Wound.care.a.handbook.for.Community.nurses.ebook EEn

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Wound Care:A Handbook for

Community Nurses

JOY RAINEY

WHURR PUBLISHERS



Wound

CareA Handbook

for

CommunityNurses



This page intentionally left blank



Wound

CareA Handbook

forCommunityNurses

J! R AINE! "S#$ BS#$ %PSN$ R&N$

%NTissue Viability Nurse, Wolverhampton Health

Car e

SERIES EDITOR

"ARIL!N E%WAR%S$ BS#'Hons($ SRN$)E*C

Specialist ractitioner, !eneral ractice Nursin", #ilbroo$

%e&ical

Centre, Sta' ' or&shir e



WW H ( R R ( # ) I S H E R S

) O N D O N * N D H I ) * D E ) H I *



+ -- Whurr ublishers )t&

.irst publishe& --

by Whurr ublishers )t&

/0b Compton Terrace

)on&on N/ (N En"lan& an&12 Chestnut Street, hila&elphia * /0/-3 (S*

*ll ri"hts reserve&4 No part o' this publication may be

repro&uce&, store& in a retrieval system, or transmitte& in

any 'orm or by any means, electronic, mechanical,

photocopyin", recor&in" or other5ise, 5ithout the prior

permission o' Whurr ublishers )imite&4

This publication is sol& sub6ect to the con&itions that it

shall not, by 5ay o' tra&e or other5ise, be lent, resol&,

hire& out, or other5ise circulate& 5ithout the publisher7s

prior consent in any 'orm o' bin&in" or cover other than

that in 5hich it is publishe& an& 5ithout a similar

con&ition inclu&in" this con&ition bein" impose& upon

any subse8uent purchaser4

Britis+ Library Cata,o-uin- in Pub,i#ation %ata

* catalo"ue recor& 'or this boo$

is available 'rom the #ritish )ibrary4

IS#N / 93/23 90 3

rinte& an& boun& in the (: by *thenaeum ress )t&,

!ateshea&, Tyne ; Wear4



vi Woun& Care< * Han&boo$ 'or Community Nurses

C+a0ter : 91

ressure sores

C+a0ter 15 :6

Woun& in'ection

C+a0ter 11 156

%iscellaneous

C+a0ter 12 111

Clinical e''ectiveness, Sarah F r eeman

!lossar y 12:

R esour ces 133

R e'er ences 137

In&e= 143



Series

This series o' han&boo$s has been &evise& to help community

nurses ans5er commonly as$e& 8uestions4 %any o' the 8uestions

are as$e& by patients, others by collea"ues4 The boo$s have been

5ritten by specialists, an& althou"h they are not inten&e& as 'ull

clinical te=ts, they are 'ully re'erence& 'rom current evi&ence

to vali&ate the content4 The purpose o' each han&boo$ is to

provi&e >'acts at the 'in"ertips7, so that tra5lin" throu"h

te=tboo$s is not nee&e&4 This is achieve& throu"h the 8uestionan& ans5er 'ormat, 5ith cr oss? re'erencin" bet5een sections4

Where 'urther in'ormation may be re8uire&, the rea&er is re'erre&

to speci'ic te=ts4 %any patients 5ant some control over their

illnesses, an& use the internet to access in' or? mation4 The use'ul

a&&ress sections inclu&e 5ebsite a&&resses to share 5ith both

patients an& collea"ues4

It is hope& that these han&y re'erence boo$s 5ill ans5er

most every&ay 8uestions4 I' there are areas 5hich you 'eel have been ne"lecte&, please let us $no5 'or 'uture e&itions4

"andy Ed;ards

vii



Prefa#

The &ay?to?&ay responsibility 'or 5oun& mana"ement is usuallyun&erta$en by nurses4 It inclu&es assessin" the 5oun&, selectin"

an appropriate treatment an& evaluatin" the patient7s pro"ress4

To &o this e''ectively the nurse nee&s to un&erstan& the healin"

process, reco"nise 'actors that may &elay 5oun& healin",

un&erstan& ho5 5oun& healin" can be optimise&, $no5 ho5 to

reco"nise complica? tions i' they arise an& $no5 ho5 to treat them4

Only 5ith a thor ou"h un&erstan&in" o' these areas 5ill it be

possible to ma$e a &etaile& assessment o' the patient an& the5oun&, an& ma$e a clinical &eci? sion on treatment that 5ill be

clinically e' 'ective4

%uch o' the success o' 5oun& care is built up 'rom

$no5le&"e an& e=perience, but ine=perience o' complications

can leave the nurse unsure 5hat to e=pect4 This can be &i''icult to

cope 5ith, espe? cially i' the nurse 5or$s in an area 5here she has

little peer support4

In recent years there have been numerous &evelopments in5oun& mana"ement, an& research has provi&e& a better un&er?

stan&in" o' the healin" process an& ho5 this can be optimise&4

%any ne5 &ressin"s have been &evelope& an&, althou"h this

shoul& enhance 5oun& mana"ement, the ran"e available may

ma$e &r ess? in" selection a &auntin" tas$4 %any 'actors a''ect

&ressin" choice, inclu&in" research articles, past e=perience,

a&vice 'rom collea"ues an& manu'acturers7 mar$etin" strate"ies4

The pro&uct chosen nee&s to be both e''icacious an& cost?e' 'ective4This boo$ is 5ritten 'or community nurses, inclu&in"

practice nurses 5ho o'ten 5or$ as the only nurse in a practice,

5hich ma$es e=chan"e o' i&eas an& $no5le&"e &i''icult4 Some

practice nurses see many 5oun&s 5hereas others see 5oun&s only

rarely, so it is more &i''icult to buil& up a $no5le&"e base on

5hich to ma$e clinical



= Woun& Care< * Han&boo$ 'or Community Nurses

i=



Prefa#&ecisions4 Nursin" home nurses can also become isolate& an&

may have &i''iculty "ettin" release 'or stu&y &ays4

The boo$ aims to provi&e a picture o' 5oun& healin" an&

r elate& 'actors 'or both acute an& chronic 5oun&s that may beencounter e& in a community practice situation4 *n overvie5 o' the

'unction o' the s$in an& phases o' 5oun& healin" is "iven be'ore

loo$in" at the rela? tionship bet5een 5oun& healin" an& the

patient7s health an& li'estyle4 Woun& assessment is an essential

component 'or 5oun& mana"ement4 This is &iscusse& in &etail

in Chapter 4 There ar e many &ressin" types available to

community nurses, an& Chapter 2 "ui&es the rea&er throu"h the

uses o' commonly use& pr o&ucts4The 8uestion an& ans5er 'ormat inclu&es many o' the

8uestions 're8uently as$e& by nurses4 Case stu&ies are also use& to

"ive e=am? ples o' both "oo& an& ba& practice4

.inally, I 5oul& li$e to e=press my sincere "ratitu&e to

Sarah .reeman, #*@HonsA, Clinical !overnance Coor&inator,

Wolver? hampton rimary Care !roups, 'or her contribution o'

Chapter /4

Joy Rainey

September 200



/- Woun& Care< * Han&boo$ 'or Community Nurses

CHAP*ER 1

Wound+ea,in-

This chapter is a basic e=amination o' the 'unctions o' the s$in,

ho5 5oun&s can be cate"orise&, the sta"es an& mechanisms o'

5oun& healin", an& ho5 a moist environment enhances 5oun&

healin"4 To un&erstan& these processes in "reater &epth, it 5oul&

be necessary to consult a &etaile& anatomy an& physiolo"y te=t4

B/4/ What 'unctions &oes the s$in have

The s$in is the lar"est or"an o' the bo&y4 It coversappr o=imately

m an& 5ei"hs aroun& 1 $"4 The s$in has many 'unctions,

5hich inclu&e the 'ollo5in"<

D %aintenance o' bo&y temperatur e

D rotection 'rom bacteria, &ehy&ration, ultraviolet ra&iation

an& physical abrasion

D resence o' nerve en&in"s that 5arn o' unpleasant stimuli such

as pain an& e=treme heat

D Helpin" the bo&y "ain vitamin D 'rom

sunli"ht4

B/4 What problems occur 5hen the s$in is bro$en

Once the s$in is bro$en the protective 'unctions o' the s$in are

lost4 The "reater the s$in loss the more serious these problems 5ill

be4

#acteria an& other micro?or"anisms can "ain entry into &eeper

tissues an& cause in'ection @see B/-4/ an& B/-4A4 .lui& is lost

'rom the bo&y an& i' the area o' s$in lost is lar"e enou"h @as in a



ma6or burnA this can be li'e thr eatenin"4

/




B/41 Ho5 is the s$in ma&e up

The s$in is ma&e up 'rom t5o layers< the outer epi&ermis an& the

&ermis4 The &ermis contains hair 'ollicles, sebaceous "lan&s an&s5eat "lan&s4 #eneath the &ermis is subcutaneous 'atty

tissue containin" nerves, bloo& vessels an& lymphatics @.i"ure

/4/A4

@aA

@bA

Epi&ermis

Dermis

Subcutaneous

tissue

)i-ure 1<1 The s$in4



Woun& healin" 1

B/4 Can I tell by loo$in" at a 5oun& 5hat layers are &ama"e&

Super'icial 5oun&s &ama"e only the epi&ermis @.i"ure /4A4 I'

the &ermis is intact, normal s$in mar$in"s 5ill be present4artial? thic$ness 5oun&s &ama"e the &ermis an& 5ill loo$ pale

pin$ @.i"ur e

/41A4 .ull?thic$ness 5oun&s reach the subcutaneous 'atty tissue or

"o &eeper to muscle an& bone @.i"ure /4A4 These 5oun&s may

r eveal islan&s o' yello5 'at an& may e=pose muscle, ten&on or

bone4

B/42 What is the &e'inition o' a 5oun&

* 5oun& is an abnormal brea$ in the s$in, as the result o' cell

&eath or &ama"e4

)i-ure 1<2 * super'icial 5oun&4

)i-ure 1<3 * partial?thic$ness 5oun&4



Woun& Care< * Han&boo$ 'or Community Nurses

)i-ure 1<4 * 'ull?thic$ness 5oun&4

B/43 Ho5 are 5oun&s &escribe& or cate"orise&

Woun&s are o'ten put into &i''erent cate"ories or classi'ications4

This enables pro'essionals to share in'ormation an& e=periences

$no5in" that they are tal$in" about similar 5oun&s4 Woun&s can be

classi'ie& in several 5ays but each 5oun& is uni8ue an& &eserves

in&ivi&ual car e4

Primary or se#ondary

intention

* common 5ay o' classi'yin" 5oun&s is by &i''erentiatin"

bet5een those that heal by primary or secon&ary intention @see

B/4FA4

Those healin" by primary intention are those 5ith s$in e&"es

that have been brou"ht to"ether, usually by sutures, clips,a&hesive strips or sur"ical a&hesive4 These may be traumatic

lacerations or sur "ical 5oun&s4

Secon&ary intention &escribes 5oun& healin" 5hen the s$in

e&"es are not brou"ht to"ether, an& have to heal by contractin"

an& 'illin" up 5ith "ranulation tissue4 These 5oun&s inclu&e le"

ulcer s, pressure &ama"e, an& lacerations 5ith substantial tissue

loss or &irty sur"ical or traumatic in6uries, 5hich may become

in'ecte& i' the s$in e&"es are oppose& an& secure&4

*y0es of

tissue

Woun&s can also be cate"orise& by the type o' tissue 5ithin the

5oun&<



Woun& healin" 2D The 5oun& contains blac$ necrotic tissue @see

B4/-A

D The 5oun& is yello5 an& slou"hy @see

B4//A



3 Woun& Care< * Han&boo$ 'or Community Nurses

D The 5oun& is re& an& "ranulatin" @see B4/A

D The 5oun& is startin" to &isplay si"ns o' the 'ormation o'

ne5 pin$ epithelial tissue @see B4/1A

D The 5oun& is "reen an& in'ecte& @see B4/A4

%e0t+ of

;ound

Woun&s can also be classi'ie& by &epth4 This is a common 5ay

o' &escribin" pressure sores an& several scales e=ist4 *n e=ample

o' this is the (: consensus classi'ication o' pressure sore severity

@Stir lin" scaleG Rei& an& %orison /00A @Table /4/A4

*lthou"h it is not usual to see pressure sores in the "eneral practi? tioner7s sur"ery, this type o' classi'ication can be use& or

a&apte& to &escribe other 5oun&s4 *lso, althou"h these are the

most common 5ays o' cate"orisin" 5oun&s, other metho&s can be

use&, such as by the cause or by the sta"e o' the healin" process that

the 5oun& has r eache&4

*ab,e 1<1 The (: consensus classi'ication o' pressure sores

Sta"e / Discoloration o' intact s$in @li"ht 'in"er pressure applie& to the intact

s$in &oes not alter the &iscolorationA

Sta"e artial?thic$ness s$in loss or &ama"e involvin" epi&ermis an&or &ermis

Sta"e 1 .ull?thic$ness s$in loss involvin" &ama"e or necrosis o' subcutaneous

tissue but not e=ten&in" to un&erlyin" bone, ten&on or 6oint capsule

Sta"e .ull?thic$ness s$in loss 5ith e=tensive &estruction an& tissue

necrosis e=ten&in" to un&erlyin" bone, ten&on or 6oint capsules

B/4F What &o the terms >primary7 an& >secon&ary intention7 mean

*s previously mentione&, 5oun&s can be &escribe& as healin" by

primary or secon&ary intention @see B/43A4 Healin" by

primar y intention shoul& be achieve& 'or all incise& sur"ical

5oun&s an& primary close& lacerations4 Woun& healin" shoul& be

rapi& because there is no tissue loss an& the s$in e&"es are hel&to"ether @see B/43A4

In 5oun&s healin" by secon&ary intention, the 5oun& e&"es ar e

apart an& the &e'ect 5ill nee& to 'ill 5ith "ranulation tissue

be'ore ne5 epi&ermis can cover the 5oun&4 These inclu&e le"

ulcers, open incisions @e4"4 a'ter &rainin" abscesses 5hen closure

may encoura"e in'ectionA an& 'ull?thic$ness bur ns4



Woun& healin" F

Occasionally, 5oun&s may be &escribe& as healin" by

tertiar y intention4 This is &esirable i' the 5oun&, such as a

laceration, has been contaminate&, e4"4 &irt 'ollo5in" an

acci&ent4 The 5oun& is initially cleane& an& le't open4 I' thereappears to be little ris$ o' in'ection it is then close& in the normal

5ay @Dealey /00A4

B/49 What are the phases o' 5oun& healin"

Woun& healin" is usually &escribe& in 'our physiolo"ical phases<

the in'lammatory, &estructive, proli'erative an& maturation

sta"es @ro'essional Development /00A4 In reality it is acontinuous process 5ith the sta"es mer"in" an& over lappin"4

The inflammatory stage! 0"# $ays %Fig&r e'()

When tissue is in6ure& or &isrupte& the bo&y7s imme&iate response

is to re?establish haemostasis4 Dama"e& cells an& bloo& vessels

release histamine, causin" vaso&ilatation o' the surroun&in"

capillaries, ta$in" serous e=u&ate an& 5hite cells to the area o'&ama"e4

It is this increase& bloo& 'lo5 an& serous e=u&ate that cause

local oe&ema, re&ness an& heat, "ivin" rise to an in'lame&

appearance4

#loo& clot

Re& bloo& cells

olymorphs

Vaso&ilate&

bloo&

vessels

%acropha"es




)i-ure 1<6 The in'lammatory sta"e< -1 &ays4



The coa"ulation system an& platelets cause the bloo& to clot,

5hich prevents 'urther blee&in" or loss o' bo&y 'lui&s4 In6ure&

vessels thrombose an& re& cells become entan"le& in a 'ibrin

mesh, 5hich be"ins to &ry an& becomes a scab4 The scab is the bo&y7s natural &e'ence to $eep out micro?or"anisms4 ha"ocytic

5hite cells @poly? morphs an& macropha"esA are attracte& to

the area to &e'en& a"ainst bacteria, in"est &ebris an& be"in the

process o' repair4 In a clean acute 5oun& this sta"e lasts up to 1

&ays4 I' the 5oun& is in'ecte& or necrotic tissue is present this

sta"e is pr olon"e&4

*estr &+ti,e phase! "- $ays %Fig&r e'-)

White cells line the 5alls o' bloo& vessels an& mi"rate throu"h

the 5alls, 5hich become more porous, into surroun&in" tissue4

Here pha"ocytic cells brea$ &o5n &evitalise& necrotic tissue,

an& the macropha"es en"ul' an& in"est bacteria an& &ea& tissue4 In

a&&ition, the macropha"es stimulate the &evelopment o' ne5 bloo&

vessels an& the 'ormation an& multiplication o' 'ibroblasts, 5hich

in turn ar e responsible 'or the synthesis o' colla"en an& other

connective tissues4 This sta"e normally lasts 'rom / to 3 &ays, but

5hite cell activity can be compromise& in &ry e=pose& 5oun&s

@%orison /00/A4

)ocalise& oe&ema

Ne5 bloo&

capillaries "ro5in"

into 5oun& mar"in

.ibroblasts

)i-ure 1<7 The &estructive sta"e< /3 &ays4



.r olif er ati,e phase! #"2/ $ays %Fig&r e')

The 'ibroblasts continue to multiply, 'ormin" colla"en 'ibrils,

5hich ma$e a 'ibrous net5or$4 This traps re& bloo& cells, 5hich

"o on to become ne5 capillary loops4 *t this sta"e the tissue is

very &elicate, havin" none o' the or"anisation o' normal tissue4

This "ranulation tissue is so calle& because o' its re& "ranular

appearance4 *s the colla"en matures, there is a rapi& increase in

the tensile str en"th4 Si"ns o' in'lammation subsi&e an& the process

o' contraction be"ins4 In an open 5oun&, this sta"e may be

prolon"e& because more colla? "en is nee&e& to repair the tissue

&e'ect4

Epithelial

cells bri&"e

5oun&

Colla"en 'ibres

!ranulation tissueWoun& contraction be"ins

)i-ure 1<8 The proli'erative sta"e< 1 &ays4

1at&ration phase! 2/ $ays to year %Fig&r e')

When the 5oun& has 'ille& 5ith "ranulation tissue, colla"en

'ibres pull in the 5oun&, causin" it to contract an& become

smaller4 This spee&s up the healin" process as less colla"en 5ill

be necessary to repair the &e'ect4 *s the 5oun& space &ecreases,

vascularity also &ecreases, 'ibroblasts shrin$ an& the colla"en

'ibres chan"e the re& "ranulation tissue to 5hite avascular tissueas epithelium mi"rates in5ar&s4 Epithelial cells 5ill mi"rate

'rom the 5oun& e&"e, s5eat "lan&s an& the remnants o' hair

'ollicles4 They mi"rate over the "ranulation tissue until they meet

5ith li$e cells 'rom another area o' the 5oun&, sometimes

'ormin" islan&s in the 5oun& centre4 This process is slo5e& &o5n

i' the 5oun& is &ry an& has a scab or eschar over it @see B4/-A4

In this case they have to burro5 un&er the &r y scab @see B/40A4



%i"ratin" cells lose their ability to &ivi&e an& so



Scab &etaches Epithelium no5

complete

*vascular scar

tissue replaces

"ranulation

Vascularity &ecreases

)i-ure 1<9 The maturation sta"e< &ays to / year4

epithelialisation &epen&s on the ability o' li$e cells to $eep

meetin"4 When the sur'ace o' the 5oun& is covere& 5ithepithelial cells, the epithelium thins4 Hair 'ollicles are not

replace&4 Woun& maturation usually ta$es bet5een &ays an& /

year 4

B/40 What is meant by moist 5oun& healin"

Tra&itionally, 5oun& care encoura"e& nurses to allo5 5oun&s to

&r y out an& 'orm a scab4 This 5as thou"ht to provi&e amechanical barrier to in'ection an& be the most appropriate

treatment4 E=ten? sive research has sho5n that this is not the case

@althou"h some clini? cians an& many patients still clin" to

tra&itional metho&sA4

Wor$ on moist 5oun& healin" starte& in the early /03-s4

The most 8uote& research in relation to this is Winter @/03A

5ho con&ucte& a clinical trial usin" super'icial 5oun&s on pi"s4

Hal' o' these 5oun&s 5ere allo5e& to &ry out an& 'orm scabs,5hereas the other hal' 5ere covere& 5ith polythene, thus creatin"

a moist envi? ronment4 The results sho5e& that those covere&

5ith polythene epithelialise& nearly t5ice as 'ast as those 5oun&s

allo5e& to &ry out4 *'ter e=aminin" the histolo"y, Winter

conclu&e& that, in the &r y 5oun&s, epithelial cells 5ere

han&icappe& 5hen mi"ratin" acr oss the 5oun& sur'ace by the



colla"en 'ibres 6oinin" the scab to the



sur'ace o' the 5oun&4 Epithelial cells in the moist 5oun&s coul&

mi"rate more 8uic$ly throu"h the 5oun& e=u&ate an& &i& not

nee& to traverse a scabbe& area @see B4/1A4

Dyson et al4 @/099A have sho5n that a moist 5oun&moves throu"h the in'lammatory sta"e o' healin" 'aster than a

&ry 5oun& an& pro&uces "reater capillary "r o5th4

Initially it 5as thou"ht that the moist environment may

encour? a"e "reater bacterial "ro5th an& lea& to a hi"her number

o' 5oun& in'ections4 This vie5 has been &isprove&4 Stu&ies by

Hutchinson an& )a5rence @/00/A sho5e& that the reverse 5as

true an& occlu&e& 5oun&s sho5e& a lo5er rate o' in'ection4

Since the late /0F-s, manu'acturin" companies have beencreat? in" &ressin"s that "ive a moist environment to spee& 5oun&

healin"4 Some clinicians 5ho clin" to tra&itional pro&ucts, such as

"auJe, use the hi"her cost o' mo&ern pro&ucts to support

their choice4 Ho5ever, mo&ern pro&ucts encoura"e 5oun&s to

heal 'aster an& "et in'ecte& less o'ten4 The unit cost becomes less

relevant 5hen vie5e& in relation to patient &iscom'ort @see B4FA,

nursin" time an& "r eater use o' other materials, such as sterile

"loves, aprons, &ressin" pac$s an& antibiotics4

Summar

y

The s$in is a lar"e or"an 5ith many 'unctions4 Woun&s can be

cate? "orise& in several 5ays, 5hich enables stan&ar&isation o'

classi'ica? tion throu"hout the nursin" pro'ession4

Woun&s can heal by primary, secon&ary or tertiaryintention, 5ith 5oun& healin" occurrin" in several phases4 In

reality this is a continuous process 5ith sta"es overlappin"4 It has

been 5ell estab? lishe& that 5oun&s "ranulate better 5hen $ept

moist4



/ Woun& Care< * Han&boo$ 'or Community Nursess5i'ter r eso? lution o' car e4

//



Thorou"h assessment o' the 5oun& 5ill ta$e time, but i' it lea&s

to the correct treatment bein" chosen an& 5oun& healin" optimise&

it is time 5ell spent4 In the lon"er term, the patient re8uires 'e5er

episo&es o' care4 *ssessment &etails can be 5ritten in the patientnotes or on a purpose?ma&e chart4 *n e=ample is sho5n in .i"ure

4/4

atient name< *nn Kones osition o' 5oun&< )e't shin

Type o' 5oun&< )aceration Duration o' 5oun&< 5ee$s

Date /H3H--

Si3e of 4o&n$!%a=imum 5i&th 1 cm

%a=imum len"th / cm

Type of tiss&e 4ithin 4o&n$ <

e4"4 slou"h, necrosis, "ranulation !ranulation

E5&$ate!

*mount, colour %inimal

O$o&r!

None, some, o''ensive None

.ain

Where, 5hen, severity Occasionally i' touche&

S&rro&n$ing skin!

Erythema, 5et&ry, ecJema Healthy

Infe+tion!

Suspecte&, s5ab ta$en, result Not clinically in&icate&

Treatment s&mmary!

Cleansin" lotion, i' use& None

Topical treatment to 5oun& an&

surroun&in" s$in None

rimary &ressin" Duo&erm

Secon&ary &ressin" None

.i=e& by N*

*ssesse& by %E

)i-ure 2<1 *n e=ample o' a 5oun& assessment chart4

B4 The nurse only has about /- minutes to see each patient4 Woul&n7t a

brie' note be su''icient

Recor&s must be $ept in or&er to ai& clinical &ecision?ma$in"

@Williams /00FA @see B4/A4 The (:CC ro'essional Co&e o'



Woun& assessment /1

Con&uct @(:CC /00A states that one o' the purposes o' recor&s

maintaine& by the re"istere& nurse is to >provi&e a base line r ecor &

a"ainst 5hich improvement or &eterioration can be 6u&"e&74

The importance o' clear concise recor&s an& the 'ailure to maintainthem can be seen as a ne"li"ent act an& a breach o' a nurse7s &uty

to car e @%oo&y /001A4

To illustrate this point consi&er the 'ollo5in" scenario4

S+enario for +ase st&$y

Nurse S ha& seen .re& on his 'irst visit to the sur"ery 5ith a le"

ulcer 4 She per'orme& a 'ull assessment, inclu&in" Dopplerrecor&in"s, an& &ia"nose& the ulcer to be the result o' arterial

insu''iciency4 .r e& &ran$ about 'our times the recommen&e&

alcohol limit each 5ee$ an& a&mitte& to smo$in" about -

ci"arettes a &ay4 He also ha& poorly controlle& type / &iabetes

an& a history o' heart problems4

Nurse S clearly remembere& her &iscussion 5ith .re& an&

stron"ly su""este& that he re&uce his alcohol an& ci"arette

consump? tion an& mo&i'y his &iet4 She also verballyrecommen&e& to the ! that a vascular opinion 5as re8uire&4

Ho5ever, a'ter per'ormin" the assessment, she 5as runnin" late

an& the entry in her recor&s reporte& >Doppler sho5s arterial,

a&vice "iven74

Over the ne=t 'e5 5ee$s, the ulcer continue& to &eteriorate an&

.re&7s approach to li'e remaine& the same4 Nurse S remembere&

tal$in" to .re& repeate&ly about his li'estyle an& &iabetes4 Her

recor&s state& >)oo$s lar"er7, >Re&resse&7, >)ar"er, a&vice "iven74

.re& receive& his appointment 'or a vascular assessment but

5ee$s be'ore this he &evelope& a severe in'ection in his le"4 This

re8uire& imme&iate a&mission an& resulte& in belo5?$nee amputa?

tion4

His 'amily complaine& to the health authority about .re&7s

car e an& sai& the amputation 5as the result o' the care he receive&

by the practice nurse4 They state& that .re& 5as una5are that his

alcohol consumption, smo$in" an& &iabetes coul& result inamputation4

.rom her recor&s coul& you &e'en& her practice

B41 What shoul& be inclu&e& in a 5oun& assessment

It is important that the cause o' the 5oun& is i&enti'ie& an&



/ Woun& Care< * Han&boo$ 'or Community Nursesrecor&e&4 ersonal observation su""ests that acute 5oun&s such

as



Woun& assessment /2

lacerations, bites an& postoperative 5oun&s are usually clearly

i&en? ti'ie&, but chronic 5oun&s such as le" ulcers are

"eneralise&4 It is important that the e=act un&erlyin" cause is

i&enti'ie&4 Is it a venous ulcer @see B942 an& B943A Is it anarterial ulcer @see B94FB940A Di& the 5oun& start 'rom trauma

or a bite In this case there may be no un&erlyin" &isease4

The treatment 'or each 5oun& type is &i''erent an&, in the case

o' venous an& arterial ulcers the opposite, so 5ithout i&enti'ication

the chosen treatment may be incorrect4 )e" ulcers are &iscusse& in

more &etail in Chapter 94

. osition

The position o' the 5oun& shoul& be clearly &ocumente& an& may

be ai&e& by the use o' &ia"rams4

Si3e

The siJe o' the 5oun& shoul& be recor&e& @see

B4A4

6istor y

The history o' the 5oun& shoul& be ta$en4 *s$ the patient ho5

lon" it has been present, 5ho, up until no5, has been &ressin"

it an& 5hat treatments have been use&4 This 5ill "ive some

in&ica? tion o' any aller"ies or treatments that have previously

'aile&4 The 5oun& may be a recurrence o' a le" ulcer @particularly

venousA an& treatment o' previous episo&es o' ulceration may berelevant @see B941A4

Skin +on$ition

It is important to assess the surroun&in" s$in4 *ny re&ness or

erythema may in&icate in'ection4 I' the patient has 'ra"ile s$in,

perhaps cause& by me&ication such as lon"?term steroi& use, it

may be inappropriate to apply an a&hesive &ressin"4

)e" ulcers may be surroun&e& by varicose ecJema, 5hich mayre8uire an emollient, or by contact &ermatitis 'rom previous tr eat?

ments, 5hich may re8uire a short course o' a topical steroi&

cr eam @see B24-, B94/ an& B943A4



/3 Woun& Care< * Han&boo$ 'or Community Nurses

Tiss&e

The state o' the tissue 5ithin the 5oun& shoul& be recor&e&4 This

5ill help to i&enti'y the "oal o' treatment an& in many 5ays

i&enti'y an appropriate treatment4 There may be more than one

type o' tissue 5ithin the 5oun& in 5hich case an estimate o' the

per centa"e o' each type shoul& be ma&e, e4"4 1-L slou"h, F-L

"ranulation @see B4// an& B4/A4

.ai

n

The patient7s level o' pain shoul& be assesse& an& treate& 5ithappropriate anal"esia4 Other 'actors to consi&er ar e<

D Is the pain ischaemic @see B949 an& B940A

D Is the 5oun& in'ecte& @see B/-4/A

D Is the &ressin" causin" pain either by &ryin" out an& a&herin"

to the 5oun& sur'ace, or by causin" an aller"ic reaction @see

B943 an& B94FA

D Is the 5oun& pain'ul at &ressin" chan"e because the &ressin"

has &rie& out or is bein" remove& inappropriately @see B4FA

*ny 5oun& o&our shoul& also be recor&e&4 This may be a si"n

o' in'ection, or may be anaerobes in necrotic tissue @see B43A4

B4 Ho5 shoul& 5oun&s be measure&

It is important to recor& 5oun& siJe so that healin" pro"ress or

&ete? rioration can be observe&4 #oth the nurse an& patient can bemoti? vate& i' healin" can be observe&4 This also encoura"es the

patient7s compliance 5ith continuin" a treatment about 5hich

they are not enthusiastic, such as compression therapy @see B940A4

The simplest 5ay to recor& 5oun& siJe is to ta$e the ma=imum

&imensions 5ith a ruler @.i"ure 4A4 * more accurate 5ay is to

trace the 5oun&, usin" a purpose?ma&e chart @available 'rom

several companies that manu'acture &ressin"sA, acetate sheets or

the clear pac$a"in" in 5hich many &ressin"s come4 The tracin"can be either store& in the patient7s notes or use& as a template to

&ra5 ar oun& an& a&& to notes4 Consi&er 5hether or not the plastic

is sterile4 It is a&visable to hol& non?sterile materials sli"htly

above the 5oun&



Woun& assessment /F

sur'ace or to cleanse the sur'ace touchin" the 5oun& both be'ore

an& a'ter5ar&s 5ith an *lco5ipe4

)i-ure 2<2 %easurin" a

5oun&4

hoto"raphs are the most accurate 5ay to recor& siJe an&

appearance o' lar"e 5oun&s @see B42A4 Woun& &epth can be more

&i''icult to measure, but use o' a sterile probe is probably the most

accurate metho&4 These are sometimes available 'rom

phar maceuti? cal companies4

B42 What sort o' issues must be consi&ere& 5hen purchasin" a camera

erhaps the most important issue is in'orme& patient consent4 I'

the materials are to be use& 'or teachin" or publication this

consent shoul& be 5ritten4 There are several other issues to

consi&er be'ore embar$in" on 5oun& photo"raphy4 #ellamy

@/002A su""ests the 'ollo5in"<

D Choice o' e8uipment

D Choice o' materials

D Choice o' pr ocessin"

D Control o' sub6ect

D Control o'

li"htin"

D Control o' bac$"r oun&4




E8uipment in the main may be 5hat is a''or&able4 %any

people choose a olaroi&?type camera because they "et instant

results an& they &o not have to 5orry about 5here to "et material

processe& or 'inishin" a 5hole 'ilm4 Results, ho5ever, may not beas "oo& as 5ith a 12?mm sin"le?lens re'le= camera4

With the choice o' materials, because the colour o' a 5oun& is

an important in&icator o' con&ition, only colour 'ilm shoul& be

use& @#ellamy /002A4 I' the pictures are to be store& in patients7

notes, prints are a&e8uate, but i' photo"raphs are to be use& 'or

publication or teachin" purposes, sli&es may be more practical4

Thou"ht shoul& be "iven to processin"4 Hi"h?street

>8uic$ process7 shops may have photo"raphs rotatin" behin& thecounter 4 )ocal labs may even have someone 5or$in" there 5ho

reco"nises the patient4 The use o' a "eo"raphically &istant

pro'essional laborator y that can provi&e con'irmation o'

con'i&entiality is recommen&e& @#ellamy /0024A .ilms shoul& be

han& trans'erre& @e4"4 by courierA or i' necessary sent by re"istere&

post, but not by re"ular mail4 ut a ruler close to the 5oun& so

that the siJe can be rou"hly ascertaine&4 This 5ill ai& reassessment

an& sho5 pro"ress4 It is also use'ul to 5rite the &ate an& the patient7s initials on a piece o' a&hesive tape an& stic$ this close to

the 5oun&G this helps to i&enti'y the patient an& also to place

photo"raphs in chronolo"ical or &er 4

)i"htin" may be &i''icult to control in a sur"ery or 5ithin the

patient7s home an& most nurses are not e=pert photo"raphers4 *

'lash or a camera 5ith an automatic 'lash 5ill be necessary in

most cases4 The bac$"roun& to any clinical photo"raph shoul& be

plain an& unobtrusive rather than the clutter o' a &ressin" trolley,tr eat? ment room, $itchen or 'ront room4

Once ta$en an& &evelope&, photo"raphs 'orm part o' a

patient7s clinical recor&s an& shoul& be store& 5ith the same car e4

B43 What can be &one about 5oun& o&our

O&our can be very &istressin" 'or the patient an& o'ten occurs in

heavily in'ecte& or 'un"atin" 5oun&s @see B//4/A4 ersonale=peri? ence sho5s that this may be the only reason a patient has

sou"ht treatment4 Some &ressin"s such as hy&rocolloi&s may

cause o&our 5hen they interact 5ith 5oun& e=u&ate @see

B24/3A4 I' this is e=pecte& to happen, either at &ressin" chan"e or

i' the &ressin" lea$s,



Woun& assessment /0

it is 5orth reassurin" the patient that the 5oun& has not become

in'ecte&4

Charcoal &ressin"s may be use& to absorb o&our @see B241A4

Oral or topical metroni&aJole may re&uce 5oun& o&our @*sh'or& etal4 /09G Ne5man et al4 /090A, or an aromatherapy oil o' the

patient7s choosin" may be applie& to the outer &ressin"4

B4F What points shoul& be consi&ere& in re"ar& to pain

ain is a sub6ective e=perience arisin" 5ithin the brain in response

to &ama"e to bo&y tissues @#on& /09A4 It is an issue that is o'ten

over? loo$e& in 5oun& care4 ain perception is uni8ue to eachin&ivi&ual an& sub6ective @%cCa''ery /091A4 ain is 5hat the

patient says it is4 Nurses7 interpretation o' a patient7s pain 5ill

a''ect the care that is "iven @Hos$ins an& Welche5 /092A4

Di''erin" 5oun&s 5ill result in &i''erent types o' pain4 S$in

&ama"e results in pain that is o'ten &escribe& as >cuttin"7 or

>burnin"74 This usually respon&s 5ell to non?steroi&al anti?

