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Practical Issues in Wound, Skin and Ostomy Management
Topical application of silver nitrate is often used in wound care to help remove and debride hypergranulation tissue or calloused rolled edges in wounds or ulcerations. It’s also an effective agent to cauterize bleeding in wounds. Silver nitrate is a highly caustic material, so it must be used with caution to prevent damage to healthy tissues. (more…)
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By Matthew Steinhauser, University of Pittsburgh
I recently visited an 83-year-old patient in the hospital after EMTs rushed her to the ER with an infected leg wound. Her ordeal started inconspicuously when she bumped into the sharp edge of a table and developed a small cut. The patient’s wound didn’t close, but she ignored it until she woke up in pain one morning two weeks after first injuring her leg. Her daughter called 911 after noticing angry, red skin discoloration and pus – both signs of an infection. Our medical team treated her with IV antibiotics and cleared up the infection, but the wound did not fully close until at least a month later, well after she was discharged from the hospital.
How different the story is when children get a cut. They may scream initially, but within days, the scab falls off, revealing new skin. Why was healing so delayed in my 83-year-old patient compared to a healthy child?
The answer is age. Decades of life slow down healing for most tissues, and wounds in skin can offer a window into why this slowdown occurs.
I am physician who studies how aging predisposes patients to diseases like diabetes and whether behavioral changes such as intermittent fasting may slow down aging. In order to understand why the skin wound in my older patient healed so slowly, it is important to first understand how wounds heal under the ideal conditions of youth.
The wound healing process is classically categorized into three stages.
Right after a wound occurs, the inflammatory response begins.
Jpbarrass via Wikimedia Commons
The first stage is inflammation, essentially the body’s attempt to clean the wound. During the inflammatory phase, immune cells called phagocytes move into the wound, kill any contaminating bacteria, and ingest and dispose of dead cells and debris.
Inflammation sets the stage for the regenerative phase, where several processes work in concert to regrow damaged skin. Replacement skin cells are born when cells at the edge of the wound divide, while fibroblast cells lay down a supportive scaffolding called the extracellular matrix. This holds the new cells together. Any damaged supporting structures of the skin, such as the blood vessels that supply critical oxygen and nutrients, also need to regrow. The second stage effectively closes the wound and restores a protective barrier against bacteria.
The regenerative phase is a relatively quick, but tenuous fix – new skin is fragile. The final remodeling phase plays out over a couple of years as the new skin is progressively strengthened by several parallel processes. The extracellular matrix, which was initially laid down in a haphazard fashion, is broken down and replaced in a more durable way. Any residual cells from prior phases that are no longer needed – such as immune cells or fibroblasts – become inactive or die. In addition to strengthening the new skin, these collective actions also account for the tendency of scars to visibly fade with time.
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One major way aging can derail the orderly and efficient progression through the stages of healing is through the health problems that stem from diseases of old age.
Diabetes is one example of a disease that is strongly associated with older age. One of the many ways that diabetes negatively affects healing is by causing blood vessels to narrow. As a consequence of inadequate circulation, crucial nutrients and oxygen do not reach the wound in sufficient quantities to fuel the second regenerative phase.
Diabetes is just one of many age-related diseases that disrupts normal processes in the body such as wound healing.
Aside from the negative impacts of age-associated diseases, cells themselves age. In an extreme sign of aging called cellular senescence, cells permanently lose the ability to divide. Senescent cells accumulate in skin and many other organs as people age and cause a host of problems.
When cells divide more slowly – or when they stop dividing altogether due to senescence – skin becomes thinner. The replacement of fat cells, which form a cushioning layer under the skin, also declines with age. The skin of older patients is therefore more prone to injury in the first place.
Once an older person’s skin is injured, the skin has a harder time healing properly as well. Aging and senescent immune cells cannot defend against bacteria, and the risk of serious skin infection rises. Then in the regenerative stage, slow rates of cell division translate into slow skin regrowth. My patient exhibited all of these negative effects of age – her thin, almost translucent skin ruptured from a minor bump, became infected and took nearly two months to fully regrow.
But senescent cells are more than just dysfunctional bystanders. For reasons that are not yet fully understood, senescent cells release toxic byproducts that damage surrounding tissue and drive inflammation – even when there’s no bacterial threat present. Some of these byproducts can even accelerate senescence in neighboring cells. This suggests that intrinsic aging of cells is in essence contagious and senescent cells actively fuel an uncontrolled cycle of inflammation and tissue damage that further impedes successful regeneration and healing.
As the most outwardly visible tissue of the body, the skin provides a window into why people heal more slowly with age, but all tissues can be injured and are susceptible to the effects of aging. Injuries may be small, repetitive and build up over time – like the effect of smoking on the lungs. Or they may be discrete and dramatic – such as the death of heart cells with a heart attack. Different tissues may heal in different ways. Yet all tissues share a sensitivity to the repercussions of an aging immune system and a decline in the ability to regrow dead or damaged cells.
