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WOUND CARE GUIDELINES

March 2008

wound care dressings

BOLTON PRIMARY CARE NHS TRUST & BOLTON HOSPITALS NHS TRUST WOUND CARE GUIDELINES CONTENTS
A INTRODUCTION ................................................................................................................................................. 2 B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES ............................................ 5 B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES (CONTINUED) ....................... 6 B:2 PRESSURE ULCERS: DRESSING SELECTION ............................................................................................................. 7 C: 1 LEG ULCERS: THE FACTS (AETIOLOGY) ..................................................................................................... 8 C2 LEG ULCERS: DRESSING SELECTION....................................................................................................................... 9 D: DIABETIC FOOT ULCERS............................................................................................................................... 10 E: WOUND INFECTION .................................................................................................................................................. 11 F: WOUND BED PREPARATION & DRESSING SELECTION .............................................................................................. 12 G: MINOR WOUNDS DRESSING SELECTION .............................................................................................................. 13 H: CELLULITIS.......................................................................................................................................................... 14 I: WOUND COMPLICATIONS: ............................................................................................................................... 15 I:1 OVERGRANULATION ............................................................................................................................................ 15 I:2 - HYPERTROPHIC / KELOID SCARS .......................................................................................................................... 15 I: 3 - FUNGATING WOUNDS ........................................................................................................................................... 16 J: WOUND CLASSIFICATION................................................................................................................................ 17 K MECHANISMS OF WOUND HEALING ......................................................................................................... 18 L WOUND ASSESSMENT ................................................................................................................................... 18 Wound Bed..................................................................................................................................... ...19 Wound Measurement ............................................................................................................................19 Exudate .................................................................................................................................................19 Infection ................................................................................................................................................20 Pain.. ...............................................................................................................................20 Surrounding Skin ..................................................................................................................................21 M FACTORS DELAYING WOUND HEALING................................................................................................... 21 N NUTRITIONAL ASPECTS OF WOUND HEALING ....................................................................................... 23 O WOUND MANAGEMENT ................................................................................................................................ 26 i. Wound Cleansing...................................................................................................................................26 ii. Choice of Dressings..............................................................................................................................27 P: FORMULARY OF PRODUCT GROUPS WITH RECOMMENDATIONS FOR USE ............................................................ 29 REFERENCES.31 APPENDICES:............................................................................................................................................................ 35 1. Clinical Evidence Grading Criteria ......................................................................................................35 2. Wound Care Assessment Tool ...............................................................................................................35

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INTRODUCTION

The wound care guidelines have been developed by clinicians who are treating patients with wounds. They reflect current research and evidence based expert opinion. The guidelines are intended for use as a resource for wound management and should be available to all medical,nursing and therapist caring for patients with wounds in Bolton Primary Care NHS Trust and Bolton Hospitals NHS Trust,Bolton Hospice and The Beaumont Hospital. Evidence based recommendations are included and a formulary of wound care products is included to promote rational prescribing. These guidelines have been produced for use by any member of the healthcare team.They are not intended as a substitute for professional judgement but are in support of the practitioner making an informed decision relating to the management of the patient,in accordance with individual professional competence. The guidelines have been developed incorporating available evidence of best practice. Where evidence of best practice is not available, expert opinion has been sought and consensus agreement between the multi-professional team has been reached. Acknowledgement to the patients who are part of the leg ulcer service who gave valuable comments and advice on leg ulcer management. They will be reviewed annually and updated every two years. Comments from users of the guidelines are welcomed.

Authors: Jacqui Ashton Consultant Nurse Tissue Viability Nicky Morton Tissue Viability Specialist Nurse Susan Beswick Podiatrist Bolton Hospitals NHS Trust Vivienne Barker Tissue Viability Podiatrist Bolton PCT Freda Blackburn Sister Beaumont Hospital Carolyn Wright Dietetics Manager Bolton Hospitals NHS Trust Lisa Turner Pharmacist Bolton Hospitals NHS Trust Kathryn Morton Dietitian Bolton PCT Andrea Jennings District Nurse

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Reviewers: Hannah Dobrowolska Assistant Chief Executive Bolton PCT Mr. G Ferguson Consultant Vascular Surgeon Mr. G Shepard Consultant Orthopaedic Surgeon Mr. R Hopkins Consultant Obstetrician Jackie Solomon Deputy Director of Nursing Bolton Hospitals NHS Trust Peter Hilton Manager Podiatry Bolton PCT Irene Pennington Podiatry Manager Bolton Hospitals NHS Trust

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Summary of Conclusions and Grading of Recommendations:


Recommendation Holistic assessment of the patient is an essential part of the wound care process All patients with wounds will have their wounds assessed by nursing staff within 24 hours of admission to an episode of care Optimal nutrition facilitates wound healing, maintains immune competence and decreases the risk of infection. It is essential to consider the nutritional status of all patients with wounds. Referral to the dietitian should then be made where appropriate Wound cleansing(where necessary) should be carried out by irrigation with sterile normal saline warmed to body temperature For chronic wounds such as leg ulcers, ordinary tap water can be used Antiseptics are toxic to human tissue and may delay wound healing Topical antibiotics are frequent sensitisers and should be used with caution Systemic antibiotics should be used to treat clinical wound infections Wound dressings should:
maintain a moist environment at the wound/dressing interface. (The only possible exceptions are peripheral necrosis secondary to arterial disease). be able to control (remove) exudate. A moist wound environment is good, a wet environment is not beneficial not stick to the wound and cause trauma on removal protect the wound from the outside environment aid debridement if there is necrotic or sloughy tissue in the wound (caution with ischaemic lesions) keep the wound close to normal body temperature be acceptable to the patient be cost-effective Diabetes choose a dressing that will allow frequent inspection

Grade of Evidence C C

B B B A B

Please refer to Appendix 2 for Evidence Grading Criteria. NB For wounds failing to respond to treatment according to the guidelines please refer to the Tissue Viability Servic. Tel No 01204 360005/2

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B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES INDICATOR / DESCRIPTOR Grade 1 Non-blanchable erythema of intact skin.
Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin.

ACTION Must relieve pressure, regular skin inspection Do not cover area easy visual inspection Adhesive dressing could cause tissue damage Re-position patient 2 4 hourly. Turning chart. Appropriate pressure relieving equipment must still reposition patient 2 4 hourly Assess nutritional needs

Grade 2

Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.

Relieve pressure, observe frequently, do not cover Small blisters may resolve without intervention If partial skin loss protect area with a thin foam dressing Assess nutritional needs

Large blistered area

Drain blister large blisters will not resolve without aseptically releasing the fluid with a sterile needle, until all the fluid is dispersed Non adherent foam dressing Relieve the pressure, observe at least daily

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B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES (continued) INDICATOR / DESCRIPTOR Grade 3
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia.

ACTION

Must relieve pressure, regular skin inspection Avoid packing if sacral wound as this will add further pressure to the area Assess nutritional needs Assess patient for appropriate pressure relieving equipment according to mobility, waterlow score etc If known peripheral vascular disease, do not debride heel pressure ulcers refer to Tissue Viability Otherwise, refer to dressing selection (B:2) for wound management Must relieve pressure, regular skin inspection Avoid packing if sacral wound as this will add further pressure to the area Assess nutritional needs Assess patient for appropriate pressure relieving equipment according to mobility, waterlow score etc If known peripheral vascular disease, do not debride heel pressure ulcers refer to Tissue Viability Otherwise, refer to dressing selection (B:2) for wound management

Grade 4
Full thickness Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss.

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B:2

Pressure Ulcers: Dressing selection


Descriptor Aims Grade 1 Grade 2 Grade 3 Grade 4

The cost of treating pressure ulcers within the UK has been estimated as high as 750 million (Roberston, 1990), which is higher than the reported national cost of treating heart disease (Durham and Grice, 1991). Much of this cost is due to the high levels of nursing time taken to manage extensive pressure ulcers, in addition to the costs associated with hospitalisation.

