Tissue Viability & Wound Management
Wound types and Management
According to NHS report, 1998, ‘Wound care has, in the past, not been well managed because of the limited understanding of the healing process and the inadequate range of dressing materials available. Wound management has now come full circle, back to Hippocrates’ principle and dressings are being developed to provide the ideal environment for nature to do its work’.
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The primary function of normal intact skin is that it can control microbial populations living on skin surface from entering underlying layers or organs and thus protects the body from pathogens. Exposure of subcutaneous tissue with a wound provides a moist and warm environment for microbial organisms. However factors such as wound type, depth, and location, quality, level of tissue perfusion and anti-microbial efficacy or resistance is important for examining microbial effects on wounds. Wounds are broadly categorized as either acute or chronic. Acute wounds are caused by external damage to intact skin and include surgical wounds, bites, burns, minor cuts and abrasions, and more severe traumatic wounds such as lacerations and those caused by crush or gunshot injuries (in Bowler et al, 2001, p.245). Acute wounds are expected to heal within a predictable and specified time frame and with minimal intervention although in severe cases such as gunshot wounds, anti-microbial therapy or surgical intervention may be necessary. In contrast, chronic wounds are most frequently caused by endogenous mechanisms associated with a predisposing condition that ultimately compromises the integrity of dermal and epidermal tissue (Bowler et al, 2001, p.245). Pathophysiological abnormalities that may predispose to the formation of chronic wounds such as leg ulcers, foot ulcers, and pressure sores include compromised tissue perfusion as a consequence of impaired arterial supply (peripheral vascular disease) or impaired venous drainage (venous hypertension) and metabolic diseases such as diabetes mellitus.
Tissue viability is considered as a growing specialty that primarily addresses all aspects of skin and soft tissue wounds including acute surgical wounds, pressure ulcers, and leg wounds and ulceration. Tissue viability includes but not just restricted to wound management and covers professional aspects of wound care, nursing and also a wide range of organizational, political and socioeconomic issues.
Wound management and tissue viability are intricately related and Schultz et al (2003) indicate that the healing process in acute wounds has been extensively studied and the knowledge obtained from these studies have been used for the care of chronic wounds with the assumption that non healing chronic wounds suggest an aberration of the normal tissue repair process. However the healing process associated with chronic wounds is quite different from that of acute wounds. As Schultz et al discuss, usually in chronic wounds, the sequence of events which lead to repair in acute cases becomes stuck or disrupted at different stages of the healing process and before the normal healing process could be resumed, the barrier to the healing process has to be recognized and correct techniques have to be applied. Thus for appropriate understanding of the healing process and the interventions necessary to speed up healing and to repair chronic wounds, it is necessary to understand the underlying molecular events. Wound bed preparation is the management of wound that accelerates endogenous healing and facilitates the effectiveness of therapeutic measures and is an important concept in wound management. Wound bed preparation is an educational tool in wound management and several key issues form part of wound management and tissue viability. These include status of wound bed preparation, analysis of acute and chronic wound environment, wound bed preparation in the clinic, cellular components of the wound bed preparation concept, and analysis of the components of wound bed preparation.
An important part of wound management is realizing the potential dangers of wound infection. Surgery itself carries a 1 to 5% risk of wound infection and if proper care is not taken, there is a 27% chance of endogenous contamination. Bowler et al (2001) write, ‘Infection occurs when virulence factors expressed by one or more microorganisms in a wound out compete the host natural immune system and subsequent invasion and dissemination of microorganisms in viable tissue provokes a series of local and systemic host responses’ (p.247). Wound infection and presence of pathogens in the skin and body are primarily responsible for delayed wound healing although host immune response and local environmental factors such as tissue necrosis, hypoxia and ischemia impair immune cell activity. Antiseptics, antibiotics, antimicrobial therapy, vacuum assisted wound closure, enzymatic and surgical debridement, pressure reduction in wounds and complementary and alternative therapies are the common techniques of wound management.
Tissue Viability and Wound Management – Nursing Perspectives
In a study by Maylor (2005), tissue viability nurses, nurse practitioners and post registration nurses responded on a wound management survey and ranked signs and symptoms of wound healing, stasis and deterioration according to their supposed importance. According to the survey the top ranking sign for a healing wound was size or reduction of the wound, a static wound was recognized by no marked changes in the wound, and a deteriorating wound is marked by increased pain. However results have been generalized with caution although the study supports the fact that some words are used in common by different respondents in specific wound phases.
Kingsley (2001) suggests that the management and treatment of infection is a complex and important area in tissue viability nursing and in this regard microbiology is important in clinical practice along with the fact that a proactive approach to management of infected wounds using an infection continuum can help promote effective care.
Pain is one of the most common accompaniments of wounds and it is important to understand whether pain relief has any relation whatsoever with wound healing. Pediani (2001) cite a study of 5150 hospital patients and found that 61% suffered pain due to wounds of which 87% had severe or moderate pain. Pain is considered to be of protective function as it warns of damage and initiates treatment. However postoperative pain can heighten cellular stress response; autonomic, somatic and endocrine reflexes are diminished resulting in a suppressed immune system which can impair wound healing.
