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Necrotizing fasciitis: Frightening disease, potentially grim prognosis

By Lydia Meyers, BSN, RN, CWCN

Necrotizing fasciitis (NF) results from an infection that attacks the fascia and subcutaneous tissues. The primary bacterial etiology is group A streptococcus, a facultative anaerobic bacterium. However, other bacteria may contribute. Sometimes called the “flesh-eating” disease because of the potentially devastating effect on the afflicted patient, NF can be monomicrobial or polymicrobial.

The four typical settings for NF are:

  • surgical bowel or abdominal trauma surgery
  • pressure ulcer and perianal abscess
  • injection sites (especially in drug users)
  • Bartholin abscess or minor vulvovaginal infection.

Because of the rapid course and ravaging nature of acute NF, clinicians must maintain a high index of suspicion if the patient has suggestive signs and symptoms. In 1990, puppeteer Jim Henson (best known for creating the Muppets) died from NF. At that time, little was known about the progression of group A streptococcal infection.
The disease can quickly cause death, so starting immediate treatment is even more crucial than confirming the diagnosis. Once the disease is suspected, antibiotics must be given immediately and the patient must be prepared for surgery at once. NF spreads rapidly, capable of progressing from a small lesion to death in days to weeks. Thus, delayed diagnosis increases the risk of death. Lack of knowledge about the disease and inability to recognize it promptly are the main reasons many victims die. This article can improve your knowledge base.

Overview

NF was discovered in 1871 by Joseph Jones, a Confederate Army surgeon. At that time, it was called hemolytic streptococcal gangrene, nonclostridial gas gangrene, nonclostridial crepitant cellulitis, necrotizing or gangrenous erysipelas, necrotizing cellulitis, bacterial synergistic gangrene, or synergistic necrotizing cellulitis.
NF involves the fascia, muscle compartments, or both. It can affect not only the muscle fascia but the superficial fascia. NF and cellulitis differ in the amount of tissue involved and extent of tissue involvement.
The most common areas of infection are the abdominal wall, perineum, and extremities. When NF affects the perineum and scrotum, it’s called Fournier gangrene, after the French dermatologist and virologist Alfred Jean Fournier.
The most common causes are trauma, surgery, and insect bites. The disease can affect persons of any age. Such comorbidities as diabetes, chronic renal failure, immunosuppressive therapy, hypertension, obesity, and malnutrition increase susceptibility.

Pathophysiology

NF falls into four classifications based on wound microbiology. Type 1, the most common, involves polymicrobial bacteria. Type 2 results from trauma and is associated with comorbidities. Type 3, rare in this country, stems from gram-negative marine bacteria. Type 4 is a fungal infection occurring mostly in immunocompromised persons. (See Comparing types of necrotizing fasciitis by clicking the PDF icon above.)

Disease progression

The four types of NF progress in a similar way. Bacteria secrete pyrogenic exotoxin A, which stimulates cytokines. These cyto­kines damage the endothelial lining; fluid then leaks into the extravascular space.
M proteins in streptococci and β-hemolytic streptococci exacerbate the immune reaction by inhibiting phagocytosis of polymorphonuclear leukocytes and normal neutrophil chemotaxis. As the immune reaction increases, blood vessels dilate, allowing toxins to leak through vessel walls, which in turn decreases blood flow. As the cascade continues, hypoxic conditions cause facultative aerobic organisms to grow and become anaerobic. These bacteria exacerbate destruction of surrounding cells and lead to release of carbon dioxide, water, hydrogen, nitrogen, hydrogen sulfide, and methane. As the infection continues to progress, toxins spread throughout the bloodstream and the patient becomes septic.

Assessment

Obtain the patient’s medical history and description of the wound. Determine when the changes first appeared and whether the affected area seemed to get worse recently.
In all NF types, patients commonly present with a small, painful area (possibly with entry marks) but no other signs or symptoms. The wound may appear as a bulla, cellulitis, or dermatitis, representing an infection developing in underlying tissues. The skin may have a wooden-hard feel as the infection progresses to the subcutaneous space and causes necrosis. The wound becomes discolored and necrotic; drainage is rare until surgical debridement begins. The patient quickly develops fever, chills, nausea, and vomiting. As NF progresses, bullae become dark purple with darkened edges; the patient grows disoriented and lethargic, and organ failure and respiratory failure
ensue. Without treatment, the patient dies.

Diagnosis

Diagnostic tests usually include magnetic resonance imaging, complete blood count with differential, comprehensive metabolic panel, and cultures. (See Diagnostic findings in necrotizing fasciitis by clicking the PDF icon above.)

Treatment

Immediate surgical debridement and broad-spectrum antibiotics are needed to stop the immune response to infection. Clindamycin, gentamicin, penicillin, or metronidazole may be given alone or in combination until culture results are available. Supportive care includes total parenteral nutrition for nutritional support, I.V. fluids, and oxygen. Limb amputation should be done only as a last resort.
Surgical debridement involves penetrating deep into the fascia and removing all necrotic tissue. After the first debridement, release of “dishwater fluid” may occur.
Administering hyperbaric oxygen therapy (HBOT) after the first debridement increases tissue oxygenation, thus reducing tissue destruction by anaerobic bacteria. During HBOT (usually given as a 90-minute treatment), the patient breathes 100% oxygen in an environment of increasing atmospheric pressure.
HBOT should be given in conjunction with surgical debridement (usually after each debridement) and should continue until necrotic tissue ceases and cell destruction stops. HBOT also promotes collagen synthesis and neoangiogenesis (new blood vessel growth), which boosts blood supply and oxygen to tissues.
Adverse effects of HBOT include ear pain, oxygen toxicity, and seizures. Ear pain can be minimized by swallowing or yawning. If the patient continues to have ear pain, ear tubes may be inserted by an otolaryngologist. During HBOT, air breaks (intervals of breathing room air) are important in controlling oxygen toxicity (the main cause of seizures).
Throughout the HBOT treatment period, wound dressings must be simple. Well-moistened gauze dressings and an abdominal pad provide good support. Once necrotic destruction occurs, dressings depend on wound size and the need to fill cavities. The patient may require a diverting colostomy, depending on wound
location and the amount of uncontrolled diarrhea. Blood glucose levels must be monitored before and after HBOT, as this treatment affects blood glucose.

