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New Approach to Wound Healing Easy on Skin, Tough on Bacteria

wound healing

Washington, D.C. — In a presentation  to the American Chemical Society meeting, Ankit Agarwal, a postdoctoral researcher at the University of Wisconsin-Madison, described an experimental approach to wound healing that could take advantage of silver’s anti-bacterial properties, while sidestepping the damage silver can cause to cells needed for healing.

Silver is widely used to prevent bacterial contamination in wound dressings, says Agarwal, “but these dressings deliver a very large load of silver, and that can kill a lot of cells in the wound.” (more…)

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Lymphedema and lipedema: What every wound care clinician should know

Imagine you have a health condition that affects your life every day. Then imagine being told nothing can be done about it; you’ll just have to live with it. Or worse yet, your physician tells you the problem is “you’re just fat.”

Many people with lymphedema or lipedema have no idea their condition has a name or that many other people suffer from the same thing. Although lymphedema and lipedema can’t be cured, proper management and resources can help patients cope. This article improves your grasp of these conditions, describes how to recognize and manage them, and explains how to support your patients.

To understand lymphedema and lipedema, first you need to understand how the lymphatic system functions. It makes lymph, then moves it from tissues to the bloodstream. It also plays a major role in the immune system, aiding immune defense. In addition, it helps maintain normal fluid balance by promoting fluid movement from the interstitial tissues back to the venous circulation. (See Lymphatic system: Four major functions.)

If the lymphatic system is impaired from a primary (hereditary or congenital) condition or a secondary problem, lymphedema can result. In this chronic, potentially progressive, and incurable condition, protein-rich fluid accumulates in the interstitial tissues.

Lymphedema basics

Lymphedema occurs in four stages.

Stage 0. During this stage (also called the subclinical or latency stage), transport capacity of the lymphatic system decreases but remains sufficient to manage normal lymphatic loads. Signs and symptomsaren’t evident and can be measured only by sensitive instruments, such as bioimpedance spectroscopy and optoelectronic volumetry. Without such instruments to quantify volume changes, diagnosis may rest on subjective complaints.

In this stage, limited functional reserve of the lymphatic system leads to a fragile balance between subnormal transport capacity and lymphatic loads. Added stress on the lymphatic system (as from extended heat or cold exposure, injury, or infection) may cause progression to stage 1.

Providing appropriate patient information and education, especially after surgery, can dramatically reduce the risk that lymphedema will progress to a more serious stage.

Stage 1. Considered the spontaneously reversible stage, stage 1 is marked by softtissue pliability without fibrotic changes. Pitting can be induced easily. In early stage 1, limb swelling may recede over – night. With proper management, the patient can expect the extremity to decrease to a normal size compared to that of the uninvolved limb. Otherwise, lymphedema is likely to progress to stage 2.

Stage 1 lymphedema may be hard to distinguish from edemas from other causes. Clinicians must rely on the patient history and monitor for swelling resolution with conventional management, such as compression and elevation, or note if swelling persists despite these standard interventions.

Stage 2. Sometimes called the spontaneously irreversible stage, stage 2 is identified mainly from tissue proliferation and subsequent fibrosis (called lymphostatic fibrosis). The fluid component can be removed spontaneously, but removal of the increased tissue proliferation (initially irreversible) takes more time. Tissue proliferation stems from long-standing accumulation of protein-rich fluid; over time, the tissue hardens and pitting is hard to induce. In many cases, swelling volume increases, exacerbating the already compromised local immune defense.

Consequently, infections (particularly cellulitis) are common; these, in turn, increase the volume of the affected area. Proper treatment can reduce volume.

With proper care (complete decongestive therapy [CDT]), lymphedema can stabilize during stage 2. But patients with chronic or recurrent infections are likely to progress to stage 3.

Stage 3. Also called lymphostatic elephantiasis, this stage is marked by further fluid volume increases and progression of tissue changes. Lymphostatic fibrosis becomes firmer and other skin alterations may occur, including papillomas, cysts, fistulas, hyperkeratosis, fungal infections, and ulcers. Pitting may be present. Natural skinfolds deepen (especially those of the dorsum of the wrist or ankle) and, in many cases, cellulitis recurs.

If lymphedema management starts during this stage, reduction can still occur. Even in extreme cases, with proper care and patient adherence to treatment, lymphostatic elephantiasis can be reduced so the leg is a normal or near-normal size.

Assessment and diagnosis

A thorough physical examination is the gold standard for diagnosing lymphedema. A complete patient history, body-systems review, inspection, and palpation can help determine if edema is lymphedema.

