Wound Management

Acute and chronic wounds pose challenges in wound management due to factors like poor tissue oxygenation, infection, and psychosocial factors. Biofilm formation is a critical physical factor that impairs wound healing. Techniques like debridement, offloading, and moist wound care are used to counter vulnerabilities. Clinical guidelines have been developed to address challenges in wound management and prevention of wound infections.

Running head: WOUND MANAGEMENT
Wound management
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Acute and chronic wound is a common health issue which is associated with reduced
quality of life, impaired working capacity and increase in cost associated with wound
management. Chronic wound is an under-recognized public health issue in Australia because of
poor coordination across health sectors, poor continuity of evidence based treatment and lack of
evidence based wound care (Järbrink et al., 2017). Chronic wound involves wounds like vascular
ulcers, pressure ulcers and pressure ulcers that share common pathophysiology like persistent
infection, prolonged inflammation and development of drug resistant microbial biofilms. These
pathophysiological features result in impaired wound healing and create challenges for health
care professionals during wound management (Frykberg and Banks 2015). The main purpose of
this essay is to develop understanding regarding the factors associated with impaired wound
healing and infection, which increase vulnerabilities of client and evaluate how these
vulnerabilities have been encountered. The essay will also examine how understanding regarding
wound infection has been integrated into policies and procedures related to prevention and
control of wound infections.
Normal wound healing process consists of four integrated phases such as homeostasis,
inflammation, proliferation and remodelling. Each of these phases should occur in a controlled
and programmed manner to promote wound healing. It is also critical that all bio-physiological
function occurs in proper sequence and optimal intensity (Wallace and Bhimji 2018). However,
there are many physical factors that leads to interruptions or delay in wound healing process.
These include multiple factors like oxygenation, infection, foreign body and venous sufficiency.
Oxygenation is critical for cell metabolism and prevention of wound infection through
angiogenesis, proliferation of fibroblast, collagen synthesis and wound contraction. However,
conditions like vascular disruption and oxygen consumption by active cells can deplete oxygen

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level in the microenvironment of wound (Guo and DiPietro 2010). This form of poor tissue
oxygenation is seen in patients with systemic conditions like advancing age and diabetes that
result in impaired vascular flow. Anderson and Hamm (2012) supports that in patients with
diabetes mostly suffer from peripheral arterial disease and the condition lead to impaired
fibroblast signalling, delay in keratinocyte migration and delayed re-epitheliazation. Hence, the
pathophysiological changes associated with diabetes increase vulnerability to delayed wound
healing. Therefore, understanding of complex patient related factors that affects wound healing
process is necessary.
Frykberg and Banks (2015) gives the evidence that infection is a significant risk factor
for wound healing and the excessive bio-burden due to infection interrupt normal progression of
wound healing process. Inflammation is a normal part of wound healing process. However, the
inflammatory process is prolonged in patients with infection because of incomplete microbial
clearance. The colonization of bacteria in the wounds result in prolonged risk of pro-
inflammatory cytokines and this is the reason behind delay in the inflammation phase. in case of
wound infected by Pseudomanas aeruginosa, presence of biofilms containing this bacteria
protects the bacteria from phagocytic activity of polymorphonuclear neutrophils. This
pathophysiological mechanism explains why some chronic wounds do not heal despite initiation
of proper antibiotic therapy (Guo and DiPietro 2010). This explanation gives the insight that
biofilms and inflammation are two interlinked process that impairs wound healing process.
Biofilm is a critical physical factor that participates in the pathogenesis of chronic
wounds. It is a tertiary living microbial cells surrounded by protective extracellular polymeric
substances. It plays a critical role in protect microbes from immune response and the persistent
presence of biofilm in chronic non-healing wound is the primary cause behind delayed healing

