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DOCUMENT REFERENCE NO:

Type: GUIDELINE
Sus

Wound Management Guidelines

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

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For

Office Use Only

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POLICY VALIDITY STATEMENT

THIS POLICY IS DUE FOR REVIEW IN July 2013..

After this date, this document will become invalid.


Policy users should ensure that they are consulting the
currently valid version of the documentation.

WOUND MANAGEMENT
GUIDELINES

SEPT West Essex Locality


NEPT

September 2011
THE TISSUE VIABILITY SERVICE

WOUND MANAGEMENT GUIDELINES


1. INTRODUCTION AND SCOPE OF GUIDELINE

Page 5

1.1 Purpose of the Wound Care Guideline

2. PROCESS OF HEALING

2.1
2.2
2.3

Healing by First Intention


Healing by Secondary Intention
Wound Bed Preparation
2.3.1 Tissue
2.3.2 Infection
2.3.3 Moisture
2.3.4 Edges

3. FACTORS AFFECTING THE HEALING PROCESS


3.1
3.2
3.3

6.3
6.4
6.5
6.6

Pages 23

Wound Assessment Form

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

Factors that can delay healing


Diet
3.2.1 Identification of patients at Risk
Pain
3.3.1 Using opiates on wounds

4. CLASSIFICATION OF WOUND TISSUE


4.1
4.2
4.3
4.4
4.5
4.6

Pages 6-17

Pages 25-31

Wounds healing by First Intention


Wounds healing by Secondary Intention
6.2.1 Epithelialising wounds
6.2.2 Granulating wounds
6.2.3 Sloughy Wounds
6.2.4 Infected Wounds
6.2.5 Necrotic Wounds
Malignant/Fungating Wounds
Criteria for Removing/Changing Dressings
How to take a swab for culture
How to treat overgranulating tissue

TVS Guidelines: Wound Management/ Sept 2011

7. PRINCIPLES OF WOUND IRRIGATION


7.1

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

WOUND BED PRODUCT INFORMATION


8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.10
8.11

Pages 33-34

Pages 35-38

Semi Permeable Film dressing


Hydrocolloids
Alginates
Foam Dressings
Hydrogels
Dressings containing charcoal
Dressing containing antimicrobial
8.7.1 Honey
Protease Modulating Therapy (PMT)
Larva Therapy/Biosurgery
Topical Negative Pressure
Topical Antibiotic

9. WOUND DRAINAGE

Page 41

10. ASEPTIC NON TOUCH TECHNIQUE

Page 41

11. WOUND COMPLICATIONS

Page 43

11.1
11.2

Infection with/without Exudate


Wound Dehiscence

12. DEBRIDEMENT OF NECROTIC OR SLOUGHLY TISSUE


12.1
12.2
12.3
12.4
12.5
12.6
12.7

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

13. MONITORING OF ADHERENCE TO GUIDLEINES

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

TVS Guidelines: Wound Management/ Sept 2011

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

Proforma Care Plans


Wound Management Audit Tool
Competency Assessment

Appendix 6

Wound Care Bundle

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.

INTODUCTION AND SCOPE OF GUIDELINE


1.1 Purpose of the Wound Guideline
1.1.1

The purpose of this guideline is to provide guidance within SEPT West


Essex Locality regarding the management of acute and chronic wounds.

1.1.2

This guideline aims to simplify the decision making regarding wound


management while ensuring that patients are provided with the best
evidence based care. To that end this guideline must be used to ensure
that all patients have been assessed and managed holistically and that
care is supported with completed care plans and assessments in
conjunction with the following guidelines:
SEPT West Essex Locality Infection Control Guidelines
SEPT West Essex Locality Pressure Ulcer Prevention and
Management Guidelines.
SEPT West Essex Locality Dressing Formulary Guidelines
Nursing and Midwifery Council (NMC) The Code: Standards of
2
conduct, performance and ethics for nurses and midwives.
3
The Royal Marsden Hospital, Manual of Clinical Nursing procedures.

1.1.3

This document also aims to ensure transparency regarding management


of patients with wounds within SEPT West Essex Locality, NHS West
Essex and NEPT, ensuring fair and equitable access to the best care and
advice regardless of whether care is provided by NHS providers or private
nursing homes providers. It is intended that adherence to these
guidelines will facilitate all patients with non healing wounds being given
access to the Tissue Viability Department if clinically appropriate as
illustrated in the Care Pathway available in Appendix 2

1.1.4

This guideline was written by the Tissue Viability Committee, which is a


properly constituted subcommittee of the Nursing & Public Health Forum
(NPHF) for SEPT West Essex Locality.

1.1.5

This guidelines is the product of collaboration between the Tissue Viability


Service, The Leg Ulcer Service, Community and Inpatient Nursing
Services, the Medicines Management Department, Infection Control,
Dietetics and the Foot Health Department. This guideline does not serve
to advise on the management of Burns and Plastics, Dermatology, or
Diabetic Foot Ulcers. Clinicians requiring support on such issues should
seek advice from the appropriate Burns and Plastics, Dermatology
Services or Foot Health Department.

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

TVS Guidelines: Wound Management/ Sept 2011


4

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.

Increased blood flow

Protein cells and fluid


leak from capillaries.

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.

Clot forms in wound.

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

Red, vascular tissue


appears in wound
Smooth marginal
zone or islands of
epithelium seen in
wound
Size of defect
reduced

Type III collagen


converted to Type I,
increasing strength
Reduction in number
of vessels, reducing
blood flow.
ECM develops
density

Scar flattens and


softens

Scar pales, itching


subsides.

IMPLICATIONS
Dress with a secure
pressure bandage.
Seek medical advice
if blood loss is
excessive persistent.

Observe the following:

Swelling and
discoloration

Signs of infection
(see section 4&5)
and inform medical
staff if concerned.

The nurse must ensure:

The patient received


a nutritious diet, high
in vitamin C and
protein.

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

Protection of the scar


from friction

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

TVS Guidelines: Wound Management/ Sept 2011

2.1

Healing by First Intention (Acute Wounds)


Definition:
Surgical or traumatic wounds where the edges are brought together by
suturing, steristrips, clip, staples or glue.
Acute wounds usually follow a well-defined process as illustrated in Table 1. These
stages overlap and the entire wound-healing process can take several months.
Blood and exudate from a surgical wound is usually minimal. Within 48 hours the wound
7 8
will have formed a natural barrier against invasion by pathogenic bacteria.
Surgical wounds, which are dry, can be left exposed after 48 hours following surgery.
The preference of individual surgeons is likely to vary and staff should adhere to the
written instruction within the patients notes.

2.2

Healing by Second Intention (Chronic wounds)


Definition:
All open wounds e.g. pressure ulcers, dehisced surgical wounds, leg
ulcers. (These guidelines do not cover the management of Leg Ulceration. Please refer
to the Leg Ulcer Guidelines)
In the past, the acute wound-healing model has been applied to chronic wounds, but it is
10
now known that chronic wound healing is different from acute wound healing. Chronic
wounds become stuck in the inflammatory and proliferative phases of healing, delaying
11
healing.
The epidermis fails to migrate across the wound tissue and there is
hyperproliferation at the wound margins, which interferes with normal cellular migration
12
over the wound bed.
In chronic wounds there appears to be an overproduction of
13
matrix modules resulting from underlying cellular dysfunction and disregulation.
Fibrinogen and fibrin are also common in chronic wounds and it is thought that these and
other macromolecules scavenge growth factors and other molecules involved in
14
promoting wound repair. So, while there may be large number of growth factors within
the wound, these can become trapped and therefore unavailable to the wound repair
process. Chronic wound fluid is also bio chemically distinct from acute wound fluid; it
slows down, or even blocks the proliferation of cells such as keritinocytes, fibroblasts and
15 16
endothelial cells, which are essential for the wound-healing process.
For these reasons chronic wounds must be viewed differently than acute wounds. There
is often a complex mix of local and host factors, which need to be assessed and treated.

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

TVS Guidelines: Wound Management/ Sept 2011

2.3

Wound Bed Preparation

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

TVS Guidelines: Wound Management/ Sept 2011

Table 2 - The TIME principles of wound bed preparation (WBP)

Source: Schultz et al (2003)

23

CLINICAL
OBSERVATIONS

PROPOSED
PATHOPHYSIOLOGY

WBP CLINICAL
ACTIONS

EFFECT OF WBP
ACTIONS

CLINICAL
OUTCOME

TISSUE NONVIABLE OR
DEFICIENT

Defective matrix and


cell debris impair
healing

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

High bacterial counts or


prolonged inflammation
inflammatory
cytokines
protease activity
growth factor activity

Remove infected foci


Topical/systemic: antimicrobials antiinflammatories
Protease inhibition

Low bacterial counts


or controlled
inflammation:
inflammatory
cytokines
protease activity
growth factor
activity

Bacterial
balance and
reduced
inflammation

MOISTURE
IMBALANCE

Dessication slows
epithelial cell migration

Apply moisturebalancing dressings

Moisture
balance

Excessive fluid causes


maceration of wound
margin

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

TVS Guidelines: Wound Management/ Sept 2011

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.

Table 3. Characteristics of Healthy and Unhealthy Granulating Tissue,


35
Source: Flanagan (1996)
Healthy Granulation |Tissue
Bright red
Moist
Shiny surface
Does not bleed easily
Rapid proliferation

2.3.2

Unhealthy granulation tissue


Dark red/bluish discolouration or very
pale
Dehydrated
Dull surface
Bleeds easily (friable)
Slow growth

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

TVS Guidelines: Wound Management/ Sept 2011

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

Wound contamination is the presence of non-multiplying bacteria in a wound. Wound


colonisation is the presence of replicating micro organisms adhering to the wound without
a host reaction. If mixtures of potential pathogens are multiplying, this may lead to a delay
39 40 41
in wound healing and the critical colonisation stage is reached.
Unsuppressed, the
natural progression from this stage is to wound infection. This is when the sum of the
bacterial load and the virulence factors the bacteria produce is greater than the hosts
42
immune defences, resulting in harm to the host.
Biofilms are communities of microbial cells, attached to surfaces and encased in a slime.
Research has shown that biofilms may be totally unperturbed by activated
43
macrophages, neutrophils, antibodies, complemented or other host defences.
This
44 45
offers protection against phagocytosis, antibiotics and antimicrobial agents.

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

Figure 1 EWMA Algorithm for Managing Wound Infection

Stage 1: Few subtle signs of


infection (some odour, pain
or exudate)

Stage 2: Increasing signs of


infection (increasing odour,
pain or exudate)

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

Are other risk factors


present, eg immunocomprise or malignancy?

Treat/correct
underlying
aetiology.
Refer to
appropriate
specialist

If no
improvement, are
any other subtle
signs of infection
present? Or
significant
culture result?