Understanding why healing slows down with age is important, but my patient asked a very practical question that physicians often face in one form or another: “Doctor, what can you do for me?”
Unfortunately, current treatment of wounds is fairly old-fashioned and often ineffective. Some of the options available include wound dressing changes, antibiotics when the wound is infected or treatment in a high oxygen chamber when circulation is bad due to diabetes.
There is hope, though, that medicine can do better and that progress in understanding the aging process will lead to new therapies. Neutralizing senescent cells in mice, for example, improves a variety of age-associated diseases. While it is way too early to say that researchers have discovered the fountain of youth, I am optimistic for a future when physicians will bend the aging curve and make skin and other organs heal faster and better.
Matthew Steinhauser, Associate Professor of Medicine, University of Pittsburgh
This article is republished from The Conversation under a Creative Commons license. Read the original article.
As a wound care specialist, you have learned about many skin conditions, some so unusual and rare that you probably thought you would never observe them. I’ve been a nurse for 38 years, with the last 10 years in wound care, and that’s certainly what I thought. But I was wrong. Let me tell you about my challenging patient with…
As full-thickness wounds heal, they begin to fill in from the bottom upward with granulation tissue. At the same time, wound edges contract and pull together, with movement of epithelial tissue toward the center of the wound (contraction). These epithelial cells, arising from either the wound margins or residual dermal epithelial appendages within the wound bed, begin to migrate in leapfrog or train fashion across the wound bed. Horizontal movement stops when…
Electrical stimulation and pressure ulcer healing in SCI patients A systematic review of eight clinical trials of 517 patients with spinal cord injury (SCI) and at least one pressure ulcer indicates that electrical stimulation increases the healing rate of pressure ulcers. Wounds with electrodes overlaying the wound bed seem to have faster pressureulcer healing than wounds with electrodes placed on intact skin around the ulcer.
Here is a round-up of resources that you may find helpful in your practice. New illustrations for pressure-injury staging The National Pressure Ulcer Advisory Panel (NPUAP) has released new illustrations of pressure injury stages. You can download the illustrations, which include normal Caucasian and non-Caucasian skin illustrations for reference. There is no charge for the illustrations as long as they are being used for educational purposes, but donations to…
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Topical application of silver nitrate is often used in wound care to help remove and debride hypergranulation tissue or calloused rolled edges in wounds or ulcerations. It’s also an effective agent to cauterize bleeding in wounds. Silver nitrate is a highly caustic material, so it must be used with caution to prevent damage to healthy tissues.
For an ostomy pouching system to adhere properly, the skin around the stoma must be dry and intact. Otherwise, peristomal skin problems and skin breakdown around the stoma may occur. In fact, these problems are the most common complications of surgical stomas. They can worsen the patient’s pain and discomfort, diminish quality of life, delay rehabilitation, increase use of ostomy supplies, and raise healthcare costs. Peristomal skin problems also perpetuate a…
By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN Many factors can contribute to the formation of a pressure ulcer, but it’s rare that one develops in an active, mobile patient. As the National Pressure Ulcer Advisory Panel 2014 guidelines state, “Pressure ulcers cannot form without loading, or pressure on the tissue. Extended periods of lying or sitting on a particular…
Imagine watching your skin tear, bleed, and turn purple. Imagine, too, the pain and disfigurement you’d feel. What if you had to live through this experience repeatedly? That’s what many elderly people go through, suffering with skin tears through no fault of their own. Some go on to develop complications. A skin tear is a traumatic wound caused by shear, friction, or blunt-force trauma that results in a partial-…
This issue marks the fourth anniversary of the “Best of the Best” issue of Wound Care Advisor, the official journal of the National Alliance of Wound Care and Ostomy. Fittingly, it comes during an Olympics year. Since 1904, the Olympics have awarded gold medals to athletes whose performance makes them the “best of the best.” This year, we’re proud to present our own “Best…
By Roxana Reyna, BSN, RNC-NIC, WCC, CWOCN As wound care clinicians, we are trained—and expected—to help heal wounds in patients of any age and to achieve positive outcomes. Basic wound-healing principles apply to all patients, whatever their age or size. The specific anatomy and physiology of vulnerable pediatric patients, however, requires detailed wound care. Unfortunately, little evidence-based research exists to…
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Keeping clinicians up-to-date on clinical knowledge is one of the main goals of the Wild on Wounds (WOW) conference held each September in Las Vegas. Every year, I present the opening session, called “The Buzz Report,” which focuses on the latest-breaking wound care news—what’s new, what’s now, and what’s coming up. I discuss new products, practice guidelines, resources, and tools from the last 12 months in skin, wound, and ostomy management. In…
Using a checklist form to document wound care can make the task easier and faster—and help ensure that you’ve captured all pertinent data needed for assessment, reimbursement, and legal support. But the form itself may not be comprehensive; some important fields may be missing. Recently, we at Wound Care Advisor received a question from a clinician who was having trouble deciding how to code a patient’s wound in her hospital’s…
