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Wound care rises in importance for aging home care patients

Monday November 19, 2012
Stephen Grab, RN
Stephen Grab, RN
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With the proportion of Americans 65 and older projected to increase from 12% in 2005 to 20% by 2030 by the American Academy of Family Physicians, and the increase in chronic illnesses, particularly diabetes and obesity, which can interfere with wound healing, wound care is becoming a more critical component of home care.

"Weíre living so much longer, but our mobility is less, so youíre going to see more pressure ulcers," said Marilynn Cino, RN, BSN, WCC, wound care specialist at the Visiting Nurse Association Home Care and Hospice of Mercer County, N.J. "From 25% to 30% of home care patients will have some kind of wound."

Innovations in materials and procedures have improved treatments and reduced the frequency and duration of nurse visits.

Silver and honey

The biggest changes through the years have been in dressings, which have advanced beyond gauze and no longer have to be changed daily. Cino said families donít have to wake up every 12 hours to change dressings because some of them can be changed once every three days, which boosts compliance rates.

Fewer dressing changes mean less pain for the patient, fewer burdens to the family, less exposure of the wound to contaminants and more efficient healing, Cino said.

One of the most effective advancements is antimicrobial dressings that use silver, which can be particularly useful on wounds whose healing has plateaued. This helps kickstart the wound healing. Ionic silver has been recognized since ancient times for its antimicrobial properties, according to the National Institutes of Health. It shuts down the enzyme that metabolizes oxygen in bacteria, viruses, and fungi. When thereís no oxygen, the toxic cells die.

Ionic silver can be used directly in the wound bed or incorporated in the dressings.

These cost more than other dressings initially but save treatment costs over time, said Stephen Grab, RN, BSN, CWON, BSB, a wound ostomy nurse for MJHS in New York City.

"Anything with silver in it is going to be more expensive, but if it helps decrease the healing time, then it has the potential to be cost-effective," he said. "Often it wonít be used for the whole treatment, just the time that itís needed."

Other advances widely used in home wound care include the following treatments:

Negative pressure wound therapy: Foam or gauze placed in the wound is hooked up to a suction device, which heals the wound by pulling out the drainage and drawing the edges of the wound together. "They heal wounds dramatically faster," said Janice Malett, RN, MPH, CWON, a wound and ostomy specialist with Visiting Nurse Services Westchester in New York. Large abdominal wounds would take months to heal using traditional dressings. With a negative pressure system, healing would take just weeks, Malett said. These suction devices also are getting smaller and more patient-friendly, Cino said, so they are much easier to manage at home. Patients can carry them in a case and walk around the house. Patients are much more mobile and therefore more compliant with their treatments, she said.

Medical grade honey: Several companies make this treatment, which uses honeyís natural antimicrobial properties transformed to medical quality to heal wounds. It comes in many forms, Cino said, including paste, a hydrocolloid form and something similar to an alginate. It is less expensive than silvers, she said.

Hydrocolloids: This is a type of dressing that can be put on and left in place. It is self-adhering and sticks to the surrounding skin. "We use it a lot on shallow pressure ulcers, and you donít have to change it every day," Cino said. "It absorbs a little bit of drainage as opposed to hydrogels, which you have to change every day. Itís an easy dressing to teach family members to put on."

Control for home environment

The home care environment presents special challenges for wound care nurses because so many factors are out of a nurseís control, such as cleanliness of the home, food preparation and even sleeping arrangements.

While having a separate hospital bed in a bedroom for the patient is often optimal, "that has to be balanced [with] the wishes of the couple who have been sharing a bed for 60 years," Malett said. "This is their turf."

Educating caregivers on proper nutrition is an important part of wound care in the home, Grab said.

Making sure patientsí diets include enough protein based on their weight is key because wound drainage saps the level of protein, he said. Education and communicating a care plan also are critical in making sure wound care continues properly outside of nurse visits.

"Youíre not just looking at the wound," Malett said. "Youíre looking at the environment. Youíre looking at the patient. Youíre looking at the whole patient."

Marcia Frellick is a freelance writer.


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