Open Wounds and Ulcers
Open wounds and ulcers are serious concerns, especially for the elderly. It’s important to understand the differences as well as treatment and management options.
An open wound is an injury involving a break in body tissue, usually involving the skin.
There are five types of open wounds:
- Abrasion: An abrasion occurs when the skin scrapes against a rough or hard surface. Often, these types of wounds are treated at home. Clean the wound, scrubbing lightly, to avoid infection. It is important to wash your hands and work on a clean surface when changing bandages and dressings. Disinfect and dry the wound thoroughly before redressing.
- Incision: A sharp object, such as a knife, causes an incision that bleeds a lot. With deep incisions, tendons, ligaments, and muscles may be damaged. A doctor generally treats incisions, and a serious incision may be considered an emergency.
- Laceration: A laceration is an irregular break or tearing of the skin, commonly caused by tools or machinery. Lacerations bleed extensively and are considered an emergency.
- Puncture: A puncture is a small hole caused by a long, pointy object, such as a needle, ice pick and a bullet. Punctures can be deep enough to damage internal organs. Depending on the depth of the wounds (bullet or needle) a puncture wound may be an emergency. Puncture wounds generally require a tetanus shot.
- Avulsion: An avulsion is a tearing away of skin and tissue, usually occurring during violent accidents. They bleed heavily and rapidly and are an emergency situation.
A chronic wound may be defined as any wound that is failing to heal as anticipated for a period of six weeks or more. Chronic wounds result from an alteration in one or more of the phases of normal wound healing. It is now thought that most chronic wounds are stuck in the phase known as early inflammation. Chronic wounds are often biopsied for possible malignancy, bacteria and fungal etiologies.
Treatments may include:
- Leg compression
- Debridement, meaning that the dead tissue is cut away.
Bedsore; Decubitus ulcer
Pressure ulcers are caused by prolonged pressure to the skin that reduces blood flow to the area. You are more likely to get a pressure ulcer if you:
- Are generally in poor health and are malnourished
- Use a wheelchair or stay in bed for a long time
- Are an older adult, as skin can be thinner and regenerates more slowly
- Cannot move certain parts of your body without help because of an injury or disease
- Are a heavy smoker as it limits oxygen in the blood
- Have Alzheimer’s disease or another condition that affects your mental status
- Have urinary incontinence or bowel incontinence.
Symptoms of a pressure ulcer in order of seriousness are:
- Red skin that gets worse over time and that doesn’t lighten when touched
- The area forms a blister, then an open sore
- Yellowish, dead skin may develop
- The damage extends beyond the primary wound
If you have a pressure ulcer:
- Relieve the pressure on that area, using pillows, foam cushions, or sheepskin to reduce the pressure. Do not use donut shaped rings as they may interfere with blood flow.
- Eat healthy foods and drink adequate water.
- Clean the ulcer as per directions from your doctor. It is important to do this properly to prevent infection. Generally, pressure ulcers are rinsed with a salt-water rinse to remove loose, dead tissue. The sore should be covered with special gauze dressing made for pressure ulcers.
- Your doctor may prescribe medications that promote skin healing.
- If the pressure ulcer changes or you get a new one, tell your doctor or nurse.
- Do not massage the wound, as that may cause additional doctor.
Signs of infection may include:
- A foul odor from the ulcer
- Pus coming from the ulcer
- Redness, tenderness and warm swollen skin around the ulcer
- Signs of infection can include fever, weakness, and confusion.
To prevent pressure ulcers, change positions or have your caregiver assist you in changing positions every two hours. Do frequent examination checking for reddened areas that do not turn white when pressed. Also look for blisters, sores, or craters.
“Stasis” is a Greek word meaning ‘the posture for standing’ and is derived from the Greek ‘histemi’ meaning ‘to make stand still.’ A common location for a stastis ulcer is the ankles which makes sense as they usually develop where circulation is poor. Blood tends to pool in the veins of the lower legs and ankles. Fluid and blood cells leak out of the veins into the skin and other tissues, which can lead to itching and inflammation. This is called venous insufficiency and it’s a chronic condition.
Symptoms of venous insufficiency include:
- Dull aching or heaviness in the leg
- Pain that gets worse when you stand
- Swelling in the leg or legs
- Brown stains on the skin
- Skin may become irritated or cracked, red or swollen, crusted, or weepy.
Exams, Tests and Management
Treatment may include the use of compression socks to reduce swelling, avoiding standing or sitting for prolonged periods of time, raising your legs when sitting and possible surgery for varicose veins. Some skin lotions are very drying, so ask your doctor what lotions are best for you.
Call your doctor if you develop leg swelling, open sores, pain and redness, as these pain be signs of infection.
There are phases to wound healing and the inflammation is the first stage in the wound-healing process. Everyone with a wound or caregivers caring for someone with a wound should understand the role of inflammation and the inflammatory response in wound healing so as to be able to assess when the process is not progressing as anticipated.
