The Chronic WoundPage 2 of 35 Produced for Ausmed by Kim Kaim, 2017 Chronic Wounds The wound-healing...

DocumentpreparedforAusmedbyKimKaim,2017

The Chronic Wound

KimKaim,RNBNursing(Dtn)[email protected]

www.woundcareresource.comChronicWounds..........................................................................................................................2PhysiologyofHealing..................................................................................................................2Haemostasis......................................................................................................................................................2Inflammation....................................................................................................................................................3Proliferation......................................................................................................................................................3Remodeling.......................................................................................................................................................4Whatcausesawoundtobedetainedinoneofthephasesofhealing?.......................................4Haemostasis......................................................................................................................................................4Impactofdelayinginthehaemostasisphase...................................................................................................4Inflammation....................................................................................................................................................4Impactofdelayingintheinflammatoryphase.................................................................................................5ProliferationandEpithelialization....................................................................................................................5Impactofdelayingintheproliferationphase...................................................................................................5Remodeling.......................................................................................................................................................5Impactofdelayingintheremodelingphase....................................................................................................6

HypertrophicScars........................................................................................................................................6KeloidScars...................................................................................................................................................6Reducedscarstrength..................................................................................................................................7

Whatisthecorrectnursingcareofsuchawound?......................................................................7AssessmentandManagement....................................................................................................7History...............................................................................................................................................................7Examination......................................................................................................................................................9

TisforTISSUE.............................................................................................................................................11IisforINFECTION/INFLAMMATION..........................................................................................................14MisforMOISTURE.....................................................................................................................................17EisforEDGES.............................................................................................................................................18

Investigation...................................................................................................................................................19Diagnosis.........................................................................................................................................................19Implementation..............................................................................................................................................21

GettingDressed..........................................................................................................................................23Howtoavoidskinbreakdown?.................................................................................................29AppendixB–DressingSelectionGuide......................................................................................32References..............................................................................................................................33

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ProducedforAusmedbyKimKaim,2017

Chronic Wounds Thewound-healingprocessconsistsoffourhighlyintegratedandoverlappingphases:hemostasis,inflammation,proliferation,andremodeling.Therearemanyfactorsthatcanaffectwoundhealing,whichinterferewithoneormorephasesinthisprocess,resultinginimpairedtissuerepair(1).Chronicwoundsarewoundswhichhavefailedtoprogressthroughthenormalstagesofhealinginatimelymanner.Oftentheybecome‘stuck’inastateofpathologicinflammation.Mostchronicwoundsseeninthehospitalandagedcareenvironmentsareulcersthatareassociatedwithischemia,diabetesmellitus,venousstasisdisease,orpressure(1).InAustralia,itisestimatedthat433,000peoplesufferfromchronicwoundsataconservativeannualestimateof$2.85billion.(informationfromtheWoundsCRC-http://www.woundcrc.com/)

Physiology of Healing Whenawoundingtotheskinoccursthebodyimmediatelyrespondstoattempttorestorethenormalfunction.Theresponseinvolvesstoppingthebleeding,cleaninguptheareaandfightingoffinfection,re-establishingasuitablebloodsupplytotheareatobeabletomakerepairs,andrepairingthedamage.Theresultisnottheregenerationofnormalskinbutarepairintheformofascar(2).

HaemostasisImmediatelyaftertheinjury,thedamagedbloodandlymphaticvesselsundergovasoconstrictiontosloworstopbloodlossintheaffectedarea.Undernormalconditionsplateletscirculatefreely,theydonotinteractwithintactvasculature.Butinaninjurytheycomeintocontactwithdistrurbedvasculatureorextracellularmatrix(ECM),thismakesthemadherent.Oncetheyadheretheybreakopen(degranulate)andreleaseclottingfactorsandessentialgrowthfactorsandcytokines.Thesecytokinesattractleukocytes,fibroblastsandkeratinocytes.Haemostasisisachievedbyformationofaplatelet-fibrinplugandthewoundspacefillswithafibrinclot.Theclotprovidestemporarycoverforthewoundandactsasaprovisionalmatrixthatsupportscellmigrationduringhealing(3,4).Thegrowthfactorsandcytokinesreleasedbytheplateletsareimportanttriggersnotonlyforhemostasis,butasimportantmessagesforthelaterphasesofhealing.Thecoagulationcascadeisneededtoinitiatewoundhealing(3).

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InflammationNeutrophilsquicklyenterthewoundsiteandbeginremovingforeignmaterials,bacteria,anddamagedtissue.Otherwhitebloodcellsandmacrophagesalsobegintoarrive.Thispointsignalstheinitiationoftheinflammatoryphase.Neutrophilnumberspeakafter1−2daysand,intheabsenceofinfectionorfurtherdamage,rapidlydecline.Macrophagescontinuetoincreaseuntilday5,theirnumbersthendecreaseslowlyashealingproceeds.Asignificantpopulationofmacrophageswillstillbepresentfortheproliferationphase.Theinflammatoryphasemustbetemporary.Ifthereisaninfectionorotherinflammatoryprocess,thisretardswoundhealing(3-5).

ProliferationOncetheinflammatoryphasehasproducedacleanedwoundareaproliferationbegins.Thisisthe‘repair’phaseofwoundhealingasnewtypesofcellsmoveintostarttheprocessesofgranulationandepithelialization.Granulationfillsthebaseofthewoundbedwithanutrientandoxygenrichenvironmentforepithelialization(themigrationofepithelialcellsoverthewoundsurface)totakeplace(3,5).Granulation:Initially,ECMisdepositedinanunorganisedway.Whilethewoundhealsthismatrixiscontinuallydegradedbyproteolysisandresynthesizedasneeded.Forexample,forbloodvesselstogrowintothearea(angiogenesis),capillaryendothelialcellsdetachand,usingproteasestodissectapathway,migrateintothehaphazardmatrix.Thesecapillarysproutscangrowuptoafewmillimetersperdayandarewhatgivesthegranulatingwoundbeditsred,‘granular’appearance(3,4).Asthegranulationphaseprogresses,myofibroblastsgrowacrossthewound,anchoringtotheedgesandstarttocontract,pullingtheedgesinanddecreasingthewoundarea(4).Epithelialization:Attheedgesofthewoundkeratinocytesproliferateandproducedaughtercellstomigrateintothewoundbed.Proteolyticactionisrequiredtodissectapathwayforkeratinocytemigration,thesameasforangiogenesis.Ifascabispresentthekeratinocyteshavetoburrowunderneaththescabandphagocytoseanddigestanydebristheymayencounter,notjusttheECM.Butinamoistenvironment,withoutascab,themigrationiseasierandhealingisaccelerated.Thisdiscoveryledtodevelopmentoftheconceptofmoistwoundhealing(4).Whilethisnewlayerofcellsisdelicate,mostmodernwounddressingsdonotremovethemwhen

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thedressingischanged.However,ifadressingisallowedtodryoutoradheretothewound,traumaticremovalofthedressingmayharmthedelicatenewepitheliallayer(3).Theprocessofre-epithelializationiscompletewhenkeratinocytesmigratingfromthewoundmarginsreacheachotherandcontactinhibitioninducesacessationofmigration.Becausekeratinocytesarelocatedaroundadnexalstructures,ifthewoundissuperficialandthesestructuresareintactthemigrationcanoccurfromthesesites.Itiscommontofind‘islandsofepithelium’inalargesuperficialwound.Forfullthicknesswoundsofthesamesizeallofthemigrationmuststartatthewoundedges,thereforere-epithelializationisslower(4).

RemodelingNowthatthewoundisclosedoverandtheimmediaterepairstotheskinarecomplete,thebodyhastime(upto2yearsactually)toremodelthetissue.Proteolysiscontinuesinthisphase,degradingtheexistingECMandresynthesizingandcross-linkingthenewmatrixtoachievegreaterwoundstrength(3,4).However,evenaftermonthsofremodeling,thetensilestrengthoftherepairedskinwillnotachievemorethan80%ofthestrengthofnon-woundedskin(4,5).Theresultantscartissueisbrittleandlesselasticthannormalskin.Hairfolliclesandsweatglandsdonotgrowback.Scartissueisunattractivebutitachievestheneedofthebodytorestoreskinbarrierfunctionandpreventtheingressofbacteria(4).What causes a wound to be detained in one of the phases of healing? HaemostasisThereareanumberofmedications(antiplateletandanticoagulantdrugs)andcomorbidities(HemophiliaAandB,FactorII,V,VII,X,orXIIdeficiencies,andvonWillebrand'sdisease)thatwillimpactonaperson’sabilitytoformaclot.ImpactofdelayinginthehaemostasisphaseThemostobviousimpactatthispointistheinabilitytostopbleeding,notonlyattheinitialinjurybutalsoatdressingchanges.Thedegreeofbleedingcanbeanythingfromannoyingtolifethreatening.Managementofthedisorderwilldependonthecause.Fortheolderpopulation,manywillbeonmedicationsthatdiscourageclotting.ThesemedicationsdonotSTOPclottingbutwillslowitdown.Thisdelayintheclottingprocessmeansareductionincytokinesreleasedtostartthehealingprocess,thereforeadelayinthehealingprocess.InflammationTherearemany,manywaystokeepawoundintheinflammatoryphase,intentionallyorunintentionally.Theoldpracticeofwettodrydressingschangedmultipletimesadaywouldkeepawoundintheinflammatoryphasetoencouragewoundcleaning.Moderndressingproductsthatarenonadherentandwillnotdryoutorleavefibresinthewoundbedreducetheriskofencouraginginflammation(6).

