RESEARCH ARTICLES

Epidemiologic and clinical overview of patients with chronic wounds treated at an outpatient clinic

ABSTRACT: The aim of this study was to perform an epidemiologic study on patients with chronic wounds, describing their clinical condition and the products used in the treatment. This quantitative study involved interviews and clinical examination of 186 patients assisted at the Wound Repair Outpatient Clinic of a university hospital in 2010. The results agree with those of international studies, as the highest percentage of patients are between 57-69 years old (28%), women (54%) and present comorbidities such as hypertension and diabetes (73%). Most of them have only one wound (65%) of venous etiology (51%). The edges of the lesions are macerated (46%), with granulated bed (40%), serous exudate (59%) and no fetid odor (89%). The most commonly used products were Hydrogel (32%) and essential fatty acids (26%). Data show the importance of considering the clinical characteristics of the patient and the wound to obtain positive results in the treatment.

Keywords: Leg ulcer; wound healing; epidemiology; nursing.

INTRODUCTION

The delay in the healing process of wounds is a significant clinical problemIV which affects the patient’s recovery and significantly increases health care costs¹. Given the complexity of the injury and its consequences to the life of the patient, comprehensive care becomes essential. The care must be adequate to the specificity of each situation, demanding special procedures from a professional with technical and scientific knowledge and qualified to follow up the healing process².

In this sense, it is essential to study the scope of health services to learn the profile of patients with wounds and point to advances in the treatment of chronic wounds and its consequent contribution to improve collective health. The aim of this research was to perform an epidemiological study of patients with chronic diseases, describing their clinical condition and the products used in the treatment.

LITERATURE REVIEW

Wound healing involves a complex process of cellular and biochemical events, and any flaws may result in delayed closure of the injury. After the injury, hemostasis and the inflammatory phase take place, characterized by an increase in vascular permeability, chemotaxis and cellular activation. The proliferation phase then starts, with the migration of fibroblasts and endothelial cells. At last, there is maturation and remodeling, with deposition of collagen.

Many extrinsic and intrinsic factors to the patient may interfere in a greater or lesser degree in this healing process. The extrinsic factors include those related to the conditions of the wound and to the treatment performed; in this case, the care with aseptic norms, the bandage technique and the choice of products are fundamental. On the other hand, intrinsic factors are related to the patient’s clinical conditions, and may be aggravated in the presence of a chronic illness, such as diabetes, cardiovascular and immunosuppressive diseases, which alter the normal blood flow and the immune state¹.

METHODOLOGY

This is an epidemiological, clinical observational, cross-sectional, quantitative study performed at the Wound Repair Outpatient Clinic of a university hospital with 186 patients assisted in nursing consultations in 2010. Patients were included if they were 18 years of age or older, with chronic wounds (diabetic, neuropathic, venous, arterial or pressure ulcers) and attending regular follow-up at the university hospital. Patients were excluded if they had any infectious and contagious diseases, mental illness or were pregnant.

Data were collected by the researchers by means of an interview during the nursing consultation and clinical exam. Decal techniques and photographic records were used to evaluate the injury. The consultation was performed systematically, according to the prescribed stages of the nursing process.

Non-parametric statistics was used, with a model of analysis of variance to study the behavior of the variables: gender, age, education, smoking, alcohol ingestion, underlying diseases, evaluation (location, classification of the wound, number of wounds, time of evolution of the wound, start of the follow-up in the outpatient clinic, features of the rim and bed tissue, exudate, depth, odor and adjacent skin) and products used. Two classification factors were adopted: the time variable (treatment factor) and each of the other variables (considered blocks)³.

The analysis of variance for the two classification criteria was used to simultaneously test the difference between means, considering two treatments or sources of variance (X_ij = µ + α_i + ß_j + e_ij) in which: μ: mean effect of the population α_i: specific effect of the i–th column; β_j: specific effect of line j; ε_ij: residual error, random error for specific causes for each observation X_ij.

The study was approved under the protocol 194/06 by the Research Ethics Committee of the Medical School of Universidade Federal Fluminense, and data were collected upon the volunteers’ signing the Free and Informed Consent Form.

RESULTS AND DISCUSSION

Results are presented in three categories: Sociodemographic factors; clinical history and wound evaluation; and products used in the wounds.

Sociodemographic factors

In relation to age, the largest percentage of patients with chronic wounds are observed in the age range between 57 and 69 years (28%), followed by 69 to 82 (27%), 44 to 57 (24%) and 31 to 44 (11%). The lowest percentages are presented by people under 31 (5%) and over 82 (5%).

