Beruflich Dokumente
Kultur Dokumente
Type: GUIDELINE
Sus
Relevant to:
All PCT Clinical Staff
Produced by:
Tissue Viability Committee
Responsible Executive Director: Director of Nursing
Date of Approval:
September 2011
Responsibilities
Date of Implementation:
Immediate after approval
Due Review Date:
September 2013
Responsible Reviewing Officer:
Cathy Malone
This document replaces:
WE/07/GUI0001/TV Version 2
Chief Executive
Signed
For
Scheme of Publication
Drive:
Name:
X
Scheme of
Publication
Section
no:
Sub Folder:
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WOUND MANAGEMENT
GUIDELINES
September 2011
THE TISSUE VIABILITY SERVICE
Page 5
2. PROCESS OF HEALING
2.1
2.2
2.3
6.3
6.4
6.5
6.6
Pages 23
6. WOUND CARE
6.1
6.2
Pages 22-23
Epithelialising Tissue
Granulating Tissue
Sloughy Tissue
Infected Tissue
Necrotic Tissue
Malignant Tissue
5. WOUND ASSESSMENT
5.1
Pages 18-21
Pages 6-17
Pages 25-31
8.
Cleansing Solutions
7.1.1 Sodium Chloride 0.9% solution
7.1.2 Chlorhexidine with cetrimide
7.1.3 Protosan
7.1.4 Iodine
7.1.5 Stellisept
Pages 33-34
Pages 35-38
9. WOUND DRAINAGE
Page 41
Page 41
Page 43
11.1
11.2
Pages 44-49
Definition of Debridement
Scope
Contra-indications for versajet or sharp debridement
Criteria for sharp debridement
Criteria for versajet debridement
Procedure of communication with other disciplines
prior to stop debridement
Procedure for debridement
Page 50
14. EDUCATION
Page 50
LIST OF TABLES
Table 1 - Stages of Healing Process
Page 6
Table 2 - The TIME principles of Wound Bed Preparation
Page 9
Table 3 - Characteristics of Healthy and Unhealthy
Page 10
Granulating Tissue
Table 4 - Signs and Symptoms of superficial and deep infection Page 14
Table 5 - Types of exudates and management
Page 17
Table 6 - Conditions and interventions known to delay
Page 18
Wound healing
Table 7 - Comparison of commonly used antimicrobials
Page 34
Table 8 Procedure for aseptic non touch technique
Page 42
LIST OF FIGURES
Figure 1 EWMA Clinical Stages of Infection and Algorithm
Figure 2- Wong Baker pain scale
Figure 3- Numerical pain rating scale
Figure 4 -Factors causing delayed wound healing
Figure 5 - Wound Assessment Form
Figure 6 - Wound Care Plan Form
APPENDICES
Appendix 1
Nutrition Assessment (MUST)
Appendix 2
TVS Referral Form
TNP Referral Form (VAC)
Care Pathway for Patient with a Wound
Care Pathway for MRSA infected Wound
Appendix 3
Appendix 4
Appendix 5
Appendix 6
Page 13
Page 20
Page 20
Page 21
Page 24
Page 32
Pages 51 -55
Page 57
Page 58
Page 59
Page 60
Pages 62-69
Pages 71-81
Pages 83-88
Pages 90-91
Foreword
As with any clinical guideline, recommendations may not be appropriate for use in all
1
circumstances. A limitation of a guideline is that it simplifies clinical decision-making. Decisions to
adopt any particular recommendation must be made by the practitioner in the light of:
Available resources
Local services, policies and protocols
The patients circumstances and wishes
Available personnel and devices
Clinical experience of the practitioner
Knowledge of more recent research findings.
Shiffman R. Representation of clinical practice guidelines in conventional and augmented decision tables. Journal
Medical Informatics 1999; 70 (3): 434, 437-40,443-9
1.
1.1.2
1.1.3
1.1.4
1.1.5
NMC (2008) The Code, Standards of conduct, performance and ethics for nurses and midwives
Dougherty L, Lister S (eds) (2008) The Royal Marsden Hospital Manual Clinical Nursing Procedures. 7 th edn. Blackwell
Publishing, Oxford
3
2.
PROCESS OF HEALING
Wound healing is a continuous process, however four stages can be identified. The length of
each phase varies with the nature of the wound and the patients general condition.
STAGE
IMMEDIATE
Haemostasis
INFLAMMATION
Mediator release
Vasodilatation
Increased capillary
permeability
Chemotaxis
Phagocytosis
PROCESS
Vasoconstriction
Bradykinin &
histamines produced.
Blood vessels dilate
and become more
permeable.
Initiation of Repair
PROLIFERATION
Granulation
Angiogensis
Collagen production
Epithelialisation
Contraction
MATURATION
Collagen remodelling
Capillary regression
Activation of
endothelial cells,
platelets and clotting
cascade.
Cell stimulation
/inhibition.
CLINICAL EFFECTS
Haemorrhage
controlled or reduced.
Inflammatory process
initiated.
Pain
Skin becomes red hot
Swelling
Exudate production
Contribute to
exudates and
swelling
Mediators attract
phagocytes
(Neutrophils first,
then Macrophages).
Neutrophils and
macrophages remove
debris and bacteria.
Macrophages
produce growth
factor.
Endothelial budding
or marginal capillaries
Fibroblasts migrate to
the scene and
secrete collagen
Epithelial cell
multiplicating and
migration over
surface
Possible due to
specialized fibroblast
action.
Reconstruction of
extra cellular matrix
(ECM) from fibrin,
fibronectin & collagen
Crust, pus or
sloughing
No Clinical effects
visible
IMPLICATIONS
Dress with a secure
pressure bandage.
Seek medical advice
if blood loss is
excessive persistent.
Swelling and
discoloration
Signs of infection
(see section 4&5)
and inform medical
staff if concerned.
Movement is
encouraged to
prevent DVT and
contractures
Physical support of
the wound area and
pain relief
The patient is
educated regarding
any physical
restriction and
provision of healing
The nurse needs to advise
on:
Scar tissue2
Encourage normal
activity
Camouflaging after 1 month
depending on the extent of
the wound if appropriate.
Table 1 Stages of Healing, Source: The Wound Programme & Wet Wounds
Kingsley A (2003) Wound healing and potential therapeutic options. Professional Nurse. Vol 17 No 9 539-544
The Wound Programme (1992) Centre for Medical Education. Dundee
6
Wicks G, J Stephen-Haynes (2008) Wet Wounds: practical steps to improving active fluid management.
5
2.1
2.2
Thomlinson D (1987) To Clean or not to Clean. Nursing Times Journal of Infection Control Nursing,Vol 83.5 - 4 Mar
Chrintz et al (1989) Need for surgical wound dressing. British Journal of Surgery. Vol 76, Pg 204 - 205
Silver I.A (1984) The Physiology of Wound Healing. JWC. Vol 2 No 2 Pg 106-109
10
Dowsett C, Ayello E (2004) TIME principles of chronic wound bed preparation and treatment. BJN Vol 13, No 15 pg
S16-S23
11
Ennis WJ, Meneses P (2000) Wound healing at the local level. The stunned wound. Ostomy Wound Manage 46: 39S
48S
12
Schultz G, Sibbald G, Falanga V et al (2003) Wound bed preparation: a systemic approach to wound management.
Wound Repair Regen 11 (2): 1-28
13
Falanga V, Grinnell F, Gilchrist B, Maddox YT, Moshell A (1994) Workshop on the pathogenisis of chronic wounds. J
Invest Dermatol 102 (1): 125-7
14
Falanga V (2000) Classification for wound bed preparation and stimulation of chronic wounds. Wound Repair Regen 8:
347-53
15
Schultz G, Sibbald G, Falanga V et al (2003) Wound bed preparation: a systemic approach to wound management.
Wound Repair Regen 11 (2): 1-28
16
Dowsett C, (2008) Using the TIME framework in wound bed preparation. Wound Care UK June pg S15-D20
8
9
2.3
Wound Bed Preparation (WBP) is a well established concept and the TIME framework is a
1718 19
practical tool to assist practitioners when assessing and managing patients with wounds.
It
20 21
is however important to remember to assess the whole patient.
WBP is a way of focusing
systematically on most of the critical components of the non-healing wound to identify the possible
cause of the problem.
WBP involves the application of the principles of Tissue, Infection, Moisture and Edge (TIME) to a
wound bed in order to enable the practioner to make a systematic interpretation of the observable
characteristics of a wound and to decide on the most appropriate intervention.
The TIME Table (Table 2) illustrates in a simple way the link between clinical observations and the
underlying cellular abnormalities, and the effects of clinical interventions at a cellular level. The first
column lists the clinical signs of a non-healing wound. As growth factors, senescent cells or
fibroblasts cannot be seen with the naked eye; the clinician needs clear, visible signs that can be
assessed at the bedside. The second column highlights the proposed pathophysiology of that
clinical observation. Column three and four suggest the clinical actions that need to be taken and
the effects of these actions. The final column is for clinical outcomes, which are objective and
22
measurable.
17
Benbow M, (2008) Exploring the concept of moist wound healing and its application. BJS ( TV supplements) Vol 17 No
15 pg S6-S16.
18
Lo SF, Hsu MY, Hu WY et al (2007) using wound bed preparation to heal a malignant fungating wound: a single case
study. JWC Vol 16 No 9 pg 373-376
19
Sibbald RG Woo K, Ayello E, (2007) Increased bacterial burden and infection:NERDS and STONES. Wounds Uk 2007
Vol 3 No 2. pg 25-46
20
Dowsett C Newton H (2005) Wound bed preparation: TIME in practice. Wounds UK Vol 1 issue 3. 58-70
21
Dowsett C, Claxton K (2006) Reviewing the evidence for wound bed preparation. JWC Vol15 No 10 439-442
22
Dowsett C, Ayello E ((2004) TIME principles of chronic wound bed preparation and treatment. BJN Vol 13, No 15 pg
S16-S23
23
CLINICAL
OBSERVATIONS
PROPOSED
PATHOPHYSIOLOGY
WBP CLINICAL
ACTIONS
EFFECT OF WBP
ACTIONS
CLINICAL
OUTCOME
TISSUE NONVIABLE OR
DEFICIENT
Debridement (episodic
or continuous)
Autolytic, sharp surgical,
enzymatic, mechanical
biological agents
Restoration of wound
base and functional
extracellular matrix
proteins
Viable wound
base
INFECTION OR
INFLAMMATION
Bacterial
balance and
reduced
inflammation
MOISTURE
IMBALANCE
Dessication slows
epithelial cell migration
Moisture
balance
Compression, negative
pressure or other
methods of removing
fluid
Restored epithelial
cell migration,
desiccation avoided.
Oedema, excessive
fluid controlled,
maceration avoided
Non-migrating
keratinocytes
Re-assess cause or
consider corrective
therapies: Debridement
Skin grafts
Biological agents
Adjunctive therapies
Migrating
keratinocytes and
responsive wound
cells. Restoration of
appropriate protease
profile
Advancing
edge of wound
EDGE OF WOUND
NON ADVANCING
OR UNDERMINED
Non-responsive wound
cells and abnormalities
in extracellular matrix
or abnormal protease
activity
23
Schultz G, Sibbald G, Falanga V et al (2003) Wound Bed Preparation: a systemic approach to wound management.
