Watch Jenny Hurlow’s Report on the Treatment Plan

Jenny Hurlow, NP, reports on the treatment plan used in the case of a 57-year-old woman who presented with a suspected insect bite of her upper left arm that she sustained while driving her car approximately 6 weeks earlier.

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Transcription:

My goal of care with this six-week-old wound on this very anxious patient was to support healing while limiting aggressive debridement to try to mitigate her anxiety. Therefore, the wound hygiene protocol was initiated.

I first cleanse the full wound area, including the peri-ulcer skin, with a noncytotoxic antiseptic wound cleanser. Then, I sharply debrided that hard, a sharp cap that you see, and dry fatty necrosis as tolerated by the patient.

Then, I refashion the rolled wound edges by abrading the epidermis to promote flattening of the epiboly. Then, I ordered daily dressing changes within an enzymatic debrider.

The wound hygiene treatment protocol promotes attention to all aspects of a wound’s healing potential, with a two-fold goal of simultaneously controlling infection risk and supporting healing. The wound hygiene protocol involves cleansing, debridement, refashioning of the wound edges, and use of a wound dressing to address the needs of the wound.

It was developed to address the growing evidence that biofilm is a key pathology in nonhealing wounds. Like dental hygiene, regular practice of wound hygiene seeks to address the root cause of that pathology. As detailed in a 2020 consensus document, wound hygiene is a structured method for overcoming the barriers associated with wound biofilm.

So, returning to the case, here is the wound one week later. Epiboly has decreased. Epithelial migration with contraction was noted at the wound edges, and the amount of wound bed fatty necrosis was lessened.

Again, a noncytotoxic antiseptic wound cleanser was used to cleanse the full wound area. The wound was again debrided as tolerated with the goal of disrupting and removing wound bed biofilm as well as other nonhealing tissue. Edges were gently abraded, and the current plan of care with an enzymatic debrider was continued.

When she returned to the clinic the next week, ongoing healing was noted. The thick devitalized tissue was predominantly cleared, so an antimicrobial hydrofiber dressing was chosen to control the chronic inflammation associated with biofilm reformation. This patient was instructed to change the dressing every other day.

Two weeks later, increased granulation tissue was seen on the wound bed. The epiboly was nearly resolved. There was ongoing decrease in wound size, and no signs of acute infection were seen. The wound hygiene protocol was again used to guide wound care including cleansing, debridement, refashioning of the wound edges, and the use of AQUACEL^® Ag Advantage dressing.

The patient was instructed to decrease dressing change frequency to Q3 days to allow optimal use of this dressing to support moist wound healing and support autolytic clearing of a small area that you can see highlighted by an arrow, a small area of remaining adherent nonhealing tissue.

Two weeks later, the wound was much smaller, but I noticed a small hole in the wound bed at 7 o'clock, with a depth of approximately 3 millimeters, that coincided with the area of nonhealing tissue seen at the last visit 2 weeks earlier.

This patient reported that she'd been doing daily, instead of Q3 day dressing changes, because of the hot weather and she wanted daily showers, meaning that this dressing was not allowed to gel between dressing changes to support autolytic debridement.

The wound hygiene protocol of care was again instituted, with attention to debridement of that small hole at 7 o'clock. This degraded area was then lightly packed with AQUACEL^® Ag Advantage and secured in place with the silicone cover dressing that was kept in place until she returned in 1 week.

One week later, 6 weeks after she first came to the wound center, at which time the wound was already 6 weeks old, this wound was healed.

Although there's no clear benchmark to confirm how fast a chronic wound like this should heal, I think that the fact that it healed in the same amount of time that it had had remained nonhealing appears to support the merits of using the wound hygiene protocol of care and AQUACEL^® Ag Advantage.

Further, despite this wound’s chronicity and the elements of complexity, acute infection was avoided, and no systemic antibiotics were required.

Thank you.