Guidelines for the Assessment and Management of Wounds

Date of Guideline July 2004


Date of review July 2006

0 4.0 10 11 12 Date of Guideline July 2004 2 Date of review July 2006 .3 5. 1.1 6.4 3.8 6.1 3.0 3.6 4.7 5.6 3.Contents Summary Guidelines for the Assessment & Management of Wounds Definition Classification Aim of Assessment Assessment Additional Assessment techniques for clients with Leg Ulcers Computer based Wounds healing Assessment Measurement may be by Skin assessment Client opinion Wound Management Aims of Management Primary Treatment objectives Frequency of dressing changes Swab taking Dressing Characteristics which influence choice Choice of dressing Features of the ideal dressing Debridement Surgical debridement Sharp debridement Other methods of debridement Rationale for debridement Choice of debridement Contraindications to sharp debridement Assessment for debridement should include Training for sharp debridement Specific types of wound management Leg Ulcers Pressure Ulcers Vacuum Assisted Wound Closure Larva therapy Documentation of Wounds Client Information Infection Control Appendix 1 Appendix 2 References Page 3 5 5 5 5 5 6 6 6 6 6 7 7 7 7 7 8 8 8 9 9 10 10 10 10 10 11 11 11 11 12 12 12 12 12 12 13 13 14 15 16 1.0 9.4 4.1 5.1 4.0 3.0 6.7 4.7 5.5 3.5 5.0 2.2 5.2 3.5 4.4 5.51 3.0 8.2 6.0 5.3 4.4 7.2 4.6 5.3 6.3 3.

with evidence of ongoing review & evaluation. Debridement / desloughment. Control bleeding Control exudates Reduce bacterial burden Reduce odour Minimise effects of infection Minimise pain at dressing changes Optimise healing potential Once the primary treatment objective /intended outcome is achieved. Use at body temperature. Consider water quality. using PCT wound evaluation frameworks Primary treatment objectives Cleansing: is it needed? Does dressing absorb exudates? Tap water or Normal Saline may be used as appropriate as an irrigation agent. exudate / pus / serous fluid Intrinsic or extrinsic factors affecting healing (see NICE & EPUAP Guidelines on Pressure Ulcers) Previous related wound management regimes. reassessment is needed to identify next objective Date of Guideline July 2004 3 Date of review July 2006 . including success / failures & how long they were used Patient’s perception of their wound Actual pressure ulcer or vulnerable to pressure areas Measurement Acetate tracings Photogrphy (valid informed consent required) Specialist assessment: deep tracks / sinuses Chronic wounds will be traced / measured at least every 4 weeks and re-evaluated each time a dressing is applied and / or if it gives rise for concern (Royal Marsden 2000) e) f) g) h) i) j) k) Effective handwashing techniques & attention to Infection Control guidance will be adhered to at all times Skin assessment Erythematous Excoriated Indurated Macerated Clinical signs of infection evident: Swab only if present Leg Ulcer suspected: Doppler assessment. consider Vascular referral Follow Avon Leg Ulcer Protocol Wound Management: all wound will have documented management plans. All wounds will be assessed within 6 hours of admission to episode of care Refer to pressure ulcer risk assessment & prevention Guidelines All wounds will be assessed using the PCT wound assessment framework: a) b) c) d) Site Size Wound history Condition of the wound • Bed • Edge • Surrounding skin Evidence of infection Odour Pain Fluid.Summary Summary guidelines for wound assessment and management This summary to be read in conjunction with South Gloucestershire PCT Guidelines for the Assessment and Management of Wounds.