Factors to consider when selecting


antimicrobials

Agent:

Dressing

specificity
efficacy
cytotoxicity
allergenicity

absorbency
conformability
odour management
pain management

Stage 4: Overt signs of focal


infection and signs of systemic
infection (pyrexia and raised
white blood cell count)
Possible evidence of
surrounding tissue
involvement, which may lead
to sepsis and organ failure and
can be life threatening

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

Stage 3: Overt signs of


local infection (discharge of
pus with swelling, pain
erythema and local warmth)

Consider
combination
therapy. Drain any
local collections

Start broadspectrum systemic


antibiotics while
awaiting culture
results

Good clinical
response

Overt signs of
infection not
eliminated

Select
alternative
antimicrobial
agent

Stage 4
systemic signs

Consider
adding
antibiotic

Stop antimicrobial therapy. Monitor wound


progress. Continue managing wound according to
local protocol. Reconsider antimicrobial treatment
if wound or patient status changes adversely.

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

MRSA stands for meticillin-resistant Staphylococcus aureus. It is sometimes known as a


super bug. There are various subtypes (strains) of S. aureus and some strains are
classed as MRSA. MRSA strains are very similar to any other strain of S.aureus. That is,
some healthy people are carriers and some people develop the types of infections
described above.
Most S. aureus infections can be treated with commonly used antibiotics. However MRSA
infections are resistant to an antibiotic called meticillin and also to many other types of
antibiotics. MRSA strains of bacteria are no more aggressive or infectious than other
strains of S. aureus. However, infections are much more difficult to treat because many
antibiotics do not work against MRSA. Infections with MRSA can sometimes become
more severe than they may otherwise have been if the cause of the MRSA infection is not

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

TVS Guidelines: Wound Management/ Sept 2011


57

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

MRSA. (2011) http://www.patient .co.uk/health/mrsa. sourced 4/8/11


EWMA 2006) Position Document. Management of wound infection
59
Bowler PG, Duerden BI, Armstrong DG (2001) wound microbiology and associated approaches to wound management.
Clin Microbiol Rev 14: 244-69
60
White RJ, Cooper RA, Kingsley A (2001) Wound colonisation and infection. Br J Nurs 10: 563-78
61
Lawerence JC (1998) The use of iodine as an antiseptic agent. J Wound Care 7:421-5
62
Sibbald RG, Brown AC, Coutts P, queen D (2001) Screening evaluation of ionised nanocrystalline silver dressings in
chronic wound care. Ostomy Wound Manag 47: 38-43
63
Wolcott R D. (2009) Regular debridement is the main tool for maintaining a healthy wound bed in most chronic
wounds. JWC Vol 18 No 2 pg 54-56.
64
Cowan T (2010) Biofilms and their management: implications for the future of wound care.. JWC Vol 19 Noo 3 pg117120.
65
Rhoads DD ((2008) Biofilms in wounds: management strategies. JWC Vol 17 No11 Nov pg 502-507
66
Bowler PG, Duerden BI, Armstrong DG (2001) wound microbiology and associated approaches to wound management.
Clin Microbiol Rev 14: 244-69
58

14

TVS Guidelines: Wound Management/ Sept 2011

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

TVS Guidelines: Wound Management/ Sept 2011

Table 5. Types of exudate and their management

Source: Scanlon E. (2004)

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

Slight bleeding from


vessel in wound bed

Blood

Viscous

Surgical

Bleeding vessel
postoperative

Blood

Viscous

Any

Trauma from dressing

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

Leg ulcer, burn


wound

Bacteria especially
Pseudomonas
aeruginosa

Clear green

Watery or slightly
viscous

Fistula to upper intestine

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

Fistula to lower bowel

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

TVS Guidelines: Wound Management/ Sept 2011

FACTORS AFFECTING THE HEALING PROCESS


3.1 Factors that can delay healing
79 80 81 82 83 84 85 86

Many factors are thought to delay healing.


Table 6 lists the commonest.
Figure 4 illustrates how such factors can be grouped into intrinsic and extrinsic factors and
can occur alongside each other. Thus some wounds can be exposed to multiple factors,
which impede its progress at any one time.
Table 6
Conditions and interventions known to delay wound healing
87
Source: Schultz et al (2003)

3.2

Use of systemic steroids


Use of immunosuppressive drugs
Use of non-steroidal anti-inflammatory
Rheumatoid arthritis
Other autoimmune diseases such as systemic lupus, uncontrolled
vasculitis or pyoderma gangrenosum.
Inadequate or poor nutrition
88 89
Diabetes
90 91
Smoking
92
Cachexia

Diet

Adequate nutrition is essential to promote wound healing. A diet rich in carbohydrates,


high in protein and moderate fat is essential. Vitamins and trace element supplements
should also be provided to all patients with established wounds where deficiency is known
93
particularly vitamins C, E and zinc. However the decision to provide trace element
94 95 96 97 98 99 100
supplements should be done following a thorough nutritional assessment.
101 102 103 104 105 106 107 108 109

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

TVS Guidelines: Wound Management/ Sept 2011

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.

Identification of Patients Risk

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

TVS Guidelines: Wound Management/ Sept 2011

3.3.1

Using Opiates on wounds

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.

Figure 2 Wong-Baker faces Scale

Figure 3 Numerical pain rating scale


0-10 Numeric Rating Scale

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

Figure 4 Factors causing delayed wound healing


TVS Guidelines: Wound Management Sept 2011

Poor Blood Supply

Hypoxia
Necrotic Tissue and
Foreign Bodies

Fall in Wound
Temperature

Cardiovascular
Disorders

Anaemia

General Pathophysiological
Factors

Adverse Local Conditions


At the Wound Site

Malnutrition
Wound Infection

Inaccurate Wound
Assessment

Dehydration

Careless Wound
Dressing Techniques

(see Article II)

Factors that can


Delay Healing

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

TVS Guidelines: Wound Management Sept 2011

4.

CLASIFICATION OF WOUND TISSUE


The Wound Healing Stage Classification as described below is recommended as it
facilitates simple and consistent verbal and written description of the appearance of the
wound bed. This is a different classification to the pressure ulcer classification. (See
Pressure Ulcer Guidelines)
4.1

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

Appearance of Acute Wound Infection.


Inflammation
Localised heat and swelling around wound edge
Yellow/green pus
Offensive odour
Presence of green slough in wound
Pain
Increased exudate
Dark in colour
The presence of bacteria does not always indicate the presence of infection. Pus, odour
and slough are not always present in the infected wound. Systemic effects and a raised
body temperature may be present. It is thus recommended that temperature, pulse, BP
and respiratory observations are taken and recorded if there is suspicion of wound
infections.

125

Garrett B (1998) Re-Epithelialisation. Journal of wound Care; 7:7, 358-359


Flanagan, M .(1999) Wound Management: theory and practice. Nursing Times Publication. pg 14-20
127
Harding, K., Cutting, K. (1994) Criteria for identifying wound infection. JWC. 3:4, 198-201
128
Cutting. K.F. (1996) Definition of Terms. JWC. Resource File. London Macmillan.
126

21

TVS Guidelines: Wound Management Sept 2011

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

Malignant (Fungating) Tissue

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

TVS Guidelines: Wound Management Sept 2011

Figure 5 Wound Assessment Form (WAF)


1. INITIAL ASSESSMENT:
Patients Name:
Address:
G.P Details:

D.O.B:

NHS. No:

Draw Wound Profile (so top of wound is towards patients head, include dimensions in cm).

2. SOURCE OF WOUND: Tick

3. INDIVIDUAL PATIENT ASSESSMENT


Any Delaying Factor?

Surgical (

Traumatic (

Leg Ulcer (
Burn (

Pressure Ulcer (

Interventions

Fungating ( )

Other ( )
DATE:
TIME:

DATE:
TIME:

DATE:
TIME:

DATE:
TIME:

4. TISSUE: Appearance, approximate % of wound surface which meets the description


Intact Incision line
Epithelialising
Granulating
Over granulating
Sloughy
Necrotic
Fungating
Exposed bone/tendon
Oedema
5.INFECTION:
EWMA Clinical stage of Infection ( 1, 2, 3, 4)
Peri wound inflammation / warmth
Pyrexia
Bleeds easily
Odour Y = Yes N = No
Pain score 1-10 (0 = no pain 10 = severe pain)
Wound swab taken, tick for yes
6. MOISTURE: Exudate
A: Serous, B: Haemoserous, C: Purulent/ Pus
L: Low, M: Moderate, H: Heavy
7.EDGES: Non advancing /undermining

Weekly measurements only required, unless sudden changes observed

Maximum Length, (head to toe)


Maximum Width. (right to left).
Surface Area (cm2)
Undermining
Cavity: Depth cm
Pressure Ulcer: Insert Grade 1,2,3,4
Insert generic dressing code number
Staff Signature
Generic
Dressing

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

TVS Guidelines: Wound Management Sept 2011

WOUND CARE
134

A holistic assessment of the patient is essential before choosing a wound dressing.


A
careplan should be drawn up using the information gathered in the WAF and directed by the
TIME WBP Clinical Actions illustrated in the Timetable. (Table 2)
Many wounds will be a combination of some of the already mentioned classifications identified in
section 4. When this occurs each area would require different management however the most
serious state should be treated first.
6.1

Wounds Healing by First Intention


6.1.1 Uncomplicated Wound
EXAMPLES:

Post surgical wounds/clipped wounds.


Traumatic wound sutured/clipped/glued

PROBLEM:

Potential risk of wound breakdown

GOALS:

To prevent infection and promote first intention healing by


providing an optimal local environment
T:
I:
M:
E:

CARE PLAN:

6.2

Promote viable granulation from the wound base


Reduce inflammation and maintain a bacterial balance
Achieve moisture balance
Measured advancing edges and base of wound.
135

Non adherent (N/A) dressing


Analgesia to control pain.
Should not require cleaning, if exudate is a problem it can be
removed by irrigating with sterile sodium chloride 0.9%
Dressing: Wounds can be left exposed after 48 hours or covered
136
with a semi-permeable film dressing.

Wounds Healing by Second Intention


6.2.1

137

Epithelialising Wound (Clean and Flat)

EXAMPLES:

Any clean wound that has filled in with granulation tissue or


superficial wounds where granulation tissue has been replaced
e.g. skin donor sites, superficial burn, and granulated pressure
ulcer.

PROBLEM:

Break in normal integument. Pain from exposed nerve endings

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.

Analgesia to control pain.


Does not require cleaning if exudate is minimal. If cleaning is
required use sterile sodium chloride 0.9%
Dressing: Minimal exudate Semi-permeable film
Low/moderate N/A Dressing
Moderate Hydrocolloid sheet

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

TVS Guidelines: Wound Management Sept 2011

6.2.2

6.2.3

Granulating Wounds
EXAMPLES:

Clean cavity pressure ulcers

PROBLEMS:

Potential of over closure of epithelial edges before the cavity


has filled with new granulation and vascular tissue.

GOALS:

T:
I:
M:
E:

CARE PLAN:

Clean with sterile sodium chloride 0.9% if required.


