Wound Care Challenges: Physical Therapy Strategies to Support Healing

Four questions may guide you in assigning etiology of areas of the trunk where moisture may be a contributing factor. Do you know what they are?

Physical therapy modalities of ultrasound, E-stim, and sharp debridement allow for aggressive treatment of wounds. Some deficits may occur in etiology treatment of skin issues traditionally not managed by therapists, such as moisture-associated skin dermatitis.

Four questions may guide you in assigning etiology of areas of the trunk where moisture may be a contributing factor:

  1. Where is the wound located on the body?
  2. What is the appearance of skin/wound?
  3. What is the clinical history?
  4. What are the best treatment options?

Below are examples of the answers to these questions as well as treatment options per four etiologies of the trunk.

Incontinence-Associated Dermatitis

  1. Location
    • Perineal, buttocks, thighs
  2. Appearance
    • Superficial
    • With or without fungal component
  3. History
    • Persistent or recurrent incontinence
    • Fecal and/or urinary
  4. Treatment Options
    • Resolve incontinence when possible through toileting, thickening stool, eliminating aggravating factors
    • Contain incontinence through super absorbent polymer (SAP) briefs/pads
    • Protect/treat skin through emollients (lanolin, mineral oil, petroleum types) or crusting applications (copolymer powders & skin barrier wipes/sprays)

Intertriginous Dermatitis

  1. Location
    • Base of body fold
    • Opposing surfaces of body fold
  2. Appearance
    • Linear opening/break in the skin
    • Shallow kissing lesions
    • No ischemia
  3. History
    • Diaphoresis
    • Trapped moisture
  4. Treatment Options
    • Separate wet skin folds
    • Use wicking products for weeping skin folds
    • Drying powders or skin barrier wipes

Friction

  1. Location
    • Fleshy skin areas in contact with linens, bed, or chair
    • Heel or area that rubs against linen, etc.
  2. Appearance
    • Skin moist or fragile
    • Serous blister over heel
    • No ischemia
  3. History
    • Patient restless
    • Fragile skin
    • Frequent perineal cleansing
  4. Treatment Options
    • Manage moisture
    • Protect skin in agitated patients
    • Emollients or skin protectants for prevention/treatment
    • Early recognition

Pressure Ulcer

  1. Location
    • Over bony prominence
    • Under medical device
  2. Appearance
    • Defined edges
    • Tissue ischemia
  3. History
    • Periods of immobility
    • Compression by device
  4. Treatment Options
    • Redistribute pressure and envelopment within a surface
    • Moisture management via surface & wicking products
    • Debridement
    • Infection prevention/treatment
    • Nutrition

This blog was brought to life by PESI speaker and author Kim Saunders, MSN/ED, RN, CWON®, CFN. Kim Saunders has 18 years as a wound, ostomy, and continence expert in home health, acute care, hospice, and outpatient settings. Kim consults for patients related to wounds, ostomy, and incontinence-associated dermatitis. Her experience includes healthcare system-projects related to bed, stretcher, and wheelchair surfaces as well as system processes for skin and wound issues. She also is a co-owner of WOC Consulting, LLC.


Our new Intensive Skin and Wound Care Course will have you feeling confident treating patients regardless of where you’re practicing right now or where you might be practicing in the future.

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The 3 Most Important Questions When Treating a Wound

Assessing a wound is never just about the ‘Polaroid’ picture. The skin being the largest organ, doesn’t fail on its own. It is affected by other factors. Thus, when treating a wound, start with 3 important questions…

Assessing a wound is never just about the ‘Polaroid’ picture. The skin being the largest organ, doesn’t fail on its own. It is affected by other factors. Thus, when treating a wound, you need to start with 3 important questions:

1. What is the wound etiology? Four examples can occur on the perineal/sacral/trunk area of the body and can be confused when assigning etiology.

  • Pressure ulcers present as well-defined edges caused by an ischemic injury to the tissue over the bone or under a medical device. They are bottom up tissue injuries that usually take longer to heal than superficial top-down injuries.
  • Moisture-associated skin damage occurs peri-stomal, peri-wound, incontinence-associated, or intertriginous dermatitis (skin folds). This top-down, irregular-edge skin damage occurs from hyper-hydrated skin. Primary goals including moisture containment and prevention/treatment of skin.
  • Friction is top-down superficial skin damage caused by the skin rubbing against something else. It can present like a blister from a shoe, or it can present initially like a patchy, irregular-edge appearance on the fleshy part of the buttocks as they rub on the bed-sheet.
  • Shearing is bottom-up damage caused by blood vessel distortion. It presents with irregular edges, often linear in the direction of the damage, and is the culprit of undermining in pressure ulcers.

2. The next question should focus on the patient as a person: What are the ‘life goals’?

  • Is the patient palliative care or hospice? If so, your goals should focus on quality of life: minimize trauma, control odor, manage excess exudate, prevent deterioration & infection, and optimize pain management.
  • There are many topical wound products that can assist in this management to support any systemic medication needed.