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Alsoprolonginginflammationarecomorbiditiesthatencourageoedema(suchasperipheralvasculardisease,lymphoedemaandheartandkidneyfailure),diabetes,medications(anti-inflammatories,immune-suppressant,chemotherapy),infection,foreignmatterordevitalizedtissueinthewoundbed,excessexudateandmechanicaltrauma(likenearajoint,flexureorfold)tonameafew.ImpactofdelayingintheinflammatoryphaseThemainimpactofadelayintheinflammatoryphase,atthecellularlevel,includesincreasedexudateformation,continuallyre-activatingneutrophilsreleasingradicaloxygenspeciesandcontinueddestructionofECMandtissue(7,8).Ithasalsobeensuggestedthatanamplifiedinflammatoryresponsecontributestoincreasedscarformation(9).Morepositiveimpactswouldincludemorerecruitmentofendothelialcellsleadingtoincreasedangiogenesisandthereforeoxygentothewoundbed(7).Thisisreflectedinanincreaseinscarstrength(10).Unfortunately,keratinocytesthatmayhaveproliferatedandsuccessfullymigratedintothewoundbedareatriskofbeingdestroyedbythehighlevelsofradicaloxygenspecies(ROS)releasedbythehighnumberofneutrophilsandMMP’sfromcontinuouslysynthesizedPDGFandTGF(7,11,12).However,oncethewoundisfinallyadvancedbeyondtheinflammatoryphasethereshouldbeanexcellentoxygensupplytothewoundbedtofueltheirmigrationandproliferation(13).ProliferationandEpithelializationAsmentionedearlier,thecontinuationoftheinflammatoryphasehasasignificantimpactontheproliferationphase.Thenewcellscannotsurviveinthehostileinflammatoryenvironment.Butalsoimpactingonproliferationarenutrition(provisionofproteinandenergy(14)),dressings(occlusivedressingscanactuallyencouragehypergranulation(15)),smoking,peripheralarterialdiseaseanddiabetes.Theselastthreeitemsallrelatetothebody’sabilitytogetoxygentothedamagedtissuetoenablerepair.Thisisoneofthefewareaswhereagealsoplaysadirectpartinslowinghealing.ImpactofdelayingintheproliferationphaseConcernsofdelayingthisphaseincludeinfection,continuationoftheinflammatoryphaseaswellasimpactsonscarformation.Also,ifproliferationisnotabletooccurandthereisaVERYlongextensionoftheinflammatoryphase,somecellshavebeenknowntoturnmalignant.ThesearecalledMarjolinUlcersandhavebeenassociatedwithburnwounds,pressureulcers,osteomyelitis,venousstasisulcers,fistulas,andchronictrophiculcersinleprosy.DevelopmentofaMarjolinulcerisslow;measuredindecadesinsteadofyears(16).RemodelingThereductioninproliferatingcellssuchasfibroblastsandendothelialcellsmarkstheestablishmentofthescar.Scarstakeupto2yearstomature(2).Duringtheremodelingphase,theextracellularmatrixisreorganized.Scarsareaproductofwoundhealing.Forhumansandmostanimals,theneedtorepairaninjuryquicklyhasresultedintheprocesswehavetoday.Thisisnotaperfectprocess–itdoesnot

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replacedamagedtissuewithidenticaltissue–butitisquick,limitingpotentialthreatstolifefromhavingabreachintheskin.Thenegativetothisquickbutimperfectrepairisthatscarscanbelimitinganddisfiguring,particularlywhentheinjuryisextensiveoroverajoint.Manyfactorsimpactonscarformationincludingtheextentoftraumatizedtissuearoundthewound,howlongthewoundremainsopen,thelocation,andgenetics(17).Thedifferencebetweenscartissueandnormaltissueisthat:(2)

• collagenisarrangedinparallelbundlesinsteadofthenormal‘basket-weave’,• elastininabnormallyarrangedintofragmentedandchaoticstructures,• epidermalappendagessuchashairandsebaceousglandsdonotregenerate,• histologicallyweseeathickenedepidermiswithaflatteneddermal-epidermaljunction,

and• therearealterationstovascularityandnervesupply.

ImpactofdelayingintheremodelingphaseWhenwethinkofimpactsonscarswethinkofpoorscarstrengthorpoorscarappearance.Thetwoareascanbeimpactedonnotjustintheremodelingphase,butbydelaysatanypointinthewoundhealing.

HypertrophicScarsHypertrophicscarsareraisedabovetheskinlevelandareveryinflamedinthebeginning.Ithasbeennotedthatdisregulationofanumberofinflammatorymediators,suchasTNFα,PDGF,andTGFβ,appeartoplayamajorroleinhypertrophicscarformation(5).Thesescarscanbeextremelydebilitating;limitingmovement,painful,disfiguring,andvirtuallyalwaysverypruritic(5).Initialrapidgrowthfollowedbygradualfadingandshrinkagecharacterizeshypertrophicscarsoverseveralyears.Thisprocessoftenleadstowidened,unattractiveskindefects(17)Hypertrophicscarringisvirtuallycertaintooccurinburnsthathavetakenalongtimetoheal,althoughrapidlyhealingburnsmayalsoresultinseriousscarformation.Geneticsandlocationalsoappeartoplayalargepartinscarformation;darkskinnedpatientsandareasonthechest,upperback,shouldersandupperarms,haveasignificantlyhigherriskofseriousscarring(2,5).Thedevelopmentofahypertrophicscaris,toacertaindegree,linkedtothetimetakentoheal.Therefore,usingdressingsandtechniquesthatreducetimetohealingmaycontributeindirectlytoreducinghypertrophicscarring.Forpatientswhoarepronetoscarring,preventativemeasurescanbetakensuchastheuseofcustomizedpressuregarments,andsiliconwounddressings.ForscarswhichimpactonADLs(ie.limitmovement)surgicalscarrevisionmayberequired(5).

KeloidScarsKeloidscarsareverydifferentthanhypertrophicscars,andwhiletheydosharesomecommonfeatures,theytendtobecomemuchlargerthantheoriginalwound.Theywillalsopersistandreoccuraftersurgicalexcision(17).Whilekeloidscarringisconsideredtobeinherited(andthereforemorerelatedtogeneticsthanhypertrophicscarring)therearesimilaritiesatthecellularlevelwiththedisregulatedinflammatorymediators(2).

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Keloidsaredisfiguring,painfulandpruritic,especiallywhenactivelygrowing.Theymayappearweekstomonthsaftertheinitiatinglesion,growingtogreaterthantheinitialscarsize.Thesescarsseldomregressspontaneously,butmaysoftenintheelderly.(2)Preventionandtreatmentofkeloidsisevenmoredifficultthanthatofhypertrophicscarring(5).

ReducedscarstrengthFibroblastsareakeytogoodscarstrength.Lackofoxygen,diabetes,systemicglucocorticoids,smokingandlackofproteinallimpairfibroblastfunction.NSAIDS(ibuprofen)havebeenshowntohaveananti-proliferativeeffectonwoundhealing,resultingindecreasednumbersoffibroblasts,weakenedbreakingstrength,reducedwoundcontraction,anddelayedepithelializationinanimalmodels(1).What is the correct nursing care of such a wound? Healingisaverycomplexbiologicalprocessandwestilldonotunderstanditcompletely.Thefactorswehavediscussed,whichinfluencetheindividualphases,arenotmutuallyexclusive.Asinglefactor,orseveralfactors,mayplayaroleincontributingtotheoveralloutcomeofthehealingprocess(1).Therefore,whenaddressingthechronicwoundweneedtobethoroughinidentifyingallthepossiblebarrierstohealing.

Assessment and Management Assessmentisaboutcolletingdata.Buttherearesomanythingstoremember!!Yearsago,clevererpeoplethanIcreatedmnemonicstomakeitallalittleeasiertoremember.TwomnemonicsthatworkwelltogetherareHEIDIandTIME.ThesestandforHistory,Examination,Investigation,DiagnosisandImplementation(HEIDI)andTissue,Inflammation,MoistureandEdges(TIME).Ihavecreatedadatacollectiontoolbasedonthesetwomnemonics,tohelpyou(seeAppendixA).Itisa2pagetoolwhichwasdevelopedtoassistpeoplenewtowoundassessment.ItisdesignedtohelpguidetheClinicianthroughastructuredproblemsolvingapproachtoinformationcollectionthatwillultimatelyresultindiagnosisofriskstowoundhealingandmanagementplansforthoserisks.Itcanalsobeusedtostructureinformationforreportingpurposes.Therestofthisdocumentwillgointomoredetailabouteachoftheseareasandthetoolitself.