in'lammatory &ru"s @Em'lor"o /000A4 I' bloo& vessels are in6ure&,

pain may be &escribe& as>throbbin"7 in nature4 I' lon"?term ischaemia is a li$ely

outcome, opiate anal"esia may be re8uire&G i' this is unli$ely it

may be r e8uir e& initially an& then re&uce& @Em'lor"o /000A4

Dama"e to nerves results in itchin", tin"lin", smartin" or stin"in"4

This may respon& to anti? epileptic &ru"s @#on& /09G War'iel&

/00FA4 Stu&ies also sho5 that a moist 5oun& healin" environment,

5hich bathes nerve en&in"s in 'lui&, prevents their stimulation an&

thus re&uces &iscom'ort @Thomas/00-A @see B/40A4 Occlusive &ressin"s that pro&uce an anaerobic

envi? ronment also re&uce 5oun& pain @ Kohnson /099A4 I' a 5oun&

&ries out or the &ressin" causes &ryin" at the sur'ace, localise& pain

results4 This can happen i' polysacchari&e bea& &ressin"s or

al"inate &ressin"s ar e applie& to li"htly e=u&in" 5oun&s @Thomas

/00-A @see B240B24/-A4

ain on &ressin" removal can occur i' the &ressin" becomes

incor? porate& into the 5oun&4 Ne5ly 'orme& capillaries may"ro5 into &ressin"s 5ith mesh sur'aces @Dealey /00A, or i'

the &ressin" becomes saturate& 5ith e=u&ate an& then &ries an&

a&heres to the 5oun& sur'ace @Value 'or %oney (nit /00FA @see

B242A4 In these situ? ations 5oun& pain occurs an& &ama"e occurs

to tissue at each &r ess? in" chan"e4 Soa$in" the &ressin" o'' is

time?consumin" an& &oes not al5ays result in pain?'ree removal



- Woun& Care< * Han&boo$ 'or Community Nurses@Thomas /00-A4



Woun& assessment /

In'ection is associate& 5ith pain, so chec$ the 5oun& 'or the

si"ns o' in'ection @Cuttin" an& Har&in" /00A @see B/-4/A an&

treat 5ith systemic antibiotics i' in'ection is present4 ain also

occurs as a r esult o' poor ban&a"e techni8ue, 5hich causes ban&a"e slippa"e, or has insu''icient pa&&in" or incorrect

application @see B940A4

Venous le" ulcers are o'ten sai& to be not pain'ul unless

accompa? nie& by oe&ema or in'ectionG ho5ever, Ho'man et al4

@/00FA reporte& that 3L o' patients e=perience& pain4 *rterial le"

ulcers o'ten cause severe an& persistent pain, 5hich may re8uire

treatment 5ith opiates @see B940A4

ain 'rom pressure ulcers &epen&s on the &epth o' the 5oun&4Deep ulcers o'ten result in less severe pain than shallo5 ones

because the nerve en&in"s in the s$in have been &estroye&

@Em'lor"o /000A4 Ho5ever, i' the area is s5ollen or in'ecte&, pain

is li$ely4 *s 5ith pres? sure ulcers, small &eep burns o'ten result in

a lo5er level o' pain than more super'icial ones, but the site o' the

burn is si"ni'icant4 Those to the han&s, 'ace or "enitalia are more

pain'ul4

B49 Ho5 shoul& pain be assesse&

*ccurate pain assessment is the $ey to pain relie'4 Nurses o'ten

'ail to use even a simple assessment tool4 * visual analo"ue scale

is a practical tool 'or assessin" a patient7s pain at &ressin"

chan"es @Choiniere et al4 /00-A4 Type an& amount o' pain vary

bet5een in&ivi&ualsG stu&ies have sho5n that nurses o'ten 'ail

to believe patients7 reports o' pain @Sa=ey /093G Seers /09FA4 *ne=ample o' a pain assessment scale is sho5n in .i"ure 414

B40 Ho5 shoul& pain be mana"e&

*ppropriate anal"esia shoul& be o''ere& 'ollo5in" liaison 5ith

the

!, but other measures shoul& also be

ta$en4* &ressin" shoul& be chosen that 5ill not stic$ to the 5oun&

an& cause trauma, an& that is ri"ht 'or the e=u&ate level,

$eeps the 5oun& moist an& allo5s pain?'ree r emoval4

Cleansin" shoul& be by "entle irri"ation 5ith 5arm

physiolo"ical saline @see B4B4A i' it is necessary to remove

&ebris4

Woun&s shoul& not be rubbe& or scrubbe&G this 5ill not only



Woun& Care< * Han&boo$ 'or Community Nursescause unnecessary pain but 5ill also &ama"e the 5oun& be&4



Woun& assessment 1

)i-ure 2<3 *n e=ample o' a pain assessment scale4 Repro&uce& by $in& permission o'

Nursin" Times 5here this 'irst appeare&, 0 %ay /09, Vol 9-, No /0, p4 294

Other therapies such as rela=ation techni8ues, heat an& col&

therapies, an& &iversion therapy can all help re&uce perceive& pain

@Em'lor"o /000A4

B4/- What is necrotic tissue an& ho5 shoul& it be treate&

* 5oun& may contain necrotic tissue, 5hich may be so't, spon"y

an& blac$"rey, or 'orm a har& blac$ eschar over the 5oun&

sur'ace4 It is the result o' tissue &eath secon&ary to ischaemia4

This 5ill al5ays &elay healin" an& increases the chance o'

5oun& in'ection4 The treatment aim 5ill be &Mbri&ement by use o'

an appropriate &ressin" @see B24// an& B24/2A, or i' necessary

see$in" a sur"ical opinion on sharp &Mbri&ement 5hen tissue is

sur"ically r emove&4

B4// What is slou"h an& ho5 shoul& it be treate&

ello5 or slou"hy tissue is 'orme& in many chronic 5oun&s4 It is

not &ea& tissue but a mi=ture o' &ea& cells an& serous e=u&ate4 It

nee&s to be remove& to optimise healin" an& is a similar process to

&Mbri&e? ment @see B24/2 an& B24/3A4 It is important not to mista$e

e=pose&



Woun& Care< * Han&boo$ 'or Community Nurses

ten&ons or epithelial islan&s 'or slou"h because they can have a

simi? lar appearance4

B4/ What is "ranulation tissue an& ho5 shoul& it be treate&

Re& or "ranulatin" 5oun&s have 'ra"ile ne5 tissue 'ormin",

5hich is easily &ama"e&4 The aim o' treatment 5ill be to protect

the tissue an& provi&e a moist environment to optimise healin"

@see B/40A4 articular care shoul& be ta$en &urin" 5oun&

cleansin" @see B4/B4A an& a &ressin" shoul& be selecte& that

5ill not a&here to the sur'ace o' the 5oun& an& cause trauma

&urin" &ressin" chan"es4

B4/1 What is epithelial tissue an& ho5 shoul& it be treate&

in$ or epithelial tissue is the ne5 layer o' epi&ermis, 5hich

5ill cover the 5oun& 5hen it has 'ille& up 5ith "ranulation

tissue4 The epithelial cells mi"rate 'rom the 5oun& mar"ins4 They

sometimes meet to 'orm clusters or islan&s on the 5oun& sur'ace4

* moist envi? ronment ai&s movement o' these cells, so the chosen&ressin" shoul& a"ain provi&e this environment an& protect the

5oun& sur'ace @see B/40A4

B4/ Ho5 &o I reco"nise an in'ecte& 5oun&

The classic symptoms o' 5oun& in'ection inclu&e the

'ollo5in"<

D Er ythema

D Oe&ema

D Increase& e=u&ate

D O''ensive o&our

D ain

D yr e=ia4

See B/-4/B/-4, B/-4F an& B/-4/1 'or more &etails on reco"?

nisin" an& treatin" 5oun& in'ection4

Summar

y

Thorou"h assessment o' all 5oun&s is a prere8uisite 'or "oo&

car e4 *llo5in" the patient to see pro"ress improves




complianceG 5oun& measurement is simple an& &oes not r e8uir e

special s$ills4 The 5oun& shoul& be treate& in relation to the

tissue state 5ithin the 5oun&4 This 5ill chan"e over time an&

r e"ular reassessment is nee&e&4 *ssessment an& treatment o' pain ar e important parts o' 5oun& care4 Recor& $eepin" is a le"al

an& pr o'es? sional re8uirement an& accurate &ocumentation is

essential4



CHAP*ER 3

)a#tors affe#tin-;ound +ea,in-

It is not only the &ressin" that is chosen 5hich a''ects the 5ay5oun&s heal4 This chapter e=amines other issues that may impact

on 5oun& healin", an& e=plains 5hy it is important to loo$ at

the patient7s li'estyle an& health status 5hen assessin" the patient

an& plannin" his or her 5oun& mana"ement4

B14/ What shoul& be inclu&e& in a "eneral assessment o' the patient

*s 5ell as assessin" the 5oun& itsel', it is important to loo$ atthe patient holistically4 %any 'actors in'luence 5oun& healin"4

I' these are not a&&resse&, healin" 5ill be &elaye& or may even

'ail to ta$e place4 Some o' the 'actors a''ectin" healin" are liste&

in Table 14/4 Not all can be treate& but, i' hi"hli"hte&, at least an

un&erstan&in" o' 5hy healin" is slo5 can be r eache&4

*ab,e 3<1 .actors a''ectin" 5oun&

healin"

*"e See B14, B04

Concurrent &isease See B141, B04

Nutritional status See B14B14F, B04

Dru"s See B149, B04

Smo$in" See B140

E=cessive alcohol consumption SeeB14/-

%obility See B04, B94/

B14 What e''ect &oes a"e have on 5oun& healin"

*s people a"e the metabolic processes slo5 &o5n, 5hich

pr olon"s tissue repair4 Woun& in'ection may also be more

common as



Woun& Care< * Han&boo$ 'or Community Nurses1



immune competence becomes less speci'ic an& in'lammation

less e''ective @Davi& /093A @see B/-4A4 El&erly people are more

li$ely to have chronic concurrent illness, 5hich may &elay

healin" an& re8uire &ru" therapy4

B141 Which concurrent &iseases particularly inter'ere 5ith 5oun& healin"

D Diabetes has lon" been associate& 5ith poor 5oun& healin"4 It

is important to control &iabetes i' 5oun& healin" is to be

achieve&4 eople 5ith &iabetes are also more susceptible to

5oun& in'ection @see B94/9A4

D Car&iovascular an& pulmonary &isease may &elay 5oun&healin" because the transport o' o=y"en to the 5oun& site may

be ina&e? 8uate, an& o=y"en is essential 'or 5oun& healin" @see

B140A4

D (raemia increases the ris$ o' 5oun& &ehiscence as a result o'

a re&uction in colla"en &eposition4 !ranulation may also

be &elaye& @see B/49A4

D Thyroi& or pituitary &e'iciency may &elay healin" as a result

o' slo5e& metabolic rates4D Cushin"7s syn&rome treate& 5ith steroi&s 5ill &elay healin"@see

B149A4

D Rheumatoi& arthritis o'ten necessitates hi"h &oses o'

cortico? steroi&s @see B94/3A4

B14 Ho5 &oes &iet a''ect 5oun& healin"

#oth obesity an& malnourishment inhibit 5oun& healin"4 *&vice

'rom a community &ietitian may be nee&e& in some cases4

oor nutrition an& malnourishment a&versely a''ect 5oun&

heal? in" in many 5ays4 The lin$s bet5een nutrients an&

healin" ar e sho5n in Table 144 It shoul& be remembere& that

in6ury may also lea& to a patient7s ener"y &eman&s bein" hi"her

than usual4 r otein is also lost in 5oun& e=u&ate4

I' a patient is unable to maintain a "oo& nutritional status,&ietar y supplements may be necessary, in the 'orm o' tablets

@e4"4 Jinc supplements, multivitaminsA, by in6ection @e4"4

Neocytamen, ironA, or as 'oo& supplements or meal r e placements4

Obese patients have re&uce& o=y"en pressures in their tissues

@*rmstron" /009A4 *&ipose tissue is poorly net5or$e& by

bloo&



.actors a''ectin" 5oun& 2

*ab,e 3<2 Important nutrients in 5oun& healin"

Nutrient Role in healin"

rotein Repair an& replacement o' tissue

Carbohy&rate Ener"y, spares protein 'or 5oun&

healin" Vitamin C Colla"en synthesis, immunity

Vitamin #/ rotein synthesis

inc Tissue repair, protein synthesis

Iron Haemo"lobin pro&uction

Copper Increases the tensile stren"th o' colla"en

vessels so there are lar"e areas o' >&ea& space7 5hich re&uce the

o=y"en tension4 ro&uction o' colla"en is also re&uce& an& thusheal? in" &elaye& @see B/49A4 Obesity is also a ma6or ris$ 'actor in

postop? erative 5oun& in'ection an& the obese patient is more

li$ely to su''er haematoma 'ormation a'ter sur"ery, 5hich may

&elay healin" by 'urther re&ucin" tissue o=y"enation @*rmstron"

/009A4

.or the patient 5ith venous ulcers, the control o' obesity is an

important 'actor in ulcer healin", re&ucin" prolon"e& bac$

pressure in the venous system cause& by &eep vein obstruction inthe pelvic area4 Re&ucin" obesity 5ill also 'acilitate increase&

mobility an& re&uce venous stasis @see B94/ an& B949A4

When &iscussin" issues such as 5ei"ht control an& &iet, it

is important to be sure o' the patient7s level o' un&erstan&in"4

This is illustrate& in the 'ollo5in" t5o scenarios4

7ase st&$y2

Nurse * 5as as$e& to visit %iss 4 *n assessment in&icate& that

she ha& a venous ulcer4 %iss 5as 1 years ol&, mo&erately

over5ei"ht an& ha& sli"ht learnin" &i''iculties4 Her mobility 5as

impaire& by both her 5ei"ht an& s5ellin" in her le"s4 Nurse *

insti"ate& a tr eat? ment re"imen o' an al"inate &ressin" an&

sin"le?layer compression4 She also "ave a&vice about elevatin"

the le"s 5hen sittin", tryin" some mo&erate e=ercise an& losin"

5ei"ht4Over the ne=t 'e5 5ee$s, the ulcer &ecrease& in siJe an& the

oe&ema 5as settlin"G %iss ha& bou"ht a lar"e beanba" on 5hich

to elevate her le"s, an& ha& noticeably lost 5ei"ht as her

clothes appeare& looser4

Nurse * &i& not see %iss 'or several 5ee$s as other sta''

un&er? too$ her care4 When she 5ent to reassess %iss , the ulcer



3 Woun& Care< * Han&boo$ 'or Community Nursesha& almost



.actors a''ectin" 5oun& F

heale&, there 5as no oe&ema an& an improvement in mobility 5as

note&4 Her 5ei"ht appeare& to have re&uce& consi&erably over a

relatively short perio&4 When nurse * insti"ate& a &iscussion

about &iet, it became apparent that %iss ha& cut out virtuallyall 'oo& e=cept 'ruit an& ve"etables4 She e=plaine& that &inner that

&ay ha& been a bo5l o' broccoli4 She $ne5 these 'oo&s 5ere "oo&

'or her the nurse ha& sai& plenty o' 'ruit an& ve"etables but

she ha& no concept o' her bo&y7s nee& 'or protein an& some 'at

an& carbohy? &rate4 Nurse * ha& assume& this level o'

un&erstan&in"4 *'ter a &etaile& &iscussion a more healthy &iet

5ith a slo5er level o' 5ei"ht loss 5as establishe&4

7ase st&$y#

%rs R 5as an e=tremely obese 5oman o' 194 Her 5ei"ht 5as

esti? mate& to be in e=cess o' - stones but an accurate

measurement 5as &i''icult to obtain4 She ha& an e=tensively

ulcerate& le", 5hich 'aile& to respon& to treatment, an& 5as

&i''icult to &ress or ban&a"e because o' the shape o' the limb4 She

5as basically con'ine& to the &o5nstair s o' the house because o'her obesity4 She ha& been previously a&vise& to lose 5ei"ht an&

ha& been seen by a &ietitian to no e''ect4

On a 6oint visit bet5een the &istrict nurse an& !, %rs R 5as

tol& that i' her 5ei"ht &i& not re&uce she stoo& no chance o' her

5oun&s healin", an& she 5as en&an"erin" her li'e4 %rs R

a"ree& to try to stic$ to a lo5?'at &iet4

Several 5ee$s later there appeare& to be no chan"e in her siJe

an& she 5as "ettin" &espon&ent4 #oth she an& her husban& 5er ea&amant that she 5as stic$in" to a lo5?'at &iet4

The nurse &eci&e& to try to probe a bit &eeper into e=actly

5hat %rs R 5as eatin"4 It transpire& that most 'oo& 5as

prepac$a"e& an& labelle& lo5 or lo5er 'at4 This inclu&e& cheese,

cream, crisps an& chips4 #ut lo5er 'at than 5hat *"ain &etaile&

&iscussion about 'oo& shattere& the myths an& enable& %rs R to

ma$e a more success'ul attempt at 5ei"ht loss4

B142 What &ietary a&vice shoul& be "iven to help improve 5oun& healin"

in a poorly nourishe& patient

D Encoura"e a hi"h ener"y inta$e, such as san&5iches,

ca$es, biscuits an& chocolate4




D Encoura"e a hi"h protein inta$e, such as meat, 'ish, poultry,

e""s an& &airy 'oo&s4

D Encoura"e small but 're8uent snac$s4

D Ensure that any supplements prescribe& are palatable an& sip'ee&s are the ri"ht 'lavour an& temperatur e4

D Ta$e care 5ith 'oo&s that have lo5 ener"y &ensity such as

'ruit an& ve"etables4 They contain essential micronutrients

but the patient may 'eel 'ull be'ore their ener"y nee&s are met

@!uest an& earson /00FA4

B143 What shoul& be inclu&e& in a nutritional assessment

The patient7s history is important4 This shoul& inclu&e the

'ollo5in"<

D What is the patient7s normal &iet

D Have there been any recent chan"es or unintentional 5ei"ht

loss

Observe i' the patient7s clothes 'it4

D hysical measurements such as 5ei"ht an& hei"ht 5illallo5 calculation o' the bo&y mass in&e=4

D Direct observation o' muscle bul$, subcutaneous 'at,

&ehy&rate& s$in an& the patient7s "rip stren"th 5ill ai&

assessment4

D * nutritional assessment scale may be use'ul, alon" 5ith

'lui& balance an& 'oo& inta$e charts i' appr opriate4

I' necessary, involve the community &ietitian4 The patientshoul& be re"ularly reassesse& by 5ei"hin" an& monitorin"

inta$e4 This shoul& all be recor&e& on the care plan to allo5

evaluation4

B14F *re supplements o' vitamins an& Jinc use'ul to promote 5oun&healin"

The recommen&e& inta$e o' vitamin C 'or a healthy a&ult is

- m"&ay @Department o' Health /00/A4 The sic$ may re8uire

more, but ho5 much more is uncertain4 It is su""este& that

patients 5ith pressure ulcers shoul& al5ays be suspecte& o' bein"

&e'icient as a r esult o' 'actors such as chronic serious illness an&

institutionalise& &iets @Dic$erson /001A4 The best 5ay to reach the

re8uirement is by &ietary inta$e, but i' the patient is suspecte& to be

&e'icient it is usual to "ive up to /--- m"&ay split into 'our &oses4



.actors a''ectin" 5oun& 0Hi"her &oses shoul& be avoi&e& because o' a relatively lo5 renal

threshol& @Dic$erson /001A4



.actors a''ectin" 5oun& 1/

transport, thus a&versely a''ectin" 5oun& healin"4 The ris$ o'

arter? ial &isease is also increase& 5hich may cause ischaemia an&

necrosis @see B94/2A4

B14/- Ho5 &oes alcohol a''ect 5oun& healin"

atients 5ho are heavy &rin$ers may have liver &isease4 This

may result in a re&uction in the number o' platelets an& in clottin"

'unc? tion4 They may also have a lo5er resistance to in'ection4

!astritis an& &iarrhoea may pre&ispose to malnourishment

throu"h malab? sorption an& anaemia cause& by bloo& loss4

B14// Do social 'actors have a role in 5oun& healin"

Research su""ests that there is a stron" lin$ bet5een a person7s

social circumstances an& his or her health @%iller /000A4 The #lac$

R e port @#lac$ /09A 'oun& that people in the lo5er

socioeconomic "r oups e=perience& poorer health an& earlier &eath

than those in the hi"her "roups4 atients 'rom these "roups may be

more li$ely to eat a less nutritious &iet or to smo$e ci"arettes 5hich5ill impair 5oun& healin"4

sycholo"ical 'actors also play a part in 5oun& healin"4

E=peri? ence sho5s that, i' a patient &evelops venous le" ulcers,

an& pr evious "enerations in their 'amily ha& ha& ulcers that 'aile&

to heal, their e=pectations o' a positive outcome are lo5er an&

they may be less 5illin" to tolerate treatments, such as

compression ban&a"in", because they vie5 them as pointless4

Other patients are o'ten suspecte& o' tamperin" 5ith their&ressin"s an& scratchin" the a''ecte& area, causin" tissue

&ama"e4 This may be because they 'ail to un&erstan& the

importance o' this or because they li$e to see the nurse an& 5oul&

rather their 5oun& 'aile& to heal4

Summar

y

I' the chosen topical treatment is not havin" the &esire&

e' 'ect, consi&er the other 'actors that may be impe&in" 5oun&

healin"4 The patient7s a"e, concurrent &isease@sA an& "eneral

li'estyle 'actors are all pertinent 'or 5oun& healin"4 !ive the

patient clear li'estyle a&vice, chec$ that he or she un&erstan&s that

a&vice an& rein'orce it 5hen appr opriate4



CHAP*ER 4

Wound#,eansin-

The topic o' 5oun& cleansin" has o'ten been surroun&e&

5ith controversy4 To clean or not to clean This chapter

&iscusses 5hat constitutes best practice 5hen cleansin" a 5oun&,

5hat solutions ar e appropriate an& 5hen 5oun& cleansin" is

necessary4 The 'ollo5in" in'ormation is pertinent 'or community

nurses, althou"h it may not be applicable to all hospital

&e partments4

B4/ Why shoul& cotton 5ool not be use& to clean 5oun&s

It is "enerally accepte& that cleansin" 5oun&s by s5abbin"

5ith cotton 5ool or "auJe results in the materials she&&in" 'ibres

into the 5oun&, 5hich may act as a 'ocus 'or in'ection

@Draper /092A4 Despite this, &ressin" pac$s available on the &ru"

tari'' all contain cotton?5ool ballsG these shoul& be &iscar&e&4

Vi"orous s5abbin" may also &ama"e healthy tissue4 !entle

irri"ation is there'ore "ener? ally the pre'erre& metho&4

B4 When shoul& 5oun&s be cleanse&

Which 5oun&s 5ill bene'it 'rom cleansin" Traumatic 5oun&s

that contain particles o' &irt or other matter 5ill bene'it 'rom

vi"or ous irri"ation @)a5rence /00FA4 Woun&s may also bene'it'rom cleansin" to remove "ross e=u&ate, remains o' previous

topical applications or crustin" @%iller an& Dyson /003G )a5rence

/00FA4 #acteria are not remove& but merely re&istribute& aroun&

the 5oun& sur'ace4 It is pointless to cleanse 5oun&s routinelyG

it is appropriate only to remove &ebris or ol& &ressin" material4



Woun& cleansin" 1/1-



Reasons 'or not cleansin" shoul& be e=plaine& to the patient to

avoi& any misun&erstan&in"s, because most patients thin$

that cleansin" is essential4

B41 What 'lui&s are recommen&e& 'or cleansin" 5oun&s, as I7ve been

tol& antiseptics are o' little value

The most 're8uently use& 'lui&s are tap 5ater,

physiolo"ical

@>normal7A saline or antise ptics4

There is little evi&ence to su""est that use o' antiseptics

re&uces the bacterial content o' 5oun&s4 Woun&s &o not nee& to besterile to heal4 Current thin$in" su""ests that the use o'

antiseptics is not a&vanta"eous in optimisin" 5oun& healin"4

Some o' the criticisms a"ainst antiseptics are liste& in #o= 4/4

re'erre& 5oun& cleansin" a"ents are &escribe& in #o= 44

The sa'er antiseptic options are su""este& by )a5rence @/00FA4

Bo/ 4<1 Disa&vanta"es o' antiseptics in 5oun& healin"

*ntiseptics &o not come into contact 5ith bacteria 'or lon" enou"h to $ill them

&urin" normal 5oun& cleansin"

#acteria may become resistant to antiseptics an& those antiseptics containin"

cetrimi&e or chlorhe=i&ine un&er certain con&itions

The 're8uent use o' antiseptics may contribute to5ar&s bacterial resistance to antibiotics

@no lin$ proven as

yetA

*ntiseptics a&versely a''ect bloo& 'lo5 in the healin" 5oun&

Or"anic matter such as pus an& 5oun& e=u&ate inactivates antiseptics

@%iller an& Dyson /003A

B4 Ho5 can physiolo"ical saline be 5arme& be'ore use

The simplest 5ay to 5arm saline be'ore 5oun& cleansin" is to

place the sachet, po& or canister in a suitable container such as a

6u", mu" or $i&ney &ish that has 5arm 5ater in it4 This 5ill raise

the tempera? ture 5ithout any ris$ o' contamination The solution

shoul& be at bo&y temperature 5hen use&4

B42 What is an emollient

Emollients are &esi"ne& either as creams or 'or a&&in" to

bathsbuc$ets o' 5ater to soothe an& rehy&rate &ry scale& areas

o'




Bo/ 4<2 re'erre& 5oun& cleansin" a"ents

Chlorhe=i&ine solutions< this is a "oo& s$in an& har& sur'ace &isin'ectant an&

sho5s lo5 to=icity to livin" tissue in animal mo&els @see B/-40A

ovi&oneio&ine< io&ine $ills bacteria rapi&ly, possibly 5ithin a 'e5 secon&s, but

can impair the microcirculation in animals

Tap 5ater< one stu&y con&ucte& 5ith tap 5ater 'oun& that there 5ere 'e5er

in'ections in 5oun&s cleanse& 5ith tap 5ater an& that no bacteria 5ere

trans'erre& to the 5oun& @*n"eras et al4 /00/A4 Ho5ever, some cell &ama"e may

occur as a result o' osmotic pressure an& this may cause pain @)a5rence /00FA4

)e" ulcers may be cleanse& in a buc$et o' 5arm 5ater @see B942A

Saline in a -40L @physiolo"icalA solution< has similar osmotic pressures to the tissue

in mammals4 This rein'orces the 'act that saline baths are inappropriate because

the concentrations vary 5i&ely4 Saline is currently 'avoure& as the treatment o'choice, minimisin" the ris$ o' tissue &ama"e an& pain4 This shoul& be use& as a

5arm solu? tion @see B241A

s$in4 I' use& in 5ater it &oes not matter i' they touch the ulcer

itsel'

@see B942A4

Summary

Woun&s shoul& be "ently irri"ate& an& not s5abbe&4 Clean

5oun&s only i' it is necessary to remove &ebris such as the

remains o' &r ess? in"s or e=u&ate4 Warm saline is the pre'erre&

cleansin" lotion4



One notable e=ception to this is in the case o' peripheral

necrosis secon&ary to arterial &isease @e4"4 necrotic toes, peripheral

&iabetic ulcersA 5here moisture may increase the ris$ o' rapi&

in'ection @see B94-A4

B24 Ho5 can maceration 'rom e=u&ate be avoi&e&

The 5oun& shoul& be $ept 'ree 'rom e=cessive e=u&ate4 *lthou"h

the 5oun& nee&s to be $ept moist, it must not be 5et4 This 5ill

allo5 the s$in to become so""y an& macerate& an& may lea& to

'urther tissue brea$&o5n4 * &ressin" shoul& be selecte& that

provi&es the correct absorbency an& the 're8uency o' &ressin"

chan"es shoul& re'lect the anticipate& level o' e=u&ate4 *ll

&ressin"s are &esi"ne& 5ith particular types o' 5oun&s in min&,

e4"4 al"inates are &esi"ne& 'or hi"hly e=u&in" 5oun&s @see B240A

an& vapour?permeable 'ilms 'or 5oun&s 5ith very little e=u&ate

@see B24/9A4 This is an important criterion in &ressin" selection @see

also B//42A4

B241 Does temperature have an e''ect on 5oun& healin"

Woun& healin" is optimise& 5hen 5oun&s are $ept at bo&y

tempera? ture4 I' the temperature o' the 5oun& &rops, mitotic

activity slo5s &o5n thus re&ucin" 5oun& healin"4 * &rop in

5oun& temperatur e also &isrupts leu$ocytic activity an&

o=yhaemo"lobin &issociation @Thomas /00-G %iller an& Dyson

/003A4

)oc$ @/09-A an& %yers @/09A 'oun& that a'ter cleansin" it

coul& ta$e a 5oun& up to - minutes to re"ain bo&y temperaturean& a 'urther 1 hours 'or mitotic activity to return to normal4

Thus it is a&visable to 5arm saline be'ore 5oun& cleansin" @see

B4A, to $eep 5oun&s e=pose& 'or as short a time as possible, to

try not to &isturb 5oun&s unnecessarily an& to consi&er the type

o' material bein" use&, i4e4 cotton "auJe 5ill $eep a 5oun& at

aroun& FP C 5hereas a hy&rocolloi& or 'oam &ressin" 5ill

increase the temperature to 12P C @Thomas /00-A4

B24 Can micro?or"anisms "et un&er &ressin"s

The &ressin" shoul& be impermeable to micro?or"anisms4 This

shoul& 5or$ both 5ays4 While micro?or"anisms shoul& be $ept

a5ay 'rom 5oun&s, it is also un&esirable to have micro?or"anisms

'rom a 5oun& sprea&in" to the envir onment4



Dressin"s 12

*ny non?a&hesive &ressin" shoul& be tape& li$e a >picture

'rame7 i' the surroun&in" s$in is in "oo& con&ition, or ban&a"e& to

cover the &ressin" completely4

I' >stri$e?throu"h7 @e=u&ate seeps throu"h or un&er the e&"eso' the &ressin"A occurs, a 5arm 5et passa"e is create& 'or

micr o? or"anisms4 Secon&ary pa&&in" shoul& be applie& or the

5oun& re&resse& @see B241A4 The patient shoul& be a&vise& that,

i' lea$a"e occurs, he or she shoul& cover it 5ith a &ressin" pa&

5hile a5aitin" a &istrict nurse visit or sur"ery appointment4

B242 Can I use tra&itional "auJe as a primary &ressin"

Dressin"s shoul& not she& particles on to a 5oun&4 %o&ern &r ess?

in"s are &esi"ne& to hi"h stan&ar&s an& 5ill not she& 'ibres on to

the 5oun& sur'ace4 Ho5ever, tra&itional "auJe, lint or cotton

5ool all she& 'ibres 5hich can serve as a 'ocus 'or in'ection4

In a&&ition, the &ressin" shoul& not cause trauma to the 5oun&4

I' the chosen &ressin" a&heres to the 5oun&, trauma an& pain

may occur 5hen the &ressin" is remove& @see B4FA4 The i&eal

healin" environment shoul& be 'ree 'rom materials thata&hereG this is provi&e& by all mo&ern &r essin"s4

.or both o' these reasons, tra&itional &ressin"s such as

cotton "auJe an& para''in "auJe shoul& not be use& on open

5oun&s4 *&herence occurs as the 5oun& e=u&ate becomes

incorporate& into the "auJe an& &ries out, a&herin" to the tissue

belo54 R emoval causes the top layer o' "ranulation tissue to be

remove& 5ith the &ressin"4 ara''in "auJe leaves a criss?cross

pattern 5here ne5 "ran? ulation tissue has "ro5n throu"h themesh, illustratin" this 8uite "raphically4

B243 *re occlusive &ressin"s recommen&e&

Occlusive &ressin"s stop any atmospheric o=y"en "ettin" to

the 5oun&4 It has been note& that an"io"enesis @'ormation o' ne5

bloo& vesselsA in "ranulatin" 5oun&s ta$es place rapi&ly in the

hypo=ic environment o' occlusive &ressin"s such as

hy&rocolloi&s @Cher r y an& Ryan /092A4 Ho5ever, 5hen a 5oun&

be"ins to sho5 si"ns o' ne5 epi&ermis 'ormin", it appears to

happen more rapi&ly in a more o=y"en?rich environment @Silver

/092A4 It may be appropriate to use an occlusive &ressin" 5hen a

5oun& nee&s to "ranulate, but to s5itch




to an o=y"en?permeable &ressin" @e4"4 a 'oam &ressin"A to

encoura"e epithelialisation @see B/49 an& B4/1A4

B24F Some &ressin"s are not available on prescription4 Can they still be use&

%any nurses have arran"ements 5here they or&er one item 'rom

a pharmacist an& e=chan"e it 'or another pro&uct o' the same

value4 This is ille"alQ Even thou"h it is &one 5ith the patient7s

best inter ests at heart, this action constitutes 'rau&4 I' prosecute&

the nurse coul& 'ace a 'ine, imprisonment an& &ismissal4

B249 What 'actors shoul& be consi&ere& 5hen choosin" a &ressin"

Here is a list o' areas to consi&er4 The &ressin" shoul& have

the 'ollo5in" 8ualities<

D Sa'e to use, i4e4 has been prove& sa'e an& e''ective by clinicaltrials

D *cceptable to the patient

D

Cost?e''ectiveG &o not 6ust thin$ in terms o' unitcost

D Capable o' stan&ar&isation an&

evaluation

D *llo5s monitorin" o' the

5oun&

D rovi&es mechanical protection

D Non?' lammable

DSterilisableD Com'ortable an& moul&able

D Re8uires in're8uent

chan"in"4

Currently, no one &ressin" meets all these criteria4 There'ore it

is important to assess the 5oun& thorou"hly, &eci&e on a

tr eatment "oal an& select the most appropriate &ressin" 'rom those

available4I' the 5oun& &oes not respon& to the chosen &ressin", it is

impor? tant to remember that the &ressin" plays only a part in the

healin" process an& any un&erlyin" causes must be treate& an&

'actors a' 'ect? in" healin" revie5e& @see B14/B14FA4

B240 What is an al"inate &ressin"



