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Because of the serious complications that can arise from wounds, I cannot stress enough the need to understand wound care and treatment.

For current information, please see:

How to Treat a Lymphedema Wound


Here is an interesting article I ran across about wound care

As the population ages, we develop disorders such as
lymphedema from previous cancer surgery or secondary lymphedema that result from previous radiation treatment. The biggest challenge we see with lymphedema and wound healing relates to lymphedema of the lower legs. The average age of patients with chronic wounds for persons with diabetic foot problems is about 60 and persons with venous leg ulcers is about 70 years old.

This challenge may also be from individuals with primary lymphedema or persons born with a propensity to develop increased swelling although this swelling may not be apparent at birth, it's often delayed into the teen years and sometimes even into adult life.

The third group we see, are those individuals with venous disease and with venous leg ulcers that are inadequately treated for years and develop secondary lymphedema to chronic venous disease. In this group, good preventative measures and good education would prevent the seondary lymphedema entirely!

Then there's a fourth group that relates to individuals who have increased body weight. In these individuals the venous return and the lymphatic return to the heart is obstructed so that lymphedema develops. This can be a vicious cycle, which requires working with the patient to control the weight problem.

The influence of low albumin in wound healing

Having a low albumin can result in lymphedema. Albumin refers to the protein that circulates within the vascular system. One of the roles of the albumin is to keep this fluid within the vascular space. This is determined by how much albumin is in the blood. Normal albumin is greater than 30. When the albumin is under 25 you get some impairment in healing of chronic wounds. When that number is under 20 you don't have enough circulating protein within your vascular system and fluid tends to leak out of the vascular system. This taxes the lymphatics. If the lymphatics cannot handle the increased fluid reserve, then it stays in the tissue. This really sets
the stage for, first of all, pitting (finger imprint remains after pressing on the swelling) edema, and with time non-pitting edema, or lymphedema.

Preparing the wound bed

Preparing the wound bed really starts with the patient. You must look at addressing the cause of the wound, but first you've got to remember that you have to treat the whole patient and not just the hole in the patient. We also have to look at patient centered concerns.

Compression therapy is important for lymphedema but there are pain and quality of life issues. Considerations include the warmth and the
uncomfortable nature of some of the bandaging and compression garments, particularly during hot summers like the one we've just been through. You've also got to look at the patient's ability to buy bandages, stockings and lymphedema devices which may not be covered by health care or private insurance plans. These items can become very expensive so that individuals cannot afford them. Lymphedema sufferers can end up being fitted before the
edema comes under adequate control. When this happens individuals can have a custom made garment which costs a lot of money and might end up not fitting them when their pitting edema is controlled.
Although we have newer biological and adjunctive therapies, our practice in chronic wounds is not ideal. Our approach to chronic wounds includes getting rid of the grunge, looking at the excess bacteria that can sometimes creep up on us, and then examining moisture balance.

There are three steps we should look at in trying to adequately prepare the wound bed for healing:

i) adjunctive therapies
ii) enzymatic therapies
iii) other interventions that help the wound to heal

i) Adjunctive therapies:

The first step is debridement which is the removal of dead tissue. Dead tissue provides a wonderful growth media for bacteria. Dead tissue sitting on the top of the wound also stimulates an inflammatory response. A wound may get stuck in the inflammatory stage and not move along the ladder to the active healing stage so we have to get rid of that debris. Sometimes the debridement stage is performed surgically, other times it can be done with
dressings. Dressings that perform autolytic debridement ideally include hydrogels and hydrocolloids. Examples of these might include Intrasite and duoderm gel as hydrogels and DuoDERM, Comfeel and Tegapore as hydrocolloids.

Debridement can also be done through mechanical means such as a "wet to dry" technique. "Wet to dry" to the lay person means putting saline soaked gauze to the wound, letting it dry out and yanking it off. It causes pain, bleeding and is really not very patient friendly. It is also very nursing time intensive. This process can also be very damaging to the wound because it can leave pieces of gauze behind. It's an older method but is still widely used. One of the reasons it is widely used is because saline and gauze is cheap - but if you look at the nursing time involved it is not a very good treatment for modern medicine when we've got better techniques

ii) Enzymatic therapies:

There are enzymes available in Canada which can used to debride wounds. Currently Collagenase (Santyl) is the only product available in Canada. There probably will be others in the future.

