Introduction

After attending the Spring Symposium for Advanced Wound Care and hearing many great lectures, I got to thinking, "What are the pillars of chronic wound care?” We have all heard of the concept “look at the whole patient and not the hole in the patient.” Heck, I have even written about it. But we also need to have a good foundation for how to implement this phrase or where to even start. I did a quick Internet search and came up with some interesting articles that talked about the basics of wound care and management. I found discussions on everything from maintaining a moist wound environment to being financially responsible. All of this information leads me to the concept of developing easy-to-understand pillars or categories to consider when caring for a patient with a chronic wound.

1. Understanding and Controlling the Underlying Disease Process

As we all know, a chronic wound is not a disease process itself. Often, the wound is a product or symptom of an underlying condition. This may be from venous disease, congestive heart failure, diabetes, autoimmune disorders, lymphedema, etc. I believe one of the first steps to managing a wound properly is to identify the underlying factors that may be contributing to the wound. Is it pressure? Uncontrolled diabetes? Obesity?

2. Wound Bed Preparation: Inflammation/Infection Control

If you have worked in wound care, you have heard about the TIME concept (tissue, inflammation/infection, moisture balance, edge of wound) of wound bed preparation that was first developed by Dr. Greg Schultz and his team.¹ I think we need to take a look beyond the TIME principle. Don’t get me wrong—we still need good debridement and biofilm control. But we also need to start looking at things like pH management of the wound and inflammation control. There are a lot of new products on the market that are aimed at addressing those factors.

3. Nutritional Support

The next pillar that we need to discuss is the nutritional status of patients. We can have patients who are overweight or obese but are still malnourished. A lack or imbalance of proper micronutrients and macronutrients can put a strain on an already ailing body’s healing ability. Make sure you are taking baseline laboratory measurements on these patient's albumin/prealbumin, vitamin D levels, and iron levels. All of these issues can impact wound healing. Make sure we are referring our patients to dietitians who can help manage these problems and supplement our patients with vitamins and minerals.

4. Mental Health/Social Disparities

Many times when we are treating patients, we overlook the mental health aspect of chronic wound care. Having a chronic condition such as a wound puts the patient at an increased risk for anxiety and depression. One study found the rate of depression amount patients with chronic wounds can be as high as 45.3%.² We also need to address any social disparities that our patients may be facing. What is their access to supplies and care? Is the patient homeless? Are they on a fixed income? Are patients in a position where they must decide between a dressing and a meal? What is their mode of transportation—can they get to appointments?

5. Adjunctive Therapies

Adding adjunctive wound therapies can improve wound healing time. There are several new therapies on the market, everything from electrical stimulation to advanced cellular tissue products. Several studies have shown that the earlier the application of adjunctive therapies, such as negative pressure wound therapy, on hard-to-heal wounds, the better the outcomes are.³ The use of adjunctive therapies in chronic wound care has been found to be cost-effective and to improve the quality of patient care.

6. Prevention

The final pillar of chronic wound care is prevention. We all know that when it comes to pressure injuries, prevention is a key component. But what about after we get a venous leg ulcer or diabetic foot ulcer healed? The recurrence rate for diabetic foot ulcers is between 30% and 78%, and this has a huge impact on both the patient and the health care system.⁴ Prevention should be focused on controlling the underlying condition, which brings us full circle. The cornerstone of prevention consists of getting patients into long-term compression therapy, ordering specialized footwear, and teaching them to do regular skin checks.

Conclusion

Clinicians who provide care to patients with chronic wounds can face many challenges. Categorizing chronic wound care into six pillars for management is a holistic way to provide evidence-based care to patients. Providing this type of care is cost-effective and also can improve outcome measures. More research in each of these categories is warranted and will provide us with a better understanding and way to care for our patients.

References

1. Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Rep Regen. 2003;11(2):S1-S28.
2. Chen Y, Zeng Y. Correlation of depression and anxiety with social support and quality of life in patients with chronic wounds Zhong Nan Da Xue Bao Yi Xue Ban (Journal of Central South University Medical Sciences). 2018;43(9):1032-1036.
3. Vowden K, Vowden P. Integrating adjunctive therapy into practice: recognizing hard to-heal wounds. J Community Nurs. 2021;35(6):43-49.
4. Smet S, Probst S, Holloway S, Fourie A, Beele H, Beeckman D. The measurement properties of assessment tools for chronic wounds: a systematic review. Int J Nurs Stud. 2021;48(4):300-305.

About the Author

Emily Greenstein, APRN, CNP, CWON-AP, FACCWS is a Certified Nurse Practitioner at Sanford Health in Fargo, ND. She received her BSN from Jamestown College and her MSN from Maryville University. She is certified as an Adult-Gerontology Nurse Practitioner through the American Academy of Nurse Practitioners. She has been certified in wound and ostomy care through the WOCNCB for the past 12 years. At Sanford she oversees the outpatient wound care and is co-director for the limb preservation program. She currently serves as the President elect for the North Central Region Wound, Ostomy, and Continence Society. Emily has served as an expert reviewer for the WOCN Society and the Journal for WOCN. Her main career focus is on the advancement of wound care through evidence-based research.