Tissue Type

Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin.

Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.

Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia. Hydrogel + semi-permeable film or adhesive foam

Full thickness Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss. Hydrogel + semi-permeable film or adhesive foam

Necrotic

Identified by presence of predominantly black / brown tissue Identified by formation of viscous, predominantly yellow tissue

To rehydrate eschar and reduce risk of infection

Not applicable

Not applicable

Sloughy

To remove all debris and promote autolysis

Not applicable

Not applicable

Low exudate: Hydrogel + semi-permeable film or adhesive foam Mod High Exudate: Hydrofibre + adhesive foam

Low exudate: Hydrogel + semi-permeable film or adhesive foam Mod High Exudate: Hydrofibre + adhesive foam

Granulating

Wound has granular appearance, looks red and bleeds easily

To promote angiogenesis and aid wound healing

Not applicable

Protect new tissue with thin foam dressing

Low exudate: adhesive foam Mod High Exudate: Hydrofibre + adhesive foam

Low exudate: adhesive foam Mod High Exudate: Hydrofibre + adhesive foam

Epithelialising

Wound is pink in appearance, tissue very fragile and needs to be kept moist Skin which is likely to break down as a result of friction/shear or site of previous injury

To protect new tissue and allow final stage of healing To prevent friction, relieve pressure and reduce risk of tissue breakdown

Not applicable

Protect new tissue with thin foam dressing

semi-permeable film or adhesive foam

semi-permeable film or adhesive foam

Reddened

No dressing - observe

Not applicable

Not applicable

Not applicable

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C: 1

LEG ULCERS: THE FACTS (AETIOLOGY)

Leg ulceration is a common condition with a point-prevalence between 1.5 and 3 per 1000 (EHCB, 1997). Bolton population is 280,000, therefore Bolton PCT might expect to have between 420 and 840 patients under treatment at any time. Annual treatment cost are estimated to be 1200 - 1500 per patient for treatment with usual care. This implies that Bolton PCT faces a total treatment cost in the range of 0.5m to 1.3million per year.

TYPE

INDICATOR/DESCRIPTOR

Venous
Usually gaiter area. Exuding wound, shallow with diffuse edge. Generalised oedema and staining of skin will occur. Some pain, Doppler assessment greater than 0.8

MANAGEMENT AIMS To rehydrate eschar To reduce pressure in superficial venous system Aid venous return by increasing velocity of flow in deep veins Reduce pain and oedema

Mixed
Of both venous and mixed aetiology Involves both venous problems and arterial insufficiency Doppler assessment between 0.6 and 0.8

Increase venous return Reduce pain and oedema Prevent infection

TREATMENT OPTIONS Multi-layer compression system 4 layer or 2 layer compression system or Compression Hoisery system Each patient should be individually assessed according to there daily activity requirements. Skin care: Hydrate with emollient Reduced compression system 3 layer Or Compression Hoisery Skincare: Hydrate skin with emollient If Doppler < 0.8 indicates significant arterial impairment

Other considerations
Only practitioners who have undertaken a leg ulcer management course (Level 2 0r 3) can undertake a full doppler assessment Compression bandages must only be applied by practitioner who have undertaken training at Lever Chambers / Satellite clinics. Doppler Assessment Must be performed on any lesion on the leg of more than six weeks at the nearest leg ulcer satalite clinic. Nutrition: Assess Nutritional Needs. Pain Assessment Consider the difference between Arterial pain and Venous pain In the case of venous leg ulcers, recurrence can be substantially reduced by continuous application of compression hosiery after healing. Complex patients ie,not responding to standard treatment after four weeks please refer to the Tissue Viability Service.

Arterial
Any part of the leg, commonly below the ankle Dry wound, deep with cliff edges Localised oedema, no staining of the skin. Pain greater at night, Doppler assessment<0.6

Prevent infection Treat symptoms Compression bandages must never be used on arterial ulcers

No compression at all Non-adherent dressing Wool and crepe lightly applied toe to knee Diabetic may have normal ABPI but high compression bandaging is not appropriate. Suspect peripheral arterial disease and refer to Tissue Viability Service

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C2

Leg Ulcers: Dressing Selection Indicator/ Descriptor Management Partial thickness aims Full thickness Other considerations

Tissue Type

Necrotic

Identified by presence of predominantly black / brown tissue

To rehydrate eschar and reduce risk of infection

Primary dressing: Hydrogel Secondary Dressing: Semi-permeable film dressing to occlude the area Primary dressing: Hydrogel Secondary Dressing: Non-adherent foam if heavy exudates or Non adherent contact dressing light/moderate exudate Non-adherent wound contact layer

Primary dressing: Hydrogel Secondary Dressing: Semi-permeable film dressing Primary dressing: Hydrogel Secondary Dressing: Non-adherent foam If slough persists consider cadexomer iodine

It is important to check the wound for signs of infection, please refer to infected wounds in section D. If unable to contain exudate, seek advice from Tissue Viability service at Lever Chambers If wound is failing to respond to treatment after following guidelines (or is deteriorating) please refer to Tissue viability Service.

Sloughy

Identified by formation of viscous, predominantly yellow tissue

To remove all debris and promote autolysis

Granulating

Wound has granular appearance, looks red and bleeds easily

To promote angiogenesis and aid wound healing

Non-adherent wound contact layer

Epithelialising

Wound is pink in appearance, tissue very fragile and needs to be kept moist

To protect new tissue and allow final stage of healing

Non-adherent wound contact layer

Non-adherent wound contact layer

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D:

DIABETIC FOOT ULCERS

Foot complications in people with diabetes are common, accounting for almost half of all diabetes-related admissions in the UK. In community-based surveys, prevalence of foot ulceration has been shown to be 3 4 %, whilst the overall incidence of foot complications in the diabetic population is 5-10%. Amputation affects 1.3% of all patients with diabetes and diabetic foot complications are responsible for 50% of all non-traumatic amputations (Williams 1985)

Tissue Type

Indicator/ descriptor

Management aims

Grade 1

Grade 2

Grade 3

Grade 4

Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin.

Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.

Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia.

Full thickness Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss.

Necrotic

Identified by presence of predominantly black / brown tissue Identified by formation of viscous, predominantly yellow tissue Wound has granular appearance, looks red and bleeds easily Wound is pink in appearance, tissue very fragile and needs to be kept moist Skin which is likely to break down as a result of friction/shear or site of previous injury

To reduce risk of infection in diabetic foot

Necrotic lesions in diabetic foot ulcers should be treated cautiously. Dry necrotic toes should be left dry and allowed to separate naturally. Due to the increased risk of infection and amputation, necrotic lesions on feet should be left dry until a full foot assessment has been performed by Podiatry. Referral to Tissue Viability for multidisciplinary assessment is essential.

Sloughy

To remove all debris and promote autolysis

Not applicable

Low exudate; Hydrogel + non adhesive Foam Mod High Exudate Hydrogel + non adhesive foam

Low exudate: Hydrogel + nonadhesive foam Mod High Exudate: Hydrofibre + non adhesive foam Low exudate: Non adhesive foam Mod High Exudate: Hydrofibre + non adhesive foam

Low exudate: Hydrogel + non adhesive foam Mod High Exudate: Hydrofibre + non adhesive foam Low exudate: Non adhesive foam Mod High Exudate: Hydrofibre + non adhesive foam

Granulating

To promote angiogenesis and aid wound healing To protect new tissue and allow final stage of healing To prevent friction, relieve pressure and reduce risk of tissue breakdown

Not applicable

Thin foam dressing for protection

Epithelialising

Not applicable

Thin foam dressing for protection

Non adhesive foam

Non adhesive foam

Reddened

No dressing observe

No dressing observe

Not applicable

Not applicable

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E: Wound Infection
According to the most recent figures wound infection in the UK accounts for 10.7% of all hospital-acquired infections and 0.7% of community acquired infection. Extra costs include in-patient stay, diagnostic procedures, cost of treatment, nursing time, pain, anxiety and quality of life. Wound infection rates can be used as a key quality indicator but care should be taken to compare criteria for definition between centres.