Sometimes the scab on the wound has to be scored with a blade by a health professional to facilitate penetration of enzymes to debride the wound. A scab is dead material and if it is completely necrotic it may be black and hard. If it has increased bacterial growth in it may have an odour.

Once the wound is debrided, the next issue is the bacterial balance. If there's loose slough, smell or very friable granulation tissue (which means it bleeds easily) it's a bright red and almost too good to be true, and the wound stops healing or it has an increased discharge: all of these signs may mean the surface of the wound has too many bacterial cells.

iii) Other techniques:

Surgery is sometimes used to remove the dead material within a chronic wound and that is safe for people with lymphedema. One may have to use pain medication before surgery is done. Surgery to remove large areas of live lymphedemtous skin is usually frought with complications from recurring infections and problems controlling residual edema within surfaces which are irregular. For this reason it is not recommended at the present time.

Fungal/bacterial situations:

To prevent fungal infections persons with lymphedema should inspect their feet particularly on a daily basis. That is to make sure their feet are dry between the toes. Fungal infections always start between the fourth and fifth toe and then spreads to the large toe because the fourth and fifth web space is the smallest space between the toes so that it gets the warmest and it experiences the most occlusion and friction.

What you first see in the toe web space is a white overly wet surface scale that we call maceration. Around the edge of that you may see a little rim of scale and may have an active margin. The other thing that may tip us off is a foul odour which usually means that anaerobic bacteria are present. And that of course can be an entry point for infection (cellulitis). Often untreated athletes' foot can be the source of recurring infection in the legs so this is really an important thing to pay attention to.

There are very good over the counter agents to treat this. Tenactin has been available since the 60's but it is much less effective than Clotrimazole or Miconazole which can be used to treat the fungus (70-80% effective). When these agents fail, Lamisil (terbinafine) is about 90% effective. The fungus can also involve the nails and the plantar skin of the feet. If it involves the plantar skin, you will see a white fine white powdery scale that goes around the sides of the feet. The involvement around the sides of the feet with a fine red line at the margin is often called a moccasin change to reflect the area usually covered by a moccasin. The fungal infection can also involve the nail which results in streaks starting distally. Nail fungus often starts asymetrically and then becomes symmetrical. With time the whole nail becomes thick and sometimes even destroyed.

Once you have nail involvement then you need a culture because nails can be abnormal simply with lymphedema by itself. Unless there is a culture which shows fungal filaments and/or the growth of the fungus, you should not use oral anti-fungal agents to treat nail abnormalities.

You should make sure your physician takes a culture before taking oral Lamisil which may be the preferred drug for fungal infections of the nail.
The health care professional has to check that there are no other drugs you are taking that might interact or change its effectiveness. Your doctor should probably do base line liver test although Lamisil only effects 1 in 10,000 people in terms of liver function abnormalities. Topical creams are safe and very few people react to them. Persons with lymphedema and anybody with chronic leg problems and ulcers should avoid substances that could cause allergies. We cause allergies in 50% to 70% of people with some products. The topical antibacterial Neomicin should be
avoided which also cross sensitizes you and wipes out intravenous Gentamicin and a lot of very important systemic agents.

Maintaining the skin moisture balance Two things can be done to keeping the moisture balance in the skin. The stratum corneum (top layer of the skin) normally has about a 10% moisture content when it dips below 10%, you start to get dryness and flakes. Next you start to get the cracks and of course, the cracks or fissures, particularly in people with lymphedema, can be the areas of source of entry for the infection.

Dry skin should be monitored and watched very very carefully. In order to treat the cracks and fissures we can either lubricate, which is like putting vaseline or something oily on the surface and preventing insensible water losses. Alternatively we can put chemicals on the surface of the skin that actually bind water - and the two important ones are urea or lactic acid. They keep the stratum corneum moisture content for above 10%. Some of these
include: Uremol, Dermol therapy, Lachydrin lotion and Dermalac cream. The most important time to apply these is after bathing, padding off excess moisture and applying the cream while damp.

