The New Zealand Wound Care Society (NZWCS) shares some tips for managing wounds in older people.
Older adults are at an increased risk of developing wounds related to ageing, chronic disease and disability; often these wounds are slow or fail to heal. Care for the older adult is complex and requires a high level of knowledge and skill. The importance of applying evidence-based wound practice is imperative in this high-risk population. This in turn can reduce the risk of wound infection, pain, sleep disruption, reduced mobility, loss of independence, anxiety, depression and other associated personal and healthcare costs.
Wound infection is mostly diagnosed clinically; laboratory testing provides further information to guide management. Conduct a wound swab if there are clinical signs of infection such as an increase in wound size, delayed healing, cellulitis, malodour, or increased pain. Be aware that people who have diabetes or are immunosuppressed may show only subtle signs of infection.
Taking a wound swab
The Levine Wound Swab Technique should be used when performing a wound swab:
- This may cause discomfort so prepare the patient.
- Thoroughly rinse the wound with normal saline (non-bacteriostatic), remove pus, exudate; if within your scope of practice, remove hard eschar or necrotic tissue.
- Wait one to two minutes before taking the swab to allow wound exudates to rise to the surface.
- If the wound bed is dry, moisten the swab in sterile saline. If fresh pus or wound fluid is present, collect this.
- Rotate the swab tip in a 1cm square area of clean granulation tissue for five seconds, using gentle pressure to release tissue exudate.
- Label the swab and complete the laboratory form, including the wound site, current or recent antibiotics, and any history of multi-drug-resistant organisms.
The use of iodine in wound management
The efficacy and safety of iodine is often questioned in clinical practice. Iodine is an effective broad-spectrum antimicrobial and with the introduction of iodophors this ensures the iodine has a controlled release of low iodine concentrations and is not cytotoxic in humans.
Unlike antibiotics, iodine resistance is considered unlikely since iodine works on the cell wall. Examples of iodine used in wound care include dressings such as inadine and iodosorb and solutions such as Betadine.
Like other antiseptics, iodine can be used to prevent wound infection or a recurrence of infection in patients who are at increased risk of infection, to treat localised infection and to treat spreading infection when healing is delayed. Always check for patient allergies and contraindications when using any antiseptic.
When does a wound become chronic?
A wound is considered chronic when healing fails to occur normally and the anatomic and functional integrity of the skin is not restored in approximately one month. This can be due to a number of underlying causes, such as medical conditions or infection. Once the skin is penetrated, the natural protective defence mechanisms can be impaired and the environment becomes conducive to bacteria from the environment, the surrounding skin or from mucous membranes.
Biofilms are bacterial colonies that occur on chronically colonised or infected wounds and delay healing. At a basic level, bacteria are encased in a thick, slimy barrier of sugars and proteins and it is this barrier that protects the bacteria from threats such as antibiotics. They are highly inflammatory, and shed bacteria onto the surface of the wound, which excites an immunological response, leading to tissue damage and ongoing chronic inflammation.
The risk factors for wounds developing biofilm include: being immunocompromised; decreased perfusion; the presence of foreign bodies; hyperglycaemia; necrotic tissue; oedema; malnutrition; increased moisture levels, and repeated trauma. Excessive moisture, for example, provides the rich nutrients needed to feed the continuation and proliferation of biofilms, and the underlying cause of the excess should be corrected or managed.
Biofilms cannot be detected using a normal wound swab and are only seen by microscopy or specialised culture techniques. Swabbing using the Levine technique will only detect planktonic bacteria which are free floating bacteria that are not attached to the wound surface. It is these bacteria that are susceptible to systemic and topical antibiotics.
An international consensus asserted that cleaning a chronic wound should occur at each dressing change, removing all dressing product and wound debris. Sharp debridement is considered the most significant method in the prevention and control of biofilm. Studies have shown that after debridement, biofilm is more susceptible to antimicrobial treatment for 24–48 hours and suggest regular debridement to remove the biofilm in conjunction with topical antimicrobials.
There is a plethora of antimicrobial dressings available to clinicians for use in practice. The main groups are silver, honey and povidine-iodine and all have broad spectrum antibacterial properties.
More recently, PHMB is available in many forms with antiseptic properties. Choose a dressing that will provide antimicrobial action and matches the properties of the wound; for example, if exudate is an issue select an alginate or hydrofibre with antimicrobial properties.
The management of the bacteria-host-wound continuum should aim to keep the balance in favour of the host by minimising opportunities for bacteria to overwhelm patient defences and cause infection.
Case study: treating unstageable pressure injuries
Southern DHB Clinical Nurse Specialist – Wound Care MANDY PAGAN shares a case study in wound management.
John*, an 87-year-old gentleman, was admitted to hospital with general deterioration and unstageable pressure injuries (100% covered in necrosis) to both heels (larger than the wound in this photo). John has dementia and does not talk or mobilise and has type 2 diabetes.
In accordance with Guidelines for the management of pressure injury for an unstageable pressure injury, stable eschar (dry, adherent, intact without erythema or fluctuance) on the heels serves as the body’s natural biological cover and should not be removed.
John was discharged to a rest home with wound care follow-up. The wound regime aim was to prevent infection, pain, offload any pressure and allow the necrosis to lift naturally. Iodine impregnated into a low-adherent dressing with a soft pad held in place with soffban and light crepe was used daily to every second day. As the necrosed edges lifted naturally, these were trimmed and revealed healed skin underneath.
This process occurred from September 2015 until March 2016. John’s heels are now fully healed.
This case study demonstrates the importance of reducing pain and distress and allowing the natural removal of dry necrosed tissue. Iodine was used to keep the area dry and infection-free.
*name has been changed
You might also like to read:
- Spotlight on...Atrial Fibrillation
- "Ground-breaking" stroke treatment on offer at some DHBs
- Dementia, intimacy and sexuality in residential aged care
- interRAI proving itself in the South Island
- Full audit reports for all rest homes to be published
- Rehab fellowship marks collaborative approach to research