Clinically, the only test with proven reliability and validity in diagnosing lymphedema is the Stemmer sign. Fibrotic changes associated with lymphedema can lead to thickened skin over the proximal phalanges of the toes or fingers. If you can’t tent or pinch the skin on the involved extremity, lymphedema is present (a positive Stemmer sign). However, a negative finding (soft, pliable tissue) doesn’t rule out  lymphedema because the condition may be in an early stage, before tissue proliferation and fibrosis have set in.

Management

Although incurable, lymphedema can be managed successfully through CDT. This approach involves proper identification of lymphedema, manual lymph drainage, skin and nail care, patient education, compression, and exercise.

CDT has two phases:

Phase I, the intensive phase, continues until the extremity has decongested or reached a plateau. The clinician provides treatments and educates the patient about all aspects of CDT to prepare him or her for phase II. Phase I can last several weeks to several months depending on lymphedema severity.

Phase II, the maintenance phase, begins once the extremity has decongested or plateaued. This phase still focuses on CDT, but now the patient, not the clinician, is responsible for all care. The goal is to reduce limb size while enabling the patient to become self-sufficient in managing lymphedema. Although CDT can bring significant improvements in limb size, skin quality, and function, patients must remember that phase II continues lifelong. Be sure to provide education about ongoing self-management strategies.

Lipedema: The disease they call “fat”

Lipedema is a painful disorder of fat deposition. Pathologic deposition of fatty tissue (usually below the waist) leads to progressive leg enlargement. Like lymphedema, lipedema is incurable but manageable. Unless managed properly, lipedema can reduce mobility, interfere with activities of daily living, and lead to secondary lymphedema. (See Lipedema stages.)

Lipedema commonly is misdiagnosed as lymphedema. However, lymphedema involves protein-rich fluid, whereas lip edema is a genetically mediated fat disorder. Because lipedema resists diet and exercise, it can lead to psychosocial complications. Lipedema occurs almost exclusively in women; typically, onset occurs between puberty and age 30. One unpublished epidemiologic study puts lip edema incidence in females at 11%. Some patients have a combination of lipedema and lymphedema. (See Viewing lipolymphedema.)

Assessment and diagnosis

As with lymphedema, lipedema diagnosis rests on clinical presentation. Lipedema characteristics include bilateral and symmetrical involvement, absence of pitting (because lipedema isn’t a fluid disorder), soft and pliable skin, and filling of the retromalleolar sulcus (called the fat pad sign.)

Key signs and symptoms include:

• feeling of heaviness in the legs (aching dysesthesia)

• easy bruising

• sensitivity to touch (called “painful fat syndrome”)

• orthostatic edema

• oatmeal-like changes to skin texture.

Nearly half of lipedema patients are overweight or obese, but many appear of normal weight from the waist up. Essentially, the upper and lower extremities don’t match. The lower extremities typically show fatty deposits extending from the iliac crest to the ankles, sparing the feet. (See Lipedema patterns.)

Management

Lipedema is best  managed through weight control, as additional weight gain through adipose tissue tends to deposit in the legs. For patients with concomitant lymphedema (lipolymphedema), modified CDT helps reduce and manage lymphatic compromise. To address excess fat deposition, newer “wet” liposuction techniques have proven beneficial. These techniques gently detach adipose cells from the tissue, helping to preserve connective tissue and lymphatic vessels.

Know what to look for

In both lymphedema and lipedema, early identification and proper diagnosis are key. (See Differentiating lymphedema and lipedema.) A thorough history and physical exam will likely lead to an accurate diagnosis, if clinicians know what to look for. Proper diagnosis and treatment can prevent expensive and ineffective interventions, which can negatively affect both the patient’s condition and psychological well being.

Heather Hettrick is an associate professor at Nova Southeastern University, Department of Physical Therapy in Fort Lauderdale, Florida.

Selected references

Fat Disorders Research Society. Lipedema description.

Fife CE, Maus EA, Carter MJ. Lipedema: a frequently misdiagnosed and misunderstood fatty deposition syndrome. Adv Skin Wound Care. 2010;23(2):81-92

Herbst KL. Rare adipose disorders (RADS) masquerading as obesity. Acta Pharmacol Sin. 2012;33(2):155-72.

Lipedema Project.

National Lymphedema Network. Position papers.

Schmeller W, Hueppe M, Meier-Vollrath I. Tumescent liposuction in lipoedema yields good long-term results. Br J Dermatol. 2012;166(1):161-8.

Zuther J. A closer look at lipedema and the effects on the lymphatic system. December 13, 2012. lymphedemablog.com/2012/12/13/a-closer-look-at-lipedema-and-the-effects-on-the-lymphatic-system/

Zuther J. Stages of lymphedema. October 3, 2012.

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Preparing the wound bed: Basic strategies, novel methods

The goal of wound-bed preparation is to create a stable, well-vascularized environment that aids healing of chronic wounds. Without proper preparation, even the most expensive wound-care products and devices are unlikely to produce positive outcomes.

