Wound treatment 101

Legal nurse consultants will encounter many medical records that detail types of wound treatment.

Hyperbaric oxygenation, negative pressure wound therapy, surgical closure, debridement, and topical dressings are all treatment options for wounds. A combination of these modalities may be utilized to treat a wound. Virtually all wound treatment regimens incorporate the utilization of a topical dressing.

Wound Treatment Options Hyperbaric Oxygenation

Hyperbaric oxygenation therapy delivers oxygen under pressure, systemically and intermittently. Oxygen carrying and oxygen delivery capabilities of the blood are enhanced. Circulation to compromised areas and cellular function may be restored.

In wound healing, the result is increased wound site oxygen. Hyperbaric oxygenation is not appropriate for everyone. This wound treatment is contraindicated in individuals with conditions that may trap oxygen or pose a risk for oxygen toxicity.

A patient who has a history of receiving bleomycin is not a candidate for hyperbaric oxygenation therapy related to the increased risk for oxygen toxicity. Hyperbaric oxygen therapy is not a primary wound treatment modality.

Negative Pressure Wound Therapy

Another wound treatment option is negative pressure wound therapy. This treatment option is believed to reduce localized edema, to reduce bacteria, and to help the wound to close while providing a moist wound environment.

Reducing localized edema increases localized blood flow and promotes the formation of granulation tissue. Negative pressure wound therapy helps the body to heal itself. A candidate for negative pressure therapy must have the physiological capacity to heal.

Contraindications for this type of therapy are those patients whose wounds contain nonviable tissue, who have untreated osteomyelitis (bone infection), and whose wound margins have malignancy. As a result, utilization of negative pressure therapy is limited.

Surgical Wound Closure

Surgical wound closure is also a limited wound treatment modality. The ideal candidate is nutritionally sound, free of wound infections, and possesses granulation tissue at the wound base along with new epithelialization (skin formation) at the wound margins. Surgical closure is typically a treatment modality for wounds caused by pressure.

Debridement

Debridement is the removal of nonviable tissue and foreign matter from the wound. This process may occur naturally. Debridement occurring naturally as a result of the wound repair process is referred to as autolysis (body digests its own tissue). Other mechanisms of debridement include chemical, mechanical, and sharp.

Chemical debridement removes tissue through the use of chemicals or enzymes. One form of enzyme debridement is maggot therapy. Maggot therapy debridement is primarily reserved for those instances when other treatments have failed. Multi-resistant strains of bacteria, however, have sparked a new interest in this therapy.

Maggot therapy involves placing sterile larvae into the wound bed. It is believed maggots secrete enzymes that liquefy dead tissue and maggots actually ingest the tissue. The end result is a clean wound that has been disinfected and has been stimulated to heal. The larvae need to be restricted to the wound bed.

This can be accomplished by utilizing dressings devised for maggot therapy, such as a hydrocolloid dressing, a mesh net, and an absorbent pad. While maggot therapy may be effective, the therapy may create a sense of revulsion in the individual to who the maggots are applied.

Mechanical debridement removes tissue by means of dressings, irrigation, and whirlpool. Debridement, in general, may be classified as selective or non-selective. Selective debridement involves the removal of only nonviable tissue. Mechanical debridement is considered non-selective as both viable and non-viable tissue is removed.

Sharp debridement can be further categorized as conservative and surgical. Conservative sharp debridement involves the removal of loosely adherent, nonviable tissue. On the other hand, surgical debridement may be an aggressive form of debridement. Typically, large amounts of tissue are removed.

Conservative sharp debridement is considered selective debridement in that only non-viable tissue is removed. As a result of this selectiveness, conservative sharp debridement is also considered to be painless. This particular type of debridement is frequently performed at the bedside and in outpatient wound care clinics.

Surgical debridement may also be performed at the bedside and in outpatient wound care clinics under a local anesthetic. Because surgical debridement may be painful, a local anesthetic is administered. In most instances, however, surgical debridement is performed in the operating room under general or spinal anesthesia.

Topical Dressings

Topical dressings are the treatment of choice for most wounds. Correct dressing choice and utilization will facilitate wound healing. Algorithms, flow charts, clinical pathways, and decision trees have all been developed to assist clinicians in the appropriate dressing identification process.

Generic dressing categories exist with design and performance variations present in each generic category. One such generic category possessing variations is hydrocolloid wound dressings. Variations within this particular category include the ability to absorb exudate, the absorbency capacity, the adhesive strength, and the thickness of the dressing.

Thus, it is imperative for the clinician to utilize a dressing whose performance parameters are tailored to meet the specific wound characteristics and requirements to facilitate healing. Nurses specializing in wound care management are the ideal resource for dressing selection.

This information is from “Wounds and Burns” by Kelly Jaszarowski, MSN, RN, CNS, ANP, CWOCN in Pat Iyer and Barbara Levin (Editors), Medical Legal Aspects of Medical Records.

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