HistoryAssessmentstartswithathoroughhistory,the“History”portionofthetooliscopiedbelow.ItisimportantthatyourassessmentconsiderstheWHOLEpatient,notjusttheHOLEinthepatient(18).Theterm“Complaint”referstothewoundorskinconditionthatyouareassessing,howlonghavetheyhadit,whenandhowdiditstart?Documenteverythingatthispoint,evenifyou’renotsurehowrelevantitmaybe.

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Page1,Part1ofthedatacollectiontool-HistoryHistory

• What is the complaint?

• How long has it existed?

• What has been done about the complaint so far?

• Medical History

• Surgical History

• Medications

• Social History

• Ever Smoked

• Alcohol Intake

• Mobility

• Allergies

• Diet

Youhavenowstartedtocollectquitealotofdatathatcanstartyouthinkingaboutpossibleriskstohealingandotherthingsyoumayneedtoconsiderwhencreatingyourplan.Thelistbelowiscertainlynotcomprehensive,butitcangiveyouanideaofsomethoughtsthedatayouhavecollectedsofarmightprovoke:

Impactonabilitytoheal plan

Medical Poorcirculation–howwillthenutrientsgettotheskin,howwillwaste/oedemabetakenaway?Pooroxygenation–howmuchoxygenismakingittotheskin?Metabolic–whatimpactdoesdiabeteshaveonwoundhealing?Auto-immune–forreasonsnotyetfullyunderstoodthebodyattacksit’sownorgans,includingtheskinandsupportingstructures.

immunecompromised-willnotshowtypicalsignsofinfection,doyouwatchforothersignsoruseaprophylactictopicalantimicrobial?impairedsensation–cannotfeelifcompressionistootight.

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Surgical/Iatrogenic

AlterationtolymphsystemsuchasinlymphnoderemovalforCancer–canleadtooedemaPreviousscartissue–suchasfromradiationorburns–structureisdifferenttonormalskinandslowertoheal,canbethesourceofmalignancyGatechanges–amputationwillchangegate,causingabnormalpressuresinotherareasofthefoot,potentialforfurtherulcerationinthosenewareas.

workingaroundsurgicalsites–applyingaVACaroundex-fixpinsmanagingexudatefromastomaorfistula

Nutrition Noteatingwell–oftenrelatedtoageorchoice(ie.Vegetarian)

expectdelay–higherproteinandcaloricintakeisrequiredforwoundhealing

Social Notmobile–pressurerelatedtissuedamage,poorcalfmusclepumpPoorhousingorincome–poorenvironmentalcontrolscanimpactonhealingSmoking–reducedoxygentoskin

onfeetallday–off-loading?Venousreturn?cost-cannotafforddressings

Medications CorticosteroidsAnti-inflammatoriesAnti-coagulents

Warfarin–wouldyoudebride?

Allergies Adhesives,Iodine,Chlorhexadine

ExaminationOnceyouhaveyourhistoryit’stimetouseyoursenses,Hear,See,SmellandTouchyourpatient.ConsiderSystemic,RegionalandLocalcontributors.Systemic–isthepatienthavingtroublebreathing,orientedornot,whatistheirskinlikeingeneral?Regional–istherepaininthearea,aretheirlocalsignsofvenousorarterialdisease,isthereoedema,whatistheperiwoundskinlike?Again,thelistbelowisnotcomprehensivebutwillstartyouthinkingabouttheimpactoftheseregionalsigns.

Impactonabilitytoheal plan

Oedema oedemamakesitdifficultforadequatedistributionofnutrientstofeedtheskin

Canitbemanaged?

Pulses indicatesabilityofnutrientstogettothearea

Present?Notpresent?Doyouneedtocollaborate?

Atrophy,nohair,thinshineyskin

Oftenassociatedwithlackofpulses,mayindicatepoorarterialsupply,possibleclaudicationpain

RequirescollaborationwithVascularSurgeonasaminimum–donotdebride

Haemosiderinstaining,varicoseveins,ankleflair,etc…

Oftenassociatedwithoedemaoraninvertedchampagnebottleappearance,mayindicatepoorvenousreturn

ConsidercollaborationwithVascularSurgeonorveinspecialilstasaminimum

Drycrackedskin Lessresilient,increasesriskofinfection

non-soapcleaning,waterintake?,humidity(airconditioning),moisturize

Charcotdeformity Changestogate,potentialforulceration

Requirescollaborationwithpodiatryasaminimum

Contractures Maybeputtingconstantpressureontocertainareasorincreasingbuildupofmoistureincreases.

Redistributepressureasable.Managemoisture.Collaboratewithoccupationaltherapistand/orphysiotherapist

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Finallywegettolooklocallyatthewounditself,whereisit,howbigisit?Serialsizemeasurementsneedtoberecordedastheyindicatewhetherornotawoundishealing;onesourcerecommendsthatawoundshouldbeatleast30%smaller(surfacearea)byweek4(19)tobeconsideredonahealingtrajectory.Also,thelocationofthewoundwillalsoimpactondeterminingadiagnosis(ifwedon’thaveone)andcontributetotheplan.Withthewounditself,wearetryingtorestorethenormalfunctionoftheskinandsupporttheunderlyingphysiologicalprocesses.TIMEisveryusefulhereasitfocusesourthinkingontothoseareasthatwillsupportwoundhealing.ThemnemonicTIMEstandsforTissue,Inflammation,MoistureandEdges.In2000Falanga(20)producedapaperdiscussingwhatneedstobedonetoprepareawoundbedtoacceptsomeofthenewwoundhealingtechnologiesthatwereemergingsuchasgraftingandgenetherapy.Hehighlightedtheneedforagranulatingwoundbed(T),lackofinfection(I)andasuitablemoisturebalance(M).Alittlelater,in2003(21),agroupformedtolookatgeneratingasimpleframeworkthatwouldfocusCliniciansonremovingthebarrierstohealing.TIME,wasborn.TIMEcanalsobeusedasaframeworktostartselectingdressingsfrom!Page1,Part2ofthedatacollectiontool-ExaminationExamination

• Systemic

• Regional

• Local Location

Size

o Tissue

o Inflammation

o Moisture

o Edges

ThenextseveralpagesgointoalotmoredetailaboutTIME.

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TisforTISSUEEpithelial Granulating Slough Necrotic

Theimageaboveistryingtoconveythatifthewoundisgreaterthan50%granulatingand/orepithelial,considerprotectionasyouraim.Ifitfallstothesloughandnecroticsidethenconsiderdebridement.Tissuetypestendtobedescribedbycolour.Pinkisforepithelial,redforgranulating,yellowforsloughandblackforeschar.Alsoconsiderotherdescriptorsthatmaybehelpful,thesefouralonedonotalwaysgiveyouagoodpictureofwhat’shappeninginthewound.Thewoundinthephotoontherightcouldbedescribedas90%escharand10%granulationtissue.Butthatcouldalsopertaintoacrustydryscab,andthisisreallywet;it’sactuallycoagulatedbloodfromunderabloodblister.Somayberatherthansayingescharitcouldberecordedaswetescharorevenclottedbloodfirmlyadheredtothewoundbed.Photosareagreatwaytorecordawound,butevenwithaphotoagooddescriptioncanbeveryhelpful.Theepithelialandgranulatingtissuetypesareconsideredviable.Thesearealiveanddoingwell.Sloughandeschararenotviable,theydonothaveabloodsupplytosupporthealingandtheyarenotalive.Itisdeadmaterialanditneedstogo.Thepresenceofnon-viabletissueanddebris(foreignbodies/olddressingproduct/sutures)(22):

• providesafocusforinfection• prolongstheinflammatoryphase• mechanicallyobstructscontraction• impedesre-epithelialization• masksunderlyingfluidcollectionsor

abscesses• makesitdifficulttoevaluatewounddepth

Debridementistheactofremovingdevitalizedtissuesfromthewoundbed.Theactofdebridingthewoundbednotonlyimprovesthetissueinthe

NonViable

Viable

Epithelial

Granulating

Slough

Necrotic

Debride

Protect

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woundbedbutitalsohasapositiveimpactoninflammation(restoresfunctionalextracellularmatrixproteins),moisture(reducesexudate)andedges(encouragesmigration)–theotherthreecomponentsofTIME.Anumberofthingsneedtobeconsideredbeforedebriding(23):

