Wound Management

Management of chronic wounds

Recognising the early signs of chronic wounds and the benefits of hydrotherapy during the healing process.

One of the consequences of increasing life expectancies in the population is the distinctive increase in chronic diseases which also include chronic wounds.

A wound is considered to be chronic if there is little or no sign of healing, despite appropriate therapy, within an acceptable timeframe. These wounds are usually not caused by external force, as seen in abrasions or burns, but have their source in underlying disorders and negative influences culminating in the development of tissues damage as a result of disturbed metabolism. These disturbances may delay or completely prevent the normal wound healing process.

The most frequent types of chronic wounds are: pressure sores (decubital ulcers/bed sores ), lower leg sores (also called ulcerated legs/leg ulcers and Ulcus cruris) and the diabetic foot syndrome.

The earlier a chronic wound is diagnosed, the better the chances of healing. Therefore it is important that the person affected interprets the initial signs correctly and obtains medical assistance at an early stage.

What early signs may be observed in individuals with such wounds?

Pressure sores 

Their prevention requires continued monitoring of skin condition and immediate and appropriate reaction to change.  Signs of skin damage may be discolouration and hardening (induration), increased local temperature and discomfort.  Blistering may be observed. 

Factors promoting pressure ulcer development are diverse and may include: advanced age, immobility, incontinence, disturbances in sensation, obesity or malnutrition and underlying disorders affecting blood circulation and cell metabolism.

Ulcers of the lower leg

Chronic wounds frequently occur on the lower leg around the ankle (malleolar region) although they can – depending on their cause - occur at any location on the lower extremity.
Weaknesses in the venous circulation of the legs may cause congestion or complete stasis of blood flow. This, in turn, can lead to tissue damage and subsequent ulceration.  
Venous ulceration doesn’t happen overnight. The following are just a few of the signs of disturbances in venous circulation that may be observed in affected individuals as the disorder develops: swelling (edema) of tissues, hyper- and/or hypopigmentation of the skin, stasis eczema, and a subjective sensation of pressure or blockage in the leg (especially toward the evening).  
 

Diabetic foot syndrome

As a result of long term damage to blood circulation and/or nerve damage in association with diabetes mellitus, complications of this metabolic disorder may occur.  The term – diabetic foot syndrome – refers to clinical symptoms observed in the foot. 

The loss of protective perception of pain and pressure is one of the main triggers for ulceration in diabetic patients. Preventive measure to protect the foot from injury are essential as even the smallest of injuries can rapidly lead to ulceration. A multidisciplinary approach to care is crucial.   

Special attention must be paid to diabetic feet and nails as even small abrasions or pressure points can be the beginning of a chronic wound development.

How can chronic wounds be prevented?

Pressure ulcers can – as the word infers – be prevented by reducing, removing or redistributing the source of pressure and friction. At risk individuals should, for this reason, be correctly identified and appropriate pressure-relieving interventions carried out. These include regular turning and repositioning of immobilised individuals and the use of pressure-relieving devices.  

Venous ulceration requires two decisive interventions: compression therapy and mobilisation.  Patient education and empowerment play a crucial role in making these therapy regimes work so, as well as understanding the importance of applying compression, patients must learn to keep their legs moving.

Self-empowerment is equally important for diabetic patients. Those affected should ensure that their feet are inspected on a daily basis. They must be kept warm and dry and walking barefoot is an absolute taboo.   Negative outcomes can be reduced by regular visits to a physician, for monitoring and assessment purposes.  

A holistic approach to care is vital for successful treatment and healing of chronic wounds. It is vital that the underlying disorder, for example diabetes mellitus or arterial disease, is addressed.  

How do wounds usually heal?

All wounds, regardless of their cause, go through phases of healing which can be divided into three general stages:
1. Cleansing Phase

During the initial period of healing the wound attempts to cleanse itself of impurities.  Wound exudate is frequently present, signs of infection may occur (redness, swelling, pain, heat, reduced function). Local wound care serves to support these processes and accelerate cleansing. 

2. Granulation Phase

A wound defect is filled with new tissues.  Exudate levels drop.  Wound cleansing must continue and new tissues must be protected.
 
3. Epithelisation Phase

Wound edges draw together.  The wound surface is covered with epithelial cells and wound closure can conclude. During this phase exudate levels may be minimal or non-existent and fragile epithelial cells must be cared for.  

How are problematic wounds treated?

Modern wound dressings support the specific physiological process in each stage of healing.  Dressings keep the wound moist, provide protection against external influences and actively support the healing process.

HydroTherapy, by PAUL HARTMANN AG, is a treatment concept especially for the treatment of chronic and poorly healing wounds. It consists of only two wound dressings which are used one after the other during the healing process: HydroClean® plus and HydroTac®.

HydroClean® can be used in all three stages of the healing process but is most effective during the cleansing and granulation phases. Due to its special absorbing and rinsing mechanism, necrosis, slough and bacteria are removed from the wound and firmly bound in the wound-dressing pad. In the core of the dressing bacteria are killed by the antiseptic polyhexanide (polyhexamethylene biguanide or PHMB) and remain enclosed there.

HydroTac® is used as a follow up to HydroClean®, predominantly in the granulation and epithelisation stages.  It not only absorbs but actively provides moisture when needed, thereby regulating the moist wound environment.  Its top film promotes healing while protecting the wound from bacteria and infection.