TYPE

Indicator / Descriptor Multiplications of organisms with, as yet, no host reaction Positive swab/biopsy

Management aims Prevent infection Reduce bacterial numbers Prevent bacterial proliferation

Treatment Options
Exudate levels No Low
Primary Dressing: Hydrogel Secondary Dressing Thin Foam

Other considerations In cases of clinical infection, systemic antibiotics must be used Measure may be required to control exudate, pain and odour Infected wounds: When assessing a wound, check for signs of a spreading infection: Pyrexia Localised heat and swelling around the wound margins Pain Friable wound bed Also pus, green slough and offensive odour may be present

Colonised

Mod - High
Primary Dressing: Hydrogel Secondary Dressing: Foam Dressing

Critically Colonised

Sufficient organisms present to interfere with healing but not invading surrounding tissue, therefore no inflammation
Characteristics:
Pain, excess exudate, Dull, dark red granulation tissue, wound is static and delayed healing

Reduce bacterial numbers Prevent bacterial infection Remove barriers to healing

Primary Dressing: Hydrogel Secondary Dressing Thin Foam

Primary Dressing: Cadexomer Iodine Secondary Dressing: Foam Dressing

Clinically infected

Deposition and multiplication of bacteria with host reaction


Characteristics of infection
Pain, Erythema, Inflammation, Pyrexia, Pus, Odour, Heavy exudate, Non-healing

Resolve deep infection using systemic antibiotics Reduce bacterial numbers Treat symptoms Prevent septicaemia Remove Barriers to healing

Primary Dressing: Hydrogel Secondary Dressing: Thin foam

Primary Dressing: Cadexomer Iodine Secondary Dressing: Foam Dressing

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F: Wound Bed Preparation & Dressing Selection


This is simply the removal of local barriers to healing. Modern wound dressings provide excellent healing rates but there are still a certain percentage of chronic wounds that fail to heal. If the wound bed is properly prepared this may yield faster healing rates from existing products and hence a greater cost effectiveness.

Type
Necrotic / Sloughy

Indicator/ Descriptor
Identified by presence of black non-viable / yellow viscous tissue

Management Aims
To rehydrate eschar and remove the physical barriers to healing

Treatment Options
Primary Dressing: Hydrogel Secondary Dressing: Adhesive Foam Dressing

Other considerations
If after 7 days there is no improvement in wound bed consider Cadexomer Iodine preparation In a large cavity must document in the care plan the number of alginate/hydrofibre ropes placed in the wound.

High bacterial Count

Identified by a chronic wound not healing, with or without clinical signs of infection

To reduce the bacterial numbers Prevent bacterial proliferation Remove barriers to healing

Primary Dressing: Cadexomer Iodine Secondary Dressing: Adhesive Foam Dressing

Chronic Exudate

Copious amounts of wound exudate Maceration of surrounding skin Lack of wound healing and cell proliferation

Control the wound exudate whilst avoiding dessication of wound bed Keep surrounding skin dry whilst maintaining a moist wound environment

Primary Dressing: Hydrofibre Secondary Dressing: Adhesive Foam Dressing

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G: Minor Wounds Dressing Selection


The minor injuries market consists of: cuts, abrasions, minor burns/scalds, skin flaps, sprains and strains. Such wounds are classified as those where damage to the epidermis or superficial damage has occurred. These wounds are characterised by redness, minor bleeding and skin abrasion and are wounds commonly seen from day to day

Tissue Type

Indicator/ Descriptor

Management aims

Broken

Shallow

Other considerations

Necrotic

Identified by presence of predominantly black / brown tissue Identified by formation of viscous, predominantly yellow tissue Wound has granular appearance, looks red and bleeds easily Wound is pink in appearance, tissue very fragile and needs to be kept moist

To rehydrate eschar and reduce risk of infection

Primary dressing: Hydrogel Secondary Dressing: Film or adhesive foam

Primary dressing: Hydrogel Secondary Dressing: Film or adhesive foam Primary dressing: Hydrogel Secondary Dressing: Film or adhesive foam Non-adherent wound contact layer

Sloughy

To remove all debris and promote autolysis

Primary dressing: Hydrogel Secondary Dressing: Film or adhesive foam

Exceptions Some pressure ulcers on heels which are necrotic and dry should beleft dry to prevent potential infection in patients with Diabetes or Arterial Disease see section D and summary recommendations

Granulating

To promote angiogenesis and aid wound healing

Non-adherent wound contact layer

It is important to check the wound for signs of infection, please refer to infected wounds in section D.

Epithelialising

To protect new tissue and allow final stage of healing

Non-adherent wound contact layer

Non-adherent wound contact layer

If wound is failing to respond to treatment after following guidelines (or is deteriorating) please refer to Tissue viability Service.

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H: CELLULITIS
Cellulitis of the lower limb can usually be managed in the community with appropriate antibiotics if recognised at an early stage. Where cellulitis has progressed, IV antibiotics may be required and can, in most cases be administered at home via the Rapid Response Team. Very occasionally cellulitis of the lower limb requires hospital admission. Antibiotics are the essential basis for therapy in these cases and they will rarely require a Tissue Viability Referral. TYPE Indicator / Descriptor Management aims Treatment Options
The extent of the Erythema should be marked as soon as it is identified then monitored to determine

Other considerations

Cellulitis of the Lower Limb


The patient will complain of feeling unwell with flu like symptoms. Resolve deep infection using systemic antibiotics

whether the cellulitis is increasing or resolving with antibiotic therapy. Exudate levels

In cases of clinical infection, systemic antibiotics must be used Measures may be required to control exudate, pain and odour Tissue Viability Referral NOT usually required

Characteristics: Blistering Pain, Erythema, Inflammation, Pyrexia, Pus, Odour, Heavy exudate, Non-healing

Drain blister large blisters will not resolve without aseptically releasing the fluid with a sterile needle, until all the fluid is dispersed

No Low

Mod - High

Primary Dressing: Non Adherent dressing Secondary Dressing Wool and crepe toe to knee

Primary Dressing: Absorbent pads Secondary Dressing Wool and crepe toe to knee Change regularly according to exudate

Reduce bacterial numbers Treat symptoms Prevent septicaemia Remove Barriers to healing As the blisters and wounds dry out, rehydrate dry legs by washing the legs in warm water with Aqueous cream

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I: WOUND COMPLICATIONS: I:1 Overgranulation Type Indicator / Descriptor


Overgranulation occurs at the proliferative stage of wound healing. It presents clinically as granulation tissue raised above the level of the surrounding skin

Management aims
To reduce further development of granulation tissue To promote epithelialisation over the surface of the wound To effectively manage wound exudate To provide a dressing that is comfortable and acceptable to the patient

Treatment Options
Foam dressing must be non adhesive Short term Hydrocortisone 1% to be applied to a layer of 3mm daily Seek advice from tissue viability service if no improvement within two weeks

Other Considerations
Silver nitrate: caustic and a potential cause of metabolic disturbances with prolonged use or possible malignancy

I:2 - Hypertrophic / Keloid scars Type Hypertrophic Indicator / Descriptor


Red/dark raised scar within the boundary of the original wound and can be very itchy or painful. Typical causes: Following any injury. Result of an imbalance in production of collagen in a healing wound. More common in the young.