• Patientpreference-includingpaintolerance(plustheymightnotlikemaggots)• Skilloftheclinician–useyourteam,getothersinvolvedifneeded• Riskmanagement–isthereachanceyoucoulddomoreharmthangood,istheretraining

youcandotoimproveyourskills,andagain,istheresomeonewhocanassistyou?• Environmentalfactors–thingslikelighting,posture,PPEandriskforcontaminationofthe

environmentorfurthercontaminationofthewound• Resources-makesureyouhaveeverythingyouneedbeforeyougetstarted.Insome

areasyoumaybelimitedinyouroptions.• Contraindications-theseincludepropensitytobleed,presenceofunderlyingstructures

andlackofadequatebloodsupply.Ifdebridementisrequiredyouneedtodeterminethebestmethod.MostoftenasNurseswemakeuseofautolyticandmechanicaldebridement(thevigoroususeofasurgispongeisconsideredmechanicaldebridement).Butyouneedtobesurethatdebridement–whateverthechosenmethod–issafe.WhennottoDebrideDebridementisnotalwaysthepreferredoptionforallwounds.Inthecaseofthenecroticheelortoeinthepatientwithpoorarterialflow.Iftheareaisdry,leaveit.Itwilleventuallymummifyandauto-amputate.Tryingtomoistenorremovethetissueisonlylikelytointroducenewwaysformicrobialinvasionthatthebodyisnotabletofight(24).Also,forthepalliativepatientwherecareissupportive,againifitisdryandnotcausinganypain,leaveit(25).Fungatingwoundsarechallenginginthattheyproducecopiousamountsofexudateandodourbutarehighlyvascular.Attemptstodebridemaycausecatastrophicbleeding,howeverleavingitcausesfurtherdamagetothesurroundingskinfrommacerationandstresstothepatientfromtheodour(26).CleaningwithsomethinglikeProntosanhelpstoreducethebioburden,whichinturnreducestheexudateandtheodour(27).

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Table1:Debridementmethods

Type Mechanisms of action Advantages Disadvantages Who/where

Autolytic

Uses the body’s own enzymes and moisture to rehydrate, soften and liquefy hard eschar and slough using occlusive or semi-occlusive dressings and/or antimicrobial products to create a balanced moist wound environment either by donating or absorbing moisture

Can be used for pre-debridement, when there is a small amount of non-viable tissue �Also suitable for wounds where other forms of debridement are inappropriate

Can be used for maintenance debridement

The process is slow, increasing potential for infection �and maceration

Can be done by both generalist and specialist

Biosurgical

Larvae of the green bottle fly are used to remove necrotic and devitalised tissue from the wound. Larvae are also able to ingest pathogenic organisms in the wound.

Highly selective and rapid

Costs are higher than autolytic debridement, but treatment is short once in place �Not suitable for all patients or wounds

Can be applied by generalist or specialist practitioner with training. Closed bag method reduces skill level required and can be left for 4-5 days

Hydrosurgical Removal of dead tissue using a high energy saline beam as a cutting implement

Short treatment time and selective. Capable of removing most if not all devitalised tissue from the �wound bed

Requires specialist equipment. There is potential for aerosol spread and it is associated with higher costs

Must be carried out by a specialist practitioner with relevant training. Can be used in a variety of settings

Mechanical

Traditional method involves using wet to dry gauze that dries and adheres to the top layer of the wound bed, which is �‘pulled’ away when the dressing is removed

Newer methods are more selective, faster and relatively pain-free �

Non-selective and traditional methods are potentially harmful Requires frequent dressing changes and can be very painful for the patient

Can be done by both generalist and specialist

Sharp

Removal of dead or devitalised tissue using a scalpel, scissors and/or forceps to just above the viable tissue level. This does not result in total debridement of all non-viable tissue and can be undertaken in conjunction with other therapies (eg autolysis)

Selective and quick. No analgesia is required normally

Clinicians need to be able to distinguish tissue types and understand anatomy as the procedure carries the risk of damage to blood vessels, nerves and tendons

Can be done at the patient’s bedside or in clinic by a skilled practitioner with specialist training

Surgical

Excision or wider resection of non-viable tissue, including the removal of healthy tissue from the wound margins, until a healthy bleeding wound bed is achieved

Selective and is best used on large areas where rapid removal is required

It can be painful for the patient and anaesthetic is normally required �It can be associated with higher costs

Must be performed in the operating theatre by a surgeon, podiatrist or specialist nurses following training

Ultrasonic

Devices deliver ultrasound either in direct contact with the wound bed or via an atomised solution (mist). Most devices include a built-in irrigation system and are supplied with a variety of probes for different wound types

Immediate and selective. It can be used for excisional debridement and/or maintenance debridement over several sessions

Availability issues due to higher costs and requirement for specialist equipment �Requires longer set up and clean up time (involving sterilisation of hand pieces) than sharp debridement.

Must be carried out by competent practitioner with specialist training in a variety of settings

TablecopiedfromDebridementMadeEasy(28)

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IisforINFECTION/INFLAMMATION

Thisimageshowstheprogressionfromnormalinflammation(wherethewoundiscontaminatedwithopportunisticandtransientpathogens)tosystemicinfection.Beloweachphasearetheactionsyoucanconsiderforeachphase.Theyarecumulative:soforawoundthatappearscriticallycolonizedyouwouldwanttoclean,debrideanduseatopicalantimicrobial.Infectionistheoutcomeofthedynamicinteractionsthattakeplacebetweenahostandapotentialpathogenwherethehostdefensestrategiesaresuccessfullyevadedandthereisanegativeimpactonthehost(29).Complexinteractionsleadingtoinfectionarenotyetcompletelyunderstoodbuthavebeengroupedinto3broadareas:Contamination

• Allwoundswillhaveatransientcollectionofmicro-organisms.Whenthehost’sdefensesareadequateandtheconditionsarenotinfavourofthemicro-organism,theywillnotmultiplyandwoundhealingisnotdelayed.

Colonisation

• Microbialspeciesareabletosuccessfullygrowandreplicatebutdonotprogressfurthertodamagethehost.Woundhealingmaybedelayed.

Infection

• Thelevelofmicrobialgrowthandreplicationoverwhelmsthehost’sdefensesleadingtocellularinjuryandhostimmunologicalreactions.Woundmaydeteriorate.

Theimageshownabove,theinfectioncontinuumarrow,isamodifiedversionoftheonein“TheMicrobiologyofWounds”byPercival&Dowd(30).Theyexpandthisspreadfromcolonizationtoinfectioninto6stages:

Clean

Debride

TopicalAntimicrobial

SystemicMedications

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Table2:Stagesofmicrobialinvasion

ContaminationorTransientStage

Thisiswherebacteriaareenteringanareaandassessingitssuitabilityforcolonization.Theymayhavecomefromsurroundingareasonthepatient(endogenous)orfromtheenvironmentorhealthcareworker(exogenous).Thesebacteriaarestillinafreefloatingor‘planktonic’stageandarevulnerabletoeradication.

ColonizationStage1—ReversibleAdhesion

Ifthebacteriadecidethatthisisasuitablelocationtogrowitwillstarttoattachitselftothehostcellsusingwhateveradhesionoptionsithas.Thisiscalledreversibleadhesionbecauseitisstillpossibletoremovethesebacteriawithlowlevelsofsheerforce(egsalinerinses)andtheyarealsostillverysusceptibletoantimicrobialagentsandhostdefenses.Astimegoesontheadhesionforcesbecomestrongerandthebacteriastarttoproduceextracellularsubstancestomaketheareamoresuitable,thusstartingthedevelopmentofthebiofilm.EarlycolonizingbacteriaaretypicallyStaphylococcusandbetahemolyticStreptococci.

ColonizationStage2—IrreversibleAdhesion

Atthispointthebiofilmisnowstartingtoaltertheconditionsinthewound,makingitmoredifficultforthehostdefensesandantibioticstogettothebacteriahidinginit.Itisstillpossibletoremovebutwithagreateramountofforcerequired.Thisnewbiofilmencouragesotherbacteriatojointhecommunity.Asthecommunitygrowsandnumbersofbacteriaincreasemicro-coloniesformandareasofthebiofilmbecomehypoxic,thuscreatingasuitableenvironmentforanaerobicbacteriaaswell.

CriticalColonizationStage—ClimaxCommunityor“Biofilm”

Fromaclinicalperspective,thisiswherethewoundissufficientlycolonizedtoexertit’seffectsonthewoundandpreventhealing.Fromamicrobiologicalpointofviewitisthecriticalmassofbacteriathathasformedaviablecolonybuthasnotyetobtainedhighenoughnumberstoinvadesurroundingtissues(causeinfection).Thereisnosetnumberasdifferentcombinationsofpathogensandhostdefensesmeanthisthresholdwillvary.

LocalInfectionStage Oncethecolonyismature,growthwillcontinueexponentiallyandbacteriawillbeabletousethissafecolonyasastagingareatoinvadelocaltissues.Alocalwoundinfectionwillpresentclinicallywithredness(erythema),excessivepain,swelling,heatgeneration,woundbreakdownandincreasedlocaltemperature.Othermoresubtleclinicalsignsofinfectionhaveincludedalterationinexudate,friablegranulationtissuethatbleedseasily,malodor,anddiscoloredgranulationtissue.Reportedgranulationtissuediscolourationhasincludedyellow,green,orbluewhenbacteriasuchasPseudomonasaeruginosa,Streptococci,andBacteroidesfragilishavebeencultured.