If you dry a wound/open skin sore out you get a California raisin. A scab does not promote cellular growth and healing. So that is why we look at moist interactive dressings. These include calcium alginates absorb a fair bit and also help with bleeding. Hydrogels and hydrocolloids are relatively neutral and for protection we use absorbant foams. Povidone-iodine, acetic acid, hydrogen peroxide and or Dakin's solution (sodium hypochlorite) should not be used to treat healing chronic wounds.

Patients should avoid any agent that contains lanolin, which is a low
sensitizer in normal people. It is a moderate sensitizer in people with asthma, hay fever and/or eczema and it is a high sensitizer for people with chronic leg problems. Over the counter products such as Keri Lotion act as lubricants but you have to be careful that they don't contain perfumes, which are another common sensitizer. Another major skin allergen is bacitracin which in found in Polysporin ointment but not polysporin cream. It often results in contact dermatitis. I don't recommend Neosporin because it has neomycin in it and neomycin is a common allergen.

Unfortunately in Canada there is no requirement to list ingredients in these products but it is compulsory in the United States. Many manufacturers voluntarily put it on their label but not all. Patients need to be informed consumers when buying topical over the counter pharmaceuticals.

Home remedies

Some patients use home remedies to reduce costs. Some are more effective than others. No product should be used without the knowledge and support of your doctor or specialist.

Bleach: Bleach is sodium hypochlorite. It's fine for your tabletop and your kitchen because it's a sanitizer. It's far too harsh and should not be used on skin since it can cause areas of breakdown.

Crisco: Crisco is an excellent lubricant, which has been used by dermatologists for very sensitive areas of the body. It has not shown any major complications as far as I am aware. Of home made remedies, this a better one.

Honey: Honey, of a commercial grade, can contain a certain number of bacteria that an individual could introduce into a wound including "botulism". The honey that has been shown to be beneficial against some resistant bacteria is predominantly produced from the Manuka plant, which is native to New Zealand, and that is the Manuka honey. This product is not currently widely available in Canada.

The problem with the honey is that it really doesn't perform
autolytic debridement (clean the wound), it doesn't maintain moisture
balance and it may only superficially address the bacterial balance -it does not eliminate it, it just reduces their number. We have agents that do a far better job in preparing the wound than honey.

Tea tree oil: Tea tree oil is something that may have some
anti-bacterial and anti-fungal properties, but it is relatively expensive and can occasionally be an allergen. It has not really shown to address the other components in preparing the wound bed that we would like it to do.

Salt water: Salt water is simply saline. If you want to make your own salt water, that is fine as long as you don't dry the wound out. The new modern dressings really do better now. But you can make your own salt water by putting a teaspoon of salt in 8 ounces of water and micro waving it or boiling it but you have to remember that since the volume decreases with boiling it might be better to put your salt in after you boil it.

Baking soda: Baking soda is something that you can use to clean clothing and surfaces - but it is not recommended for the treatment of wounds. It tends to be slightly alkaline which promotes bacterial growth in chronic wounds which can delay healing, and it stings and burns. It would be better to use dilute vinegar which is more effective, but also often stings or burns.

Menstrual pads or diaper material as dressings: Menstrual pads or diaper material can be used as dressings on wounds - but individuals should look at some of the newer products out there before they use them. Non-sterile dressings can be bought in bulk at home health store or through a medical supplier reducing costs.

All chronic wounds contain bacteria. That bacteria is usually there as a contaminant or as a colonized bacteria that don't cause the wound any harm. When you go to buy gauze pads you don't need to buy the individual sterile ones, you can buy the bulk clean ones. The only exception is for somebody who is immune compromised through, for example, breast cancer operations, chemotherapy or radiotherapy treatment. In these situations sterile dressings are recommended.

Appropriate use of antibiotics
There is a use and abuse of antibiotics. If there is a definite infection - then we have to use systemic antibiotics. If we don't use antibiotics, the infection can cause damage to the tissue which can make the lymphedema worse.

