Introduction

Wound bed maintenance is the process taken by the bedside clinician or nurse to create or preserve the wound environment at optimal conditions and thus encourage the chronic wound to move to a state of closure or healing. Critical thinking skills require a trained eye focused on the characteristics of the wound to move a chronic wound in to a healing phase and ultimately wound closure. The goal of every assessment and encounter includes promoting positive wound characteristics while suppressing negative wound characteristics. This can often feel like a balancing act with not much wiggle room, yet knowing the basic principles of wound healing can help the wound get closer to the finish line.

Wound Bed Preparation Principle 1: If it is wet, dry it

If a wound has too much drainage, the wound healing process can stall out.¹ Too much drainage can lead to non-viable tissue, infection, and the wound’s inability to heal. Look at the underlying cause of the excessive drainage. Perhaps the wound has infection or is stuck in the inflammatory phase of wound healing. Pick a dressing or device that helps you maintain the moisture balance in the wound without allowing drainage to pool in the wound bed. Consider highly absorptive dressings such as calcium alginate, abdominal (ABD) pads, or foam, for example. Perhaps utilizing negative pressure wound therapy to manage drainage while decreasing dressing changes would be ideal for this exuding wound. Maintaining moist wound healing is our goal. This helps maintain the periwound as well because too much drainage can damage the periwound tissue.

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Wound Bed Preparation Principle 2: If it is dry, moisten it (when not contraindicated)

If a wound is too dry, it becomes difficult for cells to move or proliferate across the wound bed.¹ If this is the case, reach for a dressing that contributes moisture. Great examples are hydrogels or hydrocolloids. Other dressings help wick moisture away while maintaining a moist wound healing environment, such as certain composite dressings. Wounds contraindicated for moisture contribution would be wounds with dry gangrene. If you make dry gangrene moist, it can turn to wet gangrene and spread. Arterial wounds or diabetic wounds with extremely poor perfusion and oxygenation can sometimes be a concern with too much moisture because wet gangrene can easily move into these wound types as a result of the anoxic environment and encourage anaerobic bacteria to take hold.²

Wound Bed Preparation Principle 3: If it is moist, cover and protect.

If you have a moist wound bed with clean, healthy granulation tissue, cover and protect that wound. It is in a state where the best wound healing can occur, so let the wound healing begin! Once a wound reaches the moist wound healing phase, encourage the tissue to continue to form and grow. Perhaps collagen is needed to continue the granulation tissue deposition. Calcium alginate or foam can be used to maintain a moist healing environment and, with the longer wear time of both of these products, can even be left in place for up to a week for most products in these categories.

Wound Bed Preparation Principle 4: Restore blood flow when possible

For wounds in a patient with arterial disease or possible occlusion, refer to a vascular surgeon. It is no secret that wounds need oxygen and nutrients to heal. Blood carries oxygen and nutrients to tissue that surrounds the wound bed. No blood flow, no oxygen. No oxygen, no wound healing. It is worth a consultation with a vascular specialist to determine whether blood flow can be enhanced or restored.

Wound Bed Preparation Principle 5: Identify infection and treat

As science continues to evolve when it comes to infection, so does our ability to identify and treat. The Centers for Medicare & Medicaid Services have listed in their Regulations and Guidance since at least 2004 that “superficial swab may show the presence of bacteria but is not a reliable method to identify infection.”³ It is recognized and reported in studies that a quantitative tissue culture obtained from the wound bed is the gold standard to obtain accurate wound culture results.⁴ Technology has evolved past traditional pathology as well. Polymerase chain reaction (PCR) is molecular testing utilizing DNA sequencing and reporting only the bacteria causing a problem in the wound bed, versus bacteria that is colonized. Taking it one step further, PCR testing can also determine whether a particular strain of bacteria is resistant or becoming resistant to certain types of antibiotics, thus allowing the prescribing physician or practitioner to avoid contributing to the antibiotic resistance dilemma when possible. Often, PCR tests can provide results in a matter of hours versus traditional cultures and sensitivity tests that can take days to show results.⁵

Wound Bed Preparation Principle 6: Remove non-viable tissue when possible

There are many different forms of debridement available to help keep wound beds free of non-viable tissue.⁶ Some methods of debridement are fast, such as sharp debridement. Some methods of debridement can be slow, such as enzymatic or autolytic debridement. Certain debridement options spare healthy tissue and work only on non-viable tissue. Two examples of this are enzymatic debridement and biotherapy (maggots). Autolytic debridement facilitates the body’s own endogenous enzymes to clean up the wound bed. Selective debridement targets only non-viable tissue. Mechanical debridement uses force to debride and is non-selective, so it may remove devitalized tissue and viable tissue as well as debris. Synergistic debridement combines more than one method of debridement and utilizes them together. Synergistic debridement can accelerate wound healing and reduce the quantity of necrotic debris built up in between wound assessments.⁷

Conclusion

Maintaining the wound bed in a healthy state is important to progress the wound to closure. The basic principles of wound healing can be followed using multiple modalities that can be and should be used concurrently. These principles are important when wound maintenance or wound closure by secondary intention is the goal.

References

1. Verdon A. Mythbuster: ‘I need to let the air get to this wound’ Nurs Pract. https://www.nursinginpractice.com/clinical/mythbuster-i-need-to-let-the…. Accessed June 17, 2021.
2. Buttolph A, Sapra A. Gangrene. Treasure Island, FL: StatPearls; 2021. https://www.ncbi.nlm.nih.gov/books/NBK560552/. Accessed June 17, 2021.
3. Centers for Medicare & Medicaid Services. Regulations and guidance. In: CMS Manual System. US Department of Health and Human Services; 2004:22. https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Down…. Accessed June 17, 2021.
4. Stallard Y. When and how to perform cultures on chronic wounds? J Wound Ostomy Continence Nurs. 2018;45(2):179-186. https://www.nursingcenter.com/ce_articleprint?an=00152192-201803000-000…. Accessed June 17, 2021.
5. Dowd SE, Wolcott R. Molecular diagnosis: a new era in wound care. Todays Wound Clin. February 2021. https://www.todayswoundclinic.com/molecular-diagnosis-a-new-era-wound-c…. Accessed June 17, 2021.
6. Debridement Clinicians Resource Guide. Accessed June 17, 2021.7. file:///C:/Users/Martha%20R%20Kelso/Downloads/permissive-maintenance-debridement-the-role-of-enzymatic-debridement-in-chronic-wound-care.pdf. Accessed June 17, 2021.
7. Hill R, Rennie MY, Douglas J. Using bacterial fluorescence imaging and antimicrobial stewardship to guide wound management practices: a case series. Ostomy Wound Manage. 2018;64(8):18-28. https://www.o-wm.com/article/using-bacterial-fluorescence-imaging-and-a…. Accessed June 17, 2021.