Principles of Wound Management and Topical Therapies
JoAnn D. Waldrop, MN, RN, CWOCN
Many wound care patients are admitted to home care. With changes in reimbursement, it is imperative that wounds be managed aggressively to promote resolution in a timely manner. Home care providers should be knowledgeable about the components of a comprehensive wound management program: etiologic factors, systemic factors, and topical therapies. This article provides an overview of a comprehensive wound management program and assists the clinician in selecting an appropriate topical therapy based on principles of wound care.
(Home Health Care Consultant 2000;7[4]:29-33)
Wound care has become a challenge in the home care environment in the presence of shifting reimbursement and shortened hospital stays, which have resulted in fixed reimbursements for higher-acuity patients.

The majority of wounds are managed primarily by visiting nurses; however, additional treatment is provided by family members, friends, or the patient (between nurse visits). A thorough understanding of comprehensive wound management is imperative for health care clinicians in the home care setting to provide clinically effective, cost-efficient care. Protocols and educational programs regarding optimal wound management are also crucial.
Priorities in Wound Management

Wound healing is a complex phenomenon that is dependent on cellular, local, and systemic factors and that cannot be achieved by topical therapies alone. Comprehensive wound management programs should address three major priorities: (1) identify and correct the causative factors; (2) optimize the patient’s systemic status; and (3) provide appropriate topical therapy. These issues are discussed below.

Causative Factors
Identification and correction of causative factors must be addressed in order to arrest the trauma to the tissues. A thorough assessment of the patient and wound will provide clues to the etiology of the wound. For example, a bedbound patient with a wound that is round or oval in shape and lies over a bony prominence is most likely due to pressure. If the tissues are exposed to shear forces, which is a combination of pressure and gravitational pull, the wound will appear irregular and may have undermining or sinus tracts present. Perineal tissue breakdown in an incontinent patient is most likely due to moisture maceration. In both cases, interventions to reduce tissue trauma from pressure, shear, and moisture maceration should be implemented.1

The etiology of a lower-extremity wound can be identified by performing a thorough vascular and sensorimotor assessment. In this case, measures to improve perfusion or promote venous return would be warranted for patients with arterial or venous ulcers. Neuropathic wounds of the foot would be managed with off-loading and measures to prevent further trauma.

Systemic Status
The second priority is to optimize systemic factors that impact on wound healing—such as perfusion status, nutritional support, hydration, glycemic control, infection control, and minimal use of steroids.2-5 Perfusion is critical for repair of wounded tissues and is compromised by poor pulmonary or cardiovascular function, cigarette smoking, or excess tissue edema. Nutritional status is equally important for wound repair; nutrients provide the elemental materials needed for cell activity and cellular proliferation.5 Hyperglycemia impairs leukocyte function and predisposes the wound to infection. Infected wounds will not heal until bacterial balance is achieved.3 It has been demonstrated that steroids impair wound healing. If steroid treatment cannot be tapered, topical vitamin A may counter the effects of the steroids at the wound site.4

Topical Therapy
The third priority is to provide topical therapy that eliminates impediments to healing and promotes an optimal wound environment. Principles of topical therapy (Table I) that promote healing are based on providing a favorable local wound environment (moist wound environment, protection of the healing wound, insulation of the wound surface) and removing the following impediments:

Necrotic tissue
Infection
Excess exudate
Presence of dead space
Closed nonproliferative wound edges

There are some topical wound therapies that have been shown or theorized to promote healing by actively manipulating the local environment. These therapies include topical growth factors, electrical stimulation, topical collagen, heat, vacuum-assisted closure, and hyperbaric oxygen. These second-line therapies are often used for chronic wounds that are resistant to conservative treatments.

Guidelines for Topical Wound Management

The first decision to be made regarding wound management is establishment of the goal: wound healing or wound maintenance. For the majority of wounds, the goal is to heal. There are a few circumstances, however, where wound maintenance would be an appropriate goal: for example, in a terminally ill patient or someone with ischemic disease who has a necrotic foot ulcer that is dry and noninfected.1 For these wounds, the goal is to maintain a nonproblematic, noninfected state and to preserve the intact eschar, allowing it to serve as a protective barrier to bacterial infiltration.