There are antibiotics that we use, long term in acne, that are equally beneficial in lymphedema because these antibiotics also contain anti-inflam matory actions. The anti-inflammatory actions may help us in terms of preventing recurrent infections. Repeat infection cause even more damage to the lymphatics and more selling in the long term. If an individual has had two or three episodes of cellulitis in the past, using these long term - antibiotics and sometimes rotating them - is often useful. The drugs I am talking about are erythromycins, tetracyclines, trimethoprin and

In selected situations we may use Bactroban which is very good for
Methicillin Resistant Staphylococcus Aureus (MRSA - resistant
pathogens/bacteria). But as soon as we get a lot of swelling, redness, tenderness around a wound and pain, and especially if it probes to bone, then that requires oral or intravenous antibiotics and we're really looking at systemic agents to control infections. If there is an increased discharge and foul odour, antibiotics have to be used intermittently.

With pseudomonad bacteria, which can be common in people with lymphedema, we take a four-pronged approach: dilute white vinegar 1:5 or 1:10; topical agents such as silver sulfadiazine. The third step to use is oral agents such as ciprofloxicin. And when that fails we have to go to intervenous antibiotics.

Future directionsWe are now moving into a high-tech age where genetic research may find the cause of many lymphedema related disorders. We may be able to treat lymphedema genetically through cellular or gene therapy!

We will likely have more biological agents to treat wounds more effectively in persons with lymphedema and we may be able to find what is missing in a chronic wound and what treatments will stimulate it to heal. This may be a way to deliver anti-bacterial agents.

Unfortunately it is going to take a long time to treat wounds that way. In the mean time we are going to have to develop better health care systems which offer improved diagnosis and treatment in this area. And access to the expert clinics to ensure that intervention for these problems occurs at an earlier stage.

Dr. Gary Sibald




RNWeb® Archive
Jan. 1, 2000

A practical guide to wound care

JULIA THOMPSON is a wound and ostomy nurse at Scripps
Mercy Hospital in San Diego, Calif.

KEY WORDS: Wound care, assessment, documentation,
cleansing, dressings

Getting a wound to heal may well depend on your
ability to assess, clean, and dress it properly. In
this article, we cover the basic protocols for wound
care, along with the myriad dressings available today.

John Townsend is an 80-year-old incontinent patient
with a right, below-the-knee amputation, end-stage
renal disease, and Type 2 diabetes. He's brought to
your hospital from a local nursing home for a workup
of abdominal pain. During his initial assessment, a
dressing on his sacral area is removed, revealing a
stage III pressure ulcer.

If you were Mr. Townsend's nurse, would you know how
to care for his wound? It's a common one, to be sure,
but it can be perplexing to the nurse who doesn't have
a solid understanding of wound care. In fact, her
tendency might be to quickly reapply a dressing–any

Knowing how to choose the right type of dressing is an
indispensable part of any wound care plan. So is
knowing how to clean a wound and how long to leave a
dressing on. This article, based in part on guidelines
from the Agency for Health Care Policy and Research,1
will discuss these care principles as they relate to
wounds in general.

Take a good look, then document what you see.

Effective wound care begins with an assessment of the
entire patient. On admission, get a complete health
history and do a thorough physical assessment.1 This
will help you identify the probable cause of the wound
and any contributing factors.

Next, examine the wound itself. Document its location
and size, noting its length, width, and depth in
centimeters. Also note the appearance of the wound bed
and surrounding skin. Check both for sinus tracts,
undermining, tunneling, exudate, drainage, necrotic
tissue, and signs of infection. You may also want to
photograph the wound if that's what your facility's
protocol dictates.

Document, too, how long the patient has had the wound.
Record any previous treatments and their results, and
whether the patient has any known allergies to wound
care products.