In chronic wound management and tissue viability, wound bed preparation is a popular term describing the method of treatment. Vowden and Vowden (2002) describe that the concept of wound bed preparation represents a new direction in wound care thinking as wound management tend to focus both on the wound and on the patient necessitating a multidisciplinary and structured approach to care. Wound management focuses on the study of the interrelationship of functionally abnormal cells, bacterial balance, inappropriate biochemical messengers and dysfunctional wound matrix components. These elements are influenced by the patient’s physical and psychological status and the aim of the wound bed preparation is to create optimal wound healing environment as well as vascularised and stable wound bed with no exudates. The five primary aspects of wound bed preparation include Restoration of bacterial balance, Management of necrosis, Management of exudates, Correction of cellular dysfunction and Restoration of biochemical balance (Vowden and Vowden, 2002).Vowden (2005) bring out the complicating factors in wound management and suggest that exudate, infection, co morbidity and polypharmacy constitute to a complex wound and a holistic assessment is necessary in wound care.
Pieper (2005) brings out the challenges faced by nurses in wound management and highlight the problems of wound management in rehabilitation patients as well as in vulnerable populations that are at risk. Rehabilitation nurses are challenged to understand issues that are related to working with vulnerable patients affected with wounds and these factors include poverty and payment for care, culture and literacy. Hampton (2004) emphasizes that preserving the skin’s integrity in a patient is one of the primary jobs of a nurse and this can often be a complex and difficult task especially in cases of chronic wounds. Factors affecting the repair and management of chronic wounds also shed light on maintenance of skin integrity and general nursing needs in wound management.
Nursing issues in tissue viability and wound management include acquisition of coherent knowledge and a systematic understanding of the process of healing and this naturally leads to the development of problem solving strategies. However the limitations of knowledge as well as cutting edge technological innovations in wound management that cannot be overlooked.
One challenging aspect in wound care is nursing of fungating wounds as these wounds pose a challenge as it is difficult to manage the physical aspects of such a wound which is accompanied by pain, bleeding, exudates and odour. The psychological impact of fungating wounds on patients, their families and carers can be quite strong and irreversible. Fungating wounds require sensitivity in nursing management and consideration of social and psychological issues. Dowsett (2005) emphasize on the need for nurses to work in partnership with patients to meet their clinical, quality of life and psychosocial needs. Franks and Bosanquet (2004) bring out another challenging aspect of wound management, namely cost effectiveness and discusses different methods of evaluating cost in relation to the outcomes of treatment and reviews the evidence of cost-effectiveness (CE) in the management of chronic leg ulceration. Higher cost effectiveness seems to allow either for the same number of patients to be treated more efficiently at a lower cost or more patients to be treated for the same financial input. Studies on the relative cost effectiveness for different systems of care lead to overall suggestions that modern wound dressings provide a more cost effective alternative to saline gauze. The use of compression bandaging has also been found to be more cost effective when compared with a system of care where there is no compression. The evaluation of cost effectiveness is an important aspect in wound care and management as striving for greater healthcare efficiency using scarce resources is a challenge that highlights the need for cost effective treatment methods. To make treatment more effective, many innovative techniques are used and Dunford (2005) emphasize the innovative techniques of honey-derived dressings in promoting effective wound management and healing. Clinical studies have shown that honey has significant promise as an effective treatment for many medical conditions and can be especially effective for chronic non-healing wounds. Honey has been suggested as being effective in management of chronic leg ulcers and has a number of healing and antiseptic properties.
Wilson (1999) explores the role of clinical governance on tissue viability specialists and nurse practitioners. Principles of clinical governance have considerable significance for healthcare organizations and highlight on the different processes of application, including responsibilities that have to be adopted. Wilson emphasizes that the dimensions of clinical governance are applied to the quality of care expected and given by staff and ways of assessing performance, ensuring that quality is a general feature of healthcare. Wilson concludes by saying that, ‘ It is up to us all as healthcare practitioners to ensure that we keep professionally up-to-date, enhance our education, research and development, and have a mechanism for monitoring and safeguarding our performance’ (p.95).
Dealey (1998) gives the blueprint for clinically effective wound care and suggests that in tissue viability as in other aspects of healthcare, there is an increasing recognition for the need of healthcare interventions and the randomized controlled trial (RCT) is the most accurate evidence of effectiveness. Evidence of effectiveness of healthcare interventions in wound care and other aspects of care, several factors such as funding, sample selection, sample size, recruitment of patients, mortality and attrition rates. As with other aspects of effective wound care, pain reduction during dressing is a challenging management issue and has been examined by Meaume et al (2004). Meaume and colleagues attempted to examine pain in patients with acute or chronic wounds of various causes during dressing removal and the effects of switching to non-adherent dressing and in their study 656 primary care physicians reported details of acute and chronic wounds during routine visits. The pain experienced during dressing changes was evaluated after patients completed a self-evaluation questionnaire. 5850 patients with chronic and acute wounds reported moderate to severe to very severe pain. Dressing removal was considered painful when there was an adherence to the wound bed and switching to non-adherent dressing reduced pain during dressing changes in most cases. Thus authors conclusively argue that pain is a major problem and challenge to nursing management in wound care and is almost always related to dressing selection. They point out that selecting a suitable non-adherent dressing improves patient acceptability.