The quality and extent of the inflammatory response in a wound will be dependent on the severity of the injury as well as their general health, their nutritional state, hydration and any existing disease states, such as diabetes.
Inflammation is characterized by the classic signs of heat and redness, pain and swelling, raised temperature and fever. The overall function of inflammation is to destroy any toxic agents at the site of an injury and to restore tissue.
The next phase is regeneration (also called proliferation) and during this phase the wound is ‘rebuilt.’
Foods that help you heal: Recovery Foods
Without proper nutrition the whole process of wound healing can be negatively impacted. Your diet during recovery plays a critical role in how fast your wound heals, how strong the wound tissue becomes, the duration of the recovery period and how well your body fights off infection. A poor diet can turn a normal wound into a chronic wound that never seems to be get better.
The Catabolic Phase
Even a small wound can alter the way the body metabolizes nutrients. As the body heals itself from a wound, it will divert extra resources from carbohydrates, fats, proteins, antioxidants and more to the creation of new tissue. This is referred to as the catabolic phase of healing where metabolism essentially speeds up.
If the catabolic phase lasts too long, protein energy malnutrition (PEM) can set in, which slows wound healing and deteriorates your health. The body needs extra protein to heal the wound and other important body systems and organs don’t receive enough protein, as it’s being diverted to the wound site. This can lead to reduced muscle mass and delayed wound healing.
Good nutrition is necessary for healing. During the healing process, the body needs increased amounts of calories, protein, vitamins A and C, and sometimes the mineral zinc.
Protein is the most important aspect of your diet when healing from a wound. Energy (calories from carbohydrates and fats), amino acids, antioxidants and minerals (zinc) are also important. Dietary needs should be calculated on an individual basis as we are all biochemical individuals. Your doctor or nutritionist may adjust the levels of nutrients to suit your needs and promote healing. The following guidelines are generalizations, but will give you an idea of what your diet should include.
Protein helps repair the damaged tissue from your wound. You’ll want to take in more protein than usual to help the healing process. This means 2 to 3 servings of protein a day, with each serving containing at least 2 to 3 ounces of meat, or 1 cup of beans/legumes or 2 tablespoons of peanut butter or other nut butter and raw nuts and seeds.
To consume the higher protein amounts needed for wound healing, some patients may require supplementation. The most common way to supplement protein is to add protein powder or liquid protein to the diet, generally added to smoothies.
Fats are essential for wound healing, particularly omega 3 fatty acids found in cold- water fish, flax, walnuts and other sources. Cell membranes are created with the use of fatty acids, and you’ll need to take in extra sources of these to maintain healing.
Taking in plenty of carbohydrates (our body’s main fuel source) is essential to prevent the body from using other nutrients and protein for energy. Non-starchy and starchy vegetables, some fruit, brown rice, chia seeds, quinoa, nuts and seeds and whole-grain pasta are good sources of carbohydrates.
Vitamin C is an important antioxidant for wound healing, as it increases the strength of the wound as it heals and helps with the creation of collagen in the skin. Vitamin C is also important in the creation of new blood vessels, and helps with iron absorption. Citrus fruits and leafy green vegetables are great sources of vitamin C.
Vitamin A is another crucial antioxidant. The body needs additional vitamin A to help with wound healing, fight infection, and aids in controlling the inflammatory response. Vitamin A levels have to be monitored closely, as it is a fat-soluble vitamin, because toxicity can occur if too much is consumed. Red fruits and vegetables, eggs, fish and dark green vegetables are all good sources of vitamin A.
Zinc helps the body synthesize proteins and develop collagen, so it is an important mineral for wound healing.
Bromelain reduces edema, bruising, pain, and healing time following trauma and surgical procedures. Bromelain is found in pineapples and can be taken as a supplement.
Normally, it is important to drink at least 8 cups of water or non- caffeinated, non-alcoholic beverages every day. If you do not drink this much fluid each day, now is the time to get into the habit. Drinking enough fluid is essential for maintaining adequate hydration and allowing your body to heal. You may need more fluid depending on the type of medication you are taking or the extent of your injury. Have a water bottle handy and plan for plenty of refreshing beverages throughout the day to keep your body in fluid balance.
According to research wound risk, nutrition, and wound healing are linked in multiple ways, including the following:
- Protein-energy malnutrition increases risk for pressure ulcers, in part due to loss of the “cushioning” effect of body mass when body mass is lost, and to compromised skin integrity.
- Wounds, especially serious wounds such as burns, increase energy needs.
- Nutrients, such as protein, are lost in wound fluid (exudates).
- Physiologic stress caused by wounds can increase need for dietary sources of conditionally essential amino acids.
- Nutritional supplementation can reduce risk for pressure ulcers and promote wound healing.