What do you see
Wound Management
Kathy leak
Sister Wound Care B.a (Hon’s)
Doncaster & Bassetlaw Hospitals NHS Foundation Trust
Best Practice guideline
• The practitioner can:
– Describe wound location
– Measure size of wound
– Describe wound bed
– Exudate
– Wound odour
– Pain
– Condition of surrounding skin
Best practice Guideline
• Documentation
– Detail any shared care
– Reflect assessment findings
– Timescale
– Information given
– Wound management
– SINGLE MULTIDISCIPLINARY
DOCUMENT
Best Practice Guideline
• Ongoing Review
– Regular assessments
– Timely and comprehensive
– Pt compliance
– Objectives met
– If not why not
– Reassess/ discharge
Current issues in wound
management
• Changing patient profiles
• Complex wounds
• Wound assessment/decision making tools
• Identifying wound infection
• Innovation in wound care
The 21st Century Patient: Older, sicker
and more complex
The wound site
Psychological
issues
Physical
problems:
concurrent illness
Multiple pathologies
• Patients will often present with complicated clinical pictures
• Diabetes, anaemia, cardiovascular disease and respiratory conditions may co-exist in a number of patients.
• This clinical picture will have a direct effect on the wound healing potential of the patient.
• In elderly patients with chronic wounds, cells are found to be immature and unable to function normally (Henderson 2006)
What makes a complex wound
complex?
Excess
bacteria
Alkalinic pH
Devitalised
tissue
Excessive proteases
Cell senescence
Poor local
vascular supply
Excess exudate
production
Prolonged
inflammation
Psychosocial
issues
How do we deal with wounds such
as this?
The key to dealing with complexity in
wound care lies in thorough and
accurate assessment
HEIDI
Assessment
History
• Presenting wound
• Medical background
• Drug history
• Social background
• Nutritional status
• Psychological status
• Patients’ perspective
Examination
• Basic skin assessment
• Type of wound
• Anatomical description of wound
• Size
• Wound bed appearance
• Exudate
• Odour
• Pain
Investigations
• Bloods
• X-ray
• Doppler
Wound bed preparation
• The key aim of treatment is to progress the
wound to healing or the best outcomes
possible
• The primary concerns are the removal of
necrotic/sloughy tissue and the prevention
of infection
• Wound debridement is a dynamic process
which continues until all necrotic tissue is
removed
Black
• Treatment objectives
– Debride
– Maintain bacterial
balance
– Maintain moisture
balance
Wound Management
Choosing the Right Dressing
• Hydrogels– Two basic forms – sheets
and gels
– Sheets for shallow wounds
– Gels for cavities and
desloughing and debriding
– Secondary dressings
required to keep insitu
– Maceration can occur
Wound Management
Choosing the Right Dressing• Hydrocolloids
– Mixture of pectins, gelatins, sodium carboxymethylcellulose and elastomers
– Create an environment that encourages autolysis in sloughy necrotic wounds
– Reduce pain in wounds
– Provide an hypoxic environment which encourages angiogenesis
– Has a characteristic odour
– Require wound overlap of at least 2cm
Black/yellow wound
Treatment Objectives
1. Debride
2. Maintain Bacterial
Balance
3. Maintain Moisture
Balance
4. What dressing?
Yellow
• Treatment objectives
– Debride
– Maintain bacterial
balance
– Maintain moisture
balance
Wound Management
Choosing the Right Dressing
• Alginates
– First used in 1940’s
– Made of seaweed
– Composed of galuronic and mannuronic acid – the quantities of these determines the gel forming properties
– Galuronic forms a firmer gel
– Mannuronic forms a softer gel
– For moderate to high exudate wounds
Sometimes the yellow is green
Why?
What dressing ?
Dehiscence: yellow red wound
• Treatment objectives
– Maintain bacterial
balance
– Maintain moisture
balance
Wound Management
Choosing the Right Dressing
• Foam dressings
– Made using advanced polymer technology
– They are non-adherent, absorb large amounts of exudate, can be used as a secondary dressing
– Hydropolymer swells into wound bed as exudate is absorbed
– Can absorb several times their own weight in exudate
– For moderate to heavy exudating wounds
Anyone like to guess what is
wrong here!