Supportive care and follow-up treatment

During initial treatment, patients need supportive care and monitoring. Once they’re out of danger, begin teaching them how to prevent NF recurrences. Advise them to control blood glucose levels, keeping the glycated hemoglobin (HbA1c) level to 7% or less. Caution patients to keep needles capped until use and not to reuse needles. Instruct them to clean the skin thoroughly before blood glucose testing or insulin injection, and to use alcohol pads to clean the area afterward.
Before discharge, help arrange the patient’s aftercare, including home health care for wound management and teaching, social services to promote adjustment to lifestyle changes and financial concerns, and physical therapy to help rebuild strength and promote the return to optimal physical health. One helpful patient resource is the National Necrotizing Fasciitis Foundation. The Centers for Disease Control and Prevention section on necrotizing fasciitis includes “Common sense and great wound care are the best ways to prevent a bacterial skin infection.”
The life-threatening nature of NF, scarring caused by the disease, and in some cases the need for limb amputation can alter the patient’s attitude and viewpoint, so be sure to take a holistic approach when dealing with the patient and family. Today, NF has a much better survival rate than 2 decades ago when Jim Henson died. In my practice, I’ve seen four NF cases. Thanks to early identification, good wound care, and HBOT, these patients suffered only minimal damage.

Selected references

Boyer A, Vargas F, Coste F, et al. Influence of surgical treatment timing on mortality from necrotizing soft tissue infections requiring intensive care management. Intensive Care Med. 2009;35(5):847-853. doi:10.1007/s00134-008-1373-4.

Cain S. Necrotizing fasciitis: recognition and care. Practice Nurs. 2010;21(6):297-302.

Centers for Disease Control and Prevention. Notes from the field: fatal fungal soft-tissue infections after a tornado—Joplin, Missouri, 2011. MMWR. 2011;60(29):992.

Chamber AC, Leaper DJ. Role of oxygen in wound healing: a review of evidence. J Wound Care. 2011; 20(4):160-164.

Christophoros K, Achilleas K, Vasilia D, et al. Postraumatic zygomycotic necrotizing abdominal wall fasciitis with intraabdominal invasion in a non immunosuppressed patient. Internet J Surg. 2007;11(1). doi:10.5580/17a8.

Ecker K-W, Baars A, Topfer J, Frank J. Necrotizing fasciitis of the perineum and the abdominal wall-surgical approach. Europ J Trauma Emerg Surg. 2008;
34(3):219-228. doi:10.1007/s00068-008-8072-2.

Hunter J, Quarterman C, Waseem M, Wills A. Diagnosis and management of necrotizing fasciitis. Br J Hosp Med. 2011;72(7):391-395.

Magel DC. The nurse’s role in managing necrotizing fasciitis. AORN J. 2008;88(6):977-982.

Phanzu MD, Bafende AE, Imposo BB, Meyers WM, Portaels F. Under treated necrotizing fasciitis masquerading as ulcerated edematous Mycobacterium ulcerans infection (Buruli ulcer). Am J Trop Med Hyg. 2012;82(3):478-481.

Ruth-Sahd LA, Gonzales M. Multiple dimensions of caring for a patient with acute necrotizing fasciitis. Dimens Crit Care Nurs. 2006;25(1):15-21.

Stevens DL, Bisno AL, Chambers HF, et al; Infectious Diseases Society of America. Practice guidelines for the diagnosis and management of skin and soft-tissue infections. Clin Infect Dis. 2005;41(10):1373-1406.

Su YC, Chen HW, Hong YC, Chen CT, et al. Laboratory risk indicator for necrotizing fasciitis score and the outcomes. ANZ J Surg. 2008;78(11):968-972.

Taviloglu K, Yanar H. Necrotizing fasciitis: strategies for diagnosis and management. World J Emerg Surg. 2007;2:19.

Lydia Meyers is a medical reviewer for National Government Services in Castleton, Indiana, and a clinical liaison at CTI Nutrition in Indianapolis. She has 11 years of wound care experience in nursing homes, wound clinics, and home health.

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Get positive results with negative-pressure wound therapy

By Ronald Rock, MSN, RN, ACNS-BC

Complex wound failures are costly and time-consuming. They increase length of stay and contribute to morbidity and mortality in surgical patients. Negative-pressure wound therapy (NPWT)—a common adjunct to wound-care therapy—is used to accelerate wound healing in all fields of surgery. Using a vacuum device and wound-packing material, it applies subatmospheric pressure to complex wounds.
But NPWT alone doesn’t ensure adequate wound healing. Many physiologic factors—including infection, excessive moisture, nutrition, and medications—influence wound-healing success. Failure to account for these factors or improper application of NPWT can limit patient outcomes and cause debilitating complications.
For clinicians, applying and establishing an airtight seal on a complex wound is among the most dreaded, time-consuming, and challenging NPWT-related tasks. Simply applying NPWT material under layers of transparent drape may delay wound healing or exacerbate the wound. This article provides tips on safe application of NPWT to enhance the outcomes of patients with complex wounds.

