The Infection Continuum Type CRITICALLY COLONISED INFECTED Increasing bacterial burden Host defences unable to maintain healthy balance; either too many microbes or too many species in wound base or a immunity. This results in an indolent wound that does not respond to appropriate therapy and is at increased risk of becoming clinically infected Host defences overwhelmed resulting in local cellulitis, which may lead to bacteraemia, septicaemia and death. Clinical signs of infection will be present (see criteria for diagnosis of clinical wound infection) and the patient will feel systemically unwell Management Aim To reduce the bacterial load in the wound bed to prevent clinical infection and promote wound healing Treatment Option Undertake full, holistic assessment. (Refer to Infected / Critically Colonised Wound Management Algorithm) Consider using an antimicrobial dressing. The choice of dressing will be determined by other wound and patient characteristics e.g. exudate, tissue type, location, known sensitivities. Undertake full, holistic assessment.(Refer to Infected / Critically Colonised Wound Management Algorithm) Consider using an antimicrobial dressing. The choice of dressing will be determined by other wound and patient characteristics e.g. exudate, tissue type, location, known sensitivities. Linked Information Infected wound guideline
Burns Picture Description Aims Dressing Regime Other Considerations SUPERFICIAL BURN1 (1st Degree) Heat injury to the skin resulting in damage to the epidermis and possibly part of but not completely the dermis Usually reddened, dry, painful, may have minor blister Establish how burn occurred, cause, extent and depth of burn Maintain moist environment and manage exudate Minimise risk of infection Low adherent Vapour permeable film Foam Antimicrobial First aid in all burns: Apply cold water to localised superficial burn, cover with cling film or clean plastic bag until treatment obtained Establish mechanism of injury Refer to Walk-in-Centre/ A&E Lund & Browder Surface Area Calculator (guide only) Adults only Blister management Blisters have a protective function If they are not large and will not obstruct dressing or patient’s movement - leave intact Large bullous blisters: it may be necessary to drain fluid to facilitate movement, but “de- roofing” is generally not recommended as it may increase the risk of infection Review a new burn after 24-48 hours to reassess the condition of burn Pain management Assess need for Tetanus immunisation* Superficial burns usually heal in 7-14 days if healing is delayed consider: Infection may be present. Referral to secondary care - as burn depth can be underestimated Once healed advise patient: To protect newly healed tissue The use of an emollient may soothe and ease itching Sun exposure – use of sun- block for the first year while new skin matures Linked Information 1 Any wound above first degree and/or bigger than 5% of total body surface area should be referred for specialist assessment in A&E or burns unit *Patient Group Direction for immunisations
Classification Of Wounds Wound Type Treatment Aim Treatment choice with a cavity Treatment choice without a cavity NECROTIC Dead devitalised tissue, normally black or brownish appearance SLOUGHY Moist predominantly yellow in appear- ance, a mixture of rehydrated necrotic tissue dead bacteria, leucocytes often with fibrous tissue Debride eschar Debride slough to provide base for granulating tissue Primary dressing Secondary dressing Low Exudate Hydrogel Film or Hydrocolloid Low adherent Film or Hydrocolloid Capillary action dressing Film Moderate / High Exudate Alginate Foam Capillary Action Foam Hydrofibre Foam Larval Therapy Low Exudate Low adherent Foam or Hydrocolloid Hydrogel Film or Hydrocolloid Hydrofibre Foam Moderate / High Exudate Alginate Foam Capillary action Foam Hydrofibre Foam Primary dressing Secondary dressing Low Exudate Hydrogel Film or Hydrocolloid Hydrocolloid Capillary action dressing Film Moderate / High Exudate Alginate Foam Capillary Action Foam Foam Hydrofibre Foam Larval Therapy Low Exudate Hydrocolloid Hydrogel Film or Hydrocolloid Moderate / High Exudate Alginate Foam Capillary action Foam Foam Hydrofibre Foam
Dehisced Wound Wound Type Description Aims Dressings Other Considerations Dehiscence occurs following surgery when the sutures/staples are unable to hold the wound together Manage exudate Promote granulation Reduce risk of infection Dependant on size and level of exudate Moderate Exudate Alginate Hydrofibre Foam High Exudate Hydrofibre Alginate Foam Capillary action dressing Absorbent cellulose dressing Wound management pouch Topical negative pressure Pain control Patient support re: body image Nutritional / fluid intake may need review depending on fluid loss May need surgical review