Dressing: Minimal exudate Hydrocolloid paste, cover with
adhesive non-adherant dressing
Moderate exudate Alginate rope or Hydrocolloid fibre. Cover
with adhesive non-adherant dressing
High exudate High absorbency Alginate or Hydrocolloid Fibre
and a Foam or Hydrocolloid Sheet.
TNP will manage exudate and accelerate healing from the base
of the wound.

Promote viable granulation from the wound base


Reduce inflammation and maintain a bacterial balance.
Achieve moisture balance
Prevent closure of edges before wound base has healed.
Contemplate therapies which accelerate healing from the
base. Measured advancing edges and base of wound.

Sloughy Wounds
EXAMPLES:

Common in chronic wounds such as pressure ulcers, leg ulcers


and abscess cavities.

PROBLEM:

Excessive exudate or odour due to bacteria and necrotic tissue.


Slough and necrotic tissue may encourage growth of bacteria
138
and this may delay healing.

GOAL:

T:
I:
M:
E:

Debridement of sloughy and necrotic tissue


Reduce inflammation and maintain a bacterial balance
Achieve moisture balance
Prevent closure of edges before the base has healed,
contemplate therapies which accelerate healing from the
base of wound. Measured advancing edges and base of
wound

CARE PLAN:

1) If wound infection is suspected, take a swab and send for


microscopy and culture. Inform Medical Staff and record vital
signs.
2) Clean with sterile sodium chloride 0.9%

Dressing: (Non cavity sloughy)


Minimal exudate Hydrocolloid sheet
Moderate exudate Hydrocolloid Fibre Dressing and
N/A pad
139
High Exudate Alginate and Foam Dressing
Versajet debridement can be performed by the TVS.

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

TVS Guidelines: Wound Management Sept 2011

Larvae therapy can expedite the removal of slough from


wounds on advice from the TVS.
Antibacterial dressing can be used if infection is
suspected.
TNP on advice from TVS will contain exudate, accelerate
healing and remove bacteria from the wound bed.
If concerned that a wound may be clinically infected await results
140 141 142
before using occlusive dressings.
however once
antibiotic therapy is established and infection is contained,
occlusive dressings can be used.

6.2.4

Infected wounds:
EXAMPLES:

Pressure ulcers or surgical wounds, which have become red and


inflamed with accompanying cellulitis.

PROBLEMS:

Oedema, wound pain, exudate, pyrexia and odour

GOALS:

T:
I:
M:
E:

Debridement of sloughy and necrotic tissue


Reduce inflammation and control bacterial balance.
Achieve moisture balance
Measured advancing edges and base of wound

Identify the organism causing the infection and eradicate


with systemic antibiotics. Promote healing by providing
an optimum local environment.
CARE PLAN:

Clean with sterile sodium chloride 0.9% or povidone


iodine solution if an antiseptic is required. Stellicept wash
can be used in cases of MRSA.
Dressing: Minimal exudate Hydrogel held insitu with
N/A Pad.
Moderate exudate Hydrocolloid Fibre held insitu with
N/A pad.
High Exudate Alginate or Hydrocolloid Fibre held insitu
143
with Foam Dressing.
TNP on advice from TVS will contain exudate, accelerate
healing and remove bacteria from the wound bed.
Antimicrobial/ dressings can also be used, however if
appropriate systemic antibiotics are prescribed they may
not be necessary.
It is not appropriate to use Mupirocin on wounds which
are known to be infected with MRSA. This product is for
144
use on the nose only.
Do not occlude clinically infected wounds until antibiotic
therapy is established and infection controlled.
Change dressings daily while infected or more frequently
if strike through occurs. If malodour is a problem see
section 6.3

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

TVS Guidelines: Wound Management Sept 2011

6.2.5

Necrotic Wounds
EXAMPLES:
(Eschar)

Pressure Ulcers covered with hard necrotic tissue.

PROBLEM:

Extensive cavity wound is hidden beneath the necrotic


tissue.

GOALS:

T:
I:
M:
E:

Debridement of necrotic tissue


Reduce inflammation and maintain a bacterial
balance.
Achieve moisture balance
Measured advancing edges and base of wound

.
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

145 146 147 148

EXAMPLES:

External tumour wounds

PROBLEM:

Odour, incipient bleeding, pain, exudate

GOAL:

T:
I:
M:
E:

Medical debridement of sloughy and necrotic


tissue, if indicated.
Reduce inflammation and attempt to maintain a
bacterial balance.
Achieve moisture balance
Awareness of advancing wound edges and
minimising such advancement where possible
through control of I and M.

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

TVS Guidelines: Wound Management Sept 2011

CARE PLAN:

Odour Control

Local support, comfort and pain reduction. Control of bleeding


and odour are priorities as healing cannot be a goal. Early
identification of infection and reduction of odour will
149
considerably improve the quality of life for the patient.
Understanding impact of the wound on the individual quality
of life and helping to ameliorate both physical and
150
psychological symptoms.
151 152

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

Criteria for Removing/Changing Dressings


The wound should be assessed and the appropriate dressing applied in the following
events.

wet contamination from external sources


strike through (when exudate has leaked through the dressing)
156
offensive smell
pain or prolonged tenderness at wound site
unexplained pyrexia
inflammation at site
removal of drain/clips/sutures
allergic reactions.

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

TVS Guidelines: Wound Management Sept 2011

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

How To Take A Swab For Culture 158

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.

How to Treat Over-granulating Tissue

164 165 166 167

Hypergranulation is normally transient resolving itself in time as the granulation tissue


contracts. Use of non-traumatic dressings to reduce hypergranulation should be the first
choice. If overgranulation persists nurses should discuss the situation with the TVS or the
responsible physician to exclude undiagnosed malignancy as the underlying cause.
The reduction of hypergranulation/over-granulation may be achieved through the use of
the following:
Foam Dressing; Lyofoam
Application of light pressure to the wound bed; if not contra-indicated is of benefit.
Silver Nitrate; (Sticks or .025% compresses); can be used however it is not a first line
168
measure. Morison (1991) cited in Hampton S and Collins
found silver nitrate to be
caustic with potential to initiate methaemoglobinaemia and metabolic disturbance. Silver
nitrate is therefore a treatment for very short-term use only.
Corticosteriod cream such as Elocon or Betnovate can be used under medical
supervision as a last resort and for very short-term use only. It should also be
remembered that topical steroid preparations are not licienced for the treatment of
overgranulation and therefore responsibility for its use lies with the prescriber.
157

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

TVS Guidelines: Wound Management Sept 2011

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

TVS Guidelines: Wound Management Sept 2011

Figure 6 Wound Care Plan


NURSING CARE PLAN

STICK ADDRESSOGRAPH HERE

DATE

WARD:

PATIENT PROBLEM/NEED

RGN
Signature

Review
Date

GOAL

NURSING ACTION/INSTRUCTION
CLEANING SOLUTION:

PRIMARY DRESSING:

SECONDARY DRESSING:

FREQUENCY OF DRESSING CHANGE:

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

TVS Guidelines: Wound Management Sept 2011

PRINCIPLES OF WOUND IRRIGATION

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

Sodium chloride 0.9% solution


This isotonic solution does not cause chemical damage to cells and is the
preferred irrigating agent for wounds. Sodium chloride 0.9% does not require a
prescription; all the other solutions do need a prescription.

7.1.2

Chlorhexidine with cetrimide

172

Lawrence J.C. (1997) Wound Irrigation JWC Jan Vol 6 No 1 Pg 23-26


Gilcrist B (1999) Wound Management, Theory and Practice. Nursing Times Books. Pg 104-105
174
Thomlinson D (1987) To clean or not to clean, Nursing Times, Journal of Infection Control Nursing. 4 March Vol 83.5
175
NICE (2008) . Surgical site infection. Guideline no 74 . October 2008
176
Lawrence J.C. Harding K.G. Moore D.J. (1996) The Use of Antiseptics in Wound Care. Journal of Wound Care. Jan.
Vol 5 No 1 Pg 44-47
177
NICE (2008) Surgical site infection. Guideline no 74 . October 2008
178
Cutting K F (2010) Addressing the challenge of wound cleansing in the modern era. BJN (TV Supplement) Vol 19 No
11 pg S25-S28
179
Dowd SE et al (2011) Survey of fungi and yeast in polymicrobial infections in chronic wounds. JWC Vol 20 No 1 Jan.
Pg 40-47
173

32

TVS Guidelines: Wound Management Sept 2011

This is available as chlorhexidine 0.15% w/v with cetrimide 0.015% w/v


(sometimes known as Savlon 1 in 100) for cleaning dirty wounds. The products
are easily contaminated and any remaining in a container after opening should be
discarded.
7.1.3

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

Comparison of commonly used antimicrobials

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

TVS Guidelines: Wound Management Sept 2011

8. WOUND BED PRODUCT INFORMATION

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

Semi Permeable Film Dressing

193 194

Examples: C View Film dressing


Episil Film Dressing
These films are adhesive, hypoallergenic, transparent and permeable in various degrees
to moisture vapour and other gases. They are useful for low exudate superficial wounds,
which are clean, and to cover surgical wounds healing by first intention. To ensure good
adhesion a 4 5 cm margin from the wound edge is suggested. As these dressings are
semi-occlusive they should not be used with clinically infected wounds unless antibiotic
therapy has been established and the infection is under control.
8.2

Hydrocolloids

195 196

Examples: Comfeel Ulcer


Granuflex
Duoderm Extra thin
Hydrocolloid Fibre (Aquacel)
Suitable for moderately exudating wounds. Can help promote granulation in clean
wounds. They can be used to deslough infected wounds, and to debride necrotic eschar.
The dressing should be changed when the liquidified base of the dressing is visible or by
seven days. The frequency will depend on the nature of the wound. On removal of the
dressing there will be a viscous, offensive yellow gel on the surface of the wound. This is
quite normal and can be removed with sterile Sodium Chloride 0.9% prior to the
application of the next dressing. Hydrocolloid sheets are occlusive dressings and are
contra-indicated in clinically infected wounds unless antibiotic therapy is established and
the infection is controlled.
Research using Hydrocolloids has demonstrated:
1.

Inhibition of bacterial growth particularly pseudomonas

2.

Enhanced collagen synthesis

3.

Controls spread of other bacteria by acting as a barrier

197

198

Aquacel is a soft, nonwoven pad or ribbon dressing composed entirely of hydrcolloid


fibres, (Sodium cellulose). It is indicated as a primary dressing for the management of
light to heavily exudating wounds. It may also be used on clinically infected wounds. It
should be changed when it becomes saturated with exudate or by seven days. It is 50%
more absorbent than alginates. It converts to a soft coherent gel sheet, which retains its
191

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

TVS Guidelines: Wound Management Sept 2011

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

Examples: Activheal Alginate


Sorbisan
Kaltostat (Sodium Calcium Alginate)

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

Examples: Lyofoam Non Adherent


Biatain Non Adherent
Allevyn Gentle
Biatain Adherent
Allevyn Adherent
Tegaderm Foam
These products are highly absorbent polyurethane foams designed to manage moderate
to heavily exudating wounds. Various sizes and shapes are available and it can remain in
place for up to 5 days.