3. Thirdly, what are the wound healing goals (comfort, maintenance, healing)?

  • Comfort is the usual goal at end of life. Focus on goals for palliative care, and keep wound care simple.
  • Maintenance is the goal when healing is unlikely because we are unable to correct the etiology. Focus on preventing infection and monitor wound presentation. Manage wound exudate. Use passive dressings such as alginates, foams, gels, etc.
  • Healing is the usual goal with a comprehensive approach of etiology, systemic support, and topical therapy per wound presentation. Measure weekly and consider active therapies that change the tissue, add a matrix, or promote angiogenesis if wound size doesn’t progress by 30-40% in 3-4 weeks.

Of course there are more questions in the assessment of a wound and the etiology work-up. However, these three questions are foundational in the next steps of diagnostics, topical and/or systemic treatment, and possible referrals.


CASE EXAMPLE:  A 76 year-old man with a sacral stage IV pressure ulcer is a full code. Diagnostics reveal he has sacral osteomyelitis. The patient does not desire surgery or antibiotics intravenously. He is not palliative care. His wound goals are maintenance because wound healing is unlikely due to the inability to correct/treat the osteomyelitis. Thus, our goals are to prevent symptomatic infection (pain, induration, fluctuance, odor) through passive dressings that manage drainage and address local bacterial count as needed (methylene blue/gentian violet dressings, silvers, manuka honey). Contraindicated active/adjunct therapies include negative pressure wound therapy (angiogenesis), bioengineered skin grafts, or collagen products (matrix and tissue changes). Monitor wound presentation and alter topical wound dressing as needed.


Always remember…

Skin and wound assessment can be challenging and rewarding at the same time. The wound bed and skin presentation will give you hints as to its needs; You just have to be able to interpret the presentation and know the products that will help you achieve wound bed homeostasis.


This blog was brought to life by PESI speaker and author Kim Saunders, MSN/ED, RN, CWON®, CFN. Kim Saunders has 18 years as a wound, ostomy, and continence expert in home health, acute care, hospice, and outpatient settings. Kim consults for patients related to wounds, ostomy, and incontinence-associated dermatitis. Her experience includes healthcare system-projects related to bed, stretcher, and wheelchair surfaces as well as system processes for skin and wound issues. She also is a co-owner of WOC Consulting, LLC.


Our new Intensive Skin and Wound Care Course will have you feeling confident treating patients regardless of where you’re practicing right now or where you might be practicing in the future.

LEARN MORE

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Q and A: Venous ulcers with concurrent lymphedema

Have you ever treated that wound that you just can’t get to heal even with proper assessment and treatment? There are always those few wounds that challenge our skills, and without a solid understanding of the complexities of mixed etiology, we may actually cause harm. Here are the three most commonly asked wound care questions by clinicians…

Venous ulcers account for 70-90 percent of all lower extremity ulcers in the United States. In addition, upwards of one million of these venous patients have concurrent lymphedema. In spite of this staggering statistic, most will heal well with proper assessment and treatment.

There are, however, those few wounds that challenge our skills, and without a solid understanding of the complexities of mixed etiology, we may actually cause harm. Here are the three most commonly asked wound care questions by clinicians…

Q. I routinely use compression on my venous ulcer patients with good success. This week, however, when I removed a four layer compression wrap, my patient had blistered in multiple places. What could have caused this?

Barring any sensitivity to the cast padding layer, the most common reason for blistering under compression is an underlying diagnosis of lymphedema. While venous wounds respond exceptionally well to this type of compression (known as long stretch wraps), lymphedema will worsen.

Long stretch means the wrap is giving constant and continual compression. Fragile lymphedema channels will be cut off from normal flow causing a backup of lymph leading to blisters. Patients with lymphedema should only use short stretch wraps which give compression only when the patient is walking; at rest there is no compression allowing for proper lymphatic drainage.

Q. How can I tell if my patient has lymphedema?

A simple test called the Stemmer Sign is a quick assessment tool. An inability to pinch a fold of skin at the base of the second toe is indicative of lymphedema.

Q. I have tried multiple topical antimicrobials, even those able to kill MRSA and VRE, and still my patient’s wound looks dull with no bright, beefy granulation. It has a thin vail of yellow slough throughout the bed. My patient has had this wound for over 10 years. She has good arterial flow, yet compression for over 4 weeks has yielded no result. What could be wrong?

Chronic wounds often develop a biofilm. Biofilms are bacteria and fungi encapsulated in a thick, sticky barrier made of polysaccharides and proteins. These protect the bacteria from external threats and attach it to the wound surface rendering antimicrobials and wound cleansing ineffective. The only way to eliminate them is with low frequency ultrasound treatment or surgical debridement.


Have more questions about venous disease and lymphedema? Get the answers in this FREE 2 hour CE Seminar: Venous Disease & Lymphedema Assessment and Treatment Strategies. BONUS: Get up to 1.8 free CE Hours for watching.

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This blog was brought to life by PESI speaker Cheryl Aaron, PT, DPT, CWS. Cheryl has over 36 years of hands-on experience in physical therapy and wound care. Her clinical practice, specializing in all aspects of wound care, has encompassed a variety of settings, including: acute care, subacute, long-term care, and private practice. In her current role, she is responsible for the educational and consultation needs for multidisciplinary professionals. She established an advanced wound management program and is responsible for clinical competency within the wound care team for nursing and physical therapy staff.