SystemicInfectionStage

Ifthebiofilmisnotdisturbedwithappropriatewoundbedpreparationtechniques,appropriatedressingmanagementandtheuseoftopicalantimicrobialsthecolonywillcontinuetoproduceinvadingbacteriawhichcanleadtobacteriagettingintothebloodstream(bacteremia)leadingtosepsisorsepticemia(multiplicationofbacteriainthebloodandtoxinproduction),potentialorganfailure,andinextremecases,death.

Cleaning,debridingandappropriateuseofantimicrobialdressingsallhelptoreducebioburdenandreducetheestablishmentofabiofilm.Researchersarestillunclearhowlongittakesabiofilmtoform.Therearemanyvariablesincludingstrainofbacteriaandit’sadhesionmethods,hostdefensesandtypeofmaterialbeingadheredto(ieskinvsimplant).Therearein-vitrostudies(controlledenvironment,inalab/notonalivesubject)thatindicateStaphylococcusaureuscancreateabiofilmwithin2-3hoursandotherstudiesonpigmodelsthathaveestablishedbiofilmswithin48hours(31,32).Thetheoriesbehindwhythesebacteriaformbiofilms

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arealsovaried(33).Biofilmsmaybecreatedforprotectionfromhostdefenses,colonizationofanutrient-richareaand/orutilizationofthecooperativebenefitsofacommunity(33).Thebiofilmisknowntoenhancecommunalprotectionfromphagocytosisbypolymorphonuclearleukocytes(PMNs).Thismeansthatoncethehardierspecieshavestartedtoestablishabiofilmthemoresensitivespecieswillhaveasafeplacetoattachandgrow.Itmayevenmakethesesensitivespeciesappeartobe‘resistant’.Oncetheoxygenstartstobedepletedtheanaerobescanalsojointhecommunity.Thissynergybetweenaerobicandanaerobicbacteriahasbeendocumentedtoincreasetheseverityofaninfection(34,35).Thesitethebacteriachoosetocolonizemaybenutrientrich,butthebacteriastillneedtobeabletounlockthosenutrientsincludingglycoproteins,sugars,andproteins.Inordertodothisnumerousenzymesarerequired,rangingfromproteasestoglycosidases.Havingacommunityofbacteriawitharangeofdifferentenzymaticpropertiesmeansthatmorenutrientscanbe‘unlocked’whichwouldbenefitthecommunityasawhole(30).Bycreatingcommunitieswheredifferentbacteriainhabitnichemicro-habitatsbestsuitedfortheirsurvival,andwherethebacteriacooperatetomeettheircollectivemetabolicrequirements,thebiofilmismorelikelytosucceed.Ifwedonotremovethebiofilm,thenthewoundislesslikelytoheal(30,36).Howdoweknowit’sinfected?Identifyingthedifferencebetweeninflammationandinfectioncanbetricky.Generallyspeaking,erythema,warmth,exudateandpaincanbeassociatedwithboth.Inapersonwhoisimmunocompromisedorhasareducedimmuneresponseforanotherreason(suchasinthefeetofpeoplewithdiabetes)theremaybenolocalsignthatinfectionispresent;thefirstsignscouldberigorsorpainatregionallymphnodes(37,38).Chronicandacutewoundsarealsoassesseddifferentlybecauseinacutewoundswehavethewindowofthefirst48hourswherewehaveanexpectationofwhatthe‘normal’woundhealingwilllooklike.Weexpectthatfortheacutewound,after48hoursthereshouldbeareductioninerythema,warmth,exudateandpainandifthesedonotreduce,oriftheygetworse,theremaybealocalinfection.ForchronicwoundsSibbaldetal(39)recommendtwomnemonicstohelprememberwhattolookforandtoalsodifferentiatebetweensuperficialanddeepbacterialburden.Thedifferencebeingthatsuperficialbacterialburdenmayrespondtotopicalantimicrobialswhereasdeepinfectionsusuallyrequiretheuseofsystemicmedications.Forsuperficialinfection,thinkofNERDS:

• Nonhealingwounds• Exudativewounds• Redandbleedingwoundsurface

granulationtissue(friable)• Debris(yelloworblacknecrotic

tissue)onthewoundsurface• Smellorunpleasantodourfromthe

wound.

Fordeepinfection,thinkofSTONES:• Sizeisbigger• Temperatureincreased• Os[probetoorexposedbone]• Neworsatelliteareasofbreakdown• Exudate,erythema,edema• Smell

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MisforMOISTURE

Animbalanceinmoistureresultsin:

• Desiccation-slowsepithelialcellmigration• Maceration–damagetowoundmargin

Theaimistorestoreepithelialcellmigrationthroughthemanagementofexudateanditsunderlyingcauses(40).Attheedgesofthewoundkeratinocytesproliferateandproducedaughtercellstomigrateintothewoundbed.Ifascabispresentproteaseshavetobreakdownandclearapathforthekeratinocytestoburrowunderneaththescab.Butinamoistenvironment,withoutascab,themigrationiseasierandhealingisaccelerated.Thisdiscoveryledtodevelopmentoftheconceptofmoistwoundhealing(4).Whilethisnewlayerofcellsisdelicate,mostmodernwounddressingsdonotremovethemwhenthedressingischanged.However,ifadressingisallowedtodryoutoradheretothewound,traumaticremovalofthedressingmayharmthedelicatenewepitheliallayer(3).Moistureinawoundcanbemodifieddirectlyorindirectly(41):

• Directo Theuseofabsorbentormoisture-balancingdressingso Theuseofcompressionand/orelevationtoeliminatefluidfromthewoundsiteo TheuseofTopicalNegativePressure(TNP)withdevisessuchastheVAC-Vacuum

AssistedClosure• Indirect

o Controlofinfectionorbacterialloado Controlofoedemabysystemictherapysuchasthetreatmentofheartfailureo Useofimmunosuppressionorsteroidstocontrolinflammatoryexudatefrom

woundssuchaspyodermagangrenousum,vasculiticorrheumatoidulcersGeneralobservationsaboutdressings:

• DressingthatcontributetowoundmoistureincludeTenderWet,hydrogels,Honey,IodosorbPasteandother“Wet”dressings.

TooDry:Presenceofeschar,slower‘2-stage’healing

TooWet:Macerationandexcoriationdamagesperiwoundskinandslowshealing

Justright:Warm,moistwoundhealing

ManageMoisture

Contribute/ConserveMoisture

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• Dressingsthatconservemoisture(stopitfromevaporatingawayand/orhandleasmallamountofexudate)includefilmsandhydrocolloids.

• Moderateamountsofexudatecanbemanagedbyhydrofibres,alginates,foams,simpledressings(likemelolinifchangedfrequently)anddressingswhichcontaintheseitemsasoneofitscomponents.AnexampleofacombinationdressingistheAquacelSurgical,whichhasahydrofibreinterfaceandahydrocolloidadhesivebacking.

• Highamountsofexudateneedeithermuchmorefrequentchangesofsimplerdressings(suchascombine)oruseofhighabsorbencydressingssuchasZetuvitorDrymax.Alternativelyincontinenceaids(withtheelastictrimmedoff)canbesecuredtotheexudingarea.Productslikeblueys/pinkiesandimproperlysecuredincontinenceaidscanbetriphazardssopleaseusethesecarefully.

• Otheroptions.Therearesomedressingswhichwillallowtheexudatetopassthroughtoasecondarydressingssothattheprimarydressingdoesnothavetogetchangedasoftenasthecheapersecondarydressingbutstillprovidethebenefitsofthelongerweartimefortheprimarydressing(examplesaremepilextransfer,aquacel,tullegras,andsiliconeinterfacedressings).Exudatemanagementsystemsinvolvinghydrocolloidsealsandplasticbagsarealsoanoption.Topicalnegativepressuretherapycanalsobeconsidered.

EisforEDGES

Woundedgesthatare:• rolled • at a different level to the wound bed • undermined

donotallowforthemigrationofkeratinocytesacrossthewoundbed.Addressingtheunderlyingcauseshouldbetheanswer,butdebridementortheuseofadjunctivetherapiesmayneedtobeconsidered.Theaimistoencouragekeratinocytemigrationandwoundcontraction;thiswillbeseenasanadvancingwoundedgeandreductioninwoundbedsize(22).TheedgesreallyarethefinalindicatortoletyouknowthateverythingelseyoudidwithT,I,andMisworkingornot.Theotherthingtorememberisthattheseedges,andtheperiwoundskin,needtobeprotectedduringthecourseofthewoundtreatment.Thingslikeexcessmoistureandincreasedbioburdenlevelscanaffecttheperiwoundskin.Theuseofadhesivescancausedamagefromtheirfrequentremovalormaytriggeranallergicresponse.Productsusedtodebridenecrotictissuecanbejustasreadytobreakdownthehealthytissuesocaremustbetaken.Theuseofmoisturizers/emollientsandanadequateintakeofwater,daily,helptogivetheskinresilience(42).Simpleperiwoundskinprotectioncanbeobtainedbyusingbarrierwipes,creamsor

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sprays(27).Insomecases(TNPTandexudatemanagementbags)hydrocolloiddressingsandpastesneedtobeusedtoensureadequateprotection.

