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’.
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.Nursing Essays – Wound Management
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.Nursing Essays – Wound Management
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.