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Cause of wound and nutrition drive care plan
The key to good outcomes in wound care is to assess the whole situation and develop a treatment plan that includes patient education and nutrition counseling as well as actual treatment of the wound, say experts interviewed by Hospital Home Health.
"We can’t say that a wound is just a wound anymore," says Janice A. Monforton, RN, BSN, CWCN, clinical specialist with Smith & Nephew Wound Management in Largo, FL. Because there are many different causes of wounds, it is important for the clinician to understand what is causing the wound, she says. For example, if the ulcer is a venous ulcer as opposed to an arterial ulcer, you’d use compression therapy, Monforton adds.
Chronic ulcers are difficult to assess because once a wound reaches the stage at which it doesn’t heal normally and stays inflamed, there are a number of causes that must be evaluated, she says. "The nurse must look for bioburden, necrotic tissues, poor circulation, tissue breakdown, and pressure as causes."
Once you begin treatment, good debridement is essential, Monforton points out. The traditional method of mechanical debridement using a wet-to-dry dressing is not the best method for most patients, she explains. "Wet-to-dry debridement pulls off good as well as bad tissue." Use of enzymes for debridement is more effective in home care because it works faster, can be covered by a bandage, and produces less trauma to the wound, Monforton explains.
Although there still is use of wet-to-dry debridement in home care, she sees changes occurring throughout the industry. "As more home care agencies establish wound care programs or hire nurses with specific wound care knowledge, traditional approaches to wound care are changing," Monforton says. "As wound care education improves, we are seeing that nurses are developing treatment plans that are not as programmed as they have been in the past," she adds.
For example, rather than relying on a treatment plan that only addresses the timing of dressing changes, nurses now develop plans that incorporate solutions to some of the causes of the wound, Monforton explains. "If we are treating a pressure ulcer, we need to educate the patient and family caregivers on how to avoid exacerbation of the ulcer. If the nutritional status of the patient is affecting the healing process, we need to address that issue," she adds.
Vitamins and protein speed healing process
"Nutrition is a vital component of wound care," says Samantha McLaughlin, MS, RD, account manager for Novartis Consumer Health in St. Louis. Monitoring a home care patient’s food intake is difficult because the patient may not always have meals prepared on a regular basis and may prefer to eat sweets and carbohydrates rather than protein because those foods require no preparation, she says. "A nurse should look in the refrigerator and pantry to see what type of food is available," McLaughlin suggests.
If there aren’t nutritional foods available, educate the patient and the family caregiver about the importance of good nutrition for wound care as well as for overall health, she adds. "If you notice signs of malnutrition, such as skin problems, cracks in the skin around the mouth, or weight changes of 10% of the patient’s body weight in the past six months or 5% over 30 months, the nurse should consider a thorough nutritional assessment along with recommendations for supplements," McLaughlin says. "Of course, we also need to make sure that the patient is able to eat," she adds. "Sometimes, a patient’s ill-fitting dentures or other dental problems make it painful to chew, so patients are not eating what is prepared for them," McLaughlin explains.
"Not only do we need to make sure that wound care patients are receiving enough vitamin C and overall calories, but we need to make sure they are eating enough protein to promote healing," Monforton notes. "A good way to check a patient’s protein intake is to measure their albumin level." An albumin level of 3.5 or higher is good, anything below is cause for concern, she adds. "Arginine, which is a nitrogen-rich amino acid, gives patients 4% to 5% of the protein they need each day," McLaughlin says. The supplement also provides calories that, along with the protein, increase the body’s ability to heal wounds, she adds.
Because arginine comes in a powder form that must be mixed and drunk twice each day, and costs about 70 cents a serving, it might not be appropriate for all patients, she says. "If a patient has a superficial wound and is able to eat protein-rich foods, then a multivitamin with vitamin C may be enough of a supplement to enhance wound healing, McLaughlin explains. Be aware of other medical conditions that might require a close monitoring of protein or other supplements, she adds.
You don’t want to heal the wound and exacerbate another condition with the wound care, McLaughlin says. While treating a wound, remember that a lot of wounds are overcolonized with bacteria but may not appear to be infected, Monforton notes. "For surgery wounds, look for warmth and tenderness around the wound. Chronic wounds may present increased drainage, have an odor, or bleed easily when you remove the dressing," she says.
Wound cultures are difficult and may not always produce accurate or complete identification of the bacteria, Monforton adds. "A tissue biopsy is the most accurate way to identify bacteria but it is expensive," she says. For these reasons, it is important that a nurse identify the infection as early as possible so that a broad-spectrum antimicrobial can be used effectively, Monforton notes.
Dressings that contain medication to kill bacteria can be used, and localized wounds can have the medication placed directly on the wound bed, she says.
The most important thing a home health manager can do is to provide training or resources for the nursing staff so they can assess wounds properly, Monforton says. "It’s hard to treat a wound effectively if you don’t know exactly what you’re treating."
[For information on legal issues involving management of pressure ulcers in terminally ill patients, see Elizabeth Hogue's LegalEase column in the September issue of HHH.]
For more information on wound care, contact:
• Janice A. Monforton, RN, BSN, CWCN, Clinical Specialist, Smith & Nephew, 11775 Starkey Road, P.O. Box 1970, Largo, FL 33779. Phone: (800) 876-1261 or (727) 392-1261. E-mail: Janice.firstname.lastname@example.org.
• Samantha McLaughlin, MS, RD, Account Manager, Novartis, 1119 Mississippi Ave., #202, St. Louis, MO 63104. Phone: (800) 622-2689, ext. 4125. E-mail: Samantha.email@example.com.
For information about guidelines and clinical protocols for wound care, contact:
• Wound, Ostomy and Continence Nurses Society, 4700 W. Lake Ave., Glenview, IL 60025. Phone: (888) 224-9626 or (866) 615-8560. Web site: www.wocn.org.
• American Academy of Wound Management, 1255 23rd St., N.W., Washington, DC 20037. Phone: (202) 521-0368. Fax: (202) 833-3636. Web site: www.aawm.org.]