Once wound healing has been established as the goal, measures to remove impediments and to establish an optimal wound environment should be employed. With the multitude of topical products and therapies available for wound care, decision making can become quite complex. Selecting the appropriate topical therapy for management of wounds in the home is based on a thorough, accurate assessment of the wound itself as well as the ability and motivation of the patient and caregiver to provide proper wound care.

Dressings
Gauze moistened with tap water is the most commonly used wound dressing in home care. Although it may be appropriate, this type of dressing lends itself to misuse by overpacking, oversaturating, or allowing the gauze to dry to the wound surface.6 Other commercially available products are designed to better match the wound environment and generally require less frequent dressing changes. The home care clinician should have a thorough knowledge of these products and their appropriate use. There is no one correct dressing for each type of wound, but rather multiple dressings that may be appropriate for various types of wounds. Therefore, it is important that health care providers approach topical therapy from a principle base versus a product base with consideration of the following factors:7,8

Need for a cover dressing, filler dressing, or both
Hydration status of the wound
Impact of adhesion and occlusion
Cost and availability of the product
Frequency and handling of the product

The decision to use a cover dressing, a filler dressing, or both is dependent on the depth of the wound and the presence of sinus tracts/tunnels or undermining. A superficial or shallow wound that has no depth or dead space and is free of sinus tracts/tunneling or undermining needs only a cover dressing. Examples of cover dressings are transparent thin films, hydrocolloids, solid hydrogel sheets, polyurethane foams, and gauze dressings. A cavity wound containing dead space, sinus tracts/tunneling, or undermining requires both a filler dressing to fill or pack the dead space and a cover dressing to be applied over the wound. Examples of filler dressings are absorptive granules, cavity foams, calcium alginates, hydrocellular dressings, amorphous gels, and gauze dressings. Cover dressings and filler dressings may either be moisture-retentive or provide for absorption of exudate.

Exudate absorption is another consideration in wound dressing selection. Although the accumulation of excess exudate impedes wound healing, a moist wound surface must be maintained in order for healing to occur. Heavily draining wounds need to be managed with dressings that have the ability to absorb wound exudate such as copolymer starch dressings, absorptive granules, calcium alginates, polyurethane foams, and hydrocellular dressings. In moderately exudative wounds, the dressing should be capable of absorbing exudate, but without desiccating the wound surface. Appropriate dressings include hydrocolloids, copolymer starch, calcium alginates, polyurethane foams, gauze dressings, and hydrogels that contain absorptive components. The frequency of dressing change in these groups of dressings varies, depending on how much absorption is required and the absorptive capacity of the dressing, which is variable among these products.

If the wound is producing a minimal amount of moisture, thin hydrocolloids and thin polyurethane foams will prevent any buildup of exudate while sustaining a moist environment. Preservation of a moist surface in a dry wound requires a dressing that retains or adds moisture to the wound. Examples of moisture-retentive or hydrating dressings include transparent thin films, amorphous and solid sheet hydrogels, copolymer starch, and impregnated or dampened gauze.

Occlusion. Occlusive dressings, such as the hydrocolloids, provide a bacterial barrier in noninfected wounds. Hutchinson and Lawrence9 reported that occlusive dressings are beneficial in preventing bacterial invasion of the wound and possibly preventing the spread of methicillin-resistant Staphylococcus aureus. Hydrocolloids are generally contraindicated for infected wounds until bacterial balance has been restored. Infected wounds may need to be monitored more frequently, and there are very limited data regarding the effect of occlusion on infection. Some studies have shown that occluding a wound that is infected with Pseudomonas bacteria, however, can minimize these oxygen-dependent organisms by eliminating the exogenous environmental oxygen source.9

Adhesion. Wound location and status of the periwound skin are good indicators of the amount of adhesion needed. Adhesive products are usually warranted for pressure ulcers on the trunk (ischium or sacrum) to prevent accidental removal as the patient is repositioned. On the extremities, where skin tends to be thinner and more prone to tearing from adhesives, dressings that have minimal or no adhesion and that can be held in place with a wrap are often better than those that risk further damage from epidermal stripping.