Self-management ostomy program improves HRQOL A five-session ostomy self-care program with a curriculum based on the Chronic Care Model can improve health-related quality of life (HRQOL), according to a study in Psycho-Oncology. “A chronic care ostomy self-management program for cancer survivors” describes results from a longitudinal pilot study of 38 people. Participants reported sustained improvements in patient activation, self-efficacy, total HRQOL, and physical and social well-being. Most patients had a history of…
Check out the following resources, all designed to help you in your clinical practice. Human trafficking resources Victims of human trafficking often suffer tremendous physical and psychological damage. Clinicians play an important role in identifying potential victims so they can obtain help. Here are some resources to learn more about human trafficking. • “Addressing human trafficking in the health care setting” is an online course that includes a…
Turning programs are essential to prevent and promote healing of pressure ulcers and to prevent the many negative effects of immobility, ranging from constipation to respiratory infections. However, turning a patient often puts a caregiver’s body in an awkward position, which can lead to musculoskeletal damage, especially back injuries. According to the U.S. Bureau of Labor Statistics, healthcare workers suffer…
Nearly all clinicians know exercise is good for our physical and mental health. But incorporating it into our busy lives can be a challenge. The only types of exercise some clinicians have time for are working long shifts, juggling life’s demands, balancing the books, jumping on the bandwagon, climbing the ladder of success, and skipping meals. Clinicians are in a…
Support surfaces are consistently recommended for the prevention and treatment of pressure ulcers. So patients can derive optimal benefits from support surfaces, clinicians must understand how to use them effectively. This article answers several questions about these useful tools.
Topical application of silver nitrate is often used in wound care to help remove and debride hypergranulation tissue or calloused rolled edges in wounds or ulcerations. It’s also an effective agent to cauterize bleeding in wounds. Silver nitrate is a highly caustic material, so it must be used with caution to prevent damage to healthy tissues.
Imagine watching your skin tear, bleed, and turn purple. Imagine, too, the pain and disfigurement you’d feel. What if you had to live through this experience repeatedly? That’s what many elderly people go through, suffering with skin tears through no fault of their own. Some go on to develop complications. A skin tear is a traumatic wound caused by shear, friction, or blunt-force trauma that results in a partial-…
Optimizing nutritional status is a key strategy both in preventing and managing pressure ulcers. In patients across all care settings, compromised nutrition— as from poor intake, undesired weight loss, and malnutrition—increases the risk of pressure ulcers. It contributes to altered immune function, impaired collagen synthesis, and decreased tensile strength. In many cases, malnutrition also contributes to wound chronicity and increases the risk for delayed and impaired wound healing. In patients with chronic…
This approach brings patient-centered care to life.
By Gail Rogers Hebert, MS, RN, CWCN, WCC, DWC, OMS, LNHA
Editor’s note: This article is the second in a two-part series on palliative wound care. For the first part, click here.
By preventing and relieving suffering, palliative care improves the quality of life for patients facing problems associated with life-threatening illness. This care approach emphasizes early identification, impeccable assessment, and treatment of pain and other issues—physical, psychosocial, and spiritual. (more…)
Read MoreBy Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS
Keeping clinicians up to date on clinical knowledge is one of the main goals of the Wild On Wounds (WOW) conference,held each September in Las Vegas. Each year, I present the opening session of this conference, called “The Buzz Report,”which focuses on the latest-breaking wound care news—what’s new, what’s now, and what’s coming up. I discuss innovative new products, practice guidelines, resources, and tools from the last 12 months in skin, wound, and ostomy management. (more…)
Read MoreBy Catherine R. Ratliff, PhD, APRN-BC, CWOCN, CFCN
It’s estimated that about 70% of the 1 million ostomates in the United States and Canada will experience or have experienced stomal or peristomal complications. Peristomal complications are more common, although stomal complications (for example, retraction, stenosis, and mucocutaneous separation) can often contribute to peristomal problems by making it difficult to obtain a secure pouch seal. This article will help you differentiate types of peristomal complications, including how to prevent and manage them. (more…)
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As full-thickness wounds heal, they begin to fill in from the bottom upward with granulation tissue. At the same time, wound edges contract and pull together, with movement of epithelial tissue toward the center of the wound (contraction). These epithelial cells, arising from either the wound margins or residual dermal epithelial appendages within the wound bed, begin to migrate in leapfrog or train fashion across the wound bed. Horizontal movement stops when cells meet (contact inhibition). The ideal wound edge is attached to and flush with the wound bed, moist and open with the epithelial rim thin, and pale pink to translucent. (more…)
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