Neuroischaemic Ulcers Wound Type Description Treatment Aim Dressings Other Considerations Dry gangrenous ischaemic wound Wet gangrenous wound Reduce risk of infection developing /spreading Keep wound dry, if toe is affected isolate from touching adjacent digit Control moisture level Reduce risk of infection developing /spreading Low adherent dressing If dry gangrene leave exposed if appropriate Low adherent May need charcoal dressing to control odour Typical signs: Pulse absent Foot may be cold History of intermittent claudication Painful Minimum or no callus Area of necrosis, often surrounded by erythema Evidence of gangrene Refer to vascular surgeon Manage in conjunction with Diabetes team Debridement may be considered by a competent practitioner i.e. have completed an accredited course in sharp debridement Minimise pressure on affected area Monitor for infection (remember these signs may be reduced or absent in DFU) Patient support where amputation may be considered
Wound Type Treatment Aim Allow free drainage of exudate *Debridement Dressings Low Exudate Low adherent Moderate/ High Exudate Hydrofibre Alginate Foam Other The principles of moist wound healing have not been shown to be effective in healing diabetic foot ulcers (DFU). Such is the high risk of infection that the wound exudate level must be carefully managed All DFU must be referred to the Multi-disciplinary Diabetes Team for holistic assessment, nurses must work in collaboration and reinforce individual health education (Refer to Liverpool and South Sefton Podiatry Service: Diabetes foot care advice leaflets) Maintain monitoring of blood glucose. Hba1c should be at optimum level Diabetic foot ulcers should be redressed frequently to enable close monitoring for indications of infection. Note clinical signs of infection may be reduced or absent in DFU Functions required of a dressing are: Low adherent Not bulky or take up too much space in shoe Able to withstand the pressures and shear forces of walking Able to absorb large quantities of wound exudate *Debridement Debridement of wound bed allows a deep swab to be taken and show the true dimensions of the wound. Debridement of the surrounding skin may be performed to minimise pressure and reduce the bacterial load by removing devitalised tissue Such debridement must be performed by a competent practitioner i.e. have completed an accredited course in sharp debridement
Fungating Wound Wound Type Aims Dressings Other Considerations Description Malignant wounds are caused by malignant infiltration of the skin by a primary tumour or a metastasis to the skin. These lesions can grow rapidly, and commonly present with both ulcerative and fungating features (Collier 2000) Manage exudate Reduce odour Useful combinations include low adherent dressing and secondary absorbent dressing or alginate / hydrofibre and foam dressing Charcoal / odour absorbent dressing Other methods of odour control include the use of deodorising products as used in stoma care The overall aim is to improve the patient’s quality of life and manage symptoms of the wound. Dressings should be comfortable and acceptable to the patient. It is important to ensure that a holistic patient assessment includes psychological assessment of the impact of the wound for the patient. Main symptoms include: Altered body image Excessive exudate Malodour Bleeding* Pain Itching *Dressings should be low adherent to minimise the risk of trauma induced bleeding. The use of haemostatic Alginates may be of use to control minor bleeds. Linked information: Fungating wound guideline
Hypergranulated Wound Wound Type Description Treatment Aim Dressings Other Considerations Note: also known as overgranulation Appearance - red raised granulating tissue above the level of the surrounding epidermal skin layer Reduce further hypergranulation Promote epithelialisation Manage exudate Provide comfortable dressing Low adherent dressing Polyurethane foam or silver impregnated foam If the hypergranulation is around a foreign body PEG site, the overgranulation may continue until the foreign body is removed Constant movement of suprapubic catheters, gastroscopy tubes etc should be avoided as it may create friction and prolong inflammation Stop any interactive dressings that may be promoting further granulation Ensure possibility of malignancy has been excluded Following wound assessment consider the use of antimicrobial to treat possible critical colonisation of bacteria or infection Linked Information Hypergranulating wound guideline
