sus wound management guidelines - sps · scar pales, itching subsides. activity the nurse needs to...

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DOCUMENT REFERENCE NO:

Type: GUIDELINE

Sus

Relevant to: All PCT Clinical Staff

Produced by: Tissue Viability Committee

Responsible Executive Director: Director of Nursing

Date of Approval: September 2011

Date of Implementation: Immediate after approval

Due Review Date: September 2013

Responsible Reviewing Officer: Cathy Malone

This document replaces: WE/07/GUI0001/TV Version 2

For Office Use Only Scheme of Publication

Drive: X

Name: Scheme of Publication

Section no:

Sub Folder: File:

Wound Management Guidelines

Responsibilities

Signed Chief Executive

2

POLICY VALIDITY STATEMENT

THIS POLICY IS DUE FOR REVIEW IN …July 2013…..

After this date, this document will become invalid.

Policy users should ensure that they are consulting the

currently valid version of the documentation.

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WOUND MANAGEMENT

GUIDELINES

SEPT West Essex Locality

NEPT

September 2011

THE TISSUE VIABILITY SERVICE

1

WOUND MANAGEMENT GUIDELINES

1. INTRODUCTION AND SCOPE OF GUIDELINE Page 5

1.1 Purpose of the Wound Care Guideline

2. PROCESS OF HEALING Pages 6-17

2.1 Healing by First Intention 2.2 Healing by Secondary Intention 2.3 Wound Bed Preparation 2.3.1 Tissue 2.3.2 Infection 2.3.3 Moisture 2.3.4 Edges

3. FACTORS AFFECTING THE HEALING PROCESS Pages 18-21

3.1 Factors that can delay healing 3.2 Diet

3.2.1 Identification of patients at Risk 3.3 Pain

3.3.1 Using opiates on wounds

4. CLASSIFICATION OF WOUND TISSUE Pages 22-23

4.1 Epithelialising Tissue 4.2 Granulating Tissue

4.3 Sloughy Tissue 4.4 Infected Tissue 4.5 Necrotic Tissue 4.6 Malignant Tissue

5. WOUND ASSESSMENT Pages 23

5.1 Wound Assessment Form

6. WOUND CARE Pages 25-31

6.1 Wounds healing by First Intention 6.2 Wounds healing by Secondary Intention

6.2.1 Epithelialising wounds 6.2.2 Granulating wounds 6.2.3 Sloughy Wounds 6.2.4 Infected Wounds 6.2.5 Necrotic Wounds

6.3 Malignant/Fungating Wounds 6.4 Criteria for Removing/Changing Dressings 6.5 How to take a swab for culture 6.6 How to treat overgranulating tissue

TVS Guidelines: Wound Management/ Sept 2011

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7. PRINCIPLES OF WOUND IRRIGATION Pages 33-34

7.1 Cleansing Solutions 7.1.1 Sodium Chloride 0.9% solution 7.1.2 Chlorhexidine with cetrimide 7.1.3 Protosan 7.1.4 Iodine 7.1.5 Stellisept

8. WOUND BED PRODUCT INFORMATION Pages 35-38

8.1 Semi Permeable Film dressing 8.2 Hydrocolloids 8.3 Alginates 8.4 Foam Dressings 8.5 Hydrogels 8.6 Dressings containing charcoal 8.7 Dressing containing antimicrobial 8.7.1 Honey 8.8 Protease Modulating Therapy (PMT) 8.9 Larva Therapy/Biosurgery 8.10 Topical Negative Pressure 8.11 Topical Antibiotic

9. WOUND DRAINAGE Page 41

10. ASEPTIC NON TOUCH TECHNIQUE Page 41

11. WOUND COMPLICATIONS Page 43 11.1 Infection with/without Exudate 11.2 Wound Dehiscence

12. DEBRIDEMENT OF NECROTIC OR SLOUGHLY TISSUE Pages 44-49

12.1 Definition of Debridement 12.2 Scope 12.3 Contra-indications for versajet or sharp debridement 12.4 Criteria for sharp debridement 12.5 Criteria for versajet debridement 12.6 Procedure of communication with other disciplines prior to stop debridement 12.7 Procedure for debridement

13. MONITORING OF ADHERENCE TO GUIDLEINES 0

14. EDUCATION Page 50

LIST OF TABLES Table 1 - Stages of Healing Process Page 6

Table 2 - The TIME principles of Wound Bed Preparation Page 9 Table 3 - Characteristics of Healthy and Unhealthy Page 10 Granulating Tissue Table 4 - Signs and Symptoms of superficial and deep infection Page 14 Table 5 - Types of exudates and management Page 17 Table 6 - Conditions and interventions known to delay Page 18 Wound healing Table 7 - Comparison of commonly used antimicrobials Page 34 Table 8 – Procedure for aseptic non touch technique Page 42


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LIST OF FIGURES Figure 1 EWMA Clinical Stages of Infection and Algorithm Page 13 Figure 2- Wong Baker pain scale Page 20 Figure 3- Numerical pain rating scale Page 20

Figure 4 -Factors causing delayed wound healing Page 21 Figure 5 - Wound Assessment Form Page 24 Figure 6 - Wound Care Plan Form Page 32

APPENDICES

Appendix 1 Nutrition Assessment (MUST) Pages 51 -55

Appendix 2 TVS Referral Form Page 57 TNP Referral Form (VAC) Page 58 Care Pathway for Patient with a Wound Page 59

Care Pathway for MRSA infected Wound 0

Appendix 3 Proforma Care Plans Pages 62-69

Appendix 4 Wound Management Audit Tool Pages 71-81

Appendix 5 Competency Assessment Pages 83-88

Appendix 6 Wound Care Bundle Pages 90-91

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Foreword

As with any clinical guideline, recommendations may not be appropriate for use in all circumstances. A limitation of a guideline is that it simplifies clinical decision-making.

1 Decisions to

adopt any particular recommendation must be made by the practitioner in the light of:

Available resources

Local services, policies and protocols

The patients circumstances and wishes

Available personnel and devices

Clinical experience of the practitioner

Knowledge of more recent research findings.

1 Shiffman R. Representation of clinical practice guidelines in conventional and augmented decision tables. Journal

Medical Informatics 1999; 70 (3): 434, 437-40,443-9

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1. INTODUCTION AND SCOPE OF GUIDELINE

1.1 Purpose of the Wound Guideline

1.1.1 The purpose of this guideline is to provide guidance within SEPT West Essex Locality regarding the management of acute and chronic wounds.

1.1.2 This guideline aims to simplify the decision making regarding wound

management while ensuring that patients are provided with the best evidence based care. To that end this guideline must be used to ensure that all patients have been assessed and managed holistically and that care is supported with completed care plans and assessments in conjunction with the following guidelines:

SEPT West Essex Locality Infection Control Guidelines

SEPT West Essex Locality Pressure Ulcer Prevention and Management Guidelines.

SEPT West Essex Locality Dressing Formulary Guidelines

Nursing and Midwifery Council (NMC) The Code: Standards of conduct, performance and ethics for nurses and midwives.

2

The Royal Marsden Hospital, Manual of Clinical Nursing procedures.3

1.1.3 This document also aims to ensure transparency regarding management

of patients with wounds within SEPT West Essex Locality, NHS West Essex and NEPT, ensuring fair and equitable access to the best care and advice regardless of whether care is provided by NHS providers or private nursing homes providers. It is intended that adherence to these guidelines will facilitate all patients with non healing wounds being given access to the Tissue Viability Department if clinically appropriate as illustrated in the Care Pathway available in Appendix 2

1.1.4 This guideline was written by the Tissue Viability Committee, which is a

properly constituted subcommittee of the Nursing & Public Health Forum (NPHF) for SEPT West Essex Locality.

1.1.5 This guidelines is the product of collaboration between the Tissue Viability

Service, The Leg Ulcer Service, Community and Inpatient Nursing Services, the Medicines Management Department, Infection Control, Dietetics and the Foot Health Department. This guideline does not serve to advise on the management of Burns and Plastics, Dermatology, or Diabetic Foot Ulcers. Clinicians requiring support on such issues should seek advice from the appropriate Burns and Plastics, Dermatology Services or Foot Health Department.

2 NMC (2008) The Code, Standards of conduct, performance and ethics for nurses and midwives

3 Dougherty L, Lister S (eds) (2008) The Royal Marsden Hospital Manual Clinical Nursing Procedures. 7

th edn. Blackwell

Publishing, Oxford


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2. PROCESS OF HEALING4

Wound healing is a continuous process, however four stages can be identified. The length of each phase varies with the nature of the wound and the patient’s general condition.

STAGE PROCESS CLINICAL EFFECTS IMPLICATIONS

IMMEDIATE Haemostasis

Vasoconstriction

Activation of endothelial cells, platelets and clotting cascade.

Haemorrhage controlled or reduced.

Clot forms in wound.

Dress with a secure pressure bandage.

Seek medical advice if blood loss is excessive persistent.

INFLAMMATION Mediator release

Vasodilatation

Increased capillary permeability

Chemotaxis

Phagocytosis

Initiation of Repair

Cell stimulation /inhibition.

Bradykinin & histamines produced. Blood vessels dilate and become more permeable.

Increased blood flow

Protein cells and fluid leak from capillaries.

Mediators attract phagocytes (Neutrophils first, then Macrophages).

Neutrophils and macrophages remove debris and bacteria.

Macrophages produce growth factor.

Inflammatory process initiated.

Pain

Skin becomes red hot

Swelling

Exudate production

Contribute to exudates and swelling

Crust, pus or sloughing

No Clinical effects visible

Observe the following:

Swelling and discoloration

Signs of infection (see section 4&5) and inform medical staff if concerned.

PROLIFERATION Granulation

Angiogensis

Collagen production

Epithelialisation

Contraction

Endothelial budding or marginal capillaries

Fibroblasts migrate to the scene and secrete collagen

Epithelial cell multiplicating and migration over surface

Possible due to specialized fibroblast action.

Reconstruction of extra cellular matrix (ECM) from fibrin, fibronectin & collagen

Red, vascular tissue appears in wound

Smooth marginal zone or islands of epithelium seen in wound

Size of defect reduced

The nurse must ensure:

The patient received a nutritious diet, high in vitamin C and protein.

Movement is encouraged to prevent DVT and contractures

Physical support of the wound area and pain relief

The patient is educated regarding any physical restriction and provision of healing

MATURATION Collagen remodelling

Capillary regression

Type III collagen converted to Type I, increasing strength

Reduction in number of vessels, reducing blood flow.

ECM develops density

Scar flattens and softens

Scar pales, itching subsides.

The nurse needs to advise on:

Scar tissue2

Protection of the scar from friction

Encourage normal activity

Camouflaging after 1 month depending on the extent of the wound if appropriate.

Table 1 Stages of Healing, Source: The Wound Programme5 & Wet Wounds

6

4 Kingsley A (2003) Wound healing and potential therapeutic options. Professional Nurse. Vol 17 No 9 539-544

5 The Wound Programme (1992) Centre for Medical Education. Dundee

6 Wicks G, J Stephen-Haynes (2008) Wet Wounds: practical steps to improving active fluid management.


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2.1 Healing by First Intention (Acute Wounds)

Definition: Surgical or traumatic wounds where the edges are brought together by suturing, steristrips, clip, staples or glue.

Acute wounds usually follow a well-defined process as illustrated in Table 1. These stages overlap and the entire wound-healing process can take several months. Blood and exudate from a surgical wound is usually minimal. Within 48 hours the wound will have formed a natural barrier against invasion by pathogenic bacteria.

7 8

Surgical wounds, which are dry, can be left exposed after 48 hours following surgery. The preference of individual surgeons is likely to vary and staff should adhere to the written instruction within the patients notes.

2.2 Healing by Second Intention 9 (Chronic wounds)

Definition: All open wounds e.g. pressure ulcers, dehisced surgical wounds, leg ulcers. (These guidelines do not cover the management of Leg Ulceration. Please refer to the Leg Ulcer Guidelines) In the past, the acute wound-healing model has been applied to chronic wounds, but it is now known that chronic wound healing is different from acute wound healing.

10 Chronic

wounds become ‘stuck’ in the inflammatory and proliferative phases of healing, delaying healing.

11 The epidermis fails to migrate across the wound tissue and there is

hyperproliferation at the wound margins, which interferes with normal cellular migration over the wound bed.

12 In chronic wounds there appears to be an overproduction of

matrix modules resulting from underlying cellular dysfunction and disregulation.13

Fibrinogen and fibrin are also common in chronic wounds and it is thought that these and other macromolecules scavenge growth factors and other molecules involved in promoting wound repair.

14 So, while there may be large number of growth factors within

the wound, these can become trapped and therefore unavailable to the wound repair process. Chronic wound fluid is also bio chemically distinct from acute wound fluid; it slows down, or even blocks the proliferation of cells such as keritinocytes, fibroblasts and endothelial cells, which are essential for the wound-healing process.