InvestigationOnceyouhavecollectedalloftheinformationonthefrontpagelookatitandaskyourself,Dowehaveenoughinformationtounderstandtheunderlyingproblem(diagnosis)andcreateacomprehensivemanagementplan,ordoweneedmore?Examplesofinvestigationswecandoatthebesidearethingslikecheckingforthepresenceofpulsesandsensation.Getintothepractice(onhealthypatients)offindingbrachial,dorsalispedis,posteriortibialandpoplitealpulses.Wedon’ttendtousetheseoftensodon’tgetmuchpractice.Also,having,andknowinghowtouse,amonofilamentpenortuningforktodeterminesensationperceptionisveryuseful.TheIpswichTouchTestcanalsoassesssensationbedsidewithnoadditionalequipment.Otherinvestigationsundertakenbythedoctorsincludepathologyandmedicalimaging.Youcanalwaysrecommendinvestigationsbedonewhendiscussingyourpatientwiththedoctor.Forexample,inawoundwithboneonview,itisreasonabletorecommendimagingforosteomyelitis.Inlegswithsignsofarterialorvenousdisease,itisreasonabletorecommendanABPI.Forthewoundbedthatisfriable,hasanoddorpearlytexture,especiallywherethepatienthasahistoryofskincancers,itisreasonabletorecommendabiopsy.Thedoctormayormaynotwishtoincludethisintheirplan,butatleastyouhavebroughtattentiontoapotentialproblem.RemembertouseyourSBARcommunicationskillswhenmakingtheserecommendations.Page2,Part1ofthedatacollectiontool-InvestigationsInvestigations

DiagnosisWeunderstandadiagnosistobetheidentificationofadiseaseormedicalconditionbyexaminationofthesigns,symptomsandanytestsperformed(43).InthecaseofwoundhealingwelookatbothDiagnosis(ifwehaveone)andalloftheriskfactorsthatmaycontributetopoorwoundhealing.Let’slookatanon-woundexampleoftheentireprocess.Ifapersoncomesintohospitalwithchestpainthemedicalstaffwilllookatthehistoryandallthesignsandsymptoms,runinvestigations,andeventuallycomeupwithadiagnosis(History,Examination,Investigation,Diagnosis)forthecauseofthechestpain;MyocardialinfarctorIschaemicHeartDisease,forexample.Thentherearesettreatmentprotocolsthatmayincludeanti-coagulants,vasodilators,bloodpressuremodificationandcholesterolreducingdrugsifneeded,andacertainsetof

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observationsatregularintervals(Implementation).Thepersonmaygoontoseeotheralliedhealthprofessionalstoassistwithreconditioning,longtermstrategiesforhealthyheartmaintenance,socialworkersandhomehelptoimproveindependence,andpotentiallysurgicalinterventionstoremovethecauseoftheinfarction.Thisallmakesperfectsense.Achronicwoundisnodifferent.Aninfectedulcerisjustasymptomandwe,too,needtouseHEIDI.“Ulcer”or“ChronicWound”isnotadiagnosis,butratherthemanifestationofanunderlyingdiseaseprocess(44).Givingthepersonantibioticsandawounddressing,thendischargingthemhomewhentheinfectionsettlesisonlyaddressingthesymptom.It’slikegivingthepersonwithchestpainoxycodoneandthensendingthemhomewhenthepainsettles.Whenactually,whatweneedisanaccuratediagnosistoidentifycomorbiditiesandcomplicationsthatmaycontributetodelayedhealingandtodriveappropriatetreatment(43).Somediagnosesareobvious,likewhenthepatienthitstheirarmontherollatorandgetsaskintear.Thisisaskintear(preferablywithappropriatecategory)secondarytotrauma.Wecanusuallyputadiagnosistotheacutewoundsandsomechronicwoundslikepressureinjuries.However,otherchronicwoundsthatarenothealingwithoptimumtreatmentmayeitherhavenodiagnosis,orthewrongone.Let’shaveanotherlookatthewomanwhohitherarmontherollator.Thewoundiscleaned,edgesre-apposed,anddressingswithcompressionapplied.Aftersixmonthsthewomanisseenagain,shestillhasasmallareathatappearstoheal,thengetsabitcrustyandstartsbleedingagain.Theareaisslightlyraisedcomparedtothesurroundingskin.Isthediagnosisofskintearstillappropriate?Orshouldtherebefurtherinvestigationstodeterminewhatishappeningatthecellularleveltostopthiswoundcompletelyhealing?Thisiswhereweneedtocollectasmuchinformationanddiscusstheneedforfurtherinvestigationsandpossiblyreferralwiththetreatingteam.Someexamplesofwounddiagnosesare:

• SkinTear(category1a,1b,2a,2bor3aspertheSTARclassificationsystem)• PressureInjury(stageI,II,III,IV,mucosal,unstageable,orsuspecteddeeptissueinjuryas

pertheNPUAPclassificationsystem)• Surgical• DiabeticFootUlcer• VenousUlcer• ArterialUlcer• MixedVenous/ArterialUlcer• Cancer(SCC,BCC,solarkeratosis,melanoma,andmanyothers)• Vasculitis• PyodermaGangrenosum• Toomanydermatologicalconditionstomention!

Theimportantthingtorememberisthatweneedtoknowwhattheriskstohealingaretobeabletocreatethemostappropriatecareplan.Failuretocorrectlydiagnoseawoundtypeandriskstohealingmayresultinfailedmanagementandwastedresources.Interventionsbasedonaccuratediagnosisdeliversbenefitstopatients,healthcaresystemsandsociety(45).Let’slookatthatinfectedulceragain.It’sbeenthereforoverayear.Onthisadmissiontheantibioticsreducetherednessandswellingandthewoundappearstostarthealing.Younoteinthepatient’shistorythatithasdonethisbefore.Why?Ifwehavenotgonethroughtheprocessofidentifyingriskfactorsanddeterminingadiagnosis,wedon’tknowwhy.Weneedadiagnosistoensurethewoundisadequatelymanagedandallcontributoryriskfactorsareaddressed(43,44).Asoursocietycontinuestoage,andlifestylediseasescontinuetoincrease,theproblemofpressureinjuriesand

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diabeticulcersisgrowing.Theseandothercommontypesofchronicwoundswillrequireaccurateandconcisediagnosisandappropriatetreatmentaspartofholisticcare(19).Usingthedatacollectiontool:Onceyouhavecollectedalloftheinformationonthefrontpageandcompletedyourinvestigations,gobackandhighlightthosepointsthatwillimpairwoundhealing. Lookbackonallthehighlightsandcomeupwithalistofitemsthatwillimpairhealing.Prioritiseyourlist.Thismaylooklike:Patientatriskofimpairedhealingdueto-

- venous insufficiency as evidenced by ABPI of 1.1, haemosiderin staining, ankle flair, varicose veins and pt states her ankles swell by the end of the day feeling really heavy

- >50% non-viable tissue in the wound bed - wound edges macerated - oedema++ - poor nutritional intake, unintentional weight loss of >5kg in last

~month - smoking

Also,ifyouhaveadiagnosis,writeithere.Page2,Part2ofthedatacollectiontool-DiagnosisDiagnosis

ImplementationThetoolnowhastwoparts;leftsideforthecomprehensiveplanandrightsideforthedressingplan.TakethelistofriskstowoundhealingyouhavewrittenintoyourDiagnosiswindowandconvertittoacomprehensivemanagementplan.Eachitemintheplaniscreatedtotrytomitigatetheimpactofasmanyofthehighlightedriskfactorsidentified.Theplaniswrittenintheleftsidewindow.Alist(notcomprehensive)ofthetypesofdatayoumightcollectandassociatedplansare:

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Therighthandsideofthispartofthetoolisfordescribing,step-by-step,whatdressingswillberequiredtoachieveyourgoalsassetoutinyourplanandhow.Thisisparticularlyimportanttocommunicatetheplanwheremorethanonepersonisinvolvedinthepatient’swoundcare.Thingstoconsiderare:Cleaning Doesitneedcleaning?Shoulditgetwet?Howshoulditbecleanedand

withwhatsolutions?Emollient Ithasbeenshownthatmoisturizingimprovesthebarrierfunctionofthe

skinandskinresilience(46,47).Theuseofbarriercreamsorsprayscanalsoprotectperiwoundskinfromdamagecausedbyexudate,otherbodyfluidsoradhesives(48,49).

Primarydressing Thisisthedressingthatmanagesthemoistureandmicrobialbalanceatthewoundsurface.