Management aims
To flatten and fade scar and to improve function and mobility over a joint

Treatment Options
Silicone gel sheet

Other Considerations
Not to be used on open wounds Application time should be increased gradually Refer to Tissue Viability Service for advice

Keloid

As above. Keloid scars are most common in dark skinned people

To flatten and fade scar and to improve function and mobility over a joint

Silicone gel sheet

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I: 3 - Fungating wounds
Fungating wounds are caused by a local tumour infiltrating the skin, or by metastatic spread from the primary tumour. Both ulceration and proliferative malignant growth may be present and consequently may require a number of planned interventions to control the exudate and odour, minimise the pain and prevent maceration of the surrounding skin. Although the separate indicators are listed below and described more fully in the sub-sections, management of fungating wounds (as with other complex wounds) is often by a combination of therapies.

Type

Indicator / Descriptor
Wound exudate

Management aims
Manage excess exudates Control slough/necrotic debris Keep moist Control odour Check for infection

Treatment Options Other Considerations


Alginate moderate Hydrofibre Heavy exudate Multidisciplinary management Symptom control Irrigate with metronidazole solution Topical application of Metrotop gel Charcoal dressing, protective barrier cream for surrounding skin Foam dressing Silicone dressing Psychological support Pain control Potential Haemorrhage Body image Refer to Tissue Viability Service for advice if necessary

Odour

Maceration

Difficult sizes and sites Pain

Keep skin as dry as possible to protect from breakdown Dress with appropriate product Use an appropriate primary dressing that can be left in place for up to 7 days

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J: WOUND CLASSIFICATION A wound may be defined as a defect or break in the skin that results from physical, mechanical or thermal damage, or that develops as a result of the presence of an underlying medical or physiological disorder (Thomas, 1990) Abrasions (grazes) are superficial wounds, generally caused by friction as a result of glancing or tangential contact between the skin and a harder or rougher surface. Abrasions are generally confined to the outer layers of the skin. Lacerations (tears) are more severe than abrasions and involve both the skin and the underlying tissues. Penetrating wounds may be caused by knives, bullets, or may result from accidental injuries caused by any sharp or pointed object. Internal damage can be considerable depending upon the size and depth of penetration, and/or the velocity of the bullet or missile. Bites caused by animals or humans may become infected by a range of pathogenic organisms including spirochetes, staphylococci, streptococci, and various gram positive bacilli. If untreated, these infections may have very serious sequelae, involving fascia, tendon and bone. Burns and chemical injuries There are several different types of burns: thermal, chemical, electrical, and radiation. Thermal injuries are the most common. Burns and scalds (thermal) may be classified into three types depending upon the degree of tissue damage. Superficial (first degree) burns involve only the epidermis and superficial layers of the dermis and usually result from exposure to prolonged low intensity heat. Deep dermal (second degree) burns, in which most of the surface epithelium is destroyed together with much of the dermal layer beneath. Only some isolated epidermal elements in the deeper layer remain visible such as those within hair follicles and sweat glands. Full thickness (third degree) burns, in which all the elements of the skin are destroyed. Chronic Ulcerative Wounds Ulcers can be divided into different types depending upon their underlying cause. Pressure ulcers are usually caused by the sustained application of surface pressure over a bony prominence, which inhibits capillary blood flow to the skin and underlying tissue. If the pressure is not relieved it will ultimately result in cell death followed by tissue necrosis and breakdown. Leg or foot ulcers, which may be venous, ischaemic, mixed venous and ischaemic or traumatic in origin.

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Diabetic foot ulcers Ulcers associated with certain systemic infections. Ulcers resulting from radiotherapy. Ulcers resulting from malignant disease.

MECHANISMS OF WOUND HEALING

Irrespective of the nature or type of wound, the same basic biochemical and cellular procedures are required to bring about healing. The following types of wound healing are generally recognised. PRIMARY CLOSURE. Most clean surgical wounds and recent traumatic injuries are managed by primary closure. The surgeon approximates the edges of the wound and individually sutures the different layers of tissue together. OPEN GRANULATION. In wounds that have sustained a significant degree of tissue loss as a result of surgery, trauma or chronic ulceration, it may be undesirable or impossible to bring the edges of the wound together. The wound is left to heal by secondary intention. DELAYED PRIMARY CLOSURE. Delayed primary closure is carried out when, in the opinion of the surgeon, primary closure may be unsuccessful (due to the presence of infections, a poor blood supply to the area, or the need for the application of excessive tension during closure). In these circumstances, the wound is left open for about three to four days before closure is affected. GRAFTING AND FLAP FORMATION. A skin graft is a portion of skin (composed of dermis and epidermis) that is removed from one anatomical site and placed onto a wound elsewhere on the body. If successful, grafting will ensure that the wound will heal rapidly, thus reducing the chance of infection. The disadvantage of this technique is that the patients finishes up with two wounds instead of one, and the donor site can be more painful than the original injury. L WOUND ASSESSMENT

Guideline Statement Holistic assessment of the patient is an essential part of the wound care process. All patients with wounds will have their wounds assessed by nursing staff within 24 hours of admission to an episode of care (hospital or community).

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To link in with the wound assessment tool, classification by wound bed tissue type is used in addition to the following factors: Wound measurement, exudate, presence of infection, pain and condition of surrounding skin. Wound Bed Necrotic Wound containing dead tissue. It may appear hard, dry and black. Dead connective tissue may appear grey. Eschars with time may soften by autolysis and bacterial liquefacation. The presence of dead tissue in wounds delays healing. Sloughy Slough is formed by an accumulation of dead cells in the wound exudate. It is light yellow in colour and must not be confused with infected tissue and pus. Granulating Healthy red tissue, which occurs during the proliferative phase of healing. Firbroblasts migrate to the wound to produce collagen fibres. The tissue is well vascularised and bleeds easily. Epithelializing Process by which the wound surface is covered by new epithelium, this begins when the wound has filled with granulation tissue. The tissue is pink, almost white, and only occurs on top of healthy granulation tissue.

Wound Measurement Wound measurement is a vital aid to examining the healing process within a wound. Chronic wounds should be measured 4 weekly (diabetic foot ulcers weekly). The wound should be measured at its greatest length and breadth: The two measurements are then multiplied to give an approximate wound area in CM2. This method can be unreliable where different professionals are assessing the same wound and also where the shape of the wound is quite irregular. Exudate Exudate is produced by all acute and chronic wounds (to a greater or lesser extent) as part of the natural healing process but may become more viscous and malodorous in infected wounds. It plays an essential part in the healing process in that it: Contains nutrients, energy and growth factors for metabolising cells Contains high quantities of white blood cells

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Maintains a moist environment for wound healing Uncomplicated exudate should ideally be left undisturbed on the wound surface, however the surrounding skin may require some cleansing in order to reduce odour and prevent maceration. With leg ulcers, excessive exudate may be produced as a result of venous hypertension and in this case the patient should be referred to the appropriate leg ulcer clinic for holistic assessment and doppler studies to determine suitability for compression. Infection Wound infection may be defined as the presence of bacteria or other organisms, which lead to a host reaction. A host reaction can present as any one or combination of the following signs: (Adapted from: Cutting & Harding, 1994) Redness (erythema) around the wound The production of large amounts of exudate or pus A change in exudate colour Malodour A raised systemic temperature Localised pain Localised heat Lymphangitis Delayed or abnormal wound healing Wound breakdown The appearance of fragile tissues which may bleed easily when touched or at the time of a dressing change. Guideline Statement Systemic antibiotics should be used to treat clinical wound infections Antiseptics are toxic to human tissue and may delay wound healing

Pain The pain associated with chronic wounds is often underestimated. In over 50% of cases, nurses recording of patients pain differed from self-reporting. In most of these cases, the nurses had underestimated the patients pain. Pain assessment tools have many advantages: Patient has a more active role in dealing with their pain The patient may feel that their pain is being taken seriously The tool often prompts more effective pain relieving measures, as documented evidence exists. In wound care, accurate assessment of pain is essential with regard to choice of the most appropriate dressing. Assessment of pain before, during and after the dressing change may provide the nurse with vital information for future wound management.