Leg Ulcer Management Only follow if full leg assessment and Doppler have been done to establish the aetiology Leg Ulcer Type Indicator/Descriptor Management Aims Treatment Options Other Considerations VENOUS Usually gaiter area Shallow sloping edges, usually with higher levels of exudate ABPI greater than 0.8 Aid venous return by increasing velocity flow in deep veins Reduce oedema Reduce pressure in the superficial venous system Full compression therapy, 40mmHg pressure; refer to formulary for choice of systems Dressing selection; e.g. low adherent or foam Usually requiring redressing weekly It is important to note that the ulcer is a symptom of the underlying condition. In order for successful healing to occur it is necessary to treat the underlying cause (i.e. venous or arterial problems) Pain control is an important factor in obtaining patient concordance. Careful consideration should be Never attempt compression bandaging unless aetiology assured and competent in application given to managing pain and an appropriate prescription of analgesia. The aim should be to MIXED AETIOLOGY ARTERIAL Mixture of both venous and arterial and therefore signs from both aetiologies Doppler assessment; ABPI between 0.6 and 0.8 Any part of the leg or foot Usually small ‘punched out’ defined edge ABPI less than 0.6 Increase venous return Reduce oedema Reduce pain Prevent infection Reduce pain Prevent infection Vascular investigation Prevent maceration Apply reduced compression therapy at 15-25mmHg Dressing selection; keep it simple e.g. low adherent or foam No compression Wound management as indicated within formulary Management of pain Refer to vascular surgeon maximise patient comfort and adherence to treatment Good nutritional status is essential for wound healing to take place Patient education For appropriate dressing selection according to assessment of the wound and surrounding skin characteristics refer to Classification of Wounds Keep it simple; patients with history of leg ulceration have high incidence of sensitivities For venous ulceration; when the ulcer has healed wearing compression hosiery reduces recurrence rates Refer to Classification Of Bandages for optimum compression levels and choice of therapy Linked information: Leg ulcer guideline
NB: some systems contain latex - always read the manufacturers’ instructions. Whenever possible always choose a latex-free system System Components Pressure British Standard (mmHg) Considerations Full compression Wound contact layer No compression Use the wool and extra if necessary to shape the limb, Orthopaedic wool layer pay particular attention to Light support crepe bony prominences Four layer system Bandage too loose can Light compression class 3a applied in a figure of 8 17-20mmHg cause slippage For ankle Bandage too tight can Light /moderate compression Class 3b Applied spiral 20-23mmHg measurement of cause pressure necrosis 18cm - 25cm Both can delay healing Apply all bandages at 50% stretch Full compression As above but add an Remeasure limb after for ankle application of wool measurement extra wool layer Particular attention to below 18cm tibial crest For ankle Wound contact layer This combination An increase in the ankle Orthopaedic wool layer Light support crepe Moderate compression class 3c applied in a spiral measurement gives 25-30cm approximate pressure levels of Light /moderate compression Class 3b Applied spiral 40mmHg circumference reduces the sub bandage pressure For ankle Wound contact layer This combination therefore the level of compression should be Orthopaedic wool layer increased Light compression class 3a applied in a figure of 8 with greater ankle circumference Moderate compression class 3c applied in a spiral measurement gives full above 30cm compression at Light /moderate compression Class 3b Applied spiral approximately 40mmHg
System Components Pessure British Standard (mmHg) Considerations Long stretch bandage Orthopaedic wool No compression Long stretch exerts high compression during rest and exercise Class 3c compression bandage applied at 50% extension and 50% Gives 30-40mmHg pressure overlap in a spiral Full Wool contact layer No compression Patient choice compression Alternative to four layer Proguide bandage applied 50% stretch 50% overlap in a spiral 40mmHg vari-stretch systems. Sustained pressure two layer system for 1 week Compression Liner 10mmHg Patient choice alternative to four layer systems. Self caring - Hosiery 30mmHg Hosiery Ulcer Kit useful when applying treatments e.g. regular steroid application Reduced Wound contact layer No compression Criteria for application of compression reduced compression Orthopaedic wool layer Pressure less Mixed aetiology Light support crepe than 25mmHg ABPI 0.6-0.8 when there is Light compression class 3a applied in a figure of 