Debridement “Removal of dead or foreign material just above the level of viable tissue”. Chronic wounds. Myers 1982) Dressing Changes Surgical Wounds: Leave min 48 hours. Change when leakage / strike through evident. leave as long as possible up to 10 days Non-surgical wounds Avoid frequent changes unless clinically indicated (Baker 1997). 1-day sharp debridement study day. If no infection evident. Avoid soaking dressings adhered to wound: exacerbates maceration (Hollingworth 2002) Training needs for wound management Pressure ulcer prevention: all RNs / HCAs Basic wound management: all RNs / HCAs Community Equipment Prescribing: all RNs Leg Ulcer Management: 2-day course & mandatory follow up & assessment of competence. Sharp :conservative approach: requires training from specialist TV nurse. Date of Guideline July 2004 4 Date of review July 2006 . Surgical: excision / resection necrotic material Debridement needed surgical wounds See NICE Guidelines on Debriding agents (2001) Choice of agent should be based on: Comfort Odour control Client acceptability Type & location of wound Total costs (NICE 2001) Enzymatic Autolytic:moist wound environment. All RNs as required Complex wound management: all RNs as required Sharp debridement: all RNs as required & assessment of competence Vacuum assisted wound closure: all RNs as required Larva therapy: all RNs as required Evaluation of Wounds All wounds will be evaluated using the PCT evaluation frameworks. hydrocolloid / hydrogel dressing Mechanical:wash wound / adherent dressing Bio-surgical:sterile maggots Chemical: not recommended Evidence supporting one method of debridement over another is lacking (Leaper 2002) Assessment for debridement should include: Nature / extent of necrotic tissue Risk infection / use antibiotics Underlying disease processes Extent existing ischeamia Location of wound Client consent Pain control Possible complications (Leaper 2002) Training for sharp debridement RNs must have attended accredited wound management course & min. should be evaluated using the chronic wound evaluation forms. stuck in any stage of the healing process for 6 weeks or more. Assessment of competence by TV specialist Nurse Dressing Selection Please refer to typology on laminated card & in wound guidelines ALL WOUNDS Consideration in choice of dressings Primary treatment objectives & clinical effectiveness Function of dressing Ease of application / removal Variety of size / shape & alternatives available Length of time it will be used How secured? Cost effectiveness Features of ideal dressing Comfortable & mouldable Protective Prevent contamination with particles / toxic substances (Hallet & Hampton 1999) Allows gaseous exchange Keep wound moist (Hollingworth 2002) Keep wound warm (drop in temp below 37 degrees delays mitotic activity) (Torrence 1986. Valid informed consent is essential.

NICE Guidelines on Pressure Ulcer Risk Assessment and Management (2004) .0 Definition. Community equipment Prescribing Strategy.Guidelines for the Assessment and Management of Wounds This guideline should be used in conjunction with the following South Gloucesterhsire PCT documents: Clinical Nursing Policy (2004).1 Assessment All clients with wounds will have a documented wound assessment using the PCT assessment framework. Avon Leg Ulcer Protocol (2004). Principles of Care (2003. Nurse Prescribing Policy.0 • • Aim of Assessment Improve documentation and communication (NMC (UKCC) 1998) Define the problem and identify appropriate therapeutic regime 3. Infection Control Policy (2004). A wound can be defined as “an abnormal break in the normally intact covering of the body – the skin” (Collier 2002) it may be ACUTE “wounds that are healing as anticipated” (Collier 2002) or CHRONIC “ wounds that are failing to heal as anticipated or that have become fixed in any one stage of wound healing for a period of six weeks” (ibid) 2.0 Classification • • • • Mechanical Chronic Burns Malignant eg Surgical / Traumatic eg Leg Ulcers / Pressure Ulcers Chemical or thermal injuries Primary lesions such as melanoma 3. 1. This should include: a) Site b) Size c) Wound history d) Condition of the wound • Bed • Edge • Surrounding skin e) Evidence of infection f) Odour 5 Date of review July 2006 Date of Guideline July 2004 .