Given that chronic wounds affect mostly the elderly and that the mean age of the Brazilian population has been increasing, it is possible to say that this factor becomes relevant since people who live longer will have a greater likelihood to be exposed to this problem. This fact reinforces the current significance of a public policy aimed at the health of the elderly, especially for the protection of their skin and the aggravation of chronic illnesses, additionally considering that the Brazilian Institute of Geography and Statistics (IBGE) expects an increase in the life expectancy of Brazilians in the following years⁴.

Nevertheless, the percentage of adults affected by chronic wounds is also significant, and this is a concern when the presence of the wound is related to health complications, i.e., the presence of ulcers due to a chronic illness. This means that it affects individuals in their productive age, leading to the incapacity to work or even an early retirement, worsening already precarious social and economic conditions.

As for gender, 54% of the patients with chronic illness are women, and 46% are men. A statistically significant difference has been observed between genders (p = 0.0121).

The percentage difference between women and men affected by wounds has been decreasing in the past few years. For a long time, most studies indicated a higher incidence of ulcers in women^5,6; however, a few recent studies have indicated a higher incidence in men. One study performed in England revealed 53% men and another one from Goiania (Brazil) had 67.2% of men with ulcers. Nonetheless, women are still more affected due to factors such as pregnancy and hormones⁵.

As to the level of education of the patients in follow-up at the outpatient clinic, most have incomplete primary education (53%); followed by complete primary education (16%) and complete high school (15%), with 11% being illiterate. In this case, statistically significant differences indicate that the differences between levels of education are relevant (p= 0.0002).

Health professionals should consider the education variable when providing guidance on healthcare to patients with wounds, considering that the better the understanding these individuals have on self-care activities, the greater the chances of a successful treatment, especially because patients with chronic wounds have underlying diseases that determine the etiology of the wound and harm the tissue repair process, such as diabetes, arterial hypertension and chronic venous insufficiency. Instructions must be clear and well explained during consultations; include not only the contents related to the wound, but also guidelines on underlying diseases; be provided in writing, preferably typed in large letters with short and easy-to-understand texts.

The nurse develops the process of educating/taking care of the elderly with diabetes mellitus and other comorbidities to inform and clarify doubts about the well-being and the ailment, understanding and evaluating the possible limitations that the person and his or her family may have. Thereby the professional collaborates with the prevention of recurring illness aggravations⁹.

Clinical history

Among the main underlying diseases, 20% have diabetes mellitus and arterial hypertension; 17% present only arterial hypertension; 13% have hypertension linked to other diseases; 12% have diabetes mellitus linked to other diseases; 8% only have diabetes mellitus.

Therefore, most patients assisted in the outpatient clinic refer to some kind of underlying disease, especially diabetes and hypertension, and these diseases are the cause of the wound or the delay in healing. Hence, nurses must guide the nursing care considering the patient’s clinical aspects, the signs and symptoms of the associated pathology and the aspects of the wound.

This result is also related to the age of the patients in follow-up at the outpatient clinic, which has the combined effect of biological aging, genetic predisposition, lifestyle habits and health complications.

It is difficult for the patients to alter their lifestyle, although they know that the effectiveness of the treatment partly depends on them. Nevertheless, they experience difficulties to adapt to new habits and lifestyles, mainly in terms of food¹⁰.

In relation to underlying diseases, there are statistically significant differences (p = 0.000089), indicating that the variable underlying disease is relevant to the wound healing.

It is a fact that long-term venous hypertension produces wounds, and the likely causes of the occurrence of injuries are related to the blocking of oxygen or nutrients by the accumulation of fibrine or perivascular fragments in the legs; leakage of macromolecules into the perivascular tissue and blocking of the capillaries by leucocytes. All of these factors interfere with the wound healing. The care of the nurses to the patient with venous ulcer requires compressive therapy, maintenance of the humid environment and debridement of the necrotic tissue¹¹.

In diabetes, the reduced action of the inflammatory cells, along with a reduced chemotaxis, causes a less efficient destruction of the bacteria with more subsequent infections and lower deposition of collagen. The reduced inflammation induced by steroids affects cellular migration, proliferation and angiogenesis.

Regarding the consumption of alcohol and smoking, the study data have not been statistically significant, as only 8% of patients are smokers and 9% are drinkers. These results may be related to the intense orientation of the service and the campaigns performed in the past few years by the government and the Ministry of Health against smoking and drinking.

Wound evaluation

In relation to the wound classification, 51% of patients have ulcers of venous etiology, 24% of diabetic etiology, 13% of other etiologies, such as surgical injuries, 6% have pressure ulcers, 3% have neuropathic ulcers, 2% have arterial ulcers and 1% presented no information regarding the ulcer classification. The classification of the wounds presents a statistically significant difference (p=0.000113) to the wound healing.

