Introduction: Mental Health Awareness Month and Wound Care

May is Mental Health Awareness Month and with the staggering statistics of one in four adults living with mental illness,¹ I immediately was motivated to write a personal blog. I previously shared my son’s experience here in 2020, in “Wound Management Challenges in Prison Populations,” and discussed the importance of establishing a quality of wound care. I started thinking about the high number of incarcerated people with mental health issues, and it prompted me to conduct a bit more research.

Given my son's dual diagnosis of schizophrenia and post-traumatic stress disorder (PTSD), I recall having a conversation with him during this time about debridement methods because advanced wound care would become extremely complicated. I immediately started educating him on possible dressings and debridement methods that could be used on his wound. This gave him an idea of what to expect and allowed him to decline certain treatments if he so preferred.

How About Improving Wound Management for Those With Mental Illness?

It is difficult for any patient to have a wound, and it is even more difficult for someone suffering from mental illness to have a wound and/or receive care. There has been a growing emphasis on improving physical health care for individuals diagnosed with mental disorders. How about wound management? Appropriate wound care is one such area of care that requires consideration for mental health service clients. There is a significant need for mental health nurses with knowledge and expertise in wound care assessment and management.

What Is the Connection Between Patients' Challenges With Mental Illness and Wound Chronicity?

There is an extensive list of mental illness disorders, including mood disorders (depression, bipolar disorder, etc.), anxiety disorders (generalized anxiety disorder, PTSD, etc.), personality disorders (borderline personality disorder), psychotic disorders (schizophrenia, etc.), eating disorders, impulse control disorders, factitious disorders, substance abuse disorders, and more. All these disorders impact a person’s thoughts, perceptions, feelings, and behaviors. The majority of these mental disorders may require one or more interventions, such as counseling or medication, for management. Individuals with mental illness are at an increased risk of skin injuries.²

Within the inpatient setting, this risk escalates, especially in relation to wounds caused by shear and friction forces, such as pressure injuries, diabetic foot ulcers, and vascular ulcers. A lack of ambulation, poor nutrition, and poor hygiene decrease immunity and thereby make wounds harder to heal. A recent study discussed the relationship between mental illness and difficult to heal wounds, published in the International Journal of Environmental Research and Public Health.² This study found that the increased risk of wounds results from several of the factors listed here²:

• Staff and supply shortages
• Lack of familiarity with wound care
• Patient nonadherence (miscommunication)
• Comorbidities (diabetes, obesity)

What Can Nurses Do to Help Psychiatric Patients With Skin Injuries?

Many nurses who work in inpatient psychiatric facilities are often not as familiar with wound care as they are with psychiatric care. This lack of knowledge is compounded by staff and supply shortages, comorbidities, and perceived patient nonadherence.² Psychiatric nurses should ask management to organize educational opportunities on wound care.

If this option is not available or for further resources, digital educational opportunities are also available. Education is the first step to help those with mental disorders, who already face daily obstacles, to overcome wounds that may needlessly worsen their health.² It is additionally important to review wound practices with patients before care administration. Patients with mental illness may be at higher risk of nonadherence because a treatment method could intensify psychological symptoms. Therefore, it is important to describe treatments to patients before implementing them. For certain treatments that tend to be invasive, such as debridement, this discussion is extremely important.

What Are Alternatives to Sharp Debridement?

Sharp debridement may not be the most appropriate method of debridement in patients suffering from severe anxiety, schizophrenia, PTSD, or other disorders, even if it is the most aggressive and necessary treatment. Seeing a scalpel can trigger feelings of fear and anxiety. Educate your patient about the different methods of debridement by demonstrating techniques and asking them about their preferences. Instead of sharp debridement, using a dressing technology that promotes autolytic debridement, an enzymatic debridement agent, or a monofilament debridement pad may be more practical.

Conclusion

Wound care patients diagnosed with pre-existing mental illness require personalized education and customized care planning and services in wound bed preparation and treatment. Wound management plans should incorporate an attempt at a variety of debridement methods to facilitate healing, reduce infection risks, and improve the outcomes of patients with mental illness disorders.

References

1. Kessler RC, Avenevoli S, Costello EJ, et al. Design, and field procedures in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A). Int J Methods Psychiatr Res. 2009;18(2):69-83. doi: 10.1002/mpr.279
2. Kaba E, Triantafyllou A, Fasoi G, Kelesi M, Stavropoulou A. Investigating nurses' views on care of mentally ill patients with skin injuries. Int J Environ Res Public Health. 2020;17(20):7610. doi:10.3390/ijerph17207610

About the Author

Cheryl Carver’s experience includes more than two decades as a wound nurse, educator, and content writer. Cheryl’s mother died at only 47 years old due to complications of diabetes and pressure ulcers; Cheryl used her pain from the loss to fuel a passion for wound care. Cheryl has contributed over 200 published white papers, ebooks, blogs, and articles both freelance and with WoundSource since 2014. Additionally, Cheryl also serves as an active Board of Directors member of the American Professional Wound Care Association (APWCA) and is a designated Master (MAPWCA), member of the Association for the Advancement of Wound Care (AAWC), and on the Speakers Bureau, the International Alliance of Wound Care Scholarship Foundation (IAWCSF) as Vice President Board of Directors, a Fellow with the American College of Clinical Wound Care Specialists (FACCWS), and an Ohio Prison Fellowship Justice Ambassador.