Refractory wounds are a significant worldwide health problem, affecting 5 to 7 million people per year in the United States alone, as discussed in previous blogs (Part 1, Part 2). Wounds that fail to heal not only impact quality of life, but also impose a significant physical, psychosocial, and financial burden. Additionally, individuals with refractory wounds often experience significant morbidity, and sometimes mortality.

Wound infections and amputations are common in this population, and chronic conditions often exist as well.¹ I previously defined and discussed refractory wounds in depth, including assessment and management of these non-healing wounds. Additionally, I identified and discussed intrinsic and extrinsic factors as they relate systemically in a stalled or refractory wound. In this blog, I will focus on iatrogenic factors, or treatment-related factors, and how these impact healing. Iatrogenic factors are treatment-related factors that compromise wound healing. Examples include trauma to the wound bed, a lack of evidence-based or appropriate wound care, and inappropriate wound care or topical treatment.¹

Inappropriate Wound Care

As mentioned in previous blogs, we must treat the whole patient, not just the hole in the patient. A treatment plan should be evidence based, individualized, and holistic. Additionally, the cause of the wound, or wound etiology, should be identified before initiating treatment because wound treatment is typically guided by the etiology of the wound. Appropriate wound management and topical therapy typically follow standards of care and/or evidence-based guidelines. This approach requires a clear understanding of the wound healing process and evidence-based topical treatment options. For example, it is important to know when to add moisture to a wound and when to remove moisture, along with understanding the presence of necrotic tissue and how and when to remove it. If a wound is too moist or too dry, healing will be impacted. Understanding and acknowledging presence or absence of infection are also important.

Additionally, if necrotic tissue or infection is present, healing will be delayed. Misuse of topical antiseptics can lead to cytotoxicity or resistance. Topical antimicrobial therapies are sometimes used as the first step in treatment of a slow-healing or stalled wound, but continued evaluation and assessment must be included in the plan of care to avoid overuse or misuse of topical antimicrobials in chronic wounds.¹

Trauma

Trauma slows wound healing and increases infection risk.¹ Additionally, repeated trauma may cause a continual initiation of the inflammatory phase in the healing cascade. Trauma in a wound may be caused by a myriad of external factors.

Examples include bumping of an arm or leg on a wheelchair rest, improper removal of dressings or adhesives, improper debridement techniques, excessive wound irrigation, and/or application of incorrect topical treatment. It is also important to remember that each time a dressing or topical treatment is removed, temperature in the wound may decrease; additionally, when a wound loses moisture, temperature may decrease. When temperature in a wound drops, healing is slowed. When identifying trauma in a wound, it is important to accurately identify and correct the cause of the trauma to promote an environment conducive to healing. Again, this reinforce the importance of treating the whole patient, not just the hole in the patient.

Conclusion

It is important to piece together all of the systemic factors impacting healing when looking at reasons why a wound is not improving within two to four weeks of evidence-based topical therapy and a comprehensive, holistic plan of care. In future blogs, we will be exploring and defining the final factor affecting tissue repair: adherence.

Reference

1. Netsch, DS. Refractory wounds: assessment and management. In: Doughty DB, McNichol LL, eds. WOCN Society Core Curriculum: Wound Management. Philadelphia, PA: Wolters Kluwer; 2016:181-197.

About the Author

Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.