 Consider wound location

Wounds on the body’s anterior surfaces are less susceptible to the forces of pressure, friction, and shear than those on posterior and lateral surfaces. Posterior and lateral wounds commonly require posterior off­loading or repositioning the patient in bed to reduce or eliminate direct pressure. This can be done with judicious and frequent patient turning using a specialty bed or support surface.
Bridge a posterior or lateral wound to an anterior surface by placing the drainage collection tubing to a nonpressure-bearing surface away from the wound. Bridging keeps the tubing from exerting pressure on intact skin and decreases the risk of a pressure ulcer. To create the bridge, cut foam into a single spiral of 0.5 to 1 cm, or if using gauze, fold gauze into 8 single layers.
Place the spiraled foam or gauze layers onto the drape, ensure the bridge is wider than the collection tubing disc, and secure it with an additional drape. Next, apply the NPWT collection tubing on the end of the bridge away from the wound. A wide bridge under the collection tubing disc will minimize the potential for periwound breakdown when negative pressure is initiated. You may modify this spiraling technique by varying the width of the foam to fill undermining and wounds of irregular configuration and depth.

 Protect the periwound

An intact periwound may break down from exposure to moisture, injury from repetitive removal of a transparent drape, or NPWT material coming in contact with skin. Skin protection is critical in preventing additional breakdown stemming from contact with potentially damaging material.
Transparent drapes are designed to permit transmission of moisture vapor and oxygen. Avoid using multiple layers of transparent drapes to secure dressings over intact skin, as this can decrease the transmission of moisture vapor and oxygen, which in turn may increase the risk of fungal infection, maceration, and loss of an intact seal.
Periwound maceration also may indicate increased wound exudate, requiring an increase in negative pressure. Conversely, an ecchymotic periwound may indicate excessively high negative pressures. If either occurs, assess the need to adjust negative pressure and intervene accordingly. Reassess NPWT effectiveness with subsequent dressing changes.
Apply a protective liquid skin barrier to the periwound and adjacent healthy tissue to help protect the skin surface from body fluids. The skin barrier also helps prevent stripping of fragile skin by minimizing shear forces from repetitive or forceful removal of transparent drapes. Excessive moisture can be absorbed by using a light dusting of ostomy powder sealed with a skin barrier. A “window pane” of transparent drape or hydrocolloid dressing around the wound also can protect surface tissue from contactwith NPWT material and prevent maceration.

 Avoid creating rolled wound edges

In the best-case scenario, epithelial tissue at the wound edge is attached to the wound bed and migrates across healthy granulation tissue, causing the wound to contract and finally close. With deep wound environments that lack moisture or healthy granulation tissue, the wound edges may roll downward and epibole may develop. Epibole is premature closure of the wound edges, which prevents epi­thelialization and wound closure when it comes in contact with a deeper wound bed. (See Picturing epibole by clicking the PDF icon above.)
Materials used in NPWT are primarily air-filled. Applying negative pressure causes air removal, leading to wound contraction by pulling on the wound edges—an action called macrostrain. Without sufficient NPWT material in the wound, macrostrain can cause the wound to contract downward and the wound edges to roll.
Ensure that enough NPWT material has been applied into the wound to enhance wound-edge approximation and avoid creating a potential defect as the wound heals. Before NPWT begins, material should be raised 1 to 2 cm above the intact skin. Additional material may be needed with subsequent changes if the NPWT material compresses below the periwound. The amount of NPWT material needed to remain above the periwound once NPWT starts varies with the amount of material compressed and the wound depth.

 Reduce the infection risk

To some degree, all wounds are contaminated. Usually, the body’s immunologic response is able to clear bacterial organisms and wound healing isn’t delayed. But a patient who has an infection of a complex wound needs additional support.
Systemic antibiotics alone aren’t enough because they’re selective for specific organisms and don’t reach therapeutic levels in the wound bed. In contrast, topical anti­microbial adjuncts, such as controlled-release ionic silver, provide broad-spectrum antimicrobial coverage against fungi, viruses, yeasts, and gram-negative and gram-positive bacteria, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci.
Consider using controlled-release ionic silver for a wound known to be infected or at risk for infection due to its location or potential urine or fecal contamination. To be bactericidal, ionic silver must be in concentrations of at least 20 parts per million; also, it must be kept moist and must come in direct contact with infected wound bed. At lower concentrations, organisms may develop resistance. Ionic silver has no known resistance or contraindications. Dressings using it come in several forms, including a hydrogel sheet, perforated sheet, cavity version, and semiliquid hydrogel. Be sure the form you choose doesn’t occlude the NPWT material and compromise therapy. (See NPWT for a patient with necrotizing fasciitis by clicking the PDF icon above.)

View: NPWT

Obtain a negative-pressure environment

One of the most daunting aspects of NPWT is obtaining and maintaining a good seal—in other words, avoiding the dreaded leak. Preventive skin measures may contribute to a poor seal; skin-care products containing glycerin, surfactant, or dimethicone may prevent adequate adhesion of NPWT drapes. Body oil, sweat, and hair may need to be minimized or removed.
To avoid leaks, don’t overlook the obvious—loose connections, a loose drainage collection canister, exposed NPWT material, and skinfolds extending beyond the transparent drape. Tincture of benzoin (with or without a thin hydrocolloid dressing) increases tackiness to enhance the adhesive property of a transparent drape on the diaphoretic patient and on hard-to-drape areas, such as the perineum. But be sure to use tincture of benzoin with discretion, as it may remove fragile periwound tissue when the dressing is removed.
Ostomy paste products can serve as effective filler. These pliable products can be spread into position to obtain a secure seal under the transparent drape in hard-to-seal areas, such as the perineum. Pastes remain flexible and can be removed without resi­due. Temporarily increasing NPWT pressure to a higher setting may help locate a subtle leak or provide enough negative pressure to self-seal the leak. Once the leak resolves, remember to return the pressure to the ordered setting.