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trajectory and impairment of granulation formation and epithelial migration (Hurlow, Blanz &
Gaddy, 2016). This discussion implies that to facilitate proper wound management process, there
is a need for health care professionals to have better understanding about the role of biofilm in
preventing healing. This will help them to implement strategies that control excessive host
inflammation and engage in therapeutic approach to wound healing process (Zhao et al. 2013).
Apart from physical factor, wound healing process is also influenced by psychosocial
factors. For example, experience of psychological stress is a factor that influences human
behaviour. It leads to negative emotion state, anxiety and depression which negatively influence
pathophysiological process and behaviours of patient. Stress has impact on immune function and
development of unhealthy habits such as poor nutrition, impaired sleep pattern and alcohol
abuse. All these together have a negative impact on wound healing process (Guo and DiPietro
2010). Gouin and Kiecolt-Glaser (2012) gives the opinion that wound related complications
increases stress level of patient and negative influence wound repair. The study gives the
evidence that in patients undergoing gallstone removal surgery, patient with more reported stress
had longer hospital stay compared to less anxious patients. In addition, the study also revealed
adverse impact of psychological factors on chronic wound healing process. For example, the
follow-up with older adults with chronic wound revealed that those who had experience
depression and anxiety were 4 times more likely to be experiencing delayed wound healing
compared to those with lower level of distress. Psychosocial factors like social isolation, poor
self-esteem and pain also negatively influences wound healing process. Chronic wound leads to
negative mood, pain and social isolation and these factors play a role in influencing wound
management process. Patients with chronic wound are negatively influences by physical effects
of wound such as mobility challenges, release of exudates, pain and burden associated with

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wound care (Upton 2014). Hence, increase in anxiety due to wound related pain is associated
with delayed healing. Therefore, proper communication with patient regarding wound care
process is critical to counter the negative effects of psychosocial factors on wound healing
process.
The above discussion gives the insight that physical factors like poor tissue oxygenation,
infection and vascular abnormalities increase vulnerability to impaired wound healing. These
vulnerabilities have been encountered while treating patients with chronic wounds like
diabetic foot ulcers (DFUs). The challenge that is encountered during wound management is that
neuropathy mask the detection of deep infections. In case of such complications, aggressive
techniques like wound debridement, debridement of affected bone and surgical drainage been
used to counter vulnerabilities in patient (Woo et al. 2015). Peripheral neuropathy and decrease
blood supply are some challenges encountered while treating patients with DFUs. Arterial
insufficiency is a common issue found in such patients that impairs wound healing process.
According to Kavitha et al. (2014), some of the techniques that are effective in encountering
challenges in wound healing for patients with DFUs and arterial insufficiencies includes
debridement, offloading, moist wound care and treatment of infection. Debridement involves
removal of dead and damaged tissues that impair wound healing process. Offloading is a
technique to remove pressure from foot by mechanical support and giving rest to the wound area.
In addition, wound healing process is increased in patient with DDFU by following asceptic
technique and providing moist wound healthy environment. Hydrogel and impregnated dressings
plays a vital role in reducing challenges in wound management process. The role of multi-
disciplinary team of specialist is critical for successful management of chronic wounds like
DFUs.

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In addition, for patients with chronic wound and biofilm formation, the challenges in
wound management due to biofilm formation have been countered by techniques like careful
selection of debridement and dressing technologies. Debridement technique is implemented by
specialist surgical debridement, debridement with curettes and debridement with moisture
retentive dressings (Hurlow et al. 2015). Although debridement is effective in removing
devitalized tissue and stopping reformation of bio-film formation, however effectiveness of the
technique is enhanced by appropriate wound management techniques and infection control
measures. Other techniques to encounter bio-film effect in wound healing process included use
of anti-biofilm agents and microscopic examination. Many anti- biofilm agents like lactoferrin is
used to remove biofilm from wound bed. However, the efficacy of individual anti-biofilm agent
is not known (Metcalf and Bowler 2013). Hence, multimodal approach or combination of
techniques like debridement, antibiofilm agents and antimicrobials area needed to manage
biofilm and encourage wound healing. Research evidence also demonstrate the role of effective
communication and patient engagement during dressing changes to counter psychosocial risk
factors of wound healing process. In addition, active communication with patient may help to
alleviate distress and anxiety and reduce negative effects of psychological stressors on wound
healing process (McCaughan et al. 2018).
Currently, health care professionals and wound management experts have taken the
approach to integrate wound management challenges and evidence based wound care process
into policies, procedures and guidelines. Development of these guidelines has directly
influenced clinical practices related to prevention of wound infections. For example, in response
to the challenges faced in wound healing due to biofilm formation, many consensus guidelines
has been developed for treatment of biofilms in patient with chronic and non-healing wound. As