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Exceptions: Patients with peripheral neuropathy (often diabetic patients) who may have lost sensation in the foot and therefore are unable to feel pain in the foot. In general, pain experienced by patients with chronic wounds, (although extremely subjective and variable from patient to patient) falls into the following categories: A deep, dull constant pain A superficial, burning-type pain A neuralgic type pain An ischaemic type pain The pain resulting from cellulitis Whatever the cause of the pain, the patients perception of their pain should be acknowledged, and appropriate action taken to alleviate suffering.

Surrounding Skin Surrounding tissues may present as: healthy macerated dry/flaky eczematous blue/black discolouration oedema erythema cellulitis The surrounding skin should be examined carefully as part of the process of assessment and appropriate action taken. M FACTORS DELAYING WOUND HEALING

A number of local and systemic factors are well recognised causes of delayed or impaired wound healing. Foreign bodies introduced deep into a wound at the time of injury can, if not removed, cause a chronic inflammatory response and delay healing or lead to the formation of a granuloma or abscess. Long standing wounds that heal by epithelialisation, such as burns and leg ulcers, may develop Marjolins ulcer, an uncommon slow-growing squamous cell carcinoma.

Other major factors that have an important effect upon the rate of healing include the age and the nutritional status of the patient; underlying metabolic disorders such as diabetes or anaemia; the administration of drugs that suppress the inflammatory process; radiotherapy; arterial disease which may be aggravated by smoking; and the presence of slough and necrotic tissue. (Thomas, 1990)

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Factors that may affect the healing process:


Increasing age Nutrition Dehydration Blood Supply Infection Disease Stress Lack of Sleep Adverse conditions at the wound site Inappropriate wound management Iatrogenic causes Patient compliance/motivation Unrelieved pressure

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NUTRITIONAL ASPECTS OF WOUND HEALING

Nutritional status plays a critical role in the wound healing process. Neglecting the nutritional health of the individual may totally compromise all wound management to be carried out. (Wallace, 1994) Optimal Nutrition Helps To Maintain Immune Competence. THE ESSENTIAL NUTRIENTS FOR WOUND HEALING Protein, Vitamin C, B Complex and A, Zinc, Iron and Copper are essential for wound healing. In addition to these nutrients, it is essential that adequate energy/calories are obtained from fats and carbohydrates to prevent tissue protein being used as a source of energy. PROTEIN Requirements: 1.2 2.0g protein/kg/24h Protein is required for healing tissues. Without adequate protein normal protein synthesis and wound healing are inhibited. The immune response is diminished and there is a delay in matrix formation.

Protein Sources:-

Meat, fish, eggs, milk, cheese, yoghurt, pulses and nuts. Nutritional sip feeds will provide important sources of protein and other nutrients if dietary intake is inadequate.

ENERGY Requirements: 30-40 Kcal/kg/24h An adequate energy/calorie intake is essential in order to prevent dietary and tissue protein being used as a source of energy rather than for wound healing. An excessive intake of energy, leading to obesity, also gives rise to problems with wound healing decreased mobility, increased weight bearing and vascular insufficiency may precipitate wound complications and increase the risk of pressure sores (Wells, 1994). For obese patients during recovery from major surgical or trauma wounds, a strict weight-reducing diet during this time is inappropriate, good quality nutrition is vitally important. It is important to remember that overweight does not necessarily mean well nourished. Malnutrition is a widespread problem (Edington, et al., 1996) which affects obese and underweight patients. Energy Sources:All foods provide energy and preserve tissue protein. Carbohydrate sources bread, potatoes, breakfast cereal, rice and pasta, oils,

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spreads, butter, margarine, fried foods. Fat sources oils and fats, butter, margarine, fried foods.

VITAMINS Vitamin C Requirements: A minimum of 60mg vitamin C. Vitamin supplements from 200 mg 1g per day are sometimes recommended [Taylor, 1974], however excessive doses may cause renal stones [Morton, 1995]. Vitamin C is required for collagen synthesis and aids iron absorption. Vitamin C is not stored in the body with patients rapidly becoming deficient. Supplements may be necessary. Vitamin C Sources:- Citrus fruits and juices, blackcurrant juice drinks and fruit squashes fortified with vitamin C tomato juice, all fruit and vegetables. Vitamin A Promotes epithelialization and granulation of healing wounds. Vitamin A Sources:- Liver, dairy products, oily fish, carrots, dried fruits.

Vitamin B Complex Co-factor for enzyme systems in protein, fat and carbohydrate metabolism. Vitamin B Complex Sources: Liver, kidney, meat, poultry, fortified breakfast cereals, wholemeal bread, yeast extract, eggs, and green vegetables. Vitamin E Controversial role. Some research states that it is beneficial, while others consider it detrimental (Mazzotta, 1994). Vitamin K Indirect role in wound healing, needed for normal blood coagulation. Vitamin K sources Green vegetables, potatoes, tomatoes, liver, soya beans.

MINERALS

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Zinc Deficiency is associated with poor wound healing. Zinc is required for collagen synthesis, epithelialization and cell proliferation. Zinc supplements have been found to improve the healing of leg ulcers where zinc deficiency is identified. However, where there is no deficiency excess zinc can impair healing (Wells, 1994). Zinc sources:- Liver, meat, fish, eggs, pulses including baked beans, wholegrain cereals. Iron Blood losses during injury or inadequate dietary intake, anaemia will result in decreased transport of oxygen to damaged tissue and may delay wound healing. Iron is required for collagen formation. Iron Sources:- Liver, meat, poultry, oily fish, egg yolk, pulses, dried fruits. Copper Required for collagen formation and essential for red blood cells formation. Copper Sources:- Meat, fish, cereals and pulses, green vegetables. FLUIDS Requirements:30-65 ml/kg/24h

Adequate fluids are required to prevent skin dehydration and essential with high protein diets. Fortification of foods with energy/calories and/or protein supplements can enhance the quality of the diet. Supplementary drinks such as Build-up, Complan or Vitafood provide an important source of all nutrients if dietary intake is inadequate. Nutritional assessment. Identification of high risk individuals allows prompt employment of nutritional support and optimal use of resources to improve wound healing and reduce complications. [Ward et al., 1998 ]. Guideline Statement Optimal nutrition facilitates wound healing, maintains immune competence and decreases the risk of infection. It is essential to consider the nutritional status of all patients with wounds. Referral to the dietitian should then be made where appropriate.

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O i.

WOUND MANAGEMENT Wound Cleansing

Most of the research on wound cleansing examines the efficacy of wound cleansing on removal of bacteria from the wound. It is widely accepted that chronic wounds are heavily colonized with bacterial skin flora and that attempts to remove these bacteria from a chronic wound are futile. (Thomlinson, 1997) Wound cleansing should not be undertaken to remove normal wound exudate. There is extensive evidence to support the fact that exudate is beneficial to the wound, containing growth factors and nutrients, which actually support the healing process (Leaper, 1986) Excessive wound exudate may require removal and may also cause local maceration of the skin. Some cleansing may be required in this case, however if the exudate is clear, enabling accurate wound assessment the surrounding skin may be cleansed leaving the wound untouched. The following criteria for wound cleansing are recommended in accordance with recent research: Criteria for wound Cleansing 1. 2. 3. To remove visible debris after a wound has initially occurred and to aid assessment To remove excess slough and exudate in order to aid patient comfort To remove remaining dressing material
(Miller & Gilchrist, 1998)

In cases where wound cleansing is necessary, warm normal saline should be used. Cell mitosis is inhibited by cooling the wound and may actually delay healing (Lock, 1980). Irrigation is the method of choice for cleansing wounds. This may be carried out utilising a syringe in order to produce gentle pressure in order to loosen dressing debris etc., but to prevent splashback of irrigation fluid. Gauze swabs, cotton wool etc. should not be used for cleansing the wound surface, but may be used to wipe away excess saline/exudate from the surrounding skin following irrigation. Mechanical damage to new tissue and the shedding of fibres from gauze swabs/cotton wool delays healing (Wood, 1976)