Dowsett 2002. Collier 2002. Surface area of the wound may be calculated by tracing over a square grid (preferably 0.2 Additional assessment techniques for clients with Leg Ulcers • Doppler Ultrasound • Duplex scanning • Photoplethysmography (PPG) (Moffat & Harper 1997) 3. NICE 2001. Collier 2002) Where photographs are to be used for research. This includes storage & transmission of images now.3 Computer based assessment systems may assist with objective measurement of all wound types. (Pudner 2002. exudate / pus / serous fluid i) Intrinsic or extrinsic factors affecting healing (see NICE & EPUAP Guidelines on Pressure Ulcers) j) Previous related wound management regimes. a signed consent should be obtained. Wounds healing by primary intention or minor wounds may not be subject to lengthy or formal wound assessment although the principles of this should be applied. EPUAP 1998 3.g) Pain h) Fluid. All wounds will be documented and a management plan implemented. (Pudner 2002) • Photography Informed valid consent is required to demonstrate the client understands the purpose of the photo and what will be done with it. Cling film should be applied to the wound prior to the tracing to prevent contamination of the acetate and cross infection of client notes. reviewed and evaluated. since these can assess maximum dimensions of wounds plus depth & volume of them. Measurement may be by • Acetate tracings. education or training purposes.4 3. It may be less accurate on curved wounds. & in the future.5 3. including success / failures & how long they were used NBT 2001. Assessment Should be documented using the PCT assessment framework and reviewed & evaluated regularly.5cm). Position of client for photograph should be recorded. A grid should be included so that an accurate calculation of the wound area may be made. 3. Referrals to the Tissue Viability specialist nurse should be made as required.51 Date of Guideline July 2004 6 Date of review July 2006 .

stripping of upper layers of dermis as a result of “prolonged” exposure to toxins on the surface of the skin. and so on their removal.e. • Eradication or minimising of extrinsic factors and the control of intrinsic factors which affect healing. Many dressings take up excess exudate. facilitate continuity and consistency of care and meet the professional legal requirement for record keeping (Sterling 1996) Aims of management Overall aim of wound management includes • Promotion of speedy healing.0 4.6 Skin assessment Skin surrounding the wound may be described as • Erythematous ie red as a result of a hyperaemic response. Typical objectives may include: a) Cleansing of wound Consider. Wound Management The registered nurse will complete a baseline assessment of wound in order to promote successful wound management. is this required at all? The irrigation of a wound should only be performed to remove excessive exudate. • Optimal concordance with patients. dependent on the nature rather then volume of fluid present. Chronic wounds will be traced / measured at least every 4 weeks and re-evaluated each time a dressing is applied and / or if it gives rise for concern (Royal Marsden Clinical Nursing Procedures 2000) 3.• Wounds involving sinuses / tracks may require further specialist measurement. 3. cleansing is not required.7 4. or particles of dressing.1 4.2 Date of Guideline July 2004 7 Date of review July 2006 . or dressing change. • Prevention of occurrence. pus. Primary Treatment objectives will be dependent on signs & symptoms associated with that wound. Result of pressure or infection (Collier 1999) • Excoriated i. free of complication. • Cost effective and evidence based use of products. (Collier 2002) • Indurated ie change in the texture rather than colour of the skin (less supple / hardened) (Collier 2002) • Macerated ie softening / sogginess of the skin due to retention of excessive moisture (Cutting 1999) Client opinion Client perception of the wound should be included & recorded in the assessment and ongoing evaluation of wound healing.

Ussia C. therefore removal of the dressing before this time increases the risk of infection and damage to the wound. until the wound has healed (Collier 2002).3 Frequency of dressing changes • It takes 48 hours for a surgical wound to form its own optimal healing environment. • The frequency of dressing changes of non-surgical wounds will depend on the type of dressing used and the type of wound. Beldon 2001) h)To minimise client pain experienced at time of dressing changes (Hollingworth & Collier 2002) i)To optimise client’s own healing potential NB Remember once the primary treatment objective / intended outcome has been achieved.Tap water or Normal Saline may be used as appropriate as an irrigation agent however the quality of the tap water available should be considered before it is used. 4. (Fernandez R. • Frequent dressing changes should be avoided unless clinically indicated (Baker 1997) • Dressings should be changed when leakage / strike through is evident • Soaking to remove adhered dressings is not recommended since this may exacerbate effects of maceration (Hollingworth 2002) Swab Taking • Wounds should be swabbed only if there is evidence of clinical infection Dressing Characteristics which influence the choice of dressings 1. the assessment process should be repeated in order to identify the next treatment objective and so on.4 4. Griffeths R.5 Date of Guideline July 2004 .The function of the dressing 8 Date of review July 2006 4. surgical wound dressings should be left for as long as possible up to ten days. In the absence of any signs of infection. 2002) b) To debride / deslough the wound (See NICE guidelines for difficult to heal surgical wounds 2001) This may be achieved by • Mechanical (sharp) debridement • Autolytic (rehydration of the tissues) • Ensymatic (maggots) (Collier 2002) c) To control associated bleeding d)To control wound exudates e) To decrease bacterial burden present within a wound f) To reduce associated wound odour g) To minimise effects of wound infection (Ayton 1986.Primary treatment objectives 2. Cooled boiled water or distilled water may be used if necessary.