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biofilm created uncertainty in treatment of wound, 10 clinicians and researchers with expertise in
biofilms developed consensus statements for biofilm identification and treatment. The
significance of this consensus guideline is that it develops understanding regarding clinical
indicators of biofilms, treatment strategies, diagnostic test options (Schultz et al. 2017). The
integration of such guideline can address misunderstandings and provide health care staffs with
the opportunity to use the guidelines for recognition of biofilms in chronic wounds and
adequately treating it. These consensus guidelines have been integrated in clinical practice in
UK. The significance of such clinical guidelines for health care professionals in UK is that the
debridement techniques are aligned with debridement methods available in the UK. In Australia
also the wound debridement guideline has been implemented for South Eastern Sydney district.
It has integrated the challenges in reducing bioburden of wound by providing clinical indicators
wound debridement and proper assessment and management of dressing changes in patient
(NSW Government 2015).
In case of chronic wounds like DFU, diabetic neuropathy and arterial insufficiency
contributes to delayed wound healing and additional challenges in wound care. These challenges
has been recognized and integrated in clinical guidelines in Australia to influence effective
wound choices. As DFU lead to foot complications and complete amputation in diabetes patient.
The evidence based clinical summary has been developed to guide practitioners to conduct
proper assessment and identify risk of complications in patient. The risk factor that has been
incorporated in the guideline includes peripheral neuropathy, foot deformity, peripheral arterial
disease. In addition, the management techniques like debridement, dressing, pressure reduction
and multi-disciplinary care has been given in the guidelines too (Australian Diabetic Society

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2015). This guideline has been effective in facilitating proper monitoring and prevention of
DFUs recurrence. The guidelines are effective quick decision guide for practitioners in Australia.
The challenges related to foot ulcerations and pressure areas in the foot has been
integrated in the Diabetic Foot Australia guidelines on footwear for people with diabetes. van
Netten et al. (2018) gave the evidence that to create an updated guideline of footwear for people
with diabetes, 10 recommendations were proposed to guide health care professionals in selecting
the most appropriate foot wear to reduce risk. This included advising patients to wear footwear
that fits and protects the shape of the feet, educating people with diabetes regarding appropriate
foot wear, motivating daily check and monitoring of feet to identify foot ulcerations risk and
providing medical grade footwear for patient with healed plantar foot ulcer. These forms of
guidelines are critical to ensure that patients are also involved during wound management
process and any risk of impaired wound healing is addressing from the beginning phase of care.
From the discussion regarding the factors that influence wound healing process, it can be
concluded that oxygenation, arterial resistance, peripheral neuropathy, biofilm formation and
psychosocial factor (stress, anxiety and social isolation) are important factors that delays wound
healing process and disrupts normal process of wound healing. The essay identified different
counter techniques for challenges like biofilm formation and peripheral neuropathy issues during
wound management. These techniques include use of debridement techniques, use of offloading
technique, proper dressing and appropriate multidisciplinary wound care process. The critical
involvement of patient in wound care was also identified. The essay gives the insight that wound
management experts have effectively integrated this knowledge in different clinical guidelines
related to biofilm treatment and management of DFUs. It is an effective step to make health care
staffs aware about effective wound management techniques.