15 16

For these reasons chronic wounds must be viewed differently than acute wounds. There is often a complex mix of local and host factors, which need to be assessed and treated.

7 Thomlinson D (1987) To Clean or not to Clean. Nursing Times Journal of Infection Control Nursing,Vol 83.5 - 4 Mar

8 Chrintz et al (1989) Need for surgical wound dressing. British Journal of Surgery. Vol 76, Pg 204 - 205

9 Silver I.A (1984) The Physiology of Wound Healing. JWC. Vol 2 No 2 Pg 106-109

10 Dowsett C, Ayello E (2004) TIME principles of chronic wound bed preparation and treatment. BJN Vol 13, No 15 pg

S16-S23 11

Ennis WJ, Meneses P (2000) Wound healing at the local level. The stunned wound. Ostomy Wound Manage 46: 39S –48S 12

Schultz G, Sibbald G, Falanga V et al (2003) Wound bed preparation: a systemic approach to wound management. Wound Repair Regen 11 (2): 1-28 13

Falanga V, Grinnell F, Gilchrist B, Maddox YT, Moshell A (1994) Workshop on the pathogenisis of chronic wounds. J Invest Dermatol 102 (1): 125-7 14

Falanga V (2000) Classification for wound bed preparation and stimulation of chronic wounds. Wound Repair Regen 8: 347-53 15


Dowsett C, (2008) Using the TIME framework in wound bed preparation. Wound Care UK June pg S15-D20


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2.3 Wound Bed Preparation

Wound Bed Preparation (WBP) is a well established concept and the TIME framework is a practical tool to assist practitioners when assessing and managing patients with wounds.

1718 19

It is however important to remember to assess the whole patient.

20

21 WBP is a way of focusing

systematically on most of the critical components of the non-healing wound to identify the possible cause of the problem. WBP involves the application of the principles of Tissue, Infection, Moisture and Edge (TIME) to a wound bed in order to enable the practioner to make a systematic interpretation of the observable characteristics of a wound and to decide on the most appropriate intervention. The TIME Table (Table 2) illustrates in a simple way the link between clinical observations and the underlying cellular abnormalities, and the effects of clinical interventions at a cellular level. The first column lists the clinical signs of a non-healing wound. As growth factors, senescent cells or fibroblasts cannot be seen with the naked eye; the clinician needs clear, visible signs that can be assessed at the bedside. The second column highlights the proposed pathophysiology of that clinical observation. Column three and four suggest the clinical actions that need to be taken and the effects of these actions. The final column is for clinical outcomes, which are objective and measurable.

22

17

Benbow M, (2008) Exploring the concept of moist wound healing and its application. BJS ( TV supplements) Vol 17 No 15 pg S6-S16. 18

Lo SF, Hsu MY, Hu WY et al (2007) using wound bed preparation to heal a malignant fungating wound: a single case study. JWC Vol 16 No 9 pg 373-376 19

Sibbald RG Woo K, Ayello E, (2007) Increased bacterial burden and infection:NERDS and STONES. Wounds Uk 2007 Vol 3 No 2. pg 25-46 20

Dowsett C Newton H (2005) Wound bed preparation: TIME in practice. Wounds UK Vol 1 issue 3. 58-70 21

Dowsett C, Claxton K (2006) Reviewing the evidence for wound bed preparation. JWC Vol15 No 10 439-442 22

Dowsett C, Ayello E ((2004) TIME principles of chronic wound bed preparation and treatment. BJN Vol 13, No 15 pg S16-S23


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Table 2 - The TIME principles of wound bed preparation (WBP) Source: Schultz et al (2003)23

CLINICAL

OBSERVATIONS

PROPOSED

PATHOPHYSIOLOGY

WBP CLINICAL

ACTIONS

EFFECT OF WBP

ACTIONS

CLINICAL

OUTCOME

TISSUE NON-

VIABLE OR

DEFICIENT

Defective matrix and cell debris impair healing

Debridement (episodic or continuous) Autolytic, sharp surgical, enzymatic, mechanical biological agents

Restoration of wound base and functional extracellular matrix proteins

Viable wound base

INFECTION OR

INFLAMMATION

High bacterial counts or prolonged inflammation

inflammatory cytokines

protease activity

growth factor activity

Remove infected foci Topical/systemic: - antimicrobials anti-inflammatories Protease inhibition

Low bacterial counts or controlled inflammation:

inflammatory cytokines

protease activity

growth factor activity

Bacterial balance and reduced inflammation

MOISTURE

IMBALANCE

Dessication slows epithelial cell migration Excessive fluid causes maceration of wound margin

Apply moisture-balancing dressings Compression, negative pressure or other methods of removing fluid

Restored epithelial cell migration, desiccation avoided. Oedema, excessive fluid controlled, maceration avoided

Moisture balance

EDGE OF WOUND

NON ADVANCING

OR UNDERMINED

Non-migrating keratinocytes Non-responsive wound cells and abnormalities in extracellular matrix or abnormal protease activity

Re-assess cause or consider corrective therapies: - Debridement Skin grafts Biological agents Adjunctive therapies

Migrating keratinocytes and responsive wound cells. Restoration of appropriate protease profile

Advancing edge of wound

23

Schultz G, Sibbald G, Falanga V et al (2003) Wound Bed Preparation: a systemic approach to wound management. Wound Repair Region 11 (2): 1-28


10

2.3.1 Tissue Monitoring the type of tissue in a wound is the mainstay of wound assessment in clinical practice, recording the presence of necrosis, slough, granulation tissue or epithelialium.

24

This helps predict the wounds position in the healing continuum. The presence of non-viable tissue is a significant clinical observation as it can be responsible for delayed healing.

25 It is described as necrotic, sloughy, devitalised or dead tissue. Necrotic tissue

consists of dead cells and debris, while slough or fibrinous material consists of fibrin, pus and proteinaceous material. Necrotic tissue is usually black or brown in colour and soft or liquefying in consistency. If necrotic tissue dries out, and is hard and leathery it is more commonly described as eschar.

26 Necrotic tissue when grouped with the clinical problems

of excess exudate and bacteria within dead tissue is termed necrotic burden.27

Slough may be creamy in appearance because of large amounts of leukocytes present.

28

Alternatively, a tendon may be exposed, signifying wound deterioration, presenting as striated, yellow tissue. The wound may be shiny, suggesting the presence of biofilms – sophisticated coatings often resistant to antimicrobials.

29 If granulation tissue is friable,

unstable to touch and bleeds easily it may be infected.30

The practioner should be able to differentiate between healthy and unhealthy tissue.

31 (See Table 3)

The surface or the texture of tissue can yield useful clues, for example if granulation tissue is fleshy and exuberant, it may be hyper granulating (overgranulating) and thus stuck in the proliferative stage of healing. It is suggested that healthy granulation tissue has rosettes on the surface.

32

Hyper granulating tissue is thought to arise from an extended inflammatory response. There is of course a danger that tissue could be treated as hyper granulation when it is in fact a carcinoma.

33

34 If concerned staff should refer the patient to the medical staff

responsible for the patients care.

Table 3. Characteristics of Healthy and Unhealthy Granulating Tissue, Source: Flanagan (1996)

35

Healthy Granulation |Tissue Unhealthy granulation tissue

Bright red

Moist

Shiny surface

Does not bleed easily

Rapid proliferation

Dark red/bluish discolouration or very pale

Dehydrated

Dull surface

Bleeds easily (friable)

Slow growth

2.3.2 Infection

24

Flanagan M, (2003) Wound measurement: can it help us to monitor progression to healing. JWC 12: 189-94 25

Flanagan M, (1997a) Wound Management. Churchill Livingstone, London 26

Bale S, (1997) A guide to wound debridement. JWC 6: 179-82 27

Falanga V, (2002) Wound bed preparation and the role of enzymes: a case for multiple actions of therapeutic agents. Wounds 14: 47-57 28

Flanagan M. (1997b) A practical framework for wound assessment 2: methods. Br J Nurs 6:6-11 29

Edwards R, Harding KG (2004) Bacteria and wound healing. Curr Opin Infect Dis 17: 91-6 30

Cutting K, Harding K (1994) Criteria for identifying wound infection. JWC 3: 198-201 31

Harker J, Moore K ( 2004) Tissue management and wound pathophysiology,. A Journey through TIME. Wound bed preparation in practice BJN 32

Edmonds M, Foster A (2004) the use of antibiotics in diabetic foot. Am J Surg 187 (5A): 25S-28S 33

Young, T (1995) Common problems in wound care: overgranulation. Br J Nurs 4:169-70. 34

Chraibi H (2004) The diagnosis and treatment of carcinomas occurring at the sites of chronic pressure sores. JWC Vol 13. No 10 447-448 35

Flanagan M, (1996) Characteristics of healthy and unhealthy Granulation Tissue. JWC 7: 508-10


11

All wounds contain micro-organisms, yet the majority are not infected. Infection in a wound causes pain and discomfort, delays healing and can be life threatening.

36 The

European Wound Management Association Algorithm illustrated in Figure 1 illustrates the different stages of wound infection. The spectrum of interaction between the microbial community and host may gradually reach a point at which wound healing process is impaired or localised detrimental host effects are initiated.

37 Bacteria involvement in

wounds can be divided into four categories:

Contamination

Colonisation

Critical colonisation

Wound infection.

Wound contamination is the presence of non-multiplying bacteria in a wound.38

Wound colonisation is the presence of replicating micro organisms adhering to the wound without a host reaction. If mixtures of potential pathogens are multiplying, this may lead to a delay in wound healing and the critical colonisation stage is reached.

39 40

41

Unsuppressed, the natural progression from this stage is to wound infection. This is when the sum of the bacterial load and the virulence factors the bacteria produce is greater than the hosts immune defences, resulting in harm to the host.

42

Biofilms are communities of microbial cells, attached to surfaces and encased in a slime. Research has shown that biofilms may be totally unperturbed by activated macrophages, neutrophils, antibodies, complemented or other host defences.

43 This

offers protection against phagocytosis, antibiotics and antimicrobial agents.44

45

Microbial involvement in delayed healing must be suspected when other causes have been eliminated.

46 47

48

Antimicrobials are agents that either kill or inhibit the growth and division of micro-organisms.

49

50 They include antibiotics (which act on specific cellular

target sites), antiseptics, disinfectants and other agents (which act on multiple cellular target sites).

51 Chronic wounds do not always display the classic signs of infection;

therefore other criteria need to be taken into account. (Table 4)

36 Dowsett C, (2008) Using the TIME framework in wound bed preparation. Wound Care UK June pg S15-D20 37

EWMA (2006) Position Document. Management of wound infection 38

Ayton M (1985) Woundscare: wounds that wont heal. Nursing Times 81 (Suppl 46): 16-19 39

Cutting K (2006) Wound Infection, Understanding, assessment and control. Wound Care Society Publication. 40

Kingsley A (2001) A proactive approach to wound infection. Nurs Stand 15 (30: 50-8 41


Dowsett C, Edwards-Jones V, Davies S, (2004) Infection control for wound bed preparation A Journey through TIME. Wound bed preparation in practice BJN. 43

Wolcott R, Cutting K F, Dowd SE (2008) Surgical site infections: biofilms, dehiscence and delayed healing. Wounds UK Vol 4 No 4. 44

EWMA (2005) Position Document: Identifying criteria for wound infection 45

Cooper R, Okhiria O (2006) Biofilms. Wound infection & the issue of control. Wounds UK Vol 2 No 3 48-56 46

EWMA (2006) Position Document. Management of wound infection. . London MEP Ltd. www.ewma.org 47

Rhoads DD (2008) Biofilms in wounds: management strategies. JWC Vol 17 No11 Nov pg 502-507 48

Wolcott R D et al (2010) healing and healing rates of chronic wounds in the age of molecular pathogen diagnositics. JWC Vol 19 No 7 pg 272-281 49

Cooper R, Jenkins L, Rowlands R. (2011) Inhibition of biofilms through the use of manuka honey. Wounds Uk Vol 7 No 1 pg 24-32 50

Butcher M (2011) Introducing a new paradign for bioburden management. JWC/BSN supplement May. Pg 4-9 51

EWMA (2006) Position Document. Management of wound infection. London MEP Ltd. www.ewma.org

12

Stage 1: Few subtle signs of

infection (some odour, pain

or exudate)

Healing progressing

normally

Stage 2: Increasing signs of

infection (increasing odour,

pain or exudate)

Healing no longer

progressing normally

Stage 3: Overt signs of

local infection (discharge of

pus with swelling, pain

erythema and local warmth)

Evidence of surrounding

tissue involvement; wound appears unhealthy or

deteriorating (cellulits,

lymphangitis or gangrene)

Stage 4: Overt signs of focal

infection and signs of systemic

infection (pyrexia and raised

white blood cell count)

Possible evidence of

surrounding tissue

involvement, which may lead

to sepsis and organ failure and

can be life threatening Signs of Infection

No signs other

than healing

progress altered

Stages 1 & 2

signs limited

to wound only

Stage 3

spreading local

sepsis

Stage 4

systemic signs

Are other risk factors

present, eg immuno-

comprise or malignancy?

