Risk Factors/Comorbidities for Chronic Wound Development Janice Beitz PhD, RN, CS, CNOR, CWOCN, CRNP, APNC, FAAN  Module #2 Revised September 2018

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Objectives Identify characteristics of chronic wounds Describe risk factors/co-morbidities for chronic wounds associated with patient status Explain risk factors/co-morbidities for chronic wounds related to external or environmental influences Correlate wound risk factors and patient co-morbidities with nursing concepts, diagnoses and clinical practice issues

Risk Factors and Co-Morbidities Associated with Chronic Wounds Factors can be singular but are very often multifactorial. Prevention is key to promoting a positive balance!

Chronic Wound Definition A wound that deviates from the expected sequence of repair in terms of time, appearance, and timely response to appropriate therapy

Chronic Wound Characteristics Have higher levels of proteolytic enzymes (e.g., matrix metalloproteases ‘MMPs’) Have lower levels of growth factors (e.g., PDGF) Fibroblasts fail to produce extracellular matrix proteins

Pressure Ulcer/Injury Exemplar

Risk Factors/Co-Morbidities for Chronic Wounds Categorized as intrinsic vs. extrinsic Intrinsic: Associated with patient factors Extrinsic: Associated with external or environmental influences Health care provider needs to assess all aspects

Chronic Wound Risk Factors Malnutrition Blood flow (perfusion) problems Diabetes (especially poorly controlled) Kidney disease Weight (cachexia and obesity) Smoking

Chronic Wound Risk Factors Age (both very young and very old) Swelling (edema) Infection Immunosuppression Severe stress Immobility Altered mentation

Chronic Wound Risk Factors Medications - Steroids - Non-steroidal anti- inflammatory drugs (NSAIDs) - Cancer chemotherapy - MANY others!! Alcohol abuse Chronic mechanical stress (repetitive injury)

Chronic Wound Risk Factors Chronic venous insufficiency Sickle cell disease Arthritis and connective tissue diseases Spinal cord damage/immobility

Chronic Wound Risk Factors Vasculitic disorders - Polyarteritis nodosa - Thromboangiitis obliterans - Protein C / protein S deficiency

Chronic Wound Risk Factors Iatrogenesis (caregiver generated) Device-related skin/tissue damage Unsafe/ineffective topical therapy (e.g., Betadine in wounds; saline wet to dry dressings) Dry gauze (instead of moist wound healing approaches) Failure to turn and reposition immobilized person

Critical Questions for Consideration What risk factors and co-morbidities are modifiable? Smoking Diet Unhealthy lifestyle Stress Glucose levels in persons with Diabetes Nutritional state and diet

Critical Questions for Consideration What risk factors and co-morbidities are not modifiable? Age Presence of concomitant disease(s) Use of necessary lifesaving medications

- Prevention - Chronic disease management - Health promotion Key Concepts - Prevention - Chronic disease management - Health promotion

Key Diagnoses - Alteration in Skin Integrity - Impaired Skin Integrity - Impaired Comfort - Risk for ineffective peripheral tissue perfusion - Risk prone health behavior

Key Practice Issues Assessment for chronic wounds’ risk factors and co-morbidities should occur early in care and be ongoing Risk factors and co-morbidities can change with patient status All disciplines should cooperate to assess patient holistically for potential and actual negative wound healing conditions

Websites for Further Information on Types of Wounds - Association for the Advancement of Wound Care www.aawconline.net - National Pressure Ulcer Advisory Panel www.npuap.org - Wound Healing Society www.woundheal.org - Wound Ostomy Continence Nurses Society www.wocn.org - Wounds Canada www.woundscanada.ca

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