 Knowledge optimizes healing

It’s important to be aware of potential complications of NPWT (See Take care with NPWT by clicking on the PDF icon above). However, when applied correctly, NPWT is an effective option for managing complex wounds. Recognizing and managing potential complications at the wound site, ensuring periwound protection, minimizing epibole formation, and preventing wound infection can result in a better-prepared wound bed and promote optimal healing.

View: NPWT case study

Selected references
Baranoski S, Ayello EA. (2012). Wound Care Essentials: Practice Principles. 3rd ed. Springhouse, PA; Lippincott Williams & Wilkins.

Bovill E, Banwell PE, Teot L, et al. Topical negative pressure wound therapy: a review of its role and guidelines for its use in the management of acute wounds. Int Wound J. 2008;5:511-529.

Sussman C, Bates-Jensen B. Wound Care: A Collaborative Practice Manual for Health Professionals. 4th ed. Baltimore, MD; Lippincott Williams & Wilkins; 2011.

Ronald Rock is an Adult Health Clinical Nurse Specialist in the Digestive Disease Institute at the Cleveland Clinic in Cleveland, Ohio.

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Providing wound care in the home: An option to explore

By Connie Johnson, RN, BSN, WCC, LLE, DAPWCA

Jim, a 52-year-old patient with colon cancer, received a new ostomy. He needed a custom fit for his appliance, which took 10 days. During this time, trying to obtain a good seal and treat the peristomal area wasn’t easy. Despite my best efforts, Jim’s skin was denuded from contact with stool. Although he was in great discomfort, he wanted to wait until my next visit to tell me about the problem. Fortunately, his wife was worried and contacted me directly.

Jim lives in a neighborhood with a low crime rate, so I’m able to see him within
a few hours of his wife’s call, even though it’s late at night. As it turns out, I make
extra visits to help him manage his stoma until the customized appliance is ready.  As with any home care situation, I’m ready to do my best for my patient.

Many home-care patients like Jim benefit from the interventions of a wound care clinician (WCC). More than one-third of all home-care admissions are wound related, and home wound care has become one of the fastest growing needs and skills in home-care services. So if you’re a WCC, you may want to consider home care as a practice option.

Delivering wound care in the home differs dramatically from delivering it in the hospital. Given the complexity of wound care and the multiple factors that affect healing, home wound care is a challenge. Some patients have chronic conditions, such as diabetes or wounds or open sores that don’t heal easily. In other cases, the patient or caregiver is unable to change dressings. That’s where the WCC comes in.

Special needs of home-care patients

Like other patients across the continuum of care, home-care wound patients require accurate and thorough wound assessment, as well as documentation that provides information about wound status and aids development of a plan that supports healing.
Of course, the plan of care must address the whole patient, not just the “hole” in the patient. The WCC must take into account comorbidities, individual wound-care requirements, assistance the patient may need due to physical or mental deficits, and nutritional support. Additional factors that affect wound-care strategies include wound characteristics, family support, and insurance guidelines and reimbursement.

Role of the WCC

The WCC’s role in home care includes providing clinical expertise, working with other healthcare team members, and providing education.

  • The WCC provides clinical expertise regarding wound and ostomy care to ensure delivery of the highest quality of care. This expertise helps reduce the need for readmissions to the emergency department (ED) for wound-related complications. The WCC also plays a vital role in product awareness, formu-lary development, and maintenance of cost-effective, evidence-based practice in the agency.
  • Working with other healthcare team members, the WCC serves as patient advocate, strengthening the relationship between patient and healthcare team members while promoting care coordination to help the patient achieve goals. Effective communication with the patient’s primary care pro­vider is essential to delivering the best-quality, research-based wound care. A tool for strengthening such communication is the SBAR (Situation-Background-Assessment-Recommendation) technique. SBAR structures conversations so all parties provide complete yet concise information. (See SBAR wound and skin provider communication record by clicking the PDF icon above).
  • The WCC educates patients and family members about wound healing, dressing applications, and other interventions. Teaching families allows them to be involved in the patient’s care and start to take ownership of it. The WCC also educates home health aides, who can play a vital role in preventing such problems as pressure ulcers and may be responsible for ensuring staff members are aware of the products, procedures, and dressings available.

Challenges of home care

If you’re a WCC and considering home care as a career option, know that practicing in the home can be a real eye opener. For starters, consider geography. Shortly after I started as a wound care nurse/consultant in home care, I was visiting patients all over New Jersey, some days driving 200 miles. As I quickly discovered, once you enter the home, don’t assume you’ll simply change a dressing and then be on your way. Instead, you may find you are, in essence, the family case manager who’s expected to “fix everything.” This role requires equal doses of planning and creativity.

What’s more, expect to do some improvising. In acute-care settings, all the supplies you may need to prevent infection—gowns, gloves, masks—usually are within arm’s reach. But in home care, these supplies may be absent, meaning you’ll need to set up the cleanest environment you can under the circumstances. That might mean using disposable drapes and dressings. Be sure to carry large amounts of hand sanitizer.