7 Features of the ideal Dressing The following features should be considered: 1.How is it secured. is a secondary dressing necessary? 7. To keep the wound warm. Myers 1982) 7. To ensure the wound is not contaminated with particles or toxic substances which can act as a foci for infection (Hallet & Hampton 1999) 4. To be comfortable and mouldable 2.3.Easiness of application and removal.Variety of size/shape. Lock 1979. including prevention of tissue trauma 4. Date of Guideline July 2004 9 Date of review July 2006 . To assist the removal of exudate and necrotic tissue.6 Choice of dressing The Nurse prescribing treatment must be able to state her rational for the choice made Aim Rehydrate/debride Reduce colonisation Contain exudate Remove slough/ Debride Keep Moist Manage Exudate Deep Wound Intrasite Gel Alginate Intrasite Gel Metronidazole Alginate Intrasite Gel Foams Intrasite Gel Alginate Shallow Wound Hydrocolloid Alginate Charcoal Iodoflex Alginate Intrasite Gel Inadine Hydrocolloid Hydrocolloid Intrasite Gel Alginate Semi-permeable membranes Hydrocolloid Semi-permeable membranes Heavy/ Moderate Exudate Alginate Alginate Alginate Hydrocolloid Type of wound Necrotic Infected Sloughy Granulating Epithelising To keep moist Alginate Foam Hydrocolloid 4.Cost effectiveness 4. To keep the wound moist (Hollingworth 2002) 6.Length of time dressing may be used 6. a drop in temperature below 37c delays mitotic activity for up to 4 hours (Torrence 1986. Excessive exudate can macerate healthy tissue around wound margin. To allow gaseous exchange 5. whether similar alternatives available 5. To protect the wound 3.

1 5. Hallet & Hampton 1999) 9. Sharp debridement “Removal of dead or foreign material just above the level of viable tissue”. 5.8.(Fairbairn et al 2002. To allow monitoring of the wound 10. Strike thorugh of exudates allows passage for bacteria in / out of wound (Dealey 1994. non-sensitising and hypoallergenic 11.toxic.4 Rationale for debridement This process assists wound healing in that it: • Reduces infection • Inhibits phagocytosis • Inhibits epithelial cell migration • Enables accurate assessment of extent & condition of wound bed • Reduces number of microbes & toxins in wound bed Antibiotic therapy is less effective topically if devitalised tissue is present (Fairbairn et al 2002. Leaper 2002) (See 4. To be non. hydrocolloid or hydrogel dressings) • Mechanical (washing the wound or adherent dressings*) • Bio-surgical (sterile maggots) • Chemical (not recommended) (NICE 2001. Nurses should adopt a conservative approach to this and should only undertake it when trained to do so.84) Other methods of debridement include • Enzymatic (Bacterial derived collagenases may promote healing also) • Autolytic (by use of moist wound environment.3 above Evidence supporting one method of debridement over another is lacking (Leaper 2002) 5.0 Debridement “the removal of necrotic or foreign material from and around a wound to optimise healing” (Leaper 2002) 5. Leaper 2002) Date of Guideline July 2004 10 Date of review July 2006 . To be impermeable to micro-organisms. To allow removal without causing trauma. Leaper 2002) *see 4.3 5.2 Surgical debridement Involves surgical excision or wide resection of necrotic tissue.

