Wound and Ulcer Care - Veterans Affairs



Challenging Sociocultural Health Disparities: A Collaborative Interdisciplinary Model Pododogeriatric Teaching Module

Chapter XIII: Wound and Ulcer Care

Rationale

Chronic wounds represent a significant morbid complication of common chronic diseases, especially diabetes, peripheral vascular disease and immunocompromised conditions. Although pedal ulcers can run a benign course, too often such lesions can become limb threatening. This module should serve as a review of some of the clinical presentation, diagnostic options and management strategies for the pedal ulcerations commonly encountered in the geriatric patient population.

Goal

The learner will develop a general understanding of the etiology, signs and symptoms of foot wounds and ulcers as well as established principle of wound healing including the various products available to facilitate wound healing.

1. Discuss how ethnogeriatric issues may affect wound management.

1.2 List and discuss the six principles of treatment for diabetic foot wounds including;

• Off loading (reducing pressure on wounds via shoe inserts and modifications)

• Debridement

• Dressings

• Management of infection

• Vascular reconstruction when necessary

Amputation when necessary

1. 3. Describe and discuss the signs, symptoms and management for the various types of pedal ulceration including

• Systemic causes

• Venous

• Arterial

• Neuropathic

1.4.List and discuss the factors that lead to and complicate pedal ulceration the healing process including

• Pressure

• Infection

• Burns

• Necrotic tissue

• Exudate

1. 5. List and describe the various wound care products and their role in the healing process including;

• Topical antibiotics

• Compression pumps

• Static compression and leg wrappings

• Debriding enzymes

• Absorptives

• Alginates

• Biological and biosynthetic

• Collagen

• Foams

• Hydrocolloids

• Hydrogels

• Growth factors

• Skin substitutes

Introduction

Ulceration of the lower extremity is caused by several factors both local and systemic. The American Diabetes Association Consensus Development Conference on Diabetic Wound Care in April 7-9,1999, recognized there were no widely accepted evidenced based guidelines for assessing and treating foot ulcers. To that end this conference developed a consensus on several issues including what are appropriate treatments for foot wounds and how new treatments should be evaluated.

Six principles for the treatment of diabetic foot wounds based on well-established principles of wound healing were identified and include:

• Off loading (reducing pressure on wounds via shoe inserts and modifications)

• Debridement

• Dressings

• Management of infection

• Vascular reconstruction when necessary

• Amputation when necessary

This module will introduce the etiologies, descriptions, diagnosis, management strategies and prevention strategies for each type of ulceration.

Ethnogeriatric Issues

Before becoming immersed in the etiology and diagnosis of wounds in the elderly it is imperative that we remind ourselves that successful management depends on our ability to not only make an accurate diagnosis, but also to consider the multiple ethnic and cultural issues our patient present. Many socio-economic, religious and cultural factors can affect the care of wounds and ulcers. Additionally, pain management is also a concern. One must take great care with the use of explanatory models as they may affect beliefs about appropriate interventions. For example, someone with a “hot-cold” belief system might resist advice to soak in hot water. Those patients who believe in the efficacy of herbal remedies might prefer to use them as opposed to prescribed antibiotic ointments, salves, and tablets.

Vegetarian or vegan individuals may be resistant to the use of any animal based products. Before rejecting any remedies, providers should inform themselves of their actions, keeping in mind that many Western remedies originated from traditional or natural treatments.

Systemic Issues

Lower extremity ulceration is a common manifestation of common systemic conditions included venous disease, arterial disease and neuropathic diseases such as diabetes,

Venous Ulcers

Description

• Commonly seen in patients with venous stasis and varicose veins. They are generally found on the lower leg and are usually caused by incidental trauma. They are usually only mildly painful

Diagnosis

Clinical diagnosis: Most commonly found on the medial leg although can appear on any part of the leg, with preexisting uncontrolled venous insufficiency and/or varicose veins.

