Wound Care Update
- By David Natalizia, Alan Braverman
- Jul 01, 2005
Being a dog lover since a very early age and a dog "mom" for most of my adult life, I often think about animals and how simple their lives are. Our pets are helpless in many ways, dependent on us for food, water, shelter, basic needs, love and medical care. They instinctively know when something isn't right. Advanced wound care is really no different. Our patients depend on us for wound care solutions and help. We can apply the same primitive principles that drive dogs. Come sniff along the trail as we discover the current philosophy of modern wound management, with a canine twist.
My standard poodle, William, is the smartest dog in the world (at least in my mind!) He is in tune with his body's needs, following his instincts and "listening" to his system. When William requires something, he gets help. Below are some of William's habits and characteristics that are parallel to chronic wound management:
Get help.
William is not afraid to ask for help. If he needs to go outside, he sits and stares at you until you ask him if he needs to go out. Then he dances around enthusiastically saying, "yes". Wound management is the same. Getting help from a certified wound specialist (CWS) or certified wound, ostomy and continence nurse (CWOCN) is a natural first step to healing a chronic wound. The earlier the involvement of a professional, versed in wound management, the better the outcome. A multidisciplinary approach is also recommended. For instance, if William wants to play, he goes to my husband, Joe. Joe will roughhouse with him and have as much fun as William. I'm better for brushing him or giving him a hug. When a chronic wound fails to heal, getting other experts involved such as dieticians, dermatologists, physical and occupational therapists, vascular surgeons and wound care product manufacturers and distributors is proven to increase results Get the team involved to help the wound heal.
Whine if it hurts.
Wound pain can be an indicator of other problems such as infection. William whines if he's in pain. This usually means that he's not feeling well or hurt himself, basic but functional! Patients, especially the home care variety, should be educated to alert a clinician if wound pain begins or gets worse. Often, patients think they're expected to "tough it out," "no pain no gain." But in wound care, we know pain can and should be managed. A painful wound is no longer acceptable. Pain management dressings, anesthetics, pharmaceuticals, adjunctives and skin care products developed especially to address wound pain are plentiful. Make sure that you supply and promote these important products to clinicians and end users alike.
Keep it clean.
Dogs, by nature are very clean animals. They prefer to live indoors, using the outdoors for fun and relieving themselves. Similarly, cleanliness is of utmost importance in wound care. At each and every dressing change, wounds should be cleansed with a commercially prepared wound cleanser that is gentle, non-cytotoxic and applies the right amount of pressure to clean. Normal saline does not possess surfactants to help dissolve debris and biofilm, the slimy mixture that adheres to chronic wound beds much like plaque that attaches to our teeth.
Another practical strategy is to use safe topical antimicrobials like ionic silver gels, powders and alginates or polyhexamethylene biguanide (PHMB) impregnated advanced wound dressings to address bioburden, a constant road block to healing.
A wet nose is a healthy nose.
Moist wound therapy, much like a healthy dog's nose, requires an optimal amount of moisture. The key to providing a balanced approach is moisture. If the wound is too dry, granulation tissue cannot proliferate and epithelial tissue cannot migrate. Application of a product that donates moisture to help provide an optimal moist environment is recommended. Examples include amorphous hydrogels, transparent films, hydrocolloids, polyacrylates and bioengineered cellulose.
Eat, drink and be merry.
William self feeds, meaning that his food dish is always kept full as he regulates his own feeding schedule, eating when he's hungry. Same goes for his water dish, it's always filled with cool, fresh water. We are rewarded with a happy, healthy dog. All cells need energy in the form of calories from quality food to sustain and repair. The need for protein is the highest when restoration of skin damage or wounding takes place. Consider offering some of the newer dietary supplements to your clients. Palatable shakes, bars, drinks, powders, cookies and brownies enhance their diet and assist in building up resistance and mending wounds. Also recommended is a multi-vitamin/mineral supplement that supplies 100 percent RDA.
Take a load off.
