Guidelines for the Assessment and Management of Wounds

Date of Guideline July 2004

Date of review July 2006

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

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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. 1.0 2.0 3.0 3.1 3.2 3.3 3.4 3.5 3.51 3.6 3.7 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 6.0 6.1 6.2 6.3 6.4 7.0 8.0 9.0 10 11 12

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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. 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; exudate / pus / serous fluid Intrinsic or extrinsic factors affecting healing (see NICE & EPUAP Guidelines on Pressure Ulcers) Previous related wound management regimes, including success / failures & how long they were used Patients 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, with evidence of ongoing review & evaluation, 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. Consider water quality. Use at body temperature.

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, reassessment is needed to identify next objective

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Debridement Removal of dead or foreign material just above the level of viable tissue. Sharp :conservative approach: requires training from specialist TV nurse. Valid informed consent is essential. 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,

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. 1-day sharp debridement study day. 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. Myers 1982)

Dressing Changes Surgical Wounds:

Leave min 48 hours. If no infection evident, leave as long as possible up to 10 days

Non-surgical wounds Avoid frequent changes unless clinically indicated (Baker 1997). Change when leakage / strike through 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. 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. Chronic wounds, stuck in any stage of the healing process for 6 weeks or more, should be evaluated using the chronic wound evaluation forms.

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Date of review July 2006

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), Infection Control Policy (2004), Nurse Prescribing Policy, Principles of Care (2003, Avon Leg Ulcer Protocol (2004), NICE Guidelines on Pressure Ulcer Risk Assessment and Management (2004) , Community equipment Prescribing Strategy.

1.0

Definition.
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

3.0

Aim of Assessment
Improve documentation and communication (NMC (UKCC) 1998) Define the problem and identify appropriate therapeutic regime

3.1

Assessment All clients with wounds will have a documented wound assessment using the PCT assessment framework. 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
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g) Pain h) Fluid; exudate / pus / serous fluid i) Intrinsic or extrinsic factors affecting healing (see NICE & EPUAP Guidelines on Pressure Ulcers) j) Previous related wound management regimes, including success / failures & how long they were used NBT 2001, Dowsett 2002, Collier 2002, NICE 2001, EPUAP 1998 3.2 Additional assessment techniques for clients with Leg Ulcers Doppler Ultrasound Duplex scanning Photoplethysmography (PPG) (Moffat & Harper 1997) 3.3 Computer based assessment systems may assist with objective measurement of all wound types, since these can assess maximum dimensions of wounds plus depth & volume of them. Referrals to the Tissue Viability specialist nurse should be made as required. 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. All wounds will be documented and a management plan implemented, reviewed and evaluated. Assessment Should be documented using the PCT assessment framework and reviewed & evaluated regularly. Measurement may be by Acetate tracings. Surface area of the wound may be calculated by tracing over a square grid (preferably 0.5cm). Cling film should be applied to the wound prior to the tracing to prevent contamination of the acetate and cross infection of client notes. (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. This includes storage & transmission of images now, & in the future. (Pudner 2002, Collier 2002) Where photographs are to be used for research, education or training purposes, a signed consent should be obtained. A grid should be included so that an accurate calculation of the wound area may be made. It may be less accurate on curved wounds. Position of client for photograph should be recorded.

3.4

3.5

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Wounds involving sinuses / tracks may require further specialist measurement.

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) 3.6 Skin assessment Skin surrounding the wound may be described as Erythematous ie red as a result of a hyperaemic response. Result of pressure or infection (Collier 1999) Excoriated i.e. stripping of upper layers of dermis as a result of prolonged exposure to toxins on the surface of the skin; dependent on the nature rather then volume of fluid present. (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. Wound Management The registered nurse will complete a baseline assessment of wound in order to promote successful wound management, 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, free of complication. Cost effective and evidence based use of products. Optimal concordance with patients. Eradication or minimising of extrinsic factors and the control of intrinsic factors which affect healing. Prevention of occurrence. Primary Treatment objectives will be dependent on signs & symptoms associated with that wound. Typical objectives may include: a) Cleansing of wound Consider; is this required at all? The irrigation of a wound should only be performed to remove excessive exudate, pus, or particles of dressing. Many dressings take up excess exudate, and so on their removal, or dressing change, cleansing is not required.

3.7

4.0

4.1

4.2

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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. Cooled boiled water or distilled water may be used if necessary. (Fernandez R. Griffeths R. Ussia C. 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, Beldon 2001) h)To minimise client pain experienced at time of dressing changes (Hollingworth & Collier 2002) i)To optimise clients own healing potential

NB Remember once the primary treatment objective / intended

outcome has been achieved, the assessment process should be repeated in order to identify the next treatment objective and so on, until the wound has healed (Collier 2002). 4.3 Frequency of dressing changes It takes 48 hours for a surgical wound to form its own optimal healing environment; therefore removal of the dressing before this time increases the risk of infection and damage to the wound. In the absence of any signs of infection, surgical wound dressings should be left for as long as possible up to ten days. The frequency of dressing changes of non-surgical wounds will depend on the type of dressing used and the type of wound. 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.Primary treatment objectives 2.The function of the dressing
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4.4

4.5

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3.Easiness of application and removal, including prevention of tissue trauma 4.Variety of size/shape, whether similar alternatives available 5.Length of time dressing may be used 6.How is it secured, is a secondary dressing necessary? 7.Cost effectiveness 4.6 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

4.7

Features of the ideal Dressing The following features should be considered: 1. To be comfortable and mouldable 2. To protect the wound 3. 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 allow gaseous exchange 5. To keep the wound moist (Hollingworth 2002) 6. To keep the wound warm; a drop in temperature below 37c delays mitotic activity for up to 4 hours (Torrence 1986, Lock 1979, Myers 1982) 7. To assist the removal of exudate and necrotic tissue. Excessive exudate can macerate healthy tissue around wound margin.

