topical hyperbaric oxygen therapy and topical hyperbaric oxygen used with electrical stimulation on the healing of chronic wounds. All subjects were geriatric residents of long-term care facilities with Stage III or Stage IV pressure ulcers. Topical hyperbaric oxygen was applied daily to the wounds of eight subjects; three also received electrical stimulation. Initial wound size ranged from 87.75 cm2 to 7.04 cm2 with an average size of 30.1 +/- 28.5 (mean +/- sd) cm2. Healing times ranged from 8 to 49 weeks. After 4 weeks of treatment with topical hyperbaric oxygen, wound size decreased an average of 34.4% +/- 22.9%. Incidentally, the wounds of five of the eight subjects decreased more than 20%, for an average of 51.8% +/- 17.9%. No significant differences in healing were observed between patients receiving topical hyperbaric oxygen alone and those receiving topical hyperbaric oxygen/electrical stimulation. Preliminary data indicate that topical hyperbaric oxygen facilitates wound healing and full closure for pressure ulcers in patients with and without diabetes mellitus. A multicenter, prospective, randomized, double-blind controlled study is currently under way.
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Regenerative Healing in Fetal Skin: A Review of the Literature
In mature skin, wound repair typically begins with hemostasis and inflammation. This is followed by a proliferative phase with reepithelialization, angiogenesis, and collagen production, and ends with the generation of a permanent scar. However, animal studies and clinical observations have shown that a different type of healing occurs in fetal skin in the first two trimesters of development. In early fetal skin, wounds exhibit a unique pattern of wound healing leading to regeneration. Notably, repair in the fetus takes place with little or no inflammation, faster reepithelialization, and no scarring. Although research in scarless fetal healing began several decades ago, the exact mechanisms of how this regenerative process takes place remain unknown. Knowing how the fetus will respond to potential injury from invasive diagnostic procedures or surgery is essential, especially given the development of less invasive fetal surgical techniques which could increase the number of fetal surgeries. In addition, insights into regenerative healing may provide information about how to accelerate postnatal wound healing as well as how to improve healing from a cosmetic standpoint. Future research directions include identification of the molecular controls responsible for scarless healing, with the intention that this new information will lead to improved therapeutic strategies for wound healing. KEYWORDS: wound healing, fetus, scar, embryo, regeneration
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Mind-Body Techniques in Wound Healing
Even the most skilled and resourceful wound care provider encounters stagnation of wound healing from time to time. Patients with chronic, nonhealing wounds often display negative thought patterns and behavioral tendencies that, in turn, hinder biological and emotional healing. An increasing body of research supports the negative effect of stress on wound healing. The impact of deeper, emotion-based "wounds" as complicating factors in conventional wound healing are being further explored. It is theorized that emotions such as lack of self worth, guilt, and anger are strongly correlated to the chronic, nonhealing wound. Mind-body techniques such as affirmations, creative visualization, relaxation, and conscious breathing are suggested for incorporation into the treatment program. These techniques seek to empower and engage the patient by promoting greater personal awareness and assertion in the healing process. Wound care providers are seen as facilitators of the innate healing potential inside each individual. Mind-body techniques are offered as a complement for a more comprehensive wound healing strategy.
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Successful Outcomes with the h.e.a.l. Program
The successful treatment of acute and chronic wounds can be daunting. In an effort to improve client outcomes and manage spiraling nursing and dressing supply costs, the Community Care Access Centre of Wellington-Dufferin (Canada) implemented the Healing Excellence with Advanced Learning (h.e.a.l.) program in March 2003 as a standardized, evidence-based means of providing wound care to home care clients. While implementation challenges remain and education is ongoing, indepth wound management education and standardization of care have reduced the percentage of patients receiving nonevidence-based wound care and resultant frequent dressing changes. This has enabled the Centre to reallocate $1.5 million from dressing change costs to new nursing initiatives beyond wound care. The initial goals of the program were met. Continuing documentation of its outcomes will help underscore the importance of evidence-based protocols and provider education to the wound healing process. KEYWORDS: evidence-based practice, moist wound healing, outcome measurement
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Malnutrition in the Institutionalized Elderly: The Effects on Wound Healing