Select topical

antimicrobial (box,

bottom left)

Consider

combination

therapy. Drain any

local collections

Start broad-

spectrum systemic

antibiotics while

awaiting culture

results

If systemic signs

only, look outside

wound for source of

infection

Treat/correct

underlying

aetiology.

Refer to

appropriate

specialist

If no

improvement, are

any other subtle

signs of infection

present? Or

significant

culture result?

Overt signs of

infection

eliminated

Overt signs of

infection not

eliminated

Good clinical

response

Poor clinical

response

Select

alternative

antimicrobial

agent

Consider

adding

antibiotic

Complete

course of

antibiotics.

Reassess

wound and

patient

Adjust antibiotic

selection according

to causative agent,

sensitivity and

patient preference

Stop antimicrobial therapy. Monitor wound

progress. Continue managing wound according to

local protocol. Reconsider antimicrobial treatment

if wound or patient status changes adversely.

Factors to consider when selecting

antimicrobials

Agent: Dressing

• specificity • absorbency

• efficacy • conformability

• cytotoxicity • odour management

• allergenicity • pain management

Figure 1 EWMA Algorithm for Managing Wound Infection

13

When bacteria proliferate they form micro colonies that become attached to the wound bed and secrete glycocalyx or biofilms that help to protect the microorganism from anti microbial agents and can delay healing.

52 53

The diagnosis of infection is primarily a clinical skill based on careful history taking and clinical observation, with microbiological data used to supplement the clinical diagnosis. Quantification of bacteria by wound biopsy has been considered the gold standard, but surface sampling cost less and is easier to carry out.

54 The European Wound

Management Association Algorithm for Managing Wound Infection as illustrated in Figure 1

55 should be used to assist in clinical decision making regarding the diagnosis and

management of suspected infection. Wound cleansing is an important factor in reducing bacterial burden. Organisms are physically removed by irrigation with saline. Increasing the frequency of dressing changes may also be useful particularly as infected wounds often produce copious amounts of exudate, which may promote bacterial growth causing further tissue breakdown and maceration of the surrounding skin. There is clearly a need to link the I element of WBP to the M element for intervention to be successful.

56

MRSA

MRSA stands for meticillin-resistant Staphylococcus aureus. It is sometimes known as a super bug. There are various subtypes (strains) of S. aureus and some strains are classed as MRSA. MRSA strains are very similar to any other strain of S.aureus. That is, some healthy people are carriers and some people develop the types of infections described above. Most S. aureus infections can be treated with commonly used antibiotics. However MRSA infections are resistant to an antibiotic called meticillin and also to many other types of antibiotics. MRSA strains of bacteria are no more aggressive or infectious than other strains of S. aureus. However, infections are much more difficult to treat because many antibiotics do not work against MRSA. Infections with MRSA can sometimes become more severe than they may otherwise have been if the cause of the MRSA infection is not

52

Enoch S, Harding KG, (2003) wound bed healing: the science behind the removal of barriers to healing. Wounds 15: 210- 53



EWMA (2006) Position Document. Management of wound infection 56

Dowsett C, Edwards-Jones V, Davies S, (2004) Infection control for wound bed preparation. A Journey through TIME. Wound bed preparation in practice BJN.

Table 4 Signs and symptoms of superficial and deep infection, Source: Cutting and Harding

(1991)28

, Schultz et al (2003)29

Superficial Non-healing wound

Friable granulation tissue

Exuberant bright red granulation

Increased exudates

Erythema/cellulitis around wound edge

Deep Pain

Increased size

Warmth

Erythema/cellulitis more than 1-2 cm from the wound edge

Odour

Probes/exposed bone


14

diagnosed early and antibiotics that are not effective are given at first.57

For this reason it is vital that all MRSA positive wounds are referred to either Tissue Viability, Leg Ulcer Services or Podiatry as appropriate within 72 hours of diagnosis.

Antibacterial strategy

The decision of whether to use antibiotics or antimicrobial products is a complex matter that must be based on the clinical findings of an experienced clinician. Figure 1 provides EWMA guidance on this matter.

58 Ideally systemic antibiotics are not recommended for wounds that

only show signs of local infection.59

Topical antiseptic agents whether antibiotic or antiseptics delivered from a sustained-release dressing formulation therefore represent the first line treatment, as they provide a high antimicrobial concentration at the site of infection.

60 Some

iodine and silver preparations have bactericidal effects even against multiple resistant organisms such as MRSA.

61 62

Topical antiseptics have the additional advantage that they do not interfere with the remainder of the protective bacterial flora in other parts of the body and are also less likely to produce an allergic reaction. In the case of biofilms the mainstay is frequent removal of the wound surface either with sharp or surgical debridement. At present the effective treatment of medical biofilms is its physical removal.

63

64 The early biofilm that re-emerges after debridement needs to be

suppressed with multiple strategies. This will include wound cleansers, topical antimicrobials and advanced primary dressings. Since biofilms adapt to selective stresses a rotating regime of selective antiseptics such as silver or iodine is recommended.

65

Lack of a noticeable healing response within 2 weeks may necessitate the use of other topical or systemic agents. Given the evidence that improvements in wound healing have previously been associated with the elimination of malodour-causing anaerobes and that mixed anaerobes appear to play some synergistic role in preventing wound healing, the use of a metronidazole gel may then be considered

66 under the instruction of the TVS.

Topical antimicrobials are most appropriate when used to decrease the bacterial burden in chronic wounds with active but localised infection. They are not solely suitable for highly infected wounds with soft tissue invasion or systemic sepsis and should not be used as a substitute for debridement or systemic antibotics. Increased antimicrobial resistance means these agents should not be used for an extended period of time and should be followed by an appropriate dressing once the bacterial burden has been reduced. Where infection has extended beyond the level that can be managed by local therapy, systemic antibiotics should be used in conjunction with antimicrobial products.

57

MRSA. (2011) http://www.patient .co.uk/health/mrsa. sourced 4/8/11 58

EWMA 2006) Position Document. Management of wound infection 59

Bowler PG, Duerden BI, Armstrong DG (2001) wound microbiology and associated approaches to wound management. Clin Microbiol Rev 14: 244-69 60

White RJ, Cooper RA, Kingsley A (2001) Wound colonisation and infection. Br J Nurs 10: 563-78 61

Lawerence JC (1998) The use of iodine as an antiseptic agent. J Wound Care 7:421-5 62

Sibbald RG, Brown AC, Coutts P, queen D (2001) Screening evaluation of ionised nanocrystalline silver dressings in chronic wound care. Ostomy Wound Manag 47: 38-43 63

Wolcott R D. (2009) Regular debridement is the main tool for maintaining a healthy wound bed in most chronic wounds. JWC Vol 18 No 2 pg 54-56. 64

Cowan T (2010) Biofilms and their management: implications for the future of wound care.. JWC Vol 19 Noo 3 pg117-120. 65

Rhoads DD ((2008) Biofilms in wounds: management strategies. JWC Vol 17 No11 Nov pg 502-507 66

Bowler PG, Duerden BI, Armstrong DG (2001) wound microbiology and associated approaches to wound management. Clin Microbiol Rev 14: 244-69

http://www.patient/


15

2.3.3 Moisture 67

68

Exudate. Exudate contains a variety of substances including water, electrolytes, nutrients, inflammatory mediators, white cells, protein-digesting enzymes (eg matrix metalloproteinases – MMPs), growth factors and waste products. In the healing wound exudate appears to promote healing in a number of ways, including cell proliferation. MMPs which breakdown the cell-supporting matrix, are present mainly in inactive form. In wounds not healing (Chronic wounds) exudate appears to have the opposite effects. The exudate contains elevated levels of inflammatory mediators and activated MMPs.

69

One of the most significant challenges faced by nurses is the efficient and cost effective management of excessive wound exudates which causes extreme distress and negatively impacts on patients and carers quality of life.

70 The goal of effective wound management

is to remove excess moisture, debris and chemicals from the wound, while maintaining the ideal moisture balance to allow cell migration and ultimately wound healing.

71 Poor

exudate management can either cause the wound bed to become too dry or too wet, the resultant imbalance of moisture will cause tissue damage.

72 There are no validated

precise measurements for assessing exudate, so for progress of a wound to be monitored it is preferable that the same nurse reassesses a wound in order to aid comparison with serial assessments. Colour and consistence are considered in Table 5 with some guidance on causes and how.

There are three main methods of managing exudate:

1. Use of absorbant dressings or dressing which allow evaporation of moisture. 2. Counter pressure through compression 3. Drainage systems, either wound management systems or topical negative

pressure (TNP)

2.3.4 Edges

In WBP, E stands for edges, which are non-advancing or undermining. When wound edges fail to migrate or undermining is present, the clinician needs to reassess the cause and intervene using the TIME table. Epidermal edges that are failing to advance over time towards closure are perhaps the clearest sign of all that a wound is failing to heal. Wound measurement provides baseline information while continuous measurement helps to predict healing and aids monitoring of treatment efficacy and evaluation.

73 Wounds

should be re-measured every four weeks.74

If the margin is undermined, this may be a sign of critical colonisation or infection. The use of cytotoxic agents and cortiocosteroids can totally mask all signs of local or systemic infection.

75 At a cellular level, lack of

epidermal migration could be owing to non-responsive wound cells and abnormalities in protease activity, which degrade extra cellular matrix as soon as it is formed.

76

67

Cutting K F (2003) Wound exudates: composition and functions BJN Vol 12 No 16 Supplment: The Exudate Supplement part one. 68

Morison M (2005) Moist wound healing and the role of moisture retentive dressings. Wounds UK Supplement 1 (2): 1-36 69

WUWHS (2007) Principles of best practice: Wound exudate and the role of dressings, a consensus document. London: MEP Ltd. 70 Benbow M, Stevens J (2010) Wxudate, infection and patietn quality of life. BJN TV Supplement) Vol 19 No 20 pg S 31-S36 71

Vowden K, Vouden P (2003) Understanding exudate management and the role of exudate in the healing process. The Exudate supplements part two. BJN Vol 12 No 20. 72

White R Wick G Cutting K (2006) From the wet to the dry: modern exudates management. Wound Care Society Publication. 73

Gethin G (2006) The importance of continuous wound measuring. Wounds Uk Vol 2 No 2 60-68 74

Dowsett C, (2008) Using the TIME framework in wound bed preparation. Wound Care UK June pg S15-D20 75


Falanga V (2002) Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair regen 8: 347-52


16

Table 5. Types of exudate and their management Source: Scanlon E. (2004)77

Colour Consistency Type of wound Probable cause Management

Clear/straw colour

Watery Leg ulcer Oedema/lymph oedema (sudden increase in exudate may indicate infection)

Compression or elevation of the limb

Clear/straw colour

Watery Surgical Heart failure/oedema caused by fluid overload

Diuretics

Clear/straw colour

Serous fluid Acute: traumatic or surgical

Normal inflammatory exudate

Dressings of appropriate absorbency

Blood stained Serous fluid Acute: traumatic or surgical

Slight bleeding from vessel in wound bed

Localised pressure or use of a haemostatic dressing

Blood Viscous Surgical Bleeding vessel postoperative

Excessive bleeding should be referred back to surgeon

Blood Viscous Any Trauma from dressing Traumatic bleeding can be stopped with local pressure or haemostatic dressing. Re-consider dressing choice

Yellow Slightly viscous (may appear purulent, may contain fatty globules, usually profuse)

Any sloughy wound

Autolytic debridement of non-viable tissue

Appropriate dressing or drainage system

Yellow or brown Purulent or haemopurulent

Abscess or infected wound

Bacteria Systemic antibiotics, possibly topical antiseptics and appropriate dressing

Green Very viscous, mucus-like

Leg ulcer, burn wound

Bacteria especially Pseudomonas aeruginosa

Topical antiseptic (systemic antibiotic if cellulitis present)

Clear green Watery or slightly viscous

Upper abdominal wound

Fistula to upper intestine Refer back to surgeon

Brown, faecal Viscous Lower abdominal wound

Fistula to lower bowel Refer back to surgeon

Grey or Blue78

Viscous or watery any Related to silver containing dressings

Avoid prolonged used of silver

77 Scanlon E. (2004) Moisture balance and exudate control. Clinical review. A Journey through TIME. Wound Bed Preparation in practice. BJN 78

WUWHS (2007) Principles of best practice: Wound exudate and the role of dressings, a consensus document. London: MEP Ltd.