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8. To be impermeable to micro-organisms. Strike thorugh of exudates allows passage for bacteria in / out of wound (Dealey 1994, Hallet & Hampton 1999) 9. To allow monitoring of the wound 10. To be non- toxic, non-sensitising and hypoallergenic 11. To allow removal without causing trauma.

5.0

Debridement
the removal of necrotic or foreign material from and around a wound to optimise healing (Leaper 2002)

5.1 5.2

Surgical debridement Involves surgical excision or wide resection of necrotic tissue. Sharp debridement Removal of dead or foreign material just above the level of viable tissue. Nurses should adopt a conservative approach to this and should only undertake it when trained to do so.(Fairbairn et al 2002, Leaper 2002) (See 4.84) Other methods of debridement include Enzymatic (Bacterial derived collagenases may promote healing also) Autolytic (by use of moist wound environment, hydrocolloid or hydrogel dressings) Mechanical (washing the wound or adherent dressings*) Bio-surgical (sterile maggots) Chemical (not recommended) (NICE 2001, Leaper 2002) *see 4.3 above Evidence supporting one method of debridement over another is lacking (Leaper 2002)

5.3

5.4

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)

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5.5

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, Leaper 2002)) Ischaemic digits Blood clotting disorders Fungating / malignant wounds Necrotis tissue near / involving vascular structures. 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

5.6

5.7

Assessment for debridement should include 1.Nature & extent of necrotic tissue 2.risk of spreading infection & use of antibiotics 3.possibility if underlying disease processes 4.extent of existing ischeamia 5.location of the wound in relation to surrounding anatomy 6.client consent 7. pain control 8. 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. Competency should be assessed by a Tissue Viability Nurse Specialist, Podiatrist or Surgeon. Valid, informed client consent is essential.

5.8

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6.0
6.1 6.2

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). Assessment of risk will be undertaken using the Waterlow Assessment Tool and clinical judgement based on holistic patient assessment. (see appendix 1) Classification of pressure ulcers will be undertaken using the Sterling Scale (see appendix 1). Equipment prescribing: will be in accordance with South Gloucestershire PCT Community Equipment Prescribing Strategy.

6.3

Vacuum Assisted Wound Closure Nurses must not undertake this treatment unless they have received appropriate training from an approved trainer with professional nursing input. 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.

6.4

7.0

Documentation of Wounds
NB Client documentation, including photography should inform actions. 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 4.3) should be evident on the plan of care and evidence on ongoing reassessment documented Changes to planned wound care must be documented, including rationale for the change.

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8.0

Client Information
Supporting client information should be given in an appropriate format and a record of this should be made e.g. health advice, potential complications, equipment use, emergency contact details, preventative strategies etc.

9.0

Infection Control
The key measures that can help prevent wound infection/colonisation include: . 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) . Wearing gloves when handling wounds . Wearing apron and if appropriate eye protection . Using a wound dressing that is appropriate to the wounds . Changing dressings when indicated and whenever the barrier- effect has been impaired (e.g. wet) . Selecting a dressing that will promote healing Low risk waste (dressings, incontinence pads etc.) In the home situation any clinical waste that has been assessed as low risk (e.g. dressings, incontinence pads) must not be placed in a yellow bag. The primary container should not be a yellow clinical waste bag or labelled clinical waste. Where possible it should be a white bag or a newspaper or a carrier bag. 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. Higher risk waste (dialysis, 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.g. large volumes of blood, dialysis waste, or highly infectious e.g. large volumes of diarrhoea from a patient with cryptosporidiosis) a clinical/medical waste collection must be arranged. This can be done by contacting South Gloucestershire Council, 01454 863594 ask for Kath James. A letter will also need to be sent stating in my professional opinion needs waste collecting.

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Appendix 1

Pressure Sore Grading Scale

Grade 1 Pressure Sore Discolouration of skin, with erythema after pressure released Grade 2 Pressure Sore Oedema, blistering, 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

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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.G tube /Fluids only NBM/Anorexic 0 1 2 3 1 2 1 2 3 4 5 Tissue Malnutrition e.g. Terminal Cachexia Cardiac failure Peripheral vascular Disease Anaemia Smoking Neurological Deficit e.g. Diabetes, CVA, M.S., paraplegia, Motor/Sensory Major Surgery/Trauma Orthopaedic-below waist /Spinal On table > 2 hrs Medication Steroids, Cytotoxics, 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, light finger pressure applied to site does not alter Discoloration Partial thickness skin loss or damage involving dermis or epidermis Full thickness skin loss, involving damage or necrosis of Subcutaneous tissue, not extending to underlying bone, tendon or joint capsule Full thickness skin loss with extensive destruction and tissue necrosis, extending to underlying bone, tendon or joint
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Stage 2 Stage 3

Stage 4

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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. 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, 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. 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

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