When developing the plan of care for the patient with a chronic wound, it is imperative first to look at the "whole" patient and not just the "hole" in the patient.¹ As we do, we are able to review any medical conditions or disease states that may affect wound repair and healing. Millions of Americans are affected by chronic wounds each year. These wounds include causes such as diabetic foot ulcers, venous leg ulcers, arterial insufficiency, and pressure ulcers. Common comorbid conditions that can affect healing include diabetes, venous insufficiency, peripheral arterial disease, cardiopulmonary and oxygen transport conditions, immune deficiencies, and dementia.² This discussion is focused on these conditions and factors that contribute to chronic wounds and their management.

Common Diseases That Lead to Chronic Wounds

Diabetes and Wound Healing

Persons with diabetes often have slow-healing wounds. It is the lack of glycemic control that can lead to loss of protective sensation or neuropathy, which in turn can cause repetitive trauma resulting in wounds. The effects of hyperglycemia, or uncontrolled glycemic levels, alter white blood cell function and increase the risk for infection. An article by Dangwal and associates³ explains that multifactorial pathways including peripheral arterial disease, peripheral neuropathy, a chronic inflammatory state, and altered cellular function contribute to wounds in the diabetic patient to enter a state of chronicity. Diabetes also affects other body systems that all play a role in wound healing; therefore, focused glycemic control is essential to the promotion of healing.

Venous Insufficiency and Venous Ulcers

Venous insufficiency occurs as a result of venous hypertension and can progress to severe skin changes often leading to venous leg ulcers, the final complication of chronic venous disease.⁴ Venous ulcers comprise a common lower extremity vascular disorder of great medical and socioeconomic impact, affecting millions of people worldwide. These chronic ulcers account for approximately 70% to 80% of all lower extremity wounds. The recurrence rates for venous ulcers are very high, upward of 90%. This is because venous disease and venous hypertension are lifelong conditions requiring lifelong management.

Venous ulcers many times seem to be locked or stalled in a persistent inflammatory state, which prevents normal progression through the phases of wound healing and furthers their chronicity.⁵ The reflux and obstruction associated with chronic venous disease lead to progression of the disease and ultimately ulceration. Although genetic and environmental factors influence the predisposition to venous disease, the venous obstruction and reflux lead to chronic increased ambulatory venous hypertension. The cycle continues, and management of venous ulcers requires not only comprehensive wound management, but also lifelong compression therapy.

Peripheral Arterial Disease, Cardiopulmonary Disease, and Oxygen Transport Conditions

Peripheral arterial disease, cardiopulmonary disease, and oxygen transport conditions, such as chronic obstructive pulmonary disease, are all intertwined because they affect blood flow, cellular oxygen delivery, and carbon dioxide removal. For wounds to heal, a good functioning vascular system is necessary to carry the oxygen and nutrients to the tissues. Peripheral arterial disease accounts for chronic wounds because of insufficient perfusion and is present in approximately half of all patients with foot ulcers. This decreased blood flow combined with minor trauma leads to injuries and chronic wounds in the extremities. Peripheral arterial disease, in its severity, can be limb- and life-threatening.⁶

The simplest trauma to an extremity with poor arterial flow can quickly become a disaster. This ischemic condition can lead to hypoxia, and without blood flow and oxygen, tissue begins to die and a wound begins to form. The primary focus in management of the patient with an arterial ulcer consists of assessing and determining the perfusion status in the affected limb. Adequate perfusion or improving perfusion is key to the healing potential of the wound because the ability to heal is directly correlated with the ability to provide sufficient oxygen and nutrients to support the repair and healing process.

Assessment and Formulation of the Wound Care Treatment Plan

Once the assessment for perfusion is performed, it may be determined that the perfusion in the limb is compromised but is adequate for healing. The expectations would need to be set with the patient and the caregiver, as well as the clinician, that progress toward healing may be slow.⁷ Key areas to the treatment plan include the following:

• Protecting the limb from any undue trauma
• Avoiding extreme cold temperatures and keeping the limb insulated, so that the blood vessels are not constricting and that they remain patent
• Maintaining the limb in a slightly dependent position, by using the forces of gravity to assist with distal blood flow (Often, the dependent position is the one the patients find most comfortable.)
• Maintaining an optimal moist wound environment when looking at product choices and dressing selection.
• Treating any infection or potential contamination because blood flow is compromised, as is the immune response
• Considering debridement when it is appropriate (Note: Dry stable eschar should not be debrided on heels or distal extremities because it serves as a biological dressing when no evidence of infection is present.)