Dressin"s 1FThese &ressin"s are ma&e 'rom sea5ee&, 5hich contains lar"e

8uan? tities o' al"inate4 They are hi"hly absorbent so they

shoul& not be




use& on 5oun&s 5ith very little e=u&ate, because they 5ill a&here

to the 5oun& sur'ace4 Some clinicians 5et the &ressin" 5ith

saline, but this seems pointless as the &ressin" is &esi"ne& to be

hi"hly absorbent an&, on a &ry 5oun&, 5ill &ry out at bo&ytemperature4 *ll al"inates are hi"hly absorbent an& 'orm a "el on

contact 5ith 5oun& e=u&ate, "ivin" a moist environment 5hile

absorbin" e=cess 'lui&4 They may be use& on 'lat 5oun&s an& also

to pac$ cavity 5oun&s4 Some ar e manu'acture& as ropes an&

ribbons especially 'or pac$in"4 They also have haemostatic

8ualities an& so are e=cellent 'or mana"in" some minor sur"ical

blee&s an& minor in6uries @see B343 an& BF4//A4 * secon&ary

&ressin" is re8uire& @see B241A4 E=amples o' al"inates ar e:altostat @ConvatecA, SeaSorb @ColoplastA, Sorbsan an&

Sorbsan lus @harma?last, Te"a"en @1%A, *l"osteril

@#iers&or'A, *l"isite lus @Smith ; Nephe5A an& %el"isorb

@%onlyc$eA4

B24/- What are bea& &ressin"s

These &ressin"s are ma&e up o' polysacchari&e bea&s4 They arein&i? cate& 'or 5et slou"hy 5oun&s an& shoul& not be use& on

clean or &r y 5oun&s4 The bea&s are e=tremely hy&rophilic an& 5ill

cause pain i' the 5oun& is too &ry @see B4FA4 The ones in most

common usa"e are Io&osorb an& Io&o'le= @Smith ; Nephe5A4

#oth contain io&ine an& have been use& 5ith some success on

5oun&s 5ith super'icial in'ection or super'icial 5oun&s

contaminate& 5ith methicillin? resistant Staphylo+o++&s a&re&s

@%RS*A @see B/-4F an& B/-4/1A4 *ll re8uire a secon&ary&ressin" @see B241A4

B24// What is an enJyme &ressin"

Vari&ase @Wyath )absA is a &ry po5&er containin" t5o

enJymes, strepto$inase an& strepto&ornase4 Vari&ase is &esi"ne&

to &Mbri&e necrotic or very slou"hy 5oun&s @see B4/- an&

B4//A4 The po5&er can be reconstitute& 5ith sterile saline an&applie& to &r y scabs that have been cross?hatche& 5ith a scalpel

as a soa$4 Some practitioners &o in6ect un&er scabs, but this must

be &one 5ith car e so that healthy tissue is not a''ecte& an& this

metho& is not "enerally recommen&e&4 *n alternative is to

reconstitute the po5&er 5ith

2 ml sterile 5ater an& mi= 5ith /2 ml intrasite "el4

Whichever metho& o' application is chosen, a secon&ary



Dressin"s 10&ressin" is r e8uir e&4



- Woun& Care< * Han&boo$ 'or Community Nurses

When mi=in" Vari&ase po5&er 5ith any solution, care must

be ta$en not to sha$e the vial vi"orously or the enJymes 5ill

become &enature& an& the treatment ine' 'ective4

B24/ Can the use o' topical strepto$inase a''ect the treatment o'

myocar&ial in'arction

*ll patients treate& 5ith Vari&ase sho5 an increase in

antistr e pto$i? nase titres4 %or"an @/00A recommen&s that it

5oul& be sensible not to use it on patients at ris$ o' myocar&ial

in'ar ction4

#u= et al4 @/00FA con&ucte& a stu&y to assessantistr e pto$inase levels in patients treate& 5ith intravenous

strepto$inase 'or acute myocar&ial in'arction, an& in patients

treate& 5ith topical str e pto$i? nase 'or cutaneous 5oun&s4 He

'oun& that topical application o' strepto$inase causes a

si"ni'icant humoral response 'or / month 5hich then &eclines

over a 3?month perio&4 This antibo&y response is si"ni'icantly

lo5er than 5hen strepto$inase is "iven intravenously4 #u= et al4

conclu&e that, i' a patient has been treate& 5ith topicalstrepto$inase in the last 3 months, it 5oul& be pru&ent to avoi&

intra? venous strepto$inase an& an alternative thrombolytic shoul&

be use& in the treatment o' a myocar&ial in'ar ction4

*nother small stu&y by !reen @/001A measure& the

antistr e pto$i? nase titres o' 'ive patients treate& 5ith topical

Vari&ase, 5ho all sho5e& an increase& titre4 He conclu&e& that

the use o' Vari&ase shoul& be restricte& to those not at ris$ o' a

myocar&ial in'ar ction4

B24/1 What are 'oam &ressin"s

.oam &ressin"s @inclu&in" hy&ropolymer an& hy&rocellular &r ess?

in"sA are "enerally hi"hly absorbent an& create a moist

envir onment 'or 5oun& healin"4 They can be use& on a 5i&e

variety o' 5oun&s althou"h, i' the 5oun& is very &ry, they may

stic$4

These &ressin"s are available 5ithout a&hesive, 5hich is use'ul

i' the surroun&in" s$in is 'ra"ile or &ama"e&, or as a&hesive

&r essin"s4 They can be use& on their o5n or as a secon&ary

&ressin", e4"4 5ith hy&ro"els @see B241A4

Some non?a&hesive 'oams inclu&e *llevyn @Smith ;

Nephe5A, )yo'oam an& )yo'oam E=tra @SetonA4 )yo'oam is use'ul

'or r esolvin" over "ranulation4



Dressin"s /

*&hesive 'oams inclu&e *llevyn *&hesive @Smith ;

Nephe5A, CombiDER% @ConvatecA an& Tielle @Kohnson ;

KohnsonA4

B24/ What are hy&ro'ibre &ressin"s

Hy&ro'ibre &ressin"s are ma&e o' /--L so&ium

carbo=ymethylcel? lulose4 This is the main in"re&ient o'

hy&rocolloi& &ressin"s an& it is spun into 'ibres an& ma&e into

sheets or ribbon &ressin"s4 It absorbs 'lui& &irectly into its 'ibre

structure4 In the presence o' e=u&ate it converts into a so't "el

sheet 5hich maintains a 5arm, moist, local 5oun& con&ition4Hy&ro'ibre &ressin"s 5ill absorb mo&erate?to?lar"e 8uantities

o' e=u&ate, loc$in" it a5ay 'rom "oo& s$in an& preventin"

maceration4 They can be use& to treat a variety o' 5oun&s,

slou"hy or clean, ' lat or cavities @Williams /000A4 They are use&

'or 5oun&s similar to those &resse& by al"inates4 They al5ays

re8uire a secon&ary &ressin" @see B241A4

*n e=ample o' a hy&ro'ibre &ressin" is *8uacel @ConvatecA4

B24/2 What are hy&ro"els

*morphous hy&ro"els have a hi"h 5ater content4 They are ver y

use'ul 'or &Mbri&in" or &eslou"hin" 5oun&s by rehy&ratin" the

&ea& tissue, thus allo5in" the bo&y to she& this tissue by autolysis4

!els ar e &esi"ne& to be use& on 'lat 5oun&s an& to 'ill cavities4

They are also reporte& to re&uce pain at the 5oun& site @%or"an

/00A4 They re8uire a secon&ary &ressin" @see B241A4E=amples o' hy&ro"els are Intrasite !el @Smith ;

Nephe5A, Nu?!el @Kohnson ; KohnsonA, Steri"el @SetonA an&

urilon !el @Colo? plastA4

B24/3 What are hy&rocolloi&s

Hy&rocolloi& &ressin"s are ma&e 'rom combinations o' synthetic

polymers an& are one o' the ol&est o' the >mo&ern7 &ressin"sG they

are use& in many situations4 These &ressin"s are 5aterproo',

a&he? sive an& interactive, an& 'orm a "el on contact 5ith 5oun&

e=u&ate4 This may have a sli"ht o&our, 5hich is normal, an& it is

a&visable to 5arn the patient so that he or she &oes not "et upset

i' this occur s4



Dressin"s 1

I' the cream is a 5ater?in?oil emulsion, the pro'lavine has very

little antibacterial activity because it is not release& 'rom the

emulsion base4

Hypersensitivity has been reporte& because the creamcontains lanolin, a $no5n sensitisin" a"ent @see B24-A4

B24- What common irritants an& aller"ens li$ely to cause contact

&ermatitis may be 'oun& in 5oun& care pro&ucts

Lano,i

n

)anolin @5ool alcoholA is a $no5n sensitiser4 It can be 'oun& inmany creams, ointments, bath a&&itives, baby pro&ucts an& barrier

pr e pa? rations4 It is better not to use any pro&ucts containin"

lanolin on the s$in aroun& le" ulcer s4

Antibioti#

s

Neomycin an& 'ramycetin are topical antibiotics that are

commonly reporte& as s$in sensitisers4 When mana"in" le"ulcers, "entamicin an& bacitracin are also si"ni'icant sensitisers

@Cameron /009A4 Topi? cal antibiotics are 'oun& in creams,

ointments, tulle &ressin"s an& me&icate& po5&ers4 They are best

avoi&e& because o' the problems o' both sensitisation an& resistant

bacteria4

A,#o+o,

Cetyl alcohol, stearyl alcohol an& cetylstearyl alcohol are

emulsi'iers4 These are &i''icult to avoi& because they are 'oun& in

many popular le" ulcer preparations such as a8ueous creams,

corticoster oi& creams, moisturisers, some paste ban&a"es an&

emulsi'yin" oint? ments4

Rubbe

r

Rubber may be 'oun& in elastic ban&a"es, some support hosier y,

tubular elastic supports an& late= "loves4 I' the patient has a

rub ber aller"y, the nurse shoul& 5ear vinyl "loves4

Paraben

s



Woun& Care< * Han&boo$ 'or Community NursesThe parabens "roup o' preservatives possess antibacterial an&

anti? 'un"al propertiesG they are 5i&ely use& preservatives in

topical me&icaments, moisturisers an& some paste ban&a"es4



Dressin"s 2

Ester of

resin

Colophony @an ester o' resinA is 'oun& in the a&hesive bac$in"

o' some plasters, tapes an& &r essin"s4

)ra-ran#es

.ra"rances use& in many over?the?counter pro&ucts such as

bath a&&itives an& moisturisers may cause sensitisation4

B24/ Ho5 can irritants an& aller"ens best be avoi&e&

The 'ollo5in" measures can be ta$en to minimise the ris$ o'

contact &ermatitis, particularly i' the patient is $no5n to be

sensitive to a variety o' pr e parations<

D (se 5arm physiolo"ical saline @-40LA to irri"ate le" ulcers

or 5ash the le" 5ith plain 5arm tap 5ater @see B41, B4,

B241 an& B942A4

D *voi& usin" topical antibiotics or antiseptics @see

B41A4

D Do not use a&hesive tape &irectly on to the

s$in4

D (se a simple emollient such as 2-L 5hite so't para''in,2-L

li8ui& para''inG this can be ma&e up by the pharmacist4

D Do not use any pro&uct containin" lanolin @see B24-A4

D *voi& creamsG use ointments

instea&4

D Do not apply elastic ban&a"es &irectly on to the

s$in4

D Wear vinyl not late=

"loves4

D Discoura"e the patient 'rom usin" over?the?counter

pr e parations 'or sel'?treatment4

D Consi&er re'errin" the patient to a &ermatolo"ist 'or patch

testin" i' the patient is $no5n to be sensitive to a ran"e o'

pr o&ucts4

B24 Can 5oun& &ressin"s be combine&

%any combinations are 're8uently seen, but 'ar less research



3 Woun& Care< * Han&boo$ 'or Community Nursesabout the clinical e''ectiveness o' such treatments is available4

%anu'actur? ers o' &ressin"s &o not normally ma$e statements

about their &r ess? in"s in combination 5ith other pro&ucts

because the ran"e o' primary an& secon&ary &ressin"s is vast4 I'

manu'acturers happen to ma$e e=amples o' both pro&uct types,

they may 5ell be prepare& to



Dressin"s F

provi&e some assurances that their pro&ucts use& in combination

ar e sa'e @Thomas an& Vo5&en /009A4 I' in &oubt about the sa'ety

o' a combination, a company helpline or a pharmacist may be

able to ans5er your 8uer y4*lso remember that, i' a s$in reaction occurs, you may not

be able to tell 5hich o' the pro&ucts has cause& it, 5hich may

limit 'uture mana"ement4

B241 What types o' &ressin"s can be use& as secon&ary &ressin"s

)o5 a&herence &ressin"s such as N?* Dressin" or Tricote= can be

use& over "els, creams, al"inates, etc4 These are simple &ressin"s5ith no absorbency an& may nee& more substantial pa&&in" over

them4

a&&in" such as !am"ee pro&ucts shoul& be use& only over a

suitable primary &ressin" that protects the 5oun& 'rom any loose

'ibres, 5hich may become incorporate& into the 5oun& causin"

a&herence4 lace& over a suitable &ressin", it &oes allo5 easy

passa"e o' ' lui&4

%ore mo&ern pa&s such as the Sur"ipa& are availableG thesear e sleeve& to prevent loose 'ibres enterin" the 5oun& an& 'or this

r eason shoul& not be cut4 (nless stri$e?throu"h occurs they "ive a

r eason? able barrier to bacteria @Thomas /009A @see B24A4

Orthopae&ic 5a&&in", 5hich 5as ori"inally &esi"ne& 'or

use un&er plaster casts, is no5 're8uently use& un&er

compression ban&a"in" both to protect bony prominences an& to

absorb e=u&ate @see B940A4

Vapour?permeable 'ilm &ressin"s, &esi"ne& as a primary&ressin" 'or super'icial lo5 e=u&ate 5oun&s, can also be use& to

prevent mois? ture loss 'rom hy&ro"els applie& to &ry 5oun&s or

5oun&s 5ith lo5 e=u&ate @see B24/9A4 They may also be use& over

al"inates4

There is a "ro5in" tren& to use hy&rocolloi& &ressin"s over

"els an& al"inates4 *lthou"h this may be acceptable in some

instances, it shoul& be remembere& that some hy&rocolloi&s can

absorb a consi&? erable amount o' 'lui& an& may there'ore re&uce a

hy&ro"el7s ability to rehy&rate a 5oun&4 The clinical si"ni'icance

o' this has not been &etermine& @Thomas /009A4

.oam &ressin"s are usually use& alone but, as 5ith

hy&rocolloi&s, there is a tren& to use them in combination 5ith

"els an& al"inates @see B24/1A4 There is no publishe& evi&ence to

support this practice




an& a"ain they may ta$e up moisture 'rom a "el, but this &oes

not seem to occur to any "reat e=tent an& sli"htly more "el

coul& be applie& to stop this e''ect @Stevens /009A4 * "el'oam

combination may then be a bene'it i' the 5oun& is pro&ucin" ahi"h level o' e=u&ate, but 'or &ry necrotic or slou"hy 5oun&s it

is &i''icult to 6usti'y the cost @Thomas /009A4

I' a 5oun& is malo&orous, &ressin"s containin" activate&

char coal may be appropriate @see B43A4 These 'it into t5o

cate"ories< those inten&e& as primary &ressin"s such as *ctisorb

lus, )yo'oam C an& Carbo'le=, an& those inten&e& as secon&ary

&ressin"s such as Clini? Sorb or Deni&or4 *lthou"h they have no

o&our?absorbin" pr oper? ties, occlusive pro&ucts such as 'ilm&ressin"s or hy&rocolloi&s may re&uce o&our by preventin" the

escape o' volatile molecules that ar e responsible 'or the smell

@Thomas /009A4

B24 *re there any pro&ucts that shoul& be avoi&e& 5ith ve"etarian patients

%ost pro&ucts are suitable, althou"h some hy&rocolloi&s

may contain "elatin, 5hich is an animal &erivative, 5hereas other&r ess? in"s may not4 .ibracol is a colla"en al"inate that contains

over 0-L bovine colla"en, so it is unsuitable 'or a ve"etarian

patient4

I' necessary chec$ 5ith the pro&uct manu'actur er 4

Summar

y

No one &ressin" 5ill meet all the criteria 'or the i&eal 5oun&

&r ess? in"4 Tra&itional &ressin"s such as "auJe shoul& not be

use& as a primary &ressin" on any open 5oun&s4 The chosen

&ressin" shoul& be the one most suite& to the sta"e o' healin",

e=u&ate level an& patient satis'action4 *voi& irritants an&

aller"ensG &ocument any $no5n aller"ies 'or 'uture re'erence4 I'

combinin" &ressin"s, consi&er 5hether they are li$ely to

counteract each other or react 5ith each other an& 5hether thecombination is cost?e' 'ective4



CHAP*ER 7

Sur-i#a,;ounds

Community nurses are o'ten as$e& to mana"e postoperative

sur "ical 5oun&s 'ollo5in" early patient &ischar"e 'rom hospital4

%any !s un&erta$e minor sur"ery 5ithin the practiceG this is

e=pecte& to rise un&er the chan"in" health care initiatives4

This chapter e=amines mana"ement o' sur"ical 5oun&s, an&

consi&ers 'actors that may a''ect healin" 5hich are particular

to these 5oun&s4 iloni&al sinuses an& abscesses are also&iscusse& in the 'ollo5in" te=t as these are 're8uently

mana"e& 5ithin the community settin"4

B34/ Ho5 shoul& sur"ical 5oun&s be mana"e&

Sur"ical 5oun&s are usually close& 5ith sutures or clips, 5hich

ar e le't in place 'or 2F &ays &epen&in" on the type o' sur"ery,

an& the &epth o' the 5oun& they are closin" @see B/43AStu&ies have sho5n that a'ter hours the s$in 5ill have

'orme& a natural barrier at the suture or clip line 5hich means a

&ressin" may be unnecessary @ChrintJ /090A4 atients 5ill re8uire

&ressin"s i' there is any lea$a"e 'rom the suture line or to protect

the 5oun& 'rom rubbin" on clothin"4 Some areas, such as the

"roin a'ter vari? cose vein sur"ery, may be particularly prone to

'riction an& may re8uire a li"ht &ressin" to absorb any

perspiration an& to re&uce 'ric? tion4 *s the s$in e&"es have been brou"ht to"ether tra&itional &r ess? in"s such as "auJe or %elolin

are o'ten use&4 Ho5ever, these may not be com'ortable an& are

not 5aterproo' @%iller /002A @see B242A4 It may be appropriate to

consi&er a more mo&ern alternative such as a vapour?permeable

'ilm @see B24/9A, a polyurethane &ressin" @see B24/1A or a thin

hy&rocolloi& @see B24/3A4 *&vanta"es o' these



3 Woun& Care< * Han&boo$ 'or Community Nurses2



&ressin"s inclu&e com'ort an& less bul$, they &o not re8uire

ban&a"in" or tapin" into position, are 5aterproo' an& in most

cases can be le't in position until the sutures or clips can be

remove&4 @Thomas /00-A4 Once sutures or clips have beenremove&, a &ressin" shoul& not be necessary unless the 5oun&

continues to e=u&e 'rom any areas alon" the suture line4

*&vice "iven to the patient may inclu&e coverin" the 5oun& 'or

hours a'ter sur"ery4 I' the 5oun& then appears &ry, he or she

may sho5er, but shoul& avoi& bathin" because this 5ill re&uce the

natural barrier4 While a5aitin" the removal o' sutures or clips,

the patient shoul& observe the 5oun& 'or any si"ns o' in'ection

@see B/-4/A an& see$ me&ical ai& i' any o' these occur 4

B34 What 'actors can a''ect the healin" o' sur"ical 5oun&s

The patient7s physiolo"ical con&ition an& the sur"ical an& nursin"

environment 5ill have a pro'oun& e''ect on 5oun& healin"4 *s

5ith all 5oun&s 'actors such as a"ein", un&erlyin" &isease,

nutrition an& li'estyle 5ill a''ect healin" @see B14B14//A4

The len"th o' hospital stay be'ore sur"ery has been su""este& asa 'actor a''ectin" postoperative recovery @artri&"e /009A4

Trauma patients re8uirin" sur"ery or those 5ith a preoperative

illness appear to heal more slo5ly4

Other concurrent therapies may also &elay healin" @see

B140A4 Corticosteroi&s 5ill a''ect all sta"es o' healin"4

Immunosuppressive &ru"s &elay the in'lammatory response in

5oun& healin", 5hich results in a re&uce& 5hite bloo& cell count,

increasin" susce ptibility to in'ection @Davi& /093A4*nticoa"ulants are sometimes "iven prophylactically 5hen

patients have ma6or sur"ery4 These impair bloo& clottin" an&

may result in haematoma 'ormation4 Cytoto=ic &ru"s inter'ere

5ith cell replication by suppressin" the in' lamma? tory response

an& protein synthesis in patients 5ho are alr ea&y &ebilitate&

'rom a mali"nant &isease @#lan& et al4 /09A4 Ra&iother? apy can

also &ama"e s$in by &ecreasin" vascularity an& 'ibrosis

@Cuttin" an& Har&in" /00A, 5hich ma$es it more vulnerable totrauma as 5ell as re&ucin" the patient7s non?speci'ic cell?

me&iate& response to bacterial invasion4 enicillin inter'eres

5ith colla"en 'ormation an& 5ill &ecrease a 5oun&7s tensile

stren"th @Cooper

/00-A @see B/49A4




I' no abscess has 'orme& there are several options, althou"h

tr eat? ment is controversial @Ho&"$in /009A4 Hair can be

remove& 5ith 'orceps an& curette, i' the sinus is small an& not

in'ecte&4 The patient can have phenol in6ections as an outpatient,or sur"ical tr eatments inclu&e layin" the area open to permit

&raina"e an& allo5 healin" by secon&ary intention @see B/4FA4 On

occasion the area can be opene& an& hairs an& &ebris remove&,

'ollo5e& by primary closure4

B342 What is an abscess an& ho5 shoul& incision an& &raina"e be mana"e&

*n abscess is a localise& collection o' pus, comprisin" e=u&ate, bac? teria, &ea& 5hite cells an& the partial li8ue'action o' other

cells an& tissue4 The in'ection becomes 5alle& o'' by "ranulation

tissue an& a layer o' &ea& 5hite cells4 *s the abscess increases in

siJe, the inter nal pressure increases an& this pro&uces pain4

The usual treatment is sur"ical incision o' the abscess an&

&raina"e o' the contents @The Woun& ro"ramme /00A4 The

r esult? in" cavity is then pac$e& 5ith a &ressin" such as an

al"inate or hy&ro'ibre &ressin" @B240 an& B24/A, 5hichallo5s 'or 'utur e &raina"e4 *ntibiotics penetrate poorly into an

abscess but serve as an a&6unct to sur "er y4

B343 Is there a recommen&e& mana"ement 'ollo5in" removal o'

in"ro5in" toenails

The proce&ure 'or removal o' part or all o' an in"ro5in" toenail

varies 5ith the practitioner4 Some &octors treat the area 5ith

phenol to prevent re"ro5th, others &o not4 Invariably the nail

be& blee&s pro'usely4 (se o' a haemostatic &ressin", such as an

al"inate @see B240A, covere& 5ith a 'oam &ressin" @see B24/1A

re&uces a&hesion o' the &ressin" to the toe4 The 5oun& can be

assesse& a'ter 1 &ays, 5hen 'urther mana"ement can be

planne&4 The use o' 'oam &r ess? in"s on the 'eet appears to

re&uce pressure 'rom 'oot5ear, 5hich patients 'in& com'ortable4

The use o' tulle &ressin"s is not r ecom? men&e&, because they

a&here to the 5oun& an& cause &ama"e on removal @see B242A4



Sur"ical 0

Summar

y

%ost sur"ical 5oun&s are close& 5ith the s$in e&"es appose& an&only a simple &ressin" is re8uire&4 Several 'actors 5ill a''ect the

heal? in" o' sur"ical 5oun&s, inclu&in" len"th o' hospital stay,

poor health be'ore sur"ery, concurrent therapies an& 5oun&

in'ection4 *s 5ith all 5oun&s, the choice o' &ressin" is &irecte&

by the in&ivi&ual 5oun& state4



CHAP*ER 8

Burns$ s#a,dsand minor

in=uries

The practice nurse is o'ten consulte& 'or a&vice an& mana"ement

o' minor in6uries, burns an& scal&s &urin" the &aily sur"ery4 This

chap? ter loo$s at the treatment o' these con&itions, because they

are r ele? vant to all community nurses4 Recommen&ations are

ma&e as to 5hich patients 5ill re8uire specialist a&vice4 The

a'tercare o' &onor sites an& mana"ement o' scar tissue are also

&iscusse&4 It is reco"? nise& that specialist centres may have their

o5n re"imen 'or the car e o' these 5oun&s, an& the rea&er is

e=pecte& to 'ollo5 local protocols4

BF4/ atients 5ith burns an& scal&s 're8uently atten& the ! sur"ery4

Which shoul& be re'erre& to acci&ent an& emer"ency

*s a "eneral rule, patients 'ittin" the 'ollo5in" criteria shoul&

atten& the acci&ent an& emer"ency &epartment @!o5er an&)a5r ence

/002A<

D *ny burn e=cee&in" 2L o' the bo&y sur'ace

ar ea4

D #urns o' 'unctionally important areas, such as the 'ace,

han&s, 'eet, perineum, 6oints or 'le=or sur'aces4

D I' other in6ury is suspecte&, e4"4 inhalation o' smo$e orother no=ious "as or electric shoc$4

D atients 5ith &iseases such as epilepsy or

&iabetes4

D I' the burn 5ill limit a person7s ability to sel'?mana"e, e4"4 to

the han&s o' an el&erly person livin" alone4

D atients 5ith 'ull?thic$ness burns 5hich may bene'it 'rom



#urns, scal&s an& minor 2/ear ly "ra'tin" @see .i"ure /4A4

D *nyone sho5in" si"ns o' local in'ection or evi&ence o'

se pti? caemia @see Tables /-4/ an& /-4A4

2-



#urns, scal&s an& minor 2/necessar y4




Other &ressin"s that may be suitable inclu&e 'ilm &ressin"s or

hy&rocolloi& &ressin"s @see B24/3 an& B24/9A4 %ost minor bur ns

5ill heal 5ithin a 5ee$ to /- &aysG a'ter this they shoul& be &resse&

as appropriate4 I' the burn has not heale& or almost heale& 5ithin1 5ee$s o' in6ury, it may be 'ull thic$ness an& re8uire a s$in

"ra't @!o5er an& )a5rence /002A @see .i"ure /4A4

%inor burns to the 'ace 5here it is &i''icult to apply &ressin"s

may be treate& 5ith /-L a8ueous povi&oneio&ine4 This nee&s

to be applie& three to 'our times a &ay 'or 2F &ays4 This 5ill

re&uce the possibility o' bacterial complications @see #o= 4A4

Tetanus cover shoul& also be r evie5e&4

BF4 *re there any instances 5hen treatment 'or burns 5ith col& 5ater is

not appropriate

Col& 5ater treatment is not appropriate i' the burns have been

cause& by metallic so&ium, potassium or calcium4 These all r eact

violently 5ith any a8ueous solution4 These burns are rare an&

appropriate me&ical a&vice shoul& be sou"ht4

BF42 What a&vice shoul& the patient be "iven 5hen the burn has heale&

The ne5 epithelium o' a recently heale& burn is &elicate an& sun

sensitive4 Dry &ressin"s mi"ht initially be in&icate& 'or

protection4 Total sun bloc$ shoul& be use& i' the area is e=pose& to

sunli"ht an& the area 5ell moisturise& 5ith a simple non?per'ume&

cr eam4

I' the burn 5as to the lo5er limb o' an el&erly patient, support

ban&a"es may be re8uire& to re&uce the possibility o' $noc$s to

&eli? cate s$in resultin" in episo&es o' ulceration @!o5er an&

)a5r ence

/002A4

BF43 What a&vice shoul& patients be "iven about carin" 'or heale&

&onor sites

%ost &onor sites heal 5ell 5ith little scarrin"4 The patient shoul& be a&vise& to protect the area 'rom e=tremes o' temperature,

trauma an& e=posure to the sun @.o5ler an& Dempsey /009A4 S$in

shoul& be moisturise& 5ith a simple non?per'ume& cream to $eep it

supple an& so't4 I' it is li$ely to be e=pose& to &irect sunli"ht, a sun

bloc$ o' 'actor

2 or hi"her shoul& be use&4



2 Woun& Care< * Han&boo$ 'or Community Nurses5oun&s 5here there is little 'orce nee&e& to $eep the 5oun&

e&"es



#urns, scal&s an& minor 22

to"ether4 They cause less trauma than sutures on both

application an& r emoval4

The 'ollo5in" is the application pr oce&ur e<

D Ensure that the surroun&in" s$in is

&r y4

D Start by &ra5in" the s$in 'rom each si&e o' the 5oun& to"ether

at the centre, ensurin" that the strip a&heres ri"ht up to the

e&"e o' the cut4

D %ore closures are then use& to &ra5 the si&es o' the

5oun& to"ether an& "ra&ually any "aps 'ille& in to ma$e a neat

r e pair 4D * secon&ary &ressin" is place& over the close& 5oun&

@see

B241A4

Once close& a small 5oun& shoul& have heale& 5ithin 2F &ays

@&epen&in" on positionA an& the strips may be

r emove&4

BF4/- When is sur"ical "lue appropriate

Sur"ical "lue has been use& in secon&ary care 'or many years4 It

is also a use'ul primary care tool4 The use o' sur"ical "lue in

primar y care can re&uce the nee& 'or suturin" 5oun&s, thus

re&ucin" the pain an& an=iety in chil&ren4 Sur"ical "lue is

particularly use'ul 'or closin" small lacerations on the 'ace an&

hea&, ta$in" care to avoi& the eye area4 It is not recommen&e& 'or bo&y parts 5here tension occurs, e4"4 the chin or on 'in"er 6oints4

!lue can be use& in con6unc? tion 5ith a&hesive strips4

*&vanta"es o' sur"ical "lue inclu&e the 'ollo5in"<

D Nurse?only mana"ement

D Spee& o' application

D No local anaesthetic r e8uir e&

D No 'ollo5?up 'or suturer emoval

D Re&uce& pain an& an=iety, especially 'or

chil&r en

D Re&uce& atten&ance at hospital4

The 5oun& shoul& be $ept &ry 'or 2 &ays4 No 'ollo5?up



23 Woun& Care< * Han&boo$ 'or Community Nursesis re8uire& unless the 5oun& reopens4 It can be re"lue& or suture&

i' appr opriate4



#urns, scal&s an& minor 2F

BF4// Is there a simple metho& 'or mana"in" lacerations

Stanley $ni'e bla&es are a common cause o' lacerations, 5hich

o'ten blee& pro'usely4 *l"inate &ressin"s act as a haemostat, an& i'applie& on to a blee&in" 5oun& 5hich is then elevate& the

blee&in" 5ill re&uce 'airly 8uic$ly4 It is essential to ensure that

there is no ' or ei"n bo&y in the 5oun& be'ore applyin" pressureG

this is o' particular r ele? vance i' the 5oun& 5as cause& by bro$en

"lass4

Summar

yOnly minor burns an& scal&s shoul& be treate& in the sur"eryG

r e'er any o' concern 'or secon&ary care mana"ement4 In most

instances, col& 5ater is the most e''ective 'irst ai& measure4 I'

patients atten& 5ith sunburn, consi&er health promotion issuesG

promote sunscreen an& bo&y protection to prevent 'urther episo&es

o' sunburn4 Ne5ly heale& burns an& &onor sites shoul& be

protecte& 'rom sunli"htG hi"h?'actor sun lotionsun bloc$ is

recommen&e& 'or these sites4

*&hesive strips an& sur"ical "lue are alternatives to

suturin"4 Each has a&vanta"es an& &isa&vanta"es, an& these

shoul& be 5ei"he& a"ainst patient pre'erence, cost?e''ectiveness

an& e' 'icacy4



CHAP*ER 9

Le-u,#ers

The mana"ement o' patients 5ith le" ulcers is a problem

commonly encountere& by community nurses4 Stu&ies have

sho5n that bet5een 32L an& 92L o' patients are mana"e&

e=clusively by the primary health care team @:en&ric$ et al4

/00A4 This care is costly4 In /00- Charin" Cross Hospital le"

ulcer service estimate& the annual cost o' treatin" a le" ulcer to

be bet5een F-- an& 2-- per patient4 This su""ests that the

treatment o' le" ulcers costs the National Health Service 1--

3-- million a year 'or the (: as a 5hole @%orison /00/A4

(n&erstan&in" the aetiolo"y an& mana"ement o' both venous

an& arterial ulcers can re&uce the morbi&ity o' these con&itions

an& improve the 8uality o' li'e 'or patients4

B94/ What is a le" ulcer

* le" ulcer can be &e'ine& as an area o' &iscontinuity o' the

e pi&er? mis an& &ermis on the lo5er le" persistin" 'or 5ee$s or

more, e=clu&in" ulcers con'ine& to the 'oot4

B94 What are the principal causes o' le" ulcers

)e" ulcers may be cause& by a number o' un&erlyin"

patholo"ies4 %inor trauma is o'ten the imme&iate cause o' theulcer but un&er ly? in" patholo"y lea&s to ulcer &evelopment4 The

most common o' these patholo"ies is venous &isease @see B94/A,

5hich accounts 'or about F-L o' ulcers4 *roun& /-/2L are the

result o' arterial &isease @see B94/2A4 *bout /-L o' patients 5ill

have both venous an& arterial &isease4 These ulcers are $no5n as

mi=e& aetiolo"y ulcer s4



)e" ulcers 2F23




D hlebitis o' the a''ecte& le"

D Suspecte& &eep vein thrombosis, e4"4 s5ollen le" a'ter

sur "er y, pre"nancy or trauma

D Sur"ery on a''ecte& le"D Trauma to the a''ecte& le", e4"4 'ractur e

D History o' pulmonary embolism4

B943 What is the typical appearance o' a venous ulcer

The 'ollo5in" are typical o' a venous ulcer<

DSite< o'ten near the me&ial or lateral malleolus4

D Depth an& shape< usually shallo5 5ith a poorly &e'ine& e&"e4

D ain< the pain o' venous ulceration is o'ten associate&

5ith oe&ema, 'rom local in'ections or cellulitis @see B/-42A4

ain is usually relieve& by compression ban&a"in" an&

elevation @see B940A4

D Development< usually slo5 unless in'ecte& @see B/-4/A4

B94F What are the clinical si"ns an& symptoms o' arterial &isease

Si"ns o' arterial &isease may inclu&e the 'ollo5in"<

D Col& le"s an& 'eet in a 5arm envir onment

D ale or blue 'eet 5hen raise&

D .eet &us$y pin$ 5hen unsupporte&

D Shiny hairless le"