Management

Wound treatment options:

• Infection – antibiotics (systemic and or topical)

• Necrotic tissue – local wound debridement, enzymatic debriding agents, and/or surgical debridement

• Support wound healing – keep wound moist, control exudate, encourage granulation formation

1. “Off loading” or pressure reduction is essential to allow for wound healing. This can be achieved via several methods including total contact casting, removable cast boot specially designed to reduce plantar pressures, depth shoes with special insoles and orthotics, other shoe modifications and padding, wheelchair and crutch walking, or combinations of these.

2. Compression dressings to address chronic edema after wound is stable (i.e. good granulating base)

3. Self care education

• Dressing changes

• Medication use

4. Medical referral

• Patients with complicating systemic conditions such as congestive heart failure and end stage renal disease,

Psychosocial referral

Patients with social issues that prevent them from providing self-care should be addressed by being referred to the appropriate health care provider (i.e. social worker, Psychologist, Psychiatrist, etc.)

5. Prevention:

• Maintain edema control; avoid trauma to lower leg.

Arterial Ulcers

Description

Ulcers that develop in patients’ secondary to occlusive arterial disease, such as, atherosclerosis obliterans.

Diagnosis

Clinically, ulcers appear dry and are usually found on the lateral aspect of the foot and ankle. They are usually very painful. Barely palpable or absent pulses, delayed capillary filling time, monophasic or biphasic arterial Doppler signals.

Management

Wound treatment options:

• Infection – antibiotics (systemic and or topical)

• Necrotic tissue – local wound debridement, enzymatic debriding agents. Surgical or sharp debridement is usually avoided to minimize trauma.

1) Support wound healing – keep wound moist, control exudate, encourage granulation formation, avoid infection

• Self care education

• Dressing changes

• Medication use

• “Off loading” or pressure reduction is essential to allow for wound healing. This can be achieved via several methods including total contact casting, removable cast boot specially designed to reduce plantar pressures, depth shoes with special insoles and orthotics, other shoe modifications and padding, wheelchair and crutch walking, or combinations of these

3) Medical referral

• Patients should be referred to a Vascular Surgeon for Non-invasive vascular studies and possible re-vascularization surgery

• Medications designed to vasodilate or increase flexibility of RBC’s.

4) Pain Control

• Arterial Ulcerations are often very painful due to ischemia. Pain control is a major issue with patients with such problems and may require narcotics.

5) Psychosocial referral

Patients with social issues that prevent them from providing self-care should be addressed by being referred to the appropriate health care provider (i.e. social worker, Psychologist, Psychiatrist, etc.)

6) Prevention:

• Minimize trauma to the area so that new ulcerations do not occur. I.e. regularly scheduled nail care and foot inspections, depth footwear and appropriate socks, avoidance of walking barefoot at all times.

Neuropathic Ulcers

[pic]

Description

Ulcers that develop in patients secondary to peripheral neuropathy. Commonly seen on weight bearing surfaces in Diabetics and are rarely painful.

Diagnosis

Commonly seen under pressure points that develop in patients with decreased sensation. Ulcers often have granular or fibro-granular bases with a surrounding halo of white hyperkeratotic tissue.

Management

1). Wound Treatment options

2). Infection – antibiotics (systemic and or topical)

3). Necrotic tissue – local wound debridement, enzymatic debriding agents, and/or surgical debridement

4). “Off loading” or pressure reduction is essential to allow for wound healing. This can be achieved via several methods including total contact casting, removable cast boot specially designed to reduce plantar pressures, depth shoes with special insoles and orthotics, other shoe modifications and padding, wheelchair and crutch walking, or combinations of these

5). Support wound healing – keep wound moist, control exudate, encourage granulation formation

6). Self care education

• Dressing changes

• Medication use

• Disease process education

• Importance of Off-loading and pressure reduction

7. Medical referral

• Control of complicating systemic disease

8. Psychosocial referral

Patients with social issues that prevent them from providing self-care should be addressed by being referred to the appropriate health care provider (i.e. social worker, Psychologist, Psychiatrist, etc.).

9). Prevention:

• Minimize trauma to pressure points so that new ulcerations do not occur. I.e. regular scheduled nail care and foot inspections, depth footwear and appropriate socks, avoid barefoot at all times.

Local Issues

There are several local issues that complicate ulceration and must be addressed if healing is to occur. These include; pressure, infections, burns, necrosis, and exudate.