Wound Repair Region 11 (2): 1-28
2.3.1
Tissue
Monitoring the type of tissue in a wound is the mainstay of wound assessment in clinical
24
practice, recording the presence of necrosis, slough, granulation tissue or epithelialium.
This helps predict the wounds position in the healing continuum. The presence of nonviable tissue is a significant clinical observation as it can be responsible for delayed
25
healing. It is described as necrotic, sloughy, devitalised or dead tissue. Necrotic tissue
consists of dead cells and debris, while slough or fibrinous material consists of fibrin, pus
and proteinaceous material. Necrotic tissue is usually black or brown in colour and soft or
liquefying in consistency. If necrotic tissue dries out, and is hard and leathery it is more
26
commonly described as eschar. Necrotic tissue when grouped with the clinical problems
27
of excess exudate and bacteria within dead tissue is termed necrotic burden.
Slough
28
may be creamy in appearance because of large amounts of leukocytes present.
Alternatively, a tendon may be exposed, signifying wound deterioration, presenting as
striated, yellow tissue. The wound may be shiny, suggesting the presence of biofilms
29
sophisticated coatings often resistant to antimicrobials.
If granulation tissue is friable,
30
unstable to touch and bleeds easily it may be infected. The practioner should be able to
31
differentiate between healthy and unhealthy tissue. (See Table 3)
The surface or the texture of tissue can yield useful clues, for example if granulation
tissue is fleshy and exuberant, it may be hyper granulating (overgranulating) and thus
stuck in the proliferative stage of healing. It is suggested that healthy granulation tissue
32
has rosettes on the surface.
Hyper granulating tissue is thought to arise from an extended inflammatory response.
There is of course a danger that tissue could be treated as hyper granulation when it is in
33 34
fact a carcinoma.
If concerned staff should refer the patient to the medical staff
responsible for the patients care.
2.3.2
Infection
24
Flanagan M, (2003) Wound measurement: can it help us to monitor progression to healing. JWC 12: 189-94
Flanagan M, (1997a) Wound Management. Churchill Livingstone, London
26
Bale S, (1997) A guide to wound debridement. JWC 6: 179-82
27
Falanga V, (2002) Wound bed preparation and the role of enzymes: a case for multiple actions of therapeutic agents.
Wounds 14: 47-57
28
Flanagan M. (1997b) A practical framework for wound assessment 2: methods. Br J Nurs 6:6-11
29
Edwards R, Harding KG (2004) Bacteria and wound healing. Curr Opin Infect Dis 17: 91-6
30
Cutting K, Harding K (1994) Criteria for identifying wound infection. JWC 3: 198-201
31
Harker J, Moore K ( 2004) Tissue management and wound pathophysiology,. A Journey through TIME. Wound bed
preparation in practice BJN
32
Edmonds M, Foster A (2004) the use of antibiotics in diabetic foot. Am J Surg 187 (5A): 25S-28S
33
Young, T (1995) Common problems in wound care: overgranulation. Br J Nurs 4:169-70.
34
Chraibi H (2004) The diagnosis and treatment of carcinomas occurring at the sites of chronic pressure sores. JWC Vol
13. No 10 447-448
35
Flanagan M, (1996) Characteristics of healthy and unhealthy Granulation Tissue. JWC 7: 508-10
25
10
All wounds contain micro-organisms, yet the majority are not infected. Infection in a
36
wound causes pain and discomfort, delays healing and can be life threatening.
The
European Wound Management Association Algorithm illustrated in Figure 1 illustrates the
different stages of wound infection. The spectrum of interaction between the microbial
community and host may gradually reach a point at which wound healing process is
37
impaired or localised detrimental host effects are initiated.
Bacteria involvement in
wounds can be divided into four categories:
Contamination
Colonisation
Critical colonisation
Wound infection.
38
Microbial involvement in delayed healing must be suspected when other causes have
46 47 48
been eliminated.
Antimicrobials are agents that either kill or inhibit the growth and
49 50
division of micro-organisms.
They include antibiotics (which act on specific cellular
target sites), antiseptics, disinfectants and other agents (which act on multiple cellular
51
target sites).
Chronic wounds do not always display the classic signs of infection;
therefore other criteria need to be taken into account. (Table 4)
36
Dowsett C, (2008) Using the TIME framework in wound bed preparation. Wound Care UK June pg S15-D20
EWMA (2006) Position Document. Management of wound infection
38
Ayton M (1985) Woundscare: wounds that wont heal. Nursing Times 81 (Suppl 46): 16-19
39
Cutting K (2006) Wound Infection, Understanding, assessment and control. Wound Care Society Publication.
40
Kingsley A (2001) A proactive approach to wound infection. Nurs Stand 15 (30: 50-8
41
Schultz G, Sibbald G, Falanga V et al (2003) Wound bed preparation: a systemic approach to wound management.
Wound Repair Regen 11 (2): 1-28
42
Dowsett C, Edwards-Jones V, Davies S, (2004) Infection control for wound bed preparation A Journey through TIME.
Wound bed preparation in practice BJN.
43
Wolcott R, Cutting K F, Dowd SE (2008) Surgical site infections: biofilms, dehiscence and delayed healing. Wounds UK
Vol 4 No 4.
44
EWMA (2005) Position Document: Identifying criteria for wound infection
45
Cooper R, Okhiria O (2006) Biofilms. Wound infection & the issue of control. Wounds UK Vol 2 No 3 48-56
46
EWMA (2006) Position Document. Management of wound infection. . London MEP Ltd. www.ewma.org
47
Rhoads DD (2008) Biofilms in wounds: management strategies. JWC Vol 17 No11 Nov pg 502-507
48
Wolcott R D et al (2010) healing and healing rates of chronic wounds in the age of molecular pathogen diagnositics.
JWC Vol 19 No 7 pg 272-281
49
Cooper R, Jenkins L, Rowlands R. (2011) Inhibition of biofilms through the use of manuka honey. Wounds Uk Vol 7 No
1 pg 24-32
50
Butcher M (2011) Introducing a new paradign for bioburden management. JWC/BSN supplement May. Pg 4-9
51
EWMA (2006) Position Document. Management of wound infection. London MEP Ltd. www.ewma.org
37
11
Healing progressing
normally
Healing no longer
progressing normally
Signs of Infection
Stages 1 & 2
signs limited
to wound only
No signs other
than healing
progress altered
Treat/correct
underlying
aetiology.
Refer to
appropriate
specialist
If no
improvement, are
any other subtle
signs of infection
present? Or
significant
culture result?
Agent:
Dressing
specificity
efficacy
cytotoxicity
allergenicity
absorbency
conformability
odour management
pain management
Evidence of surrounding
tissue involvement; wound
appears unhealthy or
deteriorating (cellulits,
lymphangitis or gangrene)
Stage 3
spreading local
sepsis
Select topical
antimicrobial (box,
bottom left)
Overt signs of
infection
eliminated
Consider
combination
therapy. Drain any
local collections
Good clinical
response
Overt signs of
infection not
eliminated
Select
alternative
antimicrobial
agent
Stage 4
systemic signs
Consider
adding
antibiotic
Complete
course of
antibiotics.
Reassess
wound and
patient
If systemic signs
only, look outside
wound for source of
infection
Poor clinical
response
Adjust antibiotic
selection according
to causative agent,
sensitivity and
patient preference
12
Table 4 Signs and symptoms of superficial and deep infection, Source: Cutting and
(1991)28, Schultz et al (2003)29
Harding
Superficial
Non-healing wound
Friable granulation tissue
Exuberant bright red granulation
Increased exudates
Erythema/cellulitis around wound edge
Deep
Pain
Increased size
Warmth
Erythema/cellulitis more than 1-2 cm from the wound edge
Odour
Probes/exposed bone
When bacteria proliferate they form micro colonies that become attached to the wound
bed and secrete glycocalyx or biofilms that help to protect the microorganism from anti
52 53
microbial agents and can delay healing.
The diagnosis of infection is primarily a clinical skill based on careful history taking and
clinical observation, with microbiological data used to supplement the clinical diagnosis.
Quantification of bacteria by wound biopsy has been considered the gold standard, but
54
surface sampling cost less and is easier to carry out.
The European Wound
Management Association Algorithm for Managing Wound Infection as illustrated in Figure
55
1
should be used to assist in clinical decision making regarding the diagnosis and
management of suspected infection.
Wound cleansing is an important factor in reducing bacterial burden. Organisms are
physically removed by irrigation with saline. Increasing the frequency of dressing changes
may also be useful particularly as infected wounds often produce copious amounts of
exudate, which may promote bacterial growth causing further tissue breakdown and
maceration of the surrounding skin. There is clearly a need to link the I element of WBP
56
to the M element for intervention to be successful.
MRSA
52
Enoch S, Harding KG, (2003) wound bed healing: the science behind the removal of barriers to healing. Wounds 15:
21053
Dowsett C, Edwards-Jones V, Davies S, (2004) Infection control for wound bed preparation A Journey through TIME.
Wound bed preparation in practice BJN.
54
Dowsett C, Edwards-Jones V, Davies S, (2004) Infection control for wound bed preparation A Journey through TIME.
Wound bed preparation in practice BJN.
55
EWMA (2006) Position Document. Management of wound infection
56
Dowsett C, Edwards-Jones V, Davies S, (2004) Infection control for wound bed preparation. A Journey through TIME.
Wound bed preparation in practice BJN.
13
diagnosed early and antibiotics that are not effective are given at first.
For this reason it
is vital that all MRSA positive wounds are referred to either Tissue Viability, Leg Ulcer
Services or Podiatry as appropriate within 72 hours of diagnosis.
Antibacterial strategy
The decision of whether to use antibiotics or antimicrobial products is a complex matter that
must be based on the clinical findings of an experienced clinician. Figure 1 provides EWMA
58
guidance on this matter.
Ideally systemic antibiotics are not recommended for wounds that
59
only show signs of local infection. Topical antiseptic agents whether antibiotic or antiseptics
delivered from a sustained-release dressing formulation therefore represent the first line
60
treatment, as they provide a high antimicrobial concentration at the site of infection. Some
iodine and silver preparations have bactericidal effects even against multiple resistant
61 62
organisms such as MRSA.
Topical antiseptics have the additional advantage that they do
not interfere with the remainder of the protective bacterial flora in other parts of the body and
are also less likely to produce an allergic reaction.
In the case of biofilms the mainstay is frequent removal of the wound surface either with
sharp or surgical debridement. At present the effective treatment of medical biofilms is its
63 64
physical removal.
The early biofilm that re-emerges after debridement needs to be
suppressed with multiple strategies. This will include wound cleansers, topical antimicrobials
and advanced primary dressings. Since biofilms adapt to selective stresses a rotating regime
65
of selective antiseptics such as silver or iodine is recommended.