Dressing selection is perhaps the biggest challenge in home wound care because
it involves not just wound-specific issues but financial and practical considerations. The ideal dressing in the home is one that needs to be changed only every other day, at most. Evidence shows it’s not practical to try to change dressings two or three times daily at home unless the family is providing care.

Develop a checklist

Because the home environment may lack all the resources you need, remembering every­thing you need to do before you leave the patient’s home may be challenging. To help keep things on track, develop a checklist of reminders that covers these points:

  • Have necessary medical appointments been arranged? Does the patient have transportation to appointments?
  • Are there sufficient supplies in the home?
  • Is there enough medicine? If not, who will pick up the medicine?
  • Are consults needed, such as social worker or physical therapist?
  • Who will help with any activities of daily living that the patient is unable to do?
  • Does the patient with diabetes have a glucometer?

Hours and safety concerns

Typical home wound-care hours are 8:30 a.m. to 4:30 p.m. But realistically, expect variations. For instance, as you’re about to leave, the patient might say, “My wife isn’t feeling well. Could you take her blood pressure?” This means you’ll stay a little longer.

When planning home visits, be aware of safety concerns. If visiting after hours could put you in danger, it’s safer to instruct the patient to call an ambulance and go to the local ED.

Reimbursement

Reimbursement is an important factor in wound care in the home. To be eligible for home care through Medicare, patients must be homebound—meaning they don’t routinely travel to run errands or visit or they’re not able to obtain or receive needed medical services. (With private insurance and workers’ compensation, eligibility requirements may be less restrictive.)

Know that a Medicare patient receives home care as an “episode.” Episodes are 60-day periods; within each 60-day episode, a $592 cap is allotted should a patient require supplies for wound or ostomy care needs. Except for negative-pressure wound therapy, a home care agency can’t bill Medicare for products used; instead, the home-care agency is responsible for the cost of all topical wound-care products and dressings. Agencies may keep patients on service even if they exceed the allowed amount, although patients reaching maximum benefits commonly are discharged from service. Home-care agencies have no choice but to discharge Medicare patients they find aren’t truly homebound.

Also, be aware that Medicare views home health service as an interim service. When a patient is no longer making progress, Medicare expects that the family will provide the patient’s care or the patient will enter a skilled care facility. So it’s important to work hard to obtain good outcomes—not just for the patient but to maintain Medicare reimbursement. Like many private insurance companies, Medicare reimbursement is based on pay for performance; if an agency doesn’t deliver optimal outcomes, it receives lower reimbursement, increasing its financial burden.

A worthwhile option

WCCs use their knowledge and clinical expertise to improve patient outcomes and teach patients, families, and other healthcare team members. They also give the agency recommendations for care and supplies that are evidence based and reflect current best practices in wound care. Accomplishing these goals in a timely fashion under various constraints can be challenging. But if you choose to work in the home, try to keep a smile on your face and joy in your voice for each patient and family. If you like challenges and want a job where you can apply your creativity and function independently, becoming a home-care WCC might be the right choice for you.

Connie Johnson provides wound care in the home and in acute-care settings.

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Clinical Notes

Study finds ultrasound therapy improves venous ulcer healing

In a study of 10 venous ulcers not responding to treatment, the use of noncontact ultrasound significantly reduced the wound area over 4 weeks of treatment.

It has been unclear exactly how ultrasound achieves its positive results. The
authors of “A prospective pilot study of ultrasound therapy effectiveness in refractory venous leg ulcers,” an article published online on February 1 by the International Wound Journal, found that patients treated with ultrasound and compression therapy had reduced inflammatory cytokines and bacterial counts, but the reduction wasn’t statistically significant.

The study found another important benefit for patients-reduced pain.

Serum albumin is not a goodindicator of nutritional status

Traditionally the standard of practice for wound care patients has been to review albumin blood levels as a measure of nutritional status and the effect of nutritional interventions. But as noted in The Role of Nutrition in Pressure Ulcer Prevention and Treatment: National Pressure Ulcer Advisory Panel White Paper, recent studies show that hepatic proteins (albumin, trans­thyretin, and transferrin) correlate with the severity of an underlying disease, not nutritional status. Moreover, many factors can alter albumin levels even when protein intake is adequate, including infection, acute stress, surgery, cortisone excess, and hydration status.

For these reasons, the National Pressure Ulcer Advisory Panel (NPUAP) and the Academy of Nutrition and Dietetics (previously known as The American Dietetic Association) recommend against using serum proteins as a nutritional assessment tool. Evaluation of lab values is just one part of the nutritional assessment process and should be considered along with other factors such as ensuring that the patient receives what is prescribed; daily food/fluid intake; changes in weight status, diagnosis, and medications; and clinical improvement in the wound.

For more information read “Serum proteins as markers of malnutrition: What are we treating?” and “Albumin as an indicator of nutritional status: Professional refresher.”

A profile of outpatients with wounds

Wound care outcomes and associated cost among patients treated in US outpatient wound centers: Data from the US Wound Registry” a study using data from the US Wound Registry to determine outcomes and costs for outpatient wound care, found the mean patient age was 61.7 years, slightly more than half (52.3%) were male, most (71.3%) were white, and more than half (52.6%) were Medicare beneficiaries.

Other interesting findings:

  • The mean number of serious comorbid conditions was 1.8.
  • The most common comorbid conditions were obesity/overweight (71.3%), cardiovascular or peripheral vascular disease (51.3%), and diabetes (46.8%).
  • Nearly two-thirds (65.8%) of wounds healed, with an average healing time
    of 15 weeks.
  • In half of the wounds that healed, patients received only moist wound care and no advanced therapeutics.
  • The mean cost for wound healing was $3,927.