risk of spreading infection & use of antibiotics 3.6 5.5.Nature & extent of necrotic tissue 2.possibility if underlying disease processes 4. 5. Dacron grafts / prosthesis • Underlying vascular disease • Dialysis fistula • Debridement of the foot (excluding the heel ) • Hands & face Caution should be exercised for the following • Ischaemia of the lower limbs • Clienrs on long term anti coagulant therapy • Achilles tendon area • Infected wounds 5.location of the wound in relation to surrounding anatomy 6.client consent 7. pain control 8. Valid.5 Choice of debriding agent for difficult to heal surgical wounds should be based on • Comfort • Odour control • Client acceptability • Type & location of wound • Total costs (NICE 2001) Contraindications to sharp debridement by nurses (Fairbairn et al 2002.7 Assessment for debridement should include 1. possible complications (Leaper 2002) Training for sharp debridement RNs must have undertaken an accredited education course in wound management and a minimum of a one-day sharp debridement study day.extent of existing ischeamia 5. informed client consent is essential. Competency should be assessed by a Tissue Viability Nurse Specialist. Leaper 2002)) • Ischaemic digits • Blood clotting disorders • Fungating / malignant wounds • Necrotis tissue near / involving vascular structures.8 Date of Guideline July 2004 11 Date of review July 2006 . Podiatrist or Surgeon.

1 6.0 6.0 Documentation of Wounds NB Client documentation.2 Specific types of wound management Leg Ulcers Please refer to Avon Leg Ulcer Management Protocol Pressure Ulcers Please refer to NICE guidelines (2003) and South Gloucestershire PCT Community Equipment Prescribing Strategy (2004). including photography should inform actions.4 7. Date of Guideline July 2004 12 Date of review July 2006 . 6. including rationale for the change. (see appendix 1) Classification of pressure ulcers will be undertaken using the Sterling Scale (see appendix 1).3 Vacuum Assisted Wound Closure Nurses must not undertake this treatment unless they have received appropriate training from an approved trainer with professional nursing input. 6. Equipment prescribing: will be in accordance with South Gloucestershire PCT Community Equipment Prescribing Strategy. Assessment of risk will be undertaken using the Waterlow Assessment Tool and clinical judgement based on holistic patient assessment. Please refer to PCT guidelines on Vacuum Assisted Wound Closure (in progress) Larva Therapy Nurses must not undertake this treatment unless they have received approved training.6.3) should be evident on the plan of care and evidence on ongoing reassessment documented • Changes to planned wound care must be documented. • Ensure there is a documented paper assessment • This should be available to all health care professionals involved in the management of the wound as an important communication tool • Use of PCT assessment framework should include all parameters of the wound (see 3 above) • Primary treatment objectives (see 4.

Hand hygiene before and after handling wounds and dressings using either soap and water or alcohol hand rub/gel (only use alcohol hand rub/gel on hands that are not visibly soiled) .g. Wearing gloves when handling wounds . The primary container may then be placed into a second bag (black plastic) before being placed in the dustbin for disposal with the household waste. incontinence pads) must not be placed in a yellow bag. A letter will also need to be sent stating “in my professional opinion… needs waste collecting”. The primary container should not be a yellow clinical waste bag or labelled clinical waste.g. wet) .8. Wearing apron and if appropriate eye protection . potential complications.0 Client Information Supporting client information should be given in an appropriate format and a record of this should be made e. Changing dressings when indicated and whenever the barrier. highly infectious waste or high volumes) In the home care setting if the health care worker assesses the waste as being of high risk (e. Higher risk waste (dialysis. emergency contact details. 9. Selecting a dressing that will promote healing Low risk waste (dressings.g. dressings.g. Using a wound dressing that is appropriate to the wounds .effect has been impaired (e. incontinence pads etc. dialysis waste. large volumes of blood. This can be done by contacting South Gloucestershire Council.) In the home situation any clinical waste that has been assessed as low risk (e.g. preventative strategies etc.0 Infection Control The key measures that can help prevent wound infection/colonisation include: . Where possible it should be a white bag or a newspaper or a carrier bag. Date of Guideline July 2004 13 Date of review July 2006 . 01454 – 863594 ask for Kath James. or highly infectious e. equipment use. large volumes of diarrhoea from a patient with cryptosporidiosis) a clinical/medical waste collection must be arranged. health advice.

