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INTRODUCTION

CHAPTER OBJECTIVES

At the end of this chapter, the learner will be able to:

  1. Identify wounds that are not healing due to the influence of impeding factors.

  2. Identify the impeding factors based on subjective and objective evaluations.

  3. Select the tests necessary to confirm suspected impeding factors.

  4. Adapt plan of care to minimize the effect of impeding factors on the wound healing process.

  5. Educate patients and care givers on strategies to minimize or eliminate effects of impeding factors.

Chapter 3, Examination and Evaluation of the Patient with a Wound, presented the two questions that need to be answered in order to successfully treat a patient with a wound: (1) Why does the patient have a wound? and (2) Why is the wound not healing? Once a wound diagnosis has been determined and standard care has been initiated, the wound should progress through the stages of wound healing discussed in Chapter 2, Healing Response in Acute and Chronic Wounds. When progress is not observed, the second question—Why is the wound not healing?—becomes even more imperative to answer. Sometimes the wound will respond initially and make measureable progress, then stall again for no apparent reason. This chapter focuses on those factors that are known to impede wound healing, some more obvious than others, and provides suggestions on how to identify and minimize the effect on the healing process. The factors are categorized into infection, medications, nutritional deficits, comorbidities, and extrinsic/psychosocial behaviors.

TABLE 11-1 provides laboratory values, always a good starting place for solving the conundrum, with normal values, trends that are typical when a patient does not have the normal healing response, and clinical presentations that accompany abnormal lab values. CASE STUDY

INTRODUCTION

Mr RG is a 45-year-old male with a 3+ year history of a non-healing wound on the right anterior leg (FIGURE 11-1). His medical history includes the following:

  • History of HIV for more than 15 years

  • History of Kaposi sarcoma on the right anterior leg at the site of the current wound, treated with radiation and chemotherapy (doxol or doxorubicin)

  • History of recurrent cellulitis, treated with both IV vancomycin and oral Xyvox

FIGURE 11-1

Case study at the time of initial evaluation Non-healing wound on the lower extremity of a patient with multiple factors that impede wound healing.

His HIV status is controlled with medication; he has an undetectable viral load and a low white count (≤3).

DISCUSSION QUESTIONS

  1. What subjective information is needed to determine the factors that have prevented this wound from healing?

  2. What questions would be helpful in obtaining this information?

  3. What tests and measures are indicated in order to establish a plan of care?

TABLE 11-1Laboratory Values with Implications for Wound Healing

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