Based on Mr. Townsend's history and physical, you
determine that his pressure ulcer was probably caused
by a couple of factors. Since his amputation, he has
spent most of his time in bed or a wheelchair,
allowing pressure and shearing forces to break down
the skin on the sacrum. Also, because he has diabetes
and end-stage renal disease, you suspect he is
malnourished, a condition that contributes to skin

Mr. Townsend's physician orders a specialty support
surface designed to reduce pressure and shearing
forces. (We'll cover specialty mattresses and beds in
the Market Choices department in March and April.)
You'll plan to turn him every two hours and position
him on his side. You'll also submit a request for a
nutritional evaluation.

Your wound assessment shows Mr. Townsend's sacral
wound to be 4 cm long, 6 cm wide, and 2 cm deep. The
wound bed is composed primarily of beefy red
granulation tissue–a sign that the wound is trying to
heal itself–with some yellow slough at the base. There
is 2 cm of undermining around the entire circumference
of the wound. And, while there is a moderate amount of
exudate, there is no foul odor. The surrounding skin
is intact but fragile.

Mr. Townsend tells you that he developed the wound
about a month ago. He's not sure about past treatments
he received for it, and says he has no allergies.

If Mr. Townsend's wound had shown signs of local
infection–pain, foul drainage and odor, redness,
tenderness, swelling, and an abnormal firmness around
the wound edge and adjacent tissue–you would have
treated it with a topical antimicrobial such as silver
sulfadiazine (Silvadene).1 If he had had signs of a
widespread infection, such as sepsis or bacteremia or
cellulitis in the surrounding tissue, you would have
taken a culture–the results of which would be used to
choose an effective systemic antibiotic.

When performing a culture, it's important to use
proper technique. The book, Acute & Chronic Wounds:
Nursing Management, is a good resource on this

Once you've assessed the wound and finished any
initial interventions, it's time to establish a local
wound care protocol. Depending on the facility, a
nurse may recommend a certain protocol to the
physician, who will then write the actual order. There
are four components: cleaning, dressing, determining
the frequency of dressing changes, and reevaluation.
Use the right cleanser at the right pressure

The goal of cleaning a wound is to remove dead tissue
and debris, which impede healing. You should use
products like sterile saline or a commercially
prepared non-cytotoxic wound cleanser like Comfeel
Sea-Clens (Coloplast Corporation, Marietta, Ga.) or
ClinsWound (Sage Laboratories, Inc., Shreveport, La.)
and wear a pair of protective goggles. Don't use
ordinary skin cleansers that are not FDA-approved for
open wounds. Antiseptics such as povidone iodine
(Betadine Antiseptic), sodium hypochlorite (Dakin's
solution), and hydrogen peroxide are not appropriate
for open wounds either; studies have shown that these
products are toxic to cells.1

If the wound has no necrotic (black) tissue or yellow
slough, use gentle pressure–about 4 to 5 psi–to clean
the wound. You can do this by applying the cleaning
fluid through a 60 ml catheter tip syringe. Pouring
the solution from a bottle or using a spray bottle or
bulb syringe may not provide enough pressure to do the

You will need to use more pressure to remove debris
from wounds with necrotic tissue and slough. You can
either place saline or a surfactant wound cleanser in
a 30 ml syringe and attach it to an 18- or 20-gauge
needle or use a pressurized irrigation system. (Saline
is also available in pressurized cans.) Whatever
device you use, just be sure not to deliver more than
15 psi. Doing so could traumatize tissue and drive
bacteria into the wound bed.1

Consider using a whirlpool treatment for wounds that
have a thick layer of exudate or slough.1 Position the
patient so that his wound is not directly in front of
the water jets. To prevent trauma to newly
regenerating skin, discontinue the whirlpool treatment
as soon as all debris is removed.

Whatever debris can't be removed during cleaning may
need to be removed with chemical or surgical

Picking a dressing, evaluating your plan

After the wound is cleaned, you will need to dress it.
The box entitled, "Wound care dressings at a glance,"
lists 10 main categories of dressings along with
indications and nursing considerations. This month's
Market Choices department lists specific wound care
products and their features.

Most dressings are designed to maintain a moist–not
wet–wound bed, which has a number of advantages. It
enhances cellular activity in all phases of wound
repair. It facilitates autolytic debridement of
necrotic tissue. It enables epithelial cells to
migrate into the wound bed–something they can't do
when the bed is dry and crusty. And it insulates and
protects nerve endings, thereby reducing pain.