Lack of a noticeable healing response within 2 weeks may necessitate the use of other topical
or systemic agents. Given the evidence that improvements in wound healing have previously
been associated with the elimination of malodour-causing anaerobes and that mixed
anaerobes appear to play some synergistic role in preventing wound healing, the use of a
66
metronidazole gel may then be considered under the instruction of the TVS.
Topical antimicrobials are most appropriate when used to decrease the bacterial burden in
chronic wounds with active but localised infection. They are not solely suitable for highly
infected wounds with soft tissue invasion or systemic sepsis and should not be used as a
substitute for debridement or systemic antibotics. Increased antimicrobial resistance means
these agents should not be used for an extended period of time and should be followed by an
appropriate dressing once the bacterial burden has been reduced. Where infection has
extended beyond the level that can be managed by local therapy, systemic antibiotics should
be used in conjunction with antimicrobial products.
57
14
2.3.3
Moisture
67 68
Exudate.
Exudate contains a variety of substances including water, electrolytes, nutrients,
inflammatory mediators, white cells, protein-digesting enzymes (eg matrix
metalloproteinases MMPs), growth factors and waste products. In the healing wound
exudate appears to promote healing in a number of ways, including cell proliferation.
MMPs which breakdown the cell-supporting matrix, are present mainly in inactive form. In
wounds not healing (Chronic wounds) exudate appears to have the opposite effects. The
69
exudate contains elevated levels of inflammatory mediators and activated MMPs.
One of the most significant challenges faced by nurses is the efficient and cost effective
management of excessive wound exudates which causes extreme distress and negatively
70
impacts on patients and carers quality of life.
The goal of effective wound management
is to remove excess moisture, debris and chemicals from the wound, while maintaining
71
the ideal moisture balance to allow cell migration and ultimately wound healing.
Poor
exudate management can either cause the wound bed to become too dry or too wet, the
72
resultant imbalance of moisture will cause tissue damage.
There are no validated
precise measurements for assessing exudate, so for progress of a wound to be monitored
it is preferable that the same nurse reassesses a wound in order to aid comparison with
serial assessments. Colour and consistence are considered in Table 5 with some
guidance on causes and how.
There are three main methods of managing exudate:
1. Use of absorbant dressings or dressing which allow evaporation of moisture.
2. Counter pressure through compression
3. Drainage systems, either wound management systems or topical negative
pressure (TNP)
2.3.4
Edges
In WBP, E stands for edges, which are non-advancing or undermining. When wound
edges fail to migrate or undermining is present, the clinician needs to reassess the cause
and intervene using the TIME table. Epidermal edges that are failing to advance over time
towards closure are perhaps the clearest sign of all that a wound is failing to heal. Wound
measurement provides baseline information while continuous measurement helps to
73
predict healing and aids monitoring of treatment efficacy and evaluation.
Wounds
74
should be re-measured every four weeks.
If the margin is undermined, this may be a
sign of critical colonisation or infection. The use of cytotoxic agents and cortiocosteroids
75
can totally mask all signs of local or systemic infection.
At a cellular level, lack of
epidermal migration could be owing to non-responsive wound cells and abnormalities in
76
protease activity, which degrade extra cellular matrix as soon as it is formed.
67
Cutting K F (2003) Wound exudates: composition and functions BJN Vol 12 No 16 Supplment: The Exudate Supplement part
one.
68
Morison M (2005) Moist wound healing and the role of moisture retentive dressings. Wounds UK Supplement 1 (2): 136
69
WUWHS (2007) Principles of best practice: Wound exudate and the role of dressings, a consensus document. London:
MEP Ltd.
70
Benbow M, Stevens J (2010) Wxudate, infection and patietn quality of life. BJN TV Supplement) Vol 19 No 20 pg S 31-S36
71
Vowden K, Vouden P (2003) Understanding exudate management and the role of exudate in the healing process. The
Exudate supplements part two. BJN Vol 12 No 20.
72
White R Wick G Cutting K (2006) From the wet to the dry: modern exudates management. Wound Care Society
Publication.
73
Gethin G (2006) The importance of continuous wound measuring. Wounds Uk Vol 2 No 2 60-68
74
Dowsett C, (2008) Using the TIME framework in wound bed preparation. Wound Care UK June pg S15-D20
75
Schultz G, Sibbald G, Falanga V et al (2003) Wound bed preparation: a systemic approach to wound management.
Wound Repair Regen 11 (2): 1-28
76
Falanga V (2002) Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair regen 8:
347-52
15
Colour
Clear/straw
colour
Consistency
Watery
Type of wound
Leg ulcer
Clear/straw
colour
Clear/straw
colour
Watery
Surgical
Serous fluid
Acute: traumatic
or surgical
Probable cause
Oedema/lymph oedema
(sudden increase in
exudate may indicate
infection)
Heart failure/oedema
caused by fluid overload
Normal inflammatory
exudate
Blood stained
Serous fluid
Acute: traumatic
or surgical
Blood
Viscous
Surgical
Bleeding vessel
postoperative
Blood
Viscous
Any
Yellow
Slightly viscous
(may appear
purulent, may
contain fatty
globules, usually
profuse)
Purulent or
haemopurulent
Any sloughy
wound
Autolytic debridement of
non-viable tissue
Abscess or
infected wound
Bacteria
Green
Very viscous,
mucus-like
Bacteria especially
Pseudomonas
aeruginosa
Clear green
Watery or slightly
viscous
Brown, faecal
Viscous
Upper
abdominal
wound
Lower
abdominal
wound
any
Yellow or brown
Grey or Blue
78
Viscous or watery
77
Management
Compression or
elevation of the
limb
Diuretics
Dressings of
appropriate
absorbency
Localised
pressure or use of
a haemostatic
dressing
Excessive
bleeding should
be referred back
to surgeon
Traumatic
bleeding can be
stopped with local
pressure or
haemostatic
dressing. Reconsider dressing
choice
Appropriate
dressing or
drainage system
Systemic
antibiotics,
possibly topical
antiseptics and
appropriate
dressing
Topical antiseptic
(systemic
antibiotic if
cellulitis present)
Refer back to
surgeon
Refer back to
surgeon
Related to silver
containing dressings
Avoid prolonged
used of silver
77
Scanlon E. (2004) Moisture balance and exudate control. Clinical review. A Journey through TIME. Wound Bed
Preparation in practice. BJN
78
WUWHS (2007) Principles of best practice: Wound exudate and the role of dressings, a consensus document. London:
MEP Ltd.
16
3.2
Diet
79
Jones P.L. Millman A (1990) Wound Healing and the Aged Patient. Nursing Clinic of North America. 25: pg 263-77
Descai H (1997) Ageing and Wounds Part 2. Healing in Old Age. Journal of Wound Care. May Vol. 6 No.5 Pg 237-239
Harding, K (1999) Wound Management : Theory and Practice. Nursing Times Publications. Pg 96-107.
82
Robson M et al. (1991) Wound healing alterations caused by infection. Clinics in Plastic surgery. 17: 3, 485-492/
83
Bland K.I. Palin W.E et al (1984) 80. Experimental and Clincal Observations of the effects of cytotoxic chemotherapy
drugs on wound healing. Ann Surg 199: pg 782
84
Siang J.E. (1992) The effect of smoking on tissue formation JWC July/Aug. Vol 1 No 2 pg 37-41
85
Winter, GD. (1962) Formation of scab and rate of epithelialisation of superficial wounds in the skin of a young domestic
pig. Nature;193: 293-294.
86
Cutting, F.K. (1999) The causes and prevention of maceration of the skin. Jr of Wound Care. Vol8, No 4.
87
Schultz G, Sibbald G, Falanga V et al (2003) Wound bed preparation: a systemic approach to wound management.
Wound Repair Regen 11 (2): 1-28
88
Silhi, N. ((1998) Diabetes and wound healing, Jr of Wound Care; 7: 1, 47-51.
89
Kidman K (2008) tissue repair and regeneration: the effects of diabeties on wound healing. The Diabetic Foot Journal
Vol 11 No 2 pg 73 -79.
90
Whiteford L (2003) nicotine, CO and HCN: the detrimental effects of smoking on wound healing. Wound Care Dec S22S25
91
Kean J (2010) The effects of smoking on the wound healing process. JWC Vol 19 No 1 pg 5-8
92
Ng M (2010) Cachexia an intrinsic factor in wound healing. Int Wound Jr . Vol 7 No 2 pg 107-111
93
Heyman H, Van de Looverbosch DE, Meijer EP, Schols JMGA (2008) Benefits of an oral nutritional supplement on
pressure ulcer healing in long term care residents. JWC Vol 17 No 11 Nov pg 476-480
94
Mandal A (2006) Do malnutrition and nutritional supplementation have an effect on the wound healing process. JWC
Vol 15 No 6 254 -257
95
Bradbury S (2006) Wound healing: is oral zinc supplementation beneficial. Wounds UK Vol 2 No 1. 54-61
96
Frias Soriano L et al. (2004) The effectiveness of oral nutritional supplementation in the healing of pressure ulcers. The
Journal of wound Care Vol 13, No8 319-322
97
Lansdown A (2004) Nutrition 1: a vital consideration in the management of skin wounds. BJN (Tissue Viability
supplement) Vol 13 No 19 S22-S28
98
Lansdown A (2004) Nutrition 2: a vital consideration in the management of skin wounds. BJN Vol 13 No 20, 1199-1210
99
Lewis B (1996) Zinc and Vitamin C in the Aetiology of Pressure Sores. The Journal of Wound Care. Nov. Vol 5 No 10
483-481
100
Reynolds TM. (2000) The Future of nutrition and wound healing. Journal of Tissue Viability. Vol 11 No 1.
101
Gray D. Cooper P. (2001) Nutrition & Wound Healing: What is the Link? JWC. Vol 10 No 3, 86-88.
80
81
17
If Nursing Staff are uncertain in specific situations they should discuss their concerns
regarding the need to provide supplements with either the Dietician or Medical Staff
responsible for the patient.
3.2.1.
Nutritional assessment should be carried out in line with the MUST Nutritional
Assessment Form. (Appendix 1)
3.3
Pain
110 111 112
Unresolved pain negatively affects wound healing and impacts on quality of life.
113
A painful chronic wound can often indicate that there is something wrong.
Holistic
assessment using TIME should provide indicators as to possible causes of such pain.
Pain at wound dressing-related procedures can be managed by a combination of accurate
114 115 116
assessment, suitable dressing choices
skilled wound management and
117 118
individualised analgesia regimens.
119
An initial assessment should be carried out by an experienced clinician
in partnership
with clinical staff able to prescribe the appropriate medication. Every patient with a wound
should have an individual pain management plan including regular ongoing assessment
120
which should be performed each time a dressingrelated procedure is carried out.
Background pain in the wound and surrounding tissue, plus any new regional pain that
may have developed should be assessed. The intensity should be rated, before, during
121 122
and after the procedure.