D !an"renous toes

D *bsent 'oot pulses

D Trophic chan"es to nails

D oor tissue per'usionG i' the nail be& has &irect pressure applie&

to it, it ta$es lon"er than 1 secon&s to return to normal colour4

B949 What is the typical me&ical history o' a patient 5ith arterial &isease

* me&ical history su""estive o' arterial involvement may inclu&e

the 'ollo5in"<

D Hypertension

D %yocar&ial in'ar ction



)e" ulcers 20

D *n"ina

D Transient ischaemic attac$s

D *rterial sur "er y

D Cerebrovascular acci&ent @see B94/2AD Intermittent clau&ication @see B94/2A

D Rheumatoi& arthritis @see B94/3A

D Diabetes mellitus @see B94/9A

D eripheral vascular &isease @see

B94/9A4

B940 What is the typical appearance o' an arterial ulcer

The 'ollo5in" are typical o' arterial

ulcer s<

D Site< o'ten on the 'oot or lateral aspect o' the le" but may

occur any5here inclu&in" the malleolar ar eas4

D Depth an& shape< o'ten &eep 5ith a punche&?out appearance,

o'ten irre"ular shapes or multiple small ar eas4

D ain< invariably pain'ul, o'ten the pain is ma&e 5orse byelevation or e=ercise4 atient may report han"in" the le"s out

o' be& to relieve pain4

D Development< o'ten rapi&4

B94/- What shoul& be inclu&e& in the assessment o' a patient presentin"

5ith le" ulcers

Success'ul treatment o' le" ulcers re8uires thorou"h

assessment to allo5 the &ia"nosis o' the un&erlyin"

patholo"y4 *ssessment shoul& inclu&e assessment o' the

patient7s "eneral con&ition, ulcer ? relate& history, clinical

investi"ations an& e=amination o' the ulcer itsel'4

atient assessment an& 5oun& assessment have been &iscusse&

in some &etail in earlier 8uestions, but an overvie5 an& issues

speci'ic to le" ulcers are "iven in Table 944 @see B4/B4 an&

B4/A4

:l+er8relate$

histor y

The assessment o' a patient presentin" 5ith either a 'irst or a

r ecur? rent le" ulcer shoul& inclu&e a &etaile& history o' the onset

o' the problems4 B94B943 &escribe the clinical si"ns an&



3- Woun& Care< * Han&boo$ 'or Community Nursessymptoms, appearance o' the ulcer an& relevant me&ical histor y4



)e" ulcers 3/

*ab,e 9<2 *ssessment o' the patient7s "eneral con&ition

*ssessment shoul&

inclu&e< *"e

Se=.amily history< there may be a pre&isposin" 'actor in le" ulcer &evelopment

Occupational history< venous le" ulcers are o'ten associate& 5ith occupations

involvin" prolon"e& stan&in"

%obility< re&uce& mobility contributes to ulcer &evelopment an& poor healin" @see

B94/A

Diet< poor nutritional status may &elay healin" @see B14A

Obesity< may contribute to poor healin" an& ulcer &evelopment @see B14A

Smo$in" habits< may contribute to poor healin" an& circulatory &isease @see B140 an&

B94/2A

!eneral livin" con&itions

sycholo"ical status< this is important in &eterminin" a patient7s participation in

care an& his or her compliance 5ith treatment

The patient shoul& have a thorou"h e=amination o' both the

le"s, 5hether or not ulcerate&4 *ny history o' ulceration

shoul& be inclu&e&, 5ith &uration, treatments use& or $no5n

aller"ies to &r ess? in"s @see B24-A4 * history o' the currentepiso&e o' ulceration shoul& also be &ocumente&4

B94// What clinical investi"ations may be necessary

Some routine investi"ations can ai& the &ia"nosis o' the le" ulcer

or help in its mana"ement4 Other investi"ations 5ill be necessary

only in a 'e5 circumstances4 Investi"ations are summarise& in

Table 9414

*ab,e 9<3 Clinical investi"ations

Investi"ation Rationale

#loo& pressure measurement To &etect hypertension @see B949A

(rinalysis#% stic$ To &etect &iabetes @see B949A

#loo& tests .ull bloo& count an& haemo"lobin levels to

i&enti'y anaemia4 Test 'or rheumatoi& 'actor @see

B14 an& B949AWoun& s5ab I' si"ns o' in'ection are present, to &etermine

antibi? otic sensitivity @see B/-4/A

Tissue biopsy I' mali"nancy is suspecte& @see Table 94/A

Wei"ht I' the patient is obese, &ietary a&vice an&

5ei"ht re&uction can ai& healin" @see B14A




B94/ Ho5 can vascular status be assesse&

The simplest 'orm o' vascular assessment is to palpate the

'oot pulses, both the &orsalis pe&is an& the posterior tibial @.i"ure94/A4

Ho5ever, the presence o' oe&ema may ma$e these pulses

&i' 'icult to 'eel4 * more accurate 5ay to ascertain the con&ition o'

the arterial circulation is to measure the an$le brachial pressure

in&e= @*#IA usin" Doppler ultrasono"raphy4 This shoul& be &one

only by a nur se 5ho has receive& trainin" an& practise& un&er

supervision4 The brie' &escription "iven here is not su''icient to

enable anyone to start usin" this techni8ue4

)ateral

malleolus

*nterior

tibial

eroneal

Dorsalis

pe&is

%e&ial

malleolus

osterior

tibial

)i-ure 9<1 Dia"ram sho5in" the positions o' pe&al pulses4

1eas&ring the ankle bra+hial press&re in$e 5

This &etermines the ratio o' the an$le to the brachial systolic

pres? sure 5ith the ai& o' a battery?operate& han&?hel& Doppler

probe4

The patient shoul& be lyin" as 'lat as possible 'or at least

/- minutes @%orison an& %o''att /00A4 This is to overcome the

e''ects o' e=ercise on the bloo& pressure4 This time can be use& to

ta$e the patient7s histor y4

The brachial systolic shoul& be recor&e& 'or both arms an& the

hi"her 'i"ure use& 'or calculation @Vo5&en et al4 /003A4 *n

appropri?



ately siJe& sphy"momanometer cu'' is place& aroun& the arm an&

ultrasoun& "el place& over the brachial pulse to ensure a "oo&

seal bet5een the probe an& the s$in4 The Doppler probe is place&

at a sli"ht an"le over the brachial pulse until a "oo& si"nal ishear&4 The cu'' is in'late& until the si"nal &isappears an& then

"ra&ually &e' late& until the si"nal returns4 This is the brachial

systolic pressure4

To ta$e the 'oot pulses, secure an appropriately siJe&

sphy"mo? manometer cu'' 6ust above the me&ial malleolus4 *ny

5oun&s 5ill re8uire coverin" to prevent contamination either to or

'rom the cu' ' 4 In turn, locate the &orsalis pe&is, posterior tibial an&

anterior tibial pulses4 .or each pulse in'late the cu'' until thesi"nal is lost, then slo5ly &e'late the cu'' until the si"nal returns4

.or ma=imum accu? racy each pulse shoul& be measure& t5ice4 It

shoul& be note& that the &orsalis pe&is pulse is con"enitally absent

in up to /L o' people @#arnhorst an& #arner /039A4

In practice it is o'ten necessary to use only t5o o' the pe&al

pulses 'or measurement @%o''att /009A4 I' there is any &oubt

5hatsoever about the patient7s arterial status, a&vice shoul& be

sou"ht 'rom a specialist4To calculate the *#I &ivi&e the hi"hest an$le pressure

measur e& by the hi"hest brachial pressure4

*n$le systolic pressure#rachial systolic pressure S *n$le brachial

pressure in&e=

The value obtaine& 'or the *#I shoul& normally be "reater than

/4-4 I' the rea&in" obtaine& is belo5 /4- some &e"ree o' arterial&isease is in&icate&4 *n *#I o' -49--402 5oul& in&icate

minor levels o' arterial &isease4 *n *#I belo5 -49 in&icates

si"ni'icant arterial &isease an& compression ban&a"in" is

contrain&icate&4 Re'erral 'or 'urther vascular assessment is

re8uire& @%orison an& %o''att /00A4 * ratio o' -42--4F2 5ill

o'ten mean that the patient su''ers intermittent clau&ication, an&

belo5 this level ischaemic r est pain 5hich 5ill re8uire rapi&

re'erral to a vascular sur"eon @see B94/1A4*n *#I o' over /4 may be patholo"ical, e4"4 patients

5ith &iabetes may sho5 a 'alsely hi"h *#I as a result o'

me&icinal calci? nosis, 5ith vessels bein" &i''icult to

compress4 Compression



ban&a"es shoul& not be applie& to people 5ith &iabetes e=cept

un&er close me&ical supervision @%orison an& %o''att /00A @see

B94/9A4

I' there is any &oubt about the si"ni'icance o' an *#I, a&octor shoul& be consulte& 'or a&vice4 No one 5ho has not been

traine& to &o Doppler rea&in"s shoul& attempt this proce&ure4

Contact the local tissue viability nurse, 5oun& care nurse or

&istrict nur se mana"er 'or a&vice4

Doppler rea&in"s shoul& be carrie& out 5hen the patient 'irst

presents 5ith an episo&e o' ulceration, i' the ulcer is &eterioratin"

or i' the ulcer &oes not respon& to treatment a'ter 1 months an&

at re"ular intervals &urin" treatment, e4"4 3 monthly4

B94/1 When shoul& the patient be re'erre& to another pro'essional

The vast ma6ority o' ulcers shoul& not re8uire specialist

assessment4 In some instances, 'urther a&vice an& assessment may

be r e8uir e&, e4"4<

D * si"ni'icantly re&uce& *#I4 Discuss 5ith the ! the nee&'or vascular re'erral @see B94/A4

D Rapi& &eterioration o' the ulcer 4

D Suspecte& mali"nancy @see

B94/A4

D Ne5ly &ia"nose& &iabetes mellitus @see B141 an&B94/9A4

D Si"ns o' contact &ermatitis @see

B24-A4D Cellulitus @see B/-42A4

D (lcers that 'ail to respon& to treatment a'ter a 1?month perio&

@see B941A4

Some areas may have specialist nurses 5ho may be able to

"ive a&vice in these instancesG other areas 5ill be &epen&ent on

consul? tant r e'er ral4

B94/ Ho5 &oes venous &isease cause ulceration

The venous system in the le" comprises both &eep an& super'icial

veins @.i"ure 94A4 The &eep veins are the popliteal an& 'emoral

veins4 The super'icial veins are the lon" an& short saphenous veins

5hich lie outsi&e the &eep 'ascia4



*eep fas+ia

Femoral ,ein

%t4o ,al,es)

.opliteal ,ein

%t4o to three

,al,es)

Short sapheno&s ,ein

%&p to 2 ,al,es)

Saphenofemoral ,al,e

.erforating ,ein

%4ith ,al,es)

;ong sapheno&s ,ein

%&p to 20 ,al,es)

Ankle perforators

)i-ure 9<2 Dia"rammatic illustration o' the venous supply to the le"4

The super'icial veins are &esi"ne& to carry bloo& at lo5

pressureG they &rain into the &eep vein system via per'oratin"

veins4 The &eep veins return the bloo& bac$ to the heart at a much

"reater pressure4

When a person 5al$s, the cal' muscles act as a pump an&

'orce &eep venous bloo& bac$ up the le"4 When healthy an& intact,

valves in the per'oratin" system stop bloo& 'lo5in" bac$ into the

super'icial system4 When the muscle is restin", bloo& 'lo5s 'romthe super'icial veins 'illin" the &eep veins, 5hich have a temporary

lo5er pressure4

I' the valves in the per'orators become incompetent, bloo&

'lo5s bac$ into the super'icial veins at hi"h pressure 5hen the

cal' pump 5or$s an& &ama"es the valves in these4 This eventually

lea&s to vari? cose veins4

Dama"e to valves in the &eep an& per'oratin" veins lea&s to

chronic venous hypertension in the lo5er limb, the hi"h bac$ pres?sure causin" venous stasis an& oe&ema4 Venous return is 'urther

ai&e& by the an$le movement involve& in 5al$in" @%orison an&

%o''att /00A, 5ith the *chilles7 ten&on stretchin" an& rela=in"

the cal' muscle in&epen&ently o' cal' muscle contraction4 Wal$in"

also empties the 'oot veins an& ai&s venous return 'rom the 'oot as

the heel stri$es the "roun& @!ar&ner an& .o= /093A4



In people 5ho have limite& mobility, the cal' muscle pump or

'oot pump is not bein" use& properly i' at all, an& venous return

is impaire&4 The increase& pressure in the super'icial system lea&s

to oe&ema, capillary &ama"e an& thinnin" o' the &ermis4Capillary &ama"e allo5s lea$a"e o' re& bloo& cells an&

protein molecules into the interstitial 'lui&G the re& bloo&

cells ar e &estroye&, releasin" haemo"lobin 5hich brea$s &o5n

an& causes s$in pi"mentation an& ecJema4 .ibrino"en, 5hich is

release& 5ith the re& bloo& cells, turns into 'ibrin 5hich

&eposits a cu'' ar oun& the capillaries an& re&uces the &i''usion o'

o=y"en an& other nutri? ents4 This in turn causes tissue

ischaemia4 With the s$in bein" thin an& susceptible to trauma,minor &ama"e lea&s to le" ulceration @see BF49A4

B94/2 Ho5 are arterial ulcers cause&

*rterial ulcers are cause& by an insu''icient arterial bloo& 'lo5 to

the lo5er le", 5hich results in tissue ischaemia an& necrosis4

The most common cause o' this is atherosclerosis4 .atty

materials are &eposite& on the 5alls o' arteries an& "ra&ually buil&up to 'orm pla8ues4 These "ra&ually increase 5ith a"e4 The

process is spee&e& up i' the patient has hypertension,

hyperlipi&aemia, &iabetes mellitus or smo$es4 The t5o 'actors

most stron"ly lin$e& to ischaemia ar e &iabetes an& smo$in" @see

B949A4

B94/3 Why are patients 5ith rheumatoi& arthritis susceptible to ulcers

*bout /-L o' patients 5ith rheumatoi& arthritis &evelop an ulcer

@un et al4 /00-A4 Everyone has poorly vascularise& s$in over

the tibia, but in those 5ith rheumatoi& arthritis it is particularly

susce pti? ble to trauma an& &elaye& healin" i' they are ta$in"

hi"h &oses o' corticosteroi&s @see B140A4

Other ulcers may be attribute& to arteritis4 These ten& to appear

su&&enly, &evelop 8uic$ly an& heal slo5ly4

Vasculitic ulcers are also associate& 5ith rheumatoi& arthritisan& other connective tissue &isor&ers4 They are o'ten present as

multiple small an& very pain'ul ulcers on limbs 5ith no si"n o'

chronic venous hypertension4 Healin" is slo5 an& 5ill be a''ecte&

by the cause o' the un&erlyin" &isease4



B94/F Ho5 shoul& ulcers associate& 5ith rheumatoi& arthritis be mana"e&

This &epen&s on the un&erlyin" cause o' the ulcer @see B94 an&

B941A, an& the treatment shoul& be base& on this4 I' the cause ischronic venous hypertension, "ra&uate& compression shoul& be

applie& but it is e=tremely important to e=clu&e arterial &isease

@see B94/ an& B940A4

articular attention shoul& be "iven to the s$in to prevent

'urther &eterioration or trauma4 The s$in shoul& be $ept supple an&

tr eate& 5ith emollients @see B42A, an& i' a&hesive &ressin"s are

use& "r eat care must be ta$en in removin" them so as not to

&ama"e the s$in 'urther 4%any o' these patients have a poor appetite @%orison an&

%o''att /00A an& may re8uire nutritional supplements @see

B14B14FA4

Re"ular an$le an& 'oot e=ercises 5ill be o' bene'it but the

patient may re8uire help 5ith these @see B940A4

Oe&ema may be a problem 'or patients 5ho cannot raise their

le"s as a result o' arthritic chan"es or coe=istin" peripheral

vascular &isease4

B94/9 Why are patients 5ith &iabetes mellitus prone to ulceration

atients 5ith &iabetes may &evelop ulcers as a result o' one or a

combination o' un&erlyin" patholo"ies, so care'ul assessment o'

the patient is vital4

(lceration o' the lo5er limb, particularly the 'oot, is

ver y common in patients 5ith &iabetes mellitus4 They have&elaye& heal? in" an& an increase& ris$ o' in'ection @Koseph an&

*=ler /00-A4 !an"rene may &evelop lea&in" to lo5er limb

amputation4

Diabetic 'oot ulcers may result 'rom peripheral neuropathy,

peripheral vascular insu''iciency an& in'ection, either sin"ly or as

a combination4

eripheral vascular &isease is common in people 5ith &iabetes,

an& ten&s to occur more rapi&ly an& at a youn"er a"e @)evin /099A4Calci'i? cation o' the bloo& vessels is also si"ni'icant in people 5ith

&iabetes4

Ris$ 'actors increasin" the ris$ o' vascular &isease are

increasin" a"e, &uration o' &iabetes, smo$in", hypertension an&

hypercholes? terolaemia @%orison an& %o''att /00A4



eople 5ith &iabetes may also have chan"es to small vessels

as 5ell as the lar"er arteries4 This means that the toes may

su''er ischaemic &ama"e4 This ris$ is much "reater in people

5ith poor ly controlle& &iabetes4Other &iabetic ulcers are the result o' neuropathy4 There ar e

three types o' neuropathy< sensory, motor an& autonomic4 eople

5ith &iabetes an& sensory neuropathy have re&uce& or absent

pain sensations in their 'eet, 5hich can lea& to unnotice& &ama"e4

This can be mechanical, e4"4 stan&in" on a sharp ob6ect or

shoes rubbin", thermal, e4"4 scal&in" 'rom stan&in" in 5ater

that is too hot, or chemical, e4"4 'rom sel'?treatment 5ith

chemical cor n r emover s4%otor neuropathy results in 'oot &e'ormity 5ith cla5in" o'

the toes an& metatarsal hea&s4 This chan"es the patient7s "ait

an& pro&uces unnatural pressure, 5hich may result in a buil&?up o'

callus an& ulceration on the sole o' the 'oot, especially over areas

such as the 'irst metatarsal hea&, enlar"e& bunions an& bony

prominences on the toes4

*utonomic neuropathy results in the absence o' s5eatin"

5hich means that the s$in becomes very &ry an& prone to &evelopcrac$s an& 'issures that allo5 the entry o' 'un"i an& bacteria4

(nli$e most ulcers o' the s$in, these ulcers &evelop initially 'rom

&eep 5ithin the tissues4 .lui& collects un&er callus 'ormation an&

becomes in'ecte&, lea&in" to abscess 'ormation an& ulceration

@%orison an& %o''att /00A4 The openin" o' the ulcer may be

small an& the e=tent o' the tissue &ama"e not imme&iately obvious4

This can lea& to 'urther in'ection e=ten&in" &o5n to the ten&on

an& bone4 I' treatment is not rapi&, ra&ical &Mbri&ement may bere8uire& @see B4/-, B24// an& B24/2A

*lthou"h people 5ith &iabetes are prone to the types o' ulcer

&escribe& here, they may also present 5ith venous ulceration or

some o' the more rare types o' ulcer4 *s a "roup, it is

especially important that patients 5ith &iabetes have the

un&erlyin" cause o' their ulcer &etermine& as soon as possible

@see B94/AG they have a particular nee& 'or specialist vascular

assessment4

B94/0 What a&vice shoul& patients 5ith &iabetes be "iven about 'oot care

This a&vice is probably best "iven both verbally an& 5ith a

lea'let that the patient can $eep 'or re'erence @#o= 94/A4



Bo/ 9<1 .oot care a&vice 'or people 5ith &iabetes

Wash 'eet &aily, ma$in" sure they &ry them 5ell particularly bet5een the toes

.eet shoul& be chec$e& &aily 'or any &ama"e, re&ness or blisterin"4 I' patientscannot see their o5n 'eet, they shoul& as$ a carer or 'rien& to &o this4 *ny minor

in6uries shoul& be reporte& to the ! imme&iately

Soc$s an& stoc$in"s shoul& be clean an& chan"e& &aily

.oot5ear shoul& be chec$e& 'or 'orei"n bo&ies such as stones an& 'elt 'or any

6a""e& e&"es, be'ore 5ear

Ne5 shoes shoul& be 'itte& by a traine& 'itter

Care o' toenails, callus an& corns shoul& be per'orme& by a po&iatrist, 5ho shoul&

be in'orme& that the patient has &iabetes

atients shoul& be a5are o' e=treme temperatures an& chec$ the temperature o' the

bath be'ore puttin" their 'eet in4 They shoul& also try to $eep the 'eet 5armto avoi& chilblains 5hich may ulcerate

atients shoul& be as$e& not to 5ear soc$s or stoc$in"s 5ith bul$y seams or &arns

that may &i" in, an& not to 5ear shoes 5ithout soc$s or stoc$in"s

atients shoul& not 5al$ bare 'oot

atients shoul& not per'orm their o5n po&iatry or use chemicals to remove corns

or callus

atients shoul& not to put their 'eet too close to the 'ire, put their 'eet on hot

5ater bottles or soa$ their 'eet 'or a lon" time

atients shoul& avoi& ti"ht corsets an& "arters 5hich 5ill restrict bloo& 'lo5 to

the lo5er limbsThey shoul& not smo$e

B94- Shoul& &iabetic ulcers be mana"e& li$e other arterial ulcers

*lthou"h many ulcers on patients 5ith &iabetes are the result o'

arte? rial problems, their special nee&s shoul& be borne in min&4

They shoul& have a spee&y re'erral 'or specialist treatment sothat the ulcer &oes not &eteriorate rapi&ly an& lea& to lo5er limb

ampu? tation @see B94/1A4

The care is most e''ective 5hen it is multi&isciplinary,

involvin" the physician, specialist &iabetic nurse, po&iatrist,

orthotist an&, in some cases, the vascular an& orthopae&ic

sur"eon @%orison an& %o''att /00A4

)evin @/099A su""ests that the mana"ement o' &iabetic 'oot

ulcers shoul& be a""ressive4 This involves rapi& local &Mbri&ementleavin" only healthy tissue, systemic antibiotic therapy, &iabetic

control an& non?5ei"ht?bearin" 'or plantar ulcer s4

*n appropriate local &ressin" shoul& be chosen but the ulcer 5ill



respon& only i' the above treatment is "iven4 Ho5ever, an

inappr o? priate &ressin" may ma$e the situation 5or se4

(lcerate& 'eettoes shoul& be $ept &ry to eliminate maceration

bet5een the toes 5hich 5ill allo5 in'ections to enter @seeB24/A4 atients shoul& be "iven a&vice about 'oot care @see #o=

94/A4

The person 5ith &iabetes shoul& be stron"ly a&vise& to stop

smo$? in" an& to 'ollo5 &ietary a&vice to re&uce lon"?term

complications4

.or 'urther in'ormation about mana"ement o' &iabetes, the

rea&er is re'erre& to Turner an& Crosby, *iabetes! A 6an$book f or

7omm&nity N&rses in this series4

B94 / When shoul& I suspect that an ulcer is mali"nant

%ali"nant ulcers are rare in the (: @more 're8uent in tropical

coun? triesA, but i' ulcers 'ail to respon& to treatment this shoul&

not be overloo$e& as a cause @*c$roy& an& oun" /091A4

S8uamous cell carcinoma may &evelop in a chronic venous

ulcer @it then becomes $no5n as a %ar6olin7s ulcerA4 *lthou"h

uncommon, it may be suspecte& i' the ulcer has an unusual

appearance 5ith over"ro5th o' tissue at the base o' the 5oun&

or 5oun& mar "ins4 Con'irmation is by biopsy an& histolo"ical

e=amination4

%elanomas are more common but unli$ely to be mista$en 'or

venous ulceration4

:aposi7s sarcomas are a"ain rare, but becomin" more common

5ith the sprea& o' ac8uire& immune &e'iciency syn&rome @*IDSAGthey are usually small an& multiple an& may ulcerate @%orison

an& %o''att /00A4

B94 What are the main aims o' le" ulcer treatment

The aim o' treatment is

thr ee' ol&<

/4 To heal the ulcer 4 To treat the un&erlyin"

con&ition

14 To prevent r eoccur r ence4

B941 What primary &ressin"s shoul& be use& on le" ulcers



moist, 5arm environment con&ucive to 5oun& healin" shoul& be

chosen @see B249A4 E=cessive e=u&ate shoul& be absorbe&4

Dressin"s shoul& be non?to=ic, non?a&herent, non?aller"enic an&

non?sensitisin" @%or"an /09FA4 (n&er 'our?layer compression ban&a"es, o'ten all that is necessary is a simple non?a&herent

&ressin" @see B940A4

B94 Ho5 o'ten shoul& the &ressin" be chan"e&

(nless there is e=cessive e=u&ate, &iscom'ort or ban&a"e

slippa"e, the &ressin" shoul& be chan"e& once a 5ee$ @NHS

E=ecutive /002A4 Ho5ever, the treatment re"imen shoul& be&etermine& in con6unc? tion 5ith the patient an& there 5ill be

instances 5here more 're8uent chan"es are necessar y4

B942 What is the best 5ay to cleanse an ulcer

(lcers shoul& be cleanse& by irri"ation 5ith 5arm

physiolo"ical saline i' necessary @see B41 an& B4A4 I' there is

no ol& &ressin" material or e=u&ate this may not be nee&e&4 )e"smay be 5ashe& 5ith 5arm tap 5ater containin" an emollient i'

&esire&4 I' usin" a communal buc$et, it shoul& be line& 5ith

plastic @ne5 'or each patientA an& cleanse& bet5een use by local

in'ection control meth? o&s, to prevent any cross?in'ection4

Washin" helps to $eep the s$in in "oo& con&ition by removin"

loose s$in scales an& is also pleasant 'or the patient 5ho may

other5ise be unable to 5ash the 'eet an& le"s 'or lon" perio&s4

B943 Some patients 5ith le" ulcers seem sensitive to the pro&ucts use&4

Ho5 can this be avoi&e& or treate&

atients can become sensitise& to treatments at any time @see

B24- an& B24/A4 atients 5ith reactions to un$no5n sensitisers

shoul& be re'erre& to a &ermatolo"ist 'or patch testin"4 In cases o'

sensitivity, remove the $no5n or potential aller"en, apply a simple

non?a&her ent &ressin", an& elevate an& rest the limb4 )iaise

5ith the ! to prescribe a steroi& ointment @cream may contain

sensitisersA4 * pply the ointment 'or &ays4 Re&uce the amount

o' ointment use& over the 'ollo5in" 1 &ays an& replace the

steroi& 5ith 5hite so't para'? 'in emollient4



bet5een - an& - mmH" at the an$le, to 2-L o' that value at

the $nee @:en&ric$ et al4 /00A4 * compression ban&a"e

shoul& be anchore& at the base o' the toes, e=ert ma=imum

compression at the an$le an& 'inish at the $nee4%anu'acturers7 instructions shoul& be 'ollo5e&4 #an&a"es

that are incorrectly applie& are at best uncom'ortable an& useless

an& at 5orst &an"erous4 It is important that anyone applyin" a

compression ban&a"e has been tau"ht the correct metho& o'

application, un&er? stan&s the rationale 'or the treatment an& is

competent to carry out the tr eatment4

Compression can be applie& as a sin"le?layer, lon",

str etch ban&a"e, e4"4 Sureress or Tensopress4 Orthopae&ic pa&&in" may be re8uire& to protect the le", particularly over bony

prominences4 Note that patients 5ith an an$le circum'erence o'

less than /9 cm @see .i"ure 941, p4 F3A are not suitable 'or

compression unless su' 'icient pa&&in" is applie& to buil& up the

an$le siJe4

%ultilayer compression systems @a"ain usin" lon" str etch

ban&a"esA provi&e a&e8uate pa&&in" an& a&e8uate sustaine&

compression 'or at least a 5ee$4 In most instances, a 5ee$ly&ressin" chan"e is recommen&e&4 Only accepte& systems shoul&

be use&4 These may come in $it 'orm, e4"4 ro'ore or (ltra .our or

ban&a"es can be purchase& separately4 *ll patients shoul& have

their an$le circum'erence measure& to ensure that the

appropriate ban&a"e re"imen is selecte&4 %anu'acturers7

instructions 'or application shoul& be a&here& to an& the

practitioner appropriately traine& in the application o' multilayer

ban&a"in"4*lternatively, short stretch ban&a"es can be use&, e4"4

Comprilan, Rosi&al :4 These have been use& e''ectively in

Europe since the early /03-s4 They are /--L cotton @use'ul i' the

patient is aller"ic to elastic 'ibres see B24-A4 They are applie&

at 'ull stretch so that &urin" e=ercise to the cal' muscle the

ban&a"e &oes not e=pan& in the 5ay a lon" stretch ban&a"e

5oul&4 The 5or$in" 'orce o' the cal' muscle is there'ore re'lecte&

bac$ into the le" @Charles /000A4 When 5ashe& they have noelasticity to lose an& can be reuse& 5ith the same e''ect as 5hen

ne54 a&&in" shoul& be use& over areas prone to pressure &ama"e

such as the *chilles7 ten&on, bunion area, tibia, malleoli an& the

&orsum o' the 'oot4 Initially, 5hen use& oe&ema re&uces so the

ban&a"e 5ill nee& reapplyin" as the le" cir cum'er ence re&uces,

other5ise any bene'its 5ill be lost4



E5er +is

e

Wal$in" e=ercises the cal' muscle an& 5or$s the muscle pump,

increasin" venous return4 %any patients 5ith venous ulcers ar e

capable o' a mile or moreG this shoul& be encoura"e&4 Ho5ever, i'

they are el&erly or have other &isabilities, this 5ill not be

achievableG a&vice shoul& be tailore& to suit the patient7s

capabilities4 R e"ular 'le=ion an& e=tension e=ercises are

bene'icial in 5or$in" the cal' muscle pump 'or patients 5ith

limite& mobility4

Ele,ation

atients shoul& be encoura"e& to elevate their le"s above hip

hei"ht 5hen sittin" to 'acilitate venous r etur n4

B941- Ho5 shoul& mi=e& aetiolo"y or arterial ulcers be treate&

I' the *#I is bet5een -49 an& -402, the limb can have

compression therapy @see B94/A4 #elo5 this level, unless a&vise&

to the contrar y, e4"4 by a vascular sur"eon, ulcers shoul& be treate&

as arterial4

B941/ What is the recommen&e& mana"ement 'or arterial ulceration

Compression must not be use& on ulcers 5ith a substantial

arterial component4 *ny ban&a"es use& shoul& be li"ht retention

ban&a"es4 %il& e=ercise an& an$le e=ercises shoul& be encoura"e&especially i' the patient is immobile @see B940A4 Severe arterial

&isease may restrict mobility to less than /-- yar &s4

ain control may be achieve& by rest, anal"esia an& a suitable

&ressin", e4"4 'oam, hy&ro"el or hy&rocolloi& @see B4FB40

an& B24/1B24/3A4

atients 5ith arterial &isease, particularly those 5ith an

*#I belo5 -4F2, shoul& be consi&ere& 'or a sur"ical

opinion @see B94/A4

B941 When &oes a trauma to the le" become an ulcer

I' the patient has a history o' le" ulceration an& $no5n vascular

problems, any minor in6ury to the le" shoul& be treate& as a r ecur?

rence o' ulceration, an& appropriate treatment commence&



imme&i? ately @see B41 an& B94/-A4



In other patients, i' the 5oun& &oes not respon& as you 5oul&

e=pect other minor 5oun&s to, a vascular assessment shoul& be

carrie& out an& i' either venous or arterial &isease is &iscovere&

the 5oun& shoul& be treate& as an ulcer @see B94/A4eople 5ithout vascular problems may still have problems

5ith more ma6or $noc$sG even in healthy people the s$in over the

tibia is poorly vascularise& an& pretibial lacerations can ta$e

some time to heal @see BF49A4

B9411 When shoul& the treatment be chan"e&

In&ivi&ual healin" rates 5ill vary 5hatever the un&erlyin"con&ition4 *ny ulcer not respon&in" to treatment in 9 5ee$s

shoul& be reassesse&4 Treatment may nee& to be chan"e& or the

patient may re8uire 'urther investi"ation or re'erral to a

specialist nurse or consultant @see B94/1A4

B941 Ho5 can recurrence be prevente&

*ppro=imately F2L o' patients su''er recurrence o' ulceration4This can be re&uce& i' appropriate a&vice is "iven4

atients shoul& be a&vise& to report any ne5 &ama"e to le"s as

soon as possible, so that treatment can be starte&4 atients 5ith

venous &isease re8uire compression 'or li'e4 When healin"

is complete, they shoul& be measure& 'or suitable hosiery @see

B9412B94/A4

Encoura"e patients to continue 5ith e=ercise @see B940A4

R ein? 'orce a&vice on &iet, li'estyle an& smo$in" habits4Encoura"e pr otec? tion o' the le"s 'rom trauma &ama"e an&

continue to monitor the un&erlyin" &isease4

B9412 What is the role o' compression hosiery in preventin" recurrence

o' venous ulceration

*s the primary cause o' venous ulceration is the &evelopment o'

patholo"ical venous hypertension, it is important that the

un&er lyin" cause continues to be treate& @see B94/ an& B940A4

!ra&uate& compression hosiery applies e=ternal pressure to the

s$in an& un&erlyin" tissues 5hich supports the super'icial

veins, helpin" to counteract the raise& capillary pressure an& thus

r e&ucin"



oe&ema4 The re&uction o' oe&ema has been sho5n to be a crucial

'actor in relation to both ulcer healin" an& preventin" 'urther s$in

brea$&o5n an& ulceration @%o''att an& O7Hare /002A4

B9413 Which are pre'erre& above? or belo5?$nee stoc$in"s

.or most patients either len"th is e8ually e''ective @%o''att an&

O7Hare /002A4 Ho5ever, above?$nee stoc$in"s are more

appr opriate i' oe&ema collects aroun& the $nee, or i' the patient

has arthritic chan"es to the $nee that cause belo5?$nee stoc$in"s

to be uncom? ' ortable4

In other patients, compliance may be more li$ely 5ith belo5?$nee stoc$in"s 5hich are relatively easy to put on4 *lthou"h class

1 stoc$in"s @compression 212 mmH"A are &esirable, a patient

5ith &e=terity problems may be encoura"e& to comply by movin"

