Physiological Processes of Wound Healing
Question:
What is the evidence based nursing intervention and its rationale while providing wound care in a patient with Diabetes Mellitus?
In my career as an intern in a medical ward, where I did my placement, I have provided wound care or have dressed several wounds within the hospital ward. One of the challenges faced regarding the healing of wounds is diabetes. I have found that the healing of the wounds have considerably delayed in patients having high blood sugar level. In order to provide them an appropriate and evidence based nursing care, I have brainstormed through several databases like Pubmed and CINAHL and have come across some peer reviewed selected literatures which have helped to strengthen my knowledge regarding the disease and its consequences on wound healing and the nursing interventions related to it.
High glucose levels in the blood can cause neuropathy and leads to poor circulation of blood, making it hard for the blood to reach the affected areas of the skin, needed for the repair. This leads them to remain unhealed and open for months (Xu et al., 2013). Unhealed wounds for month increases the chance of fungal and bacterial infections, gangrene. Infection of body parts might lead to the amputation of that part (Gantwerker & Hom, 2012). This essay will provide with the nursing rationale for addressing the wounds of patients with diabetes, which will be supported by authenticated evidence based research articles.
Evidence based discussion
As stated in the journal by Demidova-Rice et al.,(2013), the physiological process of wound healing involves four phases- homeostasis, inflammation, proliferation and remodeling.
The paper was successful in providing an insight to the inflammatory response in detail. The research article was relevant to my research.
According to Xu et al., (2013), wounds created by foot ulcers in diabetic patients can be managed by revascularization surgery, debriment of the necrotic tissue, mechanical offloading, management of the blood glucose level, foot care education. According to the study advanced wound care therapies are required if the wound does not heal by standard treatment. This study is a systematic review of 59 articles that compared the advanced wound care therapies with placebo or standard care. In most of the cases the diabetic ulcer was found to be cured only by the application of advanced treatment.
The paper by Ritterman et al., (2013), is a peer reviewed literature that provides an insight to the possible nursing interventions to manage the chronic diabetic wounds. This evidence has been useful for the study as the paper had provided a systematic framework of interventions for managing the chronic diabetic wounds. One of the limitations of this paper is that the interventions were only limited to chronic wounds and it also did not focus on the wounds caused by burns and accidents in diabetic patients. The study did not provide any high grade evidence for wound debriment or wound cleansing. The study also did not provide any evidence for advantages of using particular cleansing solution over another.
Nursing Interventions to Manage Chronic Diabetic Wounds
Critical analysis
According to Demidova-Rice et al.,(2013), the inflammatory response involved homeostasis, inflammatory response, proliferation and remodeling of the skin tissues. Haemostasis occurs in the first hours followed by vasoconstriction and clotting. The platelets help to secrete growth factors and cytokines to initiate the process of healing. In the inflammation phase the neutrophils and the granulocytes prevents the bacterial contamination of the wound and cleanse the wound from the cell debris. The chemotactic factors in the wound attract the monocytes, which differentiates in to macrophages that destroy the bacteria by phagocytosis (Gantwerker & Hom, 2012). The angiogenesis is carried out by certain growth factors, angiostenin which initiates the proliferation phase causing the formation of the wound matrix, which is finally replaced by collagen and proteoglycan. On the other hand, patients with diabetes, the basement membrane of the capillaries are thickened that causes impaired healing of wounds. According to Baltzis et al.,( 2013) hyperglycemia has a detrimental effect on the wound healing process, as it leads to the generation of the inflammatory molecule (TNF-α ) that interferes with the collagen synthesis. Furthermore Baltzis et al,. (2014), have showed that diabetes is associated to decreased level of proliferation, abnormal differentiation of the keratinocytes, which indicates another possible mechanism by which hyperglycemia can affect the wound healing process.
As stated by Rüttermann et al., (2013), a successful treatment of a chronic wound involves a number of steps which is known by the acronym TIME. At first the non viable tissues (T) from within and around the tissues has to be removed using debriding agents such as bacterial collagenase. Next the inflammation (I) and the infections are controlled by the application of the antibiotics. Next, the moisture (M) imbalance is addressed with a selected dressing and finally the granular tissue formation and epithelialization are promoted by the application of the growth factors. This study was quite relevant to my research question, and could vividly account for a wound bed preparation.
According to Mousley, (2003), for the optimization of the wound healing process, the patients should be encouraged to achieve the target levels of glycated hemoglobin. As stated by Gantwerker & Hom, (2012), obesity can increase the risk of infections as adipose tissue hinders the supply of nutritive blood to the cells at the wound site. Obesity has been found to increase tension on the opposition edges of the wound.
Neuropathy has been found to be the most important factor for the development of the diabetic foot ulcer. Dreifke et al., (2015) has emphasized on the importance of education imparted to the patient regarding the management of neuropathic ulcers. Appropriate foot wear can reduce the chance of occurrence of the diabetic foot ulcers.
