Wound care: something old and something new

1 September 2009

FIONA CASSIE talks to Victoria’s doyenne of wound care, Jan Rice*, about new wound science, old-fashioned wound cleaning, and eating to heal.

Wound care is not rocket science, but it definitely is science.

The army of cell platoons mobilised in response to a wound – and the elaborate web of signals they send each other to guide the healing process – is complex to say the least.

Jan Rice is a wound care nurse specialist and more than comfortable with discussing the usual suspects of macrophages, fibroblasts, and platelets but also anti-inflammatory cytokines, matrix metalloproteinases, and the some of the mindboggling 300 growth factor substances now discovered that trigger and direct cellular function.

After decades of specialising in the field, and being brought in as consultant to the most challenging of chronic wounds, Rice knows how important it is to learn the science behind healing.

“We have to know what is normal to be able to recognise what is abnormal.”

So to know the cellular process in the phases of healing – from blood clotting and inflammation through to granulation and final epithelialisation – is to have insight when the right cells or ingredients are missing in action or the cellular signals have gone haywire and the wound has failed to move on to the next healing phase.

She does not expect fellow nurses to be leading the science – the scientists are still struggling to work out when and how to use growth factor substances to aid healing – but does advocate knowing the science that can help guide clinical practice.

That science includes research showing that patients taking anti-coagulants are more at risk of haematoma, or that macrophages (the very important “boss” scavenger and cleaning cell) are less efficient in diabetics, or that if inflammation goes beyond 72 hours, then something is likely to have gone wrong at the start of the healing process.

When informed observation doesn’t give you the answer, a blood test often can.

“I say blood is the essence of life, and if a wound isn’t healing, do a blood test and then go back and take a look at the bigger picture of the person.”

As the health professional’s role is to help restore the person both physically and mentally to be in the best shape to heal (her keynote address on Wound management – do we have the answers yet? can be found under wound education at her website www.worldofwounds.com)

Rice says correct wound bed preparation (including a thorough cleansing of the wound) is also important in giving a wound the best chance to heal.

She says though it still remains controversial, the pendulum has swung back against the gentle cleansing by swabbing taught in the 1990s. “We need to get a bit rougher,” says Rice.

“When we first learnt about moist wound healing, we were taught to be gentle with the wound, and we’re told ‘it’s trying to heal and you are traumatising it’.

“But we need now for people to go back and give [the wound] a good clean and that might require a bit more pressure and a bit better technique.”

Of course, if it is going to be painful, give your patient something first.

The research shows it is not necessary to clean a wound with saline – if the water is safe to drink, it is safe to clean a wound.

The water should also be warm as it is less painful and cold saline or water can shut down healing cells when they are most needed. She says they now recommend that the majority of wounds be cleaned in the shower or in a bucket of warm water.

The choice of dressing is also important. By looking at the tissue, a decision can be made on what the tissue needs. For example, if there is necrotic tissue that needs debriding, a dressing can be used that aids the debriding process.

The range of dressings available can be mindboggling and expensive but Rice points out you don’t need to have them all – just the ones that work best for you in your setting. “You only need to have about seven dressings.”

“The big thing is that nurses need to understand how the dressing works – its functionality – more than knowing just the name.”

She also reminds that it’s not the dressing that heals the wound but the body.

“If you have the most expensive, best dressing on the market and a malnourished body, the wound is not going to heal.”

Rice says there is lots of evidence now on the role of nutrition in healing.

“They say that a minor trauma (small wound) increases our basal metabolic rate (BMR) by ten per cent and severe burns increase your BMR by 100 per cent.”

“For a nasty wound to your leg, you may need 40 per cent more nutrition because you are going to need all that energy to heal.” Therefore, that means more vitamin C, more protein, more zinc, and all the other components of good nutrition.

Rice says the best analogy is that while a patient may appear to just be lying in bed, their body is doing the equivalent of a marathon in working to heal their wound.

 

General principles of wound management

• Define aetiology: have a name for the wound type, hopefully with some evidence to back its pathology.

• Control, when possible, known factors influencing healing.

• Select appropriate wound care product, device, or treatment regime based on site, size, • volume of exudate, tissue type, and aim.

• Plan for maintenance of healing or current state and make no worse.