&o5n to class @compression /9 mmH"A4

B941F Shoul& stoc$in"s be open or close& toe

This is a 8uestion o' patient pre'erence4 Some patients, especiallythose 5ith &e'ormities o' the toe such as hammer toes, 'in& close&

stoc$in"s uncom'ortable an& restrictive, 5hereas others 'in& open

toes &i" in 5here the stoc$in" en&s4

B9419 What measurements shoul& be ta$en be'ore or&erin" stoc$in"s

%easurin" the limb accurately is important so that the stoc$in"

is 'itte& properly an& to ensure com'ort4 Ill?'ittin",

uncom'ortable stoc$in"s re&uce patient compliance in re"ular

5earin" o' the stoc$? in"4

%easurements shoul& be ta$en either 'irst thin" in the mor nin"

be'ore any oe&ema has accumulate& or imme&iately a'ter the

ulcer has heale& an& the compression ban&a"e has been r emove&4

%ost patients 5ill 'it into the stan&ar& siJes available on

prescrip? tion but those 5ith very lon" or &isproportionate le"s

may r e8uir e ma&e?to?measure stoc$in"s4 I' both le"s re8uire a

stoc$in" they shoul& be measure& separately4 The

measurements re8uire& ar e sho5n in .i"ure 9414

%anu'acturers su""est that stoc$in"s shoul& be rene5e& every

3 months4 The limb shoul& be measure& on each occasion that

a



@CA

@#A

@*A @EA

@DA

)i-ure 9<3 %easurements to be ta$en 5hen 'ittin" compression stoc$in"s4 @*A

The an$le at its narro5est pointG @#A the cal' at its 5i&est pointG @CA above $nee only<the thi"h at its 5i&est pointG @DA the len"th o' the 'ootG @EA len"th o' le", heel to

belo5 $nee4 The patient shoul& be bare le""e& an& stan&in" to ensure accurate

measurement4

stoc$in" is re8uire&4 It may be pre'erable to $eep the patient in

compression ban&a"es 'or 1 5ee$s a'ter healin" to limit the

possi? bility o' &ama"e to ne5ly 'orme& 'ra"ile s$in4

B9410 There are &i''erent classes o' compression hosiery4 What are their uses

Compression hosiery 'alls into three

classes4

D Class /< "ives //F mmH" pressure at the an$le4 They

ar e recommen&e& 'or varicose veins an& mil& oe&ema4

D Class < "ives /91 mmH" pressure at the an$le4 Theyar e recommen&e& 'or mo&erate?to?severe varicose veins an&

pr even? tion o' ulcer r eoccur r ence4

D Class 1< "ives 212 mmH" pressure at the an$le4 They

ar e recommen&e& 'or "ross varices, postphlebitic le"s,

r ecur r ent ulceration an& lymphoe&ema4



* class 1 stoc$in" is the best choice 'or patients 5ith r e peate&

episo&es o' ulceration an& consi&erable venous &isease but they

ar e &i''icult to put on, particularly 'or el&erly patients4 !enerally a

class stoc$in" is reco"nise& as su''icient to prevent recurrence i'

venous &isease is not severe, althou"h there is little available

research in this area @%o''att an& O7Hare /002A4

I' a patient has very limite& &e=terity t5o class / stoc$in"s

may prove easier to put on @this 5ill "ive "reater pressure than a

class overallA4

B94- *re there any tips 'or easier application o' hosiery

Some ai&s are available to assist 5ith application such as the

Valet @%e&iA but these are not available on prescription an&

have to be purchase& 'rom a pharmacy4

atients may 'in& application easier i' they &ust their le"

li"htly 5ith a simple non?per'ume& talcum po5&er be'ore

application to ma$e the stoc$in" slip on more easily4 Wearin"

rubber "loves may help to "rip the stoc$in"4 .or open?toe&stoc$in"s, placin" a Chinese slipper or plastic ba" over the 'oot

may ai& pullin" the stoc$in" over the 'oot4 The ba" or slipper

shoul& be pulle& out once the stoc$in" is in place4

B94/ *re there any haJar&s associate& 5ith the use o' compression stoc$in"s

The bi""est haJar& is i' the patient has a si"ni'icant amount o'

arter? ial &isease @see B94/A4 Care'ul patient assessment,

pre'erably 5ith a Doppler probe, shoul& eliminate this problem4

.or the patient 5ith arterial &isease, the &evelopment o' pressure

necrosis is a potential haJar &4

Ill?'ittin" stoc$in"s may also cause pressure or 'riction

&ama"e, particularly over the tibial crest, the &orsum o' the 'oot,

the bunion area, overcro5&e& or &e'orme& toes or any an$le

&e' or mity4

Stoc$in"s shoul& be chec$e& 'or correct 'it aroun& arthritic

&e'orme& $nees 5here they may 'orm constrictin" cu''s, "ivin"

a tourni8uet e''ect4 Some patients may su''er 'rom s$in aller"ies

or irritation @see B24-A an& 5ill re8uire a stoc$in" that has a

cotton layer ne=t to the le"4



an&



Tubi"rip an& as$e& her to &o her o5n &ressin"s4 Durin" this year,

the le" ha& 'aile& to respon& to the treatment an& the ulcer ha&

sli"htly increase& in siJe4 She 5as also 'eelin" miserable, because

the pain 'rom her ulcer 5as stoppin" her en6oyin" line &ancin",an& she 'elt unattractive4

.inally she &eci&e& to see$ a secon& opinion4 *t assessment,

her ulcer 5as sho5n to be venous4 It measure& appro=imately 1

cm an& 5as covere& by appro=imately 2-L slou"h4 .our?layer

compr es? sion 5as commence& an& she a"ree& to ta$e / month o''

5or$ to stop the necessity 'or prolon"e& stan&in"4 *'ter / 5ee$ she

5as r evie5e&4 The ulcer ha& starte& to re&uce in siJe an& 5as no5

142 cm 5ith about 2L slou"h4 She also 'elt morecom'ortable4 Within another 1 5ee$s the ulcer measure& / /42 cm an& 5as clean4

.ortunately,

5ee$s later @school holi&aysA sa5 the ulcer

heale&4

She 5as amaJe& at the pro"ress an& happy to 5ear the

pr escribe& stoc$in"s4 She 5as less happy about the 5aste& year o'

tr eatment4

7ase st&$y(

%rs ) ha& ha& a venous ulcer 'or years4 Despite compression

ther? apy an& appropriate &ressin"s, it remaine& static an& the

nursin" team, 5hile 'rustrate& at the lac$ o' pro"ress, 5ere

resi"ne& to t5ice? 5ee$ly &ressin" chan"es4

One team member starte& a &evelopmental course an& be"an to

8uestion 5hat 5as best practice4 She &eci&e& to loo$ at a 'e5

patients 5ho 'aile& to respon& to treatment an& see 5hether, by

rea&in" more about their con&itions, she coul& solve any o' the

problems4 *s part o' this, she starte& to rea& about 5oun& healin"

an& realise& that, althou"h the compression therapy an& &ressin"s

5ere 'ine, there coul& be some other un&erlyin" patholo"y

preventin" ulcer healin"4 She persua&e& the team lea&er to ta$e a

bloo& sample 'rom %rs ), an& the results sho5e& pernicious

anaemia4 *ppropriate treatment 5as commence& by the ! an& a'ter

a 'e5 months the ulcer slo5ly starte& to impr ove4

7ase st&$y-



%r . 5as an active 93?year?ol& man4 He live& alone 5ith no help

an& each &ay cycle& to the shops or 5or$in" men7s club4 He

en6oye& other people7s company an& 5as happy4 He ha& a /?year

history o' bilat? eral venous ulceration about 5hich he seeme& to

be unperturbe&4



They appeare& to cause him no &iscom'ort an& althou"h e=tensive

they 5ere static, not chan"in" in siJe 'rom month to month4 The

ulcers 5ere &resse& three times a 5ee$ by the &istrict nur se4

*s the nurses "aine& a better un&erstan&in" o' the bene'its o'compression therapy, they &eci&e& to start %r . on compression

ban&a"in"4 *n improvement in con&ition coul& be seen very

8uic$ly4 Ho5ever, %r . became pro"ressively more irritable an&

miserable4 It transpire& that he 'elt the ban&a"es 5ere impe&in" his

cyclin"4 He 5as relyin" on nei"hbours &oin" his shoppin" an&

erran&s, an& he ha& been unable to "o on his re"ular visits to the

club4 %r . 5as persua&e& to "et his bicycle out an& &emonstrate

the problem4 It 5as apparent that, 5hether or not it 5as a practical or psycholo"ical problem, he 5as unable to cycle4 He

persevere& 'or a 'urther 5ee$s "ettin" visibly lo5er in moo&4

The nurse met 5ith the health?car e team to &iscuss the problem4

The team 5ere &ivi&e&4 Hal' 'elt that the ne5 re"imen 5as

re&ucin" the 're8uency o' visits an& thus costs an&, as there 5as

an improvement, compression shoul& continue4 Hal' 'elt that his

rapi& &ecline in his "eneral con&ition an& moo& o''set any

bene'its an& that isolatin" him 5as inappropriate4What 5oul& you &o

4S4 Calle& in to a&6u&icate I &eci&e& that "iven his a"e an&

that the siJe o' the ulcers 5oul& preclu&e 'ast healin", to ma$e an

ol& man happy, 5e shoul& let him live 5ith his ulcers an& ri&e his

bi$e4

Summary

There are several causes o' le" ulceration an& it is important to

&etermine ulcer type at the onset o' treatment4 Thorou"h

assessment o' the patient7s "eneral con&ition, the a''ecte& limb,

ulcer site an& a vascular assessment are essential4 The aim o'

treatment is thr ee' ol&< to heal the ulcer, to treat the un&erlyin"

con&ition an& to pr event r eoccur r ence4




CHAP*ER :

Pressuresores

ressure ulcers are a common problem4 Inci&ence an& pr evalence

stu&ies "enerally &emonstrate that bet5een 1L an& /-L o' the

population in both hospital an& community settin"s ac8uire a

&e"r ee o' pressure &ama"e 5hile un&er"oin" care @)an& /00A,

althou"h some estimates put the 'i"ure hi"her4 .inancial costs

to the NHS have been estimate& as hi"h as FF2 million a year

@West an& riest? ley /00A4 This inclu&es sta'' time, &ru"s,

&ressin"s an& hospital over? hea&s, but e=clu&es costs to the patient

such as pain, su''erin", loss o' in&epen&ence an& in some

circumstances li'e4 These costs ar e impossible to calculate4 It

has been estimate& that 3- --- &eaths a year result 'rom

complications o' pressure &ama"e, althou"h &eath certi'icates

rarely re'lect this @Staas an& Cioschi /00/A4

atients are becomin" increasin"ly concerne& about pressure

sores bein" an unnecessary complication o' me&ical treatment

an& are be"innin" to see$ recompense throu"h the courts4 In

/09F &ama"es o' /-- --- 5ere a5ar&e& to a success'ul

claimant @Silver

/09FA4

It is obvious that the prevention o' pressure ulcers shoul& be o'

paramount importance to the nurse4 Ho5ever, it is apparent that

not all pressure sore &evelopment is preventable4 )oa&er et al4

@/00A estimate that, althou"h 02L o' pressure &ama"e can be

avoi&e&, the remainin" 2L is inevitable, resultin" 'rom 'actors

such as &ama"e bein" present be'ore the care episo&e, &ebilitatin"

un&erlyin" con&i? tions an& e=traor&inary cir cumstances4

*lthou"h nurses &o not 5or$ in isolation, nursin" care must be

re"ar&e& as a ma6or in'luence on outcomes relate& to pressure

ar ea car e4



9/



B04 What are the intrinsic 'actors that cause pressure ulcers

Intrinsic 'actors that cause pressure ulcers inclu&e the

'ollo5in"<



ressure sores 91

<en$er

The Waterlo5 @/092A ris$ assessment tool ta$es "en&er into

account an& sho5s 5omen to be at "reater ris$ o' pressure &ama"e

than men4 Ho5ever, the reasons are poorly un&erstoo&4

Age

ressure &ama"e can occur at any a"e but is more common in

el&erly people because s$in has lost elasticity an& they are more

li$ely to have concurrent &iseases @Ny8uist an& Ha5thorne /09FA4

Immobility* re&uction in mobility 'or any reason increases the ris$ o'

&evelop? in" pressure &ama"e @Dealey /00A4

=o$y

4eight

)o5 bo&y 5ei"ht "ives less protection 'rom pressure over

bony prominences4 Obese patients may s5eat, increasin" the ris$

o' shear or 'riction @Dealey /00A4

N&trition

%alnutrition is a primary contributin" 'actor an& re&uces the

tissue7s ability to 5ithstan& pressure @%a$leburst an&

Sie"r een

/003A4 It also causes &elaye& healin" @%c)aren /00G Dealey

/00A @see also B14B14FA4 Obese patients can also bemalnourishe& @see B04FA4

1e$i+ation

Steroi&s, anti?in'lammatory &ru"s, stron" anal"esics, se&atives,

U? bloc$ers an& cytoto=ic &ru"s can increase the ris$ o'

pressure &ama"e by re&ucin" mobility, sensation, s$in inte"rity

an& appetite @#an$s /00FA4

In+ontinen+e

Incontinence o' either 'aeces or urine can result in s$in

maceration or e=coriation4 This lea&s to increase& ris$ o' 'riction

&ama"e an& increases the ris$ o' in'ection @Tor rance /091G

Dealey /00A @see




B04FA4 Some &ru"s such as aperients, &iuretics an& antibiotics may

e=acerbate incontinence @Dealey /00A4

:n$erlying$isease

%any un&erlyin" &iseases contribute to the &evelopment o'

pressure &ama"e4 Neurolo"ical problems can cause loss o'

mobility an& sensation4 )o5 bloo& pressure results in a lo5er

e=ternal pressure bein" re8uire& to occlu&e the capillary vessels4

Circulatory problems can re&uce bloo& supply to the tissues an&

impair the removal o' 5aste pro&ucts4 Other con&itions

increasin" the ris$ o' pressure &ama"e inclu&e *lJheimer7s&isease, carcinoma, &iabetes, arthritis, "astrointestinal, liver an&

renal problems @Dealey /00G #an$s /00FA4

Skin +on$ition

Tissue paper s$in can be the result o' a"ein" or the use o' lon"?

ter m hi"h?&ose steroi&s @see B149A4 Oe&ematous s$in can also

result in a re&uce& o=y"en supply an& impaire& removal o'5aste pr o&ucts @Tor rance /091G Dealey /00A4

Inf e+tion

Systemic in'ection can lea& to pyre=ia, e=cessive s5eatin" an&

tissue brea$&o5n @#an$s /00FA @see B/-4/ an& B/-4A

Smoking

See B1404 Smo$in" can also result in loss o'

appetite4

Other

f a+tor s

These inclu&e pain, state o' consciousness, psycholo"ical

'actor s, sociolo"ical 'actors an& 5ho is provi&in" home care

@Dealey /00A4B042 What are the e=trinsic 'actors that cause pressure ulcers

E=trinsic 'actors resultin" in patients e=periencin" pressure

&ama"e inclu&e pressure, shear an& 'riction4

.r ess&r



ressure sores 92e

ressure &ama"e usually occurs over the bo&y7s bony

prominences4 When pressure is applie& to the s$in 'rom the

support sur'ace @i4e4



ressure sores 9F

F ri+tio

n

This is the 'orce relate& to t5o sur'aces movin" across one another4

I' a patient is not move& usin" recommen&e& movin" an&han&lin" techni8ues, but is &ra""e& or pulle& across sur'aces,

'riction can &isrupt the epi&ermis an& cause an initial brea$ in the

s$in4 This can occur in a community settin" i' the patient7s carers

are also el&erly or in'irm, an& they have &i''iculty li'tin" the

patient, or i' care sta'' ar e ina&e8uately traine&4

.riction &ama"e can also occur as a result o' an ill?'ittin"

plaster cast or limb prosthesis4

B043 Ho5 can patients at ris$ o' &evelopin" pressure &ama"e be i&enti'ie&

When initiatin" a preventive strate"y it is necessary to i&enti'y

those patients at ris$ o' &evelopin" pressure sores4 This can be

achieve& by usin" ris$ assessment tools, 5hich<

D *ct as an ai$e8m>moire to carers @.lana"an

/001AD Help provi&e 8uanti'iable &ata 'or au&itin" [email protected]"an

/001A

D rovi&e evi&ence that preventivetreatment plans are base&

on ob6ective criteria an& a speci'ic rationale @.lana"an /001A

D *i& the rational allocation o' limite& resources @such as

special mattressesA to those most li$ely to bene'it 'rom them

@ Ef f e+ti,e 6ealth 7ar e =&lletin /002AD *ct as case mi= a&6usters to help ma$e sensible comparisons

o' pressure sores bet5een units over time @ Ef f e+ti,e 6ealth 7ar e

=&lletin/002A4

The 'irst ris$ assessment scale 5as the Norton ressure Sor e

Ris$ *ssessment Scale @Norton et al4 /03A %any

mo&i'ications have appeare& since4 Norton is probably one o'the best $no5n an& most 5i&ely use& @#arrett /09FG Davies

/00A but is 'elt by some to be too simplistic4 It is important to

choose a scale that is suitable 'or your area o' 5or$4 *lthou"h

all scales have a research?base& rationale, they 5ere &esi"ne&

'or &i''er ent purposes an& settin"s4 Norton7s scale 5as &esi"ne&

speci'ically 'or use 5ith the ol&er person4 Some &i''erences are



99 Woun& Care< * Han&boo$ 'or Community Nursessho5n in Tables

04/ an& 044



ressure sores 90

*ab,e <1 The Norton Score

hysical state %ental state *ctivity

!oo& *lert *mbulant .air 1 *pathetic 1 Wal$s 5ith help 1

oor Con'use& Chairboun&

Very ba& / Stuporous / #e&boun& /

%obility Incontinence

.ull None

Sli"htly limite& 1 Occasional 1

Very limite& (sually urine

Immobile / Double /

VThe Norton Score can be use& to assess the &e"ree o' ris$ o' &evelopin" pressure

sores4 It 5as &evelope& 'or use 5ith el&erly patients4 * score o' / in&icates

vulnerability to pressure sores4 * score o' / is hi"h ris$4

*ab,e <2 Comparison o' ris$assessment

Ris$ 'actor Norton !osnall :noll Waterlo5 #ra&en

%obility H H H H H

*ctivity H H H H

Nutritional status H H H H

%ental status H H H H

Incontinencemoisture H H H H H

!eneral physical con&ition H H H

S$in appearance H H

%e&ication H H

.rictionshear H

Wei"ht H

*"e H

Speci'ic pre&isposin" H H

rolon"e& pressure H

* comparison o' pressure sore ris$ 'actors use& in various ris$ assessment scales

@.lana"an /001A4

The Waterlo5 score, Table 041, is another popular assessmenttool, &evelope& in the (: in /094 It is more comple= than the

Norton score @#irchall /001A, covers a lar"er number o' ris$

'actor s an& "roups patients into three cate"ories o' ris$ status4 It

also cover s su""estions 'or care "ui&elines4



Bui,d>Wei-+t for Hei-+t V Skin *y0e V Se/>A-e V S0e#ia, Risks

*vera"e*bove *vera"eObese

#elo5 *vera"e

-/

1

HealthyTissue aperDry

Oe&ematousClammy @ TempX

A Discoloure&#ro$enSpot

-/

/

//

1

%ale.emale/0

2-332FF29-9/Y

/

/

1

2

*issue "a,nutrition V

e4"4 Terminal Cache=ia

Car&iac .ailureeripheral VascularDisease

*naemiaSmo$in"

9

22

/

Continen#e V "obi,ity V A00etite V Neuro,o-i#a, %efi#it

CompleteCatheterise&Occasionally IncontinentCathIncontinent o' .aecesDoubly Incontinent

-/

1

.ullyRestless.i&"ety *patheticRestricte&InertTractionChairboun&

-/

1

2

*vera"eoor

N4!4 Tube.lui&s only N#%*nore=ic

-/

1

e4"4 Diabetes, %4S4, CV*,%otorSensory araple"ia 3

"a=or

Orthopae&ic#elo5 Waist, Spinalon Table hours

22

"edi#ation

Cytoto=icsHi"h Dose steroi&s*nti?In'lammatory

9 9

Woun&Care<*Han&boo$'orCommun

ityNurses

*ab,e <3 The Waterlo5 ressure Sore reventionTreatment olicy4 Repro&uce& 5ith $in& permission o' %rs Ku&y Waterlo5

Water,o; Pressure Sore Pre.ention>*reatmentPo,i#y

RIN! SCORES IN T*#)E, *DD TOT*)4 SEVER*) SCORES ER C*TE!OR C*N #E (SED

Score /-Y * Ris$ /2Y Hi"h Ris$ -Y Very Hi"h Ris$

Remember tissue &ama"e o'ten starts prior to a&mission, in casualty4 * seate& patient is also at ris$4

*ssessment< I' the patient 'alls into any o' the ris$ cate"ories then preventative nursin" is re8uire&4 * combination o' "oo& nursin" techni8ues an&

preventative ai&s 5ill &e'initely be necessary4



ressuresores

9 0

REVENTION< WUN% CLASSI)ICA*INREVENT*TIVE *IDS< Stirlin" ressure Score severity scale @SSSSA

Special %attress#e&< /-Y overlays or specialist 'oam mattresses4/2Y alternatin" pressure overlays, mattresses an&

be&systems4-Y #e& System< .lui&ise&, bea&, lo5 air lossan&alternatin" pressure mattresses4

Note < reventative ai&s cove r a 5i&e spectrumo' specialist 'eatures4 E''icacy shoul& be 6u&"e&, i'

possi? ble, on the basis o' in&epen&ent evi&ence4

Cushions< No patient shoul& sit in a 5heelchair 5ithoutsome

'orm o' cushionin"4 I' nothin" else is available Zusethe patient7s o5n pillo54/-Y[[ .oam cushion4/2Y Specialist cell an&or 'oam cushion-Y Cushion capable o' a&6ustment to suitin&ivi&ual

patient4#e& Clothin"< *voi& plastic &ra5 sheets, inco pa&s an& ti"htlytuc$e&

in sheetssheet covers, especially 5hen usin"Special?ist be& an& mattress overlay systems4(se Duvet?plus vapour permeable cover4

N(RSIN! C*RE !eneral< .re8uent chan"es o' position, lyin"sittin"

(se o' pillo5sain *ppropriate pain control

Nutrition Hi"h protein, vitamins, mineralsatient Han&lin"< Correct li'tin" techni8ue Hoists %on$ey ole

Trans'er Devicesatient Com'ort *i&s< Real sheeps$ins Z #e& Cra&leOperatin" Table

\\Theatre*;E Trolley cover plus a&e8uate protection4

S$in Care< !eneral Hy"iene, NO rubbin", cover 5ith an appro? priate &ressin"

If treatment is re?uired$ first remo.e 0ressure



Sta-e 5 Z No clinical evi&ence o' pressure sore5<1 Z Heale& 5ith scarrin"5<2 Z Tissue &ama"e not assesse& as a pressure sore @aA belo5

Sta-e 1 Z Discoloration o' intact s$in1<1 Z Non?blanchable erythema 5ith increase& local heat1<2 Z #luepurpleblac$ &iscoloration Z the sore is at least Sta-e 1 @aor bA

Sta-e 2 Z artial thic$ness s$in loss or &ama"e2<1 Z #lister 2<2 Z *brasion2<3 Z Shallo5 ulcer, no un&erminin" o' a&6acent tissue

2<4 Z

*ny o' these 5ith un&erlyin" bluepurpleblac$ &iscoloration or in&uration4 The sore is at least Sta-e 2 @a, b or cY& 'or 2<3, Ye 'or2<4A

Sta-e 3 Z .ull?thic$ness s$in loss involvin" &ama"enecrosis o'subcuta? neous tissue, not e=ten&in" to un&erlyin" bone ten&on or 6ointcapsule

3<1 Z Crater, 5ithout un&erminin" a&6acent tissue3<2 Z Crater, 5ith un&erminin" o' a&6acent tissue3<3 Z Sinus, the 'ull e=tent o' 5hich is uncertain3<4 Z Necrotic tissue mas$in" 'ull e=tent o' &ama"e4The sore is at least Sta-e 3 @b, YH?e, ', ", Yh 'or 3<4A

Sta-e 4 Z .ull?thic$ness loss 5ith e=tensive &estruction an& tissuenecrosis e=ten&in" to un&erlyin" bone ten&on or capsule

4<1 Z Visible e=posure o' bone ten&on or capsule4<2 Z Sinus assesse& as e=ten&in" to same @bYH?e, ', ", h, iA

!ui&e to types o' Dressin"sTreatment a4 Semipermeable membrane '4 *l"inate roperibbon

b4 Hy&rocolloi& "4 .oam cavity 'iller c4 .oam &ressin" h4 EnJymatic &ebri&ement&4 *l"inate i4 Sur"ical &ebri&emente4 Hy&ro"el



0- Woun& Care< * Han&boo$ 'or Community Nurses

Ris$ assessment tools shoul& be use& as an a&&ition to clinical

6u&"ement4 The Ef f e+ti,e 6ealth 7ar e =&lletin @/002A su""ests that

ther e is little evi&ence that usin" a pressure sore ris$ scale is

better than clinical 6u&"ement or that it improves outcomes4Ho5ever, any tool that can help to assist in i&enti'yin" at?ris$

vulnerable patients is valuable 5hen plannin" care, but any tool

is o' bene'it only i' it is use& correctly an& the patient7s at?ris$

status is reassesse& r e"ular ly an& 5henever there is a chan"e in his

or her con&ition4

B04F Ho5 can pressure sores be prevente&

Choice o' an appropriate support sur'ace is important @see B049A

to remove the e=trinsic 'actors si"ni'icant in the &evelopment

an& &elaye& healin" o' pressure ulcers @%orison /090A, as is

alleviatin" the e''ects o' the intrinsic 'actors contributin" to tissue

brea$&o5n4 @see B04 an& B042A

*ssess the patient7s ris$ o' &evelopin" pressure &ama"e 5hen

they 'irst come into your care, an& reassess re"ularly or 5henever

there is a chan"e in the patient7s con&ition, usin" a reliable an&vali& assess? ment tool @see B043A4

Incontinence is o'ten associate& 5ith pressure sores @.letcher

/00A4 %oisture is $no5n to be a 'actor in increasin" pressure

&ama"e ris$, an& 5oun& e=u&ate an& perspiration as 5ell as

urine may lea& to s$in maceration @riest an& Clar$e /001A4 It

has also been su""este& that 'aecal incontinence is a more

important 'actor in pressure &ama"e than urinary incontinence

@riest an& Clar $e/001A4 The patient shoul& be cleanse& as soon as possible a'ter

bein" incontinent, e=cessive soap shoul& not be use&, avoi& the

rubbin" o' &elicate s$in, an& i' possible correct the cause o' the

incontinence @E$ an& #oman /09A4 Dealey @/002A su""ests

that the use o' a mil& cleanser in a spray 'ormat, such as the

Triple Care System @Smith ; Nephe5A, may re&uce pressure

sore inci? &ence4

%alnutrition has also been &escribe& as one o' the mostcommonly cite& 'actors in the &evelopment o' pressure &ama"e

@Closs /001A @see B04A4 I' the patient is 'ailin" to eat a balance&

&iet an&or is losin" 5ei"ht, chec$ on the reason 5hy, an& arran"e

prac? tical help such as meals on 5heels i' necessary an& 'oo&

supplements



ressure sores 0/

such as .resubin @.reseniusA or Ensure @*bbottA 'or

consumption bet5een meals @see B14B14FA4 .lui& inta$e shoul&

also be moni? tor e&4

Inspect hi"h?ris$ areas re"ularly 'or any si"ns o' &ama"ean&

&evelop a plan o' mobilityturnin" appropriate to the patient7s

ris$, 5hich $eeps him or her o'' any &ama"e& s$in or hi"h?ris$

sites as much as possible, bearin" in min& the patient7s nee& 'or

com' ort, sleep, meals an& li'estyle4 I' much o' the care is bein"

carrie& out by relatives or other carers, it is important to involve

them in movin" the patient, loo$in" 'or &ama"e an& reportin"

&ama"e strai"ht a5ay4 It may help to have carers7 in'ormationlea'lets available to rein'orce a&vice "iven @see B949A4

B049 What shoul& be ta$en into account 5hen selectin" an appropriate

support sur'ace

When selectin" a suitable support sur'ace, 5hether 'or an

in&ivi&ual patient or 'or a "roup o' patients @such as in a nursin"

homeA, the 'ollo5in" 'actors nee& to be consi&ere&<

D Clinical

D ractical

D .inancial @Clar$ an& .letcher/000A4

7lini+al+onsi$er ations

The intrinsic an& e=trinsic ris$ 'actors @see B04 an& B042A nee&

to be consi&ere&, an& also issues such as< What is the patient7s

ris$ level7 an& >Is this e=pecte& to chan"e Has &ama"e

alr ea&y occurre& Does the patient have other re8uirements 'rom a

mattress, such as nee&in" a 'irm e&"e to allo5 trans'er out o'

be& *re ther e any me&ical problems that ma$e certain types o'

mattress unsuit? able @Clar$ an& .letcher /000A

.ra+ti+al+onsi$er ations

D Will the mattress 'it on the patient7s e=istin" be& Consi&er

both the 5i&th an& the chan"e in hei"ht4 Does the patient

share a &ouble be& 5ith his or her partner

D Ho5 easy is the support sur'ace to transport an& to set

up




D Will sta'' nee& to be traine& to use the e8uipment an& 5ill sta''

be re8uire& to supervise its use This is particularly important i'

it is to be use& in the patient7s home4

D Ho5 shoul& it be cleane& in bet5een patient use an& ho5much stora"e space &oes it re8uire Ho5 much

maintenance is re8uire& an& 5ho 5ill per'orm this

D Is the patient 5ithin the correct 5ei"hthei"ht limit su""este&

by the manu'actur er

D Is the mattress acceptable to the patient @Clar$ an& .letcher

/000A

Finan+ial+onsi$er ations

.inancial 'actors o'ten a''ect the availability o' support sur'aces

to patients4 The 'ollo5in" points nee& to be consi&ere& to avoi&

incur? rin" unnecessary costs an& to allo5 e8uity o' access to

e8uipment4

D Is there a clear proce&ure 'or >steppin" up an& &o5n7 to

ensure that e8uipment is remove& 'rom patients 5ho no lon"ernee& that level o' e8uipment, so that other more nee&y

in&ivi&uals can "ain access to it

D *re there any hi&&en costs, e4"4 maintenance costs or

specialist cleanin"

D What 5ill it cost the patient or relatives to run the

e8uipment, an& is this acceptable to them

B040 What type o' support sur'ace shoul& be selecte&

There is a lar"e selection o' support sur'aces available4 They can

be &ivi&e& into those provi&in" pressure re&uction an& those

pr ovi&in" pressure relie'4 ressure re&uction is the constant relie' o'

pressure that is bein" e=erte& on the patient7s bo&y4 This is

pro&uce& by e8uipment such as layere& or 'orme& 'oam?, "el?,

'ibre? or air?'ille& mattr esses, lo5 air?loss or air?'lui&ise& systems

@:enney an& Rithalia /000A4ressure relie' is intermittent lo5erin" o' the e=ternal pressure

on the patient7s bo&y by in'lation an& &e'lation o' the cells o'

the mattress or by li'tin" the bo&y clear o' the sur'ace4 This can

be achieve& by manual turns, or by the use o' an alternatin"

pressure mattr ess4



ressure sores 01

Static overlays are the simplest 'orm o' pr essur e?

r e&ucin" mattresses @Collier /000aA4 They can be ma&e o' 'oam,

'ibre or "el, 5hich con'orms to the patient7s bo&y shape an&

re&istributes 5ei"ht over a lar"er sur'ace ar ea4There are a number o' static mattresses 5ith pr essur e?r e&ucin"

properties available4 These are ma&e o' 'oam4 Consi&eration

shoul& be "iven to the &ensity an& the har&ness o' the 'oam, hi"her

&ensity 'oam usually lastin" lon"er than lo5?&ensity 'oam

@:enney an& Rithalia /000A4 The mattress may be &esi"ne& 5ith

'oam slits or be pre'orme& to 'it the patient7s contours4 *ll these

mattresses ar e &esi"ne& to &istribute pressure evenly un&er the

patient4 Consi&era? tion shoul& be "iven to ho5 o'ten the mattressnee&s turnin" to $eep it in "oo& con&ition, an& 5hat type o'

'abric the cover is ma&e o' @Collier /000aA4 Static cushions are

available an& shoul& have the same 8ualities as the mattress

chosen4

)o5 air?loss systems are available either as be& systems

or mattresses an& provi&e pressure re&uction via in&ivi&ual air ?