The authors of the article, published in March’s Wounds, analyzed 5,240 patients with 7,099 wounds in 59 hospital-based outpatient wound centers in 18 states over 5 years.

LOI index comparable to ABI for assessing PAD in patients with type 2 diabetes

The pilot study “Lanarkshire Oximetry Index as a diagnostic tool for peripheral arterial disease in type 2 diabetes,” published in Angiology, compared the gold standard ankle bra­chial index (ABI) to the Lanarkshire Oximetry Index (LOI) in 161 patients with type 2 diabetes. Researchers assessed the patients for peripheral artery disease (PAD, defined as ABI < 0.9) using both ABI and LOI.

Using a LOI cut-off value of 0.9., the sensitivity and specificity for PAD were 93.3% and 89.1%, respectively. The study concluded that LOI is a “potentially useful alternative diagnostic test for PAD” in patients with type 2 diabetes.

LOI is a noninvasive procedure similar to ABI; both indices indicate whether it’s safe to apply compression to the limb of a patient who has lower leg ulceration or venous hypertension. With LOI, a pulse oximeter is used in place of a hand-held Doppler to determine the index.

Start planning for World Diabetes Day

It’s not too early to begin planning for World Diabetes Day, November 14. Started by the World Health Organization (WHO) and the International Diabetes Federation (IDF), the day is designed to raise global awareness of diabetes.

Access materials, including posters, a campaign book, and the Word Diabetes Day Logo, from IDF’s website, which also has activity ideas.

WHO estimates that more than 346 million people worldwide have diabetes, and the number is expected to double by 2030. World Diabetes Day is celebrated on November 14 to mark the birthday of Frederick Banting who, along with Charles Best, was instrumental in the discovery of insulin in 1922.

Guidelines for PAD in patients with diabetes and foot ulceration published

February’s issue of Diabetes/Metabolism Research and Reviews includes “Specific guidelines for the diagnosis and treatment of peripheral arterial disease in a patient with diabetes and ulceration of the foot 2011,” which is based on two companion International Working Group on the Diabetic foot papers. The guidelines state that if a patient’s PAD is impairing wound healing, revascularization through bypass or endovascular technique must be considered except in a few cases such as severely frail patients. Limb salvage rates after revascularization procedures are about 80-85%, and there is ulcer healing in > 60% at 12 months.

Other points of particular interest to wound care professionals:

  • Patients with PAD and a foot infection are at high risk for major limb amputation, so should be treated as a “medical emergency”, preferably within 24 hours.
  • Half of patients with diabetes, a foot ulcer, and PAD die within 5 years because of higher cardiovascular morbidity and mortality. Cardiovascular risk management should include “support for cessation of smoking, treatment of hypertension, and prescription of a statin as well as low-dose aspirin or clopidrogel.

AHA statement focuses on PAD in women

A call to action: Women and peripheral artery disease: A scientific statement from the American Heart Association” summarizes evidence in this area and addresses risk-management issues. The statement notes that women (particularly black females) are more likely than men to experience graft failure of limb loss and calls for more research related to PAD and gender.

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Caring for chronic wounds: A knowledge update

By: Patricia A. Slachta, PhD, RN, ACNS-BC, CWOCN

Wound care has come a long way in just a few decades. With our expanded knowledge of wound healing and recent advances in treatment, we’re now able to assess wounds more accurately, recognize wound-related problems sooner, provide better interventions, and reduce morbidity.

To bring you up to date on current evidence-based wound management, this article focuses on assessing patients with chronic wounds, optimizing wound healing with effective wound-bed preparation, and selecting an appropriate dressing.

Wound chronicity and cause

Developing an appropriate plan of care hinges on conducting a thorough, accurate evaluation of both the patient and the wound. The first step is to determine whether the wound is acute or chronic.
•    A chronic wound is one that fails to heal within a reasonable time—usually
3 months.
•    An acute wound heals more quickly, causing minimal functional loss in the part of the body with the wound.
Identifying the cause of the wound also is essential. If the wound etiology is unknown, explore the patient’s medical history (including medication history) for clues to possible causes. Also review the patient’s history for conditions that could impede wound healing. (See What factors hamper healing? by clicking the PDF icon above)
Other important aspects of assessment include evaluating the patient’s nutritional status, quantifying the level of pain (if present), and gauging the patient’s self-care abilities.

General physical appearance

Conduct a general head-to-toe physical examination, focusing on the patient’s height, weight, and skin characteristics.

Height, weight, and weight trend

On admission, the patient’s height and weight should be measured to ensure appropriate nutritional and pharmacologic management. After a weight gain or loss, various factors may complicate wound healing. For instance, involuntary weight loss and protein-energy malnutrition may occur in both acute-care and long-term-care patients.

Especially note trends in your patient’s weight. For a long-term-care patient, a 5% weight loss over 30 days or a 10% loss over 180 days is considered involuntary. Arrange for a nutritional consult for any patient with an involuntary weight loss, as adequate nutrition is essential for general well-being and wound healing. (See A wound on the mend by clicking the PDF icon above.)

Skin color

Evaluate the patient’s skin color in light of ethnic background. If you note erythema—especially on a pressure point over a bony prominence—examine this area carefully for nonblanching erythema. Keep in mind that darkly pigmented skin doesn’t show such erythema and subsequent blanching, yet the patient may still be in jeopardy. So in dark-skinned patients, check for differences in skin color, temperature, or firmness compared to adjacent tissue; these differences may signify skin compromise.

