Maintenance and non-healing wounds
- A maintenance wound is one with the potential to heal, but may not be healable, slow or erratic to heal because the cause or contributing factors cannot be easily mitigated, the person with SCI chooses other life priorities over adhering with optimal care or does not have the necessary resources to implement the ideal pressure management plan. Surgical options may not be possible due to comorbidities or lifestyle pressures that are known to result in a poor surgical outcome.
- A non-healable wound is physically unable to heal due to co-morbid health conditions, such as systemic disease (eg. osteomyelitis that cannot be eliminated), poor circulation or cancer.
- Determining whether a wound is healable or non-healable involves detailed discussions with the person with SCI and their family or significant others. Categorisation in this way enables realistic goal setting, typically to promote comfort (eg. control exudate, odour, pain), maximize function and/or quality of life of the person, reduce risk of infection and prevent further deterioration, if possible.
- This should be done in consultation with the tertiary SCI team to ensure all options have been explored. For example, the tertiary team can provide additional recommendations regarding continence; spasticity and contracture; medications; infection, osteomyelitis and heterotopic calcification; co-morbidities; psychosocial support; nutrition; positioning, seating and equipment; and ensure all surgical options have been explored.
Managing maintenance and non-healable Wounds
- Refer to the Clinical Nurse Consultant and/or the tertiary SCI service. The Spinal Outreach Service Rural Coodinator in your area may also be a valuable resource to contact regarding local knowledge, expertise and support.
- Follow wound management principles for maintenance and non-healable wounds and use a validated assessment tool to monitor the wound for subtle signs of deterioration.
- Review pressure management requirements with respect to the revised wound management goal and continue to monitor Red Flags and the emotional impact of having a PI.
- Clear communication and documentation is required to prevent unnecessary investigations or previously unsuccessful interventions (Sibbald et al 2011). This may also include confirmation of the client’s capacity to make this decision. Individual client-specific information forms, the Spinal Cord Injury Health Management Plan wallet card (Hunter SCIS), the Victorian Department of Health Shared Support Plan and Electronic Medical Record alerts are a few examples of how this might be achieved. In some circumstances an Advance Care Directive may be appropriate should the client’s health deteriorate. The information in this toolkit can be used to provide information to the person and their family about best practice care for people with SCI and PI.
- Provide the person and their carers with resources to ensure they understand PI prevention and management.
- People with a maintenance or non-healable wound may express interest in various adjunctive therapies, however, the evidence is limited (see SCIRE) and guidelines often recommend all other management strategies be optimised first.
Sibbald RG, Goodman L, Woo KY, et al. 2011. Special considerations in wound bed preparation: an update. Adv Skin Wound Care. 24(9):415–36
Norton L, Coutts P, Sibbald GR. 2011 Choosing between a healable, non-healable and maintenance wound. Rehab Magazine California Fall 2011: 25-27