Ms Leak - Fixing the Puzzle Dressing on Wounds

What do you see

Wound Management

Kathy leak

Sister Wound Care B.a (Hon’s)

Doncaster & Bassetlaw Hospitals NHS Foundation Trust

Best Practice guideline

• The practitioner can:

– Describe wound location

– Measure size of wound

– Describe wound bed

– Exudate

– Wound odour

– Pain

– Condition of surrounding skin

Best practice Guideline

• Documentation

– Detail any shared care

– Reflect assessment findings

– Timescale

– Information given

– Wound management

– SINGLE MULTIDISCIPLINARY

DOCUMENT

Best Practice Guideline

• Ongoing Review

– Regular assessments

– Timely and comprehensive

– Pt compliance

– Objectives met

– If not why not

– Reassess/ discharge

Current issues in wound

management

• Changing patient profiles

• Complex wounds

• Wound assessment/decision making tools

• Identifying wound infection

• Innovation in wound care

The 21st Century Patient: Older, sicker

and more complex

The wound site

Psychological

issues

Physical

problems:

concurrent illness

Multiple pathologies

• Patients will often present with complicated clinical pictures

• Diabetes, anaemia, cardiovascular disease and respiratory conditions may co-exist in a number of patients.

• This clinical picture will have a direct effect on the wound healing potential of the patient.

• In elderly patients with chronic wounds, cells are found to be immature and unable to function normally (Henderson 2006)

What makes a complex wound

complex?

Excess

bacteria

Alkalinic pH

Devitalised

tissue

Excessive proteases

Cell senescence

Poor local

vascular supply

Excess exudate

production

Prolonged

inflammation

Psychosocial

issues

How do we deal with wounds such

as this?

The key to dealing with complexity in

wound care lies in thorough and

accurate assessment

HEIDI

Assessment

History

• Presenting wound

• Medical background

• Drug history

• Social background

• Nutritional status

• Psychological status

• Patients’ perspective

Examination

• Basic skin assessment

• Type of wound

• Anatomical description of wound

• Size

• Wound bed appearance

• Exudate

• Odour

• Pain

Investigations

• Bloods

• X-ray

• Doppler

Wound bed preparation

• The key aim of treatment is to progress the

wound to healing or the best outcomes

possible

• The primary concerns are the removal of

necrotic/sloughy tissue and the prevention

of infection

• Wound debridement is a dynamic process

which continues until all necrotic tissue is

removed

Black

• Treatment objectives

– Debride

– Maintain bacterial

balance

– Maintain moisture

balance

Wound Management

Choosing the Right Dressing

• Hydrogels– Two basic forms – sheets

and gels

– Sheets for shallow wounds

– Gels for cavities and

desloughing and debriding

– Secondary dressings

required to keep insitu

– Maceration can occur

Wound Management

Choosing the Right Dressing• Hydrocolloids

– Mixture of pectins, gelatins, sodium carboxymethylcellulose and elastomers

– Create an environment that encourages autolysis in sloughy necrotic wounds

– Reduce pain in wounds

– Provide an hypoxic environment which encourages angiogenesis

– Has a characteristic odour

– Require wound overlap of at least 2cm

Black/yellow wound

Treatment Objectives

1. Debride

2. Maintain Bacterial

Balance

3. Maintain Moisture

Balance

4. What dressing?

Yellow


– Debride


balance


balance

Wound Management


• Alginates

– First used in 1940’s

– Made of seaweed

– Composed of galuronic and mannuronic acid – the quantities of these determines the gel forming properties

– Galuronic forms a firmer gel

– Mannuronic forms a softer gel

– For moderate to high exudate wounds

Sometimes the yellow is green

Why?

What dressing ?

Dehiscence: yellow red wound



balance


balance

Wound Management


• Foam dressings

– Made using advanced polymer technology

– They are non-adherent, absorb large amounts of exudate, can be used as a secondary dressing

– Hydropolymer swells into wound bed as exudate is absorbed

– Can absorb several times their own weight in exudate

– For moderate to heavy exudating wounds

Anyone like to guess what is

wrong here!