8.5

Hydrogels

202 203

Examples: Activheal Gel


Nugel
204
Actiform Cool (Hydrogel sheet)
Useful for dry/low exudate granulating wounds as it produces a moist wound environment
and thus prevents wound desiccation. Also used to deslough low/medium exudating
wounds. Can be used on necrotic wounds to dehydrate the eschar. A secondary
dressing is needed, ideally a semi permeable film to maintain the moist wound interface.

8.6

Dressings Containing Charcoal

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

TVS Guidelines: Wound Management Sept 2011

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

Dressings Containing Antimicrobials

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:

Iodoflex, Inadine, Flaminal, Aquacel Ag, Biatain Ag,

210 211 212 213 214 215

Products available such as iodine impregnated dressings provide a controlled release of


iodine and are preferable to soaking gauze in iodine. Other controlled release products
contain silver. These products control the build up of bacteria on a wound bed without
adding a fluid burden to the wound, which increases the risk of strike through, and the
subsequent need to renew dressings to maintain the antiseptic level.

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

TVS Guidelines: Wound Management Sept 2011

8.8

Protease Modulating Therapy (PMT)

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

Larva Therapy/ Biosurgery

227 228 229

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

TVS Guidelines: Wound Management Sept 2011

8.10

Topical Negative Pressure (TNP)

232 233 234 235 236 237

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

There are two methods of TNP available on the market .


1. The Foam System
This technique involves the application of an open pore foam and tubing which is
attached to the pump, held in situ with a film dressing creating a controlled closed
wound environment.
2. The Cheriker-Jeter System
Involves application of a gauze dressing and tubing attached to a pump which is
then sealed using a film dressing creating a controlled closed wound
239
environment.
In both methods a negative pressure is applied across the wound from the pump via the
drainage tube imbedded in the foam or gauze. The complete kit, which includes foams,
gauze and suction unit, is available from KCI, Molynlycke or Smith & Nephew. All
components are available on FP10.
The Tissue Viability Service hold the budget for the hire of the pumps and thus the TVS
must be involved in every patients care where TNP is in use.
Indications:
Pressure Ulcers
Traumatic Wounds
Flaps Fresh/Compromised
Diabetic Ulcers
Arterial Ulcers
Surgical Wound dehiscence
Meshed grafts
Venous grafts
Contra-Indications
Presence of non-enteric or unexplored fistula/fistulae
Presence of necrotic tissue with eschar
Malignancy
Untreated Osteomyelitis
Exposed blood vessels or organs.

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

TVS Guidelines: Wound Management Sept 2011

Access to VAC therapy is via the Tissue Viability Department see Appendix 2 for referral
forms

8.11

Topical Antibiotic:

Example: Anabact gel


A clear gel, which contains Metronidazole BP 0.75% W/V. It is effective against anaerobic
bacteria, which often cause malodour in fungating wounds. This is a topical antibiotics
and requires prescription and should only be used following discussion with the TVS or
the Team Leader.

39

TVS Guidelines: Wound Management Sept 2011

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

ASEPTIC NON TOUCH TECHNIQUE PROCEDURE


An aseptic non-touch technique should be used for all wounds both Acute and
240
Chronic. In the case of faecal contamination the clinician responsible for care
must use discretion ensuring that best standards of infection control are
maintained at all times. Where Leg Ulcers are concerned the procedures
241
recommended in the Leg Ulcer Guidelines should be followed.
a)
b)
c)
d)
e)
f)
g)
h)

Dressing Pack - includes gloves


N/Saline
New Dressing
Tape
Forceps available if needed
CSSD bag - only if instruments used
Orange clinical waste bag (hospital only)
Sterile scissors

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

TVS Guidelines: Wound Management Sept 2011

Table 8. Procedure for aseptic non touch technique

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

Ensure all equipment required is ready and


available and that there is a clear field in which to
carry out procedure.

To prevent unnecessary movement and potential


cross-contamination

Verbally check the identity of the patient. Check


with carer/family if not able to confirm.

To confirm identity

Explain the procedure to the service user obtain


informed and understood consent
Position the patient, with dignity and privacy so that
the procedure can be performed
Decontaminate hands

To enable service user to make informed decisions


about their own health care
To gain optimal position for patients comfort

Put on single-use apron


Open wound care pack, onto a clean field
If dressing present, loosen and remove using the
inside of the waste disposal bag

To reduce the risk of transfer of transient organisms


on the healthcare workers hands
To protect clothing and prevent transfer of transient
organisms to a susceptible site
To prevent introducing organisms capable of causing
an infection into the site
To remove contaminated item without contaminating
hands

Decontaminate hands

Reduce the risk of transfer of transient organisms on


the healthcare workers hands

Put on sterile gloves in a manner which prevents


the outer surface of the sterile glove being touched
by a non-sterile item
Use aseptic principle to ensure that only sterile
items are used, to keep exposure of the susceptible
site to a maximum
On completion of the procedure, dispose of waste
Decontaminate hands

To prevent the introduction of organisms capable of


causing an infection into the site

Record all care in the patients records

To prevent the introduction of variable micro


organisms which could cause a healthcare-acquired
infection
As per clinical waste policy
To remove any accumulated transient skin flora that
may have built up under the gloves
As per SEPT policy

242

Dougherty L, Lister S (eds) (2008) The Royal Marsden Hospital Manual Clinical Nursing Procedures. 7 th edn. Blackwell
Publishing, Oxford

41

TVS Guidelines: Wound Management Sept 2011

11.

WOUND COMPLICATIONS
11.1

Infection with/without Exudate

1.

Report to person in charge and doctor.

2.

Take wound swab and send for culture and sensitivity.

3.

Monitor temperature and pulse, BP and respiration

4.

Follow EWMA Algorithm for managing wound infection. (Figure 1)

5.

Evaluate on a daily basis and record findings on WAF, reporting any concerns
Medical staff.

6.

Give treatment if prescribed, (systemic) and monitor effect.

7.

Take repeat swab at 4 days unless otherwise indicated.

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.

Ensure that the patient is pain free by offering analgesia as prescribed.

5.

Refer patient to TVS.

Beware of other complications such as abscess, haematoma, haemorrhage or


sinus, all of which may need further medical treatment.

42

TVS Guidelines: Wound Management Sept 2011

12.

DEBRIDEMENT OF NECROTIC OR SLOUGHY TISSUE


Debridement is an essential technique for all those who provide wound care. It is often
243
done badly for lack of experience and training.
It is widely accepted that the presence
244
of devitalised tissue on the wound surface impedes healing.
Cutting defines necrosis
as the death of local tissue and describes it as, tissue that is black or brown in colour, with
a leathery appearance. Slough is defined as devitalised tissue, which has a yellow/white
245
hue, may be dry or slimy in nature and is seen to adhere to the wound bed.
Surface associated bacterial populations (Biofilms) are present in chronic wounds and are
a primary barrier to healing. Evidence suggests that serial debridement and removal of
246
mature Biofilm does facilitate wound healing.
Any nurse wishing to undertake sharp debridement must be able to demonstrate his/her
ability to safely undertake the technique either through the provision of certificates of
247
training,
or a portfolio of case studies, which involved peer review, or both. Such
evidence of competence must be endorsed by the Trust either by the Director of Nursing
248
or the direct line manager if appropriate.
All nurses wishing to undertake this technique must do so in line within the
249 250
recommendations outlined within The NMC Code of professional conduct (2008)

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

Gautam V. Consultant Surgeon, East Herts NHS Trust.


Flanagan M. (1999) Reviewing the case for debridement. Journal of Wound Care: 8:6.257
245
Cutting K.F. (1996) Definition of Terms. Journal of Wound Care Resource File. London Macmillan
246
Wolcott RD et al ( 2010) Biofilm maturity studies indicate sharp debridement opens a time dependent therapeutic
window. JWC Vol 19 No 8 pg 320-327
247
Benbow M. (2000) Dealing with slough and necrosis. Essential Wound Healing. Part 8 Emap healthcare
248
Dimond B. (1900) Legal aspects of nursing pg 39-50. Prentice Hall
249
NMC (2008) The NMC code of professional conduct:, standards for conduct, performance and ethics.
250
Fairbairn K, Grier J, Hunter c (2002) A sharp debridement procedure devised by specialist nurses. JWC Vol 11 No 10
371-375
251
Dox 1. Melloni B.J. Elsner G.M. (1994) Illustrated medical dictionary 3 rd edition. The Wellcome Foundation Ltd.
252
Ousey K McIntosh C (2010) Understanding wound bed preparation and wound debridement. Wound Care, S 22-27.
253
Spruce M, Sweet J, Bowen KG et al (2007) Multidiciplinary debridement course: a new approach. Poster presentation
Wounds UK Harrogate.
254
Leak K, Johnson S, (2007) Versajet in out of theatre debridement: improving costs and clinical outcomes. Poster
presentation Wounds UK Harrogate.
255
Fraccalvieri M, et al. (2011) Surgical debridement with Versajet: An analysis of bacteria load of the wound bed preand post treatment and skin graft taken. A preliminary pilot study. International Wound Journal Vol 8 No 2 pg 155-161
244

43

TVS Guidelines: Wound Management Sept 2011

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

Contra-indications for Versajet or Sharp Debridement

256 257

Densely adherent necrotic tissue.


No visual evidence of a demarcation line between viable and non-viable tissue.
Patients with impaired clotting mechanisms.
Ischaemic limbs with ulcers where tissue perfusion is inadequate to support healing.
Cellulitis.
Diabetic foot ulceration. (Unless under supervision of Vascular Team or Foot Health
Department)
Fungating malignant wounds
Where wounds are near, vascular structures, Dacron grafts, prosthesis, dialysis fistula,
hands face or feet with the exception of the heel.
Necrotic toes or fingers
Criteria for sharp debridement
Sharp debridement of necrotic or sloughy tissue may take place if; the nurse wishing to
undertake the procedure, working in accordance with the NMC code of professional
conduct and in line with Trust Policy believes that sharp debridement offers the greatest
advantage for the patient above other methods of debridement or in cases where other
methods of debridement have been unsuccessful.

12.5

Criteria for Versajet debridement


Versajet debridement may take place if the Tissue Viability Nurse Specialist undertaking
the procedure working in accordance with the NMC code of professional conduct and in
line with Trust Policy believes that it offers the greatest advantage for the patient above
other methods of debridement.

12.6

Procedure of communication with other disciplines prior to Versajet or sharp


debridement.

The nurse wishing to undertake sharp debridement must ensure that:


Procedure
Rationale
The intention to debride should be To gain the opinion of the medical staff
discussed with the responsible medical
regarding sharp debridement, and to
team and should be documented in the
ensure they agree and support the decision
patients medical notes. If the medical team
to sharp debride.
involved hold an objection to such
debridement this should be written clearly in
the patients notes in advance of any To inform the patient of their condition and
debridement taking place.
provide them with insight into the options
available and reasons why sharp
The proposed procedure is discussed with
debridement has been chosen and to gain
the patient and is documented in line with
consent for the procedure.
Trust Consent Policy.
12.7

Procedure for debridement

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

TVS Guidelines: Wound Management Sept 2011

Procedure

Routine procedures to ensure patient comfort and


safety will be followed.

