W

ounds unfortunately do not heal in a predictable, linear fashion. Quite often it's a "two steps forward, one step back" process that can be both frustrating and perplexing. Like a jigsaw puzzle, wound healing has many "pieces" and is only successful when all the parts are put together perfectly in order for the wound to progress toward closure.
       Despite delivering exemplary wound care that includes preparing the wound bed, providing the right dressings, turning schedules, nutritional support, topical care, and offering top-of-the-line support surfaces, wounds sometime need that extra little push to "jump start" the healing cascade. Wounds fail to thrive for a variety of reasons including poor nutrition, lack of blood flow, unrelieved pressure, poor care, infection, systemic disease...the list goes on and on. Once we've exhausted our arsenal, where do we go? Alternative and adjunctive therapies may be just the answer. These secondary modalities can speed healing of chronic wounds by affecting different cellular processes in the wound healing cascade.

Causes and Therapies Unite
       When considering particular alternatives and adjunctive therapies in wound management, we must bear in mind the staff's education level and the residents' abilities to comply with specific regimens. For instance, what is each resident's activity level? How often must the therapy be delivered, changed, or tended? Is extensive training or certification necessary for the staff performing the therapy? What is the overall cost of the therapy? How accessible is it?
       We must also look at what cause or etiology we are trying to affect or counteract. Has the wound changed significantly? Has healing simply stagnated? Is the blood supply challenged in some way? Is there an unidentified infection, systemic problem, or immune issue that needs assessment and treatment? Once these important questions are answered, we can then look for other methods for treating a difficult wound. Let's review the various adjunctive therapies, their applications, uses, pros, and cons.