'ille& cells, o'ten "roupe& re"ionally to ma=imise the pr essur e?

r e&ucin" e''ect4*lternatin" pressure sur'aces can be supplie& as overlays or

replacement mattresses4 They consist o' a number o' seale& cells in

a removable cover, 5hich in'late an& &e'late alternately, thus

r e&istrib? utin" the pressure over the so't tissues o' the bo&y an&

allo5in" reper'usion o' previously supporte& areas @%c)eo&

/00FA4

Natural sheeps$ins may re&uce 'riction or shear but &o not

re&uce pressure @Collier /000bA4 Synthetic sheeps$ins have been sho5n to be ine''ective an&, i' poorly laun&ere&, to increase

inter'ace pressure @)othian an& #arbenal /091A4

Rubber or Sorbo rin"s shoul& never be use& to re&uce pressure,

because they actually concentrate pressure on a smaller sur'ace

an& may cause ne5 ulcers @)othian an& #arbenal /091A4

Su""estions 'or types o' mattress are &i''icult4 I&eally, all

health? care areas shoul& have a local policy that su""ests

e8uipment base& on clinical e''ectiveness4 The Ef f e+ti,e 6ealth 7ar e =&lletin @/002A states that >most o' the e8uipment available 'or the

prevention an& tr eat? ment o' pressure sores has not been reliably

evaluate& an& no ]best buy^ can be recommen&e&74




* "eneral "ui&e coul& be the 'ollo5in"<

D !ra&e / sore< static

over laycushionD !ra&e 1 sore< alternatin" air5aveover laycushion

D !ra&e 1 sore< alternatin" air5ave

mattr esscushion4

Ho5ever, a patient 5ith no sore may in&icate a hi"h level o'

ris$ an& re8uire an appropriate support sur'ace4 Immobile patients

5ho cannot turn 5ill nee& re"ular position chan"es to $eep them'ree o' sores4

Summar

y

ressure sores are cause& by e=trinsic an& intrinsic 'actors4 The

ris$ o' &ama"e &evelopin" shoul& be pre&icte& usin" a suitable,

r eliable an& vali& tool4 ressure &ama"e shoul& be prevente& by both select? in" an appropriate support sur'ace an& alleviatin" the

e''ects o' the intrinsic 'actors that contribute to pressure &ama"e4



03 Woun& Care< * Han&boo$ 'or Community Nursesor &iabetic may 'ail to sho5 si"ns o' in'lammation an& si"ns o'

clinical in'ection, an& may re8uire a s5ab to be ta$en i' the 5oun&

is 'ailin"

02



Woun& in'ection 0F

practice nurse4 * 'ull assessment, inclu&in" Doppler stu&ies,

in&i? cate& that the ulcer 5as o' venous ori"in4 Treatment 5as

commence& 5ith a 'oam &ressin" an& sin"le?layer compression,

an& the treatment 5as to be chan"e& once a 5ee$4Initially the ulcer respon&e& 5ell an& 5as re&ucin" in siJe4 *'ter

a 'e5 5ee$s it became in'ecte& an& nee&e& treatment 5ith

antibiotics4 The in'ection resolve&4 *'ter another couple o' 5ee$s

the ulcer a"ain became in'ecte& an& antibiotics 5ere re8uire&4

This became a pattern over the ne=t couple o' months an& no

pro"ress to5ar &s healin" 5as bein" ma&e4 Eventually, a'ter

"entle 8uestionin", it 5as reveale& that %rs K 5ante& her le"

&resse& more 're8uently than once a 5ee$ as she ha& al5ays&one it once or t5ice a &ay 5hen loo$in" a'ter it hersel'4 To

achieve this she 5as ta$in" o'' the ban&a"e, 5ashin" an&

&ryin" the 'oam &ressin" an& care'ully reban? &a"in" the limb4

The nurse e=plaine& to her that this 5as the cause o' the 're8uent

in'ections an& that it 5as pre'erable that the &ressin" be le't in

place to optimise 5oun& healin"4

To achieve a better level o' compliance, a compromise 5as

reache& 5hereby she atten&e& the sur"ery t5ice a 5ee$4 Theulcer a"ain starte& to pro"ress an& 'inally 5ent on to heal4

7ase st&$y

%r H 5as a F3?year?ol& 'armer4 He ha& al5ays been active an&

still mana"e& a small mi=e& 'arm inclu&in" co5s, &uc$s, sheep

an& hens4 He ha& recently &evelope& a venous le" ulcer 5hich ha&

&evelope& rapi&ly an& $ept "ettin" in'ecte&4 This situation 5asnot helpe& by copious amounts o' 'armyar& manure4 His con&ition

5as startin" to limit his mobility an& his ability to ta$e care o'

the 'arm4 This 5as ma$in" him e=tremely an=ious4 T5o?layer

compression ban&a"in" ha& been attempte&, but constant pullin"

o'' o' Wellin"ton boots $ept &isturbin" the ban&a"es 5hich 5ere

'ilthy 5ith manur e4

* 'our?layer ban&a"e ha& been consi&ere& but, 5ith the

amount o' e=u&ate an& the necessity 'or the Wellin"ton boot,&ismisse&4 *'ter a 6oint consultation o' the vascular specialist,

tissue viability nurse, &istrict nurse, %r H an& his sister, it 5as

a"ree& that the prior? ities 5ere to re&uce the amount o' in'ection

an& thereby the e=u&ate, an& to achieve a "oo& level o'

compression4 .our?layer ban&a"in" 5as commence&, %r H7s

sister purchase& a lar"er Wellin"ton boot




an& cut it &o5n to hal' le" len"th to ai& easier application an&

removal, an& a pop soc$ over the ban&a"e ma&e it less stic$y,

5hich also helpe&4 Initially the ban&a"e 5as chan"e& t5ice a

5ee$4%r H7s le"s improve& &ramatically, the e=u&ate &ecrease&,

the ban&a"es staye& in place an& the 'armyar& manure &i& not

pene? trate the layers o' ban&a"e, an& so the in'ections

subsi&e&4 His mobility returne&4 *'ter 3 months o' treatment, the

le" 5as heale& an& %r H continue& to run his 'ar m4

B/-41 Is there a recommen&e& metho& o' ta$in" a 5oun& s5ab

There is some controversy over the best metho& o' per'ormin" a

5oun& s5ab4 The metho& &escribe& by Cooper an& )a5r ence

@/003A is "ently to irri"ate the 5oun& 5ith physiolo"ical saline, to

use the s5ab in a Ji"?Ja" motion over the entire 5oun& sur'ace

5hile slo5ly rotatin" it4

B/-4 Ho5 shoul& in'ecte& 5oun&s be treate&

Treatment o' in'ection shoul& be 5ith systemic antibiotics,

because the use o' topical treatments 5ith antibacterial creams

can lea& to the "ro5th o' resistant or"anisms, an& shoul& be

avoi&e& @%or "an

/09FA4

(ntreate& 5oun& in'ection can lea& to septicaemia an& &eath

@see B/-4/1A4

B/-42 What is cellulitis an& ho5 shoul& it be treate&

Cellulitis is an acute, rapi&ly s5ellin" in'lammation o' the s$in

an& so't tissues @!rey /009A4 It is characterise& by s5ellin",

pain, erythema an& heat, an& sometimes 'ever4 These si"ns are

usually con'ine& to the area aroun& the 5oun&, but in some

severe cases it may be accompanie& by 'eatures o' systemic

to=icity, inclu&in" se pti? caemia4 It o'ten occurs a'ter minor

brea$s in the s$in, lacerations, sur"ical 5oun&s an& ulcer s4

The t5o main causative or"anisms are Staphylo+o++&s a&re&s an&

Strepto+o++&s pyogenes @!rey /009A4 Streptococcal in'ection ten&s to

be associate& 5ith small brea$s in the s$in an& staphylococcal

in'ections 5ith lar"er 5oun&s such as ulcer s4



Woun& in'ection 00

I&enti'ication o' the causative or"anism is o'ten &i''icult,

5ith tests such as 5oun& s5abs an& bloo& cultures "ivin" poor

r esults4 Dia"nosis an& treatment ten& to be empirical an& base&

on the bacteriolo"y o' the associate& 5oun&4 Ho5ever, culture o'any tissue 'lui& or pus shoul& be attempte&4 #loo& shoul& be ta$en

i' there ar e clinical si"ns o' in'ection, but these tests are not al5ays

positive even i' there are si"ns o' systemic in'ection @!rey /009A4

Severe cases 5ill re8uire hospital a&mission4

atients 5ith &iabetic or ischaemic 'oot ulcers @see B94/9A,

5ho &evelop associate& cellulitis, are at hi"h ris$ o' &evelopin"

systemic to=icity @!rey /009A, an& i' un&ertreate& this can have

"rave conse? 8uences such as the loss o' a limb4Treatment is normally a systemic antibiotic @%orison an&

%o' 'att

/00AG in'ection present 5ithin the tissues cannot be reache& by

applyin" topical a"ents @see B/-4A4

B/-43 What is the sin"le most important thin" that can be &one in

clinical practice to re&uce the ris$ o' cross?in'ection

E''ective han& 5ashin" is the most important 'actor in re&ucin"

cr oss? in'ection @ar$er /000A4 *lthou"h this is routinely

ac$no5le&"e&, a constant application o' this practice still &oes

not e=ist4 %icr o? or"anisms 'oun& on the s$in are terme& >resi&ent7

an& >transient7 ' lora4

>Resi&ent7 or"anisms live an& multiply on the s$in an& 5ill

var y 'rom person to person4 They "enerally are not virulent an&

rar ely cause the person harm4 Ho5ever, i' trans'erre& to &eeperstructures they coul& be harm'ul, e4"4 &urin" invasive proce&ures

such as minor sur"ery4 HaJar& can be minimise& by usin" an

antiseptic han& 5ash @ar$er /0004A

>Transient7 or"anisms are ac8uire& 'rom contact 5ith another

person or ob6ect, such as 'rom contaminate& sur'aces4 Durin"

>&irty7 proce&ures, e4"4 chan"in" the &ressin" on an in'ecte&

5oun&, they can be pic$e& up even 5hen "loves are 5orn4 They

ten& to be loosely attache&, so 5ashin" 5ith soap an& 5ater 5illremove them4

Han&s shoul& be 5ashe& as 'ollo5s<

/4 Rub palm to palm

4 Rub bac$s o' both

han&s




14 Rub palms a"ain 5ith 'in"ers

inter lace&

4 Rub bac$s o' interlace&

'in"er s24 Remember to 5ash both thumbs

34 Rub both palms 5ith 'in"er

tips4

Washin" shoul& be un&er runnin" 5ater 5ith chosen cleanser

an& han&s shoul& be thorou"hly &rie& on a paper to5el4 Routine

social han& 5ashin" shoul& be /-/2 secon&s 5ith either soap or an

antise p? tic, 5hereas 'or minor sur"ery 5ashin" shoul& be 2minutes4

Other points to consi&er ar e<

/4 *voi& 5earin" 6e5ellery especially rin"s @5e&&in" rin"s

shoul& be manipulate& &urin" han& 5ashin" to remove micro?

or "anismsA4

4 :eep nails short4

14 Wet han&s be'ore applyin" han&5asha"ent4

4 (se only non?ionic han&creamG &o not use communal 6ar s4

24 *l5ays cover any cuts 5ith a 5aterproo'

&ressin"4

34 Han&5ash a"ents can become contaminate&G bar soap shoul&

be allo5e& to &rain &ry @no slimy soap &ishesAG &o not top up

li8ui& soap or antiseptic a"ents4F4 I' han&s sho5 si"ns o' irritation "et me&ical a&vice @ar$er

/000A4

B/-4F What is %RS*

%RS* stan&s 'or methicillin @or multiA?resistant Staphylo+o++&s

a&re&s4 Staphylo+o++&s a&re&s is a bacteria carrie& by --L o' the

population 5ith no ill e''ects @Weaver /003AG it colonises the s$in,nasal passa"es an& mouth4

Wi&esprea& use o' antibiotics has le& to an emer"ence o'

r esistant strains4 %RS* is resistant to penicillin, important anti?

staphylococcal a"ents such as 'luclo=icillin, cephalosporins

an& other r elate& antibiotics4

I' a patient has a severe clinical in'ection o' %RS*, he or she



Woun& in'ection /-/5ill nee& hospitalisation an& treatment 5ith intravenous

vancomycin, but most patients are colonise& rather than in'ecte&4

I' the patient is a heavy carrier an& &isperser, althou"h not at

ris$ to him? or hersel' other patients 5ho are sic$ or have 5oun&s

may be at ris$ 'rom cross?in'ection @Wolverhampton Health Care

Control o' In'ection Committee /002A4




B/-49 What s5abs shoul& be ta$en to screen 'or %RS*

S5abs shoul& be pre?moistene& 5ith sterile saline in or&er to

collect more bacteria4 The 'ollo5in" sites are recommen&e&<

D E=ternal nares

@nostrilsA

D *=illa an& "r oin

D *ny 5oun&s

D Sputum @i' the patient has a pro&uctive

cou"hA

D The 5oun& itsel' D I' the patient has a catheter, a urinespecimen4

* patient is clear 5hen three sets o' s5abs at 5ee$ly intervals

ar e ne"ative a'ter any treatment is terminate&4

B/-40 Ho5 shoul& a patient 5ho is a carrier o' %RS* be treate&

The patient shoul& be a&vise& to have a &aily bath or strip 5ash4

He or she shoul& apply an antiseptic &eter"ent &irectly to the s$in

5ith a 5ash cloth an& rinse o''4 I' the a=illa an& "roin are

colonise&, he=a? chlorophene po5&er shoul& be applie&4

Hair shoul& be 5ashe& &aily an& on the 'irst an& thir& &ay o'

treatment 5ashe& 5ith an antiseptic &eter"ent4 *'ter bathin"

the patient shoul& put on clean clothes4 #e& linen shoul& be

chan"e& as 're8uently as possible4 )aun&ry can "o on a normal5ash pre'erably at 3-PC4 I' the e=ternal nares are colonise&,

mupirocin ointment is applie& three times a &ay 'or F &ays4

The patient poses no ris$ to anyone in his or her o5n home

unless they have a 5oun&, catheter or other invasive line

@Weaver /003A4 Visitors shoul& be a&vise& that they are at no

special ris$ an& that e=cessive han& 5ashin" 5ith antiseptics may

ma$e the patient 'eel isolate&4 It is recommen&e& that antiseptic

han& 5ashin" is bene'i? cial only i' there is prolon"e& contact or&irty materials such as &r ess? in"s have been han&le&4 This is not

the case 'or visitin" nurses or home helps 5ho may be in contact

5ith other at?ris$ in&ivi&uals a'ter5ar&s @see B/-4/-A4

The patient can continue 5ith normal social activities4 There

ar e no restrictions on usin" public transport4 I' the patient nee&s to

"o to outpatients, ambulance control shoul& be in'orme&, as




outpatients &epartment4 I' the patient re8uires hospital a&mission

the receivin" &octor shoul& be in'orme&4

!eneral &omestic cleanin" is a&e8uate, althou"h it is

important to $eep the environment as clean as possible, especially&ust contr ol4 *ny home carershome helps shoul& be e&ucate& in

"oo& han&? 5ashin" techni8ues an& have &isposable "loves an&

aprons available4 I' the patient has e8uipment on loan such as

mattresses or commo&es, the loan centre shoul& be in'orme&

be'ore the return o' any e8uipment4

B/-4/- What precautions shoul& the &istrict nurse ta$e

District nurses shoul& use &isposable "loves an& aprons, 5hich

can then be &ispose& o' in the patient7s normal househol& 5aste

@Wolver? hampton Health Care Control o' In'ection

Committee /002A4 Han&s shoul& be 5ashe& thorou"hly 5ith

antiseptic han&5ash such as Hibiscub4 aper to5els shoul& be le't

in the house 'or use rather than usin" househol& to5els4 *ny

cuts or abrasions shoul& be covere& 5ith a 5aterproo' plaster

@Weaver /003A4atients in'ecte& or colonise& 5ith %RS* shoul& have their

&ressin"s chan"e& at the en& o' the &ay4 Rubbish shoul& be

&ispose& o' in line 5ith the local in'ection control policy4

When the patient no lon"er re8uires &ressin"s no le't?over

stoc$s shoul& be ta$en out o' the house 'or use in other ar eas4

B/-4// What precautions shoul& be ta$en in the ! sur"ery 'or a patient 5ith

%RS* in'ection

atients 5ho are %RS* positive or a5aitin" s5ab results shoul&

have their &ressin"s atten&e& to at the en& o' the &ay7s sur"ery4

The 5oun& shoul& be cleane& 5ith a chlorhe=i&ine?base& solution4

I' the patient has 'la$y s$in, such as those 5ith venous ecJema,

care shoul& be ta$en to catch all s$in 'la$es4

Sta'' members are at no personal ris$ because the %RS*

&oes not pose a ris$ to healthy in&ivi&uals @Weaver /003A4

!oo& han&?5ashin" techni8ue is the best metho& o'

controllin" sprea& o' %RS* an& the use o' "loves @in line 5ith

your local in'ec? tion control policyA an& aprons is recommen&e&

@Duc$5orth /00-A4



Woun& in'ection /-2

Han&s shoul& be 5ashe& 5ith an antiseptic chlorhe=i&ine a"ent or

5ith an alcohol rub, an& &rie& on &isposable paper to5els4 *ny

open cuts shoul& be covere& 5ith a 5aterproo' plaster 4

*ll soile& &ressin"s shoul& be ba""e& an& seale& in in'ecte&5aste ba"s an& sent 'or incineration, in line 5ith your local

in'ection control policyG contact your local in'ection control nurse

'or a&vice4

B/-4/ *re there any speci'ic "ui&elines 'or nursin"resi&ential homes

atients shoul& be care& 'or in a sin"le room an& a5ay 'rom other

patients 5ith open 5oun&s or brea$s in the s$in @WolverhamptonHealth Care Control o' In'ection Committee /002A4 Ensuite han&?

5ashin" 'acilities shoul& be available i' possible an& an

antise ptic han& 5ash available4 The patient7s personal clothin"

an& be& linen shoul& be care& 'or as in'ecte& in accor&ance 5ith

the home7s policy4 Contact your local in'ection control

&epartment to see i' there is a speci'ic >Nursin" Home7 policy4

!eneral cleanin" 5ith a "eneral purpose &eter"ent is satis'actory4

Damp &ustin" is recommen&e&4

B/-4/1 What is the recommen&e& mana"ement 'or 5oun&s colonise& 5ith

%RS*

Topical antibiotics are o'ten a&vocate& 'or the treatment o'

%RS*4 There is, ho5ever, concern about the e''icacy i' they are

applie& in're8uently or over a lar"e area @Weaver /003A @see

B/-4A4T5o antibiotics are recommen&e& an& treatment shoul& be

no lon"er than F/ &ays4 %upirocin can be applie& to shallo5

5oun&s no lar"er than 1 cm in &iameter4 .usi&ic aci& is a "oo&

anti? staphylococcal a"ent but, i' use& alone or over a lar"e area,

r esis? tance may occur4 It may be use'ul in combination

5ith oral trimethoprim 'or /- &ays4

*'ter the antibiotics have stoppe&, the 5oun& shoul& be tr eate&

accor&in" to its clinical appearance, e4"4 slou"hy, necrotic, etc4T5o &ays a'ter antibiotic therapy has stoppe&, repeat 5oun&

s5abs shoul& be ta$en4 I' the 5oun& is colonise& or not severely

in'ecte&, it may respon& to antiseptics alone4 Dressin"s such as

.lamaJine an& Ina&ine have been 'oun& to be e''ective a"ainst

some strains o' %RS*4




B/-4/ Do sta'' nee& to be screene& 'or %RS*

%RS* &oes not pose a threat to sta''4 There'ore a sta'' member

carin" 'or a patient 5ith %RS* is at no personal ris$, nor aretheir 'amilies4 #ecomin" a carrier o' %RS* is no re'lection on an

in&ivi&? ual7s personal hy"iene4

I' in'ection control precautions are ta$en the ris$ o' becomin"

a carrier is minimal4 Ho5ever, in an institution 5here several

patients are %RS* positive, it is possible that sta'' may

become car rier s @Wolverhampton Health Care Control o'

In'ection Committee

/002A4 I' sta'' &o become carriers they can easily be treate& 5ithanti? septic preparations4 Sta'' can be screene& 5ith a"reement

5ith the local in'ection control team an& they or the occupational

health &epartment 5ill a&vise on treatment an& 5hen to return to

5or $4

Summar

y

Routine s5abbin" is ine''ective an& an unnecessary 5aste o'

money4 It important to reco"nise si"ns o' in'ection4 Woun&

in'ection shoul& be treate& systemically4 #e a5are o' the

principles o' cr oss?in'ection an& asepsis4 *lso be a5are o'

necessary precautions i' the patient has %RS*4



CHAP*ER 11

"is#e,,aneous

This chapter &eals 5ith other 're8uently as$e& 8uestions that &o

not 'it into any o' the other chapters in the boo$4 These inclu&e

care o' 'un"atin" 5oun&s, &ressin" &i''icult areas, maceration an&

the use o' ma""ots @larval therapyA4

B//4/ What is a 'un"atin" 5oun&

.un"atin" &escribes a con&ition o' ulceration an& proli'eration

that arises 5hen mali"nant tumour cells in'iltrate an& ero&e

throu"h the s$in @%ortimer /001A, or mali"nant cells sprea& alon"

path5ays o' least resistance, e4"4 bet5een tissue planes an&

lymph capillaries @%osely /099A4 .un"atin" tumours may be

complicate& by sinus or 'istula ' or mation4

.un"atin" tumours &evelop in a number o' sites4 %ost common

is the breast but melanoma, lymphoma, an& cancers o' the lun",

stom? ach, hea&, nec$, uterus, $i&ney, ovary, colon an& bla&&er

may also in'iltrate in this 5ay @%ortimer /001A4

Tissue hypo=ia in a 'un"atin" 5oun& is a si"ni'icant

problem lea&in" to a loss o' tissue viability4 *naerobic an&

aerobic bacteria thrive in these con&itions an& are the cause

o' the associate& malo&our an& pro'use e=u&ate @!roscott

/002A4 In a&&ition, the capillaries o' tumours are 'ra"ile an&

pre&ispose the tissue to blee&? in"4 Tumour "ro5th results in

5oun&s that are continually enlar "in", irre"ular in shape, necrotic

an& e=u&in"4

Woun& mana"ement is comple= an& involves mana"in"

o&our @see B43A, e=u&ate @see B24A, blee&in" @see B//4A an& pain

contr ol @see B4FB40A4



/-3 Woun& Care< * Han&boo$ 'or Community Nurses/-2



/-3 Woun& Care< * Han&boo$ 'or Community Nursesan& heels 5her e



%iscellaneous /-F

the &ressin" has to be shape& @.letcher /000A4 To &ress heels, a

' lat &ressin" such as a hy&rocolloi& or 'oam can be cut an& then

shape& aroun& the heel4

To &ress &i"its, many people use a cotton net an& applicator tosecure the primary &ressin"4 Other solutions inclu&e cuttin" a ' lat

pro&uct to allo5 it to be shape& aroun& the &i"it 5ithout too much

bul$4 I' the &ressin" re8uires securin" 5ith tape, ensure that the

tape &oes not completely 5rap aroun& the 'in"er4 I' oe&ema

occurs it coul& cause constriction4

Dressin"s over 6oints such as elbo5s or the $nee can r estrict

mobility because the &ressin" &oes not stretch or it is bul$y4

Cuttin" a thin hy&rocolloi& or 'ilm an& applyin" it in sli"htlyoverlappin" strips 5ill allo5 some 'le=ibility @.letcher /000A4 This

can be use& either as a primary &ressin" or a retention &ressin"4

(sually no other bul$y pa&&in" is r e8uir e&4

B//42 What causes s$in maceration

%aceration is cause& by prolon"e& e=posure to 'lui& that remains

in contact 5ith the s$in4 This may be 5oun& e=u&ate, urine ors5eat4 It may cause &eterioration in the 5oun& an& also lea& to

s$in brea$? &o5n4

The bo&y7s normal 5oun&?healin" response o' in' lammation

causes local oe&ema, 5hich seeps 'rom the 5oun& sur'ace @see

B/49A4 The e=u&ate 'rom acute an& chronic 5oun&s has &i''er ent

constituents @Cuttin" /000A4 The e=u&ate 'rom chronic 5oun&s

contains proteases, 5hich brea$ &o5n protein an& 5ill actually

&ama"e 5hat may be other5ise healthy tissue @Ho'man et al4/00FA4 E=u&ate pro&uction o'ten increases i' the 5oun&

&eteriorates4

%oist 5oun& healin" has been sho5n to spee& up 5oun&

healin" @Winter /03A @see B/40A an& many &ressin"s such as

'ilms, ' oams, hy&rocolloi&s, al"inates an& hy&ro'ibres promote

healin" usin" the theory o' moist 5oun& healin" @see B24A4Occlusive &ressin"s @see B243A are o'ten blame& 'or maceration

@Cuttin" /000A but it 5ill only occur i' the &ressin" re"imen is bein" use& inappropriately4 Wear time shoul& not e=cee& the time

beyon& 5hich the &ressin" can a&e8uately cope 5ith the

pro&uction o' e=u&ate4 The choice o' &ressin" nee&s to re'lect

e=u&ate levels as 5ell as the site an& con&ition o' the 5oun&4

Hy&ro'ibre an& al"inate



/-9 Woun& Care< * Han&boo$ 'or Community Nurses

&ressin"s are very absorbent an& can be covere& 5ith absorbent

pa&s @see B240 an& B24/A4E=u&ate 'rom venous ulcers can be controlle& 5ith compression

therapy an& elevation 5hen clinically in&icate& @Cuttin" /000A@see

B940A4

I' s$in becomes macerate&, some people use eosin as an astrin?

"ent to &ry it @&o not use on the actual 5oun&A @%or"an

/00FA4 Others soa$ the le", inclu&in" the 5oun&, in a solution o'

potassium perman"anate4 Neither o' these t5o approaches has

been evaluate& in comparative clinical trials @Cuttin" /000A4

inc o=i&e paste or ban&a"es may be use& to provi&e protection by actin" as a barrier4 It is 5orth patch testin" be'ore

'ull application to avoi& sensitivity4 I' hi"h levels o' e=u&ate

persist, the possibility o' in'ection shoul& be consi&ere&4 @see B/-4/

an& B/-4A4

B//43 What is meant by over"ranulation an& ho5 shoul& I treat it

Over"ranulation, or hyper"ranulation as it is sometimes calle&,

is "ranulation tissue that rises above the e&"es o' the 5oun&4E=peri? ence has sho5n that removin" an interactive &ressin"

such as a hy&rocolloi& an& usin" a simple &ressin" such as a lo5

a&herent &ressin" or 'oam allo5s the 5oun& to settle &o5n on its

o5n4 Silver nitrate use& either as a -42L compress or as a silver

nitrate stic$ is also sometimes use& @%or"an /00FA4

*+e use of ma--ots: ,ar.a,

t+era0y

B//4F *re ma""ots available only 'or treatin" 5oun&s in hospital

There is no reason 5hy ma""ots or larvae cannot be use&

'or patients 5ithin their o5n homes or a nursin" home, provi&in"

that the patient an& their 'amily are in a"reement4 Ho5ever,

larvae are not on prescription at present an& so 'un&in" 5oul&

have to be provi&e& by the primary care "roup or trust4

B//49 What types o' 5oun& are suitable 'or treatment 5ith larvae

%a""ots remove both &ea& tissue an& bacteria, leavin" in most

cases a healthy "ranulatin" 5oun& @Thomas et al4 /003A4 Their

main use 5oul& be on a necrotic, slou"hy or in'ecte& 5oun& @see

B4/- an& B4// an& Tables /-4/ an& /-4A4



%iscellaneous /-0

B//40 Ho5 are the ma""ots applie& to the 5oun&

The most common metho& o' application is to surroun& the 5oun&

5ith a bor&er o' hy&rocolloi&4 This is applie& to the intact s$in li$e

a picture 'rame4 The ma""ots are 'lushe& out o' their carria"e

contain? ers 5ith saline an& applie& to the 5oun& sur'ace,

appro=imately /- larvaecm @Thomas et al4 /0034A %a""ots are

appro=imately mm in len"th4 * piece o' sterile, 'ine nylon mesh

covers the ma""ots an& 5oun&, an& is hel& in position by stic$in"

it to the hy&rocolloi& 5ith a&hesive tape4 !auJe &ampene& 5ith

physiolo"ical saline is place& over this to $eep the ma""ots

hy&rate&4 *ny pa&&in" can then be applie& to contain e=u&ate

an& li8ue'ie& necrotic tissue4 The ma""ots shoul& be chan"e&

every 1 &ays4

B//4/- Ho5 shoul& ma""ots be remove& an& &ispose& o'

When the soile& &ressin"s are remove& the larvae either 'all o''

or can be 'lushe& o'' the 5oun& sur'ace 5ith saline4 Dressin"s

shoul& be place& in a yello5 ba", seale& securely an& sent 'or

incineration4B//4// Is there any ris$ o' ma""ots turnin" into 'lies

* ne5ly hatche& larvae ta$es F/ &ays to complete its li'e cycle

an& turn into a 'ly4 *s &ressin"s are chan"e& every 1 &ays they

5ill be remove& 'rom the 5oun& 5ell be'ore they pupate an& turn

into a ' ly4

B//4/ Can the patient 'eel the ma""ots movin" on the 5oun& or eatin"

the &ea& tissue

%ost patients cannot 'eel the ma""ots on the 5oun&4 I' they are

on intact s$in they may tic$le but surroun&in" the 5oun& 5ith

hy&r o? colloi& eliminates this4

The ma6ority o' patients receivin" larval therapy report a

r e&uc? tion in 5oun&?relate& pain @Thomas et al4 /003A,

althou"h a 'e5 report an increase in pain @see B4FB40A4

The sterile larvae supplie& &o not burro5 into healthy tissue4

Information

B//4/1 *re there any sources o' in'ormation about 5oun& care on the internet

There are many sources o' in'ormation about 5oun& care on the



//- Woun& Care< * Han&boo$ 'or Community Nursesinternet4 !eneral search en"ines can be use& as 5ell as tools to

assist



%iscellaneous ///

in locatin" me&ical in'ormation an& &irect access uni'orm resource

locators @(R)sA to appropriate sites4

This is becomin" an increasin"ly popular 5ay o' searchin"

the literature4 In'ormation is accessible 5orl&5i&e at any timean& to anyone 5ith the appropriate technolo"y4 It is a rich

e&ucational source 5hich can assist e&ucational &evelopmentG it

also "ives an e? mail lin$ 5ith research 'oun&ations an& other

contributors an& thus ai&s the easy &iscussion o' 'in&in"s @itcher

/009A4

Some use'ul 5eb sites are liste& un&er Resources, pp4 /124

Summary

.un"atin" 5oun&s can be comple= to treat, an& specialist a&vice

may be nee&e&4 The nee& 'or sensitive care 5hen &ealin" 5ith

malo&orous 5oun&s cannot be overstresse&4 %a""ots can be a

use'ul an& e''ective therapy, 5hich is currently "ainin" in

popularity4 atient e&ucation an& support are essential 'or

compliance 5ith this therapy4



///



chosen option *ppraise an&

evaluate

evi&ence

vali&ity,

use'ulness

// Woun& Care< * Han&boo$ 'or Community Nurses

B/4 What is clinical e''ectiveness

Clinical e''ectiveness or evi&ence?base& health care is an

appr oach to practice that helps you to consi&er 5hether you are pr ovi&in" optimum care 'or your patients throu"h i&enti'yin"

e=istin" evi&ence on best practice4 The chart sho5n in .i"ure

/4/ 5as pro&uce& by the North Thames Research *ppraisal

!roup @/009A to help "ui&e people in ensurin" that they are

ma$in" the best possible use o' research in their clinical practice4

There are several steps to &evelopin" the process an& s$ills

involve& in ensurin" that the care you provi&e is evi&ence base&4

ou may 'eel that you currently &o not possess all o' the s$illsthat ar e involve& in the process, an& i' this is the case &o not

5orry, 5e all have a lot to learn4 There are lots o' people 5ho can

len& their s$ills an& e=pertise to help you alon" the 5ay4

*&&ressin" the sta"es o' the process in a little more &epth 5ill

i&enti'y 5ho the $ey people are to contact 'or help in &evelopin"

your e=pertise in this area4 ou mi"ht 'in& it help'ul to raise any

trainin" nee&s that you i&enti'y at your ne=t per'ormance revie5

meetin"4

In'ormation

nee&

Evaluate

*ns5erable per'ormance

8uestion

HE*)TH

*TIENT C*RE

TE*%

Select an& Search 'or

implement evi&ence

)i-ure 12<1 The clinical e''ectiveness process4

B/41 What in'ormation is nee&e&

This 8uestion is really as$in" about 5here the "aps in the

mana"e? ment o' your patients are4 Each patient is uni8ue an& may

come 5ith



Clinical //1

one hun&re& an& one &i''erent 8uestions, so you 5ill almost

al5ays 'in& that there is somethin" 'or you to &iscover4 Buestions

can be about all aspects o' patient care4 In 5oun& care they may

inclu&e thin"s such as<

D What is the best sort o' &ressin" 'or this5oun&

D Ho5 lon" 5ill it ta$e to

heal

D Woul& physiotherapy help

D Ho5 can I stop another ulcer &evelopin"

Once you start thin$in" about issues re"ar&in" all your

&i''er ent patients, you 5ill probably 'in& that you have 'ar more

potential 8uestions than you coul& possibly 'in& the time to ans5er

so you 5ill nee& to &eci&e 5hat the $ey problems are an& ho5 to

prioritise4 Topics that are li$ely to come to the top o' the priority

list inclu&e problems common to a number o' patients, unusually

severe or seri? ous presentations o' con&itions, concerns about the

8uality o' the service raise& by sta'', patients or relatives, an&areas 5here there is perceive& to be real potential to improve the

8uality o' car e4

B/4 What &oes it mean to as$ an ans5erable 8uestion

Once you have thou"ht about the issues an& concerns that are o'

interest to you, it is 5orth 'ormulatin" them into a clear 8uestion4

This 5ill help you to tar"et your search 'or the ans5er to the8ues? tion4 These 8uestions ten& to inclu&e 'our elements<

D The $ey 'eatures o' the patient or problem4

D Details o' the intervention or test that you are

consi&erin"4

D ossible alternatives to thatintervention4

D In&ications o' the outcomes o'

inter est4

When i&enti'yin" the $ey 'eatures o' the patient or problem

you shoul& thin$ about ho5 you 5oul& &escribe a similar "roup

o' patients4 This may inclu&e aspects such as con&ition, a"e, se=

an& ethnicity4 The intervention or test an& possible alternatives

re'er to 5hat you thin$ your options are in treatin" your patients4



// Woun& Care< * Han&boo$ 'or Community Nursesou may have to &eci&e bet5een t5o &i''erent types o' ban&a"es

or &ressin", or ans5er more "eneral 8uestions about 5hat is the

best 'orm o' 'oot5ear 'or someone 5ho has 'oot ulceration 5hen

you are not yet



Clinical //2

a5are o' the possible options4 Outcomes can come 'rom a variety

o' perspectives, 5hether that o' the patient, carers, &octors or

nursin" sta'', an& on occasion can con'lict 5ith each other4 our

main aim may be the complete healin" o' a 5oun&, 5hereas the patient may be &esperate to maintain mobility an& in&epen&ence,

an& so may be prepare& to accept continuin" ulceration in return

'or that 'ree&om4

To help put this into some sort o' conte=t, a short scenario can

sho5 ho5 that can be use& to &evise an ans5erable 8uestion4

The s+enario

When people come to see you about 5oun& care, you currently

"ive them verbal a&vice about treatin" the 5oun&, &iet,

e=ercise an& li'estyle4 ou have recently &evelope& several

concerns about this4 ou have rea& that "enerally people only

remember /-L o' 5hat they have been tol& &urin"

consultations an& are particular ly concerne& that a substantial

number o' the local population belon" to ethnic minority "roups

an& &o not spea$ En"lish as their 'irst lan"ua"e4 ou have

there'ore &eci&e& to revie5 the 5ay you pr ovi&e in'ormation to

your patients4

The ?&estion

Element E=ample

atient or problem eople 5ith 5oun&s 5ho &o not spea$ En"lish as their

'irst lan"ua"e

Intervention or test Simple verbal e=planation supporte& by 5ritten

material

@possibly in relevantlan"ua"esA

ossible alternatives Cassettes an& vi&eo tapes in relevant lan"ua"es,

accessin" interpretation services

Outcome@sA o' interest (n&erstan&in" an& retention o' in'ormation,

compliance 5ith recommen&ations, increase& healin"

rates 'or 5oun&s

our 8uestion is there'ore li$ely to be somethin" li$e<

Is it more e''ective to provi&e oral, 5ritten, cassette or vi&eo

a&vice 'or people 5ith 5oun& care nee&s 5ho &o not spea$

En"lish as their 'irst lan"ua"e in or&er to ensure that they

un&erstan& an& remember the a&vice, comply 5ith treatment an&

have 5oun&s that heal



//3 Woun& Care< * Han&boo$ 'or Community Nurses

B/42 Ho5 &o I search 'or evi&ence

The 'irst port o' call 'or most o' us 5hen 5e have a clinical

8uestion is to consult a collea"ue4 This is an entirely le"itimateaction an& the pro'essional $no5le&"e that you an& your

collea"ues share is a $ey 'actor in patient care4 Ho5ever, you also

nee& to be a5are that it is impossible 'or anyone to stay

abreast o' current practice an& research in all areas o' care4

Rea&in" all the 6ournal articles that come out each month about

community nursin" 5oul& in itsel' be more than a 'ull?time 6ob,

an& you are still e=pecte& to $eep seein" the patientsQ )i$e your

collea"ues, te=tboo$s can become rapi&ly out o' &ate, an& in someareas o' me&icine it is estimate& that the te=t? boo$s 5ill be out

o' &ate be'ore they even hit the shelves, so you 5ill nee& to turn to

other sources o' evi&ence an& ma$e 'rien&s 5ith your local

librarian 5ho can assist you in this4

The best evi&ence that you can 'in& comes 5hen

comprehensive literature searches have been &one to ans5er

8uestions about speci'ic areas o' care, the results consi&ere& 'or

their 8uality an& then combine& to in&icate best possible practicein the "iven area4 This is $no5n as a systematic revie5 or meta?

analysis4 These can be use& to pro&uce "ui&elines on best practice4

*n e=ample o' this is the Ef f e+ti,e 6ealth 7ar e =&lletins pro&uce& by

the Centre 'or Revie5s an& Dissemi? nation at or$ (niversity4

Topics covere& inclu&e prevention an& treatment o' pressure

sores an& mana"ement o' venous ulcers, an& copies o' these

shoul& be available throu"h your practice, clinic or your local

librarian or local au&it a&viser4 Other sources are&atabases

o'systemic revie5s inclu&in" the Cochrane )ibrary, Database o'

Revie5s o' E''ectiveness an& #est Evi&ence, an& your local

librarian shoul& be able to put you in touch 5ith these4 It is also

5orth contact? in" the Royal Colle"e o' Nursin" an& other

pro'essional bo&ies to see 5hether they have pro&uce& evi&ence?

base& "ui&elines4

I' you cannot 'in& the ans5er to your 8uestion in a systematic

revie5 or throu"h your pro'essional bo&y, you 5ill nee& to

un&erta$e your o5n literature search4 There are various &atabases

that you can search4 The main ones that you are li$ely to

come across ar e %e&line, 5hich inclu&es abstracts an& &etails o'

articles pro&uce& in over /--- &i''erent me&ical an& relate&

6ournals 5orl&5i&e, an& CIN*H) @Cumulative In&e= o' Nursin"

an& *llie& Health )itera? tureA 5hich a"ain contains abstracts an&

&etails o' articles in nursin"



Clinical //F

an& pro'essional clinical service 6ournals4 *"ain your

librarian shoul& be able to a&vise you ho5 to be able to tap into

these resources e' 'ectively4

One o' the main sources you can use to search 'or in'ormationis via the internet4 One o' the issues raise& by the case stu&y on

pr ovi&? in" in'ormation relates to a possible nee& 'or 5ritten

in'ormation 'or patients4 I' your literature search in&icate& that

this 5oul& be e' 'ec? tive then you coul& also search 'or user

&isease?base& "roups 5ho may alrea&y be provi&in" in'ormation,

5hich you coul& inte"rate 5ith the resources that you provi&e 'or

your patients4 %any o' these "roups no5 have 5ebsites on the

internet @see B//4/1A4

B/43 Ho5 can I learn to appraise evi&ence

Clinical appraisal is a techni8ue to assist you in revie5in" research

to ensure that the results are vali&, believable, impressive an&

applica? ble4 Chec$lists have been pro&uce& 'or &i''erent types o'

r esear ch such as 8ualitative trials comparin" &i''erent

interventions @ran&omise& controlle& trials or RCTsA, trials

loo$in" at the patter n o' an illness or &isease over time

@lon"itu&inal stu&iesA, etc4 by or "an? isations such as NTR*!