To best prepare the wound bed, you need to understand wound healing physiology and wound care basics, as well as how to evaluate the patient’s overall health and manage wounds that don’t respond to treatment. (See Normal wound healing.) (more…)

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A collaborative approach to wound care and lymphedema therapy: Part 2

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By Erin Fazzari, MPT, CLT, CWS, DWC

Have you seen legs like these in your practice?

Before-After

These legs show lymphedema and chronic wounds before treatment (left image) and after treatment (right image) with complex decongestive therapy (CDT)—the gold standard of lymphedema care. The patient benefited from multidisciplinary collaboration between wound care and lymphedema therapists. (more…)

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Palliative wound care: Part 2

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…)

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Make your patient-teaching idea a patented reality

By Joy Hooper, BSN, RN, CWOCN, OMS

Have you ever had an idea for improving patient care that you wanted to market? You may have lacked confidence or know-how, as I once did. But one patient, a crafty idea, and a trip to Walmart put me on the path to becoming a successful nurse entrepreneur. (more…)

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Using maggots in wound care: Part 2

Maggots Wound Care

By Ronald A. Sherman, MD; Sharon Mendez, RN, CWS; and Catherine McMillan, BA

Note From the Editor: This is the second of two articles on maggot therapy. The first article appeared in our July/August 2014 issue, Read part 1 here.

Whether your practice is an acute-care setting, a clinic, home care, or elsewhere, maggot debridement therapy (MDT) can prove to be a useful tool in wound care. But setting up any new program can meet resistance—and if you seek to establish a maggot therapy program, expect to meet significant resistance. By arming yourself in advance, you can achieve your goal more easily. This article covers all the bases to help you get your maggot therapy program off the ground. (more…)

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2014 Journal: September – October Vol. 3 No. 5

Wound Care Advisor Journal Vol3 No5

Managing venous stasis ulcers

Venous disease, which encompasses all conditions caused by or related to diseased or abnormal veins, affects about 15% of adults. When mild, it rarely poses a problem, but as it worsens, it can become crippling and chronic.

Chronic venous disease often is overlooked by primary and cardiovascular care providers, who underestimate its magnitude and impact. Chronic venous insufficiency (CVI) causes hypertension in the venous system of the legs, leading to various pathologies that involve pain, swelling, edema, skin changes, stasis dermatitis, and ulcers. An estimated 1% of the U.S. population suffers from venous stasis ulcers (VSUs). Causes of VSUs include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Preventing VSUs is the most important aspect of CVI management.

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Becoming a wound care diplomat

By Bill Richlen, PT, WCC, CWS, DWC, and Denise Stetter, PT, WCC, DCCT The Rolling Stones may have said it best when they sang, “You can’t always get what you want,” a sentiment that also applies to wound care. A common frustration among certified wound care clinicians is working with other clinicians who have limited current wound care education and…

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Best of the best, the sequel

By Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS Welcome to our second annual “Best of the Best” issue of Wound Care Advisor, the official journal of the National Alliance of Wound Care and Ostomy (NAWCO). This may be the first time you have held Wound Care Advisor in your hands because normally we come to you via the Internet.…

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Clinical Notes: Wound Photography, Lymphedema, GI Complaints

Wound photography may motivate patients Having patients view photographs of their wounds can motivate them to become more involved in managing those wounds, according to a study in International Wound Journal, particularly when wounds are in difficult-to-see locations.

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Clinician Resources: Opioid-Prescribing, Diabetes, Pressure Injuries

Here are a variety of resources you might want to explore. Considering opioid-prescribing practices Healthcare providers’ prescribing patterns for opioids vary considerably by state, according to a report in Vital Signs from the Centers for Disease Control and Prevention (CDC). Here are some facts from the report: • Each day, 46 people die from an overdose of prescription painkillers in…

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safe negative-pressure wound therapy

Guidelines for safe negative-pressure wound therapy

By Ron Rock MSN, RN, ACNS-BC Since its introduction almost 20 years ago, negative-pressure wound therapy (NPWT) has become a leading technology in the care and management of acute, chronic, dehisced, traumatic wounds; pressure ulcers; diabetic ulcers; orthopedic trauma; skin flaps; and grafts. NPWT applies controlled suction to a wound using a suction pump that delivers intermittent, continuous, or variable…

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dietary protein intake promotes wound healing

How dietary protein intake promotes wound healing

By Nancy Collins, PhD, RD, LD/N, FAPWCA, and Allison Schnitzer Nutrition is a critical factor in the wound healing process, with adequate protein intake essential to the successful healing of a wound. Patients with both chronic and acute wounds, such as postsurgical wounds or pressure ulcers, require an increased amount of protein to ensure complete and timely healing of their…

