Recently I was able to attend the Spring Symposium on Advanced Wound Care (SAWC) in San Antonio, Texas. I attended many different lectures, presented, and sat on a few expert panels. The one recurring theme that kept echoing was the need to look at the whole picture. Often, as wound specialists, we get in the habit of looking just at the wound without taking into consideration the underlying comorbidities and potential causes of the wound in the first place. This got me thinking, how do I treat a new patient who comes into my wound center? I decided to put together the top five "tips" to remember to look at the whole patient, not just the hole in the patient (as originally stated by Dr. Carrie Sussman, DPT, PT).

Five Tips for a Patient-Centered Approach

1. Always take a thorough history and physical. Ask the patient when they first noticed the wound and what they have done for treatments in the past. Make sure to ask very specific questions; for example, I had a patient who presented with a wound to her lateral hip. It appeared as a burn. After questioning her, I found out she was using vasoconstricting cream to treat her hip pain. On top of this, she used aerosol menthol-based pain reliever on the same area for three to five minutes straight. Because of the vasoconstriction cream and the aerosol menthol-based pain reliever, she basically gave herself frostbite. The area was treated as a deep partial-thickness burn and went on to heal well.
2. Always look at the patient’s medication list and review it with them. Sometimes patients are on medication for the treatment of a disease or disorder that they do not even know they have. Sometimes they cannot remember why they are on the medication. Reviewing medication lists can be helpful, especially for those patients who are on immunosuppressants, which could affect wound healing. Or they may have an ulcer related to an underlying autoimmune disease.
3. Always order basic tests. This includes imaging and lab tests. For example, patients with lower extremity ulcers should always have an ankle-brachial index test and venous ultrasound scans for insufficiency. Many times, people order venous duplex ultrasound scans that truck for deep vein thrombosis and do not show incompetence in the superficial system. Other basic lab tests to get include complete blood count, comprehensive metabolic panel, hemoglobin A1c, prealbumin, and vitamin D. It is also helpful to get an initial x-ray for patients with diabetic foot ulcers.
4. Always make the appropriate referrals.This includes referrals to the dietitian to help optimize nutrition, physical therapy to help with mobility, the psychologist or psychiatrist to help with coping skills, and any ancillary services needed. These are all important health care professionals within the multidisciplinary team to contact for patients who have multiple comorbidities.
5. Always practice evidence-based medicine. Many different organizations create evidence-based guidelines. They review collections of literature and studies to create a guideline to provide optimal care. For example, venous leg ulcers need to be compressed. The guidelines recommend compression of 30-40mmHg.¹ Another example is that a diabetic foot ulcer needs to be offloaded at all times.²

Conclusion

So, as we all know, wound care patients are complicated. They often present with many different comorbidities. It is not unusual for a patient to have a medication list and past medical history a mile long. We need to remember to treat them with a holistic approach, managing all of their symptoms and underlying conditions. We also need to remember the importance and aspects of care that each member of the multidisciplinary team can bring.

References

1. Wittens C, Davies AH, Bækgaard N, et al. Editor's choice: management of chronic venous disease clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2015;49(6):678–737.

2. Snyder RJ, Frykberg RG, Rogers LC, et al. The management of diabetic foot ulcers through optimal off-loading. J Am Podiatr Med Assoc. 2014;104(6):555–567.

About the Author

Emily Greenstein, APRN, CNP, CWON, 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 8 years. At Sanford she oversees the outpatient wound care program, serves as chair for the SVAT committee and is involved in many different research projects. She is an active member of the AAWC and currently serves as co-chair for the Research Task Force and Membership Committee. She is also a working member of the AAWC International Consolidated Diabetic Ulcer Guidelines Task Force. She has been involved with other wound organizations and currently serves as the Professional Practice Chair 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.