@North Thames Research * ppraisal !roupA an& C*S @Critical

*ppraisal S$ills ro"rammeA4 The clini? cal "overnance lea& o'

your primary care "roup or trust shoul& be able to arran"e 'or you

to have some trainin" on this either thr ou"h local trainin"

initiatives or CD RO%?base& learnin" pac$s 5hich may be

available 5ithin the or "anisation4

In or&er to &evelop your s$ills in this area, it 5oul& be

5orth consi&erin" 6oinin" a 6ournal club4 Kournal clubs consist

o' small "roups o' sta'' 5ho meet re"ularly to &iscuss research

papers an& their application to practice4 I' you &on7t 'eel li$e

6oinin" one 5ith !s you coul& thin$ about settin" one up 5ith

other practice sta''4

B/4F So i' I "o throu"h all this process, i&enti'y my problem, 'in& some

evi&ence that helps ans5er it an& intro&uce some chan"es to my prac? tice, ho5 &o I $no5 5hether or not it has ha& the &esire& e''ect

This is 5here the ne=t sta"e o' the clinical e''ectiveness process

comes in as you can start to thin$ about evaluatin" your

per' or mance, re'lectin" on 5hat has 5or$e& 5ell an& 5hat nee&s

to be chan"e& to be even more e''ective4 Tools that can be use'ul in

this process inclu&e clinical au&it, patient participation an&



//9 Woun& Care< * Han&boo$ 'or Community Nursesre'lective practice4



Clinical //0

B/49 What is clinical au&it

Clinical au&it is a tool to help you re'lect on your clinical

practice an& to evaluate the e''ectiveness o' the care that you provi&e @.i"ur e

/4A4

*s in the clinical e''ectiveness process you nee& to i&enti'y

the area or issue o' concern an& see$ to i&enti'y 5hat current best

prac? tice is in this area4 ou use this to set stan&ar&s 'or the care

process4 .or 5oun& care these coul& inclu&e<

D *ll patients presentin" 5ith le" ulcers have a thorou"hassessment inclu&in" Doppler stu&ies4

D *ll patients 5ith venous ulcers receive compression therapy4

D *ll patients are provi&e& 5ith 5ritten in'ormation about the

car e an& mana"ement o' venous ulcers an& relate& health an&

li'estyle a&vice4

Havin" set your stan&ar&s, you then nee& to &eci&e the best

5ay o' i&enti'yin" 5hether they have been achieve&4 This can bethr ou"h a variety o' techni8ues inclu&in" revie5in" patient notes,

&o5nloa&? in" in'ormation 'rom the practice computer an&

collectin" speci'ic

Select topic

%onitor by *"ree criteria

an& repeatin" cycle

stan&ar&s

*"ree an& Set &ata

collection implement chan"e

rules

Re'lect on results Collect &ata



/- Woun& Care< * Han&boo$ 'or Community Nurses)i-ure 12<2 The clinical au&it cycle4



Clinical //

in'ormation over a limite& time scale4 our practice, clinic,

or primary care "roup or trust may be luc$y enou"h to have an

in' or? mation technolo"y @ITA or computer specialist 5ho coul&

a&vise you on retrievin" in'ormation 'rom in'ormation systems4.or the stan&ar&s liste& above, you may &eci&e to create a

chec$? list 5hich you coul& use 5hile "oin" throu"h the notes to

tic$ o'' 5hether or not each stan&ar& has been achieve&4 ou may

5ish to a&& a comments column in 5hich you can recor& such

thin"s as "aps in the patient history or len"th o' time since the

last Doppler r esult 5as recor&e& i' it 5as not in the previous 1

months4

It is very har& to loo$ ob6ectively at our o5n notes an& practice, so you mi"ht 'in& it help'ul to 6oin up 5ith some other

practice nurses or community sta'' an& a"ree to loo$ at each

other7s notes4 Comin" to a set o' notes 5ith 'resh eyes, you o'ten

notice thin"s that you 5oul& overloo$ in your o5n notes, an& you

can learn 'rom other people7s "oo& practice an& their mista$es4

ou coul& also lear n 5hether your han&?5ritin" is li$ely to be

le"ible 'or someone cover? in" you 5hen you are on holi&ay or

'or someone ta$in" over i' you shoul& choose to chan"e 6obs4I' you are revie5in" patient recor&s, you 5ill nee& to &eci&e

ho5 many notes to select to provi&e a representative sample4 I'

you pull only one set o' notes you mi"ht 'in& that the results are

e=ce ptionally poor or "oo&, but you 5oul& not $no5 5hether the

results 'or that patient 5ere abnormal 'or some reason4 #oo$s on

statistics pr ovi&e samplin" tables that you coul& use to &eci&e

ho5 many notes you 5oul& nee& to revie5 to be con'i&ent that

the results 5ere not the result o' chance4 These are base& on the population siJe, i4e4 the number o' people 5ith the particular

con&ition that you are loo$in" at, not the population o' the entire

practice4 Ho5ever, you may 'eel that, rather than pursue a ri"i&

statistical approach, you 5oul& be happy to "et a 'eel o' 5hat is

happenin" in your practice4 In this case you may choose to select

the last /- sets o' notes o' people you sa5 5ith the chosen

problem or select one set 'or each o' the 'irst letter s in the

alphabet4 This approach is also help'ul 5hen you are $een torevie5 your practice but have only very limite& time to &evote to

it4 In such circumstances, provi&in" you are prepare& to ta$e on

boar & the results 5hether they are "oo& or ba&, you can

le"itimately r evie5 smaller numbers o' notes4



Clinical /1

&ocumentation4 ou may 'in& you nee& to revie5 the 5aitin"

room to see 5hether posters provi&e appropriate an& up?to?&ate

in' or ma? tion an& are o' a "oo& con&ition4 Stran"ely, si"ns an&

posters o'ten &isappear on a re"ular basis at reception an&else5here in the clinic4 *lternatively, you may 'eel the nee& to

a&opt a >mystery patient7 approach4 This involves arran"in" 'or

someone to atten& the prac? tice an& provi&e con'i&ential 'ee&bac$

on 5hat it 5as li$e 'rom their perspective4 I' this 5as &one by

someone 5ith a &isability they coul& in'orm you not only about

5hether their con'i&entiality 5as main? taine& an& 5hether they

5ere treate& 5ith &i"nity an& respect, but also about 5i&er issues

such as physical access an& the provision o' in'ormation4 This is 6ust one o' the many approaches that you can ta$e in investi"atin"

patient e=periences4

The 'ollo5in" scenario &emonstrates ho5 clinical au&it can

bene? 'it practice4

*s senior practice nurse, nurse T ha& an interest in improvin" practice an&

ensurin" that it 5as evi&ence base&4 She ha& insti"ate& an au&it to e=amine

the amount o' 5oun& s5abs ta$en an& the levels o' 5oun& in'ection4

The practice ha& clear >best practice statements7 that 5oun&s shoul& be

s5abbe& only i' si"ns o' in'ection 5ere present an& also 'or the treatment o'

5oun&s an& on the principles o' cross?in'ection4

Over the previous / months both the number o' 5oun& s5abs ta$en an&

in'ection levels ha& &roppe&4 These 'i"ures 5ere collecte& 1 monthly4 *t the

'ollo5in" reau&it it appeare& that the number o' s5abs ta$en ha& more than

&ouble& an& in'ection rates ha& increase& but not so &ramatically4

Nurse T realise& that &urin" this time perio& the only real chan"e

5ithin the sur"ery 5as that a ne5 practice nurse ha& starte&4 Re?e=aminin"

the 'i"ures in more &etail sho5e& that she 5as s5abbin" all 5oun&sroutinely an& that many o' the patients 5ho ha& &evelope& in'ections ha&

been treate& more or less e=clusively by this ne5 nurse4

This i&enti'ie& several trainin" nee&s that nurse T 5as able to

'acilitate4 B/40 What is meant by investi"atin" patient e=periences

.or many years patients have been seen as passive recipients o'

heath care, but increasin"ly the move is to5ar&s partnership in

care, 5her e patients have an active role an& responsibility in

&ecision?ma$in" an& care mana"ement4 When you are revie5in"

the 8uality o' the care you provi&e, one o' the $ey aspects o' this

is to re'lect on the patient7s e=periences4 Some in'ormation

5oul& be available 'rom patient complaints an& comments as

&iscusse& previously, but i' you



/ Woun& Care< * Han&boo$ 'or Community Nurses

5ere loo$in" 'or speci'ic in'ormation about mana"ement o'

5oun& care you 5oul& probably have to consi&er ta$in" a more

positive approach to 'in&in" out 5hat people thin$ about the care

that you are o''erin"4 The main approaches to this are postal orother surveys, 'ace?to?'ace or phone semi?structure& intervie5s

or 'ocus "r oups4 There are various stren"ths an& 5ea$nesses

attache& to all o' these, 5hich you nee& to consi&er be'ore

&eci&in" on the best 5ay ' or5ar &4

The 'irst 8uestion that you nee& to consi&er be'ore embar$in"

on any o' these techni8ues is B/4/-4

B/4/- What am I "oin" to &o 5ith the results

ou nee& to be clear in your o5n min& 5hat 8uestions you 'eel

nee& ans5erin" an& 5hat you 5ill &o 5ith the ans5ers, 'rom both

techni? cal an& service &elivery points o' vie54 (n&erta$in" a

lar "e?scale survey o' everyone 5ho lives in your clinical area

5oul& be ver y e=pensive in terms o' both time an& resources4

Even be'ore you ha& any results bac$, you 5oul& nee& to &evelop

an& pilot 8uestion? naires, "et them printe& an& &istribute&, an&then you 5oul& have to thin$ about 5hat you 5oul& &o 5ith the

results, inclu&in" &ata input an& analysis4 ou mi"ht thin$ that it

5oul& be easier to hol& a 'ocus "roup or intervie5 some

patients, but a"ain you nee& to thin$ throu"h all the

implications such as preparin" intervie5 sche&ules, time to

arran"e an& un&erta$e the intervie5s, an& ho5 you ar e "oin"

to collate an& use the results4 Other issues that you nee& to

consi&er are ethical ones4 There is no point as$in" patients i' they5oul& pre'er to be treate& in the bac$ room o' the local pub i' you

$no5 the lan&lor& is terri'ie& by mention o' all thin"s me&ical

an& 'aints at the si"ht o' a stethoscope4 %ore seriously you 5oul&

nee& to consi&er the implications o' unmet nee&s or &esires4 ou

may 'eel that "ettin" patients to tal$ about 5antin" treatments

that are not 'un&e& by your health authority raises unrealistic

e=pectationsG alter? natively startin" to 8uanti'y an& e=plore

such &eman&s may help in'orm o' such &ecisions4 #e'oreembar$in" on a patient consultation or participation e=ercise, you

nee& to thin$ throu"h 5hat support an& resources you have to

compile, &isseminate an& action the results o' your 5or$4 This

may inclu&e "ainin" access to computer s an& s$ills in mana"in"

in'ormation, sprea&sheets an& &atabases4 ou 5ill re8uire

commitment 'rom all the practice sta'' to &iscuss an&



Clinical /2

consi&er any issues raise& seriously an& you 5ill nee& to &eci&e

ho5 'ee&bac$ an& chan"es coul& best be provi&e& 'or the patients

them? selves4 our local Community Health Council @CHCA, an

in&e pen? &ent or"anisation appointe& to support patientempo5er ment 5ithin the NHS, may be able to a&vise an&

support you in see$in" the vie5s o' your patients4

B/4// What sort o' 8uestions shoul& be as$e&

#e'ore &eci&in" on the best approach to use in 'in&in" out

patient vie5s, it is 5orth5hile thin$in" about 5hat it is you 5ant

to $no54 ou mi"ht 5ant to collect statistics on the prevalence o'

si&e e''ects, 5hether speci'ic in'ormation 5as provi&e& or on 5hat

other health services 5ere accesse& by the patient4 These can be

establishe& by as$in" 5hat are re'erre& to as >close& 8uestions7,

i4e4 a 8uestion 5ith yesno or a limite& number o' possible

responses4 E=amples inclu&e<

D Ho5 o'ten is the &ressin" chan"e& on your5oun&

D Have you ha& one or more episo&es o' 5oun&

in'ection

D Do you see a hospital consultant about your

5oun&

In research terms these 8uestions provi&e in'ormation that is

8uantitative in natureG it ans5ers the >ho57 8uestions, loo$in" at

issues such as >ho5 many7, >ho5 o'ten7 an& >ho5 much7 The

other sorts o' in'ormation that you are li$ely to 5ant to collect

relate to 8ualitative research4 Bualitative research a&&resses the

>5hy7 an&

>5hat7 8uestions, the so'ter in'ormation that e=plains 5hy people

&o the thin"s that cannot be counte& in 'i"ures4 E=amples o' these

sorts o' 8uestions can inclu&e<

D What &o you 'eel has been "oo& about the care that you have

receive&

D What coul& have been &one &i''erently to provi&e better

stan? &ar&s o' care

D In 5hat 5ays have you ha& to chan"e your li'estyle because

o' your le" ulcer

These 8uestions can o'ten be use& to e=plore the statistical &ata



/3 Woun& Care< * Han&boo$ 'or Community Nursesin a little more &epth, e4"4 you mi"ht 5ish to e=plore 5hat people

'eel



Clinical /F

are the a&vanta"es an& &isa&vanta"es o' comin" to the practice

'or treatment rather than bein" seen in their o5n home4 ou 5ill

pr oba? bly 'in& that you 5ant a variety o' 8ualitative an&

8uantitative in' or? mation4 In as$in" patients about theire=perience o' 5oun& care, you mi"ht 5ant to $no5 both

8uantitative in'ormation, about ho5 lon" they have ha& their

5oun& an& ho5 many &ays it has cause& them to miss 5or$, as

5ell as 8ualitative in'ormation inclu&in" ho5 they 5oul&

&escribe the pain they ha& e=perience& an& 5hat their e=peri?

ences 5ere o' accessin" car e4

B/4/ What are the a&vanta"es an& &isa&vanta"es o' un&erta$in" a patient survey

atient surveys are "enerally han&e& out to patients or sent

to them at home 5ith a 'reepost envelope 'or them to return

their responses4 They can be 8uite use'ul 'or 'in&in" out ho5

many people have opinions an& 'eelin"s about particular issues

an& ar e most e''ective 5hen consistin" o' mostly yesno an&

multiple choice ans5ers4 Response rates are improve& i' the8uestionnair es are relatively short @a ma=imum o' 'our si&es o'

* paper, pr e'er? ably t5o si&esA an& are relevant to the people

ans5erin" them, e4"4 you are li$ely to "et a lo5er response to

about ho5 people 'eel about the practice than you are to a

more speci'ic survey about ho5 people 'eel about the

mana"ement o' their le" ulcer or post? sur"ical 5oun&4

Response rates 'or "eneral surveys are notoriously lo5 an& o'ten

less than 1-L are returne&4 It is better to avoi& open?en&e&8uestions as 'ar as possible because people &o not li$e spen&in"

time provi&in" len"thy 5ritten responses an& the results o' these

are &i''icult to collate4 Surveys li$e this can be most use'ul 5hen

you have i&enti'ie& a particular issue or concern, perhaps as a

result o' a 'ocus "roup or throu"h patient complaints or sta' '

concerns, an& you are an=ious to see ho5 5i&esprea& the

'eelin"s are amon" the practice population4 One issue you 5oul&

nee& to consi&er 5oul& be 5hether your tar"et population coul&rea& an& 5rite En"lish to a speci'ically hi"h stan&ar& to be able

to partici? pate in the survey4 ou may nee& to "et the

8uestions an& responses translate& or a&opt alternative

approaches to "ainin" patient vie5s4




B/4/1Have you any thou"hts about intervie5s an& 'ocus "roups

The use'ulness o' intervie5s an& 'ocus "roups principally lies in

the opportunity to e=plore 'eelin"s about an& e=periences o'service &elivery in more &epth than that allo5e& by a 5ritten

survey4 Rather than havin" a series o' set 8uestions 5ith a small

ran"e o' ans5er s you 5oul& use a semi?structure& 8uestionnaire

that 'ocuses on more open?en&e& responses an& allo5s

participants to e=pan& on the issues that they 'oun& o' particular

concern4 .ocus "roups "enerally consist o' 'our to ten people

5ho have e=perience& a particular service, an& throu"h sharin"

their e=periences they o'ten spar$ i&eas o'' each other an& canhelp to i&enti'y particular themes4 This can be particularly help'ul

i' you are loo$in" 'or su""estions about 5ays o' improvin" or

chan"in" service &elivery4 These "roups can be hel& either in the

sur"ery or at a >neutral7 venue4

Intervie5s are "enerally hel& on a one?to?one basis,

occasionally 5ith the participant bein" accompanie& by a 'rien&

or relative an& the intervie5er bein" accompanie& by someone

5ho ta$es notes on the &iscussion4 They can be hel& in any venueo' the intervie5ee7s choosin" an& so can be particularly "oo& 'or

&iscoverin" the vie5s about mobility problems or 'rom those

5hose con&itions are such that they &o not 'eel li$e &iscussin"

them in 'ront o' a lar"e "roup o' people4 One issue to bear in min&

is that people o'ten 'eel uncom? 'ortable 5hen tal$in" about the

care they have receive& 5ith the person 5ho actually provi&e&

that care4 eople &o not "enerally li$e tellin" someone that they

5ere not happy 5ith 5hat they &i& an& may 'eel that their 'uturecare coul& be pre6u&ice&4 ou may 'eel that it 5oul& be better to

"et someone 5ho is less involve& 5ith &irect patient care to

un&erta$e the intervie5 or 'ocus "roup, maybe a practice

mana"er or someone su""este& by your local clinical

"overnance lea& or a practice nurse 'rom another practice, or

community nurse mana"er or collea"ue4

There are various approaches to enlistin" participants 'or

these intervie5s4 ou may choose to put up posters in the5aitin" room an& then 5ait to see 5ho atten&s, althou"h this

can be a soul? &estroyin" e=ercise as you may 'in& yoursel' alone

in the room4 *lter? natively, you coul& use the meetin" o' an

e=istin" user "roup or patient council to elicit their vie5s4

ou may tar"et a particular "roup o' patients an& 5rite invitin"

them to participate, e=plainin"



Clinical /0

5hat the meetin" is li$ely to inclu&e an& ho5 lon" it is li$ely to

ta$e an& provi&in" them 5ith a tear?o'' slip 'or them to in&icate

5hether they 5ish to participate4 The response may also in&icate

nee&s 'or interpreters or &isable& access4 In settin" up the "roup,you 5oul& also nee& to consi&er issues o' lan"ua"e nee&s,

transportation, re'reshments an& chil&care 'acilities4

The "eneral pattern to such intervie5s or "roups is to start by

e=plainin" the purpose o' the meetin" an& to clari'y that the

partic? ipants un&erstan& an& consent to this4 This is o'ten the

time that permission is "aine& to tape?recor& the intervie54 I' you

&eci&e not to recor& the intervie5s or "roups, you 5oul& nee& to

arran"e 'or a collea"ue to ta$e e=tensive notes on the procee&in"s because it is virtually impossible to 'acilitate the conversation

an& recor& it simultaneously4 ou 5ill nee& to reassure the

participants that, althou"h their comments are recor&e&, they

5ill be treate& 5ith con'i&entiality an& that they 5ill not be

personally i&enti'ie& in any subse8uent reports4 The 'irst

8uestions "enerally aim to be non? controversial to allo5 people

to "et use& to tal$in" 5ithout 'eelin" that they have to reveal too

much too soon4 This can inclu&e 8ues? tions such as<

Ho5 lon" have you ha& your le" ulcer an& 5here have you receive& care 'or it

This then lea&s to more personal 8uestions about 5hat people

have 'oun& help'ul about their care an& 5hat coul& have been

&one &i''erently4 With a 'ocus "roup the i&ea is to allo5

participants to tal$ amon" themselves, althou"h not to the e=tent

that they 'orm splinter "roups, an& 'or them to share theire=periences 5ith each other as 5ell as 5ith you4 Even i' your

concerns are 'ocuse& on a particular issue such as 5aitin" times,

you shoul& allo5 time 'or participants to e=press their vie5s on

other aspects o' their care an& tr eatment4

When closin" the intervie5 or 'ocus "roup, you nee& to than$

the members 'or their time an& participation an& e=plain 5hat

5ill happen ne=t4 ou shoul& tell people 5hat you are "oin" to

&o 5ith their comments an& the results o' the pro6ect, an& ho5 youare "oin" to let them an& other patients $no5 5hat you have

&one4 This may inclu&e sen&in" them copies o' any reports an&

action plans, plus puttin" up posters in the practice an& invitin"

them to the openin" o' any ne5 services that 5ere in part the

results o' their comments4



/1- Woun& Care< * Han&boo$ 'or Community Nurses

B/4/ What else can be &one to ensure that patient vie5s are ta$en on boar&

Sta'' 5or$in" in primary care o'ten have the closest lin$s to

the health nee&s an& e=periences o' the local community4 This 5as part o' the &rivin" 'orce o' the establishment o' C!s an& the

chan"es in the NHS, an& puts the community nurse in a $ey

position to help ensure that service &elivery is sensitive to

local nee&s4 atient comments an& complaints can be $ey in

assistin" in this process4 *lthou"h a patient complaint is o'ten

e=perience& as a ne"ative e=perience or as a brea$&o5n in

communication, it can also o''er a real opportunity to the primary

care team4 #y re'lectin" on 5hat has "one 5ron" in the past 5ecan start to a&&ress policies an& proce? &ures to help ensure that

similar &i''iculties &o not arise in the 'utur e4 %any complaints

arise 'rom lac$ o' communication an& may help stimulate you to

thin$ about ho5 you can best relate to your local population,

5hether throu"h conversation, &emonstration o' tech? ni8ues,

lea'lets, boo$ lists, or even cassettes an& vi&eos in a variety o'

lan"ua"es4 #y startin" to tap into local concerns you can start

to tac$le the issues that are 'ace& at the coal 'ront, a uni8ue seto' circumstances an& con&itions e=perience& at local level4

Rather than thin$ about complaints as a ne"ative thin" to

be avoi&e& an& &iverte& at all costs, you coul& start to thin$

more creatively about ho5 patients can share their e=periences,

comments, compliments an& concerns 5ith you an& your team4

One o' the simplest 5ays o' &oin" this is by settin" up a comments

bo= 5ithin the sur"ery or clinic, perhaps accompanie& by a 5ipe

boar& on 5hich you coul& hi"hli"ht issues raise& an& 5hat youhave &one about them4 ou may 'in& that the number o' complaints

receive& by the practice actually re&uce as patients can share their

concerns be'ore they r each that level o' severity4 One o' the other

e''ects that you are li$ely to e=perience is the encoura"ement

&erive& 'rom positive comments an& e=periences4 %any patients

5elcome the opportunity to say than$ you an& to comment on

5hat they have 'oun& help'ul, an& you can 'urther &evelop your

stren"ths by re'lectin" on these remar$s4

B/4/2 What is re'lective practice an& critical inci&ent analysis

Re'lective practice an& critical inci&ent analysis are techni8ues

that can help the in&ivi&ual re'lect on the care receive& by

in&ivi&ual



Clinical /1/

patients4 Critical inci&ence analysis o'ten ta$es place 5ithin

multi&is? ciplinary "roups o' sta'' 5hen particular patients 5ho

ha& e=ce p? tional outcomes, 5hether "oo& or ill, are &iscusse&4

These may inclu&e une=pecte& &eaths, avoi&able amputation,violence a"ainst sta'' or other patients, areas 5here care is

suspecte& to be less than optimum an& patients 5ith

e=ceptionally "oo& outcomes4 *ll members o' sta'' coul& be

encoura"e& to i&enti'y such cases 'rom 5hich lessons coul& be

learne& by the team as a 5hole4 In trac$in" 5hat happene& to an

in&ivi&ual patient, you may be able to i&enti'y &elays in

treatment, problems 5ith communication an& possible trainin"

nee&s4 The aim o' such "roups is not to be 6u&"emental but toencoura"e on"oin" learnin" in all members o' the team on a

permanent basis4

It is also use'ul to un&erta$e re'lective practice as an in&ivi&ual

practitioner by thin$in" about 5hat has happene& to a particular

patient4 ou shoul& be able to i&enti'y 5hat 5or$e& 5ell an&

5her e thin"s coul& be improve& to help in'orm the 'uture care o'

similar patients4 %any sta'' $eep a re'lective practice &iary as

part o' their on"oin" &evelopment port'olio an& use it to thin$throu"h issues in relation to in&ivi&ual patients such as<

D What 5ere you e=pectin" to happen 5ith this patient

D What 5as your role in the patient7s

care

D What happene& that you e=pecte& to happen

D What happene& that you &i& not pre&ict

D Ho5 &o you 'eel about 5hat happene&

D Ho5 &o you 'eel about your role in 5hat

happene&

D What &o you thin$ coul& have been &one

&i''erently

D What have you learnt 'rom 5hat happene&

D What mi"ht you &o i' a similar situation arosea"ain

D What are the pros an& cons o' &i''erent options

D What outcomes 5oul& you loo$ 'or

Such recor&s can help you to recor& your successes, personal

&evelopment an& learnin", 'eelin"s an& moo&s, insi"hts an&

8ues? tions4 They can also be as a basis 'or see$in"



/1 Woun& Care< * Han&boo$ 'or Community Nurses'ee&bac$ 'rom collea"ues about their perceptions o' the same

inci&ents an& to inte? "rate on? an& o''?site learnin" an& trainin"

nee&s4



/1- Woun& Care< * Han&boo$ 'or Community Nurses

&,ossary

Abs#ess< a localise& collection o' necrotic tissue, bacteria an&

5hite cells, $no5n as pus containe& in a capsule, the 5all o'

5hich is 'orme& 'rom pha"ocytes an& stran&s o' 'ibrin @see

B342A4

A,bumin< a soluble protein 5hich is a ma6or component o'

serum proteins @see B14A4

Anaerobe< bacteria that &o not tolerate 'ree o=y"en 'rom the air,

an& "ro5 5here there is either no air or there are lo5 levels o'

o=y"en @see B4FA4

Anaerobi#< con&itions 5ith a lac$ o' o=y"en @see B 243A4

An-io-enesis< the 'ormation o' ne5 bloo& vessels at the base o'

a 5oun&G this occurs &urin" the proli'erative phase o' healin"

@see B/49A4

Ank,e bra#+ia, 0ressure inde/ 'ABPI(< the result o' a Doppler

ultra? sono"raphy test use& to &etermine the presence an& level

o' arte? rial &isease in patients 5ith le" ulcers @see B94/A4

Ank,e f,are< associate& 5ith venous &isease o' the le"4 Small

vessels &isten& an& appear aroun& the an$le an& heel @see B94A4

At+eros#,erosis< a &isease o' the arterial 5all in 5hich the

inner layer thic$ens causin" a narro5in" an& har&enin" o' the

vessels @see B94/2A4

Auto,ysis< the brea$&o5n o' &evitalise& tissue by leu$ocytes@see

B/49A4

Ce,,u,itis< a sprea&in" in'ection o' the so't tissue, 5hich is

charac? terise& by re&ness, heat, oe&ema an& pain @see B/-42A4

Co,,a-en< a protein substance, 5hich provi&es 'ibres that ma$e

up the supportive net5or$ o' connective tissue4 ro&uce& &urin"

the proli'erative sta"e o' 5oun& healin" an& remo&elle&

&urin" the maturation phase @see B/49A4

/0




&ranu,ation< the 'ormation o' ne5 tissue 5hich 'ills the

5oun& &urin" the proli'erative sta"e o' healin" @see B/49 an&

B4/A4

Haematoma< a collection o' bloo& in the tissues4Haemostasis< process lea&in" to the re&uction o' bloo& loss

'rom the bo&y @see B/49A4

Hea,in- by 0rimary 'first( intention< close& 5oun&s 5ith a

minor &e'ect @see B/4FA4

Hea,in- by se#ondary intention< open 5oun&s allo5e& to heal

by "ranulation @see B/4FA4

Hea,in- by tertiary intention< 5oun& initially le't open to

&rain an& sur"ically close& at a later &ate @see B/4FA4Infe#tion< multiplication o' micro?or"anisms pro&ucin" a host

reac? tion @see Chapter /-A4

Inf,ammation< initial response o' the bo&y a'ter in6ury @see B/49A4

Is#+aemia< localise& &e'iciency o' bloo& an& there'ore

o=y"en, cause& by obstruction o' the bloo& vessels @see B4/- an&

B94/2A4 e,oid< a protuberance o' pro"ressively enlar"in" scar

tissue, cause& by e=cessive colla"en, 5hich may e=ten& into

normal tissue @see

BF4FA4

Li0odermatos#,erosis< bro5n stainin" o' the lo5er le"

occurrin" as a result o' haemo"lobin brea$&o5n, closely

associate& 5ith venous hypertension an& ulceration @see B94A4

"a#eration< so'tenin" or so""iness o' the tissues resultin" 'rom

the retention o' e=cessive moisture @see B//42A4

"a#ro0+a-e< pha"ocytic cell 5hich plays a vital role in

in' lamma? tion an& initiates an"io"enesis @see B/49A4

"aturation sta-e< the 'inal sta"e o' 5oun& healin" @see B/49A4

Ne#rosis< localise& tissue &eath4 (sually blac$ or bro5n in

colour

@see B4/-4 an& B94/2A4

Neutro0+i,< a 5hite bloo& cell 5hich in"ests bacteria @see B/49A4

##,usi.e dressin-< a &ressin" that totally covers a 5oun&,

sealin" it o'' 'rom the environment @see B243A4edema< e=cess tissue 'lui& @see B/494 an& B943A4

steomye,itis< in'ection o' bone4

.er-ranu,ation '+y0er-ranu,ation(< "ranulation tissue

5hich is raise& above the level o' the 5oun& @see B//43A4

P+a-o#ytosis< the process o' en"ul'in" micro?or"anisms,

' or ei"n cells an& &ebris by macropha"es or neutrophils @see



!lossary /1/B/49A4




P,ate,et< component o' bloo&4 Involve& in the in'lammatory sta"e

o' healin" @see B/49A4

Pus< 'lui& consistin" o' e=u&ate, &ea& an& e=hauste&

macr opha"es an& bacteria @see B342A4S#ab< see Eschar 4

Se0ti#aemia< systemic &isease4 atho"enic micro?or"anisms

or other to=ins are present an& persist in the bloo&stream @see

B/-4A4

Skin -raft< s$in is remove& 'rom its normal location an& use&

to cover another open area @see BF43A4

S,ou-+< &evitalise& tissue 5hich is yello5, cream or "rey in

colour @see B4//A4

*o/in< substance havin" a &etrimental @to=icA e''ect on livin" cells4

U,#er< a persistent area o' &iscontinuity o' the epi&ermis an& &ermis

@see B94/A4

as#u,itis< in'lammation o' small arteries or veins 5ith

r esultin" 'ibrosis an& thrombus 'ormation4 O'ten associate&

5ith rheuma? toi& &isease @see B94/3A4

enous +y0ertension< abnormally hi"h pressure in thevenous system @see B94A4



R esour#es

Con.ate# ';ound #are +e,0,ine(

Tel< -9-- 90F19

Creden+i,, Limited

/- Cossall In&ustrial Estate

Il$eston

Derbyshire DEF 2(!

Tel< -//2 01 -/

.a=< -//2 0 -1F

Email< sales_c re&enhill4c o 4u$

%a&e?to?measure compression hosiery on NHS prescription4

Euro0ean Pressure U,#er Ad.isory Pane,

E(* #usiness O''ice

Woun& healin" unit

Department o' Der matolo"y

Churchill Hospital

Ol& R oa&

Hea&in"ton, O='or& O`1 F)KTel< -/932 930

.a=< -/932 911

Email< Eu ropean r essu r e(lcer*&vis anel_compuser v e 4com

SCAR information ser.i#e

O #o= --1

Hull H(1 DK

Tel< -92 /- -- Website< 55 54carin ' o 4o r

" In'ormation on scarrin" treatments an& support or "anisations4

/11

mailto:[email protected]




























http://www.carinfo.org/



















Smit+ Ne0+e; ';ound #are +e,0,ine(

Tel< -9-- 20-/F1

*issue iabi,itySo#iety !lanville

Centr e Salisbur yWiltshire S 9#K

Tel< -/F 0-2F

.a=< -/F 231

Email< tvs_&ial,pip e=4com

Website< 55 54tv s 4o r " 4u$

*+e Water,o; Pressure Sore Pre.ention>*reatment Po,i#y

Ku&y

Water lo5

Ne5tons

Cur lan&

Taunton T*1 2S!

