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Don’t Be Wounded By Wound Care

By Alison Hope

Community pharmacies are in an ideal position to help patients with wound care. If information given is accurate and conducive to wound healing, patients will trust you as their health care provider.

The Healing Process

The skin heals in a three-stage process1.
Inflammatory stage: Blood vessels constrict to prevent blood loss and platelets begin to clot. Once a clot has formed, the blood vessels expand to allow blood flow to the injured area. This is characterised by a red, warm wound. White blood cells move to the area to destroy microbes and other foreign bodies. The skin cells proliferate and grow across the wound.
Fibroblastic stage: Collagen growth is promoted within the wound. Collagen, a protein fibre that gives skin its strength, encourages the edges of the wound to close and capillaries form at the wound site.
Maturation stage: More collagen is added to the wound.

There are many factors that can delay wound healing. These include:
Infection: Open wounds can develop a bacterial infection1.
Diet: While malnutrition hinders wound healing, there is little evidence that nutritional therapy with vitamins helps wound healing. If a deficiency is identified, however, it should be treated2.
Medical Conditions: Diabetes, vascular disease and anaemia can hinder wound healing1.
Medications: Medications can inhibit cytokine production and impact healing e.g. corticosteroids and colchicine. Medications can also cause the destruction of replication cells e.g. antineoplastic drugs and leflunomide2.
Age: Wounds take longer to heal in elderly patients1.
Smoking: Impairs the healing process1.
Dryness: Open dry wounds heal slower than moist wounds3.

Treatment

It is important to look after a wound to ensure it heals quickly. The routine use of antiseptics applied at each dressing change can do more harm than good and the cleansing of wounds with an antimicrobial agent is not recommended unless the wound shows signs of infection4. Sterile normal saline (0.9%) has long been recommended for use to irrigate wounds because of its isotonic qualities which ensure the healing process is not disrupted. A recent systematic review found no difference in rates of infection in wounds cleansed with potable tap water compared to those cleansed with sterile normal saline solution5.

Chronic wounds are more prone to infection because they tend to remain open for longer periods of time. Research4 suggests that antiseptic cleansing solutions can be used:

1. In critically colonised wounds when localised infection has already developed.
2. In patients with a history of recurrent infections.
3. When systemic antibiotics need to be given to stop the spread of infection e.g. cellulitis.

Optimal moisture balance should be the focus of treatment1,2,6. Insufficient moisture can cause tissue desiccation, inhibition of granulation tissue and inhibition of epithelialisation. Too much moisture can cause too much exudate, the formation of excessive granulation tissue and maceration of skin which impairs epithelialisation.

The growth of new skin has been found to be faster when moist wound healing is used6. Wound dressings should be selected on the basis of their action to meet healing demands.

Exudate level Dressing Type Properties Wound Example
Nil-to-low Transparent – Breathable but impermeable to bacteria
– Flexible
Wounds that need monitoring e.g. surgical incision sites Tegaderm Film, Opsite Flexigrid
Low Hydrogel – Comfortable
– Reduce pain
– Fight infection
Necrotic wounds, dry sloughy wounds, pressure ulcers Aquasorb, Comfeel, SoloSite Gel
Low-to-moderate Hydrocolloid – Create moist condition
– Absorb water and make a gel keeping wound clean and protecting it
Burns, necrotic wounds, pressure ulcers and venous ulcers Duoderm, Comfeel Plus
Low-to-moderate Cloth – Large range of sizes and shapes Minor wounds like cuts/grazes Primapore
Moderate-to-high Alginate – Absorb excess liquid- – Create a gel that helps to heal more quickly Wounds that needs lots of drainage, venous ulcers, wounds that need packing Algisite M, Curasorb
Moderate-to-high Foam – Absorb exudate from wounds
– Allow water to pass through, keeping the area moist
Odorous wounds, highly exudating wounds Allevyn, Mepilex

When to refer

It is important to refer patients with wounds that fail to heal despite following best practice recommendations for wound healing. The following types of wounds should also be referred2:

  1. Rapidly deteriorating
  2. Large or complex
  3. Atypical
  4. Could lead to amputation
  5. Requires specialised treatment e.g. hyperbaric oxygen or pressure redistribution
  6. Recurs without obvious cause
  7. Painful and pain is not resolving

References

1. Better Health Channel (AU). Wounds [Internet]. Department of Health & Human Services; 2014 [cited 2018 November 23] Available from: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/wounds-how-to-care-for-them

2. Therapeutic Guidelines (AU). Wound Care [Internet]. Therapeutic Guidelines Limited; 2015 [cited 2018 November 23].

3. CLH Healthcare (USA). 7 Types of Wound Dressings [Internet]. CLH Healthcare; 2017

[cited 2018 November 22]

Available from: https://www.clhgroup.co.uk/news-article/2017/09/12/7-types-of-wound-dressings-when-to-use-each/258

4. Nursing Times (UK). When is wound cleansing necessary and what solution should be used? [Intenet] EMAP; 2018 [cited 2018 November 20] Available from: https://www.nursingtimes.net/clinical-archive/tissue-viability/when-is-wound-cleansing-necessary-and-what-solution-should-be-used/7025661.article

5. Cooper DD, Seupaul RA. Is Water Effective for Wound Cleansing? Annals of Emergency Medicine. 2012 November;60(5):626-7

6. Independence Australia (AU). Wound care management [Internet]. ParaQuad; 2018 [cited 2018 November 23] Available from: https://www.independenceaustralia.com/info/health-articles/wound-care-3

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