8 17-20mmHg evidence of clinical signs of venous hypertension N.B. the rationale for OR Light compression class 3b applied spiral 50% stretch 50% overlap 20-23mmHg compression therapy is to optimise venous return and reverse hypertension within the veins Reduced compression Pressure Compression hosiery systems Class1 14-17mmHg Alternative choice N.B. if ulcer does not show signs of healing consider less than Class 2 15-24mmHg reverting to bandaging 25mmHg system which will increase pressure level Short stretch Orthopaedic wool layer No compression Indication for venous hypertension and reduction Short stretch bandage Applied full stretch 50% Applied at full 18-25cm of oedema and overlap stretch this will Initially the patient will Apply second bandage in the opposite direction give pressures of require more frequent Above 25cm 35-40mmHg rebandaging as bandage will be prone to slippage
Malodorous Wound Wound Type Description Aims Dressings Other Considerations Wound which has an offensive change in odour may indicate infection or colonisation of bacteria May be fungating carcinoma Reduce bacterial burden Treat infection Debride devitalised tissue Promote dignity and patient comfort Reduce/contain odour Charcoal dressings only contain the odour Choice of product depends on characteristics of wound If infection is present use an antimicrobial Review frequency of dressing change The odour from wounds is most commonly caused by the presence of infection and devitalised tissue, therefore it is important to treat cause Swab and identify organism and treat with antibiotics where appropriate Consider: Patient support Surgical/Sharp debridement Autolytic debridement Larval therapy Linked information: Wound assessment guideline Fungating wound guideline Debridement guideline
Sinus Wound Wound Type Description Aims Dressings Other Considerations A narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation Free drainage of exudate Protect surrounding skin Prevent infection Remove necrotic or sloughy material Promote granulation from the base of the wound Primary Dressing Hydrofibre Alginate Secondary Dressing Occlusive low adherent or Foam If premature closure occurs the sinus may reoccur and then it may need surgical intervention All dressings put into and removed from sinus must be recorded at every dressing change and dimensions regularly reassessed Any dressing used in a sinus must be removable Caution should be taken when inserting dressing - DO NOT PACK - loosely fill Moist cotton gauze should not be used to manage surgical wounds that are healing by secondary intention An appropriate interactive occlusive dressing should be used to manage surgical wounds that are healing by secondary intention Other considerations: Nutrition Pain – analgesia may be required prior to dressing change Surgical intervention Pilonidal sinuses – meticulous attention to hygiene Linked information: Cavity wound guideline Surgical wound guideline
Skin Laceration Wound Type and Description Management Aims Dressings Other Considerations Superficial Skin Laceration Skin Laceration Description: breach or split in the skin caused by blunt instrument or force (e.g. result of fall) Initial aims include: debridement of any foreign material loosely align skin edges with wound closure strips leaving gaps to allow exudate drainage, promote healing; provide optimal environment for healing General aims include: manage characteristics of wound prevent infection manage exudate acceptable cosmetic outcome Description: partial or full thickness wound involving loss of some or all affected tissue. Depending on mechanism of injury, refer to A&E e.g. crush injuries need to be observed for signs of compartment syndrome; where an impact causes bleeding within a closed anatomical space causing swelling with subsequent compromise of circulation and tissue function, which can lead to irreversible nerve damage or tissue necrosis within hours of injury. Particularly common in the compartment of lower leg and forearm. Signs include: pain, swelling, numbness, loss of peripheral pulse, contracture. Also refer to A&E if: Indications of bone involvement Indications of full thickness laceration exposing deeper lying structures Lower limb looks discoloured and capillary refill is reduced Indication of change in sensation to lower limb Treatment Choice: Low Exudate: Tissue adhesive Wound closure strips Low adherent dressing Moderate Exudate: Alginate / Hydrofibre Foam High Exudate: Foam Secure with light retention bandage, bandage toe to knee (if lower leg wound) Dressings will depend on skin fragility. Superficial lacerations to face / scalp may be inappropriate to apply dressings Pain management Note: pre-tibial lacerations often result in haematoma formation. Haematomas can cause tissue necrosis and may need assessment in for evacuation of haematoma formation If lower limb laceration does not heal within 6 weeks perform leg ulcer assessment After care advice: Elevate legs, rest, steristrip management (keep dry, leave in situ until wound review)