Date of Guideline July 2004 14 Date of review July 2006 .

with erythema after pressure released Grade 2 Pressure Sore Oedema. epidermal skin loss Pain Grade 3 Pressure Sore Tissue is lost through the dermis Grade 4A Pressure Sore Wound extends into the subcutaneous tissue Wound has a sinus Grade 4B Pressure \sore Necrotic tissue / eschar present Depth of damage unclear Date of Guideline July 2004 15 Date of review July 2006 . blistering.Appendix 1 Pressure Sore Grading Scale Grade 1 Pressure Sore Discolouration of skin.

S. Terminal Cachexia Cardiac failure Peripheral vascular Disease Anaemia Smoking Neurological Deficit e.Appendix 2 Waterlow risk assessment Build/weight for height Average Above average Obese Below average Continence Complete/ Catheterised Occasional incontinence Cath/incont of faeces Doubly incontinent Risk areas visual skin type Healthy Tissue paper Dry Oedematous Clammy Discoloured Broken/spot Mobility Fully Restless/Fidgety Apathetic Restricted Inert/Traction Chairbound 0 1 2 3 4 5 Sex/Age 0 1 1 1 1 2 3 Male Female 14-49 50-64 65-74 75-80 81+ Appetite Average Poor N. Diabetes.g. light finger pressure applied to site does not alter Discoloration Partial thickness skin loss or damage involving dermis or epidermis Full thickness skin loss.g.G tube /Fluids only NBM/Anorexic 0 1 2 3 1 2 1 2 3 4 5 Tissue Malnutrition e. Anti-inflammatory 8 5 6 2 1 0 1 2 3 0 1 2 3 4-8 5 5 4 10= at risk 15= high risk 20=very high risk Sterling Pressure Sore Severity Scores Stage 1 Discoloration of intact skin. CVA. extending to underlying bone. involving damage or necrosis of Subcutaneous tissue. not extending to underlying bone.. Motor/Sensory Major Surgery/Trauma Orthopaedic-below waist /Spinal On table > 2 hrs Medication Steroids. paraplegia. tendon or joint 16 Date of review July 2006 Stage 2 Stage 3 Stage 4 Date of Guideline July 2004 . tendon or joint capsule Full thickness skin loss with extensive destruction and tissue necrosis. M. Cytotoxics.

References BMA (2002) Nurse Prescribers’ Formulary 2002-2003 BMA & BPS London Collier M (2002) A ten-point assessment plan for wound management Journal of Community Nursing Vol 16 No 6 Collier M (1996) The Principles of Optimum Wound Management Nursing Standard Vol 10 No 43 pp47-52 Fairbairn K et al (2002) A sharp debridement procedure devised by specialist nurses Journal of Wound Care Vol 11 No 10 Fernadez R Griffeths R Ussia C (2002) Water for Wound Cleansing (Cohrane Review) in The Cochrane Library. mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care. NCC London (Guidelines commissioned by the National Institute of Clinical Excellence October 2003) NICE (2001) Guidelines on Pressure ulcer risk assessment and prevention NICE London NICE (2001) Guidance on the use of debriding agents and specialist wound care clinics for difficult to heal surgical wounds. Issue 4 Oxford: Update Software Hollingworth H (2002) Professional Concerns in wound care. a discussion of questionable practice recorded by nurses Wound Care September Leaper D (2002) Sharp technique for wound debridement World Wide Wounds December Pudner R (2002) Measuring Wounds Journal of Community Nursing Vol 16 No 9 National Collaboration Centre for Nursing & Supportive Care (2003) The use of pressure relieving devices (beds. NICE London North Bristol NHS Trust (2002) Wound Care Policy unpublished Royal Marsden Hospital (2001) Manual of Clinical Nursing Procedures London Blackwell Sciences Todorovic V (2002) Food and wounds: nutritional factors in wound formation and healing Wound Care September Date of Guideline July 2004 17 Date of review July 2006 .

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