17

3 FACTORS AFFECTING THE HEALING PROCESS

3.1 Factors that can delay healing

Many factors are thought to delay healing.

79 80

81

82

83

84

85

86

Table 6 lists the commonest. Figure 4 illustrates how such factors can be grouped into intrinsic and extrinsic factors and can occur alongside each other. Thus some wounds can be exposed to multiple factors, which impede its progress at any one time.

Table 6

Conditions and interventions known to delay wound healing Source: Schultz et al (2003)

87

Use of systemic steroids

Use of immunosuppressive drugs

Use of non-steroidal anti-inflammatory

Rheumatoid arthritis

Other autoimmune diseases such as systemic lupus, uncontrolled vasculitis or pyoderma gangrenosum.

Inadequate or poor nutrition

Diabetes88

89

Smoking90

91

Cachexia92

3.2 Diet

Adequate nutrition is essential to promote wound healing. A diet rich in carbohydrates, high in protein and moderate fat is essential. Vitamins and trace element supplements should also be provided to all patients with established wounds where deficiency is known particularly vitamins C, E and zinc.

93 However the decision to provide trace element

supplements should be done following a thorough nutritional assessment. 94

95

96

97

98

99

100

101

102

103

104

105

106

107

108

109

79

Jones P.L. Millman A (1990) Wound Healing and the Aged Patient. Nursing Clinic of North America. 25: pg 263-77 80

Descai H (1997) Ageing and Wounds Part 2. Healing in Old Age. Journal of Wound Care. May Vol. 6 No.5 Pg 237-239 81

Harding, K (1999) Wound Management : Theory and Practice. Nursing Times Publications. Pg 96-107. 82

Robson M et al. (1991) Wound healing alterations caused by infection. Clinics in Plastic surgery. 17: 3, 485-492/ 83

Bland K.I. Palin W.E et al (1984) 80. Experimental and Clincal Observations of the effects of cytotoxic chemotherapy drugs on wound healing. Ann Surg 199: pg 782 84

Siang J.E. (1992) The effect of smoking on tissue formation JWC July/Aug. Vol 1 No 2 pg 37-41 85

Winter, GD. (1962) Formation of scab and rate of epithelialisation of superficial wounds in the skin of a young domestic pig. Nature;193: 293-294. 86

Cutting, F.K. (1999) The causes and prevention of maceration of the skin. Jr of Wound Care. Vol8, No 4. 87


Silhi, N. ((1998) Diabetes and wound healing, Jr of Wound Care; 7: 1, 47-51. 89

Kidman K (2008) tissue repair and regeneration: the effects of diabeties on wound healing. The Diabetic Foot Journal Vol 11 No 2 pg 73 -79. 90

Whiteford L (2003) nicotine, CO and HCN: the detrimental effects of smoking on wound healing. Wound Care Dec S22-S25 91

Kean J (2010) The effects of smoking on the wound healing process. JWC Vol 19 No 1 pg 5-8 92

Ng M (2010) Cachexia – an intrinsic factor in wound healing. Int Wound Jr . Vol 7 No 2 pg 107-111 93

Heyman H, Van de Looverbosch DE, Meijer EP, Schols JMGA (2008) Benefits of an oral nutritional supplement on pressure ulcer healing in long term care residents. JWC Vol 17 No 11 Nov pg 476-480 94

Mandal A (2006) Do malnutrition and nutritional supplementation have an effect on the wound healing process. JWC Vol 15 No 6 254 -257 95

Bradbury S (2006) Wound healing: is oral zinc supplementation beneficial. Wounds UK Vol 2 No 1. 54-61 96

Frias Soriano L et al. (2004) The effectiveness of oral nutritional supplementation in the healing of pressure ulcers. The Journal of wound Care Vol 13, No8 319-322 97

Lansdown A (2004) Nutrition 1: a vital consideration in the management of skin wounds. BJN (Tissue Viability supplement) Vol 13 No 19 S22-S28 98

Lansdown A (2004) Nutrition 2: a vital consideration in the management of skin wounds. BJN Vol 13 No 20, 1199-1210 99

Lewis B (1996) Zinc and Vitamin C in the Aetiology of Pressure Sores. The Journal of Wound Care. Nov. Vol 5 No 10 483-481 100

Reynolds TM. (2000) The Future of nutrition and wound healing. Journal of Tissue Viability. Vol 11 No 1. 101

Gray D. Cooper P. (2001) Nutrition & Wound Healing: What is the Link? JWC. Vol 10 No 3, 86-88.


18

If Nursing Staff are uncertain in specific situations they should discuss their concerns regarding the need to provide supplements with either the Dietician or Medical Staff responsible for the patient.

3.2.1. Identification of Patients Risk

Nutritional assessment should be carried out in line with the MUST Nutritional Assessment Form. (Appendix 1)

3.3 Pain

Unresolved pain negatively affects wound healing and impacts on quality of life.

110 111

112

A painful chronic wound can often indicate that there is something wrong.

113 Holistic

assessment using TIME should provide indicators as to possible causes of such pain. Pain at wound dressing-related procedures can be managed by a combination of accurate assessment, suitable dressing choices

114

115

116 skilled wound management and

individualised analgesia regimens.117

118

An initial assessment should be carried out by an experienced clinician

119 in partnership

with clinical staff able to prescribe the appropriate medication. Every patient with a wound should have an individual pain management plan including regular ongoing assessment which should be performed each time a dressing–related procedure is carried out.

120

Background pain in the wound and surrounding tissue, plus any new regional pain that may have developed should be assessed. The intensity should be rated, before, during and after the procedure.

121 122

This should be documented in the patient notes and a care plan developed to address the pain. The level of pain should also be recorded on the wound assessment chart using a recognised pain scale as illustrated in Figure 2 and 3

102

Ronaghy HA. (1987) The role of zinc in human nutrition. World Review of Nutrition and Dietetics. 54: 237-54. 103

Casey, G. (1998) The Importance of Nutrition in Wound Healing. Nursing Standard: 13:3 (supplement) 51-56. 104

Lewis, BK, Harding, KG. (1993) Nutritional intake and wound healing in elderly people.The Journal of Wound care; 2: 4,227-229. 105

Collins, CM (1996) Nutrition and Wound Healing. Care of the Critically Ill; 12:3, 87-90 106

Wallace, E. (1992) Feeding the Wound: Nutrition and Wound Healing. Br J Nursing; 3: 13,662-667 107

Foster A. Greenhill M.T Edmonds ME (1994) Comparing 2 dressings in the treatment of diabetic foot ulcers JWC Vol 3 No 5 Pg 224-228 108

Capper C.J. (1994) The Management of Pressure Sores in a patient with Diabetes Mellitus. JWC Vol 3 No 8 pg 360-362 109

McIlwaine C (2003) Importance of holistic nutritional assessment in wound healing. JWC Vol 12 No 8 285-288 110

WUWHS (2004) Principles of best practice: Minimising pain at wound dressing-related procedures. A consensus document. London: MEP Ltd 111

Hofman D ((2006) Practical steps to address pain in wound care. BJN Supplement. Vol 15 No 21, pg10-15 112

Young T Roden A (2006) Pains-taking care. Everyday issues in wound pain management. Wound Care Society Publication. 113

Sibbald R G, Katchky A, Queen D (2006) Medical management of chronic wound pain. Wounds UK Vol 2 No 4 pg 74-89 114

Young S Hamption S (2005) Pain management in leg ulcers using ActiFormCool. Wounds UK Vol 1 Issue 3. 94-101 115

Fletcher J (2010) managing wound pain during application and removal of dressings BJN TV Supplement Vol 19 No 20 S4-S6 116

Taylor Alison ( 2010) Principles of Pain Assessment. Wound Essentials Vol 5 Pg 104-110 117

Briggs M, Ferris F D, Glynn C, et al (2004) Assessing pain at wound dressing-related procedures. Nursing Times Vol 100 No 41 56-57 118

European Wound Management (2002) Position Document: Pain at wound dressing changes. London MEP Ltd. www.ewma.org 119


Solowiej K et al (2010) Psychological stress and pain in wound care. Part 2:management. JWC Vol 19 No 4 pg 153-155 121


Lloyd Jones M (2010) Living with wound associated pain: impact on the patietn and what clinicians really think. JWC Vol 19 No 8 pg 340-343


19

3.3.1 Using Opiates on wounds 123

124

Topical opiates act centrally and peripherally and can be alternative or concurrent forms of pain control for wounds. Opiates can be used on viable and non-viable tissue. The effective analgesia dose is low (10mgs) with analgesia occuring within a few minutes. The duration of pain relief from one dose can last up to 2 days.

The opiate should be mixed with hydrogel carrier and apply directly to the wound

A foam dressing can be used to secure the hydrogel. The effective dose concentration is 10mgs morphine opiate to 1gram hydrogel. Application should be daily or ‘as required’ basis. There are minimum adverse effects however it is preferable to keep certain wounds such as ischaemic gangrene dry and thus the use of hydrogels would be contraindicated.

Figure 2 Wong-Baker faces Scale

Figure 3 Numerical pain rating scale

0-10 Numeric Rating Scale

123

Riberio, M.D.C. Joel, S.P. Zeppetalla.G. (2004) The bioavailability of morphine applied topically to cutaneous ulcers. Journal of Pain and Symptom Management Vol 27 Issue No 5 434-439 124

Zeppetalla G. (2004) Topical opioids for painful skin ulcers: do they work? European Journal of Palliative Care Vol 11 No 3 pg 93-96

0 1 2 3 4 5 6 7 8 9 10

None Mild Moderate Severe

TVS Guidelines: Wound Management Sept 2011

20

Adverse Local Conditions

At the Wound Site

Inappropriate Wound

Management By Nurses

Intrinsic

Factors that can

Delay Healing

Extrinsic

General Pathophysiological

Factors

Adverse Effects Of

Other Therapies

Hypoxia

Necrotic Tissue and

Foreign Bodies

Poor Blood Supply

Fall in Wound

Temperature

Wound Infection Dehydration

Inaccurate Wound

Assessment (see Article II)

Inappropriate Application

Of Topical Agents &

Primary Wound Dressing

Products

Drug Therapy

Negative attitudes of

Staff to Treatment and

Healing

Chemotherapy

Careless Wound

Dressing Techniques

Malnutrition Decreased Resistance

To Infection

Cardiovascular

Disorders

Anaemia

Radiation Therapy

Figure 4 – Factors causing delayed wound healing


21

4. CLASIFICATION OF WOUND TISSUE

The Wound Healing Stage Classification as described below is recommended as it facilitates simple and consistent verbal and written description of the appearance of the wound bed. This is a different classification to the pressure ulcer classification. (See Pressure Ulcer Guidelines)

4.1 Epithelialsing Tissue125

Appearance.

Translucent appearance, usually whitish-pink

Small islands of epithelial cells may be visible originating from the wound margin or reminents of hair follicles, sebaceous or sweat glands

The epithelial cells rapidly multiply and migrate across granulation tissue, until they form a continuous layer. At this stage the wound will have smooth edges

4.2 Granulating Tissue126

127

Appearance:

Granular appearance, slightly uneven

Pinky-red colour (well vascularised)

Healthy granulating tissue does not bleed easily

Granulating tissue which is dark in colour may signal ischaemia or infection

4.3 Sloughy Tissue128

Appearance:

Yellow/ white hue

May be dry or slimy

Adherent to wound bed (Slough forms when dead cells accumulate in the exudate, yellow colour due to the presence of a large number of leucocytes)

4.4 Infected Tissue

Appearance of Acute Wound Infection.

Inflammation

Localised heat and swelling around wound edge

Yellow/green pus

Offensive odour

Presence of green slough in wound

Pain

Increased exudate

Dark in colour

The presence of bacteria does not always indicate the presence of infection. Pus, odour and slough are not always present in the infected wound. Systemic effects and a raised body temperature may be present. It is thus recommended that temperature, pulse, BP and respiratory observations are taken and recorded if there is suspicion of wound infections.

125

Garrett B (1998) Re-Epithelialisation. Journal of wound Care; 7:7, 358-359 126

Flanagan, M .(1999) Wound Management: theory and practice. Nursing Times Publication. pg 14-20 127

Harding, K., Cutting, K. (1994) Criteria for identifying wound infection. JWC. 3:4, 198-201 128

Cutting. K.F. (1996) Definition of Terms. JWC. Resource File. London Macmillan.