This should be documented in the patient notes and a care
plan developed to address the pain. The level of pain should also be recorded on the
wound assessment chart using a recognised pain scale as illustrated in Figure 2 and 3
102
Ronaghy HA. (1987) The role of zinc in human nutrition. World Review of Nutrition and Dietetics. 54: 237-54.
Casey, G. (1998) The Importance of Nutrition in Wound Healing. Nursing Standard: 13:3 (supplement) 51-56.
104
Lewis, BK, Harding, KG. (1993) Nutritional intake and wound healing in elderly people.The Journal of Wound care; 2:
4,227-229.
105
Collins, CM (1996) Nutrition and Wound Healing. Care of the Critically Ill; 12:3, 87-90
106
Wallace, E. (1992) Feeding the Wound: Nutrition and Wound Healing. Br J Nursing; 3: 13,662-667
107
Foster A. Greenhill M.T Edmonds ME (1994) Comparing 2 dressings in the treatment of diabetic foot ulcers JWC Vol 3 No 5 Pg
224-228
108
Capper C.J. (1994) The Management of Pressure Sores in a patient with Diabetes Mellitus. JWC Vol 3 No 8 pg 360362
109
McIlwaine C (2003) Importance of holistic nutritional assessment in wound healing. JWC Vol 12 No 8 285-288
110
WUWHS (2004) Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus
document. London: MEP Ltd
111
Hofman D ((2006) Practical steps to address pain in wound care. BJN Supplement. Vol 15 No 21, pg10-15
112
Young T Roden A (2006) Pains-taking care. Everyday issues in wound pain management. Wound Care Society
Publication.
113
Sibbald R G, Katchky A, Queen D (2006) Medical management of chronic wound pain. Wounds UK Vol 2 No 4 pg 7489
114
Young S Hamption S (2005) Pain management in leg ulcers using ActiFormCool. Wounds UK Vol 1 Issue 3. 94-101
115
Fletcher J (2010) managing wound pain during application and removal of dressings BJN TV Supplement Vol 19 No 20
S4-S6
116
Taylor Alison ( 2010) Principles of Pain Assessment. Wound Essentials Vol 5 Pg 104-110
117
Briggs M, Ferris F D, Glynn C, et al (2004) Assessing pain at wound dressing-related procedures. Nursing Times Vol
100 No 41 56-57
118
European Wound Management (2002) Position Document: Pain at wound dressing changes. London MEP Ltd.
www.ewma.org
119
WUWHS (2004) Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus
document. London: MEP Ltd
120
Solowiej K et al (2010) Psychological stress and pain in wound care. Part 2:management. JWC Vol 19 No 4 pg 153155
121
WUWHS (2004) Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus
document. London: MEP Ltd
122
Lloyd Jones M (2010) Living with wound associated pain: impact on the patietn and what clinicians really think. JWC
Vol 19 No 8 pg 340-343
103
18
3.3.1
123 124
Topical opiates act centrally and peripherally and can be alternative or concurrent forms
of pain control for wounds. Opiates can be used on viable and non-viable tissue.
The effective analgesia dose is low (10mgs) with analgesia occuring within a few minutes.
The duration of pain relief from one dose can last up to 2 days.
The opiate should be mixed with hydrogel carrier and apply directly to the wound
A foam dressing can be used to secure the hydrogel. The effective dose concentration is
10mgs morphine opiate to 1gram hydrogel. Application should be daily or as required
basis.
There are minimum adverse effects however it is preferable to keep certain wounds such
as ischaemic gangrene dry and thus the use of hydrogels would be contraindicated.
None
Mild
Moderate
10
Severe
123
Riberio, M.D.C. Joel, S.P. Zeppetalla.G. (2004) The bioavailability of morphine applied topically to cutaneous ulcers.
Journal of Pain and Symptom Management Vol 27 Issue No 5 434-439
124
Zeppetalla G. (2004) Topical opioids for painful skin ulcers: do they work? European Journal of Palliative Care Vol 11 No 3
pg 93-96
19
Hypoxia
Necrotic Tissue and
Foreign Bodies
Fall in Wound
Temperature
Cardiovascular
Disorders
Anaemia
General Pathophysiological
Factors
Malnutrition
Wound Infection
Inaccurate Wound
Assessment
Dehydration
Careless Wound
Dressing Techniques
Drug Therapy
Inappropriate Wound
Management By Nurses
Extrinsic
Inappropriate Application
Of Topical Agents &
Primary Wound Dressing
Products
Negative attitudes of
Staff to Treatment and
Healing
Decreased Resistance
To Infection
Intrinsic
Adverse Effects Of
Other Therapies
Chemotherapy
Radiation Therapy
20
4.
Epithelialsing Tissue
125
Appearance.
Translucent appearance, usually whitish-pink
Small islands of epithelial cells may be visible originating from the wound margin or
reminents of hair follicles, sebaceous or sweat glands
The epithelial cells rapidly multiply and migrate across granulation tissue, until they
form a continuous layer. At this stage the wound will have smooth edges
4.2
Granulating Tissue
126 127
Appearance:
Granular appearance, slightly uneven
Pinky-red colour (well vascularised)
Healthy granulating tissue does not bleed easily
Granulating tissue which is dark in colour may signal ischaemia or infection
4.3
Sloughy Tissue
128
Appearance:
Yellow/ white hue
May be dry or slimy
Adherent to wound bed (Slough forms when dead cells accumulate in the exudate,
yellow colour due to the presence of a large number of leucocytes)
4.4
Infected Tissue
125
21
4.5
Necrotic Tissue
129
Appearance:
Black/Brown leathery appearance
Hard skin-like surface below which is a cavity full of dead tissue
Depth will not be known until the dead tissue is removed
4.6
Appearance:
Raised irregular islands of malignant tissue
Often bleeds on contact
Characterised by very offensive odour due to colonisation by bacteria
It is acknowledged that no classification is likely to be wholly exhaustive; with this in mind it
is important to complete a full assessment on a wound as directed on The Wound
Assessment Form (WAF) (Figure 5). If the wound is a pressure sore, it is also necessary
to state the grade (see Pressure Ulcer Guidelines)
5.
WOUND ASSESSMENT.
Wounds need regular assessed if appropriate care is to be provided.
Wound care
products are designed to suit a wound at a particular stage of healing. As the wound
changes, dressing type may also need to be changed. It is important to use a
classification that all staff understand when assessing, planning and evaluating wound
care. This facilitates monitoring the progress and selecting appropriate wound care
130 131
products.
Wounds should be assessed using the principles of WBP and application of the acronym
TIME illustrated in Table 2. Tissue observed should be classified according to the Wound
Tissue Classification described in Section 4. The Wound Assessment Form (Figure 5)
which incorporates the principles of WBP (TIME) should be completed at every dressing
132
change as documentation is as essential as the assessment itself.
The use of the WAF and a comprehensive care plan ensures that registered nurses are
fulfilling their obligations under the NMC Standards for Records and Record Keeping.
Failure to keep such records exposes the Nurse and the Trust to the risk of litigation. It is
crucial that wound assessment forms and care plans are completed on all patients who
133
have wounds. These records must be clearly written, signed and regularly updated.
An
entry must be made on the WAF following every dressing change.
129
Cutting K..F. (1996) Definition of Terms. Journal of Wound Care Resource File. London Macmillan
Dowsett C, (2008) Using the TIME framework in wound bed preparation. Wound Care UK June pg S15-D20
131
Briggs M (1996) Documenting Wound Management JWC Vol 5 No 5 Pg 229 - 231
132
Oldfield A (2010) Assessing the Open Surgical Wound. Wound Essentials Vol 5 pg 48-55
133
NMC (2006) Record Keeping advice sheet. www.nmc-uk.org
.
130
22
D.O.B:
NHS. No:
Draw Wound Profile (so top of wound is towards patients head, include dimensions in cm).
Surgical (
Traumatic (
Leg Ulcer (
Burn (
Pressure Ulcer (
Interventions
Fungating ( )
Other ( )
DATE:
TIME:
DATE:
TIME:
DATE:
TIME:
DATE:
TIME:
1. N.A.dressing
4. Hydrogel
7. Foam
10. TNP
Code Numbers.
2 Semi-permeable
5. Alginate
8. Hydrofibre
11.
3. Hydrocolloid
6.Activated charcoal
9. Antimicrobial
12.
23
WOUND CARE
134
PROBLEM:
GOALS:
CARE PLAN:
6.2
137
EXAMPLES:
PROBLEM:
GOALS:
T:
I:
M:
E:
CARE PLAN:
Promote epithelialsation
Reduce inflammation and maintain a bacterial balance.
Achieve moisture balance
Measured advancing edges and base of wound.
134
Morris C (2006) Wound management and dressing selection. Wound Essential. Vol 1 178-183
NICE (April 2006) Surgical site infection: Prevention and treatment of surgical site infection.
Chintz et al (1989) Need for surgical wound dressing. British Journal of Surgery. Vol 76. 204-205
137
Thomas S (1997) A Guide to dressing selection . JWC. Nov. Vol 6 No 10 Pg 479-482
135
136
24
6.2.2
6.2.3
Granulating Wounds
EXAMPLES:
PROBLEMS:
GOALS:
T:
I:
M:
E:
CARE PLAN:
Sloughy Wounds
EXAMPLES:
PROBLEM:
GOAL:
T:
I:
M:
E:
CARE PLAN:
138
Haury B (1998) Debridement: An essential component of traumatic wound care in wound healing and wound infection.
Hunt T.K. Ltd. New York. Appleton Century Crofts. Pg 229-240
139
NICE (2006) Surgical site infection: Prevention and treatment of surgical site infection draft doc
25
6.2.4
Infected wounds:
EXAMPLES:
PROBLEMS:
GOALS:
T:
I:
M:
E:
140
Cutting K.F (1994) Criteria for identifying Wound Infection. JWC. Vol 3. No 4. Pg 198-210
Grey J.E. (1998) Cellulitis Associated with Wounds. JWC, July Vol 7 Pg 338-339
142
Heggers J.P. (1998) Defining Infection in Chronic Wounds Does it Matter? JWCCare. Sep. Vol 7 No 8 Pg 389-392
143
NICE (2006) Surgical site infection: Prevention and treatment of surgical site infection draft doc.
144
Visu Dr, Kirkham A (2009) Infection Control Services WEPCT & PAHT
141
26
6.2.5
Necrotic Wounds
EXAMPLES:
(Eschar)
PROBLEM:
GOALS:
T:
I:
M:
E:
.
CARE PLAN:
Surgical debridement:
Sharp debridement is the quickest means of removing
eschar. Nurses wishing to pursue this form of
management must be clinically competent to do so.
Versajet debridement can be performed on soft necrotic
tissue by the TVS
Medical debridement:
Dressings: Hard dry eschar will need to be hydrated if
medical debridement is to occur.
Hydrocolloid sheets will trap the bodies humidity and
facilitate debridement
Hydrogels will actively hydrate eschar
Bio Surgical debridement:
Larvae therapy will effectively and efficiently debride
slough and soft eschar.