Secondarydressing Thismaybeneededtoholdthedressinginplaceand/orforexcessexudatemanagement.Considertheeffectofadhesivesontheskinandanyskinallergies.

Retention/compression Retentiondressingstendtobeusedinpreferencetoadhesivesonvulnerableskin.Compressionisusedprimarilyforoedemaandscarmanagement.

Frequency Basedontherecommendationsofthemanufacturer,howeverclinicaljudgmentmustbeappliedtoeachindividual’scircumstance.

DataCollected PlanHistory • Smoking • Educationtoquitsmoking

• HeartFailurewithFluidoverload

• Thetreatingteamwillbemanagingthefluidoverload,buttheconditionwillimpactonanyplansforcompression:compressionshiftsthefluidfromthelegsbackintocirculation,whichwillexacerbatethefluidoverloadproblem.

• Lossof10kginthelast2months

• Refertodieticianfornutritionalsupportinlightoftheextrarequirementsneededforwoundhealing

• Onapension • FindaffordabledressingsorsupportoptionsExamination • >50%slough • debride

• Highexudate • Managemoisture,preventperiwoundmaceration

• Oedema • Manageoedema(options:compression,elevationand/orpneumaticcompression)

• Varicoseveins,ankleflair,haemosiderinstaining

• Indicationsofvenousinsufficiency

• Longdurationofulcer(6years)and‘lumpy’tissueinpartofthewoundbase

• Furtherinvestigationrequired:DiscusswiththetreatingteamtheneedtoruleoutMarjolin’sulcerviabiospy

Investigation • ABPI:Leftleg1,Rightleg1.1

• Legswilltoleratecompressionbutthereisstilltheproblemoffluidshifts.Startlow(compression)andgoslow.

• Palpabledorsalispedis,warmfeet

• Indicationsofagoodarterialsupply

• Biopsy

Diagnosis ?VenousLegUlcer Discusscompressionoptionswiththetreatingteam–thefluidoverloadmayhavetobecontrolledfirst.DiscusswiththetreatingteamtheoptiontorefertoVascularSurgeonforasurgicalsolution.

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Page2,Part3(finalpart)ofthedatacollectiontool-InterventionIntervention

Cleansing

Emollient/Barrier

Primary Dressing

Secondary Dressing

Retention/Compression

Dressing change frequency

Review:

Somewoundswillbereallysimpleandsomewillbereallycomplexandrequireverybroadcollaboration.Havingaguidetocollectingdatahelpstobreakdownhowcomplexitis,whoelseneedstobeinvolved,andwhatwillimpactonthewoundhealingthatwemayormaynotbeabletohaveaneffecton.Theverylastpartoftheformaskswhenwillthisneedtobereviewed?Thisistoremindusthatplans,oncelaid,arenottobeforgottenbutre-visited.Whatshouldweexpectandwhen?Areareduction?Nomaceration?Edgesadvancing?Reductioninodour?Howlongshouldittakebeforeweseethesechanges?Woundsareeverchangingandwhatmaybetheperfectplannowmayneedtoberevisedinthefutureasthewoundexudatereduces,non-viabletissuereducesorperhapsitstartstoshowovertsignsofinfection.

GettingDressedTherearehundredsofdressingsonthemarket,eachcompanyinformingyouthattheirproductisthebest.Andasdressingsbecomemorecomplextheyalsobecomemoreexpensive.Despitethecomplexityandtheexpense,thereisnosingledressingsuitableforallwounds.Dressingselectioncomesdowntowhatyourwoundislike,whatyourpatientprefers/cantolerateandwhatyouhaveaccessto.Firstyouneedtoconsiderwhatitisyouwantfromadressing.Consider:

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• Moisturemanagement-Absorbsandremovesexcessexudatewhileprovidingamoistenvironmentforhealing

• Temperaturemanagement• Bioburdenmanagement–Providea

barriertopathogensorhavebactericidal/bacteriostaticproperties.

• Doesnotpromoteinfection• Nodead-space• Protection-Promotesagainst

mechanicaltrauma(pressure,shearing)

• OdourControl

• Painmanagement• Beautify• Allowsgaseousexchangeif

appropriate• Doesnotleaveresidualfibresor

toxins• Doesnotcausehypersensitivity• Issimpletoapplyandeasytoremove

(atraumatic)• Comfortabletowear• Adaptabletobodyparts• Doesnotinterferewithbodyfunction• Iscosteffective

It’salsoimportanttounderstandthedifferencebetweenGenericdressingtypesandbrandnames.Dressingchartsfromindividualcompanieswilllisttheproductsbytheirbrandname,butnon-brand-specificcharts(suchastheNHSFormularyandthetableswithinthisdocument)willusetheirGenericNames.Byunderstandingthegenerictypesandwhattheydoyoucanapplythatknowledgetoanycompany’sproducts.Someofthegenericnamesare:NaturalFibreHydrofibreNonAdherentMuti-layeredIslandCalciumAlignateSemipermeableOdourAbsorbingTulleGrasHydrogelsTransparentSiliconHypertonicSaline

FoamMonosaccharidePolyurethane/SurfactantInteractiveWetCelluloseDressingZincCadexomerIodineNegativePressurePolyacrylateFixationSheetAntimicrobial&Antibacterial

Therecanalsobecombinationsofthesedressingswheremanufacturer’sareattemptingtocombinethebenefitsofdifferentmaterials,suchascombiningatullegraswithanantimicrobialtomakeanantimicrobial,non-stickdressing–AtraumanAg,Bactigras,Inadine.Knowing,however,thateachoftheseisstillatullegraswillinformtheclinicianthatnomatterwhichoneischosenitwillnotabsorbexudate,willrequireasecondarydressingandmaypromotehypergranulation.Tohelpexplainthedifferentstrengthsandweaknessesofthevariousgenericdressingtypes,theRoyalChilden’sHospitalMelbourne(50)hasproducedthetableonthenextpages(modifiedslightlybytheauthor).Itdoesnottellyouwhattouse,butitdoesgiveyouthestrengthsandweaknessesofthedressingsyoumayhavetochoosefrom.ThereisalsoadressingselectiongridinAppendixBwhichmaybeuseful.

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Types Examples Indications Advantages Disadvantages Contraindications

Syntheticfibregauze TopperCombine

Onlyuseonminorwoundsorassecondarydressings

Moreabsorbentthancotton.Doesnotshedfibres

Oftenstickstowoundsurfaceanddisruptswoundbedwhenremoved.Createsadrywound

Moderatetoheavilyexudatingwounds

Islanddressings–slightly

absorbantnon-adherent

padwithanadhesivecover

PrimaporeMeporeOpsitepostopCompose

Acutesurgicalincisions.Woundshealingbyprimaryintentionorlowexudatingwounds

Absorbsexcesswoundfluid,maintainasterileenvironementandprovidesaprotectivebarrieragainstfurthertrauma

UnabletoabsorbhighamountsofexudateRemovalmaycausetraumatosurroundingtissue

Moderatetohighlyexudatingwounds

Semi-permeable–thin,

adhesive,transparent

polyurethranefilm

OpSite,Tegaderm

Superficialwounds.Asasecondarydressing.

Somemoistureevaporation,Reducespain.Barriertoexternalcontamination.Allowsinspection.

Exudatemaypool,maybetraumatictoremove.

Moderatetohighexudativewounds.

NonadherentMoist(Tulle

GrasDressing)–Gauze

impregnatedwithparaffin

orsimilar.

Jelonet,InterposeUnitulleCuticernMepitel(silicone)

Woundshealingbysecondaryintention,superficialcleanwounds

Reducesadhesiontowound.Moistenvironmentaidshealing.

Doesnotabsorbexudate.Requiressecondarydressing.Maypromotehypergranulation

AllergytoparaffinproductsAllergytosiliconeproducts

��NonadherentMoistfor

contaminatedwounds–

Gauzeimpregnatedwith

antisepticsorantibiotics

BactigrasXeroform

Burns.Contaminatedorinfectedwounds

Reducesadhesiontowound.Moistenvironmentaidshealing.Antiseptictherapyincontaminatedorinfectedwounds.

Doesnotabsorbexudate.RequiressecondarydressingMayinduceallergyordelayhealingwhenimpregnated

Allergy

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��NonadherentDryThin

perforatedplasticfilm

coatingattachedto

absorbentpad

MelolinMeloliteTricoseExu-dryMesorb

WoundswithmoderateexudatesEpidermalwoundsorwoundshealingbyprimaryintention

Lowwoundadherence.Mayabsorblightexudate.

Notsuitableinhighexudate(exceptexu-dry&mesorb).Candryoutandsticktowound.Mayrequiresecondarydressing.

Drywounds(maycausetissuedehydration)

��CalciumAlginate.Natural

polysaccharidefrom

seaweed

��KaltostatSorbsan,AlgiSiteM

Moderatetohighexudingwoundsandforwoundswithminorbleeding.Chronicwounds:legulcers,pressureulcers,diabeticulcersAcutewounds:donorsites,abrasions.