Rationale

To ensure the patient is comfortable and safely


positioned for the procedure.

Routine analgesic normally provided for the


individual concerned prior to dressing changes
will be provided. However to ensure patient
comfort and allay anxiety additional analgesia
may be prescribed by Medical Staff or
Independent Prescribers if required.

As debridement of necrotic issue only will take


place, there should be no reason to cause
increased pain and thus no requirement for
additional or stronger analgesia however
holistic patient assessment may indicate that
additional analgesia may enhance the patient
experience and ensure an improved outcome.

Aseptic technique and a sterile debridement pack


/Versajet pack will be used.

To prevent cross infection.

An additional nurse will be present to comfort the


patient throughout the procedure and assist the
debridor.

To comfort the patient and ensure that the


debridor is assisted when necessary.

Additional gauze and bandages will be at hand in


case of accidental haemorrhage.

To ensure immediate control of any accidental


bleeding.

Good seating and lighting will be available for the


debridor.

To promote optimum visualisation of the area to


be debrided.

No callous or chronic ulceration tissue with a


blood supply will be removed by sharp
debridement. Suspected Biofilm or devitalised
granulating tissue can be debrided using Versajet
Debridement

The purpose of debridement is to remove


necrotic, sloughy tissue only and in the case of
versajet biofilm and senescent devitalised
tissue only.

Necrotic eschar and sloughy tissue only will be


removed via sharp debridement.

To remove devitalised tissue and facilitate


proliferation of the wound bed.

If accidental cutting of viable tissue should occur,


direct pressure will be applied with sterile gauze
until bleeding ceases. A haemostatic pressure
259
dressing can also be used.

To ensure accidental blood loss is minimal and


that no haemodynamic instability occurs.

If direct pressure fails to control bleeding within 15


minutes medical staff will be contacted for
immediate assistance.

To obtain expert assistance in curtailing blood


loss.

In all cases of accidental bleeding an entry to


detail the extent of the situation will be made in
the medical notes.

To ensure patient records provide evidence of


the event and the action taken to minimise
patient harm

If accidental cutting of healthy tissue occurs


medical staff will be contacted to discuss the
possibility of prophylactic antibiotics.

If medical staff feels there might be a risk of


septicaemia as a result of incident, prophylactic
antibiotics may be provided to reduce the risk.

All patients who have undergone sharp


debridement or Versajet debridement should be
monitored for signs of bleeding or pyrexia
following the procedure.

To detect any signs of complications as a result


of the procedure and to ensure prompt action
should such events take place.

The patients notes will be updated giving full


details of the extent of debridement and providing
instructions for aftercare. Together with date of
review by the Debridor. Versajet handset serial
numbers will be place in the notes.

To provide good record of the procedure and


ensure good communication will all staff
regarding aftercare.

A registered nurse will inspect the wound after 24


hours and any deterioration reported to the

To check that the wound is healthy and to


detect any complication. Should complication

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

TVS Guidelines: Wound Management Sept 2011

debridor and medical staff immediately.

occur the debridor and medical staff will provide


advice regarding action to be taken.

DEBRIDEMENT PORTFOLIO

46

TVS Guidelines: Wound Management Sept 2011


PATIENT DETAILS
NAME:
ADDRESS:

DATE OF BIRTH:

HOSPITAL NUMBER:

CONSULTANT:

BRIEF MEDICAL DETAILS

DETAILS OF AREA TO BE DEBRIDED

RESULTS OF PROCEDURES OF RELEVENCE

TECHNIQUE TO BE USED INCLUDING SERIAL NUMBER OF VERSAJET HANDSET

DESCRIPTION OF PROCEDURE

EVALUATION OF DEBRIDEMENT

FOLLOW UP VISIT

BRIEF DESCRIPTION OF ANY COMPLICATIONS AND TREATMENT

MEDICAL EVALUATION OF END RESULT

NAME:
SIGNATURE:

TRAINING RECORD

47

TVS Guidelines: Wound Management Sept 2011

COURSES
DATE & VENUE

COURSE TITLE

RECORD OF CLINICAL OBSERVATION


CLINICAL AREA

OBSERVED
INDIVIDUAL

PROCEDURES
OBSERVED

DATE

48

TVS Guidelines: Wound Management Sept 2011

13

MONITORING OF ADHERANCE TO GUIDELINE

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

TVS Guidelines: Wound Management Sept 2011

Appendix 1

The MUST Nutrition Risk Score

50

TVS Guidelines: Wound Management Sept 2011

MUST FOR COMMUNITY HOSPITALS AND RESIDENTIAL


/NURSING HOMES

MUST FOR THE COMMUNITY

MUST SCORE RECORDING SHEET

51

TVS Guidelines: Wound Management Sept 2011

MALNUTRITION UNIVERSAL SCREENING TOOL (MUST)


FOR COMMUNITY HOSPITALS and
RESIDENTIAL/NURSING HOMES

STEP 1

BMI Score *
BMI kg/m2
> 20
18.5 20
< 18.5

STEP 2

Weight loss score


Score =
0
1
2

STEP 3
Acute disease effect score

Unplanned weight loss in past


3 6 months
%
Score =
<5
0
5 -10
1
> 10
2

If the patient is acutely ill


AND there has been or is
likely to be NO nutritional
intake for > 5 days
Score 2

STEP 4 - Overall risk of malnutrition


Add scores together to calculate overall risk of malnutrition
Score 0 = Low risk
Score 1 = Medium risk
Score 2 or more = High risk

STEP 5 - Care Plan


MUST = 0 (LOW RISK)
(If BMI is greater than 30 kg/m2 then include a healthy eating plan)
ROUTINE CARE: Repeat MUST score weekly in Community Hospitals and monthly in Residential/Nursing Homes
MUST = 1 (MEDIUM RISK)
OBSERVE: Observe intake using food chart and fluid chart
If oral intake is poor encourage oral intake, offering high calorie snacks and meals implement
Food First
If there is no improvement then there is clinical concern implement nutrition care plan
If improved/adequate oral intake then there is little clinical concern continue routine care

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

TVS Guidelines: Wound Management Sept 2011

MALNUTRITION UNIVERSAL SCREENING TOOL


(MUST)

FOR THE COMMUNITY

STEP 1

BMI Score *
BMI kg/m2
> 20
18.5 20
< 18.5

STEP 2

Weight loss score


Score =
0
1
2

STEP 3
Acute disease effect score

Unplanned weight loss in past


3 6 months
%
Score =
<5
0
5 -10
1
> 10
2

If the patient is acutely ill


AND there has been or is
likely to be NO nutritional
intake for > 5 days
Score 2

STEP 4 - Overall risk of malnutrition


Add scores together to calculate overall risk of malnutrition
Score 0 = Low risk
Score 1 = Medium risk
Score 2 or more = High risk

STEP 5 - Care Plan


MUST = 0 (LOW RISK)
(If BMI is greater than 30 kg/m2 then include a healthy eating plan)
ROUTINE CARE: Repeat MUST score annually for at risk patients e.g. those over 75 yrs
People with neurological degenerative diseases need to be monitored every 4 months
MUST = 1 (MEDIUM RISK)
OBSERVE: Observe intake using food chart and fluid chart
If oral intake is poor encourage, offering high calorie snacks and meals implement
Food First
If there is no improvement then there is clinical concern implement nutrition care plan
If improved/adequate oral intake then there is little clinical concern continue routine care

Repeat MUST at least every 2 3 months


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 Food First
If no improvement after 4 weeks refer to the dietitian
Also refer to dietician if MUST is 3 or more and BMI < 18.5 kg/m2
Monitor and review care plan monthly
*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

53

TVS Guidelines: Wound Management Sept 2011

MUST Score Recording Sheet


Name:
Location:
Date

Weight

Usual weight (kg)


Height (m)
Step 1

A = Actual
E = Estimated U =
BMI Score
Unable to weigh
kg/m2
BMI
Score
with rationale

Date Step 5: Action taken

Step 2

Step 3

Acute disease score


Weight loss score
Weight
Score
loss %

Step 4

Risk

MUST score
=
1+2+3

0 = Low
1 = Medium
2 = High

Print and sign name

Review Date

54

TVS Guidelines: Wound Management Sept 2011

Appendix 2

TVS Referral Form


TNP Referral Form
Care Pathway for a Patient with a Wound
Care Pathway for MRSA infected Wound

55

TVS Guidelines: Wound Management Sept 2011


Tissue Viability Department
st
1 Floor Birchwood House
St Margarets Hospital
The Plain
Epping
Essex, CM16 6TN
Tel: 01992 561 666 Ext 5551
Fax: 01279 827178

TISSUE VIABILITY PATIENT REFERRAL FORM


Ward referrer to complete sections 1 to 6 fax no 01279 827178. All Sections must be completed before TVS will accept referral.

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:

D.O.B

G.P and G.P Base:


Consultant:
NHS No
Is the Patient eligible for NHS care
Section 3: Consent:
Patient consents to being assessed by TVN?

Yes
Yes

No

No

Section 4: Referral Details:


Wound Management
Surgical
Traumatic
Burn
Malignant
Other
Duration:

Pressure Ulcer Category/Grade 1


2
3
4

Waterlow Score

for all Category 2 & above


please provide
incident form no --------------------

Must Score

Has a SET SAF 1 Form been completed, please give date ----------------------------------------Has TNP Therapy been requested

Yes

No

Pressure Reducing/ Relieving Mattress: Propad Alpha x cell Auto x cell


Eclipse Nimbus 2 Nimbus 3 Biwave Airwave Other State:
Section 5: Wound Details
Site: Sacrum Trochanter Buttocks Heels: Left Right Both Head
Other State:
Tissue Appearance: Necrotic
%, Sloughy
%, Granulating
%, Epithelialising

Current Wound Management (State):


Please attach copy of current Wound Assessment Form and TV Care Plans:
Medical History/ Diagnosis/ is patient taking Steriods / Nsaids
Section 6
Is the Patient Diabetic YES / NO CBG------------

HbA1c --------------

Urinalysis ---------Tissue Viability Department


1st Floor Birchwood House

56

TVS Guidelines: Wound Management Sept 2011


St Margarets Hospital
The Plain
Epping
Essex, CM16 6TN
Tel: 01992 561 666 Ext 5551
Fax 01279 827179

TISSUE VIABILITY TNP REFERRAL FORM


Referrer to complete sections 1 to 5 and fax no 01279 827178

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:

Community Pressure Sore: Sore present on admission to Acute Trust


District Nurse or Practice Nurse involved:
District Nurse or Practice Nurse Name:
Acute Wound: Reason required:

Which Hospital?
Yes/No
Yes/No

Surgeons Name:

Chronic Wound: Reason required:


Section 4: Ordering TNP
When was TNP Therapy commenced:
Who requested commencement:
How long will TNP be required:
Should funding be refused what other treatment could be used:
If TNP is used what is the potential reduction in length of stay:
State method of TNP: (Gauze or Foam).. Canister in use Dressings in use
Section 5: Wound Details:
Site: : Sacrum Trochanter Buttocks Heels: Left Right Both Head
Other State:
Tissue Appearance: Necrotic
%, Sloughy
%, Granulating
%, Epithelialising

Please attach copy of current Wound Assessment Form:


Brief Medical History/Diagnosis
Section 6: N.B Tissue Viability Nurse to complete Section 6
Appointment Made:

Date. Timeam/pm

Tissue Viability Nurse:

Name..

