Managing a Traumatic Wound in a Geriatric Patient

    The aging process produces multiple changes in the skin and underlying tissues that render elderly persons more susceptible to injury and less able to heal. Clinical study results have documented a decline in the number of mast cells and compromised macrophage function that leads to a decreased inflammatory response, a limited mitogenic response of keratinocytes, response of fibroblasts, reduced rates of collagen synthesis, and slower epithelialization.^1–5

    All stages of wound healing are affected by aging1; the rate of cell proliferation, wound tensile strength, collagen deposition, wound contraction, and healing of blisters declines through the years.⁶ Although physiologic skin changes play a key role, healing also may be complicated by other problems commonly associated with aging, such as poor nutrition and hydration, the presence of a chronic condition, decreased perfusion, and the use of multiple medication.⁷

    Impediments to healing. Commonly cited factors that impede healing in older patients include slower turnover rate in epidermal cell; less efficient oxygenation at the wound due to increasingly fragile capillaries and a reduction in skin vascularization; reduced dermal and subcutaneous mass leading to increased risk of chronic pressure ulcers; and lack of tensile strength in a healed wound, putting the skin at risk for re-injury.^6,8,9
In addition, ischemic damage and subsequent necrosis of tissues resulting from intense or prolonged pressure can occur when older adults are bedridden, chairbound, or unable to self-reposition6 because the older adult has less fat and muscle mass to dissipate pressure. Other possible causes of devitalized tissue include neurologic or vascular disease, infection, medication reaction, urinary or fecal incontinence, and increased friction and shearing.^8-10 Hence, when considering treatment options, care must be taken to avoid putting the elderly patient at risk for further injury or skin compromise.

    Debridement. Debridement — commonly defined as the removal of necrotic tissue, exudate, and metabolic waste from a wound¹¹ — presents an opportunity to improve the healing process. The benefits of removing necrotic and devitalized tissue have been reviewed elsewhere^12,13 and are believed to include a reduction in wound bioburden, control and potential prevention of wound infection, improved wound assessment, and wound bed visualization. Necrotic tissue can impede wound healing related to protein loss, osteomyelitis, and generalized infection, potentially leading to septicemia, limb amputation, or even death.¹³

    In an otherwise healthy person, the body’s natural defenses will debride a wound. However, when the natural debridement process is ineffective, as in elderly patients and/or patients with comorbidities, the practitioner must intervene to prevent impaired wound healing. Debridement options include surgical, mechanical, chemical or enzymatic, and autolytic debridement.

    Chemical debridement. Chemical debridement involves the topical use of enzymatic gels and solutions that can dissolve necrotic tissue from the wound. The Agency for Health Care Policy and Research (AHCPR)¹⁴ recommends considering chemical debridement for pressure ulcers when individuals cannot tolerate surgery, if they are in long-term care facilities or receiving care at home, or when the ulcer does not appear to be infected. Generally, chemical debridement is an ideal option for patients who are unable to tolerate surgery or who are being cared for at home,¹⁵ such as the patient presented in this case study. Two of these enzymatic debridement agents, papain-urea and papain-urea-chlorophyllin copper complex products (Accuzyme and Panafil, respectively, Healthpoint, Ft. Worth, Tex) were used in this case study. Both have been shown¹⁶ to be clinically safe and papain-urea has been found to be efficacious for debridement of necrotic tissue in pressure ulcers.

    Alvarez et al,¹⁷ in a comparative, prospective clinical study of 26 nursing home patients with pressure ulcers, found papain-urea to effectively and quickly debride nonviable tissue. After 1 week of treatment, 80% of the eschar initially present had been removed as compared with wounds treated with collagenase, a statistically significant difference (P < .0167). The rapid debridement was associated with concomitant appearance of granulation tissue, no incidents of pain were associated with the treatment, and none of the patients withdrew from the study as a result of failure of the treatment regimen.

    In a safety study, a papain-urea preparation was applied to intact skin of 59 human subjects to evaluate the level of irritation and/or sensitization following multiple, repeated applications (10 applications per subject). No visible signs of erythema or edema were noted for any treated sites compared to corresponding untreated control site on any subject.¹⁶

    Alvarez et al¹⁸ conducted a safety study to determine any negative impact of a debriding agent on healthy tissue as evidenced by delayed reduction in transepidermal water loss (TEWL) in skin where the barrier properties of the skin had been compromised. The results of this study indicated no negative impact of papain-urea on intact skin. The manufacturer’s directions should be followed.¹⁹ To the author’s knowledge, no studies using the products from this case study in combination have been conducted.

Case Study

    History. Mr. H, a 75-year-old Caucasian man, was transferred from an acute care facility to a subacute care unit. A wound nurse was consulted for evaluation of an anterior pelvis wound. Mr. H’s admitting diagnosis was exacerbation of Parkinson’s Disease, syncope, status post fall, and anterior pelvis wound. His medical history included chronic obstructive pulmonary disease, coronary artery disease, myocardial infarction, hypertension, hyperlipidemia, and gastric esophageal reflux disease. He had no previous surgery.