22

4.5 Necrotic Tissue 129

Appearance:

Black/Brown leathery appearance

Hard skin-like surface below which is a cavity full of dead tissue

Depth will not be known until the dead tissue is removed

4.6 Malignant (Fungating) Tissue

Appearance:

Raised irregular islands of malignant tissue

Often bleeds on contact

Characterised by very offensive odour due to colonisation by bacteria

It is acknowledged that no classification is likely to be wholly exhaustive; with this in mind it is important to complete a full assessment on a wound as directed on The Wound Assessment Form (WAF) (Figure 5). If the wound is a pressure sore, it is also necessary to state the grade (see Pressure Ulcer Guidelines)

5. WOUND ASSESSMENT.

Wounds need regular assessed if appropriate care is to be provided. Wound care products are designed to suit a wound at a particular stage of healing. As the wound changes, dressing type may also need to be changed. It is important to use a classification that all staff understand when assessing, planning and evaluating wound care. This facilitates monitoring the progress and selecting appropriate wound care products.

130 131

Wounds should be assessed using the principles of WBP and application of the acronym TIME illustrated in Table 2. Tissue observed should be classified according to the Wound Tissue Classification described in Section 4. The Wound Assessment Form (Figure 5) which incorporates the principles of WBP (TIME) should be completed at every dressing change as documentation is as essential as the assessment itself.

132

The use of the WAF and a comprehensive care plan ensures that registered nurses are fulfilling their obligations under the NMC Standards for Records and Record Keeping. Failure to keep such records exposes the Nurse and the Trust to the risk of litigation. It is crucial that wound assessment forms and care plans are completed on all patients who have wounds. These records must be clearly written, signed and regularly updated.

133 An

entry must be made on the WAF following every dressing change.

129

Cutting K..F. (1996) Definition of Terms. Journal of Wound Care Resource File. London Macmillan 130

Dowsett C, (2008) Using the TIME framework in wound bed preparation. Wound Care UK June pg S15-D20 131

Briggs M (1996) Documenting Wound Management JWC Vol 5 No 5 Pg 229 - 231 132

Oldfield A (2010) Assessing the Open Surgical Wound. Wound Essentials Vol 5 pg 48-55 133

NMC (2006) Record Keeping advice sheet. www.nmc-uk.org .


23

Figure 5 Wound Assessment Form (WAF) 1. INITIAL ASSESSMENT:

Patient’s Name:

Address:

G.P Details: D.O.B: NHS. No:

Draw Wound Profile (so top of wound is towards patients head, include dimensions in cm).

2. SOURCE OF WOUND: Tick 3. INDIVIDUAL PATIENT ASSESSMENT

Any Delaying Factor? Interventions

Surgical ( ) Leg Ulcer ( )

Traumatic ( ) Burn ( )

Pressure Ulcer ( ) Fungating ( ) Other ( )

DATE:

TIME:

DATE:

TIME:

DATE:

TIME:

DATE:

TIME:

4. TISSUE: Appearance, approximate % of wound surface which meets the description

Intact Incision line

Epithelialising

Granulating

Over granulating

Sloughy

Necrotic

Fungating

Exposed bone/tendon

Oedema

5.INFECTION:

EWMA Clinical stage of Infection ( 1, 2, 3, 4)

Peri wound inflammation / warmth

Pyrexia

Bleeds easily

Odour Y = Yes N = No

Pain score 1-10 (0 = no pain 10 = severe pain)

Wound swab taken, tick for yes

6. MOISTURE: Exudate

A: Serous, B: Haemoserous, C: Purulent/ Pus

L: Low, M: Moderate, H: Heavy

7.EDGES: Non advancing /undermining Weekly measurements only required, unless sudden changes observed

Maximum Length, (head to toe)

Maximum Width. (right to left).

Surface Area (cm2)

Undermining

Cavity: Depth cm

Pressure Ulcer: Insert Grade 1,2,3,4

Insert generic dressing code number Staff Signature Generic Dressing

Code Numbers.

1. N.A.dressing 4. Hydrogel 7. Foam 10. TNP

2 Semi-permeable 5. Alginate 8. Hydrofibre 11.

3. Hydrocolloid 6.Activated charcoal 9. Antimicrobial 12.


24

6 WOUND CARE A holistic assessment of the patient is essential before choosing a wound dressing.

134 A

careplan should be drawn up using the information gathered in the WAF and directed by the TIME WBP Clinical Actions illustrated in the Timetable. (Table 2) Many wounds will be a combination of some of the already mentioned classifications identified in section 4. When this occurs each area would require different management however the most serious state should be treated first.

6.1 Wounds Healing by First Intention

6.1.1 Uncomplicated Wound

EXAMPLES: Post surgical wounds/clipped wounds. Traumatic wound sutured/clipped/glued

PROBLEM: Potential risk of wound breakdown

GOALS: To prevent infection and promote first intention healing by providing an optimal local environment

T: Promote viable granulation from the wound base

I: Reduce inflammation and maintain a bacterial balance

M: Achieve moisture balance

E: Measured advancing edges and base of wound.

CARE PLAN: Non adherent (N/A) dressing135

Analgesia to control pain.

Should not require cleaning, if exudate is a problem it can be removed by irrigating with sterile sodium chloride 0.9%

Dressing: Wounds can be left exposed after 48 hours or covered with a semi-permeable film dressing.

136

6.2 Wounds Healing by Second Intention 137

6.2.1 Epithelialising Wound (Clean and Flat)

EXAMPLES: Any clean wound that has filled in with granulation tissue or superficial wounds where granulation tissue has been replaced e.g. skin donor sites, superficial burn, and granulated pressure ulcer.

PROBLEM: Break in normal integument. Pain from exposed nerve endings

GOALS: T: Promote epithelialsation

I: Reduce inflammation and maintain a bacterial balance.


E: Measured advancing edges and base of wound.

CARE PLAN: Analgesia to control pain. Does not require cleaning if exudate is minimal. If cleaning is

required use sterile sodium chloride 0.9%

Dressing: Minimal exudate Semi-permeable film

Low/moderate N/A Dressing

Moderate Hydrocolloid sheet

134

Morris C (2006) Wound management and dressing selection. Wound Essential. Vol 1 178-183 135

NICE (April 2006) Surgical site infection: Prevention and treatment of surgical site infection. 136

Chintz et al (1989) Need for surgical wound dressing. British Journal of Surgery. Vol 76. 204-205 137

Thomas S (1997) A Guide to dressing selection . JWC. Nov. Vol 6 No 10 Pg 479-482


25

6.2.2 Granulating Wounds

EXAMPLES: Clean cavity pressure ulcers

PROBLEMS: Potential of over closure of epithelial edges before the cavity has filled with new granulation and vascular tissue.

GOALS: T: Promote viable granulation from the wound base



E: Prevent closure of edges before wound base has healed. Contemplate therapies which accelerate healing from the base. Measured advancing edges and base of wound.

CARE PLAN: Clean with sterile sodium chloride 0.9% if required.

Dressing: Minimal exudate Hydrocolloid paste, cover with adhesive non-adherant dressing

Moderate exudate Alginate rope or Hydrocolloid fibre. Cover with adhesive non-adherant dressing

High exudate High absorbency Alginate or Hydrocolloid Fibre and a Foam or Hydrocolloid Sheet.

TNP will manage exudate and accelerate healing from the base of the wound.

6.2.3 Sloughy Wounds

EXAMPLES: Common in chronic wounds such as pressure ulcers, leg ulcers and abscess cavities.

PROBLEM: Excessive exudate or odour due to bacteria and necrotic tissue. Slough and necrotic tissue may encourage growth of bacteria

and this may delay healing.138

GOAL: T: Debridement of sloughy and necrotic tissue



E: Prevent closure of edges before the base has healed, contemplate therapies which accelerate healing from the base of wound. Measured advancing edges and base of wound

CARE PLAN: 1) If wound infection is suspected, take a swab and send for microscopy and culture. Inform Medical Staff and record vital signs. 2) Clean with sterile sodium chloride 0.9%

Dressing: (Non cavity sloughy)

Minimal exudate Hydrocolloid sheet

Moderate exudate Hydrocolloid Fibre Dressing and N/A pad High Exudate Alginate and Foam Dressing

139

Versajet debridement can be performed by the TVS.

138

Haury B (1998) Debridement: An essential component of traumatic wound care in wound healing and wound infection. Hunt T.K. Ltd. New York. Appleton Century Crofts. Pg 229-240 139

NICE (2006) Surgical site infection: Prevention and treatment of surgical site infection draft doc


26

Larvae therapy can expedite the removal of slough from wounds on advice from the TVS. Antibacterial dressing can be used if infection is suspected. TNP on advice from TVS will contain exudate, accelerate healing and remove bacteria from the wound bed.

If concerned that a wound may be clinically infected await results before using occlusive dressings.

140

141

142 however once

antibiotic therapy is established and infection is contained, occlusive dressings can be used.

6.2.4 Infected wounds:

EXAMPLES: Pressure ulcers or surgical wounds, which have become red and inflamed with accompanying cellulitis.

PROBLEMS: Oedema, wound pain, exudate, pyrexia and odour

GOALS: T: Debridement of sloughy and necrotic tissue

I: Reduce inflammation and control bacterial balance.


E: Measured advancing edges and base of wound

Identify the organism causing the infection and eradicate with systemic antibiotics. Promote healing by providing an optimum local environment.

CARE PLAN: Clean with sterile sodium chloride 0.9% or povidone iodine solution if an antiseptic is required. Stellicept wash can be used in cases of MRSA.

Dressing: Minimal exudate Hydrogel held insitu with N/A Pad.

Moderate exudate Hydrocolloid Fibre held insitu with N/A pad. High Exudate Alginate or Hydrocolloid Fibre held insitu with Foam Dressing.

143

TNP on advice from TVS will contain exudate, accelerate healing and remove bacteria from the wound bed.

Antimicrobial/ dressings can also be used, however if appropriate systemic antibiotics are prescribed they may not be necessary. It is not appropriate to use Mupirocin on wounds which are known to be infected with MRSA. This product is for use on the nose only.

144

Do not occlude clinically infected wounds until antibiotic therapy is established and infection controlled. Change dressings daily while infected or more frequently if strike through occurs. If malodour is a problem see section 6.3

140

Cutting K.F (1994) Criteria for identifying Wound Infection. JWC. Vol 3. No 4. Pg 198-210 141

Grey J.E. (1998) Cellulitis Associated with Wounds. JWC, July Vol 7 Pg 338-339 142

Heggers J.P. (1998) Defining Infection in Chronic Wounds – Does it Matter? JWCCare. Sep. Vol 7 No 8 Pg 389-392 143

NICE (2006) Surgical site infection: Prevention and treatment of surgical site infection draft doc. 144

Visu Dr, Kirkham A (2009) Infection Control Services WEPCT & PAHT


27

6.2.5 Necrotic Wounds

EXAMPLES: Pressure Ulcers covered with hard necrotic tissue. (Eschar)

PROBLEM: Extensive cavity wound is hidden beneath the necrotic tissue.

GOALS: T: Debridement of necrotic tissue



E: Measured advancing edges and base of wound .

CARE PLAN: Surgical debridement: Sharp debridement is the quickest means of removing eschar. Nurses wishing to pursue this form of management must be clinically competent to do so. Versajet debridement can be performed on soft necrotic tissue by the TVS Medical debridement: Dressings: Hard dry eschar will need to be hydrated if medical debridement is to occur.

Hydrocolloid sheets will trap the bodies humidity and facilitate debridement

Hydrogels will actively hydrate eschar Bio Surgical debridement:

Larvae therapy will effectively and efficiently debride slough and soft eschar.

6.3 Malignant/Fungating Wounds 145

146

147

148

EXAMPLES: External tumour wounds

PROBLEM: Odour, incipient bleeding, pain, exudate

GOAL: T: Medical debridement of sloughy and necrotic tissue, if indicated.

I: Reduce inflammation and attempt to maintain a bacterial balance.


E: Awareness of advancing wound edges and minimising such advancement where possible

through control of I and M.

145

Grocott P (1998) Exudate management in fungating wounds. Journal of Wound Care. Oct. Vol 7 No 9 Pg 445-448 146

Grocott P (1995) The Palliative management of fungating malignant wounds. Journal of Wound Care. May. Vol 4 No 5. Pg 240-242 147

McDonald A, Lesage P (2006) Palliative management of pressure ulcers and malignant wounds in patients with advanced illness. Jr Palliative Medicine, April 9 (2): 285-295 148

Hampton S, (2008) Malodorous fungating wounds: how dressings alleviate symptoms. Wound care June 2008 pg S31- S38


28

CARE PLAN: Local support, comfort and pain reduction. Control of bleeding

and odour are priorities as healing cannot be a goal. Early

identification of infection and reduction of odour will

considerably improve the quality of life for the patient.149

Understanding impact of the wound on the individual quality

of life and helping to ameliorate both physical and

psychological symptoms.150

Odour Control

151 152

Establish the cause of the odour by sending a wound swab for microscopy and culture. Clean with sterile sodium chloride 0.9% if required. Dressing: Dress according to the classification of the wound. Additional management: Antibacterial dressing, which includes charcoal or silver can help to reduce odour.

153 Metronidazole gel can be used following a doctor’s

prescription.