In'ormation on the use o' Waterlo5 an& other pressure sore

pr evention techni8ues4

*+e Wound Care So#iety

%rs HaJel %or ley

O #o= /F-

Huntin"&on E/9 F)

Tel< -/9- 1-/

Email< 5oun&4car e4society_tal$/4com

Website< 55 545 oun&ca r esociet y 4o r "

In'ormation about all aspects o' 5oun& mana"ement4

Websites

%ermato,o-i#a, issues

55 54s$insit e 4com

Wound #are ;it+ edu#ationa, basis

55 54me&icale&u4com

mailto:tvs@dial

http://www.tvs.org.uk/














http://www.woundcaresociety.org/

















http://www.skinsite.com/







http://www.medicaledu.com/



mailto:tvs@dial

mailto:tvs@dial








Resources /12

Abstra#ts$ arti#,es$ 0rodu#t ,inks and industry ne;s

55 545 oun&ca r enet4com

)ree re-istration D in#,udes mi#robio,o-y$ #ase studies$

tria,s and ,ar.a, t+era0y

55 54me&scap e 4com

Wound #are usin- aromat+era0y

55 54alte r n a ti v eme&icin e 4com

&enera, ;ound #are forum

55 545 oun&4net

Conne#tion to a,, of t+ese sites #an be made at:

55 54maslt&4c o 4u$

http://www.woundcarenet.com/









http://www.medscape.com/







http://www.alternativemedicine.com/



















http://www.wound.net/





http://www.masltd.co.uk/














R eferen#es

*c$roy& KS, oun" *E @/091A )e" ulcers that &o not heal4 =ritish 1e$i+al Jo&rnal 297<

-F-94*n"eras %H, #ran&enber" *, .al$ *, Seeman T @/00/A Comparison bet5een

sterile saline an& tap 5ater 'or the cleansin" o' acute traumatic so't tissue

5oun&s4 E&ropean Jo&rnal of S&rgery 169@11A< 1F12-4

*rmstron" % @/009A Obesity as an intrinsic 'actor a''ectin" 5oun& healin"4 Jo&rnal of

9o&n$ 7are 8@2A< -/4

*sh'or& R., lant !T, %aher K @/09A Double blin& trial o' metroni&aJole in

malo&or? ous ulceratin" tumours4 )ancet i< /1/114

*s8uith S @/000A The use o' aromatherapy in 5oun& care4 Jo&rnal of 9o&n$ 7are 9@3A<

1/91-4

#an$s V @/00FA ressure sore e&ucation4 Jo&rnal of 9o&n$ 7are 7@/-A< 2-32-F4

#arnhorst D*, #arner H# @/039A revalence o' con"enitally absent 'oot pulses4 Ne4

Englan$ Jo&rnal of 1e$i+ine 289< 3324

#arrett E @/09FA uttin" ris$ calculators in their place4 N&rsing Times 93@FA< 32F-4

#ellamy : @/002A hoto"raphy in 5oun& assessment4 Jo&rnal of 9o&n$ 7are 4@FA<

1/11/34

#ennett ), )ee # @/093A ressure versus shear in pressure sore 'ormation4 In< )ee

#, e&4 7hroni+ :l+ers of the Skin4 Ne5 or$< %c!ra5?Hill, pp4 10224

#irchall ) @/001A %a$in" sense o' pressure sore pre&iction calculators4 N&rsing Times

9:@/9A< 11F4

#lac$ D @/09A Ine?&alities in 6ealth %=la+k Report)' Harmon&s5orth< en"uin4

#lan& :I, lain WE, von .raunho'er K* @/09A E=perimental an& clinical

observations o' the e''ects o' cytoto=ic chemotherapeutic &ru"s on 5oun& healin"4

Annals of S&rgery

1< F9F0-4

#on& %R @/09A .ain! Its nat&re@ analysis an$ treatment 4 E&inbur"h< Churchill

)ivin"stone4 #u= %, #ai" %:, Ro&ri"ues E, *rmstron" D, #ro5n * @/00FA

*ntibo&y response to

topical strepto$inase4 Jo&rnal of 9o&n$ 7are 7@A< F-F14

Cameron K @/009A S$in care 'or patients 5ith chronic le" ulcers4 Jo&rnal of 9o&n$ 7are8@0A< 2034

Charles H @/000A Short stretch ban&a"es in the treatment o' venous le" ulcers4 Jo&rnal of

9o&n$ 7are 9@3A< 1-11-4

Cherry !W, Ryan TK @/092A Enhance& 5oun& an"io"enesis 5ith a ne5

hy&rocolloi& &ressin"4 In< Ryan TK, e&4 An En,ironment for 6ealing' The role of o++l&sion4

International Con"ress an& Symposium4 Series no4 994 )on&on< Royal Society o'

%e&icine4



Resources /1F/13



Re'erences /1F

Choiniere %, %elJac$ R, !iran& N @/00-A Comparisons bet5een patient an&

nurses assessment o' pain an& me&ication e''icacy in severe burn in6uries4

.ain 45<

/1/24

ChrintJ H @/090A Nee& 'or sur"ical 5oun& &ressin"s4 =ritish Jo&rnal of S&rgery 87<--24

Clar$ %, .letcher K @/000A ro&uct selection4 Resource 'ile4 %attresses an& be&s4

Jo&rnal of 9o&n$ 7are @suppl A< /94

Closs KS @/001A %alnutrition4 The $ey to pressure soresC N&rsing Stan$ar$ 9@EA< 1

134 Collier % @/000aA %attresses an& be&s4 art /4 Jo&rnal of 9o&n$ 7are @suppl 9A<

F4

Collier % @/000bA ressure ulcer &evelopment an& principles 'or prevention4 In<

%iller %, !lover D, e&s4 9o&n$ 1anagement Theory an$ .ra+ti+e4 )on&on< Nursin"

Times #oo$s4

Cooper D% @/00-A Optimisin" 5oun& healin"4 N&rsing 7lini+s of North Ameri+a26@/A<

/324 Cooper R, )a5rence KC @/003A The isolation an& i&enti'ication o' bacteria

'rom

5oun&s4 Jo&rnal of 9o&n$ 7are 6@FA< 1121-4

Cuttin" :. @/000A .actors in'luencin" 5oun& healin"4 N&rsing Stan$ar$ 9@2-A< 11134

Cuttin" :., Har&in" :! @/00A Criteria 'or i&enti'yin" 5oun& in'ection4 Jo&rnal

of

9o&n$ 7are 3@EA< /09-/4

Davi& K @/093A 9o&n$ 1anagement' A +omprehensi,e g&i$e to $ressing an$ healing 4 )on&on<

%artin DunitJ4Davies : @/00A ressure sores< aetiolo"y, ris$ 'actors an& assessment scales4

=ritish

Jo&rnal of N&rsing 3@3A< 233-4

Dealey C @/001A %easurin" the prevalence an& inci&ence o' pressure sores4

=ritish

Jo&rnal of N&rsing 2@-A< 009/--34

Dealey C @/00A The 7are of 9o&n$s! A g&i$e for n&rses4 O='or&< #lac$5ell Scienti'ic

ublications4

Dealey C @/002A ressure sores an& incontinence< a stu&y evaluatin" the use o'

topical a"ents in s$in care4 Jo&rnal of 9o&n$ 1anagement 4@1A< /-1/-24Department o' Health @/00/A *ietary Referen+e Aal&es for Foo$@ Energy an$ N&trients for the

:B 4 @Report on Health an& Social Sub6ects no4 /A )on&on< H%SO4

Dic$erson KWT @/001A *scorbic aci&, Jinc an& 5oun& healin"4 Jo&rnal of 9o&n$ 7are

2@3A<

12-1214

Draper K @/092A %a$in" the &ressin" 'it the 5oun&4 N&rsing Times 91@EA< 1124

Duc$5orth !K @/00-A Revise& "ui&elines 'or the control o' epi&emic methicillin

resistant

Staphylo+o++&s a&re&s4 Jo&rnal of 6ospital Infe+tion 17< 12/1FF4

Dyson %, oun" S, en&le C @/099A Comparison o' the e''ects o' moist an& &rycon&i? tions on &ermal repair4 Jo&rnal of In,estigati,e *ermatology :1@2A< 1204

Effe+ti,e 6ealth 7are =&lletin @/002A Nu''iel& Institute 'or Health4 (niversity o' )ee&s4

NHS Centre 'or Revie5s an& Dissemination4 (niversity o' or$4

E$ *C, #oman ! @/09A * &escriptive stu&y o' pressure sores< the prevalence o'

pressure sores an& characteristics o' patients4 Jo&rnal of A$,an+e$ N&rsing 8< 2/2F4

Em'lor"o C* @/009A )etters4 Jo&rnal of 9o&n$ 7are 8@2A< 124

Em'lor"o C* @/000A The assessment o' 5oun& pain4 Jo&rnal of 9o&n$ 7are 9@9A< 19

1924 European ressure (lcer *&visory anel @E(*A @/00FA .ress&re :l+er



/19 Woun& Care< * Han&boo$ 'or Community NursesTreatment

<&i$elines4 O='or&< E(*4

.lana"an % @/001A re&ictin" pressure sore ris$4 Jo&rnal of 9o&n$ 7are 2@EA< /2/94

.letcher * @/00A The epi&emiolo"y o' t5o common a"e relate& 5oun&s4 Jo&rnal

of

9o&n$ 7are 1@EA< 1014



Re'erences /10

.letcher K @/000A * practical approach to &ressin" 5oun&s in &i''icult positions4

=ritish

Jo&rnal of N&rsing 9@/A< FF0F934

.o5ler *, Dempsey * @/009A Split thic$ness s$in &onor sites4 Jo&rnal of 9o&n$ 7are 8@9A<

100-4!ar&ner *%N, .o= RH @/093A The return o' bloo& to the heart a"ainst the 'orce

o' "ravity4 In< Ne"us D, Kantet !, e&s4 .hlebology4 )on&on< )ibby, pp4 323F4

!oul& D @/00FA iloni&al sinus4 N&rsing Times :3@supplA< 14

!o5er K, )a5rence KC @/002A The inci&ence, causes an& treatment o' minor burns4

Jo&rnal of 9o&n$ 7are 4@A< F/F4

!reen C @/001A *ntistrepto$inase titres a'ter topical strepto$inase4 ;an+et 341<

/3-/3-14

!rey KE @/009A Cellulitis associate& 5ith 5oun&s4 Jo&rnal of 9o&n$ 7are 8@FA< 1191-4

!roscott @/002A The palliative mana"ement o' 'un"atin" mali"nant 5oun&s4 Jo&rnal

of

9o&n$ 7are 4@2A< -4

!uest !, earson S @/00FA Recovery on a plate4 N&rsing Times :3@3A< 9934

Ho&"$in W @/009A iloni&al sinus &isease4 Jo&rnal of 9o&n$ 7are 8@0A< 9/

914

Ho'man D, Ryan T, *rnol& . @/00FA ain in venous le" ulcers4 Jo&rnal of 9o&n$ 7are 7@2A<

4

Hos$ins K, Welche5 % @/092A .ost8operati,e .ain' :n$erstan$ing its nat&re an$ ho4 to treat it 4

)on&on< .aber ; .aber4

Hutchinson KK, )a5rence KC @/00/A Woun& in'ection un&er occlusive &ressin"s4 Jo&rnal of 6ospital Infe+tion 18< 9194

Kohnson * @/099A Woun& mana"ement4 *re you "ettin" it ri"ht .rofessional N&rse 3@9A<

1-31-04

Koseph WS, *=ler D* @/00-A %icrobiolo"y an& antimicrobial therapy o' &iabetic

'oot in'ections4 7lini+s in .o$iatri+ 1e$i+ine an$ S&rgery 8@1A< 3F9/4

:en&ric$ %, )uc$er :, Cullun N, Roe # @/00A 7lini+al Information .a+k 4 Number /4

The management of leg &l+ers in the +omm&nity4 (niversity o' )iverpool4

:enney ), Rithalia S @/000A Technical aspects o' support sur'aces4 %attresses an& be&s4

Resource 'ile4 Jo&rnal of 9o&n$ 7are @suppl part 1A< /94

)an& ) @/00A A Re,ie4 of .ress&re *amage .re,ention Strategies4 * report initiate& by West%i&lan&s Re"ional Health *uthority4

)a5rence KC @/003A .irst ai& measures 'or the treatment o' burns an& scal&s4 Jo&rnal of

9o&n$ 7are 6@FA< 1/014

)a5rence KC @/00FA Woun& irri"ation4 Jo&rnal of 9o&n$ 7are 7@/A< 134

)evin %E @/099A The &iabetic 'oot< pathophysiolo"y, evaluation an& treatment4 In

)evin %E, O7Neal )W, e&s4 The *iabeti+ Foot , th e&n4 St )ouis< CV %osby, pp4

//24

)e5is #: @/009A Nutritional inta$e an& the ris$ o' pressure sore &evelopment in

the ol&er patient4 Jo&rnal of 9o&n$ 7are 8@/A< 1/124

)oa&er S, Delue %, Ho''man D @/00A * constancy service that pays &ivi&en&s,settin" up a pressure service relie' "roup4 .rofessional N&rse 15< 20334

)oc$ % @/09-A The e''ect o' temperature on mitotic activity at the e&"e o'

e=perimen? tal 5oun&s4 In< )un&"ren *, Soner *#, e&s4 Symposia on 9o&n$ 6ealing!

.lasti+@ s&rgi+al an$ $ermatologi+al aspe+ts4 S5e&en< %oln&al4

)othian , #arbenal K, e&s @/091A N&rsing Aspe+ts of .ress&re Sore *e,elopment in .ress&re Sores4

)on&on< %acmillan4

%cCa''ery % @/091A N&rsing the .atient in .ain4 )on&on< Harper ; Ro54




%c)aren S%! @/00A Nutrition an& 5oun& healin"4 Jo&rnal of 9o&n$ 7are 1@1A<

2224

%c)eo& * @/00FA rinciples o' alternatin" pressure sur'aces4 A$,an+es in 9o&n$ 7are

15<

1-134%a$leburst K, Sie"reen % @/003A .ress&re :l+ers' <&i$elines for pre,ention an$ n&rsing

manage8 ment , n& e&n4 Sprin"house, *< Sprin"house Corporation4

%iller % @/002A Woun& care 'or minor in6uries4 .rimary 6ealth 7are 6@/-A< 134

%iller % @/000A Woun& assessment4 In< %iller %, !lover D, e&s4 9o&n$ 1anagement@

Theory an$ .ra+ti+e4 )on&on< Nursin" Times #oo$s4

%iller %, Dyson % @/003A The .rin+iples of 9o&n$ 7are4 )on&on< %acmillan %a"aJines

)t&4

%o''att C @/009A Issues in the assessment o' le" ulceration4 Jo&rnal of 9o&n$ 7are

8@0A<

30F14

%o''att C, O7Hare ) @/002A !ra&uate& compression hosiery 'or venous ulceration4

Jo&rnal of 9o&n$ 7are 4@/-A< 2034

%oo&y % @/001A *ccountability in 5oun& care< a practical approach4 9o&n$

1anagement

3@/A< 3F4

%or"an D @/09FA Form&lary of 9o&n$ 1anagement .ro$&+ts4 Car&i''< Whitchurch Hospital4

%or"an D @/00A Form&lary of 9o&n$ 1anagement .ro$&+ts, 3th e&n4 Haselmere<

Eurome&

Communications4

%or"an D @/00FA Form&lary of 9o&n$ 1anagement .ro$&+ts, Fth e&n4 Haselmere< Eurome&

Communications4

%orison % @/090A ressure sores< removin" the cause o' the 5oun&4 .rofessional N&rse 6<

0F/-4

%orison % @/00/A A 7olo&r <&i$e to the Assessment an$ 1anagement of ;eg :l+ers4 )on&on<

Wol'e ublishin" )t&4

%orison %, %o''att C @/00A A 7olo&r <&i$e to the Assessment an$ 1anagement of ;eg

:l+ers,

n& e&n4 )on&on< %osby, Times %irror International ublishers )t&4

%ortimer @/001A S$in problems in palliative care< me&ical aspects4 In< Doyle D,Han$s !, %ac&onal& N, e&s4 O5for$ Te5tbook of .alliati,e 1e$i+ine4 O='or&< O='or&

%e&ical ublications4

%osely K! @/099A .alliation in 1alignant *isease4 E&inbur"h< Churchill )ivin"stone4

%yers K* @/09A Woun& healin" an& the use o' a mo&ern sur"ical &ressin"4 The

.harma+e&ti+al Jo&rnal 22:@3/93A< /-1/-4

Ne5man V, *ll5oo& %, Oa$es R @/090A The use o' metroni&aJole "el to control

the smell o' malo&orous lesions4 .alliati,e 1e$i+ine 3@EA< 1-11-24

NHS E=ecutive @/002A 7onsens&s Strategy For 1anagement of ;eg :l+ers4 )ee&s<

NHS E=ecutive4

North Thames Research *ppraisal !roup @/009A The 7lini+al Effe+ti,eness .ro+ess4)on&on< NTR*!4

Norton D, %c)aren R, E=ton Smith *N @/03A In,estigations of <eriatri+ N&rsing .roblems

in

6ospital 4 E&inbur"h< Churchill )ivin"stone4

Ny8uis t R, Ha5thorn e K @/09FA The prevalence o' pressure sores in a Health

*uthority4 Jo&rnal of A$,an+e$ N&rsing 12< /91/9F4

ar$er )K @/000A Importance o' han& 5ashin" in re&ucin" cross in'ection4 =ritish

Jo&rnal of N&rsing 9< F/3F-4



Re'erences //artri&"e C @/009A In'luential 'actors in sur"ical 5oun& healin"4 Jo&rnal of 9o&n$

7are

8@FA< 12-1214




itcher % @/009A Internet sources on le" ulcer mana"ement4 Jo&rnal of 9o&n$ 7are 8@3A<

1/11/34

le5a % @/00-A *ltere& host response an& special in'ections in the el&erly4 Emergen+y

1e$i+ine 7lini+s in North Ameri+a 9@A< 01-34

riest C, Clar$e % @/001A (p&ate< pressure sore ris$ 'actors4 Jo&rnal of 9o&n$ 7are 2@A</3/F4

ro'essional Development @/00A Woun& care4 :no5le&"e 'or practice4 N&rsing Times

5< 04

un )W, #arraclou"h DRE, %uir&en :D @/00-A )e" ulcers in rheumatoi& arthritis4

1e$i+al Jo&rnal of A&stralia 163@/-A< 29229F4

Rei& K, %orison % @/00A To5ar&s a consensus classi'ication o' pressure sores4 Jo&rnal of

9o&n$ 7are 3@1A< 0104

Sa=ey S @/093A The nurses response to postoperative pain4 N&rsing 3@/-A< 1FF

19/4 Seers : @/09FA erceptions o' pain4 N&rsing Times 93@9A< 1F194

Silver I* @/092A O=y"en an& tissue repair In< Ryan TK, e&4 An En,ironment for 6ealing'

The role of o++l&sion4 International Con"ress an& Symposium4 Series no4 994

)on&on< Royal Society o' %e&icine4

Silver K @/09FA )etter4 7are S+ien+e an$ .ra+ti+e 6< 1-4

Staas WE, Cioschi H% @/00/A ressure sores a multi'acete& approach to

prevention an& treatment4 Rehabilitation me&icine4 9estern Jo&rnal of 1e$i+ine 164<

21024

Stevens K @/009A )etters4 Jo&rnal of 9o&n$ 7are 8@2A< 124

Thomas S @/00-A 9o&n$ 1anagement an$ *ressings4 )on&on< The harmaceutical ress4

Thomas S @/009A The importance o' secon&ary &ressin"s in 5oun& care4 Jo&rnal of9o&n$

7are 8@EA< /90/04

Thomas S, Kones %, Shutter S, *n&re5s * @/003A Rea&er 8uestions4 Jo&rnal of 9o&n$

7are N&rsing 2< 34

Thomas S, Vo5&en : @/009A Rea&ers7 8uestions4 Jo&rnal of 9o&n$ 7are 8@1A< /24

Thompson D, Smith DK @/00A What is in'ection Ameri+an Jo&rnal of S&rgery

78a@supplA<

F2//24

Torrance C @/091A .ress&re Sores! Aetiology@ treatment an$ pre,ention4 )on&on< Croom Helm4

Turner TD @/092A Which &ressin" an& 5hy In< Wesby S, e&4 9o&n$ 7are4 )on&on<William Heinemann %e&ical #oo$s4

(nite& :in"&om Central Council @/00A 7o$e of .rofessional 7on$&+t 4 )on&on< (:CC4

Value 'or %oney (nit @/00FA A .res+ribersC <&i$e to *ressings an$ 9o&n$ 1anagement

1aterials4 Report pro&uce& 5ith Jo&rnal of 9o&n$ 7are4

Vo5&en :R, !oul&in" V, Vo5&en @/003A Han& hel& Doppler assessment 'or

periph? eral arterial &isease4 Jo&rnal of 9o&n$ 7are 6@1A< /2/94

War'iel& C* @/00FA E5pert .ain 1anagement 4 Sprin"house, *< Sprin"house

Corporation4 Waterlo5 K @/092A * ris$ assessment car&4 N&rsing Times 91@9A< 0224

Weaver * @/003A %RS* an& its mana"ement in the community4 7omm&nity N&rse 2@0A<

13194West , riestley K @/00A %oney un&er the mattress4 6ealth Ser,i+e Jo&rnal 14< -4

Williams C @/000A *n investi"ation into the bene'its o' *8uacel Hy&ro'ibre

5oun& &ressin"4 =ritish Jo&rnal of N&rsing 9@/-A< 3F339-4

Williams E @/00FA *ssessin" the 'uture4 N&rsing Times :3@supplA< 14

Winter ! @/03A .ormation o' the scab an& the rate o' epithelialiJation o'

super'icial 5oun&s in the s$in o' the youn" &omestic pi"4 Nat&re 13< 0104



Inde/

a"e re'erences in bo,d ty0e re'er

to &e'initions o' terms in the

!lossary

abscess 9,

12: piloni&al

F action plan

//0

*ctisorb lus

a&hesive strips ,21 a&ipose tissue

2

a"e, e''ect on healin" 1, F,

91 air5ay overlay 01

alcohol, in ulcer preparations /

alcohol consumption, e''ect on

5oun&

healin" /1, 1, 0

al"inate &ressin"s /9, 12, 13F, 1,

/-3, /-F9

as cavity &ressin" F,

9 as haemostat 21

aller"ens /

*llevyn 19

*llevyn *&hesive 10

alternatin" pressure mattress

0 anaerobe 12:

anal"esia /0,

F/ an"ina 20an"io"enesis 12, -, 12:

an$le brachial pressure in&e= @*#IA

3/1, 12:

an$le 'lare 2F,

12: antibiotics /0

systemic 09,

00 topical /, /-1

anticoa"ulants 3

anti?in'lammatory &ru"s

e''ects on 5oun& healin" 9

an& pressure sore healin"

91

antimicrobial therapy 9,

- antiseptics 1/

antistrepto$inase titre 19

an=iety F

*8uacel 10

aromatherapy /-3

arterial &isease 29

0

arterial ulceration 20, 32,

F1 pain associate& 5ith

/0

arteritis 32 aspirin 9

athersclerosis 32,

12: atrophe blanche

2F autolysis 10, 12:

U?bloc$ers, e''ect on pressure

sore healin" 91

bacitracin /

bacterial colonisation /, 02

#ioclusive -

#lac$ Report 0

blisterin" 2/

bovine colla"en

#ritish #urns *ssociation2/ burns 2, 2-

&ressin"s 'or 2/

'ull?thic$ness 2-,

2 minor 2/

pain associate& 5ith /0




/1



Cushin"7s syn&rome

Cuti'ilm -

cytoto=ic

&ru"s

e''ect on pressure sores

91 an& 5oun& healin"

9, 3

Database o' Revie5s o'

E''ectiveness an& #est

Evi&ence //2

&Mbri&ement -, 1F, 135

&eep vein thrombosis 2F,

29 &ehiscence , 9,

135

Deni&or

&ermis ,

1

thinnin" o' 32,

9 &eslou"hin" -

&iabetes

an& *#I 3

e''ect on 5oun& healin" /1, , F,

20, 31,

33F 'oot care3F9

'oot ulcers 339,

00 an& ischaemia

32

&ietary a&vice, +ase st&$ies

2F &ietary supplements

, 2 &i"its, &ressin"s 'or

/-3, /-F

&iversion therapy, 'or pain control

- &ocumentation //&onor sites 2

Doppler ultrasono"raphy /1, 3/1,

135

&ressin"s

choice o' 13

combinations 1

're8uency o' chan"in"

F- lea$a"e /F/9

pac$s 1-

prescription an& non?prescription

13

removal, trauma /9, /0,

12 secon&ary 1F, 1

ulcer 30F-

see also al"inate &ressin"sG

charcoal &ressin"sG enJyme

&ressin"sG 'oam &ressin"s<

occlusive &ressin"sG

hy&rocellular

&ressin"sG hy&rocolloi&

&ressin"sG hy&ro'ibre &ressin"sG

lo5? a&hesive &ressin"sG



In&e= /2

polysacchari&e bea& &ressin"sG

vapour?permeable &ressin"s

Duo&erm -

&uty to care /1

ecJema 32

Effe+ti,e 6ealth 7are =&lletins //2

emollients /, 1/, 33

enJyme &ressin"s

1F eosin /-9

epi&ermis , 1

epithelial cells an& tissue 2, 9, 135

islan& /

mi"ration 0/-

epithelialisation 0, 13, 135

erythema 2/, 135

eschar 9, -, 135

Es+heri+hia +oli

- ester o' resin

European ressure (lcer *&visory

anel 9

evaluation //

evi&ence appraisal //3evi&ence?base& health care //

e=ercise 33, F/, F1

e=u&ate 3, /0, /, 1-, 1, 12, 10, /-2,

/-F, /-9, 135

an& al"inate &ressin"s 13

F an& protein loss

.ibracol

'ibrin 135

'ibroblasts F,9

.lamaJine 2/, /-1

'lui& loss /

'oam &ressin"s 190, 1,

9 'ocus "roups /, /2

'ra"rances, as irritants

'ramycetin /

'riction 2, 93

an& incontinence 91

'un"atin" 5oun& /-2'usi&ic aci& /-1

!am"ee 1

"auJe 12, 2

"el'oam combination &ressin"

"entamicin /

!ranu'le= -

!ranu"el -

"ranulation tissue , 9, /, 12, 131

haemostasis 3, 131

haematoma 'ormation 2, 3, 131

han& 5ashin" 00/--, /-1

heat an& col& therapy, 'or pain relie'

-

heel, &ressin"s 'or /-3F

hy&rocellular &ressin"s 19

hy&rocolloi& &ressin"s 12, 10-,

1,

2o&our 'rom /F/9

hy&rocolloi& "el &ressin"s -

hy&ro'ibre &ressin"s 10, /-F

9 hy&ro"els 10, -

hy&ropolymer &ressin"s

19 hypercholesterolaemia

33 hyper"ranulation /-9

hypertension 29, 33

hypertrophic scar 21

immunosuppressive &ru"s, e''ect

on 5oun& healin" 9, 3

Ina&ine /-1

incontinence, 'aecal an& urinary 91,

0- in'ection /, , /0, /, F, 131

e''ect o' a"e on 1

in'lammation 3, /-F, 131

in"ro5in" toenail 9

intermittent clau&ication

20 internet /-0/-, //3Intrasite !el 10

io&ine 1F

Io&o'le= 1F

Io&osorb 1F

irritants /

ischaemia /9, -, 32, 92,

131 e''ect o' smo$in" 0

ischaemic 'oot ulcer 00

6oint &ressin"s

/-F 6ournal clubs

//3

:altostat 21

:aposi7s sarcoma

30 $eloi& scar 21,

131



laceration

pretibial 21

traumatic , 22

lanolin /

larval therapy /-90

le" elevation 29, F1,/-9 le" ulcer , 23''

assessment 2031

+ase st&$y /1

causes o' 23

F

clinical investi"ations3- costs o' treatin" 23

&ressin"s 30F-

i&enti'ication /in'ection, +ase st&$y 03F

recurrent /, Flipo&ermatosclerosis 2F, 131

literature search //2

lo5 a&herence &ressin"s 1

)yo'oam 19

)yo'oam C

maceration 1, 10, 0-, /-F, /-9, 131

an& incontinence 91macropha"e F, 131

ma""ots see larvaltherapymalnourishmentG malnutrition , 3,

F, 0-/

e''ect on pressure sore healin" 91

%ar6olin7s ulcer 30

mattresses see support sur'aces%e&line //2

%e'ilm -melanomas 30%elolin 2

methicillin?resistant Staphylo+o++&s

a&re&s

@%RS*A 1F, /--

metroni&aJole /9

micro?or"anismscolonisation, /, 02,135 resi&ent 00

transient 00an& 5oun& &ressin"s

1 mobility 1, 2, 32moist 5oun& healin" 0/-, /9, /,11,

-, /-F mupirocin

/-1 myocar&ial in'arction 29

>mystery patient7 /-

N?* Dressin" 1

necrosis, necrotic tissue , -, 92, 131

e''ect o' smo$in"

0 peripheral 1neomycin /

ne"li"ence

/1

nerve &ama"e, pain associate& 5ith

/9 neuropathy 3F

Norton ressure Sore Ris$ *ssessment

Scale 93F

NS*IDs /9

Nu?!el 10

nutrition, nutritional status 1,91 assessment F

an& rheumatoi& arthritis 33

nutritional supplements 33

obesity, e''ect on 5oun& healin" 2,

F, 91

+ase st&$y 23

occlu&e& 5oun&, in'ection /-

occlusive &ressin"s /9, 11, 12, /-F,

131 oe&ema /, 29, 3/, 32, 33, F2, 03,131 opiate anal"esia /9

Opsite .le=i"ri& -

over"ranulation /-9,

131 o=y"en

atmospheric 12

o=y"en?permeable &ressin"s

13 re&uce&, an& oe&ema 9

tension an& obesity 2

pa&&in", as secon&ary &ressin" 12, 1,

F

pain /2, /9, 9

abscess 9

assessment /0

assessment scale

- control F1

ischaemic /9

le" ulcers /0,

F/ venous ulcer29

arabens /

para''in "auJe

12 patients

a&vice "iven to

// assessment o'

1 complaints /-



compliance /2, F9G +ase st&$ies F0

9-,

03F

con'i&entiality /F,

/2 consent /3

e&ucation F/, //

recor&s //9

surveys //1, //

1 vie5s o' //

pe&al pulse 29, 3/, 3

penicillin, e''ect o' on

colla"en

'ormation 3

peripheral vascular &isease 20,33 pha"ocytic 5hite cells F, 131

phenol, 9

phlebitis 29

photo"raphic recor&s /3

piloni&al abscess F, 9

piloni&al sinus -, F9

pituitary &e'iciency

polymorphs F

polysacchari&e bea& &ressin"s /9,

1F polyurethane &ressin" 2 postoperative

recovery 3

5oun& in'ection 2

potassium perman"anate /-9

povi&oneio&ine 1, 2

pressure sores, ulcers 2, /0,

9/''

causes o' 93

costs o' treatin"

9/ &e'inition 9inci&ence 9/, 9

mortality associate& 5ith

9/ prevalence 9/, 9

prevention 0-

ris$ assessment 93

0- an& 5omen 91

pressure?re&ucin" mattress 01

see also support sur'aces

ro'lavine -/, F

ro'ore F

protease /-F

protein loss

.rote&s -

.se&$omonas spp4 -

psycholo"ical 'actors, e''ect on

5oun& healin" 0

pulmonary &isease

pulmonary embolism 29

urilon !el 10

pyre=ia /, 9,

03

ra&iotherapy 3

ran&omise& controlle& trials //3

recor& $eepin" //, /

+ase st&$y /1

revie5 //9

re'lective practice /3F

rela=ation techni8ue -

rheumatoi& arthritis, 32 33

ris$ assessment 9F0-Rosi&al : F

rubber aller"y /

saline, physiolo"ical 1/,

1 temperature o' 1

scab 'ormation F, 9, 0

scal&s 2/

scars 2, 21

secon&ary &ressin"s 1F,

1 septicaemia 09, 132shear ulcers 92

shearin" -, 923

sheeps$in 01

silver nitrate /-9

silver sulpha&iaJine

2/ s$in

con&ition /

'unction o' /

"ra't 2

stainin", an& vascular &isease 2F,

32 structure o'

slou"h , -/, 132

smo$in"

e''ect on 5oun& healin" /1,

1,

90, 9

an& ischaemia 32

social 'actors, e''ect on 5oun& healin"

0>social7 ulcer F9

s8uamous cell carcinomas

30 staphylococcal in'ections

09

see also methicillin?

resistant

Staphylo+o++&s a&re&s

stasis ecJema 2F



Steri"el 10

steroi&s

e''ect on pressure sores 91

e''ect on 5oun& healin"

an& s$in thinnin" /

topical /

see also

corticosteroi&s

strepto&ornase 1F

strepto$inase 1F, 19

stress F

stri$e?throu"h 12,

1 subcutaneous 'at

, 1 sunburn 2/support sur'aces 0-, 0/

Sureress F sur"ical

"lue , 2 sur"ical

clips 23 sur"ical

5oun& , 2''

postoperative recovery 3

Sur"ipa& 1 sutures

, 23 systematic

revie5 //2 systemic

in'ection 9 systemicto=icity 00

Te"a&erm -

Te"asorb -

Tensopress F

thyroi& &e'iciency

tissue

brea$&o5n 9, 0-

hypo=ia /-2

o=y"enation 2types /2

tissue paper s$in

9 total sun bloc$

2 trauma 5oun&s

1-

an& ulcer F1

treatment "oals //

Tricote= 1

trimethoprim /-1

tulle 2/

tumour

blee&in" 'rom /-3

'un"atin" /-2

(: consensus classi'ication o'

pressure sores 2

(:CC ro'essional Co&e o' Con&uct

//1

ulcers 132

cleansin" F-costs o' treatin"

23 mali"nant 30

recurrence F

types o' /

see also 'oot ulcersG le" ulcersG

pressure ulcersG vasculitic ulcers

(ltra .our F

un&erlyin" &isease, e''ect on

5oun& healin" 9

uraemia

vapour?permeable 'ilm &ressin"s 1,

-, 1, 2

varicose ecJema /

varicose veins 2F,

3

Vari&ase 1F9

vascular status, assessment o'

3/ vasculitic ulcers 32

ve"etarians, &ressin"s suitable 'or venous &isease 23, 2F, 312,

132 venous le" ulcer /0, 21, 29, F/

+ase st&$ies 2 F90

vitamin C supplements

F

see also malnourishmentG nutritionG

nutritional supplements

Waterlo5 ris$ score 9F

0 5ell ulcer clinic F9

5hite cell activity

F 5oun&

acute /1 a&herence

/9 assessment, //''

assessment chart

/ cate"orisation

chronic /

cleansin" /0, 1-

cleansin" a"ents 1/,1 closure strips 21

&ebris clearance 9

&epth 2, /3

&ressin"s /F

/9 &ry 9

'ull thic$ness 1



'un"atin" /F, /-2

healin"< by primary an&

secon&ary intention , 2, 131G

by tertiary intention 3, 131G

nutrient re8uirements 'or 2G

phases o'

30

in'ection F, 02''

irri"ation 1-

maturation 0

measurement /2/3

o&our /2, /F, /, , 03, /-2

partial thic$ness 1

recor&in" /

super'icial 1s5ab 02, 09,

/-/ temperature

1 tracin" /2

/3

Jinc &e'iciency 9

Jinc o=i&e paste an& ban&a"es /-9

Wound.care.a.handbook.for.Community.nurses.ebook EEn

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Transcript of Wound.care.a.handbook.for.Community.nurses.ebook EEn