Pressure

This is the most common cause of Neuropathic Ulcerations. Pressure must be removed from the ulceration in order for it to properly heal. After healing the pressure must be addressed further to minimize reoccurrence.

[pic][pic]

“Off loading” or pressure reduction is essential to allow for wound healing. This can be achieved via several methods including total contact casting, removable cast boot specially designed to reduce plantar pressures, depth shoes with special insoles and orthotics, other shoe modifications and padding, wheelchair and crutch walking, or combinations of these

Infection

Must discriminate between local and systemic infections. Most common organisms on the foot are Staph and Strep however patients with diabetes commonly have polymicrobial infections.

[pic]

Burns

Patients with neuropathy may present with burn wounds from placing their feet to close to radiators or space heaters. These wounds are treated based on the presenting local and systemic conditions. Burn wounds may become infected with pseudomonas. [pic]

Necrotic Tissue

Necrotic tissue includes fibrotic tissue or devitalized eschar. These tissues should be debrided in order to facilitate healing and decrease the breeding ground for bacteria.

[pic]

Exudating

Serous, serosanguanous, sanguineous or purulent drainage All must be removed from the wound area. Excessive exudate can cause maceration, infection and increased necrotic tissue.

[pic]

Depth/Character of Wound

Partial Thickness: Wounds that extend into the epidermis, but not into the dermis.

[pic]

Full Thickness

Wounds that extend through the dermis. May involve subcutaneous, muscle, or bone.

[pic]

Tunneling

Tissue that is overlying an existing ulceration. [pic]

Sinus Tract

A blind ended tract that opens on an epithelial surface. May indicate an abscess or Foreign body within the tissue planes.

[pic]

Wound Care Products

Topical Antimicrobials

Available in a variety of forms including creams, ointments, powders, sprays. Used in locally infected wounds. Systemic infections must be treated with systemic antibiotics in addition to topical agents. (Examples of topical antibiotics: povidine- iodine, bacitracin, mupirocin)

Compression Pumps

Intermittent sequential pressure applied to the extremities to reduce edema and promote venous blood flow back to the heart. Used in venous ulcer management conditions.

Static Compression and leg wrappings

Roll materials (such as Unna boot) that provide compression to a limb. Used to reduce edema, promote venous flow back to the heart and to manage venous ulcers.

Debriding Enzymes

Topical creams/ointments that digest necrotic tissue. Indicated in pressure ulcers, diabetic ulcer burns post-operative wounds, traumatic wounds and infected wounds. (Examples: Panafil, collagenase Santyl, Accuzyme)

Absorptives

Multi-layered wound covers designed to minimize adherence to wounds and absorb exudate. Used in exudating wounds. (Examples: Medipore, Iodoflex, Exu-dry)

Alginates

Non-woven, non-adhesive materials that convert exudate to a moist gel through an ion exchange process. Used in moderate to heavy exudating wounds such as pressure ulcers, infected wounds, diabetic ulcers and venous stasis ulcers. (Examples: CarraSorb, PolyMem, Sorbsan)

Collegens

Materials that interact with exudate to form a gel. Indicated for partial thickness or full thickness ulcers, pressure, venous, arterial, diabetic, second degree burns, traumatic wounds. (Examples: Medifil, Fibracol, Promogran)

Foams

Materials capable of absorbing and holding fluids. Indicated for partial and full thickness wounds. (Examples: Reston, Flexzan, Curafoam)

Hydrocolloids

Materials composed of gelatin, pectin or carboxymethylcellulose that absorb exudate depending on the thickness of the material. Indicated for partial and full thickness wounds with or without necrotic tissue. (Examples: Tegasorb, Duoderm, Cutinova Hydro)

Hydrogels

Materials designed to donate moisture and rehydrate dry wound. Indicated for partial and full thickness wounds, and wounds with necrotic tissue. (Examples: CarraSorb, NuGel, IntraSite)

Growth Factors

Topical agent of recombinant DNA that stimulate cell growth and migration. Indicated for lower extremity diabetic neuropathic ulcers. (Examples: Regranex)

