Best practice wound management

Liz Milner

Wound Consultant

The goals of wound care:

• reducing risks that inhibit wound healing,

• enhancing the healing process, and

• lowering the incidence of wound infections.

Reduction in wound area as a predictor of healing

• Reduction in wound size @ week 2 and 4 is a good predictor of the ability to heal by week 12

• Venous leg ulcers a 20 -40% reduction in wound area within 2 to 4 weeks

• Diabetic foot ulcer a reduction of >50% by week 4

Clinical

Poor tissue perfusion/hypoxia

Necrotic tissue

High bacterial load/infection

Oedema

Copious exudate/maceration

Skin problems, e.g. eczema, hypersensitivities

Malnutrition/dehydration

Systemic conditions

Educational

Traditional knowledge/ritualistic practice

Inappropriate training and support

Lack of understanding of research process

Poor quality research

Lack of critical appraisal skills

Negative attitudes to evidence-based practice

Information overload

Psychosocial

Effects if pain, e.g. sleep disturbances

Effects of odour, e.g. social isolation

Reduced motivation with treatment

Lack of education and support

Inability to self care

Altered mood, e.g. apathy/depression

Professional /organisational

Lack of consensus; expert opinion

Inconsistent research findings

No standardisation of accepted practice

Interprofessional rivalry

Lack of effective clinical role models

Instability of health services

Lack of resources

Lack of focus on wound management

Barriers to healing

Wounds UK wounds-uk.com

Assess - Identify Short / Long Term Goals, Expected Outcomes

Plan Care, * Implement,* Evaluate Outcomes

Product selection / interventions based on skin / wound needs

Focus on Person

with wound

Understand Cause

Aetiology acute / chronic wound History, examination, investigations, referrals

Diagnosis!

Identify / Rx Factors

effecting healing

Heal

Prevent / Maintain

Palliative ongoing care

PRINCIPLES OF WOUND MANAGEMENT

W.White 05

Their Journey – Aims of Care Expected Outcome

• Healing

• Maintenance

• Palliation

• Our role is crucial: – Identifying needs addressing

• Person / wound / skin

So why does an acute wound lead to a chronic ulcer?

• Many factors e.g. impaired oxygenation, malnutrition, non-adherence to care

partnership

• Infection, increase in protease activity; decreased growth factor activity.

So why don’t wounds heal? Has it got something to do with excess protease

activity!

• It is difficult to assess the level of proteases in wound beds

– Research show a consistent trend of low levels in acute wounds and high levels in stalled wounds

The use of a point-of-care diagnostic test for protease activity

• Principles

– Treat the underlying cause and any factors that may aggravate the wound e.g. compression, pressure relief, correct ischemia etc

– Optimise the wound bed and patient condition

– Modulate protease activity, e.g. Protease-modulating dressings

Reducing excess protease activity

• Cleansing: regular wound cleansing

• Debridement: remove slough at each dressing change reducing bacterial load that may acts as an inflammatory stimuli

• Protease inactivators: to bind and inactivate MMPs and elastase

• Antiseptic dressings: ( Iodine or silver) a reduction in bacterial levels may reduce protease activity by reducing the host and bacterial protease production

Reducing excess protease activity

• Anti-inflammatories: oral or topical doxycycline is a potent anti-inflammatory and antimicrobial.

• Steroid therapy has an anti-inflammatory effect by up-regulating the anti-inflammatory proteins and down-regulating the pro-inflammatory proteins

• Dressings and devices: that absorb/remove wound exudate: absorbant dressings and materials may reduce protease activity by removing protease-containing wound fluid. An effect of Negative pressure wound therapy may reduce protease activity

Ideal best practice guidelines • Patient-centred wound care, • Reflects increasing awareness and interest among practitioners in the social impact of living with a chronic wound. • Patients are now more knowledgeable about treatment options and are increasingly becoming involved as active members of the wound-management team. • Practitioners need to keep themselves up to date on new technologies and techniques in wound healing.