Guideline Statement Wound cleansing (where necessary) should be carried out by irrigation with sterile normal saline warmed to body temperature. For chronic wounds such as leg ulcers, ordinary tap water can be used
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Other Solutions Used for Wound Cleansing: The following solutions should not be routinely used in the cleansing of wounds. They should only be used where the risk of infection outweighs the reported detrimental effects of the solution and should only be used further to Consultant, Microbiological or Pharmacological advice: Povidone Iodine only licensed as a skin antiseptic and not for use on open wounds Chlorhexidine 0.5% shown to inhibit epithelialization and granulation of tissue (Neider & Scoph, 1986). If used on traumatic wounds with a high risk of infection, then 0.05% in aqueous form should be used. Potassium Permanganate: No research traced relating to benefits, toxicity or allergies. BNF states that it may be irritant to mucous membranes. Sometimes used under instructions of dermatologist, vascular surgeon or General Practitioner for weeping eczema. Hydrogen Peroxide: Not recommended for wound cleaning except in exceptional circumstances. There have been unsubstantiated reports of air emboli resulting from its use in cavity wounds. (Sleigh & Winter, 1985)

Guideline Statement
Systemic antibiotics should be used to treat clinical wound infections Antiseptics are toxic to human tissue and may delay wound healing ii. Choice of Dressings

It should be recognised that a wound will require treating differently at various stages of its healing. No dressing is suitable for all wounds. Following careful selection of the appropriate management plan for the patient, the wound assessment tool should be used to monitor the progress of the wound through to its healing stage.

Guideline statement
Criteria for Choosing a Dressing In Order of Importance (Miller & Collier, 1997)
1. 2. 3. 4. 5. 6. 7. 8. 9. Choose a dressing that maintains a moist environment at the wound/dressing interface. (The only possible exceptions are peripheral necrosis secondary to arterial disease. Choose a dressing that is able to control (remove) exudate. A moist wound environment is good, a wet environment is not beneficial Choose a dressing that does not stick to the wound and cause trauma on removal Choose a dressing that protects the wound from the outside environment Choose a dressing that will aid debridement if there is necrotic or sloughy tissue in the wound (caution with ischaemic lesions) Choose a dressing that will keep the wound close to normal body temperature Choose a dressing that is acceptable to the patient Choose a dressing that is cost-effective Diabetes choose a dressing that will allow frequent inspection

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Dressings Supplies Methods for wound management should be re-assessed at each dressing change. However, the following list is issued as guidance to minimise wastage of prescribed dressings as the wound changes. Wound Type / Suggested Duration of Supply * Black/Necrotic Sloughy Low or no exudate Medium to high exudate Granulating Epithelialising 7 days 7 - 10 days >10 days 2 - 4 weeks 2 - 4 weeks 2 - 4 weeks

* The amount supplied depends on the frequency of dressing changes. Manufacturers instructions are provided with all products and these must be read and followed at all times.

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P:

Formulary of Product Groups With Recommendations for Use

Alginates

Formulary choice: Kaltostat (Convatec) Sorbsan Plus (Unomedical)

NB.

Indicated in the management of moderately to heavily exuding wounds Calcium alginate with sodium alginate Active haemostatic dressing Fibres convert to a hydrophillic gel (biodegradable) when in contact with exudates Use Sorbsan Plus for very heavy exudate only

Use placed on the surface of the wound. Alginate rope can be used in cavity wounds or sinuses but do not pack tightly Cover with film dressing or adhesive foam dressing Change every 1 - 7 days depending on amount of exudate Removal: Kaltostat - remove with forceps once moistened with saline. At dressing changes the fibre in contact with the surface should have formed a gel. If dressing moist but not gelled, increase interval between dressing changes. If dressing has gelled and dried out, use of a more occlusive dressing may be appropriate.

Antiseptics

Formulary Choice: Cadexomer Iodine: Iodosorb &Iodoflex (Smith & Nephew) Inadine (Johnson and Johnson)

Cadexomer Iodine is the product of choice within Bolton PCT as it releases Iodine slowly into the wound at a controlled rate. Inadine contains 10% povidone iodine with 1% available iodine, which imparts pronounced (though short-term) antibacterial activity to the dressing (Thomas, 1990). Inadine adheres to the wound bed and is deactivated by wound exudate (in some cases in only a few hours). Absorption of iodine occurs and therefore it is contraindicated in patients on Lithium or thyroxine therapy. It should NOT be used on children as it often causes trauma on removal. The debate on the use of iodine continues at National and European levels (Gilchrist, 1997) and therefore the use of these (and other iodine) dressings should remain restricted until clear guidance is available.

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Foam Dressings

Formulary Choice: Allevyn thin, adhesive and non-adhesive (Smith & Nephew)

Use

Indicated for medium exuding wounds Exudate absorbed horizontally across the hydrophillic surface Place on wound surface Secure with adhesive tape (if non-adhesive) Change every 1 - 7 days depending on volume of exudate Low adherence

Hydrocolloids

Formulary Choice: Hydrocoll basic, Hydrocoll border, Hydrocoll thin film (Hartmann)

Indicated for light / medium exuding wounds Interactive with the wound exudate, slowly absorbing fluid leading to a change in the physical state of the dressing. The dressing provides an environment for rapid debridement and an initial increase in the size or depth of the wound therefore often occurs.

Use Dressing should extend at least 2 cm beyond the edge of the wound Dressings should be changed every 3 - 7 days depending on the amount of exudate

Hydrofibre

Formulary Choice: Aquacel (Convatec)

Indicated for medium/heavy exuding wounds Interactive with the wound exudate, slowly absorbing fluid leading to a change in the physical state of the dressing. The dressing provides an environment for rapid debridement and an initial increase in the size or depth of the wound therefore often occurs. Use There is minimal lateral wicking therefore it can overlap healthy skin slightly When packing a wound with the ribbon, it must be very lightly packed to avoid further trauma

Hydrogel

Formulary Choice Purilon (Coloplast)

Suitable for wound debridement and for light to medium exuding wounds Dressing allows either the release of water to rehydrate surrounding tissues or the absorbtion
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of exudate from the wound Use Apply to the wound Requires a secondary dressing which will encourage occlusion (eg film or adhesive foam dressing)

Film Dressings

Formulary Choice: Mefilm (Molynlycke)

Suitable for flat/shallow low exudate wounds Sterile, thin, waterproof, self adhesive film Can be used as a retention dressing aid alone Some patients may be allergic to the adhesive

Odour Absorbing Dressings

Formulary Choice: Actisorb Plus (Johnson &Johnson) Carboflex (Convatec)

Actisorb Plus is a primary dressing and is designed to be placed directly onto a wound and covered with a secondary dressing. It contains 0.15% Silver, which provides antimicrobial properties, and therefore this product, should only be used for malodorous and infected wounds. Carboflex has an alginate wound contact layer and carbon layer for odour absorption. It is a particularly useful dressing for fungating malignant wounds.

Polysaccharide Pastes Not Available in Bolton Formulary (eg. Sugar Paste)


Unfortunately most of the evidence supporting use of sugar paste is anecdotal (Thomas, 1990), however its use for rapid debridement of slough/eschar and reduction in bacterial contamination are frequently reported. Wounds treated with sugar paste should be redressed daily, and may cause severe pain therefore use of sugar paste is not advocated in Bolton.

Tulle Dressings

Formulary Choice Jelonet

Although this is cited as a non-adherent dressing, this dressing often adheres to the wound bed. There has also been evidence of granulation tissue protruding through the dressing, thus increasing adherence. The dressing should therefore be changed frequently to avoid this and a double layer of the product should be used to reduce adherence.

Antibiotic
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Impregnated Dressings
(eg Sofra-tulle, Fucidin-Intertulle) Due to increasing numbers of resistant strains of micro-organisms and also sensitivity reactions, the use of antibiotic dressings is not recommended. Wherever possible antibiotics should be administered orally, NOT by dressings applied to the wound.