Formsgelonwoundkeepingenvironmentmoist.Reducespain.Packscavities.Absorbentinexudativewounds.Haemostasis.

Mayrequiresecondarydressing.Gelcanbeconfusedwithsloughorpusinwound.

Kaltostatnotsuitableforuseininfantslessthan12monthsDrywoundsorhardescharSensitivity

��Foam-

��Polyurethanefoam

dressing,somewith

adhesivelayerincorporated

PolyMemAllevynHydrasorbMepilexMepilexborderAllevyncavity

Woundswithmildtomoderateexudate.

Moistwoundenviroment,highlyabsorbentandprotectivePermeabletooxygenandwatervapour

Willnotdebridehardexudate

Drywounds.Necroticwoundsorhardeschar.

Hydrocolloid-

Polyurethanefilmcoated

withadhesivemass

DuodermComfeelColoplastsheet

Burns(small)Abrasions

Waterproof.Conformswelltowound.Gelformationprovidesmoistwoundenviroment

AvoidonhighexudatewoundsGelmistakenforwoundinfection

DirtywoundsInfectionWoundswheremuscle,tendonor,boneexposedIfwoundrequiresfrequentchanges

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��Hydrogel–

Composedmainlyofwater

inacomplexnetworkor

fibresthatkeepthe

polymergelintact.Wateris

releasedtokeepthewound

moist

��IntrasitegelIntrasiteconformableSolositeSolugel

Necroticorsloughywound

Createsoptimalmoistenvironmentrehydratingwoundbedandremovingdeadtissue.Reduceswoundpain.Conformstowound.

PotentialtomaceratesurroundingtissueRequiresadditionalsecondarydressingtosecure

ModeratetoheavilyexudatingwoundsAlllergySuperficialwounds

��Hydrofibre–Softnon-

wovenpadorribbon

dressingmadefromsodium

carboxymethylcellulose

fibres

Aquacel

LesionsandcavitywoundsacuteandchronicWoundshealingbysecondaryintention

InteractwithwounddrainagetoformasoftgelAbsorbsexudate.Providesamoistenvironment

Secondarydressingneeded

Dryandnecroticwounds

��Multilayerabsorbent

dressings–eithersemi-

adherentornon-adherent

layer,combinedwithhighly

absorptivelayersoffibers

CombiDerm

Lowtomoderatelyexudingchronicandacutewounds

Promotemoistwoundhealing,mayreducemaceration

Mayrequiretapeorbandagetosecure

Nottobeusedwithhydroactivegel

��Odourabsorbing

ActisorbplusCarboFlex

Malodorouswounds

Maskwoundodours

Mayneedasecondarydressing

Dressingnottobecut

��Hypertonicsaline

impregnated-infusedwith

sodiumchloride

��HypergelMesalt

��Woundswithexcessiveexudate.Moistnecrotic,drainingandinfectedwounds.

��Wicksmoistureawayfromwounds.Promotesautolysis,reducesodour.

��Maydrythewoundouttoomuch.Maycausestinging/discomfort

��Bleedingwoundsorexposedtendon,boneormuscle

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��Silverdressings

Dressingscontaining

variousdosesofsilver

content

ActicoatActicoat7AquacelAGAtraumanAGMepilexAG

Infectedwounds�Burns

��Bacteriocidal–killspathogenssuchasMRSAandVRE

Questionsremainregardingaccumulationtoxicityandresistance.Shouldbeusedwithcare.

Allergy.Somecan’tbeusedwithoilbasedproductsortopicalantimicrobial

��Paperadhesivetape-

adhesivetapemaybe

applieddirectlytohealing

laceration

Micropore ��SmallwoundsDressingretention

Nonallergenic.ProvideswoundsupportPermeabletowaterandwatervapour

Nonabsorbent Exudativeorlargewounds.

��FixationSheet-Porous

polyesterfabricwith

adhesivebacking

FixomullHypafixMefix

SuperficialwoundsTosecuredressings

ConformstobodycontourshypoallergenicCanbesterilisedwithoutreducingadhesiveness

Requiresadhesiveremovertoremove

Infectedwoundsallergytoadhesives

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How to avoid skin breakdown? Whatmakesskinbreakdown?Ischaemia,frictionandexcessmoistureandnotenoughmoisture

wouldbeatthetopofthislist.Dryskincracksandisitchy,encouragingscratchingandfurther

damagetotheskin.Thisencouragesopportunisticpathogensontheskintoinvadeandleadto

infections.Skinthatistoowet,suchasthoseinskinfolds,aroundthetoesandsacralareainthe

incontinentpatientcanbecomeexcoriated.Again,opportunisticpathogensawait,butthistime

theyhaveamoistenvironmenttoexploit!Friction,eventhesimpleactionofslidingupanddown

abedonnicecottonsheets,canbeenoughtostripepidermis,onceagaincreatingabreakinthe

naturaldefenses.Toavoidtheseyouneedtoaddressthecause:

• Moisturisertokeepskinfromdryingout

• Thoroughdryingofskinfoldsanduseofbarriercreamsasneeded

• Avoidanceoffrictionwherepossible(useofslidesheetsforrepositioning,a‘break’inthe

bedsothepatientdoesnotslidedownthebed,avoidingadhesives)

Ischaemiacausesthegreatesttissuedestruction.Ifthetissuesdonotgetoxygentheywilldie.

Tissuestrappedbetweenaboneandahardsurfacebecomeischaemic,theresultisapressure

injury.Forpatientsatriskensuretheyareassistedwithpressureareacare.Anexcellentresource

forinformationonassessmentandmanagementofpressureinjuriesisthe“PreventionandTreatmentofPressureUlcers:ClinicalPracticeGuideline(2014)”availablefrom

https://international-pressure-ulcer-guidelines.myshopify.com/

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AppendixA–WoundAssessmentDataCollectionTool

History

• What is the complaint?

• How long has it existed?

• What has been done about the complaint so far?

• Medical History

• Surgical History

• Medications

• Social History

• Ever Smoked

• Alcohol Intake

• Mobility

• Allergies

• Diet

Examination

• Systemic

• Regional

• Local Location

Size

o Tissue

o Inflammation

o Moisture

o Edges

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Investigations

Diagnosis

Intervention

Cleansing

Emollient/Barrier

Primary Dressing

Secondary Dressing

Retention/Compression

Dressing change frequency

Review:

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Appendix B – Dressing Selection Guide NonetoLow LowtoModerate ModeratetoHigh HightoVeryHigh

Epithelial

Film

Interface

Simpledressing

Foam

Hydrocolloid

HighAbsorbent HighAbsorbent

Antimicrobial/interface

Antimicrobial/simple


Antimicrobial/Foam

Medicatedbandage Medicatedbandage

Granulating

Film

Hydrogel

Interface

Foam

Hydrocolloid

Alginate

Hydrofibre

HighAbsorbent

Povidone-Iodine

EnzymaticGel

Antimicrobial/Foam


Cadexomer-Iodine

Antimicrobial/Alginate

Antimicrobial/Hydrofibre


Slough

Hydrogel

Foam

Alginate

Hydrofibre

HighAbsorbent

EnzymaticGel

Cadexomer-Iodine

EnzymaticGel

Cadexomer-Iodine

Antimicrobial/Foam

Curasalt(Curity)


Cadexomer-Iodine

Mesalt


Necrotic Hydrogel

Hydroactive

Hydrocolloid Foam

Alginate

HighAbsorbent

Povidone-Iodine

Antimicrobial/Hydroactive

Cadexomer-Iodine Cadexomer-Iodine

Antimicrobial/Foam


Antimicrobial

ThistablehasbeenmodifiedfromthoseusedintheNHSExampleproductsGeneric Brand Generic BrandFilm Tegaderm

Opsite

MedicatedBandage ZipZok

Viscopaste,Icthopaste

Interface Jelonet Antimicrobial/Interface Bactigras

Sorbact

Acticoat

Simple Primapore

Compose

Antimicrobial/Simple KendallAMDislanddressing

Hydrogel Solosite Antimicrobial/Hydrogel Hypergel

ProntosanGel

Hydrocolloid Comfeel

Duoderm

HighAbsorbent Combine

Zetuvit

IncontinenceAid

EnzymaticGel FlamminalHydro

Honey

Cadexomer-Iodine IodosorbPaste

IodosorbPowder

Foam Allevyn

Mepilex(fordelicateskinonly)Antimicrobial/Foam KendallAMDFoam

AllevynAg

MepilexAg(fordelicateskinonly)Alginate Kaltostat Antimicrobial/Alginate Silvercel

Hydrofibre Aquacel Antimicrobial/Hydrofibre AquacelAg

Notcategorisedabove:

SkinProtector

§ Cavilon

§ Menalind

§ Whiteparaffin

Cavity

§ Alginate

§ Hydrofibre

Bleeding

§ CaAlginate

Malodorous

§ Charcoal

WoundClosure

§ Steristrips

Irrigation

§ Prontosan

Hypergranulation

§ Foam

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