Managing Chronic Wounds.

Hello, my name is Cindy Broadus. I'm the Executive Director of the National Alliance of Wound Care and Osteomy. Our organization works with our sister foundation, the International Alliance of Wound Care Scholarship Foundation, to promote and enhance education and certification in wound care. Our health shared community will provide education and information that is specific to wound care for both clinicians and patients. Thank you for viewing this video and visiting our community. In this video, we will be discussing chronic wounds and strategies for their management. Wound bed preparation is a systematic approach that provides a framework for managing chronic wounds. TIMERS is an acronym that helps us to remember the framework and gives us steps for identifying the essentials in wound bed preparation. This well-established concept is helping clinicians manage patients throughout the wound care continuum. Starting with the letter T, this identifies that necrotic, devitalized, or nonviable tissue should be removed to help move the wound towards healing. The wound bed should be clear of slough and eschar. The letter I is for inflammation and infection. Wounds that are in a continuous inflammatory or infected state will not heal. Identifying and treating the infection is imperative if the wound is going to heal. The letter M is for moisture balance. Wounds require an even, balanced micro-environment, not too wet and not too dry. Various dressing technologies may be used to wick away moisture or create an optimal moist wound healing environment that's conducive for healing. The letter E is for epithelial edge advancement. Epithelialization takes place as the epithelial cells move across the wound bed towards closure. Uninterrupted wound edge advancement is crucial to wound closure. R is for tissue repair or regeneration. You need to find out what influences wound healing and apply the appropriate treatments. And S is for social factors. Patients and caregivers may require education so that they understand the disease process. Appropriate support and adherence to the plan are an important component to the wound healing process. Our next approach is wound hygiene. The concept of wound hygiene arose during an expert advisory board meeting that was held in early 2019. There, the international panel agreed that almost all hard-to-heal wounds contain biofilm, which delays or stalls healing. Wound hygiene is a four-step process that is used to clean and decontaminate wounds of biofilm and overcome the barriers they cause. So let's take a look at this process. First we cleanse. Cleansing the wound will disrupt the biofilm and remove excess exudate, dressing residual, foreign debris, and devitalized tissue. Cleansing the periwound will decontaminate the area and remove dead skin and calluses. When cleansing, use as much physical force as the patient can tolerate. You also want to cleanse 10 to 20 centimeters away from the wound edges and change the cloths to prevent cross-contamination. It's recommended to use cleansers with antiseptics that have surfactants or pH-balanced solutions. The next step is debridement. Debriding the wound will remove dead, devitalized tissue and progress a wound into healing. Debridement should be performed every time the wound is managed. The debridement method used will be based on the wound bed and the periwound appearance as well as the patient's tolerance. Mechanical debridement can be effective in disrupting and removing biofilm. The third step is refashioning the wound edges. The wound edges of full thickness wounds are where biofilm is most active. Removing necrotic, crusty, and or overhanging wound edges will facilitate the alignment of skin edges with the wound bed to help facilitate epithelial advancement and contraction. The final step is dressing application. Residual biofilm should be addressed with dressings that contain antimicrobials or antibacterials. This will help prevent or delay the regrowth of biofilm. Utilizing the wound hygiene regimen will reduce continuous inflammation, infection, and promote wound healing. The presence of biofilm and infection are the most common causes of delayed healing. The wound hygiene concept provides a systematic and consistent early intervention approach and optimizes healing. You see, disrupting and preventing biofilms will assist in reducing infection and decrease the need for antibiotic therapy or antimicrobial dressings, and it supports antimicrobial stewardship. Identifying and treating all potential underlying factors in all wound ideologies is paramount in overall healing. Lastly, in this video, we'll discuss full thickness wound healing. Chronic wounds are full thickness and will heal in a series of stages. These stages of wound healing proceed in an organized way and follow four processes. hemostasis, inflammation, proliferation, and maturation, also called remodeling. Although the stages of wound healing should follow and organize in timely fashion, wounds can progress backward or forward depending on internal and external patient conditions, and they can be overlapping. Wounds that do not follow this systematic process may become stalled and lead to wound chronicity. The four stages of wound healing start with hemostasis. Hemostasis is the first phase of healing, and it begins at the onset of injury, and the objective is to stop the bleeding. In this phase, the body activates its emergency repair system, which is the blood clotting system, and it forms a dam to block the drainage. During this process, platelets come into contact with collagen. This results in what's called activation and aggregation. An enzyme called thrombin is at the center of this. It initiates the formation of a fiber mesh, which strengthens the platelet clumps into a stable clot. The second phase is the inflammatory phase. During phase two, neutrophils, which are a type of white blood cell, enter the wound to destroy bacteria and remove debris. These cells often reach their peak population between 24 to 48 hours after the initial injury. They reduce greatly in number after about three days. As the neutrophils leave, Specialized cells called macrophages arrive to continue clearing the debris. These cells also secrete growth factors and proteins that attract immune system cells to the wound to facilitate tissue repair. This phase typically lasts about four to six days and is often associated with edema, erythema, which is reddening of the skin, heat, and pain. Once the wound is cleaned out, the wound enters into the third phase known as the proliferative phase. The objective of this phase is to fill and cover the wound. The proliberative phase features three distinct stages, fill the wound with granulation tissue, contraction of the wound margins, and covering the wound with epithelial cells, called epithelialization. During the first stage, shiny, deep red granulation tissue fills the wound bed with connective tissue and new blood vessels are formed. During contraction, the wound margins contract and pull toward the center of the wound. In the third stage, epithelial cells arise from the wound bed or margins and begin to migrate across the wound bed until the wound is covered with epithelium. The proliferative phase often lasts anywhere from 4 to 24 days. The final phase is the maturation or remodeling phase. In this phase, the wound remodels and increases its tensile strength. The scar starts to lighten up and flatten out as the collagen begins to realign and build some strength. This phase can last up to two years. Remember, even though the wound has closed, it will never have the strength that it had prior to the wound, as it will only be about 80 percent of its previous strength. Chronic wounds are hard to heal, but with a systematic approach, diligent management, and appropriate treatments applied, these wounds can be healed more timely and with less negative outcomes. Thank you for viewing this video. We hope you found it to be informative and helpful.