Topical Negative Pressure


Also known as Vacum-assissted closure (VAC KCI Medical Ltd). This is a treatment that subatmospheric pressure to a wound via a computerised therapy unit (Mendez Eastman 2001). This device removes excess exudates, which is collected in a canister, reduces oedema, improves the micro-circulation, decreases bacterial load and stimulates both new tissue formation and wound contracture (Ballard and Baxter 2002). It has been shown to be effective in a variety of wounds, particularly surgical dehiscence, pressure ulcers, leg ulcers, diabetic foot ulcers and skin grafts (Baxandall 1997:Collier 1997:Ballard and Baxter 2002). The Tissue Viabiltiy Team MUST be involved in the initial assessment for Vac therapy. Vac therapy does have a cost implication. The funding has to be agreed by a department prior to an order being placed. The Tissue Viability service does not have a budget for this treatment. Important Note: A single product is unlikely to be suitable for a particular wound throughout the wound healing process. Regular re-assessment of the wound is essential together with documentation to support rationale for change of dressing. Communication between the acute/community setting and joint visits with other disciplines aid holistic assessment and promote multidisciplinary team approach to wound care.

Guideline Statement Wounds which are being managed in accordance with wound care guidelines but are deteriorating should be referred to Tissue Viability Team. Wounds failing to respond to treatment within a four to six week period can be referred to the Tissue Viability Team for review. Please also refer to specific referral and wound management criteria for leg ulcers & diabetic foot ulcers within specific guidelines.

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Bibliography Ballard K,Baxter H (2002) Developments in wound care for difficult to manage wounds In:White R Ed Trends in Wound Care.Mark Allen Publishing:Salisbury,Wiltshire UK. Baxandall T (1997) Healing cavity wounds with negative pressure.Elderly care 9 (1):20-2. Burton A and Burton M., (1981) The Management and prevention of Pressure Sores London, Faber and Faber, Collier M (1997) Know How:Vacuum-assisted closure (VAC).Nursing Times 93(5):32-3. Cutting K. F., Harding, K. G. (1994) Criteria for identifying wound infection. Journal of Wound Care 3: 4, 198-201 Dealey C (1994) The Care of Wounds. Blackwell Scientific Publications, Oxford. Duckworth, C Ed. (1996) Guide to the Research Base to Support a Wound Care Policy Edington J., Kon P, Martyn CN. Prevalence of Malnutrition in Patients in General Practice. Clinical Nutrition, Vol 15, 1996, Pp 60-63. Feller N. and Lurie A., The early care of wounds caused by human and animal bites, Fam Physn, 1977, 7, 29-30. Gilchrist B.(1996) Wound infection: sampling bacterial flora: a review of the literature. Gilchrist B (1997) Should iodine be reconsidered in Wound Management? Journal of Wound Care 6: 3, 148-150 Harding K. and Jones V. (1996) Lock, P.M. The effects of temperature on mitotic activity at the edge of experimental wounds. In: Sundell, B. (ed) Symposia on wound healing; plastic surgical and dermatological aspects. Molndal; Switzerland: Lindgren, A. & Soner, A. B., 1980 Mazzotta M. Nutrition and Wound Healing. Journal American Podiatr. Medical Association, Vol 84 (9), 1994, pp 456-462. Mendez-Eastman S (2001) Guidelines for using negative pressure wound therapy. Adv Skin Wound Care 14 (6):314-325 Miller & Collier, (1997)Understanding Wounds. Professional Nurse Supplement Miller & Gilchrist, (1998) Understanding Wound Cleansing and Infection. Professional Nurse
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Supplement Moffatt C.J. et al, (1992) Community Clinics for Leg Ulcers and Impact on healing. BMJ 1992 305`3989-1392. Morrison MJ, (1992) A Colour Guide to the Assessment and Management of Leg Ulcers, 2nd Edition Mosby, London. Morton, K. Nutrition and wound care. (1995) 5th European Conference on advances in wound management proceedings. 21-24 November 1995, pp 31 34

Owen-Smith M., Wounds caused by weapons of the war, in Wound Care, Westaby S. (ed), London Heinemann Medical, 1985, 110-120. RCN (1998) Clinical Practice Guidelines.The Management of Patients With Venous Leg Ulcers. SIGN (1998) The Care of Patients With Chronic Leg Ulcer.A National Clinical Guideline.Scottish Intercollegiate Guidelines Newtwork. Sims R and Fitzgerald V (1985) Community Nursing Management of Patients with Ulceration/Fungating Malignant Breast Diseases. Oncology Nursing Society London. Taylor A. D., Taylor R. and Marcuson RW, (1998) Prospective comparison of healing rates and therapy costs for conventional and four-layer high-compression bandaging treatments of venous leg ulcers. Phlebology 13:20-24 Thomas S. (1990) Wound Management and Dressings. The Pharmaceutical Press. Thomas B. (Ed). Dietetic management of acute trauma. In Manual of Dietetic Practice, Blackwell Scientific Publications, Oxford, 1994, p 637. Thomlinson, D. (1997) To Clean or Not To Clean? Nursing Times; 83: 9, 71-75 Wallace E. Feeding the Wound: nutrition and wound care. British Journal of Nursing Vol 3(13), 1994, pp 662-667. Ward, J. et al., Development of a screening tool for assessing risk of undernutrition in patients in the community. Journal of Human Nutrition and Dietetics, Vol.11, No 4, 1998, pp 323 -330. Wells L. The Importance of Nutrition in Wound Management. Professional Nurse, Vol 9, 1994, pp 525-530.

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APPENDICES: 1. Wound Care Assessment Tool


(a) Hospital (b) Community

2. Clinical Evidence Grading Criteria 3. Summary of Recommendations and supporting graded evidence

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Bolton Hospitals NHS Trust

WOUND ASSESSMENT CHART


Date of Initial Assessment ..
Name: Address GP Consultant

SIZE OF WOUNDS Width Length TYPE OF WOUNDS Surgical Pressure Ulcer / Grade Diabetic foot ulcer Leg Ulcer Other (eg. Fungating)

WOUND WOUND WOUND 1 2 3

WOUND WOUND WOUND 1 2 3

Known Patient Allergies

POSSIBLE DELAYED HEALING DUE TO: TICK ONE OR MORE IF APPLICABLE Age 75+ Anorexia Dehydration Bedbound Chairbound Cachexia Anaemia Diabetes Vasc Disease Oedema Incontinence Steroids Infection Other please state: If 4 or more factors consider impact on healing and try to correct factors if possible Date..

Refer on to appropriate teams below ONLY if significant complication or deterioration in wound: Infection Control (if complications) Tissue Viability Nurse (if wound deteriorating) Dietitian (if required following nutritional assessment) Pain Nurse (eg Uncontrolled pain at dressing) Podiatrist (for complex foot ulcers , footwear etc) Other (Please state) Date .. Sign . Date .. Sign . Date .. Sign . Date .. Sign . Date .. Sign . Date .. Sign .