Literature data confirm that the main type of leg ulcer is of venous etiology, and its main features are: being located in the area of the medial or lateral malleolus, being large, superficial and very exudative. The diagnosis is made by clinical exam, in which the presence of varicose veins in the lower limbs is sought, as well as complaints of numbness, cramps, nighttime edema, weight sensation, smoking and venous hypertension in the antecedents¹². The conclusive diagnosis is given through the history of the client, location of the injury, skin aspect around the wound and presence of arterial pulses. The evolution of the wound must be followed up by measuring it, analyzing the type of its tissue and the presence of exudate¹²  . The classification of the ulcers is important to determine nursing care and the therapeutic indication of the product.

As to the number of wounds, approximately 65% of the patients have only one wound, 23% have two, 8% three and only 4% more than three. Yet, 51% of patients have venous ulcer, and one of its features is the presence of a single injury¹².

In relation to the location of the wounds, there was a prevalence in the lower third of the leg (28%), followed by the medial malleolus region (24%) and the lateral malleolus (12%); in the lower and medium third of the leg (2%), the foot's dorsal region, on the plantar region of the foot (1%), in the region of the medium third of the leg (5%), in the toes (4%), in the hip region (1%) in the heel area (4%) and in the upper third of the leg (2%). The other wounds were located in the sacral region (5%), in the thighs (2%) and in the hand (1%).

Another study showed that the highest percentage of patients assisted in the outpatient clinic had injuries in their legs; and the authors emphasized that the perfusion into the injured tissues was the most important objective of the wound treatment, and the expectations were that the wounds on the ends would heal more slowly than the wounds in the face¹¹.

The number (p=0.824611) and location (p=0.050700) of the injuries is not statistically significant for the wound healing.

Another major result is the presence of diabetic ulcers (24%) which usually appear on the feet (toes, heels and metatarsal region) and are triggered by factors such as arteriosclerosis, which is the reduction in blood flow causing reduction in nutrition and oxygen transportation. The wounds are caused by arterial flow insufficiency, whose main problem is ischemia, of which hypoxia is the main element.

As for the size of the wounds in the beginning of the treatment, the following results stand out: 22% measured between 0.1cm² and 10cm², 21% measured between 11cm² and 99cm² and 8% had over 100cm²;, in some cases up to 300cm²;. It is worth pointing out that after treating the patients in the outpatient clinic of the university hospital, with regular follow-up, 39% of the wounds measured from 0.1cm² to 10cm², 28% measured from 11cm²; a 100cm²; 11% over 100cm²; 13% of the wounds were not measured and 9% were healed. The perimeter measurements and the area of the wounds are important to compare treatment regimes and to monitor the individual therapeutic response13.

As to the features of the wound-edge tissue, 46% of these injuries had macerated areas; 36% had edges with epithelization tissue; 10% were already healed; 7% hypercheratinized; 1% had another type of tissue. In this variable, there was a statistically significant difference of the edge tissue in the wound healing (p=0.004589).

Macerated areas make the healing process difficult, whereas the epithelization tissue is responsible for closing the injury¹⁴. Epithelization starts through the proliferation of cells on the edge of the wound, which then migrate over the fibronectine of the wound surface collagen using contractile proteins¹¹.

As to the bed tissue, it is interesting to point out that 40% only had granulation tissue, 30% of the wounds presented granulation and little devitalized tissue and 16% had more devitalized tissue.

The feature of the wound bed tissue is an important indicator of the healing stage reached or of complications that may be present¹⁴. The granulation tissue in the bed is a positive aspect, since it favors tissue reparation and therefore the closure of the injury.

In relation to the wounds’ exudate, results pointed that 61% of the injuries presented production of serous exudate, 25% had serosanguinous exudate, 3% had purulent exudate, 2% had serosanguinous and piosanguinous exudate and 8% of these injuries did not produce any kind of exsudate because they had already healed and 1% did not provide the information. No statistically significant difference of the kind of exudate was observed in the wound healing (p=0.143302).

The wound’s liquid reflects its environment at any moment during the healing process; studies have shown the presence of larger amounts of cytokine in the initial phase of the healing, with a gradual reduction in the following days, stimulating the proliferation of fibroblasts and collagen synthesis¹¹.

The high percentage of wounds producing serous exudate is a positive point in the study, as the presence of exudate is a natural process in chronic ulcers, meaning the absence of infection in the wound's bed, evolving to a better prognosis.