6.3
Malignant/Fungating Wounds
EXAMPLES:
PROBLEM:
GOAL:
T:
I:
M:
E:
145
Grocott P (1998) Exudate management in fungating wounds. Journal of Wound Care. Oct. Vol 7 No 9 Pg 445-448
Grocott P (1995) The Palliative management of fungating malignant wounds. Journal of Wound Care. May. Vol 4 No
5. Pg 240-242
147
McDonald A, Lesage P (2006) Palliative management of pressure ulcers and malignant wounds in patients with
advanced illness. Jr Palliative Medicine, April 9 (2): 285-295
148
Hampton S, (2008) Malodorous fungating wounds: how dressings alleviate symptoms. Wound care June 2008 pg
S31- S38
146
27
CARE PLAN:
Odour Control
Establish the cause of the odour by sending a wound swab for microscopy and
culture.
Clean with sterile sodium chloride 0.9% if required.
Dressing: Dress according to the classification of the wound.
Additional management: Antibacterial dressing, which includes charcoal or silver
153
can help to reduce odour.
Metronidazole gel can be used following a doctors
prescription.
Incipient Bleeding
Kalostat, an alginate dressing is a licensed haemostat and can help control
154
bleeding.
Relief and Comfort
Foam sheets can be cut to fit a protruding wound and thus provide comfort and
support.
Small amounts of hydrogel can minimise adherence in dry wounds.
Good provision of analgesia is crucial, particularly prior to dressing changes.
Exudate
155
Foam sheets and high absorbency alginates should be used to control exudate.
VAC therapy is contraindicated in malignant wounds.
6.4
149
Alexandra S J (2010) An intensive and unforgettable experience: The lived experience of malignant wounds for the
perspectives of patients, caregivers and nurses. Int Wound Jr. Vol 7 No 6. Pg 456-465
150
Piggin C, Jones V (2009) Malignant fungating wounds: and analysis of the lived experience. JWC Vol 18 No 2 pg 5764
151
Van Toller S (1994) Invisible Wounds: The effects of skin ulcer malodour. JWC Vol 3 No 2 Pg 103-105
152
Morris C (2008) Wound odour: principles of management and the use of Clinisorb. BJN (TV Supplement) Vol17 No 6
pg
153
Hack A (2003) Malodourous wounds taking the patients perspective into account. JWC Vol 12 No 8 319-321
154
Hamilton S (1999) Wound Management theory and practice. Nursing Times Books. Pg 119
155
Thomas S (1997) Assessment and Management of Wound Exudate. Journal of Wound Care. July Vol 6 No 7 Pg 327330
156
Greenwood J.E. Crawley B.A. (1997) Monitoring Wound Healing by Odour. Journal of Wound Care. May. Vol 6 No 5
28
The frequency of the dressing change will be influenced by the condition of the wound
and dressing product used. (see manufacturers instructions)
Frequent unnecessary changes should be avoided, as this will reduce the
temperature and humidity of the wound. It may also cause trauma to newly formed
157
cells and may permit colonisation of the wound by microganisms.
Dressing changes should be concluded promptly, adhering the aseptic principles as
necessary.
6.5
159
Wound swabs should be taken when the wound presents with the signs of infection.
(Figure 1and Table 4)
6.6
160
Cleanse the wound bed well with saline, bacteria are not washed away during
cleansing and thus can still be identified;
Do not swab eschar, exudate or pus;
Select the cleanest area of the wound;
161
162
First, dip the clean swab in the swab medium
or sterile saline.
Firmly press and rotate the swab in the cleanest area of the wound area, mover
163
the swab across the area in a ziz-zag motion from the centre to the outside.
Include tunnelling if present;
If pus is present take a separate sample of the fluid in a pot.
Lock A.M.(1980) The effect of temperature at the edge of experimental wounds, Symposia on wound healing, plastic
surgical and dermalogical aspects. Pg 103-109
158
Cutting K. Harding K. (1994) Criteria for identifying wound infection in Wounds. Essential Vol 1 2006
159
RDNS Research Unit (2002) The Pursuit of Excellence. Promoting Evidence-Based Nursing Practice Wound
Swabbing. ISSN 1449-44X Issue No 11. Sept
160
Community & primary Care Infection Control Manual. (2006) EFPCT Ref GUI00062/HP
161
Microbiology advice from PAHT
162
Patten H (2010) Identifying wound infection: Taking a swab. Wound Essentials Vol 5 pg 64-66
163
Patten H (2010) Identifying wound infection: Taking a swab. Wound Essentials Vol 5 pg 64-66
164
Hampton S. Collins F (2004) Tissue Viability, Ch 3 Pg 96. Whurr publishers. ISBN 1 88156 237 3
165
Dunsford C (1999) Hyperegranulation Tissue. JWC Vol 8 No 10 pg 506-507
166
Young T (1997) Use of a hydrocolloid in over granulation. JWC Vol 6 No5 pg216167
Young T (1995) Common problems in wound care: overgranulation. British Journal of Nursing. Vol 4 No 3
168
Hampton S. Collins F (2004) Tissue Viability, Ch 3 Pg 96. Whurr publishers. ISBN 1 88156 237 3
29
Haelan tape; which contains the steroid Fludroxycortide within it has been reported as
169 170
suitable for use for over granulation.
169
Johnson, S (2007) Haelan Tape for the treatment of overgranulation tissue. Wounds Uk Vol 3 no 3 pg 70 -74
Vowden K, Vowden P, (2010) Understanding and managing hypergranulation. Ind Nurse Sept.
www.independentnurse.co.uk.
170
30
DATE
WARD:
PATIENT PROBLEM/NEED
RGN
Signature
Review
Date
GOAL
NURSING ACTION/INSTRUCTION
CLEANING SOLUTION:
PRIMARY DRESSING:
SECONDARY DRESSING:
OTHER INSTRUCTIONS:
The use of the WAF and a comprehensive care plan ensures that
registered nurses are fulfilling their obligations under the NMC
Code171 . Failure to keep good records exposes the Nurse and the
Trust to the risk of litigation. It is crucial that wound assessment
forms and care plans are completed on all patients who have
wounds. These records must be clearly written, signed,dated and
timed and are regularly updated. The WAF must be completed
after every dressing change.
171
NMC (2008) The Code, Standards of conduct, performance and ethics for nurses and midwives
31
172 173
The purpose of wound irrigation is to help create optimum local conditions of healing. It
should remove wound debris. It should be performed in an atraumatic method, so that
epithelialising and granulation tissue is not damaged. The method used to do this should
be based upon an assessment of the wound and the patients general condition.
Clean epithelialising/granulating wounds do not benefit from mechanical irrigation, which
removes exudate containing valuable healing factors. These wounds should be left
undisturbed for as long as possible to enhance the rate of healing. Wiping may damage
new granulation tissue. Chronic wounds with excess exudate may benefit from
irrigation.(See section 2.3.3)
Irrigation using a syringe or by showering is often preferred providing that the pressure
achieved is adequate to remove wound debris, but not damage healthy tissue.
When irrigation is not effective in removing remnants of the dressing (e.g. Hydrocolloids,
Alginates) gentle wiping can be instituted. It is recommended that non-woven gauze (as
supplied in dressing packs) be used in conjunction with either a gloved hand or forcep
technique.
Some methods of mechanical wound cleaning can result in the redistribution of bacteria
174
rather than an actual reduction.
Care must be taken to wipe from clean areas to dirty
and not visa versa.
7. 1
Cleansing solutions
Sterile sodium chloride 0.9% solution is the most appropriate for irrigating wounds. When
a surgical wound has separated or has been surgically opened to drain pus, then the use
175
of tap water may be considered for wound cleansing.
It is however preferable in
wounds which are not contaminated with faecal or other severe contamination matter that
staff use sterile saline.
A variety of antiseptic preparations are sometimes used for more complex wounds.
Traditional antiseptics (e.g. Eusol, diluted Milton, hydrogen peroxide, chlorhexidine with
cetrimide) are quickly rendered ineffective by body fluids and pus. The potential
disadvantages of using such antiseptics should be weighed against any possible benefits
176
before they are used.
NICE guidelines advise against the use of Eusol and mercuric
177
antiseptic on wounds.
Products which contain polyhexamethylene biguanide (PHMB)
have a broad range spectrum of biocidal activity with demonstrated clinical evidence to
178
support their use.
Some studies have indicated that Fungi and Yeasts are more
important wound pathogens than previously reported and thus antimicrobial products must
179
be able to target these pathogens if healing is to occur.
It is advisable to warm the cleaning solutions to body temperature just before use.
7.1.1
7.1.2
172
32
Prontosan
Prontosan Wound Irrigation Solution and Gel are ready to use products for
cleansing, moisturising and decontamination of acute and chronic wounds. They
contains unique ingredients that have a double effect on the wound bed to create
a wound environment optimal for healing. Betaine a gentle effective surfactant to
penetrate, clean and remove wound debris and biofilm. Polyhexanide (PHMB) a
powerful antimicrobial agent that can reduce bioburden. This product is not on
the Dressing Formulary and should only be prescribed on the instruction of the
Tissue Viability Service
7.1.4
Iodine
Iodine is active against a wide range of organisms including Gram-negative and
Gram-positive bacteria, fungi and bacterial spores. If an antiseptic solution is
required Iodine is the solution of preference. Cadexomer Iodine has in studies
been shown to produce a marked decrease in MRSA, and it is recognised as
180 181
having a role in enhancing healing of chronic wounds.
However for
management of MRSA Stellisept as discussed below should be used.
7.1.5
Stellisept
If a wound is colonised or infected with MRSA it can washed using Stellisept at
182
dressing changes.
The wound should subsequently be redressed using an
antimicrobial dressing according to its classification and in adherence with the
EWMA Algorithm as illustrated in Figure 1.
Table 7
Antimicrobial properties
Gram+ve Gram ve
184
Chlorhexidine
+++
++
183
Fungi
Endospores
Viruses
Resistance
185
Honey 110,
Iodine 109,110
186 187 188
Maggots
+++
+++
+++
+++
+++
++
+++
+++
ND
0
+++
ND
+
++
ND
0
0
0
+++
+++
ND
189 190
Silver 109,110
ND= No data
180
Mertz. P Davis S Brewer L (1994) Can Antimicrobials be effective without impairing healing
Marshall C, Queen J Manjooran J (2005) Honey Vs povidone iodine following toenail surgery. Wounds UK May Vol 1
Issue 1: 10-17
182
Olivo, S. (2011) SEPT Internal communication on management of MRSA in Wounds. 3/8/11
183
European Wound Management Association (EWMA) position Document: Management of wound infection. London
MEP Ltd 2006
184
McDonnellG RussellAD. Antiseptics and disinfectants:activity, actions and resistance. Clin Microbiol Rev 1999:12 (1):
147-79
185
Cooper R. A review of the evidence for the use of topical antimicrobial agents in wound care.
www.worldwidewounds.com/2004/February/Cooper/Topical-Antimicrobial-agents.html(assessed 2 February 2006)
186
Thomas S Andrews AM, Hay NP et al. (1999)The antimicrobial activity of maggot secretions:results of a preliminary
study. J tissue Viability 9:127-32
187
Beasley WD, Hirst G. (2004) Making a meal of MRSA the role of biosurgery in hospital acquired infection. J Hosp
infect: 56:6-9
188
Horobin AJ, ShakesheffKM, Woodrow S et al. Maggots and wound healing: an investigation of the effects of
secretions from Lucillia sericata upon interactions between human dermal fibroblasts and extracellular matrix
components. Br J Dermatol 2003; 148(5):923-33
189
Steenvoorde P Jukema GN. The antimicrobial activity of maggots: in-vivo results, J Tissue Viability 2004: 2004; 14
93):97-101
190
Cooper R. A review of the evidence for the use of topical antimicrobial agents in wound
care.www.worldwidewounds.com/2004/February/cooper/Topical-Agents.html (accessed 2 february 2006)
181
33
191
New dressing products are released in to the health care market daily. It is thus
192
recommended that staff refer to the BNF or the Wound Care Handbook for up to date
information on products. However information on the main generic types is provided
below to facilitate learning. The Trust Dressing Formulary Guidelines should be referred to
regarding selection of products for patient use.