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WOUND PROGRESS AND TREATMENT RECORD This record should be used in conjunction with the patients care plan

Ongoing Wound Assessment:


Date Wound Number DESCRIPTION Necrotic (Black)

%age

Sloughy (Yellow / Green) %age Granulating (Red) %age Epithelialising (Pink) %age Condition of surrounding skin Eg fragile, dry etc EXUDATE Exudate present (Yes or No) Odour None Slight Offensive Colour clear Straw Blood Purulent Amount (Mild/ Mod/ excessive) PAIN None/mild/moderate/ severe INFECTION Spreading Erythema Excessive Inflammation Green Slough / Exudate Pyrexia Pus (take a sample for C & S) If clinical signs of infection obtain a wound swab (Date)
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Bolton Primary Care NHS Trust

WOUND ASSESSMENT CHART


Date of Initial Assessment ..
Name: Address GP Consultant

SIZE OF WOUNDS Width Length TYPE OF WOUNDS Surgical Pressure Ulcer / Grade Diabetic foot ulcer Leg Ulcer Other (eg. Fungating)

WOUND WOUND WOUND 1 2 3

WOUND WOUND WOUND 1 2 3

If skin tear or laceration in a residential / nursing home, please ensure that you have seen documented evidence that the home has completed an accident / incident report prior to accepting patient on caseload Evidence of completed Accident / Incident Report seen Signature Date Known Patient Allergies

POSSIBLE DELAYED HEALING DUE TO: TICK ONE OR MORE IF APPLICABLE Age 75+ Anorexia Dehydration Bedbound Chairbound Cachexia Anaemia Diabetes Vasc Disease Oedema Incontinence Steroids Infection Other please state: If 4 or more factors consider impact on healing and try to correct factors if possible Date..

Refer on to appropriate teams below ONLY if significant complication or deterioration in wound: Infection Control (if complications) Tissue Viability Nurse (if wound deteriorating) Dietitian (if required following nutritional assessment) Pain Nurse (eg Uncontrolled pain at dressing) Podiatrist (for complex foot ulcers , footwear etc) Other (Please state) Date .. Sign . Date .. Sign . Date .. Sign . Date .. Sign . Date .. Sign . Date .. Sign .

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WOUND PROGRESS AND TREATMENT RECORD This record should be used in conjunction with the patients care plan

Ongoing Wound Assessment:


Date Wound Number DESCRIPTION Necrotic (Black)

%age

Sloughy (Yellow / Green) %age Granulating (Red) %age Epithelialising (Pink) %age Condition of surrounding skin Eg fragile, dry etc EXUDATE Exudate present (Yes or No) Odour None Slight Offensive Colour clear Straw Blood Purulent Amount (Mild/ Mod/ excessive) PAIN None/mild/moderate/ severe INFECTION Spreading Erythema Excessive Inflammation Green Slough / Exudate Pyrexia Pus (take a sample for C & S) If clinical signs of infection obtain a wound swab (Date)
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Appendix 1

Levels of Evidence
This hierarchy is for use by Guideline and Pathway authors when preparing their work. It should be used to help analyse individual items of evidence used. Any staff using the Guidelines and Pathways should be able to see easily what type of evidence is informing the document they refer to. Guideline and Pathway authors should make this clear in their document. Good examples of this type of presentation are NICE Guidelines (www.nice.org.uk)
1++ 1+ 12++ 2+ 23 4 High quality meta analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias Well conducted meta analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias Meta analyses, systematic reviews of RCTs, or RCTs with a high risk of bias High quality systematic reviews of case control or cohort or studies High quality casecontrol or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal Well conducted case control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal Case control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal Non-analytic studies, e.g. case reports, case series Expert opinion

Grading
Grading is done by Guideline and Pathway authors when preparing their work for submission to the Clinical Effectiveness Group. An overall single grading for the Guideline/Pathway should be stated on the document proforma submitted for ratification. A At least one meta analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results A body of evidence including studies rated as 2++, directly applicable to the target population, and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 1++ or 1+ A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or Extrapolated evidence from studies rated as 2++ Evidence level 3 or 4; or extrapolated evidence from studies rated as 2

level of evidence and grading, August 2003

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Appendix 3

Evidence Ratings Used Within Guidelines


Recommendation Holistic assessment of the patient is an essential part of the wound care process All patients with wounds will have their wounds assessed by nursing staff within 24 hours of admission to an episode of care Optimal nutrition facilitates wound healing, maintains immune competence and decreases the risk of infection. B 21. Albina JE (1994) Nutrition and wound healing. Journal of Parenteral and Enteral Nutrition 16: 367-376 2. Martin MTM, (1998) In: Leaper D (ed) 2++ th Proceedings of the 7 European Conference on: Advances in Wound Management. London: EMAP Healthcare Ltd 129-133 2++ 3. Sitton-Kent L, Gilchrist B (1993) The intake of nutrients by hospitalized pensioners with chronic wounds. Journal of Advanced Nursing 18: 12, 1962-1967 21. Albina JE (1994) Nutrition and wound healing. Journal of Parenteral and Enteral Nutrition 16: 367-376 2. Martin MTM, (1998) In: Leaper D (ed) 2++ th Proceedings of the 7 European Conference on: Advances in Wound Management. London: EMAP Healthcare Ltd 129-133 2++ 3. Sitton-Kent L, Gilchrist B (1993) The intake of nutrients by hospitalized pensioners with chronic wounds. Journal of Advanced Nursing 18: 12, 1962-1967 Grade of Evidence C Evidence to support recommendation 1. Van Rijswijk L (1996) Wound assessment and documentation. Chronic Wound Previews 8 (2) 57-68 2++

It is essential to consider the nutritional status of all patients with wounds. Referral to the dietitian should then be made where appropriate

Wound cleansing(where necessary) should be carried out by


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2++ 1. Lock PM The effect of temperature on mitotic activity at the edge of experimental wounds.(1980) IN: Lundgren A , Soner AB (eds) Symposia on Wound Healing: Plasitc surgical
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irrigation with sterile normal saline warmed to body temperature

and dermatologic aspects. Sweden: Molndal

For chronic wounds such as leg ulcers, ordinary tap water can be used Antiseptics are toxic to human tissue and may delay wound healing

Topical antibiotics are frequent sensitisers and should be used with caution Systemic antibiotics should be used to treat clinical wound infections Wound dressings should:
maintain a moist environment at the wound/dressing interface. (The only possible exceptions are peripheral necrosis secondary to arterial disease). be able to control (remove) exudate. A moist wound environment is good, a wet environment is not beneficial not stick to the wound and

1. Angeras MH, Brandberg A, Falk A, Seeman T. Comparison between sterile saline and tap water for the cleaning of acute traumatic soft tissue wounds. (1992) European Journal of Surgery 158: 33, 347-350 1. OMeara S M, Cullum NA, Majid M, Sheldon TA (2001) Systematic review of antimicrobial agents used for chronic wounds. British Journal of Surgery 88, 4-21 2. Brennan SS and Leaper D J (1985) The effect of antiseptics on the healing wound: a study using the rabbit ear chamber 3. Tatnall FM, Leigh IM, Gibson JR (1990) Comparative study of antiseptic toxicity on basal keratinocytes, transformed human keratinocytes and fibroblasts. Skin pharmacology 3, 3, 157163 1. OMeara S M, Cullum NA, Majid M, Sheldon TA (2001) Systematic review of antimicrobial agents used for chronic wounds. British Journal of Surgery 88, 4-21 1. OMeara S M, Cullum NA, Majid M, Sheldon TA (2001) Systematic review of antimicrobial agents used for chronic wounds. British Journal of Surgery 88, 4-21

1+

1++

2++

2+

1++

1++

1. Winter GD (1962) Formation of the scab and the 2+ rate of epithelialisation of supervicial wounds in the skin of the young domestic pig Nature 193: 293-294 2++ 2. Hinman, CD, Maibach H (1963) Effect of air exposure and occlusion on experimental skin wounds. Nature 200: 377-378 2++ 3. Dyson M, Young S, Pendle CL, Webster DF, Lang SM (1988) Comparison of the effects of moist and dry conditions on dermal repair. Journal of Inversitgative Dermatology 91; 5, 435-439 4. Lock PM The effect of temperature on mitotic activity at the edge of experimental wounds.(1980) IN: Lundgren A , Soner AB (eds)

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cause trauma on removal protect the wound from the outside environment aid debridement if there is necrotic or sloughy tissue in the wound (caution with ischaemic lesions) keep the wound close to normal body temperature be acceptable to the patient be cost-effective Diabetes choose a dressing that will allow frequent inspection

Symposia on Wound Healing: Plasitc surgical and dermatologic aspects. Sweden: Molndal

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