In relation to the amount of exudate, 52% of the wounds had poor exudation, 18% had medium exudation, 19% had major exudation and 10% of the wounds had no exudation because the wounds had already healed, 1% was not informed. A statistically significant difference in the amount of exudate was observed in the wound healing (p=0.032851).

The amount of exudate present in the wound varies according to the stage of healing. In the inflammation stage, there is greater drainage of this secretion, and it decreases in the later stages. A highly exudative wound may mean a prolonged inflammation stage or infection¹⁵.

The amount of exudate in the wound is determinant to choose the product that covers the wound. Highly exudative wounds need highly absorbing bandages, such as alginate and secondary bandages with gauze.

As to the depth of the wounds, 59% had superficial depth, 28% had partial depth, 4% had full depth, 8% were healed and 1% did not have their depth informed. The more superficial the ulcers, the greater the chance of healing.

As the wound heals, it becomes more superficial and smaller; this stage is called contraction, and it is an important stage that reduces the scars and contracts open wounds, being affected by growth factors and inhibited by anti-inflammatory steroids¹¹.

Most wounds (89%) did not have a fetid odor, whereas only 10% of the injuries had an odor and 1% was not reported. There is no statistically significant difference of the odor in the wound healing (p=0.383212).

A strong odor is related to highly exudative ulcers and infections, to bacteria growth or the presence of necrotic tissue, this not being the case of most patients studied^12,16.

As to the evolution of wounds, 33% of patients developed chronic ulcer less than 1 year ago, 20% had the injury for 1.1 to 2 years, 10% already had the wound for over 10 years, 8% from 2.1 to 3 years, 10% from 5.1 to 10 years, 5% from 3.1 and 5 years and 14% could not inform.

A long healing period is estimated, since they are chronic wounds, which usually take longer to heal, besides the possibility of recurrence of these ulcers.

Statistic data showed how the variables have contributed to the repair process. Nevertheless, a superficial wound with epithelized edge, bed with granulation tissue, small amount of serous exudate, with no bad odor and hydrated adjacent skin will provide a faster healing process.

There is no statistically significant difference of the evolution of the injury in wound healing (p=0.096983).

Products used in the wounds

The most commonly used products in the treatment of chronic wounds were hydrogel (30%), essential fatty acid (EFA) (23%), collagenase (16%), vaseline (9%), silver sulfadiazine (5%), calcium alginate (4%), bota de unna (1%) and aquasept gel (1%).

Still with 1% each, the following were applied: activated coal, topic antibiotic, topic anti-fungic and hydrocoloid, a combination of alginate and collagenase, 70%-grade alcohol, a combination of EFA and hydrogel, a combination of collagenage and EFA 1%. In 3% of patients, the products used were not informed. 70% alcohol was used in surgical incision.

The use of different products in the bandage services is related to the features of the wound, the type of tissue, the amount of exudate and the presence of infection. Nevertheless, the lack of products available at public institutions is common, forcing nurses to interrupt treatment and replace the products in use with those available. Other products need to be studied as for their effectiveness, stability, indications and counter indications.

The knowledge of the profile of patients with wounds helps improve treatment with the purchase of adequate products to the demand of the service, besides offering subsidies to the training and updating of professionals.

CONCLUSION

Based on the results of this study, the conclusion is that in order to verify the efficacy in wound treatment it is necessary to consider the occurrence of statistically significant differences (p < 0.05) for the healing process in the variables of education, underlying diseases, wound classification, edge tissue and amount of exudate. In this study, there were no statistically significant differences (p> 0.05) between treatments considering gender, the amount of wounds, location, previous and current size, wound evolution, bed tissue, type of exudate, depth and odor.

The elderly were the most affected group by hardly healed wounds and comorbidities such as arterial hypertension and diabetes. As to the wound classification, most patients have venous ulcers and approximately one quarter of them have diabetic ulcers. Most had only one injury, predominantly located in the lower third of the leg. As to the features of the injury, although approximately half of them had macerated edges, which makes cellular migration difficult, over one third had granulation tissue and most had serous exudate without bad odor, which demonstrates positive aspects for healing.

As for products to cover the wound, hydrogel and EFA were the most commonly used, since these are appropriate for wounds with less exudate, presence of granulation and no signs of infection, which was the case of most wounds in this study. The data point to a positive treatment outcome, as the wounds present a good aspect and reduced size.

A limitation of this study is the lack of therapeutic continuity in public service. The lack of the product or the inadequate purchase leads to the interruption in treatment, and in this case the nurse is even more important in the management and direct care of the patient.

The study also stresses the need to discuss the relation between comorbidities and injuries, and the clinical reasoning for team decision making, since the approach to the wounded patient is an interdisciplinary challenge that transcends the treatment of the wound.

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