Incipient Bleeding

Kalostat, an alginate dressing is a licensed haemostat and can help control bleeding.

154

Relief and Comfort

Foam sheets can be cut to fit a protruding wound and thus provide comfort and support. Small amounts of hydrogel can minimise adherence in dry wounds. Good provision of analgesia is crucial, particularly prior to dressing changes.

Exudate

155

Foam sheets and high absorbency alginates should be used to control exudate. VAC therapy is contraindicated in malignant wounds.

6.4 Criteria for Removing/Changing Dressings

The wound should be assessed and the appropriate dressing applied in the following events.

wet contamination from external sources

strike through (when exudate has leaked through the dressing)

offensive smell 156

pain or prolonged tenderness at wound site

unexplained pyrexia

inflammation at site

removal of drain/clips/sutures

allergic reactions.

149

Alexandra S J (2010) An intensive and unforgettable experience: The lived experience of malignant wounds for the perspectives of patients, caregivers and nurses. Int Wound Jr. Vol 7 No 6. Pg 456-465 150

Piggin C, Jones V (2009) Malignant fungating wounds: and analysis of the lived experience. JWC Vol 18 No 2 pg 57-64 151

Van Toller S (1994) Invisible Wounds: The effects of skin ulcer malodour. JWC Vol 3 No 2 Pg 103-105 152

Morris C (2008) Wound odour: principles of management and the use of Clinisorb. BJN (TV Supplement) Vol17 No 6 pg 153

Hack A (2003) Malodourous wounds –taking the patients perspective into account. JWC Vol 12 No 8 319-321 154

Hamilton S (1999) Wound Management theory and practice. Nursing Times Books. Pg 119 155

Thomas S (1997) Assessment and Management of Wound Exudate. Journal of Wound Care. July Vol 6 No 7 Pg 327-330 156

Greenwood J.E. Crawley B.A. (1997) Monitoring Wound Healing by Odour. Journal of Wound Care. May. Vol 6 No 5


29

The frequency of the dressing change will be influenced by the condition of the wound and dressing product used. (see manufacturers instructions) Frequent unnecessary changes should be avoided, as this will reduce the temperature and humidity of the wound. It may also cause trauma to newly formed cells and may permit colonisation of the wound by microganisms.

157

Dressing changes should be concluded promptly, adhering the aseptic principles as necessary.

6.5 How To Take A Swab For Culture 158

159

Wound swabs should be taken when the wound presents with the signs of infection.

160

(Figure 1and Table 4)

Cleanse the wound bed well with saline, bacteria are not washed away during cleansing and thus can still be identified;

Do not swab eschar, exudate or pus;

Select the cleanest area of the wound;

First, dip the clean swab in the swab medium 161

or sterile saline.162

Firmly press and rotate the swab in the cleanest area of the wound area, mover the swab across the area in a ziz-zag motion from the centre to the outside.

163

Include tunnelling if present;

If pus is present take a separate sample of the fluid in a pot.

6.6 How to Treat Over-granulating Tissue 164

165

166

167

Hypergranulation is normally transient resolving itself in time as the granulation tissue

contracts. Use of non-traumatic dressings to reduce hypergranulation should be the first choice. If overgranulation persists nurses should discuss the situation with the TVS or the responsible physician to exclude undiagnosed malignancy as the underlying cause. The reduction of hypergranulation/over-granulation may be achieved through the use of the following:

Foam Dressing; Lyofoam

Application of light pressure to the wound bed; if not contra-indicated is of benefit.

Silver Nitrate; (Sticks or .025% compresses); can be used however it is not a first line measure. Morison (1991) cited in Hampton S and Collins

168 found silver nitrate to be

caustic with potential to initiate methaemoglobinaemia and metabolic disturbance. Silver nitrate is therefore a treatment for very short-term use only.

Corticosteriod cream such as Elocon or Betnovate can be used under medical

supervision as a last resort and for very short-term use only. It should also be remembered that topical steroid preparations are not licienced for the treatment of overgranulation and therefore responsibility for its use lies with the prescriber.

157

Lock A.M.(1980) The effect of temperature at the edge of experimental wounds, Symposia on wound healing, plastic surgical and dermalogical aspects. Pg 103-109 158

Cutting K. Harding K. (1994) Criteria for identifying wound infection in Wounds. Essential Vol 1 2006 159

RDNS Research Unit (2002) The Pursuit of Excellence. Promoting Evidence-Based Nursing Practice – Wound Swabbing. ISSN 1449-44X Issue No 11. Sept 160

Community & primary Care Infection Control Manual. (2006) EFPCT Ref GUI00062/HP 161

Microbiology advice from PAHT 162 Patten H (2010) Identifying wound infection: Taking a swab. Wound Essentials Vol 5 pg 64-66 163

Patten H (2010) Identifying wound infection: Taking a swab. Wound Essentials Vol 5 pg 64-66 164

Hampton S. Collins F (2004) Tissue Viability, Ch 3 Pg 96. Whurr publishers. ISBN 1 88156 237 3 165

Dunsford C (1999) Hyperegranulation Tissue. JWC Vol 8 No 10 pg 506-507 166

Young T (1997) Use of a hydrocolloid in over granulation. JWC Vol 6 No5 pg216- 167

Young T (1995) Common problems in wound care: overgranulation. British Journal of Nursing. Vol 4 No 3 168

Hampton S. Collins F (2004) Tissue Viability, Ch 3 Pg 96. Whurr publishers. ISBN 1 88156 237 3


30

Haelan tape; which contains the steroid Fludroxycortide within it has been reported as suitable for use for over granulation.

169 170

169

Johnson, S (2007) Haelan Tape for the treatment of overgranulation tissue. Wounds Uk Vol 3 no 3 pg 70 -74 170

Vowden K, Vowden P, (2010) Understanding and managing hypergranulation. Ind Nurse Sept. www.independentnurse.co.uk.

http://www.independentnurse.co.uk/


31

Figure 6 Wound Care Plan

NURSING CARE PLAN

STICK ADDRESSOGRAPH HERE WARD:

DATE PATIENT PROBLEM/NEED RGN

Signature

Review

Date

GOAL

NURSING ACTION/INSTRUCTION

CLEANING SOLUTION:

PRIMARY DRESSING:

SECONDARY DRESSING:

FREQUENCY OF DRESSING CHANGE:

OTHER INSTRUCTIONS:

The use of the WAF and a comprehensive care plan ensures that registered nurses are fulfilling their obligations under the NMC Code

171 . Failure to keep good records exposes the Nurse and the

Trust to the risk of litigation. It is crucial that wound assessment forms and care plans are completed on all patients who have wounds. These records must be clearly written, signed,dated and timed and are regularly updated. The WAF must be completed after every dressing change.

171

NMC (2008) The Code, Standards of conduct, performance and ethics for nurses and midwives


32

7 PRINCIPLES OF WOUND IRRIGATION 172

173

The purpose of wound irrigation is to help create optimum local conditions of healing. It should remove wound debris. It should be performed in an atraumatic method, so that epithelialising and granulation tissue is not damaged. The method used to do this should be based upon an assessment of the wound and the patient’s general condition. Clean epithelialising/granulating wounds do not benefit from mechanical irrigation, which removes exudate containing valuable healing factors. These wounds should be left undisturbed for as long as possible to enhance the rate of healing. Wiping may damage new granulation tissue. Chronic wounds with excess exudate may benefit from irrigation.(See section 2.3.3) Irrigation using a syringe or by showering is often preferred providing that the pressure achieved is adequate to remove wound debris, but not damage healthy tissue. When irrigation is not effective in removing remnants of the dressing (e.g. Hydrocolloids, Alginates) gentle wiping can be instituted. It is recommended that non-woven gauze (as supplied in dressing packs) be used in conjunction with either a gloved hand or forcep technique. Some methods of mechanical wound cleaning can result in the redistribution of bacteria rather than an actual reduction.

174 Care must be taken to wipe from clean areas to dirty

and not visa versa.

7. 1 Cleansing solutions

Sterile sodium chloride 0.9% solution is the most appropriate for irrigating wounds. When a surgical wound has separated or has been surgically opened to drain pus, then the use of tap water may be considered for wound cleansing.

175 It is however preferable in

wounds which are not contaminated with faecal or other severe contamination matter that staff use sterile saline. A variety of antiseptic preparations are sometimes used for more complex wounds. Traditional antiseptics (e.g. Eusol, diluted Milton, hydrogen peroxide, chlorhexidine with cetrimide) are quickly rendered ineffective by body fluids and pus. The potential disadvantages of using such antiseptics should be weighed against any possible benefits before they are used.

176 NICE guidelines advise against the use of Eusol and mercuric

antiseptic on wounds.177

Products which contain polyhexamethylene biguanide (PHMB) have a broad range spectrum of biocidal activity with demonstrated clinical evidence to support their use.

178 Some studies have indicated that Fungi and Yeasts are more

important wound pathogens than previously reported and thus antimicrobial products must be able to target these pathogens if healing is to occur.

179

It is advisable to warm the cleaning solutions to body temperature just before use.

7.1.1 Sodium chloride 0.9% solution This isotonic solution does not cause chemical damage to cells and is the preferred irrigating agent for wounds. Sodium chloride 0.9% does not require a prescription; all the other solutions do need a prescription.

7.1.2 Chlorhexidine with cetrimide

172

Lawrence J.C. (1997) Wound Irrigation JWC Jan Vol 6 No 1 Pg 23-26 173

Gilcrist B (1999) Wound Management, Theory and Practice. Nursing Times Books. Pg 104-105 174

Thomlinson D (1987) To clean or not to clean, Nursing Times, Journal of Infection Control Nursing. 4 March Vol 83.5 175

NICE (2008) . Surgical site infection. Guideline no 74 . October 2008 176

Lawrence J.C. Harding K.G. Moore D.J. (1996) The Use of Antiseptics in Wound Care. Journal of Wound Care. Jan. Vol 5 No 1 Pg 44-47 177

NICE (2008) Surgical site infection. Guideline no 74 . October 2008 178 Cutting K F (2010) Addressing the challenge of wound cleansing in the modern era. BJN (TV Supplement) Vol 19 No 11 pg S25-S28 179

Dowd SE et al (2011) Survey of fungi and yeast in polymicrobial infections in chronic wounds. JWC Vol 20 No 1 Jan. Pg 40-47


33

This is available as chlorhexidine 0.15% w/v with cetrimide 0.015% w/v (sometimes known as Savlon 1 in 100) for cleaning dirty wounds. The products are easily contaminated and any remaining in a container after opening should be discarded.

7.1.3 Prontosan

Prontosan® Wound Irrigation Solution and Gel are ready to use products for cleansing, moisturising and decontamination of acute and chronic wounds. They contains unique ingredients that have a double effect on the wound bed to create a wound environment optimal for healing. Betaine a gentle effective surfactant to penetrate, clean and remove wound debris and biofilm. Polyhexanide (PHMB) a powerful antimicrobial agent that can reduce bioburden. This product is not on the Dressing Formulary and should only be prescribed on the instruction of the Tissue Viability Service

7.1.4 Iodine Iodine is active against a wide range of organisms including Gram-negative and Gram-positive bacteria, fungi and bacterial spores. If an antiseptic solution is required Iodine is the solution of preference. Cadexomer Iodine has in studies been shown to produce a marked decrease in MRSA, and it is recognised as having a role in enhancing healing of chronic wounds.

180

181 However for

management of MRSA Stellisept as discussed below should be used.

7.1.5 Stellisept If a wound is colonised or infected with MRSA it can washed using Stellisept at

dressing changes.182

The wound should subsequently be redressed using an antimicrobial dressing according to its classification and in adherence with the EWMA Algorithm as illustrated in Figure 1.

