MANAGEMENT OF �NON-HEALING ULCERS

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

1. Definition
2. Causes
3. Management
4. Treatment
5. Precautions
6. Adjuncts
7. Palliative Care

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Content

Wound Care Training Module - National Wound Care Committee

Content

Wound Care Training Module - National Wound Care Committee

DEFINITION

• Any wound that has no signs of healing process within 2-4weeks after intervention by proper wound management team.

Wound Care Training Module - National Wound Care Committee

CAUSES

1. Patient/Systemic:
1. Malnutrition
2. Poorly controlled comorbid conditions e.g Diabetes
3. Smoking
4. Hygiene
5. Medication e.g Steroids / Chemotherapy
6. Pressure Ulcer
7. Patient immobility factors e.g paraplegia
8. Appliance related e.g poor fitting shoes

Wound Care Training Module - National Wound Care Committee

2. Disease / Local:

• Arterial
• Venous
• Mixed Arterial and Venous
• Infective e.g
• +/- Biofilms
• Osteomyelitis
• Chronic infections e.g. TB / Fungal

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• Immunopathic including Pyoderma Gangrenosum
• Malignancy
• Post radiation
• Systemic disease e.g Connective Tissue Disease
• Idiopathic

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Wound Care Training Module - National Wound Care Committee

MANAGEMENT

1. Goals Of Management

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• Timely healing of wounds with minimal morbidity and best cosmetic and functional outcome
• Prevent recurrences
• Improve Quality of Life

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Wound Care Training Module - National Wound Care Committee

2. Principles Of Management

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• Multidisciplinary Approach
• Careful Documentation of Progress of the Wound
• Utilisation of appropriate adjuncts where applicable
• Identify the cause if possible and treat
• Treat associated symptoms e.g. pain
• Consider Lifestyle Modifications
• Risk factor reduction to prevent recurrences

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Wound Care Training Module - National Wound Care Committee

3. Clinical Assessment

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• HISTORY: Some Points to identify possible cause as well as associated problems
• Duration of wound
• Symptoms caused by wounds
• Disability caused by wound
• Co-morbid history
• Medications
• Previous treatment
• Lifestyle
• Occupation

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Wound Care Training Module - National Wound Care Committee

• Examination: Color, Odor, Texture and Warmth are signs of infection
• Inspection:
• To identify clues to make a diagnosis from
• eg location, ulcer character, surrounding tissues
• Palpation:
• To elicit problems eg signs of infection, neurovasculer status, tendon involvement etc

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• Investigation:
• To help in the diagnosis or identify complications eg X-Ray for osteomyelitis, Duplex for vasculer disease, Biopsy and Culture for suspected malignancy or infection.

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Wound Care Training Module - National Wound Care Committee

TREATMENT

• Toilet and debridement of unhealthy tissues / or biofilm:
• Surgical
• Hydrotherapy
• Enzymatic / Chemical
• Biological

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• Dressings:
• Choice depends on local situation, expertise and resources.
• Special wounds may require special dressing e.g. compression bandaging (refer to chapter on respective ulcer).
• Dressing is targeted to the current wound condition e.g. exudative requires absorbent dressings.

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Wound Care Training Module - National Wound Care Committee

PRECAUTIONS

• Arterial ulcers associated with peripheral arterial disease is a systemic disease
• May have associated malignancy eg Marjolin’s Ulcer due to the chronicity
• Certain contraindications for specific conditions eg:
• Avoid venous compression stocking for presence of arterial disease.
• Avoid debridement for pathergic ulcers.

Wound Care Training Module - National Wound Care Committee

ADJUNCTS

1. Antibiotics:
• Choice depends on disease, site, suspected pathogens and local sensitivity patterns.
• Duration depends on similar reasons and the response pattern.
• Ideally obtain deep tissue cultures before stating antibiotics.
• Routine swab culture is generally discouraged.
• Consider empirical antibiotics in the following situations;
• Local conditons eg thickened skins in lipodermatosclerosis make it difficult to diagnose infections.
• Immunocompromised patients who may not show signs or symptoms of sepsis.

Wound Care Training Module - National Wound Care Committee

ADJUNCTS

2. Analgesics
3. Pentoxifylline for special ischemic ulcers
4. Off load devices for pressure associated ulcers
5. Stop smoking
6. Splints: for immobilisation in special situations
7. Colostomy for certain perineal wounds
8. Continuos Bladder Drainage (CBD) for certain situations
9. Hyperbaric chamber if available for indicated wounds

Wound Care Training Module - National Wound Care Committee

PALLIATIVE CARE

• In the event the wound cannot be healed for whatever reason, consider palliative care aimed at optimising quality of life.

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Wound Care Training Module - National Wound Care Committee

Algorithm for treating

non-healing wounds

Wound Care Training Module - National Wound Care Committee

TAKE HOME MESSAGES

• You should recognize when a wound can be termed non-healing and may need specialised intervention.
• Palliative care may be appropriate in certain situations. The possibility of malignant change in such ulcers must also be remembered.

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Wound Care Training Module - National Wound Care Committee

REFERENCES

• ABC of arterial and venous disease: ulcerated lower limb BMJ volume 320 10JUNE2000
•  The Non Healing Wound(Review) MMW Fortschr Med. 2004 Oct 28;146(44):45-8.(Translated from German)
•  Care of chronic wounds in palliative care and end-of-life patients Int Wound J. 2010 Aug;7(4):214-35.
•  Complex Wounds Clinics (Sao Paulo). 2006 Dec;61(6):571-8.
•  Diagnosis and treatment of pyoderma gangrenosum BMJ VOLUME 333 22 JULY 2006
•  Outcomes in controlled and comparative studies on nonhealing wounds: recommendations to improve the quality of evidence in wound management. Journal of Wound Care Vol 19 No 6 June 2010

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Wound Care Training Module - National Wound Care Committee

THANK YOU

Wound Care Training Module - National Wound Care Committee