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How to apply a spiral wrap

By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS Each issue, Apple Bites brings you a tool you can apply in your daily practice. Description The spiral wrap is a technique used for applying compression bandaging. Procedure Here’s how to apply a spiral wrap to the lower leg. Please note that commercial compression wraps come with specific instructions for…

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how to assess wound exudate

How to assess wound exudate

By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS Each issue, Apple Bites brings you a tool you can apply in your daily practice. Exudate (drainage), a liquid produced by the body in response to tissue damage, is present in wounds as they heal. It consists of fluid that has leaked out of blood vessels and closely resembles blood…

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wound care formulary and guideline

How to set up an effective wound care formulary and guideline

By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN Navigating through the thousands of wound care products can be overwhelming and confusing. I suspect that if you checked your supply rooms and treatment carts today, you would find stacks of unused products. You also would probably find that many products were past their expiration dates and that you have duplicate products…

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It takes a village: Leading a wound team

By Jennifer Oakley, BS, RN, WCC, DWC, OMS I used to think I could do it alone. I took the wound care certification course, passed the certification exam, and took all of my new knowledge—and my new WCC credential—back to the long-term care facility where I worked. I was ready to change the world. It didn’t take me long to…

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Managing chronic venous leg ulcers — what’s the latest evidence?

Managing venous stasis ulcers

By Kulbir Dhillon, MSN, FNP, APNP, WCC Venous disease, which encompasses all conditions caused by or related to diseased or abnormal veins, affects about 15% of adults. When mild, it rarely poses a problem, but as it worsens, it can become crippling and chronic. Chronic venous disease often is overlooked by primary and cardiovascular care providers, who underestimate its magnitude…

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The DIME approach to peristomal skin care

By 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…

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2014 Journal: September – October Vol. 3 No. 5
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Creating effective education programs on a shoestring budget

By Jennifer Oakley, BS, RN, WCC, DWC, OMS

It’s time again for annual staff education, and you, the certified wound clinician, need to teach the staff at your organization. You dream of staff entering a state-of-the-art classroom with computers at each station, mannequins, wound anatomy models, and enough products for each student to do hands-on demonstrations. But when you open your eyes, you’re sitting in a room with ordinary tables and chairs, your laptop, a screen, a brain full of knowledge, and a very tight budget. (more…)

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Hidden complications: A case study in peripheral arterial disease

By Pamela Anderson, MS, RN, APN-BC, CCRN, and Terri Townsend, MA, RN, CCRN-CMC, CVRN-BC

Jan Smith, age 59, is admitted to the coronary intensive care unit with an acute inferior myocardial infarction (MI). Recently diagnosed with hypertension and hyperlipidemia, she smokes a pack and a half of cigarettes daily. She reports she has always been healthy and can’t believe she has had a heart attack. (Note: Name is fictitious.)

On physical exam, the cardiologist finds decreased femoral pulses bilaterally and recommends immediate cardiac catheterization. Fortunately, primary percutaneous coronary intervention (PCI) is readily available at this hospital. PCI is the preferred reperfusion method when it can be provided by skilled cardiologists in a timely manner. (more…)

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Guidelines for safe negative-pressure wound therapy

safe negative-pressure wound therapy

By Ron Rock MSN, RN, ACNS-BC

Since its introduction almost 20 years ago, negative-pressure wound therapy (NPWT) has become a leading technology in the care and management of acute, chronic, dehisced, traumatic wounds; pressure ulcers; diabetic ulcers; orthopedic trauma; skin flaps; and grafts. NPWT applies controlled suction to a wound using a suction pump that delivers intermittent, continuous, or variable negative pressure evenly through a wound filler (foam or gauze). Drainage tubing adheres to an occlusive transparent dressing; drainage is removed through the tubing into a collection canister. NWPT increases local vascularity and oxygenation of the wound bed and reduces edema by removing wound fluid, exudate, and bacteria. (more…)

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Managing venous stasis ulcers

Managing chronic venous leg ulcers — what’s the latest evidence?

By Kulbir Dhillon, MSN, FNP, APNP, WCC

Venous disease, which encompasses all conditions caused by or related to diseased or abnormal veins, affects about 15% of adults. When mild, it rarely poses a problem, but as it worsens, it can become crippling and chronic.

Chronic venous disease often is overlooked by primary and cardiovascular care providers, who underestimate its magnitude and impact. Chronic venous insufficiency (CVI) causes hypertension in the venous system of the legs, leading to various pathologies that involve pain, swelling, edema, skin changes, stasis dermatitis, and ulcers. An estimated 1% of the U.S. population suffers from venous stasis ulcers (VSUs). Causes of VSUs include inflammatory processes resulting in leukocyte activation, endothelial damage, platelet aggregation, and intracellular edema. Preventing VSUs is the most important aspect of CVI management. (more…)

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