Epithelial Regeneration:
Pink wound• Treatment objectives
– Maintain bacterial
balance
– Maintain moisture
balance
Wound Management
Choosing the Right Dressing
• Film dressings
– Primary and secondary
dressing
– Clear polyurethane coated
with an adhesive
– Conformable
– Resistant to shear and
friction
– Prevent bacterial
colonisation
– Do not absorb EXUDATE
– Vapour permeable
Wound Infection Continuum
Spreading Infection Local Infection Critically Colonised Colonised
Dealing with increased bacterial load
• Recognise importance of bacterial load
– Contamination, colonisation, infection
• Monitor the impact of bacteria on healing
– Pain, exudate, bleeding, odour, systemic effects
• Treat the wound appropriately
– Wound debridement
– Antimicrobial dressings: containing povidone iodine/iodine (e.g. Inadine, Iodosorb/Iodoflex) or silver (e.g. Acticoat, Actisorb Silver, Flamazine)
– Increase frequency of dressing changes
– Systemic antibiotics
• Address host systemic factors
How do we know when a wound
is infected ?• Presence of pus?
• Inflammation?
• Delayed healing
• Discolouration of the wound
• Friable Granulation Tissue
• Unexpected pain or tenderness
• Pocketting at the base of the wound
• Bridging
• Odour
• Cellulitis?
• Positive culture?
• Serous exudate
plus positive
culture?
• Localised pain?
• All of the
above? Cutting
and Harding
(1994)
The effects of bacteria on wounds
• Compete with the bodies cells
for oxygen and nutrients
• Cell destruction can lead to
further necrosis
• Odour develops due to
anaerobic bacteria giving off
ammonia and other waste
products
• Cross contamination between
patients is common
• Systemic effects follow if left
untreated
Biofilms
• Form when a collection of
bacteria attach to a surface and
subsequently encase
themselves in an exopolymeric
material
• As a “community” benefit
from metabolic efficiency
• Sometimes appear as a “glaze”
on surface of wounds
Abscess formation
• Collection of pus and
necrotic material
• Pus contains bacteria and
white cells
• Contained within a wall of
fibrin and phagocytes
• May lead to lymphangitis
Cellulitis: local infection
• Bacterial infection causing a spreading, non-suppurative inflammation of the skin.
• Most commonly haemolytic strep.
• Painful and often oedematous
• Ulceration and necrosis may ensue if severe.
• Lymphangitis also common.
• Can be confused with inflammation
Spreading Infection
Wound Management
Choosing the Right Dressing• Antiseptics and
disinfectants
– Silver – flamazine,
particularly effective in
treating pseudomonas
– Film dressings containing
silver reduce colonisation
– Silver and carbon dressings
reduce bacterial count and
odour
• Iodine
– No proven resistance to
iodine
– No adverse affects on
wound healing
– Rapidly deactivated in
presence of pus
– Cadexomer iodines absorb
exudate in exchange for
iodine
– Useful in treating colonised
wounds
Exudate management
3
Discharge
• Wound exudate is normal.
• Copious exudate and
continued inflammation
may indicate infection
• Seropurulent and
haemopurulent discharges
indicate liquefaction of
tissues as a result of the
micro-organisms in the
wound.
Wound Exudate
• Assess exudate
– Colour; viscosity; volume; odour
• Assess wound
– Acute; chronic; infection; fistula; oedema; bleeding
• Document
– High; moderate; low
• Select dressing
– Conventional; NPWT; wound manager
Summary
• Accurate assessment
• Appropriate dressing
leads to
• Happy patient
• Happy nurse
• Happy manager
HAPPY ENDING
References and Further Reading
Cooper R (2004) A review of the evidence for the use of topical antimicrobial agents in wound care. http://www.worldwidewounds.com/2004/february/.../Topical -Antimicrobial-Agents.htm
Collier M (2004) Recognition and management of wound infections, http://www.worldwidewounds.com/2004/janu.../Management-of-Wound-infections.htm
Cutting K and Harding K (1994) Criteria for identifying wound infection, J. Wound Care 3 (4), pp 198-201
Kingsley A, White R and Gray D, (2004) The Wound Infection Continuum: a revised perspective, August, pp 22-25
References and further reading
• Lansdown ABG, (2004) A review of the use of silver in wound care: facts and fallacies, Br. Journal Of Nursing, (TV Supplement), Vol 13, No. 6 pp s 6 – s 19.
• ReillY J McIntosh J And Currie K. (2002) Changing surgical practice through feedback of performance data. Journal Of Advanced Nursing, 38 (6) pp 607-614.
• Sunghal H and Zamit C, (2002) Wound Infection, http://www.emedicine.com/med/topic/2422.htm
• Tachi M, Hirabiayashi S, Yonehera Y, Suzuki Y and Bowler P. (2004) Comparison or bacteria-retaining ability of absorbent wound dressings, International Wound Journal, Vol 1 No. 3, pp 177- 181.