Other Factors Contributing to Chronic Wounds

Immune deficiencies play a role in chronic wounds, since without a functioning immune system the body will not be able to proceed through the normal inflammatory phase of wound healing. Immune deficiencies not only affect inflammation, but the proliferative and maturation phases of wound healing as well. The immune system is our defense against infection, and when a wound becomes infected the healing process again gets altered and healing slows or stalls. As stated earlier, this typically occurs in the inflammatory phase of healing.⁸

As people age, their immune systems naturally become weaker. For this reason, older people are more susceptible to infection. Additionally, poor immune function can mean a higher risk of other chronic diseases that can negatively affect the body's ability to heal, such as conditions that restrict circulation and oxygenation to the affected area. The aging process alone can have an impact on wound healing and skin health and chronic wounds disproportionately impact older adults. This substantially impacts morbidity and mortality of millions of older adults in the United States. Also, the surgery rate is higher in older adults, placing them at higher risk for wound complications and infections.² Also affecting older adults is dementia, which can play a role in the patient's ability to follow the plan of care. Based on the degree of dementia, these patients may not be able to care for themselves at all. Even with minor impairment, the information provided in a verbal conversation may not be well understood The list could go on and on. The point is to make sure you are assessing the health status and disease state of a patient and consider these factors as you develop treatment plans and goals for taking care of a wound.

References

1. Johnson S. Five steps to successful wound healing in the community. J Community Nurs. 2015;29(4):30–9. Available at: https://www.jcn.co.uk/journal/08-2015/wound-management/1761-five-steps-…. Accessed March 6, 2018

2. Gould L, Abadir P, Brem H, et al. Chronic wound repair and healing in older adults: current status and future research. Wound Repair Regen. 2015;23(1):1–13. doi: 10.1111/wrr.12245. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4414710/. Accessed March 13, 2018

3. Dangwal S, Stratmann B, Bang C, et al D. Impairment of wound healing in patients with type 2 diabetes mellitus influences circulating micro RNA patterns via inflammatory cytokines. Arterioscler Thromb Vasc Biol. 2015;35(6):1480–8. doi: 10.1161/ATVBAHA.114.305048. Available at: https://insights.ovid.com/arteriosclerosis-thrombosis-vascular-biology/…. Accessed March 6, 2018

4. Ligi D, Croce L, Mosti G, Raffetto JD, Mannello F. Chronic venous insufficiency: transforming growth factor-β isoforms and soluble endoglin concentration in different states of wound healing. Int J Mol Sci. 2017;18(10):1–11. doi:10.3390/ijms18102206. Available at: http://www.mdpi.com/1422-0067/18/10/2206. Accessed March 13, 2018.

5. Raffetto JD. Pathophysiology of chronic venous disease and venous ulcers. Surg Clin North Am. 2018;98(2):337–47. doi: 10.1016/j.suc.2017.11.002. Available at: https://www.sciencedirect.com/science/article/pii/S0039610917301974. Accessed March 13, 2018.

6. Gulati A, Garcia L, Acharji S. Epidemiology of chronic critical limb ischemia. In: Dieter R, Dieter RA, Nnjundappa A, eds. Critical Limb Ischemia Acute and Chronic. Basel, Switzerland: Springer; 2017:671. Available at: https://link.springer.com/chapter/10.1007/978-3-319-31991-9_2#citeas. Accessed March 13, 2018.

7. Federman DG, Ladiiznski B, Dardik A, et al. Wound Healing Society 2014 update on guidelines for arterial ulcers. Wound Repair Regen. 2016;24:127–136. doi:10.1111.12395. Available at: http://onlinelibrary.wiley.com/doi/10.1111/wrr.12395/full. Accessed March 13, 2018.

8. Advanced Tissue. Immune system and wound healing. 2018. Available at: https://www.advancedtissue.com/the-immune-system-and-wound-healing/. Accessed March 13, 2018.