Contemporary approach to chronic wounds
National Consultant in Nursing Chronically Ill and Disabled People
„One of the indicators used to assess the quality of long-term care of an immobilised person is the skin condition in areas exposed to constant pressure. It would seem that nurses know everything on the prevention of pressure ulcers, and that is why I wonder what is the reason for such a high incidence of pressure ulcers in people who are under constant nursing supervision.”
The scale of the problem entitles me to claim that in our country we have common and very serious failings in the care of the sick and disabled, both in stationary health-care and social assistance, as well as in home conditions. These neglects are the cause of immense suffering and generate substantial costs of treatment and care.
There have been many publications on the subject of pressure ulcers referring to numerous medical research and statistics. They repeat the same key information:
- the major etiological factor is the pressure on tissue located over bone prominences, leading to the development of necrosis and then to ulceration,
- skin damage occurs as a result of repeated pressure exceeds the average pressure in skin capillaries (32 mmHg), the impairment of sensation is a contributing factor,
- the formation of pressure ulcers is accelerated by skin maceration, which is a consequence of increased humidity due to urine and faecal incontinence or perspiration,
- the most common location is around the sacrum, ischiadic tubers, trochaners, ankles and heels,
- each immobilised patient is at risk of pressure ulcer formation,
- modern technologies ought to be used to reduce the pressure on the skin, such as specially designed mattresses, pillows, textiles and equipment for sliding movement, modern protective and therapeutic dressings, and aids absorbing urine,
- the treatment cannot be focused on the topical management of decubitus ulcer.
Basic principles relating to prevention:
- proper nutrition – adequate intake of protein, calories and fluids will prevent the occurrence of negative nitrogen balance, weakness and dehydration,
- reduction or elimination of pressure and friction on the skin – this effect is achieved through the use of pressure relief mattresses and pillows, frequent change of body position, application of proper rules for lifting and moving patients,
- strictly comply with the basic care principles of people with incontinence (also the faecal type), including:
- daily washing and cleaning after every contamination with excretions,
- systematic control of skin condition in areas exposed to moisture,
- using absorbent products adequate to the level of micturition,
- preventing skin inflammation through the use of special protective dressings,
- protecting the skin against overdrying and irritants (urine and sweat) through the use of appropriate skin care products.
Modern approach to the treatment of pressure ulcers and other chronic wounds favours wound healing in a humid environment with the use of various specialist dressings, which are applied depending on the type and the location of the wound.
Scientific studies and practical experience have shown that increased moisture in the wound stimulates epidermisation, and this, in turn, stimulates the growth of connective tissue underlying the skin. Specialist dressings compared to conventional gauze dressings also affect the rate of healing. They prevent the damage to the young epidermis during each dressing change, and they contain substances that affect the treatment and healing of wounds. Not to be underestimated is the fact that effective protection of the interior of the wound against external factors, and to perform normal hygiene procedures without changing the dressing.
Therapeutic proceedings (including the selection of a dressing) and the cost depends on the type of wound and the stage of healing . Some wounds are treated for many months, sometimes over a year. There are often problems in the healing process, and the most dangerous of them cause infections. An unsecured wound may be infected with bacteria, viruses or fungi. They proliferate spontaneously and poison tissues with their secretions. The wound infection can spread quickly up to the form of sepsis, which threatens the patient’s life. The cost of treating infected chronic wounds significantly increases mainly due to the need to use more specialist dressings and the use of expensive antibiotics.
As a national consultant I observe with great concern that the number of people who suffer from pressure ulcers and other chronic wounds is not decreasing despite years of educational campaigns. The responsibility for this situation falls not only on the nurses but also on those responsible for creating the conditions for the care of sick and dependent people, and the National Health Fund as a payer financing the costs of treatment. It is difficult to understand the fact that the National Health Fund does not require health care centres to report on patients with bedsores and the course of treatment. Isolating procedures concerning the treatment of bedsores, and leaving the treatment costs within the institution in which they occur, would highly affect and activate the creation of suitable conditions for the prevention of pressure ulcers. It should of course take into account the fact that some chronic wounds are not the result of negligence but result from the patient’s physical condition; most often it relates to end-phase of long-term biologically devastating neoplastic disease.
As part of my own professional practice I was able to watch quite remarkable effectiveness of modern specialised dressings in the treating of pressure ulcers. Of course, the nurses should be aware of all the known methods of chronic wounds treatment, not only of pressure ulcers but also ulcers, malignant ulcers, diabetic foot ulcers and burns. The bottom line is to be aware that it is unacceptable not to obey the basic prevention principles and to expose the patient to the formation of pressure ulcers or other chronic wounds. Both health and financial consequences of economising on absorbent products and protective dressings are very serious, not only for the patient but also for the nurses and the unit they work for.