The major challenges in tissue viability and wound management seem to be the following:
- pain management
- wound infection and pathogens
- providing cost effective treatment
- maintaining quality of care according to principles of clinical governance
- improving healing and reducing mortality rates
Stalick (2004) discusses the case of a 91 year old woman who has been admitted to the hospital from her own home and was found to be with reduced mobility, constipation, increased confusion, and reduced oral intake. She has been reported to have small vessel disease and a stroke and also two pressure ulcers on her buttocks. The surrounding skin of the ulcer was macerated although after the skin was cleaned and treated, it was expected to heal fast. The healing however took longer than expected and exposed many risk factors for macerated skin conditions. Among the vital factors in the management of wounds, nutrition has been considered important and the role of nutrition has been studied by Lansdowne (2002). Lansdowne’s review suggests that the essential biological features of human skin, their origins and cellular relationships serve as the basis for understanding nutritional requirements in health and disease. The importance of a well balanced diet, sufficient in proteins, fats, carbohydrates, vitamins, and minerals is emphasized in the management of skin wounds. The evidence for the study is based on clinical trials and case studies of patients who have genetic deficiencies affecting dietary metabolism. Experimental studies on laboratory animals also provide information on the role of nutrient deficiencies in wound repair. Lansdowne emphasize on the need for a detailed study of key nutrients at principle phases of wound healing cascade and on how metabolism is regulated by growth factors such as cytokines and hormones and metals and how all these factors affect wound healing as a whole.
Considering a completely different aspect of tissue viability and wound management, Flanagan (1997) tried to establish a profile of practicing tissue viability clinical nurse specialists in the UK. The aim of his study was to establish baseline data on the role and conditions of employment and identify any discrepancies and he used a sample of 110 practitioners and 87 participated. The majority of practitioners were in general wound management, with 36% having responsibility for tissue viability services and responsible for pressure sore preventive equipment. The study highlighted the lack of available role models and isolation of a practitioner’s position. Most (90%) of practitioners seemed to be working full time and 62% are on Grade H; 28% are graduates with a further 19% studying for a first degree; 6% already hold a master’s degree while 20% are undertaking courses at this level. However, according to Flanagan, 39% have no academic qualifications and only 34% had completed ENB courses in tissue viability (Flanagan, 1997). These results suggest that increasing workforce and specialist nurse practitioners for tissue viability seems to be an important challenge for nursing and clinical management.
In this essay we provided a detailed evaluation of wound management and tissue viability using various studies to show the nursing perspectives of wound care and the various aspects of wound management including nutrition, dressing and pain conditions. The challenges of wound management have been highlighted suggesting that clinical governance, pain management from wounds and improving quality of life through effective wound care are intricately related.
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Bowler PG, Duerden BI, Armstrong DG. Wound microbiology and associated approaches to wound management. Clin Microbiol Rev. 2001 Apr;14(2):244-69.
Bowler PG, Jones SA, Davies BJ, Coyle E. Infection control properties of some wound dressings. Journal of Wound Care. 1999 Nov;8(10):499-502.
Bowler PG, Davies BJ. The microbiology of infected and noninfected leg ulcers. Int J Dermatol. 1999 Aug;38(8):573-8.
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Franks PJ, Bosanquet N.
Cost-effectiveness: seeking value for money in lower extremity wound management. Int J Low Extrem Wounds. 2004 Jun;3(2):87-95.
Flanagan M. A profile of the nurse specialist in tissue viability in the UK. Journal of Wound Care. 1997 Feb;6(2):85-7.
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Silver: its antimicrobial properties and mechanism of action
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What has pain relief to do with acute surgical wound healing? Ramon Pediani, 2001
World wide wounds – www.worldwidewounds.com
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Schultz GS, Sibbald RG, Falanga V et al. (2003) Wound Bed Preparation: A Systematic Approach to Wound Management Wound Repair and Regeneration; 11, Supplement : 1-28
Vowden K Complex wound or complex patient? Strategies for treatment. Br J Community Nurs. 2005 Jun;Suppl:S6, S8, S10 passim.
Vowden K, Vowden P. Understanding exudate management and the role of exudate in the healing process. Br J Community Nurs. 2003;8(11 Suppl):4-13.
Vowden K. Common problems in wound care: wound and ulcer measurement. Br J Nurs. 1995 Jul 13-26;4(13):775-6, 778-9.
Wilson J. Clinical governance and the potential implications for tissue viability. J Tissue Viability. 1999 Jul;9(3):95-8. Review.
NHS report on wound care www.nhsdirect.nhs.uk
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