Signature.

57

TVS Guidelines: Wound Management Sept 2011

Care Pathway for a Patient with a Wound


Chronic Wound more than 6 weeks old

Acute Wound less then


6 weeks old.

Is the wound healing well, and likely to be healed


within 12 weeks

Is the wound healing well without complications.

YES

Continue normal post


operation plan

NO
YES

NO

Has the G.P / Medic/ Surgeon been


informed?

NO

GP, Medic, Surgeon to be contacted


for advice/ review
& consideration for referral to
Tissue Viability Service

YES

Follow advice given & make Tissue


Viability referral concurrently for
collaborative care

Tissue Viability Service to be involved, collaborating with Surgeon


to support patient in primary care.

Consider a review of
management by Tissue
Viability Team to check
that care is optimum

Refer to Tissue
Viability Team for
assessment

58

TVS Guidelines: Wound Management Sept 2011

Care Pathway for MRSA Infected Wound


All MRSA infected wounds must be referred to the Tissue Viability Service, the Leg Ulcer Service
or Podiatry (According to Type of Wound) within 72 hours of diagnosis.
Holistic Wound
Assessment and
complete SEPT
WEL WAF

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

Wound Dressing Options


Iodoflex
Actilite Honey
Physiotulle Ag
Sorbisan Silver flat
Allevyn AG

YES

Wound Dressing Options


Iodoflex
Algivon
Aquacel AG
Sorbisan Silver packing
Suprasorb X Plus
PHMB
Larval Tharapy
TNP Therapy
59

TVS Guidelines: Wound Management Sept 2011

Appendix 3

Proforma Care Plans

These care plans are available electronically and


must be amended and tailored electronically to
each individual patient wound before printing.
Please speak to your team leader or ward manager
for access or contact The Tissue Viability Dept on
EXT 5551

60

TVS Guidelines: Wound Management Sept 2011

WOUND CARE PLAN


Patients Name:
Address:
G.P Details:

D.O.B:

Hosp. No:

DATE/TIME

PATIENT PROBLEM/NEED

RGN SIGNATURE REVIEW DATE

DATE/TIME

Patient has a clean epithelialising flat wound


(State where and cause) If the wound is a leg
ulcer refer to the leg ulcer guidelines. Patient
understands nature of problem and consents to
treatment.
GOAL

RGN SIGNATURE REVIEW DATE

DATE/TIME

Maintain patients involvement and concordance.


Ensure patients pain is controlled.
T: Promote epithelialisation
I: Reduce inflammation and maintain bacterial
balance
M: Achieve moisture balance
E:
Measure advancing edges
NURSING ACTION/INSTRUCTION

RGN SIGNATURE REVIEW DATE

DATE/TIME

Discuss progress with patient, explaining changes


and maintaining concordance.
Wound Assessment Form (WAF) completed:
Date:
The WAF must be completed at each dressing
change.
If a pressure ulcer, develop a care plan to prevent
deterioration and development of new sores.
Provide analgesia 30 minutes prior to dressing
change if required, record pain rating on WAF.
Establish a pain care plan if required.
If wound is clean no cleaning is required. Sterile
saline should be used if cleaning is required to
remove dressing debris.
Minimal exudate: Use semi -permeable film
Low/moderate exudates: Non - adherent or low
adherent dressing
Moderate exudate: Hydrocolloid sheet
FREQUENCY OF DRESSING CHANGE

RGN SIGNATURE REVIEW DATE

DATE/TIME

Follow manufacturers guidelines regarding


frequency of dressing changes and state this on
this plan
Change dressing every ..Days.
However all dressings should be changed when
strike through occurs or if the dressing is soiled
from other sources.
Refer to the Tissue Viability Service if wound is
failing to progress.
OTHER INSTRUCTIONS:

RGN SIGNATURE REVIEW DATE

Care plan discussed and agreed with patient


Patient signature:

61

TVS Guidelines: Wound Management Sept 2011

WOUND CARE PLAN


Patients Name:
Address:
G.P Details:

D.O.B:

Hosp/NHS. No:

DATE/TIME

PATIENT PROBLEM/NEED

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Patient has a granulating cavity wound (State where


and cause) If the wound is a leg ulcer refer to the leg
ulcer guidelines. Patient understands nature of
problem and consents to treatment.
GOAL

RGN SIGNATURE

REVIEW DATE

RGN SIGNATURE

REVIEW DATE

DATE/TIME

If wound is clean no cleaning is required. Sterile


saline should be used if cleaning is required to
remove dressing debris.
Minimal exudate: use Hydrocolloid paste. Cover with
adhesive N/A dressing.
Moderate exudate: Alginate rope or Hydrofibre rope.
Cover with adhesive non adherent dressing.
High exudate: High absorbent Alginate or Hydrofibre.
Cover with Foam or Hydrocolloid sheet.
TNP Therapy will manage a high amount of exudate
and accelerate healing from the base of the wound.
FREQUENCY OF DRESSING CHANGE:

RGN SIGNATURE

SIGNATURE

DATE/TIME

Follow manufacturers guidelines regarding frequency


of dressing changes and state this on this plan.
Change dressing every..Days.
However all dressings should be changed when strike
through occurs or if the dressing is soiled from other
sources.
Refer to TVS if wound is failing to progress.
OTHER INSTRUCTIONS:

RGN SIGNATURE

REVIEW DATE

Maintain patients involvement and concordance.

Ensure patients pain is controlled.

DATE/TIME

T: Promote viable granulation from the wound base


I: Reduce inflammation and maintain a bacterial
balance.
M: Achieve moisture balance
E: Prevent closure of edges before would base heals
Measure advancing edges and base of wound.
NURSING ACTION/INSTRUCTION
Discuss progress with patient, explaining changes
and maintaining concordance.
Wound Assessment Form (WAF) completed:
Date:
The WAF must be completed at each dressing change.

If a pressure ulcer develop a care plan to prevent


deterioration and development of new sores.

Provide analgesia 30 minutes prior to dressing


change if required, record pain rating on WAF.
Establish a pain care plan if required.

Care plan discussed and agreed with patient


Patient signature:

WOUND CARE PLAN


62

TVS Guidelines: Wound Management Sept 2011

Patients Name:
Address:
G.P Details:

D.O.B:

Hosp/NHS. No:

DATE/TIME

PATIENT PROBLEM/NEED

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Patient has a granulating non-cavity wound (State


where and cause) If the wound is a leg ulcer refer to
the Leg Ulcer Guidelines Patient understands nature
of problem and consents to treatment.
GOAL

RGN SIGNATURE

REVIEW DATE

RGN SIGNATURE

REVIEW DATE

DATE/TIME

If wound is clean no cleaning is required. Sterile


saline should be used if cleaning is required to
remove dressing debris.
Minimal exudate: use Hydrocolloid adhesive sheet.
Moderate exudate: Hydrocolloid fibre covered with
Hydrocolloid sheet.
High exudate: High absorbent Alginate or Hydrofibre.
Cover with a Foam or sheet. A gauze pad may also
be used for additional absorbancy as an outer layer.
FREQUENCY OF DRESSING CHANGE:

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Follow manufacturers guidelines regarding frequency


of dressing changes and state this on this plan.
Change dressing every..Days.
However all dressings should be changed when strike
through occurs or if the dressing is soiled from other
sources.
Refer to the Tissue Viability Service if wound is failing
to progress.
OTHER INSTRUCTIONS:

RGN SIGNATURE

SIGNATURE

Maintain patients involvement and concordance.

Ensure patients pain is controlled.

DATE/TIME

T: Promote viable granulation from the wound base


I: Reduce inflammation and maintain a bacterial
balance
M: Achieve moisture balance
E: Measure advancing edges
NURSING ACTION/INSTRUCTION
Discuss progress with patient, explaining changes
and maintaining concordance.
Wound Assessment Form (WAF) completed:
Date:
The WAF must be completed at each dressing
change.
If a pressure ulcer develop a care plan to prevent
deterioration and development of new sores.

Provide analgesia 30 minutes prior to dressing


change if required, record pain rating on WAF.
Establish a pain care plan if required.

Care plan discussed and agreed with patient


Patient signature:

WOUND CARE PLAN


Patients Name:
63

TVS Guidelines: Wound Management Sept 2011

Address:
G.P Details:

D.O.B:

Hosp/NHS. No:

DATE/TIME

PATIENT PROBLEM/NEED

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Patient has an infected wound. (State where and


cause) If the wound is a leg ulcer refer to the Leg
Ulcer Guidelines. Patient understands nature of
problem and consents to treatment.
GOAL

RGN SIGNATURE

REVIEW DATE

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Clean with sterile saline 0.9%, Stellisept wash or


povidine iodine solution if an antiseptic is required to
remove dressing debris
Minimal exudate: use a Hydrogel held in place with a
N/A Pad.
Moderate exudate: use an Alginate or Hydrofibre
held in place with a non-adherent Pad.
High exudate: use an Alginate or Hydrofibre held in
place with a foam dressing.
Do not use occlusive dressings on infected
wound until antibiotic therapy has controlled the
infection.
FREQUENCY OF DRESSING CHANGE:

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Follow manufacturers guidelines regarding frequency


of dressing changes and state this on this plan.
Change dressing every.days.
However all dressings should be changed when strike
through occurs or if the dressing is soiled from other
sources.
Refer to the Tissue Viability Service if wound is failing
to progress.
OTHER INSTRUCTIONS:

RGN SIGNATURE

REVIEW DATE

Maintain patients involvement and concordance.

Ensure patients pain is controlled.

DATE/TIME

T: Debridement of sloughy and necrotic tissue


I: Reduce inflammation and control bacterial balance
M: Achieve moisture balance
E: Measure advancing edges and base of wound
NURSING ACTION/INSTRUCTION
Discuss progress with patient, explaining changes
and maintaining concordance. Provide analgesia

30 minutes prior to dressing change, record pain


rating on WAF.
Wound Assessment Form (WAF) completed:
Date:
The WAF must be completed at each dressing change.

If a pressure ulcer develop a care plan to prevent


deterioration and development of new sores.

Provide analgesia 30 minutes prior to dressing


change if required, record pain rating on WAF.
Establish a pain care plan if required.

