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Guest Editorial: Wound Care: The Challenges Ahead
Knowledge of how wounds heal and are best managed has advanced rapidly over the past two decades. The understanding that guides care is founded on basic and clinical science combined with expert experience and opinion. Much has been learned about physiologic and biochemical differences between wounds that heal normally and those that do not. Yet, much remains to be understood to prevent wounds when possible and effectively treat healing complications and wounds that become chronic.
Further discoveries regarding the intricate pathways and cellular interactions involved in wound healing are on the horizon as technological capability advances. One example is the proposed application of gene array technology to identify at the molecular level the specific genes expressed during the healing process and pathogenesis of wounds that are chronic or slow to heal (Cole & Isik, 2002; Tomic-Canic & Brem, 2004). Basic research in genetic manipulation of wound cells is another area of wound-healing science that is moving forward rapidly, with the potential of up-regulating (turning on) or down-regulating (turning off) the production of specific growth factors and other proteins that are critical to wound healing (Petrie, Yao, & Eriksson, 2003).
Patient characteristics associated with poor healing outcomes, as well as local and systemic factors that help overcome obstacles to tissue repair, have been identified. Better understanding of promoters and inhibitors of healing has provided a basis for many new therapies. Wound treatment has advanced from the simple concept of wound protection to the application of dressings and topical treatments that interact with wound tissue or provide skin-equivalent coverings. Newer wound-care modalities aim to alter the local wound environment to favor healing through cell migration, replication, nutrition, tissue synthesis, and wound closure. Treatments designed to address a number of wound responses include reducing elevated bacteria and protease levels, increasing perfusion, and providing stimulatory signals (e.g., growth factors and tissue replacements).
Even with significant advancements in knowledge of healing and treatment options, however, wounds remain a major and costly healthcare concern. In the United States alone, estimates indicate that more than 1 million people suffer from chronic wounds (Bonham, 2003; Mastow, 1994).
To say that the physiology of healing and chronic wounds is complex understates the clinical reality faced by patients and the providers who care for them. The varied and specific attributes of individuals who have wounds, and the multiple etiologies of wounds themselves, add to this complexity. While wound care gains recognition as a specialty within the healthcare delivery system, wounds and related care concerns cross multiple disciplines, diagnoses, and populations. Difficult wounds to manage arise in all populations, including complex acute wounds, chronic wounds, wound infections, and wounds associated with disability, drug abuse, or specific diseases and injuries (e.g., diabetes, venous hypertension, and burns).
At the same time as we grapple with how to provide the best wound care to patients with complex needs, the importance of bridging the science-to-service gap by translating research findings to practice is receiving increased emphasis. Strengthening clinical research and translation is a major component of the NIH Roadmap (National Institutes of Health, 2005). It is clear that the work needed to advance clinical science and its practice application is not a quick, easy, or transparent process. While the rigorous design of randomized clinical trials protects the integrity of evaluating and establishing treatment efficacy, it may limit the application of findings to patients that are seen in day-to-day practice (Sidani, 2004). Nonetheless, nurses excel in their perception, understanding, and evaluation of issues that influence treatment effectiveness for individuals. Perhaps to a greater extent than in any other nursing specialty, these skill are highly developed in nurses who practice rehabilitation nursing.
It has been a pleasure to serve as the guest editor for this special issue of Rehabilitation Nursing. The articles selected for this issue address challenges and aspects of wound care raised in my introductory comments, specifically centering on wound assessment and management from the perspective of knowledge generation and application in the context of individual differences and vulnerability. Dr. Pieper focuses attention on salient socioeconomic factors that increase risk for poor healing outcomes and provides an approach to improving care for vulnerable populations. Pressure sores, which are prevalent and costly wounds among individuals with disabilities (Byrne & Salzberg, 1996), are the subject of two articles included in this issue. Dr. Brillhart describes the implementation of a successful program for the prevention of pressure sores in people with advanced Alzheimer’s disease. Insight into four well-known evaluation tools for pressure sore healing and the refinement of these tools for monitoring persons with disabilities is provided by Dr. Mullins and her coauthors. Beth Hall identifies the unique clinical challenges and practice solutions for providing wound care to burn patients during rehabilitation. Dr. Kroll and coauthors address development of new knowledge in their discussion of the advantages of mixed-method research designs in rehabilitation nursing. Application of these designs to wound healing studies could provide valuable data on how environmental or personal factors and experiences affect healing and other important clinical outcomes.
I hope you enjoy and benefit from the content in this special-focus issue of Rehabilitation Nursing and find ways to apply what is presented to benefit your patients.
Bonham, P.A. (2003). Assessment and management of patients with venous, arterial and diabetic/neuropathic lower extremity wounds. AACN Clinical Issues, 4, 442–456.
Byrne D.W., & Salzberg C.A. (1996). Major risk factors for pressure ulcers in the spinal cord disabled: A literature review. Spinal Cord, 34, 255–263.
Cole, J., & Isik, F. (2002). Human genomics and microarrays: Implications for the plastic surgeon. Plastic and Reconstructive Surgery, 110, 849–858.
Mastow, E.N. (1994). Diagnosis and classification of chronic wounds. Clinical Dermatology, 12, 3–9.
National Institutes of Health (2005). NIH Roadmap accelerating medical discovery to improve health: Re-engineering the clinical research enterprise. Bethesda, MD: Author.
Petrie, N.C., Yao, F., & Eriksson, E. (2003). Gene therapy in wound healing. Surgical Clinics of North America, 83, 597–616.
Sidani, S. (2004). Rethinking the research-practice gap: Relevance of the RCT to practice. Canadian Journal of Nursing Research, 3, 7–18.
Tomic-Canic, M., & Brem, H. (2004). Gene array technology and pathogenesis of chronic wounds. American Journal of Surgery, 188 (Suppl to July 2004), 67S–72S.