Table 7 Comparison of commonly used antimicrobials183

Antimicrobial properties

Gram+ve Gram -

ve

Fungi Endospores Viruses Resistance

Chlorhexidine184

185

+++ ++ + 0 + +

Honey 110, +++ +++ +++ 0 + 0

Iodine 109,110 +++ +++ +++ +++ ++ 0

Maggots186

187

188

189

190

+++ ++ ND ND ND 0

Silver 109,110 +++ +++ + ND + +

ND= No data

180

Mertz. P Davis S Brewer L (1994) Can Antimicrobials be effective without impairing healing 181

Marshall C, Queen J Manjooran J (2005) Honey Vs povidone iodine following toenail surgery. Wounds UK May Vol 1 Issue 1: 10-17 182

Olivo, S. (2011) SEPT Internal communication on management of MRSA in Wounds. 3/8/11 183

European Wound Management Association (EWMA) position Document: Management of wound infection. London MEP Ltd 2006 184

McDonnellG RussellAD. Antiseptics and disinfectants:activity, actions and resistance. Clin Microbiol Rev 1999:12 (1): 147-79 185

Cooper R. A review of the evidence for the use of topical antimicrobial agents in wound care. www.worldwidewounds.com/2004/February/Cooper/Topical-Antimicrobial-agents.html(assessed 2 February 2006) 186

Thomas S Andrews AM, Hay NP et al. (1999)The antimicrobial activity of maggot secretions:results of a preliminary study. J tissue Viability 9:127-32 187

Beasley WD, Hirst G. (2004) Making a meal of MRSA –the role of biosurgery in hospital acquired infection. J Hosp infect: 56:6-9 188

Horobin AJ, ShakesheffKM, Woodrow S et al. Maggots and wound healing: an investigation of the effects of secretions from Lucillia sericata upon interactions between human dermal fibroblasts and extracellular matrix components. Br J Dermatol 2003; 148(5):923-33 189

Steenvoorde P Jukema GN. The antimicrobial activity of maggots: in-vivo results, J Tissue Viability 2004: 2004; 14 93):97-101 190

Cooper R. A review of the evidence for the use of topical antimicrobial agents in wound care.www.worldwidewounds.com/2004/February/cooper/Topical-Agents.html (accessed 2 february 2006)

http://www.prontosan.co.uk/docs/Biofilm/Bioflim%20Building%20up.pps

http://www.prontosan.co.uk/polyhexanide.html

http://www.worldwide/


34

8. WOUND BED PRODUCT INFORMATION 191

New dressing products are released in to the health care market daily. It is thus recommended that staff refer to the BNF or the Wound Care Handbook

192 for up to date

information on products. However information on the main generic types is provided below to facilitate learning. The Trust Dressing Formulary Guidelines should be referred to regarding selection of products for patient use.

8.1 Semi Permeable Film Dressing 193

194

Examples: C View Film dressing

Episil Film Dressing

These films are adhesive, hypoallergenic, transparent and permeable in various degrees to moisture vapour and other gases. They are useful for low exudate superficial wounds, which are clean, and to cover surgical wounds healing by first intention. To ensure good adhesion a 4 – 5 cm margin from the wound edge is suggested. As these dressings are semi-occlusive they should not be used with clinically infected wounds unless antibiotic therapy has been established and the infection is under control.

8.2 Hydrocolloids 195

196

Examples: Comfeel Ulcer

Granuflex

Duoderm Extra thin

Hydrocolloid Fibre (Aquacel)

Suitable for moderately exudating wounds. Can help promote granulation in clean wounds. They can be used to deslough infected wounds, and to debride necrotic eschar.

The dressing should be changed when the liquidified base of the dressing is visible or by seven days. The frequency will depend on the nature of the wound. On removal of the dressing there will be a viscous, offensive yellow gel on the surface of the wound. This is quite normal and can be removed with sterile Sodium Chloride 0.9% prior to the application of the next dressing. Hydrocolloid sheets are occlusive dressings and are contra-indicated in clinically infected wounds unless antibiotic therapy is established and the infection is controlled.

Research using Hydrocolloids has demonstrated: 1. Inhibition of bacterial growth particularly pseudomonas

2. Enhanced collagen synthesis

197

3. Controls spread of other bacteria by acting as a barrier

198

Aquacel is a soft, nonwoven pad or ribbon dressing composed entirely of hydrcolloid fibres, (Sodium cellulose). It is indicated as a primary dressing for the management of light to heavily exudating wounds. It may also be used on clinically infected wounds. It should be changed when it becomes saturated with exudate or by seven days. It is 50% more absorbent than alginates. It converts to a soft coherent gel sheet, which retains its

191

Hamilton S (1999) Wound Management, Theory and Practice. Nursing Times Books. Pg 112-125 192

Wound Care Handbook 2011-2012. MA Healthcare Ltd. London 193

Thomas S (1994) Low Adherence Dressings. JWC Vol 3 No 1 Pg 27-30 194

Thomas S (1996) Vapour-Permeable Film Dressings JWC. Jun Vol 5 No 6 Pg 271-274 195

Banks V. Harding K (1994) The use of two dressings for moderately exuding pressure sores. JWC 32 Vol 3 No 3 Pg 132-134 196

Thomas S (1992) Hydrocolloids. JWC Jul/Aug Vol 1 No 2 Pg 27-30 197

Alvarez I.M (1980) The Effect of occlusive dressings on collagen synthesis, re epithelization in superfical wounds Journal Sur Res 35 pg 142-180 198

Lawerence JC Lilly HA (1988) Bacterial barrier properties of hydrocolloid dressings in vitro in: Beyond Occlusion: Wound Care proceedings. International Congress and Symposium Series No 136


35

integrity during handling. It should not be cut; excess dressing should be overlapped.199

200

This dressing should only be used on the recommendation of the TVS or Team Leader.

8.3 Alginates 201

Examples: Activheal Alginate

Sorbisan

Kaltostat (Sodium Calcium Alginate)

Made from salts of alginic acid, a polysaccharide derived from seaweed. Suitable for heavily exuding sloughy and infected wounds. The dressing should be changed when “strike through” is visible and may be left for up to 3 days.

8.4 Foam Dressings

Examples: Lyofoam Non Adherent

Biatain Non Adherent

Allevyn Gentle

Biatain Adherent

Allevyn Adherent

Tegaderm Foam

These products are highly absorbent polyurethane foams designed to manage moderate to heavily exudating wounds. Various sizes and shapes are available and it can remain in place for up to 5 days.

8.5 Hydrogels 202

203

Examples: Activheal Gel

Nugel

Actiform Cool (Hydrogel sheet)204

Useful for dry/low exudate granulating wounds as it produces a moist wound environment and thus prevents wound desiccation. Also used to deslough low/medium exudating wounds. Can be used on necrotic wounds to dehydrate the eschar. A secondary dressing is needed, ideally a semi permeable film to maintain the moist wound interface.

8.6 Dressings Containing Charcoal

Examples: Clinisorb

Currently all odour-absorbing dressings contain a layer of activated charcoal cloth. Charcoal is a natural and efficient absorber of volatile molecules, odour and gasses.

205

Odour is frequently caused by bacteria such as Proteus, Klebsiella, Pseudomonas, and Bacteroides. More uncommonly Clostridium welchi, the causative organisms of gas gangrene.

199

Morgan D.A (1997) Formulary of Wound Management Products 7th

Edition ISBN 1 899015 18 3 200

Foster L. Moore P. (1997) The Application of Cellulose-based fibre dressings in Surgical Wounds. J/wc Nov Vol 6 No 10 Pg 469-474 201

Thomas S (1994) Low Adherence Dressings JWC Vol 3 No 1 Pg 27-30 202

Flanagan, M (1995) The efficacy of a hydrogel in the treatment of wounds with non viable tissue. JWC Vol 4 No 6 1995 Pg 264 203

Thomas S (1994) Wound Cleansing Agents JWC Oct Vol 3 No 7 Pg 325-328 204

Maund M (2008) Use of an ionic sheet hydrogel dressing on fungating wounds: two case studies. JWC Vol 17 No 2 pg 65-68 205

Lee G, Anand S C Rajendran S Walker I (2006) Overview of current practice and future trends in evaluation of dressings for malodorous wounds. JWC Vol 15 No 8 344-346


36

Milward treated fifty patients with Activated charcoal, paraffin gauze or charcoal and found that the former was most effective in controlling odour, exudate, and promoting wound cleansing and overall improvement.

206

8.7 Dressings Containing Antimicrobials

The pathogens responsible for wound infection delay healing by destroying viable tissue cells. They also attract polymorphonucleocytes to the wound which express enzymes that destroy invading microbes and, in turn ‘digest viable tissue cells. While systemic antibiotic therapy is indicated for established skin infections the increase in antibiotic resistance has led to a resurgence of interest in topical antiseptics. There is growing evidence as to the effectiveness of antimicrobial dressings in limiting bacterial cell growth.

207 208

However a wound does not need to be sterile to progress towards healing and the use of topical antimicrobial therapy simply to lower microbial load in the healing wound can never be justified.

209 The decision to use an antimicrobial dressing must be underpinned by

documented clinical observations. Nurses should be clear on the reasons why they have chosen such products and if in doubt refer to the TVS or their Team leader. The products identified below should only be used where wound infection is suspected. In cases of MRSA wound infection the Care Pathway as illustrated in Appendix 2 should be followed.

Examples: Iodoflex, Inadine, Flaminal, Aquacel Ag, Biatain Ag, 210

211

212

213

214

215

Products available such as iodine impregnated dressings provide a controlled release of iodine and are preferable to soaking gauze in iodine. Other controlled release products contain silver. These products control the build up of bacteria on a wound bed without adding a fluid burden to the wound, which increases the risk of strike through, and the subsequent need to renew dressings to maintain the antiseptic level.

8.7.1 Honey

Examples: Algivon216

Actilite

Honey is an ancient treatment that is increasingly earning its place in modern wound care. Evidence suggests it compares with other dressings in terms of its antibacterial properties, ease of use and ability to promote a moist environment.

217

218

219 220

221

222

223

224

206

Milward S (1991) Comparing treatments for leg ulcers – Nursing Times – Mar 27 Vol 87 No 13 207 Cutting K (2011) Why use topical antiseptics. JWC/The Silver debate. March pg 4-7 208 Lipp C et all (2010) Testing wound dressings using an invitro wound model. JWC Vol 19 No 6. Pg 220-226 209

European Wound Management Association (EWMA). Position DFocument: Management of wound infection.London MEP Ltd 2006 210

IM et al ( 2006) antimicrobial activities of silver dressings: an invitro comparison. Jr Med Microbiology Vol 55 pg 59-63 211

Thomas S, McCubbin P (2003) A Comparison of the antimictobial effects of four silver-containing dressings on three organisms. JWC Vol 12 No 3 101-107 212

Lansdown A B (2003) Silver in Wound Care and Management. WCS Vol 1 No 3 213

Edwards-Jones V (2006) Antimicrobial and barrier effects of silver against MRSA. JWC Vol 15 No 7 285-290. 214

Lansdown,A B (2006) Silver in Healthcare:Antimicrobial Effects and Safety in Use. Burg G (ed):Biofunctional Textiles and the Skin. Curr Probl Dermatol. Base; Karger, 2006 vol 33.pp 17-34 215

Munter KC et al. (2006) Effect of a sustained silver-releasing dressing on ulcers with delayed healing. JWC 15 (5) p 155-206 216

Stephen-Haynes J (2004) Evaluation of a honey-impregrated tulle dressing in primary care. Wound Care June 2004 S21-S27 217

Schumacher H H A. (2004) Use of medical honey in patients with chronic venous leg ulcers after split-skin grafting. JWC. Vol 13 No 10 Nov 4451-452. 218

Molan P C, Betts J A (2004) Clinical usage of honey as a wound dressing: an update. JWC Vol 13, No 9 353-356. 219

McIntosh CD Thomas CE (2006) Honey versus parfintulle gras following toenail surgery. JWC; 15:3 133-136 220

Booth S (2004) Are honey and sugar paste alternatives to topical antiseptic? JWC Vol 13 No 1 31-33 221

Gethin G (2004) Is there enough clinical evidence to use honey to manage wounds. JWC Vol 13 No 7 275-278 222

Saini J, (2008) A honey-based dressing for diabetic foot ulcers: A controlled study. The Diabetic Foot Journal. Vol 11 No 2 pg 87-91 223

Lay-flurrie K (2008) Honey in wound care:effects, clinical application and patient benefits. BJN (TV supplement) Vol 17 No 11S30-S36 224

Blaser G, Santos K et al (2007) Effect of medical honey on wounds colonised or infected with MRSA. JWC Vol 16 No 8 sept pg 325-328.


37

8.8 Protease Modulating Therapy (PMT)225

Examples: Aquacel

Cadesorb

Promogram

Promogram modulates and rebalances the chronic wound environment by:

Binding and inactivating protease, which have a detrimental effect on wound healing when present in excessive quantities in chronic wounds.

Protecting naturally occurring growth factors from degradation by the excess protease.

Protease are the body’s natural enzyme providers without which haemostasis would not occur. Proteases degrades foreign material at the inflammatory stage and clean the wound. They also help cells to migrate into, and re-epithelialise over the wound. Normally, the level of protease decreases as a wound heals. However if their activity becomes uncontrolled, causing protease levels to rise in the wound, delayed healing can occur. Growth factors are also proteins. They are synthesised by a number of different cell types in the wound and work by binding to a specific receptor on the cells surface. This stimulates the cells to migrate, proliferate and produce granulation tissue, required for wound healing. Cadesorb has a similar outcome/effect to promogram but works by altering the Ph of the wound and thus making the wound bed less suitable for protease activity.

226

8.9 Larva Therapy/ Biosurgery 227

228

229

Sterile larvae, break down necrotic tissue within a chronic wound, transforming it into an acute wound.