Care plan discussed and agreed with patient


Patient signature:

WOUND CARE PLAN


Patients Name:
Address:
64

TVS Guidelines: Wound Management Sept 2011

G.P Details:

D.O.B:

Hosp/NHS. No:

DATE/TIME

PATIENT PROBLEM/NEED

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Patient has a hard necrotic eschar covering a wound.


(State where and cause) If necrotic area is a toe or
hand do not debride, seek advice from medical staff
or Tissue Viability Service If the wound is a leg ulcer
refer to the Leg Ulcer Guidelines Patient understands
nature of problem and consents to treatment.
GOAL

RGN SIGNATURE

REVIEW DATE

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Refer patient to a clinician who can sharp debride


wound OR use debridement agents such as
Hydrocolloid sheet:
Hydrogel:
Secure primary dressing with non-adherent dressing
where required
FREQUENCY OF DRESSING CHANGE:

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Follow manufacturers guidelines regarding frequency


of dressing changes and state this on this plan
Change dressing every ..Days. However
all dressings should be changed when strike through
occurs or if the dressing is soiled from other sources.
Refer to the Tissue Viability Service if wound is failing
to progress.
OTHER INSTRUCTIONS:

RGN SIGNATURE

REVIEW DATE

Maintain patients involvement and concordance.

Ensure patients pain is controlled.

DATE/TIME

T: Debride necrotic tissue


I: Reduce inflammation and maintain bacterial
balance
M: Achieve moisture balance
E: Measure advancing edges and base of wound
NURSING ACTION/INSTRUCTION
Discuss progress with patient, explaining changes
and maintaining concordance.
Wound Assessment Form (WAF) completed:
Date:
The WAF must be completed at each dressing
change.
If a pressure ulcer develop a care plan to prevent
deterioration and development of new sores.

Provide analgesia 30 minutes prior to dressing


change if required, record pain rating on WAF.
Establish pain care plan if required.

Care plan discussed and agreed with patient


Patient signature:

65

TVS Guidelines: Wound Management Sept 2011

WOUND CARE PLAN


Patients Name:
Address:
G.P Details:

D.O.B:

Hosp/NHS. No:

DATE/TIME

PATIENT PROBLEM/NEED

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Patient has a sloughy wound ( Cavity) (State


where and cause) If the wound is a leg ulcer refer
to the Leg Ulcer Guidelines Patient understands
nature of problem and consents to treatment.
GOAL

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Maintain patients involvement and concordance.


Ensure patients pain is controlled.
T: Debride Slough
I: Reduce inflammation and maintain bacterial
balance
M: Achieve moisture balance
E: Measure advancing edges and base of wound
NURSING ACTION/INSTRUCTION

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Discuss progress with patient, explaining changes


and maintaining concordance
Wound Assessment Form (WAF) completed:
Date:
The WAF must be completed at each dressing
change.
If a pressure ulcer develop a care plan to prevent
deterioration and development of new sores.
Provide analgesia 30 minutes prior to dressing
change if required, record pain rating on WAF.
Establish a pain care plan if required.
Clean with Sterile Saline to remove debris.
Minimal Exudate: Hydrogel, & non adherent
dressing
Moderate Exudate: Hydrogel and non adherent
pad.
High Exudate: Hydrocolloid fibre rope and foam
dressing. A gauze pad can be used as an outer
dressing if additional absorbency is required.
FREQUENCY OF DRESSING CHANGE:

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Follow manufacturers guidelines regarding


frequency of dressing changes and state this on
this plan
Change dressing every ..Days.
However all dressings should be changed when
strike through occurs or if the dressing is soiled
from other sources.
Refer to the Tissue Viability Service if wound is
failing to progress
OTHER INSTRUCTIONS:

RGN SIGNATURE

REVIEW DATE

Care plan discussed and agreed with patient


Patient signature:

66

TVS Guidelines: Wound Management Sept 2011

WOUND CARE PLAN


Patients Name:
Address:
G.P Details:

D.O.B:

Hosp/NHS. No:

DATE/TIME

PATIENT PROBLEM/NEED

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Patient has a sloughy wound (Non Cavity)


(State where and cause) If the wound is a leg
ulcer refer to the Leg Ulcer Guidelines)
Patient understands nature of problem and
consents to treatment.
GOAL

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Maintain patient involvement & concordance.


Ensure patients pain is controlled
T: Debride Slough
I: Reduce inflammation and maintain
bacterial balance
M: Achieve moisture balance
E: Measure advancing edges
NURSING ACTION/INSTRUCTION

RGN SIGNATURE

REVIEW DATE

DATE/TIME

If a pressure ulcer develop a care plan to


prevent deterioration and development of
new sores.
Provide analgesia 30 minutes prior to
dressing change if required, record pain
rating on WAF. Establish a pain care plan if
required.
Clean with Sterile Saline to remove debris
Minimal Exudate: Hydrocolloid sheet
Moderate Exudate: Hydrocolloid fibre
dressing and Non adherent pad.
High Exudate: Alginate and foam dressing.
A gauze pad can be used as an outer layer if
additional absorbency is required
FREQUENCY OF DRESSING CHANGE:

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Follow manufacturers guidelines regarding


frequency of dressing changes and state this
on this plan. Change dressing every
..Days. However all dressings should
be changed when strike through occurs or if
the dressing is soiled from other sources.
Refer to the TVS if failing to progress.
OTHER INSTRUCTIONS:

RGN SIGNATURE

REVIEW DATE

Discuss progress with patient, explaining


changes and maintaining concordance. .
Wound Assessment Form (WAF) completed:
Date:
The WAF must be completed at each dressing
change.

Care plan discussed and agreed with patient


Patient signature:

67

WOUND CARE PLAN


Patients Name:
Address:
G.P Details:

D.O.B:

Hosp/NHS. No:

DATE/TIME

PATIENT PROBLEM/NEED

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Patient has a uncomplicated post surgical


wound (State where ) Patient understands
nature of problem and consents to treatment.
GOAL

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Maintain patient involvement &concordance.


Ensure patients pain is controlled.
T: Promote viable granulation from the wound
base
I: Reduce inflammation and maintain a
bacterial balance
M: Achieve moisture balance
E: Measure advancing edges
NURSING ACTION/INSTRUCTION

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Discuss progress with patient, explaining


changes and maintaining concordance.
Wound Assessment Form (WAF) completed:
Date:
The WAF must be completed at each
dressing change.
Provide analgesia 30 minutes prior to dressing
change if required, record pain rating on WAF.
Establish a pain care plan if required.
If wound is clean no cleaning is required.
Sterile saline should be used if cleaning is
required to remove debris.
Leave wound exposed after 48 hours or cover
with semi-permeable film dressing.
FREQUENCY OF DRESSING CHANGE:

RGN SIGNATURE

REVIEW DATE

DATE/TIME

Follow manufacturers guidelines regarding


frequency of dressing changes and state this
on this plan.
Change dressing every.. Days.
However all dressings should be changed
when strike through occurs or if the dressing is
soiled from other sources.
OTHER INSTRUCTIONS

RGN SIGNATURE

REVIEW DATE

Care plan discussed and agreed with patient


Patient signature:

68

Appendix 4
Wound Management Audit Tool
Staff questionnaire
Questionnaire answers
Patient questionnaire
Audit tool

69

WOUND MANAGEMENT STANDARD STAFF QUESTIONNAIRE


CODE

QUESTION

P1

1. Name five factors which impair wound healing in patients?

P2

What factors can promote wound healing? (Include two local


and two systemic factors)

ANSWERS
a)
b)
c)
d)
e)
Systemic
a)
b)
local
a)
b)

S5 &
S10

What would be the cleaning solution for a granulating wound


(non- infected)?

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)

What would be the cleaning solution for a sloughy wound (noninfected)?

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

What does the acronym TIME stand for?

S10 &
P4

Give an example of the following dressings:-

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)

When would you photograph or trace/illustrate a wound?


What is the basic procedure that minimises the risk of cross
infection?
Name two means by which bacteria is transferred:

a)
b)

S8

If you are concerned about cross infection, where would you


obtain advice?

a)

b)

71

WOUND MANAGEMENT STANDARD STAFF ANSWERS

CODE

QUESTION

P1

Name five factors which impair wound healing in patients?

P2

What factors can promote wound healing? (Include two local


and two systemic factors)

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

What would be the cleaning solution for a granulating wound


(non- infected)?

Sodium Chloride 0.9%

72

CODE

QUESTION

S5 &
S10

What would be the dressing for a granulating wound with:a)


b)
c)
d)

minimum exudate
low exudate
moderate exudate
heavy exudates

S5 &
S10

What would be the cleaning solution for a sloughy wound (noninfected)?

S5 &
S10

What would be the dressing for a sloughy wound with:-

a) low exudate
b) moderate exudate
c) heavy exudate

P3

What does the acronym TIME stand for?

S10 &
P4

Give an example of the following dressings:a)


b)
c)
d)
e)

S3 &
P4

Semipermeable
Alginate
Hydrocolloid
Hydrogel
Foam

Where would you commence a wound care plan?

ANSWERS

a) Non-adherent or semi occlusive/semipermeable


b) Hydrocolloid
c) Foam
d) Alginate or Hydrocolloid fibre

Sodium Chloride 0.9%

a) Hydrocolloid sheet or Hydrogel


b) Hydrocolloid fibre
c) Alginate and Foam

Tissue, Infection, Moisture, Edges

a) C View, Episil Film.


b) Kaltostat, Sorbsan.
c) Granuflex, Comfeel.
d) Activheal Gel, Nugel
e) Allevyn, Lyofoam, Biatain
Where a wound exists

73

CODE

QUESTION

ANSWERS

S3 &
P4

When would you photograph or trace/illustrate a wound?

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

What is the basic procedure that minimises the risk of cross


infection?

Hand washing before patient contact and between each patient contact

S8
B&C

Name two means by which bacteria is transferred:

a) dust particles

b) droplet nuclei

S8

If you are concerned about cross infection, where would you


obtain advice?

a) The Infection Control folder


b) The CNS, Infection Control

74

WOUND MANAGEMENT STANDARD


QUESTIONS TO ASK THE PATIENT

CODE

QUESTIONS

P12

Do you know how the wound will be dressed (Dressing name)?

P12 & O5

O6A

O6B

Do you know how often you wound will be redressed?

Do you find the dressing painful?

If yes, were you given painkillers before the dressing?

75

Audit Objective:
Sample:
Time Frame:
Auditor(s):
Audit Criteria

AUDIT PROTOCOL FOR TISSUE VIABILITY WOUND CARE STANDARD


To check that patient receive care in line with ratified guidelines on wound management
Two patients and their notes
Annually
Tissue Viability Nurse or Nursing Staff responsible for patient
Method of
Points allocated
Structure
Process Outcome Data
(yes=1) (no = 0)
Collection

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

Wound Management (2011)


3. Is a) the Wound Assessment Form (WAF) available on the ward
for each patient with an open wound?
b) Have all wounds present on admission been traced or
photographed with written consent
c) Is TVS/LUS/Podiatry involved if wound is MRSA positive?
4. Is the pre printed Wound Care Plan template available
electronically or in paper.
5. Is (a) Sterile Normal Saline for wound cleansing available
and (b) Dressing products available to dress the wound?
6. Are dressing packs available?