Cost Considerations
Wound dressing costs, frequency of dressing change, and ease of use are important factors to consider for wound management in the home care setting, especially if family members, friends, or the patient may be doing the dressing change. Cost is a function of per-item cost plus frequency of dressing change. For example, a dressing that costs $3.50 per dressing change and that must be changed twice daily is more expensive than a dressing costing $4.50 that has to be changed only once daily ($7.00 versus $4.50 per day, respectively). Decreasing dressing change frequency may reduce the number of nurse visits as well as the external exposure and manipulation of the wound environment. The dressing change procedure should be simple enough for a layperson to perform. There should also be a clear understanding about the risk of inappropriate dressing use or an application that may lead to wound deterioration. A quick and simple method of dressing selection, based on wound depth and volume of exudate, is provided in Table II.10

Ongoing Assessment
Ongoing wound assessment may warrant a modification in topical therapy, but unless a change in wound status is evident, clinicians and laypersons should resist the urge to change the dressing protocol unnecessarily. Wound changes that justify altering the topical therapy include changes in the volume of exudate or depth. A deep cavity wound that has granulated to skin level would no longer need a filler dressing, but just a cover dressing. If a wound surface is found to be desiccated when the absorptive dressing is removed, a hydrating dressing may then be more feasible. Periwound maceration would be an indication that the current dressing has insufficient holding capacity and that a more absorbent dressing is required. Prior to changing the topical therapy, the wound healing priorities should be reevaluated. Have the causative factors been appropriately identified and addressed? Have the systemic factors been accounted for? Have the principles of topical therapy been addressed? Are there any impediments to wound healing that are still operational, such as necrotic tissue, infection, excess exudate, dead space, or closed nonproliferative wound edges? Is the current topical therapy providing an optimal or suboptimal environment? Typically it is not the dressing that is preventing the wound from healing, but failure to have sufficiently controlled for etiologic or systemic factors.

Summary
As more patients with chronic wounds enter the home care arena, it becomes more important to ensure that home care providers possess the skills and knowledge needed to develop and implement a comprehensive wound management program. The three priorities in managing wounds—correction of causative factors, attention to systemic factors, and appropriate topical therapy—must be addressed. Clinicians should approach topical therapy based on principles rather than products, keeping in mind the goal of therapy. Routine ongoing assessment of wound status and patient status is important in order to document patient outcomes and responses to the wound management program.

References
1.Clinical Practice Guideline Number 3: Pressure Ulcers in Adults: Prediction and Prevention. Rockville, MD: U.S. Dept of Health and Human Services, Agency for Health Care Policy and Research; May 1992. AHCPR publication 92-0047.

2. Doughty DB, Waldrop JD. Wound healing physiology. In: Bryant R, ed. Acute and Chronic Wounds: Nursing Management. St. Louis, MO: Mosby Year Book; 2000.

3. Robson MC. Wound infection: A failure of wound healing caused by an imbalance of bacteria. Surg Clin North Am 1997;77:637-650.

4. Anstead G. Steroids, retinoids, and wound healing. Advances in Wound Care 1998;11:277-285.

5. Flanigan KH. Nutritional aspects of wound healing. Advances in Wound Care 1997;10:48-52.

6. Pieper B, Templin TN, Dobal M, Jacox A. Wound prevalence, types, and treatments in home care. Advances in Wound Care 1999;12:117-126.

7. Doughty D. Physiology of wound healing. In: Bryant R, ed: Acute and Chronic Wounds: Nursing Management. St. Louis, MO: Mosby Year Book; 1992:31-68.

8. Clinical Practice Guideline Number 15: Treatment of Pressure Ulcers. Rockville, MD: U.S. Dept of Health and Human Services, Agency for Health Care Policy and Research; December 1994. AHCPR publication 95-0652.

9. Hutchinson JJ, Lawrence JC. Wound infection under occlusive dressings. J Hosp Infection 1991;17:83-94.

10. Emory University. Wound Ostomy and Continence Nursing Education Program Course Syllabus. Atlanta, GA; 1999.

Ms. Waldrop is Assistant Director, Emory University Wound, Ostomy, Continence Nursing Education Center, Atlanta, GA. Address for correspondence: JoAnn D. Waldrop, MN, RN, Rm AT-732, The Emory Clinic, 1365 Clifton Rd, NE, Atlanta, GA 30322.
For more information, email info@mmhc.com

Wound, Ostomy, Health