Skin Substitutes

Bio-engineered human derived tissues that support wound closure, replace the need for skin harvest and surgical skin grafting. Indicated for partial and full thickness ulcers. (Examples: Apligraf, Dermagraph, Oasis)

Off Loading Methods

Off loading refers to the process of reducing, removing and minimizing pressure from areas of skin (usually over bony a prominence) likely to breakdown and become wound and/or ulcers. Loss of protection sensation places patients at significant risk for tissue breakdown. When subjected to low continuous pressure such as that placed on the sacrum or heel during prolonged hospitalization, pressure ulcers are common. High short duration pressure such as stepping on a nail or toothpick results in a puncture wound. The most insidious type of pressure injury is the moderate repetitive pressure injury. Here we find pressure and friction forces over a bony prominence that causes hyperkeratosis of the skin followed over time with sub-lesional necrosis and eventual ulceration.

The choice of off loading technique depends on the location and severity of the wound/ulcer, the activity level of the patient and the psychosocial support system. Examples are listed below.

Healing shoes and Shoe Inserts

[pic][pic]

[pic][pic]

Cam Walkers

[pic]

Molded Shoes

[pic]

Depth Shoes

[pic]

Total Contact Casting

[pic]

Wheelchair

[pic]

Internet sites for more information







References

1. Wound Management, Flanagan, Marks-Maran, Churchill Livingstone, New York 1997.

2. Nurse’s Clinical Guide Wound Care 2nd edition, Hess, Springhouse Corporation, Springhouse, PA 1998.

Acute and Chronic Wounds 2nd Edition, Bryant, Mosby, Philadelphia, 1992.

3. Bradley M, Cullum N, Nelson EA, Petticrew M, Sheldon T, Torgerson D. Systematic reviews of wound care management: (2) Dressings and topical agents used in the healing of chronic wounds. Health Technol Assess 1999;3(17).

4. O’Meara S, Cullum N, Majid M, Sheldon T. Systematic reviews of wound care management: (3) antimicrobial agents for chronic wounds; (4) diabetic foot ulceration. Health Technol Assess 2000;4(21).

5. Reiber GE, Smith DG, Carter J, Fotieo G, Deery HG, 2nd, Sangeorzan JA, et al. comparison of diabetic foot ulcer patients managed in VHA and non-VHA settings. J Rehabil Res Dev 2001;38:309-317.

6. The American Diabetes Association Consensus Development Conference on Diabetic Wound Care in April 7-9, 1999.

7. Armstrong DG, Nguyen HC, LaveryLA, et al. Off-Loading the diabetic foot wound: A randomized clinical trial. Diabetes Care 2001;24(6):1019-1022.

Test Your Knowledge

1. Which of the following are considered principles for the treatment of diabetic foot wounds based the 1999 American Diabetes Association Consensus Conference on Diabetic Wound Healing?

1. Off loading

2. Debridement

3. Hyperbaric oxygen

4. Infection control

5. Amputation

A. 1 and 3

B. 1,2, and 3

C. 1,2, and 4

D. 1,2,4 and 5

Answer D

Offloading, Debridement, Infection Control, and Amputation when necessary are key in the proper management of ulcerations and potential limb salvage. Hyperbaric Oxygen is a treatment modality not a principle to be considered with every ulceration.

2. Which of the following pedal ulcerations is/are generally NOT painful?

A. Venus ulcer

B. Arterial ulcer

C. Diabetic ulcer

D. Neuropathic ulcer

E. A and D

Answer E

Venous and neuropathic ulcers are generally painless and while some diabetic ulcers have a sensory neuropathy component as a complication they can also be ischemic in addition.

3. Which of the following pedal ulcerations is/are generally painful?

A. Venous ulcer

B. Arterial ulcer

C. Diabetic ulcer

D. Neuropathic ulcer

E. A and C

Answer B

It is the arterial or ischemic ulcer that is always painful. (See explanation to questions 2 above)

4. Which of the following are appropriate local wound care principles?

A. Debride all necrotic tissue

B. Keep wound moist

C. Avoid trauma

D. Off load pressure areas

E. All of the above

Answer E

In order to provide the best chance for healing all of the above should be present. Necrotic tissue must be removed to diminish bacterial infections. Wound bases must be moist to support revitalized tissue growth. Trauma should be avoided so as not to further damage tissues. Finally, pressure loads must be diminished (“off loading”) to reduce injury and trauma to the tissues, which can further devitalize the ulcerated area.

