Vol. 8 Issue 21
Organized treatment plans bring success and closure of infected wounds
Nursing offers many challenges in the care of patients, one being the recognition and correct treatment of wounds. These wounds include surgical, chronic, environmental and even self-inflicted.
The human body is in continual contact with multiple microorganisms originating from both endogenous and exogenous sources. Usually, these microorganisms are present without any evidence of infection because a balance exists between the host immune system and microbial growth. Infection occurs when this balance is upset, either because of lowered host defenses or increased microorganism quantity or virulence.
Infection is related directly to the number of organisms and the virulence of the organisms, and is inversely related to the host resistance.
Breaks in the skin, including wounds, provide an opportunity for exogenous microorganisms to enter into deeper tissue layers and internal body structures where they can adhere and increase in numbers.
Growth of Microorganisms
The host responds to invading microorganisms in a wound in nonspecific and specific ways. The nonspecific response occurs regardless of the microbes. It is activated by generalized tissue injury and is classified as the first phase of wound healing. Called the inflammatory phase, it encompasses the first 3-5 days of healing and includes phagocytosis by leukocytes and macrophages, which work to clean up the wound.
The specific responses are initiated by the specific microorganisms and involve the immune system. Identifying these precise microbes makes it possible to be more accurate in treatment with antibiotics.
When the host resistance fails to control the growth of microorganisms, localized infection occurs. Uncontrolled localized infection of a wound can lead to deep, more severe infections such as extensive cellulitis, osteomyelitis, bacteremia and sepsis. The presence or increase of microorganisms on a wound surface does not necessarily represent infection. Contamination and colonization are conditions common to all wounds healing by secondary intention. Contamination is the presence of bacteria on a wound surface with no increase of bacteria. Colonization is the presence and growth of bacteria on a wound with no wound tissue penetration and no immune system response by the host.
In contrast, wound infection is multiplication of invasive bacteria within viable wound tissue, which usually has initiated a host response. (Individuals in immunosuppressed conditions or on immunosuppression drugs will have a reduced response to the inflammatory phase of wound healing.)
To support the definition, bacteria cultured from pus, necrotic tissue or slough does not give a true picture of possible bacteria in living tissue. A culture from deeper viable tissue or tissue biopsy is the most accurate standard for determination of virulent bacteria in the wound. If necessary, the medical professional is then directed by the laboratory sensitivities to the correct selection of antibiotic therapy.
Identifying Wound Infection
There are many times when a patient does not immediately see a medical professional, either because of patient limitations or physician availability. Knowing if and when to seek help requires a knowledgeable understanding of initial wound treatment with recognition of infection from immediate injury to 72 hours and then into subsequent weeks of treatment.
The most practical and common method to identify wound infection is to assess for clinical signs and symptoms. Those standard five signs include erythema, pain, edema, heat and purulent drainage. These signs and symptoms can be assessed by direct observation of the wound and surrounding tissue or as reported by a perceptive patient.
Acute wounds, such as surgical wounds, usually will present with the five classic symptoms. Chronic wounds do not always display the classic signs. This is likely due to diminished inflammatory responses among patients with comorbidities of diabetes, peripheral vascular disease, autoimmune diseases and other systemic disorders. The one exception to diminished signs in patients with comorbidities may be pain. In our clinical experience, pain in a wound with delayed healing has been shown to be a sign of infection even when the normal inflammatory responses of erythema, edema, heat and purulent draining are missing.
Along with the local wound, signs and symptoms, treatment evaluating the patient from a holistic approach:
How did the wound occur?
What came in contact with the wound?
Management of care to the wound
Emotional and mental status
Medications: prescription and over-the-counter (OTC)
Vascular and neurological assessment
Mechanical pressures to area
With these facts in hand, the pieces of the puzzle come together and a treatment plan can begin. It includes helping the patient correct factors that contributed to the infection, removing contaminated or necrotic tissue by a medical professional and wound treatment.
The wound treatment begins with cleansing the infected wound. There can be an overemphasis on wound cleansers. Normal sterile saline (NSS) is the most adequate for cleansing a wound. Homemade saline solution works well, but plain water is adequate. If we drink it and put it in our bodies, it is adequate for most wound infections.
The exception would be a heavily infected wound or skin area that is spreading. In that situation, an antimicrobial scrub may be ordered. It is usually applied twice a day for a limited period of time. Skin cleansers should never be used in a wound.
A small area with slight pain, slight erythema, no necrotic or slough tissue and minimal drainage can be treated with an OTC antibiotic ointment. In clinical practice, it has been observed patients do exhibit an allergic reaction to a specific ointment. Asking the patient what has worked for him in the past will help in determining a present course of treatment.
Instructing the patient in elevation or rest of the area, good nutrition and daily cleansing with applied ointment twice a day should be sufficient to resolve a small, localized infection.
Showering with an open wound is a debatable topic. Professionals on one side express concern about the amount of surface bacteria washed over an open wound, especially on the lower extremities, and request the patient cover the wound while bathing. Professionals of the opposite view believe water is healthy and important for cleansing and does not contaminate the wound surface. A 2-week limit with antibiotic ointment toward progressive healing is a good test as to whether the wound infection will resolve or need to be assessed by a medical professional.
If the wound is not responding to treatment and, after 4-5 days, is exhibiting the classic signs (or the predominant sign of pain in immunosuppressed patients), the patient should see a physician. In the interim, cleansing twice a day with water or NSS and applying an antimicrobial are important.
There are a variety of antimicrobial dressings on the market. The dressings are classified as advanced wound care products and need clear direction from a health professional. Some of these dressings are covered by health insurance plans, but require a prescription. Pharmacies do have the ability to order the products if on their formulary.
The body is an amazing creation made to protect patients from their environment along with enjoying the surroundings. When the host is overwhelmed by microbial invasion in a wound, an organized treatment plan needs to be in place to bring success and closure of infected wounds.
Gardner, S., & Frantz, R. (2004). Wound bioburden. In S. Baranoski & E. Ayello (Eds.), Wound care essentials: Practice principles (pp. 91-116). Philadelphia: Lippincott.
Kathy Gilchrist is program director of the Wound Healing and Hyperbaric Medicine Center at Paoli (PA) Hospital.