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References:
Anderson, K. and Hamm, R.L., 2012. Factors that impair wound healing. Journal of the
American College of Clinical Wound Specialists, 4(4), pp.84-91.
Australian Diabetic Society 2015. Prevention, identification and management of foot
complications in diabetes. Retrieved from:
https://www.adea.com.au/wp-content/uploads/2013/08/Foot_ClinicalGuide_ONLINE.pdf
Frykberg, R.G. and Banks, J., 2015. Challenges in the treatment of chronic wounds. Advances in
wound care, 4(9), pp.560-582.
Gouin, J.P. and Kiecolt-Glaser, J.K., 2012. The impact of psychological stress on wound healing:
methods and mechanisms. Critical Care Nursing Clinics, 24(2), pp.201-213.
Guo, S.A. and DiPietro, L.A., 2010. Factors affecting wound healing. Journal of dental
research, 89(3), pp.219-229.
Hurlow, J., Blanz, E., & Gaddy, J. A. (2016). Clinical investigation of biofilm in non-healing
wounds by high resolution microscopy techniques. Journal of wound care, 25(Sup9), S11-S22.
Hurlow, J., Couch, K., Laforet, K., Bolton, L., Metcalf, D. and Bowler, P., 2015. Clinical
biofilms: a challenging frontier in wound care. Advances in wound care, 4(5), pp.295-301.
Järbrink, K., Ni, G., Sönnergren, H., Schmidtchen, A., Pang, C., Bajpai, R. and Car, J., 2017.
The humanistic and economic burden of chronic wounds: a protocol for a systematic
review. Systematic reviews, 6(1), p.15.

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Kavitha, K.V., Tiwari, S., Purandare, V.B., Khedkar, S., Bhosale, S.S. and Unnikrishnan, A.G.,
2014. Choice of wound care in diabetic foot ulcer: a practical approach. World journal of
diabetes, 5(4), p.546.
McCaughan, D., Sheard, L., Cullum, N., Dumville, J. and Chetter, I., 2018. Patients’ perceptions
and experiences of living with a surgical wound healing by secondary intention: A qualitative
study. International journal of nursing studies, 77, pp.29-38.
Metcalf, D.G. and Bowler, P.G., 2013. Biofilm delays wound healing: A review of the
evidence. Burns & Trauma, 1(1), p.5.
NSW Government 2015. Wound debridement. Retrieved from:
https://www.seslhd.health.nsw.gov.au/sites/default/files/migration/
Policies_Procedures_Guidelines/Clinical/Surgery_Anaesthetics/documents/
FINALWoundDebridementProcedureSESLHDPR348.pdf
Schultz, G., Bjarnsholt, T., James, G.A., Leaper, D.J., McBain, A.J., Malone, M., Stoodley, P.,
Swanson, T., Tachi, M., Wolcott, R.D. and Global Wound Biofilm Expert Panel, 2017.
Consensus guidelines for the identification and treatment of biofilms in chronic nonhealing
wounds. Wound Repair and Regeneration, 25(5), pp.744-757.
Upton, D., 2014. Psychological aspects of wound care: implications for clinical practice. J
Community Nurs, 28(2), pp.52-7.
van Netten, J.J., Lazzarini, P.A., Armstrong, D.G., Bus, S.A., Fitridge, R., Harding, K., Kinnear,
E., Malone, M., Menz, H.B., Perrin, B.M. and Postema, K., 2018. Diabetic Foot Australia
guideline on footwear for people with diabetes. Journal of foot and ankle research, 11(1), p.2.

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Wallace, H.A. and Bhimji, S.S., 2018. Wound Healing Phases. In StatPearls [Internet].
StatPearls Publishing.
Woo, K.Y., Keast, D., Parsons, N., Sibbald, R.G. and Mittmann, N., 2015. The cost of wound
debridement: a Canadian perspective. International wound journal, 12(4), pp.402-407.
Zhao, G., Usui, M.L., Lippman, S.I., James, G.A., Stewart, P.S., Fleckman, P. and Olerud, J.E.,
2013. Biofilms and inflammation in chronic wounds. Advances in wound care, 2(7), pp.389-399.