5. Which of the following are the two most common organisms infecting pedal ulcerations?

A. Staphylococcus and Streptococcus

B. Streptococcus and Diplococcus

C. Enterococcus and Staphlococcus

D. Diplococcus and Enterococcus

E. A and B

Answer A

Staphylococcus and Streptococcus are the two most commonly found organisms found in foot infections and ulceration.

6. Which of the following is the most common organisms infecting diabetic pedal ulcerations?

A. Streptococcus

B. Trycophyton rubrum

C. Generally a single infecting organism

D. Commonly found to be polymicrobial infections

E. Methacilin resistant staphylococcus aureas

Answer D

Diabetic pedal ulcerations are commonly polymicrobial. This may be due in part to the immunopathy that complicates diabetic infections where the ability of phagocytes to digest bacteria and foreign matter is impaired.

7. When referring to a wound, which of the following best describes a sinus tract?

A. Wound that extends through the dermis

B. Wound that extends into the epidermis

C. Tissue that overlay an existing ulcer

D. A blind ended tunnel that opens on the epithelial surface

E. A sinus track does not relate to wounds

Answer D

A Sinus Tract is a blind ended tract that opens on an epithelial surface. It represents the possibility of deeper infection and potentially bone involvement and should be probed. It bone is contacted osteomyelitis should be suspected.

8. Which of the following describes the function of alginate dressings?

A. Topical creams or ointments that digest necrotic tissue

B. Multi-layered wound covering to minimize adherence to wounds

C. Non-woven, non-adhesive material that convert exudates to moist gels

D. Materials composed of gelatin, pectin or carboxymethylcellulose that absorb exudates.

ical agent of recombinant DNA that stimulate cell growth and migration.

Answer C

Alginates are non-woven, non-adhesive materials that convert exudate to a moist gel through an ion exchange process. Alginates are used in moderate to heavy exudating wounds such as pressure ulcers, infected wounds, diabetic ulcers and venous stasis ulcers

9. Which of the following best describes the function of hydrocolloid dressings?

A. Topical creams or ointments that digest necrotic tissue

B. Multi-layered wound covering to minimize adherence to wounds

C. Non-woven, non-adhesive material that converts exudates to moist gels

D. Materials composed of gelatin, pectin or carboxymethylcellulose that absorb exudates.

E. Topical agent of recombinant DNA that stimulates cell growth and migration.

Answer D

Hydrocolloids are materials composed of gelatin, pectin or carboxymethylcellulose that absorb exudate depending on the thickness of the material. Indicated for partial and full thickness wounds with or without necrotic tissue.

10. Which of the following “off loading” modalities would be best for non-compliant patients?

A. Total contact casting

B. Surgical shoe with multi-density insert

C. Depth shoe with multi-density insert

D. Cam walker

E. Ankle-foot orthosis

Answer A

Unlike other off-loading modalities, a total contact cast cannot be removed. This does require more skill and time to apply the cast and must be changed on a weekly basis. In addition it should not be used until all infections are resolved.

Challenging Sociocultural Health Disparities:

A Collaborative Interdisciplinary Model Podogeriatric Curriculum Plan

Podogeriatric Module Evaluation

Chapter XIII: Wound & Ulcer Care

Name:___________________________________________Date:______________________

Circle:

Status: PGY-11 PGY-22 PGY-33 Faculty Other__________________________

Discipline: Allopathic Osteopathic Podiatric Medicine Podiatric Surgery

Specialty: Internal Medicine Family Medicine Podiatry Other____________

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By way of clarification for PODIATRY RESIDENTS:

[1] PGY 1=PPMR, POR, RPR

2 PGY 2=PSR12 (Preceded by one of the above)

2 PGY 2=PSR24 (If preceded by 1 year)

3 PGY 3=PSR24 (If preceded by 2 years)

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