8.1
193 194
Hydrocolloids
195 196
2.
3.
197
198
Hamilton S (1999) Wound Management, Theory and Practice. Nursing Times Books. Pg 112-125
Wound Care Handbook 2011-2012. MA Healthcare Ltd. London
193
Thomas S (1994) Low Adherence Dressings. JWC Vol 3 No 1 Pg 27-30
194
Thomas S (1996) Vapour-Permeable Film Dressings JWC. Jun Vol 5 No 6 Pg 271-274
195
Banks V. Harding K (1994) The use of two dressings for moderately exuding pressure sores. JWC 32 Vol 3 No 3 Pg
132-134
196
Thomas S (1992) Hydrocolloids. JWC Jul/Aug Vol 1 No 2 Pg 27-30
197
Alvarez I.M (1980) The Effect of occlusive dressings on collagen synthesis, re epithelization in superfical wounds
Journal Sur Res 35 pg 142-180
198
Lawerence JC Lilly HA (1988) Bacterial barrier properties of hydrocolloid dressings in vitro in: Beyond Occlusion:
Wound Care proceedings. International Congress and Symposium Series No 136
192
34
199
integrity during handling. It should not be cut; excess dressing should be overlapped.
200
This dressing should only be used on the recommendation of the TVS or Team
Leader.
8.3
Alginates
201
Made from salts of alginic acid, a polysaccharide derived from seaweed. Suitable for
heavily exuding sloughy and infected wounds. The dressing should be changed when
strike through is visible and may be left for up to 3 days.
8.4
Foam Dressings
8.5
Hydrogels
202 203
8.6
Examples: Clinisorb
Currently all odour-absorbing dressings contain a layer of activated charcoal cloth.
205
Charcoal is a natural and efficient absorber of volatile molecules, odour and gasses.
Odour is frequently caused by bacteria such as Proteus, Klebsiella, Pseudomonas, and
Bacteroides. More uncommonly Clostridium welchi, the causative organisms of gas
gangrene.
199
Morgan D.A (1997) Formulary of Wound Management Products 7th Edition ISBN 1 899015 18 3
Foster L. Moore P. (1997) The Application of Cellulose-based fibre dressings in Surgical Wounds. J/wc Nov Vol 6 No
10 Pg 469-474
201
Thomas S (1994) Low Adherence Dressings JWC Vol 3 No 1 Pg 27-30
202
Flanagan, M (1995) The efficacy of a hydrogel in the treatment of wounds with non viable tissue. JWC Vol 4 No 6
1995 Pg 264
203
Thomas S (1994) Wound Cleansing Agents JWC Oct Vol 3 No 7 Pg 325-328
204
Maund M (2008) Use of an ionic sheet hydrogel dressing on fungating wounds: two case studies. JWC Vol 17 No 2 pg
65-68
205
Lee G, Anand S C Rajendran S Walker I (2006) Overview of current practice and future trends in evaluation of
dressings for malodorous wounds. JWC Vol 15 No 8 344-346
200
35
Milward treated fifty patients with Activated charcoal, paraffin gauze or charcoal and found
that the former was most effective in controlling odour, exudate, and promoting wound
206
cleansing and overall improvement.
8.7
The pathogens responsible for wound infection delay healing by destroying viable tissue
cells. They also attract polymorphonucleocytes to the wound which express enzymes that
destroy invading microbes and, in turn digest viable tissue cells. While systemic antibiotic
therapy is indicated for established skin infections the increase in antibiotic resistance has
led to a resurgence of interest in topical antiseptics. There is growing evidence as to the
207 208
effectiveness of antimicrobial dressings in limiting bacterial cell growth.
However a
wound does not need to be sterile to progress towards healing and the use of topical
antimicrobial therapy simply to lower microbial load in the healing wound can never be
209
justified.
The decision to use an antimicrobial dressing must be underpinned by
documented clinical observations. Nurses should be clear on the reasons why they have
chosen such products and if in doubt refer to the TVS or their Team leader. The products
identified below should only be used where wound infection is suspected. In cases of
MRSA wound infection the Care Pathway as illustrated in Appendix 2 should be followed.
Examples:
8.7.1
Honey
Examples: Algivon
Actilite
216
Honey is an ancient treatment that is increasingly earning its place in modern wound care.
Evidence suggests it compares with other dressings in terms of its antibacterial
217 218 219 220 221 222 223
properties, ease of use and ability to promote a moist environment.
224
206
Milward S (1991) Comparing treatments for leg ulcers Nursing Times Mar 27 Vol 87 No 13
Cutting K (2011) Why use topical antiseptics. JWC/The Silver debate. March pg 4-7
208
Lipp C et all (2010) Testing wound dressings using an invitro wound model. JWC Vol 19 No 6. Pg 220-226
209
European Wound Management Association (EWMA). Position DFocument: Management of wound infection.London
MEP Ltd 2006
210
IM et al ( 2006) antimicrobial activities of silver dressings: an invitro comparison. Jr Med Microbiology Vol 55 pg 59-63
211
Thomas S, McCubbin P (2003) A Comparison of the antimictobial effects of four silver-containing dressings on three
organisms. JWC Vol 12 No 3 101-107
212
Lansdown A B (2003) Silver in Wound Care and Management. WCS Vol 1 No 3
213
Edwards-Jones V (2006) Antimicrobial and barrier effects of silver against MRSA. JWC Vol 15 No 7 285-290.
214
Lansdown,A B (2006) Silver in Healthcare:Antimicrobial Effects and Safety in Use. Burg G (ed):Biofunctional Textiles
and the Skin. Curr Probl Dermatol. Base; Karger, 2006 vol 33.pp 17-34
215
Munter KC et al. (2006) Effect of a sustained silver-releasing dressing on ulcers with delayed healing. JWC 15 (5) p
155-206
216
Stephen-Haynes J (2004) Evaluation of a honey-impregrated tulle dressing in primary care. Wound Care June 2004
S21-S27
217
Schumacher H H A. (2004) Use of medical honey in patients with chronic venous leg ulcers after split-skin grafting.
JWC. Vol 13 No 10 Nov 4451-452.
218
Molan P C, Betts J A (2004) Clinical usage of honey as a wound dressing: an update. JWC Vol 13, No 9 353-356.
219
McIntosh CD Thomas CE (2006) Honey versus parfintulle gras following toenail surgery. JWC; 15:3 133-136
220
Booth S (2004) Are honey and sugar paste alternatives to topical antiseptic? JWC Vol 13 No 1 31-33
221
Gethin G (2004) Is there enough clinical evidence to use honey to manage wounds. JWC Vol 13 No 7 275-278
222
Saini J, (2008) A honey-based dressing for diabetic foot ulcers: A controlled study. The Diabetic Foot Journal. Vol 11
No 2 pg 87-91
223
Lay-flurrie K (2008) Honey in wound care:effects, clinical application and patient benefits. BJN (TV supplement) Vol
17 No 11S30-S36
224
Blaser G, Santos K et al (2007) Effect of medical honey on wounds colonised or infected with MRSA. JWC Vol 16 No 8
sept pg 325-328.
207
36
8.8
225
Examples: Aquacel
Cadesorb
Promogram
Promogram modulates and rebalances the chronic wound environment by:
Binding and inactivating protease, which have a detrimental effect on wound
healing when present in excessive quantities in chronic wounds.
Protecting naturally occurring growth factors from degradation by the excess
protease.
Protease are the bodys natural enzyme providers without which haemostasis would not
occur. Proteases degrades foreign material at the inflammatory stage and clean the
wound. They also help cells to migrate into, and re-epithelialise over the wound. Normally,
the level of protease
decreases as a wound heals. However if their activity becomes uncontrolled, causing
protease levels to rise in the wound, delayed healing can occur. Growth factors are also
proteins. They are synthesised by a number of different cell types in the wound and work
by binding to a
specific receptor on the cells surface. This stimulates the cells to migrate, proliferate and
produce granulation tissue, required for wound healing.
Cadesorb has a similar outcome/effect to promogram but works by altering the Ph of the
226
wound and thus making the wound bed less suitable for protease activity.
8.9
Sterile larvae, break down necrotic tissue within a chronic wound, transforming it into an
230
acute wound.
They do not normally harm healthy and healing tissue. They do not
invade the body, though they will go into nooks and crannies in the depths of complex
wounds. They can be used with other treatments that may be necessary. There is
compelling evidence to support the use of larval therapy for the purpose of eradicating
231
MRSA from wounds.
Larva are contained in specially designed dressings, which confine them to the wound
itself, and are covered so that they need not be seen. When they have done their job, and
have grown about 10mms, they are removed with the dressing, usually after about 48
hours. Some chronic wounds will be slow to heal and need repeated treatment.
No serious complications of this treatment method have been reported. Some patients
can feel the larvae in their wounds, and some patients with painful wounds will continue to
have pain during the treatment, such pain can normally be relieved by pain relieving
treatments. Once the wound starts to heal however, the pain becomes less. Pain due to
the larvae can be immediately relieved by removal of the larvae. Ulcers, which are
malodorous usually, become markedly less so after one or two treatment cycles.
Treatment can be undertaken in secondary or primary care as larvae are available of Drug
Tariff.
225
Treating Wounds with Promogran. (2003) Proceedings of four educational meetings. Medical Education Partnership
Ltd London
226
Rodgers A Westret L (2005) The role of pH modulation in wound bed preparation. The Diabetic Foot Journal. Vol 8 No
3 154-157
227
Thomas S (2006) Cost of managing chronic wounds in the UK, with particular emphasis on maggot debridement
therapy. JWC Vol 15 No 10 465-469
228
Thomas S (1996) Using Larvae in Modern Wound Management The Journal of Wound Care. Feb Vol 5 No 2 Pg 60-69
229
Guidance on the use of debriding agents and specialist wound care clinics for difficult to heal surgical wounds. NICE
2001.