Under-nutrition and protein-energy malnutrition are seen at alarmingly high rates in institutionalized elderly and in patients admitted to hospitals. A combination of immobility and loss of lean body mass ? which comprises muscle and skin ? and immune system challenges increases the risk of pressure ulcers by 74%. The development of pressure ulcers in the hospital affects 10% of admissions, with the elderly at the highest risk. Common causes of malnutrition in the elderly involve: decreased appetite, dependency on help for eating, impaired cognition and/or communication, poor positioning, frequent acute illnesses with gastrointestinal losses, medications that decrease appetite or increase nutrient losses, polypharmacy, decreased thirst response, decreased ability to concentrate urine, intentional fluid restriction because of fear of incontinence or choking if dysphagic, psychosocial factors such as isolation and depression, monotony of diet, and higher nutrient density requirements along with the demands of age, illness, and disease on the body. All have been found to delay healing and increase the risk of pressure ulcer development. In addition, what is ingested should contain nutrients to support health and healing. The financial impact of malnutrition is high and the consequences for patient morbidity and mortality are severe. Practical suggestions to improve the nutritional status of long-term care residents include liberalizing previous diet restrictions where safe and appropriate, addressing impairments to dentition and swallowing, addressing physical and/or cognitive deficits, encouraging family and friends to provide favorite foods, auditing/addressing specific food under-consumption, and providing prudent nutrient supplementation. Clinicians must be aware of the numerous factors in play with regard to nutrition and its impact on not only general well-being but also on wound care. Nutritional intervention in pressure ulcer management is truly ?healing from the inside out.? KEYWORDS: malnutrition, el
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SAWC 2004 Abstract Preview
Methods: A prospective, comparative study was conducted over a 4-year period at our Wound Treatment Center. Results: In our study, 88 of the 99 patients (89%) had wound healing. Studies that have examined patients?
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Negative Pressure Wound Therapy Achieved by Vacuum-Assisted Closure: Evaluating the Assumptions
Wounds and the accompanying loss of skin integrity often place a patient at increased risk for disability or death. Billions of dollars are spent each year to treat wounds and the effectiveness of these different treatments is highly variable. Following a 1997 publication describing a new treatment therapy that involved creating negative pressure over the wound, many publications have described the purported mechanism of action by which negative pressure may help wounds heal. Although this therapy appears effective, it remains unknown whether it is more effective than other wound closure techniques. In addition, although many uncontrolled, non-randomized studies describing the effectiveness of this therapy have been published, few prospective randomized trials have been conducted. Small sample sizes, variable outcome measures across studies, and significant methodological problems in the available randomized control trials further limit the conclusions that can be drawn regarding the relative effectiveness of vacuum-assisted wound closure. Analysis of these data provides weak evidence to suggest that negative pressure therapy is superior to saline gauze dressings in healing chronic wounds. Randomized controlled trials comparing healing, costs of care, patient pain, and quality-of-life outcomes of this treatment to non-gauze type dressings and other treatment modalities are needed. KEYWORDS: topical negative pressure, wound closure, dressings, subatmospheric pressure, wound management
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Risk Factors Associated with Healing Chronic Diabetic Foot Ulcers: The Importance of Hyperglycemia
Diabetic foot ulcer management presents a significant challenge for wound care clinicians; numerous approaches to encourage healing in these difficult wounds have been explored. To determine risk factors related to diabetic foot ulcer time to healing and closure, a secondary analysis of data from a prospective randomized study involving 245 patients treated with a bioengineered human dermal substitute (n = 130) or control treatment (n = 115) was conducted. Analyzed variables included age, race, gender, ulcer duration, initial ulcer size, initial hemoglobin (HgbA1c), average HgbA1c, change in HgbA1c, diabetes type, average hours of weight-bearing, study ulcer infection, history of smoking or alcohol use, and laboratory values. Time to healing was significantly affected by initial ulcer size (risk ratio 0.75, confidence interval 0.59?0.96), gender (risk ratio 2.01, confidence interval 1.20?3.40), and wound infection during the study (risk ratio 2.9, confidence interval 1.45?4.22). Initial ulcer size (>2 cm2), male gender, and an episode of infection during the study were associated with an increased risk of nonclosure after 12 weeks of care (P <0.05). In patients whose HgbA1C increased during the study (n = 101), 20.7% of all wounds and 21% of dermal substitute-managed wounds (n = 105) healed; whereas, in patients whose HgbA1C levels remained stable or decreased, 26.3% of all wounds and 47% of dermal substitute-managed wounds healed (P <0.05). Female gender, small ulcer size, and the absence of infection were found to have a positive effect on healing all diabetic foot ulcers; improved glucose control had a significant effect on healing wounds managed with the dermal substitute only. This is the first diabetic foot ulcer study to find a relationship between hyperglycemia and wound healing. Further research into factors that improve healing of wounds, including diabetic foot ulcers, is warranted. KEYWORDS: diabetes mellitus, foot ulcers, healing, risk factors, hyperglycemia
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