7. Is a ruler/instrument to measure the wound available?


8. Can nurses describe the principles of preventing cross infection in

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

Points allocated Comments


(yes=1) (no = 0)

PROCESS

1. Is the patient assessed and factors which delay wound healing


identified within 24 hours of admission or the agreed time frame
on the care plan?
2. Are actions instituted to minimise delaying factors?
3. Is the patients wound assessed according to the TIME

Acronym using the WAF?


4. Is a care plan developed which identifies appropriate:
(a) solutions
(b) dressing products for wound type
5. Is the wound cleansed using solutions identified on the care
plan?
6. Is the wound dressed using products identified on the care
plan?
7. Is the wound dressing product applied correctly?
8. Do the prescription chart and care plan name the same
dressing if appropriate?
9. Are the principles of preventing cross infection adhered to?

10. Is the wound evaluated at each dressing change or and


recordings made on the WAF
11. Is the care plan revised as the wound classification
changes?
12. Is the patient informed of the nature of:
(a) wound dressing ?
(b) how often it will be changed?
13. Is the patient assessed for pain and discomfort, and are
analgesics offered?

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?

2. Is the cleansing solution appropriate for the classification of the


wound?

3. Is the dressing product used appropriate for the classification of

Structure Process

Outcome

Method of
Data
collection

Documentatio
n

Documentatio
n

wound?

4. Is TVS/LUS/Podiatry involved in all cases of MRSA infection

Documentation

Documentatio
n

Ask Patient

Ask Patient

5. Is there evidence that the wound is healing (eg reduction in size,


depth or
improved classification)?

6. Does the patient know


(a) the frequency of dressing changes
(b) The name of the dressing
(c) that they feel involved in their care

7. Does the patient find:


(a) the wound dressing painful
and
(b) were they offered analgesics

Points allocated
(yes=1) (no = 0)

Comments

78

THE AUDIT RESULTS FOR


WOUND CARE STANDARDS

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

WECHS /TVS/WCP/Competencies Band 5 and above. Sept 2011

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

WECHS /TVS/WCP/Competencies Band 5 and above. Sept 2011


Self-Assessment Competency Statement
Wound Assessment and Dressing Selection
Surname:

Forename(s):

Dept & Ward / Unit:

Job title / designation:

Self-verification of competence is undertaken by assessment against the statements below.


These statements are designed to indicate competence to undertake this skill. If you are in
any doubt regarding your competence, you should seek education or advice (consider selfdirected learning, clinical experts coaching and formal training) to bring about improvement.
Your statement of competence will provide evidence towards the following dimensions in the
knowledge and skills framework:
Core dimension 1: Communication: Level 3 a,b,c,e,f
Core dimension 3: Health, Safety and Security: Level 3 a, b, c, d, e
Core dimension 5: Quality: Level 2 a, b, e, f
Health and Well Being: HWB1 Level 1:
HWB2 Level 3:
HWB5 Level 3:
HWB6 Level 2
Carry out an initial assessment. You must be able to answer Yes to all the questions before
considering yourself to be competent. If you are not competent, instigate learning and then
repeat self-verification

Ask yourself the following questions.

Have I read the Trusts guidelines for Wound


Management; Pressure Ulcer and Leg Ulcer
Management?
Can I explain the need for a holistic patient
assessment in conjunction with a wound
assessment?
Can I explain the different wound types and the
stages of healing?
Can I identify slough, necrotic, granulating and
epithelial tissue?
Can I identify when taking a wound swab is
appropriate?
Do I know which dressings are in the Trust
Formulary?
Can I undertake a wound assessment and
complete the relevant assessment form?
Can I identify the types of dressings which are
suitable for different wound types and / or
symptoms?
Can I explain to the patient my rationale for the
chosen treatment regime?
Do I understand the need to gain consent and
maintain privacy and dignity throughout the
wound assessment and procedure?
Do I know:
- When an aseptic or clean technique should be
undertaken?

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

WECHS /TVS/WCP/Competencies Band 5 and above. Sept 2011


- What solution should be used to clean acute
and chronic wounds?
- What the indications and contraindications are
for hydrocolloids, hydrogels, films, and
antimicrobial dressings?
- How to apply and remove each dressing
according to the manufacturers
recommendations to avoid trauma and
discomfort?
- How to use Topical Negative Pressure,
including application, removal, trouble shooting
and cancellation of pump
- Which dressings may alleviate pain and / or
odour?
- How long a treatment regime should be
adhered to before the treatment is stopped or
changed?
- How to identify a clinical infection?
- The difference between contamination,
colonisation and infected wounds?
- Do I know when to initiate and stop
antimicrobial dressings?
- Do I know how to treat and protect skin
surrounding a wound?
-Do I know when and how to refer to the Tissue
Viability Service
Who to involve in all cases of MRSA Wound
infection?

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

TVS/TCS/ WCP Competency Framework Form June 2010

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:

I am competent to undertake wound assessment and management without


further training
Signature:

Date:

My Team Leader is aware of my competency and evidence of my competency is included within


my annual Appraisal.
Team Leader Signature & Name .
I require further training or supervision before I can undertake wound assessment and
management in a competent manner
Signature & Name
Date:.
My Team Leader is aware of my competency deficits and my annual appraisal identifies learning
needs to be addressed within the next 6 months through training and clinical supervision
opportunity within my Team or with the Tissue Viability Service. The Clinical Competency
Framework for Wound Assessment and Management will be the method used to direct and record
that training and supervision has taken place.
Team Leader Signature & NameDate:.
Keep this form in your personal portfolio or training record. Ensure your manager has seen the form
when completed.
A new self-assessment competency statement must be completed each year for Personal Development
Review.

Indicate how you plan to meet your learning needs:

By when:

84

TVS/TCS/ WCP Competency Framework Form June 2010

Clinical Competency Framework for Wound Assessment and Management


The aim of this clinical competency framework is to demonstrate that supervised correct wound assessment, application of
dressings and completion of an individualised holistic patient wound care plan has been achieved in a productive clinical
learning environment.
Name of Student.. Clinical Base assessment undertaken:.

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

TVS/TCS/ WCP Competency Framework Form June 2010

Competence

Performance

Evaluation method

1.1 Demonstrates an ability to communicate and


explain to patient the rationale for assessment and
wound care management.

Questioning &
Direct observation

1.2 Demonstrates understanding of the importance


of a Consistent Assessor in wound management
and how this translates in practice by frequent
reassessments by the Care Plan Initiator for each
patient, ensuring continuity of care and adding
value and benefit to the level of assessment and
care provided.
1.3 Explores patients lay and health beliefs in order
to determine ability to adhere and comply with
chosen wound management care plan including
obtaining patient consent. Identifies other comorbidities within assessment documentation. Is
aware of pain levels and takes action to address
pain within care plan.
2.1 Identifies type of wound including classification
of tissue, explaining the desired outcome and effect
of treatment within the wound management care
plan. Correctly completes the wound assessment
form (WAF)

Questioning &
Direct observation

2.2 Correctly chooses a dressing product including


demonstration of understanding as to why and
when a wound needs redressing.
2.3 Correctly applies dressings adhering to infection
control practices and completes notes.
2.4 Demonstrates understanding of the use of
Advanced Wound Care Products such as Topical
Negative Pressure & antimicrobials. Demonstrates
the skill of how to apply such treatment including
trouble shooting a, resolution of therapy problems
and cancellation of pump.

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

2. Assesses patients wound


taking action to ensure safe
practice, Traces wound, WAF
completion and care plan
production

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

TVS/TCS/ WCP Competency Framework Form June 2010

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

3.1 Care plan and notes reflect adherence and


action to address additional risk factors

Questioning &
Direct observation

4. Demonstrates an
understanding
of the theory of wound
types, classification and
grading. Knowledge on
how identify wound
infection

4.1 Aware of Trust wound care, pressure area and


leg ulcer guidelines and knows how to access.
Aware of NICE guidelines and how to access

Questioning &
Direct observation

4.2 Knowledge of WECHS Dressing Formulary and


how to access. Ability to identify generic dressing
types

Questioning &
Direct observation

4.3 Ability to diagnose wound infection, acting


appropriately including taking of swab and
amending care plans to address the infection
4.4 Aware of involving TVS/LUS/Podiatry for all
cases of MRSA infection

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

TVS/TCS/ WCP Competency Framework Form June 2010

Appendix 6
Wound Care Bundle

88

TVS/TCS/ WCP Competency Framework Form June 2010

WOUND CARE BUNDLE


WOUND CARE ACTIONS
1. Hygiene
Hands are decontaminated immediately before and after each patient contact, using
correct hand hygiene technique.260
2. Personal Protective Equipment
Disposable apron and gloves are worn and disposed of following use and between
each patient 261
3. Risk Assessment
Holistic assessment of patient including wound and pain assessment, in line with
SEPT West Essex Locality Wound Care Guidleines occurs with all patients with
wounds.
4. Dressings
All wounds are dressed in line with SEPT West Essex Locality Wound Care
262
Guidelines and Dressing Formulary Guidelines.
5. Documentation
All wound assessments are documented, dated and signed in patient notes within 6
hours of care provision263 All wound care is supported with a detailed care plan which
is reviewed weekly and updated as the wound progresses.
6. Patient Information
All patients provided with information on their wound care including frequency of
changes and types of dressings in use.264
7. Referral to other Health Care Specialists
Referrals are made to relevant clinicians such as Tissue Viability or Leg Ulcer
Services as appropriate where there is failure to progress or when clinically indicated
and especially 265 266 to surgical teams when relevant or podiatrists in the case of
diabetic foot ulceration.
8. Diabetes
Optimal glucose control is maintained in patients with diabetes. Referral to the
patients GP or Physician should be made to assess control and treat as required.
Referral to the Specialist Community Diabetes Service may be made for Type 1 and

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

TVS/TCS/ WCP Competency Framework Form June 2010

Type 2 diabetics on insulin who are socially/psychologically compromised (ie house


bound/care home) if control is suboptimal following GP agreement.267 268 269
9. Off loading
Any wound on the foot or pressure point should be off loaded including providing
appropriate footwear and insoles, this is particularly the case if the patient is
270
diabetic.
10. Pressure Ulcers
All Patients placed on minimum of high specification foam mattress within 2 hours of
admission, upgraded to dynamic system if high risk or signs of any pressure ulcers
or wounds on pressure points within 6 hours of admission. 271 272
11. Communication of Infection status
Clear communication of patients known to be infected or colonised with pathogenic
organisms including MRSA, is given to all relevant healthcare providers involved in
273
patients care.

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

Tadman J (2011) Input on guidelines email communication. 23/8/11

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