230
Jones J, Green J, Lille AK ( 2011) Maggots and thei role in wound care. Wound Care March . S24-S33
231
Laurie R (2010) Larval therapy:is it effective against MRSA? JCN Vol 24 No 4 pg 10-12
37
8.10
TNP is a system which applies topical negative pressure to a wound, promoting wound
healing, under the influence of continuous or intermittent negative pressure.
TNP promotes healing by:
removes infectious materials and /or other fluids
assist tissue granulation through increased perfusion
draws the edges of the wound together
provides a moist wound healing environment
238
232
Flack S, Apelqvist J et al ( (2008) An economic evaluation of VAC therapy compared with wound dressings in the
treatment of diabetic foot ulcers. JWC Vol 17 No 2 pg 71-78
233
Thompson G (2008) An overview of negative pressure wound therapy. Wound Care June pg S 23-S29
234
Banwell P.E. (1999) Topical Negative Pressure Therapy in Wound Care. The Journal of Wound Care Feb Vol 8 No 2
Pg 79-84
235
Demaria, R. Giovanni, UM Teot. et al (2001)Using VAC to treat a vascular bypass site infection. The Journal of Wound
Care. Vol 10, No 2. Pg 12-13.
236
Dhar R, CopsonD, Williamson K Nunns D. (2006) Use of topical negative pressure to close a large MRSA-infected
groin wound following vulvectomy. JWC Vol 15 No 7 312-313
237
Zie X et al (2010) The clinical effectiveness of negative pressure wound therapy:a systemic review. JWC Vol 19 No
11 pg 490-493
238
Malmsjo M et al (2010) Influence on pressure transduction when using different drainage techniques and wound fillers
(foam and gauze) for negative pressure wound therapy, Int Wound jr Vol 7 No 5 pg 406-411.
239
Bondokji DPM et al (2011) Clinical efficacy of a new variant of a foam based NPWT system. JWC Vol 20 No 2 pg 6267
38
Access to VAC therapy is via the Tissue Viability Department see Appendix 2 for referral
forms
8.11
Topical Antibiotic:
39
WOUND DRAINAGE
Flow must be maintained at all times. Tubes should not become blocked, kinked
or removed by accident. Reduce risk of tension on wound from weight of long
tubing can be achieved by using a carrier attached to bed if appropriate.
Accurate measurement of all wound drainage must be kept. Contamination of the
wound must be prevented where possible. The drain site must be covered by a
dressing or a sterile drainage bag. If appropriate the patient must be encouraged
to maintain mobility. Disposable equipment must be discarded un-emptied into a
yellow clinical waste bag.
10
Analgesia should be provided if the patient is in pain or it is anticipated that the dressing
change will cause pain.
240
241
Newton H (2010) Reducing MRSA bacteraemias associated with wounds. Wounds Uk Vol 6 No 1 pg 56-65.
PAHT (2010) West Essex Leg Ulcer Guidlelines.
40
242
AIM
To minimize the risk of introducing organisms
capable of causing an infection into a wound
or other susceptible site where micro organisms
would normally colonize or be expected.
To prevent the transfer of organisms capable of
causing an infection to other susceptible sites,
service users of staff.
INDICATIONS
Wounds healing by primary and secondary
intention (before the skin has healed), e.g.
surgical wounds and chronic wounds.
Urinary catheterization
Suturing
Coil fitting (family planning service)
Insertion of intravenous canualae
Any other medical invasive procedure
Dressing intravenous lines
PROCEDURE
RATIONALE
To confirm identity
Decontaminate hands
242
Dougherty L, Lister S (eds) (2008) The Royal Marsden Hospital Manual Clinical Nursing Procedures. 7 th edn. Blackwell
Publishing, Oxford
41
11.
WOUND COMPLICATIONS
11.1
1.
2.
3.
4.
5.
Evaluate on a daily basis and record findings on WAF, reporting any concerns
Medical staff.
6.
7.
11.2
Wound Dehiscence
1.
Inform medical staff immediately. Assess severity, length and depth and record.
2.
Cover with sterile saline soaked dressing with support bandage until further
medical advice is available.
3.
Make sure patient understands the problem and anticipated plan of care.
4.
5.
42
12.
12.1
Definition of Debridement
Debridement is the excision of devitalised tissue and the removal of all foreign matter from
251
a wound surface.
There are several debridement options available ranging from wound
care products which enhance or promote autolytic debridement to techniques using
252
instruments.
For the purpose of the policy, sharp debridement is the removal of devitalised tissue with
the assistance of instruments such a scalpel and scissors.
Blunt debridement is the removal of tissue with the assistance of forceps and or the
application of traction to separate tissue from its anchorage.
Versajet debridement is the removal of devitalised tissue using the Versajet Hydrosurgery
253 254
system .
This system is a debridement tool which makes uses of an innovative
technology based on a jet of water and the Venturi effect resulting from it, which is
capable of demolishing, and at the same time, removing by suction the necrotic tissue.
255
The treatment is well tolerated by the patient and drastically reduces bacterial load.
12.2
Scope
243
43
In SEPT WEL sharp debridement by nurses will only be performed on devitalised tissue,
which is necrotic or sloughy. No removal or cutting of healthy tissue with a blood supply
will occur. No debridement of ischaemic digits will be performed. No perforation of
vessels should occur during the procedure. Blood loss as a result of contact with
granulating tissue during the procedure will be minimal. Versajet debridement of slough,
soft necrosis, senescent cells, biofilm and devitalised tissue can be performed by the TVS
within competency.
12.3
12.4
256 257
12.5
12.6
258
256
Doughty D. (1992) Principle of wound healing and wound management. In Bryant R.A (ed) Acute and Chronic wounds:
Nursing Management. St. Louis, MO: Mosby
257
O Brien M, (2003) Debridement : ethical, legal and practical considerations. Wound Care March 2003
44
Procedure
Rationale
258
Doughty D (1992) Principles of wound healing and wound management. In Bryant R.A (ed) Acute and Chronic
Wounds: Nursing Management. St.Louis MO: Mosby
259
Vowden K R ( 1999) Wound debridement, Part 2: Sharp techniques. JWC Vol 8 No 6 291-293
45
DEBRIDEMENT PORTFOLIO
46
DATE OF BIRTH:
HOSPITAL NUMBER:
CONSULTANT:
DESCRIPTION OF PROCEDURE
EVALUATION OF DEBRIDEMENT
FOLLOW UP VISIT
NAME:
SIGNATURE:
TRAINING RECORD
47
COURSES
DATE & VENUE
COURSE TITLE
OBSERVED
INDIVIDUAL
PROCEDURES
OBSERVED
DATE
48
13
It is the responsibility of clinical teams to regularly audit wound care practice as part of their audit
cycle. Appendix 4 provides an audit tool which has been developed to facilitate the review of
practice relative to these guidelines. It is recommended that clinical teams incorporate wound
management into their audit cycle as a regular occurrence and action plan to achieve continuous
improvement.
14
EDUCATION
This guideline has been compiled to facilitate the continuous education of clinical groups. In
addition the Tissue Viability Service provides regular training sessions to support these guidelines.
Detail of planned training can be obtained from the Trust Education Directory available on the
Intranet
49
Appendix 1
50
51
STEP 1
BMI Score *
BMI kg/m2
> 20
18.5 20
< 18.5
STEP 2
STEP 3
Acute disease effect score
Repeat MUST weekly in Community Hospitals, and monthly in Residential/Nursing Homes or more
frequently if clinical condition deteriorates
MUST = 2 or More (HIGH RISK)
TREAT: - (Unless detrimental or no benefit is expected from nutritional support e.g. terminal phase of illness)
Observe intake using a food chart and fluid chart
Implement nutrition care plan
Aim to improve and increase oral intake. This could be done by offering high calorie snacks
and meals and nutritional supplements. Implement Eat Well Tray System and/or Food First
If no improvement after 7 days (Hospital) or 4 weeks (NH), consider referral to the dietitian
Also refer to dietician if MUST is 3 or more and BMI < 18.5 kg/m2
Monitor and review care plan weekly in Community Hospitals and monthly in Res/Nursing Homes
*If height, weight or BMI cannot be obtained due to strict bed rest, the following criteria can assist your
professional judgement of the patients nutritional risk: a) BMI
Clinical impression thin; acceptable weight; overweight. Obvious wasting (very thin) and obesity
(very over weight) can also be noticed.
b) Unplanned weight loss
Clothes and/jewellery have become loose fitting
History of decreased food intake, reduced appetite or swallowing problems over 3 6 months,
and underlying disease or psycho-social/physical disabilities are likely to cause weight loss
52
STEP 1
BMI Score *
BMI kg/m2
> 20
18.5 20
< 18.5
STEP 2
STEP 3
Acute disease effect score
53
Weight
A = Actual
E = Estimated U =
BMI Score
Unable to weigh
kg/m2
BMI
Score
with rationale
Step 2
Step 3
Step 4
Risk
MUST score
=
1+2+3
0 = Low
1 = Medium
2 = High
Review Date
54
Appendix 2
55
D.O.B
Yes
Yes
No
No
Waterlow Score
Must Score
Has a SET SAF 1 Form been completed, please give date ----------------------------------------Has TNP Therapy been requested
Yes
No
HbA1c --------------
56
Sssss
Date of Referral:
Section 1: Referrers Details:
Name:
Contact Tel No:
Name of Hospital/ G.P. Practice/Clinic
Section 2: Patients Details:
Name:
Address:
Tel No:
G.P and G.P Base:
Consultant:
NHS No
Is the Patient eligible for NHS care
Section 3: Reason TNP Required
Hospital Acquired Pressure Ulcer: Yes/No
D.O.B
Yes
No
Category/Grade:
Which Hospital?
Yes/No
Yes/No
Surgeons Name:
Date. Timeam/pm
Name..
Signature.
57
YES
NO
YES
NO
NO
YES
Consider a review of
management by Tissue
Viability Team to check
that care is optimum
Refer to Tissue
Viability Team for
assessment
58
Identify
wound
aetiology and
develop care
plan for
appropriate
treatment
Treat according to
condition of wound
bed and TIME.
MRSA
Colonised
Antibiotics not
required
MRSA
Locally/systemically
infected.
Treat with
antibiotics as per
SEPT WEL
Guidelines
Heavy Exudate?