Skin texture and turgor

Generally, healthy skin feels smooth and firm and has an even surface and good turgor (elasticity). To test turgor, gently grasp and pull up a fold of skin on a site such as the anterior chest below the clavicle. Does the skin return to place almost immediately after you release it, or does it stand up (“tent”)? Tenting indicates dehydration. But keep in mind that skin loses elasticity with age, so elderly patients normally have decreased turgor.

Skin temperature

With normal circulatory status, the skin is warm and its temperature is similar bilaterally. Areas of increased warmth or coolness suggest infection or compromised circulation. Be sure to check the temperature of skin surrounding the wound.

Wound assessment

Proper wound assessment can significantly influence patient outcome. Measure the wound carefully and document the condition of the wound bed. Remember that accurate descriptions are essential for guiding ongoing wound care. Repeat wound measurement and wound-bed assessment at least weekly, after the wound bed has been cleaned and debrided.

Keep in mind that assessing a chronic wound can be challenging. Wounds commonly have irregular shapes that can change quickly. Also, the multiple clinicians caring for the same patient may each describe the wound a bit differently.

Wound location

Note the precise anatomic location of the wound, as this can influence the wound care plan. A venous ulcer on the lower leg, for instance, requires different care than an arterial ulcer in the same site or a pressure ulcer on the ischium.

Circumference and depth

Use a paper or plastic measuring device to measure wound circumference and depth in centimeters (cm) or millimeters (mm). To promote accurate assessment of healing, be sure to use the same reference points each time you measure the wound.

You can use several methods to measure circumference. The most commonly used method of measurement is done in the head to toe direction. Measure the wound at its greatest length in that direction & measure the width at a 90 degree angle, at the widest point of the wound. Then multiply these two measurements (greatest length x greatest width) to obtain the total wound area. Although such linear measurements are imprecise, they yield gross information relative to wound healing when repeated over time.

Classify wound depth as partial thickness or full thickness.
•    Partial-thickness wounds are limited to the skin layers and don’t penetrate the dermis. They usually heal by reepithelialization, in which epidermal cells regenerate and cover the wound. Abrasions, lacerations, and blisters are examples of partial-thickness wounds.
•    Full-thickness wounds involve tissue loss below the dermis.
(Note: Pressure ulcers usually are classified by a four-stage system and diabetic foot ulcers by a grading system. Both systems are beyond this article’s scope.)
Measure and record wound depth based on the deepest area of tissue loss. To measure depth, gently place an appropriate device (such as a foam-tipped applicator) vertically in the deepest part of the wound, and mark the applicator at the patient’s skin level. Then measure from the end of the applicator to the mark to obtain depth.

Surrounding skin and tissue

Inspect for and document any erythema, edema, or ecchymosis within 4 cm of the wound edges, and reevaluate for these signs frequently. Because compromised skin near the wound is at risk for breakdown, preventive measures may be necessary.

Appearance of wound-bed tissue

Document viable tissue in the wound bed as granulation, epithelial, muscle, or subcutaneous tissue. Granulation tissue is connective tissue containing multiple small blood vessels, which aid rapid healing of the wound bed; appearing red or pink, it commonly looks shiny and granular. Epithelial tissue consists of regenerated epidermal cells across the wound bed; it may be shiny and silvery.

Check for nonviable tissue (also called necrotic, slough, or fibrin slough tissue), which may impede wound healing. It may vary in color from black or tan to yellow, and may adhere firmly or loosely to the wound bed. (See Picturing a necrotic wound by clicking the PDF icon above.)

Be sure to document the range of colors visible throughout the wound. Identify the color that covers the largest percentage of the wound bed. This color—and its significance—guide dressing selection.

Wound exudate

Document the amount, color, and odor of exudate (drainage) in the wound. Exudate with high protease levels and low growth factor levels may impede healing.

If the wound is covered by an occlusive dressing, assess exudate after the wound has been cleaned. Describe the amount of exudate as none, minimal, moderate, or heavy.

Describe exudate color as serous, serosanguineous, sanguineous, or purulent. Serous exudate is clear and watery, with no debris or blood present. Serosanguineous exudate is clear, watery, and tinged pink or pale red, denoting presence of blood. Sanguineous exudate is bloody, indicating active bleeding. Purulent exudate may range from yellow to green to brown or tan.

Describe wound odor as absent, faint, moderate, or strong. Note whether the odor is present only during dressing removal, if it disappears after the dressing is discarded, or if it permeates the room.

Wound edges

Wound edges indicate the epithelialization trend and suggest the possible cause and chronicity of the wound. The edges should attach to the wound bed. Edges that are rolled (a condition called epibole) indicate a chronic wound, in which epithelial cells are unable to adhere to a moist, healthy wound bed and can’t migrate across and resurface the wound.

Undermining and tracts

Gently probe around the wound edges and in the wound bed to check for undermining and tracts. Undermining, which may occur around the edges, presents as a space between the intact skin and wound bed (resembling a roof over part of the wound). It commonly results from shear forces in conjunction with sustained pressure. A tract, or tunnel, is a channel extending from one part of the wound through subcutaneous tissue or muscle to another part.

Measure the depth of a tract or undermining by inserting an appropriate device into the wound as far as it will go without forcing it. Then mark the skin on the outside where you can see or feel the applicator tip. Document your findings based on a clock face, with 12 o’clock representing the patient’s head and 6 o’clock denoting the feet. For instance, you might note “2.0-cm undermining from 7:00 to 9:00 position.”

Pain level

Ask the patient to quantify the level of pain caused by the wound, using the pain scale designated by your facility. Find out which pain-management techniques have relieved your patient’s pain in the past; as appropriate, incorporate these into a pain-management plan. Reevaluate the patient’s pain level regularly.