Emollient Efficacy level Product Indications for use Contraindications The cosmetic acceptability of emollients must be considered on an individual basis to ensure concordance with treatment. Rational for use of other moisturisers can be due to patient choice. Bath emollient Very little effect used in isolation Hydromol bath emollient Can be applied directly onto wet skin or diluted in water. Product should not be used were patients are know to have sensitivities or allergies to excipients or preservatives. Excipients, non listed Cream Less effective as moisturiser than ointment Epaderm Can also be used as a soap as dissolves in water and is more cosmetically acceptable than ointment. Product should not be used were patients are know to have sensitivities or allergies to excipients or preservatives. Excipients include chlorocresol Ointment Most effective as moisturiser Hydromol ointment Can also be used as a soap as dissolves in water and effective as moisturiser. It is gold standard practice to use ointment as moisturiser under compression bandaging Product should not be used were patients are know to have sensitivities or allergies to excipients or preservatives. Excipients include cetostearyl alcohol
DESCRIPTION Vacuum Assisted Closure (VAC) is a wound management system that applies pressure to promote wound healing. It is a machine that can apply intermittent or continuous vacuum therapy to a wound MODE OF ACTION The suction stimulates the blood supply to the wound bed by creating a hypoxic environment forcing the microcirculation to regenerate rapidly and produce a large amount of capillaries. The suction also removes any slough or loose necrotic tissue. By effectively removing wound exudate, interstitial fluid, decreasing localised oedema and increasing blood flow, it is possible that the VAC can reduce the incidence of infection or bacterial colonisation as tissue bacterial levels are reduced. Among other reported benefits is the mechanical effect on wound closure whereby a centripetal force is created which draws the wound edges together. Therefore, negative pressure promotes faster granulation and moist wound healing INDICATIONS FOR USE Vacuum Assisted Closure (VAC) negative pressure technique may be considered as a wound management system to promote wound healing by secondary intent: When conventional wound management techniques have been unsuccessful For chronic or compromised wounds It is deemed in the patient’s best interest e.g. where rapid wound closure is desirable or needed CONTRAINDICATIONS Maligancy in wound Fistula of unknown origin Exposed artery or vein Necrotic tissue with escar Untreated osteomylitis Active bleeding METHOD OF APPLICATION Only nurses who are knowledgeable and skilled in its use should assess and apply VAC therapy to patients (see VAC guidelines). Training is accessible via the learning and development bureau Linked information Refer identified patients to the Skin Care Service to arrange funding VAC guideline Vacuum Assisted Closure
PLEASE NOTE: Product sizes shown are not necessarily full range of product. Pack sizes have been included for information purposes, although products should be prescribed according to required need. Prices indicated are per single unit and correct as of September 2009 Drug Tariff. ABSORBENT Eclypse: Absorbent cellulose dressing with fluid repellent backing. Indicated for medium to highly exuding wounds, may require a low adherent primary dressing. Not suitable under compression Sorbion Sachet S: Absorbent hydroactive dressing for highly exuding wounds, for use under compression PRODUCT PACK SIZE UNIT COST SIZE ECLYPSE 20 97p 15cm x 15cm Advancis Medical 20 £2.14 20cm x 30cm 10 £8.15 60cm x 40cm SORBION SACHET S 10 £2.22 10cm x 10cm Sorbion 10 £3.68 20cm x 10cm ALGINATE An absorbent calcium alginate dressing, high in mannuronic acid that produces a soft gel when in contact with wound exudate. Suitable for medium to highly exuding flat or cavity wounds. Has haemostatic properties. PRODUCT PACK SIZE UNIT COST SIZE SORBSAN 10 78p 5cm x 5cm Aspen medical 10 £1.64 10cm x 10cm 5 £3.08 10cm x 20cm SORBSAN PACKING (with probe) 5 £3.41 30cm/2g SORBSAN RIBBON (with probe) 5 £1.99 40cm SORBSAN PLUS (with absorbent backing) 5 £1.66 7.5cm x 10cm 5 £2.93 10cm x 15cm SORBSAN PLUS SA (with adhesive border) 10 £2.89 11.5cm x 14cm 10 £4.22 14cm x 19cm 5 £5.10 14cm x 24cm