NO
YES
Appendix 3
60
D.O.B:
Hosp. No:
DATE/TIME
PATIENT PROBLEM/NEED
DATE/TIME
DATE/TIME
DATE/TIME
DATE/TIME
61
D.O.B:
Hosp/NHS. No:
DATE/TIME
PATIENT PROBLEM/NEED
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
SIGNATURE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
Patients Name:
Address:
G.P Details:
D.O.B:
Hosp/NHS. No:
DATE/TIME
PATIENT PROBLEM/NEED
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
SIGNATURE
DATE/TIME
Address:
G.P Details:
D.O.B:
Hosp/NHS. No:
DATE/TIME
PATIENT PROBLEM/NEED
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
G.P Details:
D.O.B:
Hosp/NHS. No:
DATE/TIME
PATIENT PROBLEM/NEED
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
65
D.O.B:
Hosp/NHS. No:
DATE/TIME
PATIENT PROBLEM/NEED
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
66
D.O.B:
Hosp/NHS. No:
DATE/TIME
PATIENT PROBLEM/NEED
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
67
D.O.B:
Hosp/NHS. No:
DATE/TIME
PATIENT PROBLEM/NEED
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
DATE/TIME
RGN SIGNATURE
REVIEW DATE
68
Appendix 4
Wound Management Audit Tool
Staff questionnaire
Questionnaire answers
Patient questionnaire
Audit tool
69
QUESTION
P1
P2
ANSWERS
a)
b)
c)
d)
e)
Systemic
a)
b)
local
a)
b)
S5 &
S10
S5 &
S10
What would be the dressing for a granulating wound with:a) minimum exudate
b) low exudate
c) moderate exudate
d) heavy exudate
S5 &
S10
a)
b)
c)
d)
70
CODE
S5 &
S10
QUESTION
What would be the dressing for a sloughy wound with:a) low exudate
b) moderate exudate
c) heavy exudate
P3
S10 &
P4
S3 &
P4
S3 &
P4
S8A
S8
B&C
a) Semipermeable
b) Alginate
c) Hydrocolloid
d) Hydrogel
e) Foam
Where would you commence a wound care plan?
ANSWERS
a)
b)
c)
a)
b)
c)
d)
e)
a)
b)
S8
a)
b)
71
CODE
QUESTION
P1
P2
ANSWERS
Hypoxia
Low blood flow
Pain
Stress
Infection
Poor nutrition
Abnormal blood sugar levels
Sleep deprivation
Drugs eg Steroids
Reduced immunity
Jaundice
Uraemia
Length and type of operation
Systemic
Nutrition
Analgesia
Sleep
Adequate blood supply to wound
Antibiotics
Adequate oxygenation
Local
Maintenance of high humidity between wound and dressing
Removal of excess exudate and toxic components
Thermal insulation
Dressing impermeable to bacteria
Freedom from particles and toxic wound contaminants
A traumatic removal of dressings
Maintenance of a physiological pH and promotion of O2 delivery to wound surface
S5 &
S10
72
CODE
QUESTION
S5 &
S10
minimum exudate
low exudate
moderate exudate
heavy exudates
S5 &
S10
S5 &
S10
a) low exudate
b) moderate exudate
c) heavy exudate
P3
S10 &
P4
S3 &
P4
Semipermeable
Alginate
Hydrocolloid
Hydrogel
Foam
ANSWERS
73
CODE
QUESTION
ANSWERS
S3 &
P4
All wounds should be measured as part of the wound assessment process, see
WAF.
Photographs can also be taken, however they must be calibrated with a ruler and
consent must be obtained
S8A
Hand washing before patient contact and between each patient contact
S8
B&C
a) dust particles
b) droplet nuclei
S8
74
CODE
QUESTIONS
P12
P12 & O5
O6A
O6B
75
Audit Objective:
Sample:
Time Frame:
Auditor(s):
Audit Criteria
STRUCTURE
1. Has the patient and the wound been assessed by a registered Nurse
within 24 hours of admission or the time agreed on the patients wound care
plan?
2. Is there access to a copy of the SEPT WEL Guidelines on
Check
Check
relation to:
(a) handwashing
(b) instruments
(c) dust particles and droplet nuclei
9. Are the following multidisciplinary staff available by phone or in
person to give advice on wound management:
(a) Tissue Viability Nurse Specialist
(b) Pharmacist
(c) Medical Staff
10. Can nursing staff involved in application of solutions and
dressings emonstrate knowledge of the therapeutic and adverse
effects of dressings and solutions used?
Check
Check
Check
Check
Check
Nurse
Questionnaire
Check
Check
76
Audit criteria
Structure Process
Outcome
Method of
Data
collection
PROCESS
Documentation
& Nurse
Question
Documentation
& Nurse
Question
Documentation
Documentation
& Nurse
Question
Documentation
& observation
Documentation
& observation
Observation
Observation &
Nurse
Questionnaire
Documentation
Documentation
Documentation
Ask Patient &
Check
documentation
Ask Patient &
Check
documentation
77
Audit Criteria
OUTCOME
1. Has the patient and the wound been assessed by a registered Nurse
within within 24 hours of admission or within the time frame agreed on
the care?
Structure Process
Outcome
Method of
Data
collection
Documentatio
n
Documentatio
n
wound?
Documentation
Documentatio
n
Ask Patient
Ask Patient
Points allocated
(yes=1) (no = 0)
Comments
78
KEY FINDINGS
RESULTS
TOTAL POINTS
POINTS OBTAINED
PERCENTAGE
ACHIEVED
79
ACTION PLAN
PROBLEM IDENTIFIED
SUGGESTED ACTION
STAFF
RESPONSIBLE
Proposed
Completion
Date
Actual
Completion
Date
80
Appendix 5
Competency Assessment
Self Assessment Competency Statement
Clinical Competency framework for Wound
Assessment and Management
Adapted from Queens Medical Centre Nottingham competence framework and acquired 81
via Tina Chambers at Hampshire Primary Care Trust. Further additions made by Cathy
Malone Senior CNS TVS WECHS April 2010, & Sept 2011
Forename(s):
Initial
assessment
date:
Final
assessment
date:
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Adapted from Queens Medical Centre Nottingham competence framework and acquired 82
via Tina Chambers at Hampshire Primary Care Trust. Further additions made by Cathy
Malone Senior CNS TVS WECHS April 2010, & Sept 2011
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Yes / No
Adapted from Queens Medical Centre Nottingham competence framework and acquired 83
via Tina Chambers at Hampshire Primary Care Trust. Further additions made by Cathy
Malone Senior CNS TVS WECHS April 2010, & Sept 2011
STATEMENT OF COMPETENCE
I certify that I am aware of my professional responsibility for continuing professional development
and that I am accountable for my actions. With this in mind I make the following statement:
Date:
By when:
84
Completion of the clinical competencies should be within 2 months from attending SEPT West Essex day training and
action any areas identified in the Self Assessment Competency Statement.
Successful completion of competencies has been assessed by:
Name & Signature of clinical assessor.... Date... //
(Primary assessor of wound assessments, application of dressing and completion of care plan)
Name & Signature of clinical assessor...Date... //
(Secondary assessor, a student may have one or two assessors)
Name & Signature of Team leader.....Date..//.
Name & Signature of Assessee.... ..Date .//..
Name & Signature of TVS Lecturer on Wound Management day....Date././
( Please attach certificate of Attendance to Competency form)
The Assessee is expected to undertake 2 wound assessments, and complete 2 wound care plans specific to the wound and the patients
holistic needs assessment. This may be repeated if the student requires further support.
The assessor must ensure that each individual assessment is signed of at the top of each page.
The assessor must also initial each box relating to the performance criteria of each individual assessment undertaken.
There is a space at the end of each assessment for the student to add comment s relating to their performance whilst undertaking each
wound assessment and dressing and how they overcame any difficulties they encompassed during the procedure.
Adapted from competency frameworks of Lynfa Edwards and used with permission of @Lynfa Edwards
Developed further be Cathy Malone CNS TVS For WECHS WCP MAR 2010 & Sept 2011
85
Competence
Performance
Evaluation method
Questioning &
Direct observation
Questioning &
Direct observation
Questioning &
Direct observation
Criteri
1. Has knowledge of
underlying medical
conditions & holistic
assessment of patient and
ability to link all these factors
with wound healing
Assessment
1
Date
Assessors Name &
Signature
Assessment
2
Date
Assessors Name &
Signature
Assessee
Comment relating
to performance.
How they
overcame any
difficulties?
Questioning &
Direct observation
Questioning &
Direct observation
Questioning &
Direct observation
Questioning &
Direct observation
86
Competence
Performance
Questioning &
Direct observation
3. Identifies and
establishes action to
protect areas of further
risk including pressure
injury risk, infection
risk, nutrition risk,
moving & handling etc
Questioning &
Direct observation
4. Demonstrates an
understanding
of the theory of wound
types, classification and
grading. Knowledge on
how identify wound
infection
Questioning &
Direct observation
Questioning &
Direct observation
Questioning &
Direct observation
Assessment
1
Date
Assessors Name &
Signature
Assessment
2
Date
Assessors Name &
Signature
Assessee
Comment relating
to performance.
How they
overcame any
difficulties
87
Appendix 6
Wound Care Bundle
88
260
Pratt RJ, Pellowe CM, Wilson JA et al (2007) epic 2: Nastional evidence-based guidelines of r preventing
healthcare-associated infections in NHS hospitals in England. Jr Hosp Infetion. 65:S1-S64
261
Pratt RJ, Pellowe CM, Wilson JA et al (2007) epic 2: Nastional evidence-based guidelines of r preventing
healthcare-associated infections in NHS hospitals in England. Jr Hosp Infetion. 65:S1-S64
262
WECHS 2009) Wound Care Guidelines. www.wepct.uk
263
NMC (2008) The Code, Standards of Conduct, performance and ethics for nurses and midwives.
264
NICE (2005) Prevention and Treatment of Pressure Ulcers: Guidance for patients, public, cnd carers
www.nicw.org.
265
Diabetes uk (2009) Putting feet first; Commissioning specialist services for the management and
prevention of diabetic foot disease in hospitals. www.diabetes.org.uk/Documents/Reports/putting Feet First
010709.pdf
266
NICE (2008) Surgical site infection: prevention and Treatment of Surgical Site Infection. CG74
www.nice.org.uk/nicemedia/pdf/CG74FullGuideline.pdf
89
Observation
Care
Action
2
N
Care
Action
3
Y
Care
Action
4
Y
Care
Action
5
Y
Care
Action
6
Y
Care
Action
7
Y
Care
Action
8
Y
Care
Action
9
Y
Care
Action
10
Y
Care
Action
11
Y
All
Actions
Care
Action
1
Y
N/A
N/A
N/A
N/A
N/A
Total number
of times an
individual
action was
compliant
% when
action of care
was compliant
100%
80%
80%
100%
80%
100%
80%
100%
80%
100%
80%
60%
267
268
Bongiovanni C (2006) Nonsurgical Management of Chronic Wounds in patients with Diabetes. The Journal of
Vascular Ultrasound 30 (4):215-218
269
NICE (2008) Surgical site infection: prevention and Treatment of Surgical Site Infection. CG74
www.nice.org.uk/nicemedia/pdf/CG74FullGuideline.pdf
270
Donnelly J, Winder J, Kernohan W G (2011) An RCT to determine the effect of a heel elevation device in pressure
ulcer prevention post hip fracture. JWC Vol 20 No 7 pg 309-318
271
NICE (2005) The prevention and treatment of pressure ulcers. www.nice.org.uk/CG029
272
WECHS (2011) Prevention and Management of Pressure Injury. www.wepct.uk
273
DOH (2008) The Health and Social Care Act: Code of Practice on the prevention and control of infection and related
guidance> DOH, London. http://www.dh.gov.uk/en/Publicationsandstatistics/Publication/PublicationsPolicyAndGuidance/DH
122604
90