    Mr. H’s pharmacotherapy included ciprofloxacin (500 mg PO BID times 14 days), metronidazole (500 mg PO every 8 hours times 10 days), guaifenesin (600 mg PO every 12 hours times 7 days), diltiazem HCl (240 mg PO every 12 hours), celecoxib (200 mg PO every 12 hours), zolpidem (5 mg PO nightly), aspirin (81mg PO daily), pergolide mesylate (0.75mg PO daily, later reduced to 0.5 mg PO daily), isosorbide mononitrate (30 mg PO daily), esomepreazole magnesium (40 mg PO daily), furosemide (20 mg PO every other day), azelastine nasal spray (two sprays each nostril every 12 hours), and acetominophen (grains X every 4 hours PRN) for pain. Although multiple medications and chronic conditions can complicate the healing process⁶ and clinicians should be vigilant regarding nonhealing or worsening wounds, these did not seem to affect the clinical outcome. The Registered Dietitian who was consulted noted that he tolerated meals with fair to improving appetite, maintained adequate fluid intake, and had a stable weight.

    Before his hospital admission, Mr. H lived home alone, ambulating and handling his activities of daily living independently with minimal support from his daughter and sister. For example, he was able to use a riding mower but relied on his neighbors for help with the additional yard work. The hospital admission was triggered by a syncopal episode caused by dehydration, culminating in a fall at home. The patient reported being too weak to get up from the floor where he fell; he remained there for approximately 24 hours. An anterior oval-shaped pelvis wound developed after the fall, possibly the result of laying on an object on the floor.

    Assessment and management. The wound nurse assessed a non-infected 6.4-cm x 3.8-cm superficial anterior pelvic wound involving the epidermal layer of skin. The wound bed was pink and no discharge or drainage was noted. Assessment of the wound was complicated by extensive periwound swelling and ecchymosis. No slough or necrosis was visible.

    The wound nurse recommended cleansing the wound with .9% saline solution, prophylactic daily application of a triple antibiotic ointment, application of a dry sterile dressing, obtaining a prealbumin level, providing pain management, and reassessing the wound in approximately 1 week. Mr. H’s prealbumin level was 20 mg/dL (normal range at this facility is 20 mg/dL to 40 mg/dL). A nutritional supplement was ordered three times daily with meals.

    At reassessment 1 week later (1 to 2 weeks is facility protocol), the pelvic wound measured 6.0 cm x 3.2 cm with yellow and white slough present at the wound base, decreased swelling, decreased ecchymosis, and a red periwound area. The wound nurse recommended discontinuing the triple antibiotic ointment treatment and instead using a papain-urea ointment, applied daily for slough removal, and castor oil/balsam of Peru/trypsin ointment (Xenaderm, Healthpoint, Ft. Worth, Tex) to the periwound area. Two weeks later, the wound measured 4.5 cm x 2.0 cm with decreased swelling and ecchymosis, increased thick, yellow slough at the wound base, and increased reddened periwound area. The wound nurse recommended a second dressing change nightly and use of the papain-urea-chlorophyllin spray (in addition to the papain-urea product) applied daily to aide in thick slough removal and decrease redness around periwound area, continuing the nightly application of the castor oil/balsam of Peru/trypsin ointment.

    At reassessment 2 weeks later, the wound measured 3 cm x 1 cm with minimal yellow slough at the wound base and no periwound redness. Mr. H was educated on wound care and discharged home 1 week later, the wound measuring 2.3 cm x 1 cm with minimal yellow slough, and no redness, swelling, or ecchymosis. Mr. H was discharged with a prescription for papain-urea-chlorophyllin cream to be applied once daily. A referral for home health care was initiated for follow-up wound care with daily dressing changes, recommended by the manufacturer, to reduce risk of wound site irritation. Mr. H was able to change his own dressings and could bathe as long as the dressing remained dry. His progress was followed by a home health nurse who was instructed to report signs of skin irritation, rash, pain, and/or necrosis to the physician, per manufacturer recommendations (see Table 1).

Discussion

    Effective wound management in a geriatric patient requires an understanding of skin changes that influence healing. A geriatric patient’s skin tends to be thinner, less vascular, and dry, has less subcutaneous tissue, less thermoregulatory control, compromised sensory receptors, and delayed healing time compared to a younger adult patient.¹ In addition, wound assessment in a geriatric patient after a traumatic injury may be difficult related to swelling and ecchymosis of the area. Product choice to facilitate healing must take these factors into consideration, as well as size, position, and type and condition of wound; moisture level; time available for debridement; and the type of healthcare setting.²⁰ When Mr. H’s wound worsened and exhibited yellow slough, the preferred strategy was to use enzymatic debridement to remove necrotic tissue and cell debris from the wound.²⁰ The decision to use a combination of products was based on the clinical judgment of the wound nurse after assessing the condition of the wound and presence of necrotic tissue. Also, even though Mr. H’s prealbumin was within range, he was considered to be at nutritional risk based on his fair to improving appetite; hence, additional nutrition (liquid dietary supplement) was added to his plan of care. No further prealbumin test was conducted but his improved intake could have affected the wound progress observed.

Conclusion

    When managing a traumatic wound in an elderly patient, physiological factors of aged skin and patient condition are key considerations. Thorough assessment and re-assessment are essential. Product choice is dependent on the individual’s unique requirements; in the case study, alternating chemical debriding agents was a safe and effective clinical management option for this geriatric client. Extra vigilance is required to assess wounds in geriatric patients to achieve optimum results — frequent wound reassessment of at least once every week to 2 weeks is necessary to determine evidence of healing in the geriatric client with a traumatic wound. If no progress is demonstrated, the overall treatment plan needs to be re-evaluated. Further research is recommended to study clinical management of traumatic wounds in the growing geriatric population.

Acknowledgment

    The author thanks Helene Ortiz, RN, BSN, graduate student, for research assistance in manuscript preparation. The author additionally is grateful to her colleagues, associates, and the Administrators at Kennedy Health Care Center who demonstrate everyday the value of teamwork in maintaining quality patient outcomes.