A non-removal total contact cast (TCC), helps to redistribute the pressure evenly along the lower leg that can reduce the time of healing. As stated by Dreifke et al., (2015) most of the common problems that is found is that the patients do not wear the removable devices for the pressure offloading.
Hyperglycemia’s Detrimental Effect on Wound Healing
According to the study by Singh et al.,(2013), cleaning of the wound with unsterile solutions and unfiltered tap water can increase the risk of contamination with pathogenic microbes, hence Ringer’s lactate solution can be used. But no other evidences have been found that supports the efficacies of ringer lactate’s solution as a rinsing solution over normal saline water. Solutions like polyhexanide, hypochlorite, octenidine, H2O2 have not shown any evidence to enhance the wound healing process (Tsourdi et al., 2013).
In order to accelerate the rate of wound healing process, there are six key steps that are to be fulfilled.
Wound assessment- since diabetic wound fall under three categories like ischemic wound, neuropathic and neuroischemic. Failure to monitor and assess the type of wounds may lead to a faulty wound treatment plan (Tsourdi et al., 2013).
Wound assessment will be followed by wound debriment, where the necrotic tissues have to be removed with the help of scissors or sharp scalpels. Other tissue removing techniques such as autolytic, larval and ultrasonics can also be used (Fan et al., 2013).
Wound infection can be prevented by wound care dressings that contain iodine, and silver or medical grade honey (Fan et al., 2013). Neutral solutions can be used for active periodic cleansing of wound. Polyhexamethylene can be given to enhance the time of healing. Alginates, films and hydrocolloids can be given to the dressings to keep the wound moist. Scotchcast boots, healing sandals, TCC can be given as removable offloading services (Tsourdi et al., 2013).
Furthermore it is essential to look after the underlying risk factors that may cause wounds in the first place. Other factors such that should be kept in mind while providing care to the patients with chronic wounds is to impart them with education regarding the maintenance of the blood glucose levels, proper nutrition, high blood pressure and cessation of smoking (Demidova-rice et al., 2012).
Conclusion
It can be said that slow healing wound is quite critical to the overall health status of a diabetic patient. The development of an open wound should be prevented. It can be said that tissue debriment, infection control, application of proper dressing with suitable antimicrobial agents accelerate the wound healing in diabetic patient. However, self management of diabetes and obesity can accelerate the process of wound healing in diabetic patients.
References
Baltzis, D., Eleftheriadou, I., & Veves, A. (2014). Pathogenesis and treatment of impaired wound healing in diabetes mellitus: new insights. Advances in therapy, 31(8), 817-836.
Demidova-Rice, T. N., Hamblin, M. R., & Herman, I. M. (2012). Acute and Impaired Wound Healing: Pathophysiology and Current Methods for Drug Delivery, Part 1: Normal and Chronic Wounds: Biology, Causes, and Approaches to Care. Advances in Skin & Wound Care, 25(7), 304–314. https://doi.org/10.1097/01.ASW.0000416006.55218.d0
Dreifke, M. B., Jayasuriya, A. A., & Jayasuriya, A. C. (2015). Current wound healing procedures and potential care. Materials Science and Engineering: C, 48, 651-662. https://doi.org/10.1016/j.msec.2014.12.068
Fan, Z., Liu, B., Wang, J., Zhang, S., Lin, Q., Gong, P., … & Yang, S. (2014). A novel wound dressing based on Ag/graphene polymer hydrogel: effectively kill bacteria and accelerate wound healing. Advanced Functional Materials, 24(25), 3933-3943.
Gantwerker, E. A., & Hom, D. B. (2012). Skin: histology and physiology of wound healing. Clinics in plastic surgery, 39(1), 85-97.
Mousley, M. (2003). Diabetes and its effect on wound healing and patient care. Nursing times, 99(42), 70-73.
Rüttermann, M., Maier-Hasselmann, A., Nink-Grebe, B., & Burckhardt, M. (2013). Local Treatment of Chronic Wounds: in Patients With Peripheral Vascular Disease, Chronic Venous Insufficiency, and Diabetes. Deutsches Ärzteblatt International, 110(3), 25–31. https://doi.org/10.3238/arztebl.2013.0025
Singh, B., Sharma, S., & Dhiman, A. (2013). Design of antibiotic containing hydrogel wound dressings: biomedical properties and histological study of wound healing. International journal of pharmaceutics, 457(1), 82-91.
Tsourdi, E., Barthel, A., Rietzsch, H., Reichel, A., & Bornstein, S. R. (2013). Current aspects in the pathophysiology and treatment of chronic wounds in diabetes mellitus. BioMed research international, 2013.
Xu, F., Zhang, C., & Graves, D. T. (2013). Abnormal cell responses and role of TNF-in impaired diabetic wound healing. BioMed research international, 2013.
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