Epithelial Regeneration:

Pink wound• Treatment objectives


balance


balance

Wound Management


• Film dressings

– Primary and secondary

dressing

– Clear polyurethane coated

with an adhesive

– Conformable

– Resistant to shear and

friction

– Prevent bacterial

colonisation

– Do not absorb EXUDATE

– Vapour permeable

Wound Infection Continuum

Spreading Infection Local Infection Critically Colonised Colonised

Dealing with increased bacterial load

• Recognise importance of bacterial load

– Contamination, colonisation, infection

• Monitor the impact of bacteria on healing

– Pain, exudate, bleeding, odour, systemic effects

• Treat the wound appropriately

– Wound debridement

– Antimicrobial dressings: containing povidone iodine/iodine (e.g. Inadine, Iodosorb/Iodoflex) or silver (e.g. Acticoat, Actisorb Silver, Flamazine)

– Increase frequency of dressing changes

– Systemic antibiotics

• Address host systemic factors

How do we know when a wound

is infected ?• Presence of pus?

• Inflammation?

• Delayed healing

• Discolouration of the wound

• Friable Granulation Tissue

• Unexpected pain or tenderness

• Pocketting at the base of the wound

• Bridging

• Odour

• Cellulitis?

• Positive culture?

• Serous exudate

plus positive

culture?

• Localised pain?

• All of the

above? Cutting

and Harding

(1994)

The effects of bacteria on wounds

• Compete with the bodies cells

for oxygen and nutrients

• Cell destruction can lead to

further necrosis

• Odour develops due to

anaerobic bacteria giving off

ammonia and other waste

products

• Cross contamination between

patients is common

• Systemic effects follow if left

untreated

Biofilms

• Form when a collection of

bacteria attach to a surface and

subsequently encase

themselves in an exopolymeric

material

• As a “community” benefit

from metabolic efficiency

• Sometimes appear as a “glaze”

on surface of wounds

Abscess formation

• Collection of pus and

necrotic material

• Pus contains bacteria and

white cells

• Contained within a wall of

fibrin and phagocytes

• May lead to lymphangitis

Cellulitis: local infection

• Bacterial infection causing a spreading, non-suppurative inflammation of the skin.

• Most commonly haemolytic strep.

• Painful and often oedematous

• Ulceration and necrosis may ensue if severe.

• Lymphangitis also common.

• Can be confused with inflammation

Spreading Infection

Wound Management

Choosing the Right Dressing• Antiseptics and

disinfectants

– Silver – flamazine,

particularly effective in

treating pseudomonas

– Film dressings containing

silver reduce colonisation

– Silver and carbon dressings

reduce bacterial count and

odour

• Iodine

– No proven resistance to

iodine

– No adverse affects on

wound healing

– Rapidly deactivated in

presence of pus

– Cadexomer iodines absorb

exudate in exchange for

iodine

– Useful in treating colonised

wounds

Exudate management

3

Discharge

• Wound exudate is normal.

• Copious exudate and

continued inflammation

may indicate infection

• Seropurulent and

haemopurulent discharges

indicate liquefaction of

tissues as a result of the

micro-organisms in the

wound.

Wound Exudate

• Assess exudate

– Colour; viscosity; volume; odour

• Assess wound

– Acute; chronic; infection; fistula; oedema; bleeding

• Document

– High; moderate; low

• Select dressing

– Conventional; NPWT; wound manager

Summary

• Accurate assessment

• Appropriate dressing

leads to

• Happy patient

• Happy nurse

• Happy manager

HAPPY ENDING

References and Further Reading

Cooper R (2004) A review of the evidence for the use of topical antimicrobial agents in wound care. http://www.worldwidewounds.com/2004/february/.../Topical -Antimicrobial-Agents.htm

Collier M (2004) Recognition and management of wound infections, http://www.worldwidewounds.com/2004/janu.../Management-of-Wound-infections.htm

Cutting K and Harding K (1994) Criteria for identifying wound infection, J. Wound Care 3 (4), pp 198-201

Kingsley A, White R and Gray D, (2004) The Wound Infection Continuum: a revised perspective, August, pp 22-25

http://www.worldwidewounds.com/2004/janu.../Management-of-Wound-infections.htm

References and further reading

• Lansdown ABG, (2004) A review of the use of silver in wound care: facts and fallacies, Br. Journal Of Nursing, (TV Supplement), Vol 13, No. 6 pp s 6 – s 19.

• ReillY J McIntosh J And Currie K. (2002) Changing surgical practice through feedback of performance data. Journal Of Advanced Nursing, 38 (6) pp 607-614.

• Sunghal H and Zamit C, (2002) Wound Infection, http://www.emedicine.com/med/topic/2422.htm

• Tachi M, Hirabiayashi S, Yonehera Y, Suzuki Y and Bowler P. (2004) Comparison or bacteria-retaining ability of absorbent wound dressings, International Wound Journal, Vol 1 No. 3, pp 177- 181.

http://www.emedicine.com/med/topic/2422.htm