Wound-bed preparation

An evolving science, wound-bed preparation is crucial for minimizing or removing barriers to healing. The goal is to minimize factors that impair healing and maximize the effects of wound care. The key elements of wound-bed preparation are controlling bioburden and maintaining moisture balance. (For online resources on wound-bed preparation and other wound-care topics, see Where to get more information by clicking the PDF icon above.)

Controlling bioburden

Necrotic tissue and exudate harbor bacteria. A wound’s bioburden—the number of contaminating microbes—contributes to poor healing. All chronic wounds are considered contaminated or colonized, but not necessarily infected. In a colonized wound, healing is impeded as bacteria compete for nutrients; also, bacteria have harmful byproducts. To control bioburden, the wound must be cleaned and necrotic tissue must be debrided.

Cleaning the wound. Clean the wound before assessing it and applying a dressing. Use a noncytotoxic agent (typically, potable water, normal saline irrigating solution, or an appropriate wound-cleaning agent). Anti­septic solutions generally aren’t recommended for wound irrigation or dressings because they’re toxic to fibroblasts and other wound-repairing cells. If you must use such a solution, make sure it’s well diluted.

To ensure gentle cleaning or irrigation, pour solution over the wound bed or gently flush the wound with solution (using a 60-mL catheter-tip syringe) until the drainage clears. Know that pressurized irrigation techniques and whirlpool therapy aren’t recommended for wound cleaning because they disturb cell proliferation in the wound bed.

Debriding the wound. Debridement removes slough and necrotic tissue. Nonselective debridement techniques remove any type of tissue within the wound bed, whereas selective methods remove only necrotic tissue. (See Wound debridement techniques by clicking the PDF icon below.)

Maintaining moisture balance

To maintain moisture balance in the wound bed, you must manage exudate and keep the wound bed moist. The proper dressing (which may stay in place for days or longer) supports moist wound healing and exudate management. To minimize fluid pooling, a drain may be inserted into the wound. Negative-pressure wound therapy also may aid removal of excess exudate.

Choosing an appropriate dressing

The wound dressing plays a major role in maintaining moisture balance. Dressing selection is challenging because of the large number and variety of dressings available. Each product has specific actions, benefits, and drawbacks, so determining which dressing best suits the patient’s needs is a multifaceted process.

Dressing choice depends on such factors as wound type and appearance, exudate, presence or absence of pain, and required dressing change frequency. (See Dressings Options by clicking the PDF icon above.)

In a traditional dressing, gauze is applied in layers. The initial (contact) layer in the wound bed absorbs drainage and wicks it to the next layer; most often, this layer consists of woven cotton gauze or synthetic gauze. Remove the gauze gently, because it may be stuck to the wound or incision (especially if the gauze is cotton). For easier removal, moisten the dressing with normal saline solution to loosen it.

With a traditional dressing, the cover layer or secondary dressing is an abdominal pad with a “no-strike-through” layer next to the outside of the dressing. Be aware that wet-to-dry dressings are highly discouraged for their nonselective debriding effect and inability to provide a moist wound bed.

Reassess the patient’s wound at least weekly (after preparing the wound bed and dressing the wound) to determine healing progress. Keep in mind that wound-care management is a collaborative effort. Once you’ve assessed the patient, discuss your findings and subsequent wound management with other members of the team.

Wound care wisdom

Getting wiser about wound care will help your patients achieve good outcomes. Poor wound healing can be frustrating to patients, family members, and healthcare providers alike. Chronic wounds may necessitate lifestyle changes and lead to severe physical consequences ranging from infection to loss of function and even death. By performing careful assessment, tailoring patients’ wound care to wound etiology, and using evidence-based protocols to manage wounds, you can promote speedier wound healing, help lower morbidity, and improve quality of life.

Selected references
Bryant RA, Nix DP. Acute and Chronic Wounds: Current Management Concepts. 4th ed. St. Louis, MO: Mosby; 2011.

Gardener SE, Frantz R, Hillis SL, Park H, Scherubel M. Diagnostic validity of semiquantitative swab cultures. Wounds. 2007;(19)2:31-38.

Krasner DL, Rodeheaver GT, Sibbald RG. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 4th ed. Wayne, PA: HMP Communications; 2007.
Langemo DK, Brown G. Skin fails too: acute, chronic, and end-stage skin failure. Adv Skin Wound Care. 2006;19(4):206-211.

Langemo DK, Anderson J, Hanson D, Hunter S, Thompson P. Measuring wound length, width, and area: which technique? Adv Skin Wound Care. 2008;21:42-45.

Milne C, Armand OC, Lassie M. A comparison of collagenase to hydrogel dressings in wound debridement. Wounds. 2010:22(11):270-274.

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

Ovington LG. Hanging wet-to-dry dressings out to dry. Adv Skin Wound Care. 2002;15(2):79-86.

Sibbald RG, Coutts P, Woo KY. Reduction of bacterial burden and pain in chronic wounds using a new polyhexamethylene biguanide antimicrobial foam dressing—clinical trial results. Adv Skin Wound Care. 2011;24(2):78-84.

Solway DR, Consalter M, Levinson DJ. Microbial cellulose wound dressing in the treatment of skin tears in the frail elderly. Wounds. 2010:22(1):17-19.

Wound Ostomy and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers. Mt. Laurel, NJ: Author; 2010

Patricia A. Slachta is a Clinical Nurse Specialist at The Queens Medical Center in Honolulu, Hawaii and an adjunct nursing instructor at the Technical College of the Lowcountry in Beaufort, South Carolina.

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