Learning Objectives
By the end of this section, you will be able to:
- Explain the clinical implications of hyperbaric oxygen therapy
- Describe other common treatment modalities for wound care
- Examine the interdisciplinary team members and their roles in the treatment of the wound care patient
Sometimes wounds require specialized therapy or medical interventions. This module explores several treatment options used to manage and treat complex wounds. For example, hyperbaric oxygen therapy (HBOT) is known for treating deep sea divers affected by rapid changes in pressure around them. HBOT is also used to treat a variety of health problems, including wounds. As with all aspects of health and patient care, teamwork is essential for specialized interventions. From the bedside nurse to the occupational therapist, every team member plays a role in helping the patient achieve their wound care goal.
Hyperbaric Oxygen Therapy
HBOT involves breathing pure oxygen in a pressurized environment, known as a chamber. This type of therapy helps to heal wounds. There are two types of hyperbaric chambers: monoplace and multiplace. A monoplace chamber accommodates one person. It is a long plastic tube that resembles an MRI machine. The patient lies on a table within the chamber and breathes oxygen while the pressure slowly increases. A multiplace chamber (or room) can accommodate two or more people. Patients breathe oxygen through a mask or hood. HBOT prevents reperfusion injury and encourages formation of new collagen. Therapy typically lasts two hours. Examples of wound types treated by HBOT include radiation injuries, infections, burns, crush injuries, necrotizing fasciitis, decompression sickness, and gas gangrene. The most significant contraindication to HBOT is untreated pneumothorax. Other contraindications for HBOT include patient claustrophobia, COPD, history of seizures, febrile patients, or the presence of a pacemaker or implantable device.
Nursing Considerations
Hyperbaric oxygen therapy nurses are specially trained to assist with HBOT and supervise patients undergoing this type of therapy. The most common complication after HBOT is trauma to the middle ear; therefore, HBOT should not be used by those with recent ear injury or ear surgery (Sibbald et al., 2021). The primary safety concern during the administration of HBOT is that the use of concentrated oxygen is a fire hazard. Thus, fire prevention is critical. Use of scented perfumes, creams, or lotions is not advised while in the chamber. Examples of other prohibited items include all flammable materials, oils, silk, wool, synthetic textiles, matches, lighters, battery operated materials, electronic hearing aids, metal framed eyeglasses, contact lenses, jewelry, watches, dentures, and other devices. Patients are provided with 100 percent cotton gowns to wear rather than street clothes.
Other Common Wound Treatment Options
Some wounds require additional support to foster healing and or closure. Here we will discuss some of the common treatment options beyond topical.
Negative Pressure Wound Therapy
Vacuum assisted wound closure, or negative pressure wound therapy (NPWT), is a therapeutic technique that applies negative pressure to the wound bed to manage exudate and facilitate healing. The negative pressure applied to the wound bed allows for cells to quickly stretch to the point of replication, facilitating a healing environment for the stalled or difficult-to-heal wound. There are two types of NPWT: traditional therapy and single-use therapy (or portable therapy). Traditional NPWT includes open cell foam filler, cover dressing, fluid collection system, tubing, and a suction pump. Single-use therapy is typically used for incision management or shallow, difficult-to-heal wounds and may include a dressing attached to a pump that can be disposed of when therapy is complete. NPWT pressure ranges from 75 mmHg to 145 mmHg, depending on the type of wound, exudate level, and goal of therapy. Dressing changes occur every forty-eight to seventy-two hours, depending on the exudate level and dressing stability. Single-use devices may be worn as long as seven days. Contraindications to NPWT include untreated osteomyelitis, active sepsis, coagulopathies, allergies to NPWT components, and unexplored fistulas.
Link to Learning
This video describes how to use negative pressure wound therapy by applying a wound vac to a wound bed.
Drains
Surgical drains are tubes placed near surgical incisions in the postoperative patient to remove exudate, blood, or other fluid to prevent fluid accumulation in the body. The type of drain used is based on patient need, type of surgery, and amount of drainage. Common drains include the Jackson-Pratt, a soft, pliable tube and compressible bulb that creates negative pressure, and the Penrose, a flat, ribbonlike drain with gauze applied at the end to absorb drainage. The nurse’s role in managing drains includes assessing the insertion site, securement, drainage amount, and patency.
Interdisciplinary Collaboration
Wound care is a common concern across multiple disciplines, which is why interdisciplinary collaboration is critical to patient care. The team approach incorporates all facets of wound management into a cohesive treatment plan. Some of the team members are surgeons, nurses, podiatrists, physical therapists, dietitians, and accompanying specialists.
Wound Care Nurses Certifications
Wound care nurses assess, treat, and create care plans for patients with complex wounds. They also provide wound prevention recommendations, strategies, and interventions for at-risk patients. There are several avenues to obtaining a wound care certification, and not all programs are created equal. Table 28.6 explains the various certifications a nurse can pursue.
| Nursing Credentials | Certification Board | Description |
|---|---|---|
| Certified Wound Ostomy Continence Nurse (CWOCN) Certified Wound Ostomy Nurse (CWON) Certified Wound Care Nurse (CWCN) Certified Continence Care Nurse (CCCN) Certified Ostomy Care Nurse (COCN) Certified Foot Care Nurse (CFCN) |
Wound Ostomy Continence Nursing Certification Board (WOCNCB) | Only accredited certification by the Accreditation Board of Specialty Nursing Includes Advanced Practice designations RN and BSN minimum requirements Only designated for RNs |
| Certified Wound Specialist (CWS) | American Board of Wound Management (ABWM) | Requires BSN or higher Any licensed health-care, sales, or marketing professional can obtain |
| Wound Care Certified (WCC) | National Alliance of Wound Care and Ostomy (NAWCO) | Any licensed professional can obtain |
Physical Therapists and Occupational Therapists
Patients who are weak or struggling to ambulate may require the assistance of a physical therapist (PT). Physical therapists can create an exercise plan that strengthens the patient to help facilitate healing. Some physical therapists focus on wound care and are often the providers performing and making recommendations for care.
Occupational therapists (OT) also have a role within the interdisciplinary team. Prevention of wounds is critical, as discussed, and OTs are experts in the repositioning, placement, and use of equipment while analyzing patient activity. OTs can teach patients how to manage wounds while safely engaging in daily tasks. OTs also have special training to incorporate techniques to assist with the management of lymphedema.
Dieticians
Nutrition, though sometimes overlooked, is critical to successful wound management. For example, macronutrient and micronutrients are essential for proliferation. A dietician can create appropriate meal plans according to a patient’s dietary and nutritional needs for healing.
Pain Assessment and Management in Wound Care
A complete pain assessment enables the patient and care team to develop an effective pain regimen. Pain is commonly overlooked when assessing a wound. Dressing changes, debridement, infection, turning, and repositioning are some of the factors that can cause wound-related pain. Pain treatment varies according to the specific wound etiology and associated factors. For example, if pain results from dressing changes, it may be necessary to administer pain medication prior to changing the dressing or dressing type.