Adjunctive Therapies and Their Applications
       Electrical stimulation (e-stim). Electrical stimulation involves the application of an electrical current in various wavelengths to stimulate tissue regeneration and collagen production. Effects include increasing fibroblast proliferation and collagen deposition, reducing edema and pain, increasing oxygen, blood, nutrient transport, and antibacterial effects, and improving the tensile strength and elasticity of granulation tissue. These properties can be appreciated during virtually every phase of wound healing.
       A skilled professional (generally a physical therapist) must deliver this type of therapy. Current research shows that e-stim has the potential to enhance healing of incalcitrant wounds.
       Ultrasound. Ultrasound entails the application of high-frequency sound waves transmitted through water or sonic gel to increase oxygen delivery, cellular proliferation, collagen strength, wound recovery, and elasticity and to decrease pain, hyperemia, and edema. Generally, ultrasound works best to activate the inflammatory process or stimulate new tissue formation of nonhealing, clean ulcers. Again, a skilled clinician, usually a physical therapist, administers ultrasound therapy.
       Topical growth factors. Autologous (derived from the resident's blood) or recombinant (off-the-shelf) biologically developed products are applied directly to the wound to increase healing via increasing the cellular content, controlling the collagen deposition, and increasing the wound's strength. They play critical roles, allowing the cells of the wound healing process to "talk."
       These topical applications require a physician's prescription as well as prudent wound bed preparation and local wound care, often including debridement. Effects are dependent on the target cell of the product being used.
       Hyperbaric oxygen. Hyperbaric oxygen involves the application of greater than one atmosphere of pressure in a chambered environment (designed for one or multiple patients). The resident concurrently breathes 100-percent oxygen. Ordered by a physician, this adjunctive wound healing treatment increases oxygenation to the tissue and fosters wound healing by supporting bacterial destruction by white blood cells, collagen growth via fibroblast proliferation, and assisting in the development of new epithelial tissue.
       The resident must be stable enough to allow transfer to the facility offering hyperbaric oxygen. Those with known claustrophobia may need to be premedicated with a sedative or be placed in a large multipatient chamber. Since hyperbaric oxygen is a physician-ordered adjunctive treatment, often a nurse and respiratory therapist apply the therapy in conjunction with a physician.
       Warmth therapy. Warmth therapy delivers a controlled level of infrared heat (38 degrees C or 100.4 degrees F) into the wound and surrounding skin. Recent research suggests that warming the wound and wound fluid weakens the inhibitory effect. The warmer wound environment may make it possible for cells involved in the tissue repair processes, like fibroblasts, to increase in number and thus produce more collagen and heal the wound.
       The warmth is delivered twice a day with a special warming element that slides into a foam island dressing that allows visualization through a transparent window in the center. The warming element doesn't actually touch the wound or wound bed. Rather, it warms the wound's surrounding environment.
       This therapy is ordered by a physician and applied by licensed personnel.
       Hydrotherapy. This type of adjunctive wound therapy involves the application of water or cleansing fluids to the wound bed. Often used to clean or debride a wound with substantial necrotic tissue (>50% of the wound bed), hydrotherapy can take the form of a traditional whirlpool or one of the newer irrigation systems like pulsed lavage. Its use should be limited to stage 3 and stage 4 pressure ulcers and is not recommended for venous ulcers.
       Performed by a licensed physical therapist, the Agency for Health Care Policy and Research (AHCPR, now the Agency for Healthcare Research and Quality or AHRQ) Guidelines for the treatment of pressure ulcers state that whirlpool treatments be discontinued when debriding objectives have been met (wound bed is clean and free of devitalized material).1
       Skin substitutes. Bioengineered in-vitro cultured skin cells that produce replacements for skin deficits and wounds are the new frontier in wound healing. These skin substitutes include epidermal, dermal, and composites. The products begin as harvested skin from the donor and from neonatal foreskin and are literally "grown" in the lab. Sometimes they are combined with animal material, such as Type 1 bovine collagen, to provide the dermal matrix component. Useful in a variety of wounds, these "epithelial sheets" can give quick cover and rival autologous grafts for burn patients.
       Skin substitutes are physician-directed adjunctive treatments. They can be quite costly yet may be the only option for closing an elderly client's venous stasis ulcer or diabetic foot wound. Speak with a wound care doctor familiar with the use of these products and their clinical application. Your manufacturers also provide a valuable resource for using these advanced treatments.
       Nutritional support. Every at-risk resident or resident with an existing wound should have a nutritional assessment. Many studies cite a strong link between deteriorating nutritional status and the development and healing of chronic, nonhealing wounds. If deficits in calories, protein, nutrients, and fluids exist, a registered dietitian can offer supplements and medical diet therapy to assist in holistic wound healing.
       In order for a wound to heal, the body must be in positive nitrogen balance and have the ability to build new tissue. Nutritional support can offer this basic building block to healing.
       Compression. Compression consists of garments, dressings, hose, devices, and surfaces that increase venous return and decrease venous stasis and resulting edema. Compression therapy is the mainstay of treatment for venous stasis and venous ulcer ailments. Compression therapy involves increasing the external pressure on vascular elements to assist with the pumping of venous fluid return by the heart.
       Compression items are ordered by a physician and can be applied by various personnel, both licensed and unlicensed, depending on the therapy.
       Vacuum-assisted closure. Vacuum-assisted closure is the application of negative pressure from a vacuum and tube computerized device that is connected to a foam dressing. This dressing is placed in the wound bed and sealed with an adhesive transparent occlusive dressing, which is changed every other day. This adjunctive therapy is reported to "stretch" the cells involved in the wound healing process, releasing biochemical mediators of cell proliferation and pulling them together, thus healing the wound by secondary intention or preparing the wound for surgical intervention. The controlled negative pressure creates a vacuum, which additionally evacuates stagnant wound fluid, reduces edema, helps form new blood vessels and granulation tissue, debrides, and reduces the bacterial burden at the wound site.
       This is a physician-ordered treatment that requires a wound care specialist, advanced practice nurse, or enterostomal therapy (ET) nurse consultation and special training certification.
       Surgical repair. Surgical repair of a wound can be accomplished by free tissue transfer flap, myofasciocutaneous flap or rotation, random flap, split- and full-thickness skin graft, and primary and secondary approximation. The ultimate goal of surgical intervention is to move healthy tissue to an area of deficit (chronic wound), which has also been surgically prepared. This procedure is performed by a physician, usually a general or plastic surgeon, to hasten healing, reduce pain, save a limb or life, and theoretically decrease costs.
       The resident must be stable enough to be transferred to an acute care facility and sustain general anesthesia and major surgery.
       Support surfaces. One of the basics in pressure ulcer prevention and treatment, support surfaces can be considered adjunctive therapy in wound healing. Support surfaces consist of seat or wheelchair cushions, mattresses, overlays, and full beds that reduce the effects of four extrinsic risk factors: pressure, shear, friction, and moisture. These products are comprised of air, foam, gel, and other various mediums. The surfaces distribute the body's weight, diminishing peak pressures and potential skin breakdown as a result of lack of blood flow and poorly controlled skin microclimate.
       Generally, these products are available for both rental and purchase. As much as they are considered adjunctive, these pressure distributing surfaces should be considered early, even before a resident actually falls victim to a pressure ulcer, potentially saving the client's skin and your facility's budget!

Where to Start?
       When healing is impeded or delayed, adjunctive and alternative wound management therapy may provide viable options for the long-term care patient. No matter what the treatment, however sophisticated and sound, we can only truly support the host, our resident. Without a healthy body, wound healing, which takes much energy, is a fruitless battle.
       If you are considering an adjunctive treatment for a resident whose wound has failed to heal, consult with a wound care expert, an ET nurse, a wound, ostomy, and continence nurse, or a certified wound specialist regarding which treatments will offer the best therapy and fit for your resident. After that, a plan of care can be developed and agreed upon by the entire team. Be sure to include the resident and his or her family and significant others. As with any procedure or treatment, we need their buy-in and cooperation more than anything.
       Don't forget to include your manufacturers and providers in your quest for education and information. They can offer cutting-edge help regarding the use, costs, clinical applications, as well as training when considering a specific adjunctive or alternative wound management therapy. It is difficult to remain abreast of the new technology with regard to wound care and all the products continuously being introduced in the marketplace. As the science of wound healing evolves, look to your wound care experts and manufacturers as your partners in providing both products and education.