William the standard poodle instinctively knows the most comfortable place in the house, his parents' bed! When he's especially tired after a rough day at doggy day care, he heads for the comfy resting spot and curls up on top of our down comforter. Off-loading products can offer your clients the right environment for healing and promotion of blood flow. Support surfaces such as therapeutic mattress replacements, overlays and cushions are important for prevention and healing of pressure ulcers. Diabetic shoes, inserts and heel protectors provide off-loading and cushioning to allow healing and prevention of both pressure ulcers and diabetic ulcers. Stock your shelves with all the products necessary to redistribute pressure.
Let nature take its course.
Nature and instinct guides most dogs' decisions. We should take a lesson from William. If the wound is healing, follow moist wound healing principles. If not, consider the amount and type of microorganisms present. Address other factors that can affect wound healing such as debris and dead tissue in the wound bed, temperature of the wound, circulation, maceration, desiccation, chemical stress and medications. Debriding a wound with devitalized tissue is a first step in wound bed preparation. A simple solution is autolytic debridement with a transparent or hydrocolloid dressing. An enzymatic debriding ointment or spray could also be used; however, these methods tend to take a longer time than novel option such as polyacrylate debriding systems activated with Ringer's Solution.
The nose, knows.
Dogs sense of smell is their most highly evolved sense, allowing them to detect things we cannot smell. Odor can assist us by alerting us to changes in the wound. Often wound odor occurs when a wound becomes critically colonized or infected. This is a sign to increase cleansing and apply topical antimicrobials. Take a tip from the poodle and let your nose be your guide.
Find a warm, dry place.
Wounds heal best in an area that is kept warm and dry, especially if there is copious drainage. If the wound is too wet, application of a product that manages exudate (drainage) while maintaining an optimal environment is the name of the game. Examples include alginates, alginate/carboxymethylcellulose combinations, foams, powders, polyacrylates, etc. fit the bill. Wounds that are kept covered have better outcomes than those that are left open to air. Advanced wound care, much like a dog looking for shelter, prefers a warm, dry environment.
Take care of your coat.
William's coat is thick and luxurious. He loves to be brushed and groomed. Obtain advice from the standard poodle, our patients' "coats" or skin is their primary protection from the environment and pathogens. Keeping the skin intact is our first goal. Caring for clients' skin ranks up there with keeping other vital organs alive and well. Cleansing the skin with a gentle, pH balanced cleanser, no soap is the answer. Soap and even surfactant liquid cleansers strip the skin of its natural acid balance and lipids that act as a protectant. Look for products that offer phospholipids cleansers made from vegetable oils, the most mild of cleansers. After every incontinent episode, or cleansing, a moisturizer or barrier product should be applied. Look for products with advanced silicones like dimethicone that resist wash-off.
If a fungus or yeast rears its ugly head and manifests on the skin, begin the use of a broad spectrum anti-fungal product containing 2 percent Miconazole Nitrate. Advanced skin care products, like advanced wound care products are now available. Say "no" to products that contain ingredients like mineral oil and petrolatum which can clog pores and cause inflammation. These ingredients do not contribute to lipid replacement and come from the same fraction as asphalt!
Bury the bone, or at least cover it up!
In William's world, treats and bones rule. In the world of wound care, burying the dressing is more important! If the sore has depth, or dead space, application of a dressing that can be loosely packed in the open area is important for adequate granulation and healing. Wounds must heal from the inside out. If the wound is flat, it is imperative to cover the area, protecting it from further damage, allowing the body's own growth factors to mobilize and go to work.
Wound Care Obedience 101
Becoming keenly aware of your client's wound care needs is much like going to obedience school. Rather than sit, stay, come, and heel, the mantra is prevent, assess, treat and heal. If you get down to basics, much of current wound management can be compared in canine terms. As providers, you are the voice for many patients. So, "speak" up, be an advocate and help wounds "heel," I mean heal. Don't let your business go to the dogs. What's good for the home care client is good for your bottom line. Woof-Woof!
This article originally appeared in the July 2005 issue of HME Business.