Moist healing does not promote infection. In fact, the
infection rate for all types of moisture-retentive
dressings is 2.5%, compared to 9% for dry dressings.3

Moisture does, however, make the skin more susceptible
to injury, so you may want to apply a skin sealant or
protectant to the skin around the wound before you
dress it to keep it dry. It is an especially good idea
when there is drainage or when the wound is located
near the perianal area of an incontinent patient. You
can also apply a skin sealant to fragile periwound
skin to keep it from tearing when you remove the

Keep in mind that the moisture content of a wound can
vary as it heals. So it's not unusual for a wound to
need extra absorption at one point and then extra
moisture at another.

The schedule for dressing changes will depend, in
part, on exudate and drainage. In general, the more
exudate/drainage, the more frequent the dressing
change. The box entitled, "Wound care dressings at a
glance," provides a more specific timetable for each
type of dressing.

Assess and clean the wound bed at each dressing
change. Remember to follow basic infection control
measures to prevent cross-contamination. Thoroughly
wash your hands and change gloves between each patient
contact, for example.

You'll reevaluate the treatment protocol according to
the time frame set by your facility's policies and
procedures–earlier if there's an immediate problem,
such as the dressing becomes loose before its
scheduled change time.4 During reevaluation, don't
just measure the wound. Make sure you assess it to see
if it has improved. If not, you will need to consider
whether you have correctly identified all of the
causative factors and whether you need to change the

Keep in mind that no wound care product can overcome
poor clinical practice. I've seen patients positioned
directly on their pressure ulcer! Practices like that
obviously negate any healing effects of the wound care

A positive outcome for our patient

When helping formulate a wound care protocol for Mr.
Townsend, you suggest to his physician that you use
sterile saline in a 60 ml catheter tip syringe for the
wound cleansing. Because his ulcer has moderate
exudate, you would like to use an alginate pad for his
primary dressing. A secondary dressing of transparent
film will hold the non-adhesive pad in place. A skin
sealant will help protect the fragile periwound skin
from fecal matter and tearing.

Because there is a moderate amount of exudate, a daily
dressing change is called for. The doctor approves of
the treatment plan and writes the order for it. You
will reevaluate it in a week.

In the meantime, Mr. Townsend's nutritional evaluation
confirms that he was not getting enough nutrients to
promote wound healing. So his doctor orders
supplemental oral feedings and a daily, high-potency

By the end of the first week, an increase in
granulation tissue and a decrease in slough are
evident. By day 14, healing has progressed, as
evidenced by a decrease in undermining to less than
1.5 cm and an increase in granulation tissue. You and
his other nurses continue the protocol. When Mr.
Townsend is discharged to his nursing home a few days
later, the wound is well on its way to complete

When any type of wound develops, it's a disheartening
experience for patients and staff alike. But with an
understanding of wound assessment, documentation, and
the components of a good care plan, nurses can make
the experience as short-lived as possible.


1. Bergstrom, N., Bennett, M. A., et al. (1994).
Treatment of pressure ulcers: Clinical practice
guideline, No. 15. (AHCPR Publication No. 95-0652).
Rockville, MD: Agency for Health Care Policy and
Research, Public Health Service, U. S. Department of
Health and Human Services.

2. Bates-Jensen, B. (1998). Management of exudate and
infection. In C. Sussman & B. Bates-Jensen (Eds.),
Wound care: A collaborative practice manual for
physical therapists and nurses (pp. 165 – 166).
Gaithersburg, MD: Aspen Publishers.

3. Keast, D. H., & Orsted, H. (1998). The basic
principles of wound care. Ostomy and Wound Management,
44(8), 24.

4. Mulder, G. D., & Haberer, P. A. (Eds.). (1998).
Clinicians' pocket guide to chronic wound repair (4th
ed.). Bethlehem Pike, PA: Springhouse Corp.


Morison, M. (1997). A color guide to the nursing
management of wounds (2nd ed.). Prescott, AZ: Wolfe


Signs of Wound Infection

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