230 They do not normally harm healthy and healing tissue. They do not

invade the body, though they will go into nooks and crannies in the depths of complex wounds. They can be used with other treatments that may be necessary. There is compelling evidence to support the use of larval therapy for the purpose of eradicating MRSA from wounds.

231

Larva are contained in specially designed dressings, which confine them to the wound itself, and are covered so that they need not be seen. When they have done their job, and have grown about 10mms, they are removed with the dressing, usually after about 48 hours. Some chronic wounds will be slow to heal and need repeated treatment.

No serious complications of this treatment method have been reported. Some patients can feel the larvae in their wounds, and some patients with painful wounds will continue to have pain during the treatment, such pain can normally be relieved by pain relieving treatments. Once the wound starts to heal however, the pain becomes less. Pain due to the larvae can be immediately relieved by removal of the larvae. Ulcers, which are malodorous usually, become markedly less so after one or two treatment cycles. Treatment can be undertaken in secondary or primary care as larvae are available of Drug Tariff.

225

Treating Wounds with Promogran. (2003) Proceedings of four educational meetings. Medical Education Partnership Ltd London 226

Rodgers A Westret L (2005) The role of pH modulation in wound bed preparation. The Diabetic Foot Journal. Vol 8 No 3 154-157 227

Thomas S (2006) Cost of managing chronic wounds in the UK, with particular emphasis on maggot debridement therapy. JWC Vol 15 No 10 465-469 228

Thomas S (1996) Using Larvae in Modern Wound Management The Journal of Wound Care. Feb Vol 5 No 2 Pg 60-69 229

Guidance on the use of debriding agents and specialist wound care clinics for difficult to heal surgical wounds. NICE 2001. 230

Jones J, Green J, Lille AK ( 2011) Maggots and thei role in wound care. Wound Care March . S24-S33 231

Laurie R (2010) Larval therapy:is it effective against MRSA? JCN Vol 24 No 4 pg 10-12


38

8.10 Topical Negative Pressure (TNP) 232

233

234

235

236

237

TNP is a system which applies topical negative pressure to a wound, promoting wound healing, under the influence of continuous or intermittent negative pressure. TNP promotes healing by:

removes infectious materials and /or other fluids

assist tissue granulation through increased perfusion

draws the edges of the wound together

provides a moist wound healing environment

There are two methods of TNP available on the market238

. 1. The Foam System

This technique involves the application of an open pore foam and tubing which is attached to the pump, held in situ with a film dressing creating a controlled closed wound environment.

2. The Cheriker-Jeter System Involves application of a gauze dressing and tubing attached to a pump which is then sealed using a film dressing creating a controlled closed wound environment.

239

In both methods a negative pressure is applied across the wound from the pump via the drainage tube imbedded in the foam or gauze. The complete kit, which includes foams, gauze and suction unit, is available from KCI, Molynlycke or Smith & Nephew.

All

components are available on FP10.

The Tissue Viability Service hold the budget for the hire of the pumps and thus the TVS must be involved in every patients care where TNP is in use. Indications:

Pressure Ulcers

Traumatic Wounds

Flaps Fresh/Compromised

Diabetic Ulcers

Arterial Ulcers

Surgical Wound dehiscence

Meshed grafts

Venous grafts

Contra-Indications

Presence of non-enteric or unexplored fistula/fistulae

Presence of necrotic tissue with eschar

Malignancy

Untreated Osteomyelitis

Exposed blood vessels or organs.

232

Flack S, Apelqvist J et al ( (2008) An economic evaluation of VAC therapy compared with wound dressings in the treatment of diabetic foot ulcers. JWC Vol 17 No 2 pg 71-78 233

Thompson G (2008) An overview of negative pressure wound therapy. Wound Care June pg S 23-S29 234

Banwell P.E. (1999) Topical Negative Pressure Therapy in Wound Care. The Journal of Wound Care Feb Vol 8 No 2 Pg 79-84 235

Demaria, R. Giovanni, UM Teot. et al (2001)Using VAC to treat a vascular bypass site infection. The Journal of Wound Care. Vol 10, No 2. Pg 12-13. 236

Dhar R, CopsonD, Williamson K Nunns D. (2006) Use of topical negative pressure to close a large MRSA-infected groin wound following vulvectomy. JWC Vol 15 No 7 312-313 237

Zie X et al (2010) The clinical effectiveness of negative pressure wound therapy:a systemic review. JWC Vol 19 No 11 pg 490-493 238

Malmsjo M et al (2010) Influence on pressure transduction when using different drainage techniques and wound fillers (foam and gauze) for negative pressure wound therapy, Int Wound jr Vol 7 No 5 pg 406-411. 239

Bondokji DPM et al (2011) Clinical efficacy of a new variant of a foam based NPWT system. JWC Vol 20 No 2 pg 62-67


39

Access to VAC therapy is via the Tissue Viability Department see Appendix 2 for referral forms

8.11 Topical Antibiotic:

Example: Anabact gel A clear gel, which contains Metronidazole BP 0.75% W/V. It is effective against anaerobic bacteria, which often cause malodour in fungating wounds. This is a topical antibiotics and requires prescription and should only be used following discussion with the TVS or the Team Leader.


40

9 WOUND DRAINAGE

Flow must be maintained at all times. Tubes should not become blocked, kinked or removed by accident. Reduce risk of tension on wound from weight of long tubing can be achieved by using a carrier attached to bed if appropriate.

Accurate measurement of all wound drainage must be kept. Contamination of the wound must be prevented where possible. The drain site must be covered by a dressing or a sterile drainage bag. If appropriate the patient must be encouraged to maintain mobility. Disposable equipment must be discarded un-emptied into a yellow clinical waste bag.

10 ASEPTIC NON TOUCH TECHNIQUE PROCEDURE

An aseptic non-touch technique should be used for all wounds both Acute and Chronic.

240 In the case of faecal contamination the clinician responsible for care

must use discretion ensuring that best standards of infection control are maintained at all times. Where Leg Ulcers are concerned the procedures recommended in the Leg Ulcer Guidelines should be followed.

241

a) Dressing Pack - includes gloves b) N/Saline c) New Dressing d) Tape e) Forceps available if needed f) CSSD bag - only if instruments used g) Orange clinical waste bag (hospital only) h) Sterile scissors

Analgesia should be provided if the patient is in pain or it is anticipated that the dressing change will cause pain.

240

Newton H (2010) Reducing MRSA bacteraemias associated with wounds. Wounds Uk Vol 6 No 1 pg 56-65. 241

PAHT (2010) West Essex Leg Ulcer Guidlelines.


41

242

Dougherty L, Lister S (eds) (2008) The Royal Marsden Hospital Manual Clinical Nursing Procedures. 7th

edn. Blackwell Publishing, Oxford

Table 8. Procedure for aseptic non touch technique 242

AIM INDICATIONS

To minimize the risk of introducing organisms capable of causing an infection into a wound or other susceptible site where micro organisms would normally colonize or be expected. To prevent the transfer of organisms capable of causing an infection to other susceptible sites, service users of staff.

Wounds healing by primary and secondary intention (before the skin has healed), e.g. surgical wounds and chronic wounds.

Urinary catheterization

Suturing

Coil fitting (family planning service)

Insertion of intravenous canualae

Any other medical invasive procedure

Dressing intravenous lines

PROCEDURE RATIONALE

Ensure all equipment required is ready and available and that there is a clear field in which to carry out procedure.

To prevent unnecessary movement and potential cross-contamination

Verbally check the identity of the patient. Check with carer/family if not able to confirm.

To confirm identity

Explain the procedure to the service user obtain informed and understood consent

To enable service user to make informed decisions about their own health care

Position the patient, with dignity and privacy so that the procedure can be performed

To gain optimal position for patient’s comfort

Decontaminate hands

To reduce the risk of transfer of transient organisms on the healthcare worker’s hands

Put on single-use apron

To protect clothing and prevent transfer of transient organisms to a susceptible site

Open wound care pack, onto a clean field

To prevent introducing organisms capable of causing an infection into the site

If dressing present, loosen and remove using the inside of the waste disposal bag

To remove contaminated item without contaminating hands

Decontaminate hands

Reduce the risk of transfer of transient organisms on the healthcare workers hands

Put on sterile gloves in a manner which prevents the outer surface of the sterile glove being touched by a non-sterile item

To prevent the introduction of organisms capable of causing an infection into the site

Use aseptic principle to ensure that only sterile items are used, to keep exposure of the susceptible site to a maximum

To prevent the introduction of variable micro organisms which could cause a healthcare-acquired infection

On completion of the procedure, dispose of waste As per clinical waste policy

Decontaminate hands

To remove any accumulated transient skin flora that may have built up under the gloves

Record all care in the patient’s records

As per SEPT policy


42

11. WOUND COMPLICATIONS

11.1 Infection with/without Exudate

1. Report to person in charge and doctor.

2. Take wound swab and send for culture and sensitivity.

3. Monitor temperature and pulse, BP and respiration 4. Follow EWMA Algorithm for managing wound infection. (Figure 1)

5. Evaluate on a daily basis and record findings on WAF, reporting any concerns Medical staff.

6. Give treatment if prescribed, (systemic) and monitor effect.

7. Take repeat swab at 4 days unless otherwise indicated.

11.2 Wound Dehiscence 1. Inform medical staff immediately. Assess severity, length and depth and record.

2. Cover with sterile saline soaked dressing with support bandage until further medical advice is available.

3. Make sure patient understands the problem and anticipated plan of care.

4. Ensure that the patient is pain free by offering analgesia as prescribed. 5. Refer patient to TVS.

Beware of other complications such as abscess, haematoma, haemorrhage or

sinus, all of which may need further medical treatment.


43

12. DEBRIDEMENT OF NECROTIC OR SLOUGHY TISSUE

“Debridement is an essential technique for all those who provide wound care. It is often done badly for lack of experience and training.

243 It is widely accepted that the presence

of devitalised tissue on the wound surface impedes healing.244

Cutting defines necrosis as the death of local tissue and describes it as, tissue that is black or brown in colour, with a leathery appearance. Slough is defined as devitalised tissue, which has a yellow/white hue, may be dry or slimy in nature and is seen to adhere to the wound bed.

245

Surface associated bacterial populations (Biofilms) are present in chronic wounds and are a primary barrier to healing. Evidence suggests that serial debridement and removal of mature Biofilm does facilitate wound healing.

246

Any nurse wishing to undertake sharp debridement must be able to demonstrate his/her ability to safely undertake the technique either through the provision of certificates of training,

247 or a portfolio of case studies, which involved peer review, or both. Such

evidence of competence must be endorsed by the Trust either by the Director of Nursing or the direct line manager if appropriate.

248

All nurses wishing to undertake this technique must do so in line within the recommendations outlined within The NMC Code of professional conduct (2008)

249 250

12.1 Definition of Debridement

Debridement is the excision of devitalised tissue and the removal of all foreign matter from a wound surface.

251 There are several debridement options available ranging from wound

care products which enhance or promote autolytic debridement to techniques using instruments.

252

For the purpose of the policy, sharp debridement is the removal of devitalised tissue with the assistance of instruments such a scalpel and scissors. Blunt debridement is the removal of tissue with the assistance of forceps and or the application of traction to separate tissue from its anchorage. Versajet debridement is the removal of devitalised tissue using the Versajet Hydrosurgery

system ®. 253

254

This system is a debridement tool which makes uses of an innovative technology based on a jet of water and the Venturi effect resulting from it, which is capable of demolishing, and at the same time, removing by suction the necrotic tissue. The treatment is well tolerated by the patient and drastically reduces bacterial load.

255

12.2 Scope

243

Gautam V. Consultant Surgeon, East Herts NHS Trust. 244

Flanagan M. (1999) Reviewing the case for debridement. Journal of Wound Care: 8:6.257 245

Cutting K.F. (1996) Definition of Terms. Journal of Wound Care Resource File. London Macmillan 246 Wolcott RD et al ( 2010) Biofilm maturity studies indicate sharp debridement opens a time dependent therapeutic window. JWC Vol 19 No 8 pg 320-327 247

Benbow M. (2000) Dealing with slough and necrosis. Essential Wound Healing. Part 8 Emap healthcare 248

Dimond B. (1900) Legal aspects of nursing pg 39-50. Prentice Hall 249

NMC (2008) The NMC code of professional conduct:, standards for conduct, performance and ethics. 250

Fairbairn K, Grier J, Hunter c (2002) A sharp debridement procedure devised by specialist nurses. JWC Vol 11 No 10 371-375 251

Dox 1. Melloni B.J. Elsner G.M. (1994) Illustrated medical dictionary 3rd

edition. The Wellcome Foundation Ltd. 252

Ousey K McIntosh C (2010) Understanding wound bed preparation and wound debridement. Wound Care, S 22-27. 253

Spruce M, Sweet J, Bowen KG et al (2007) Multidiciplinary debridement course: a new approach. Poster presentation Wounds UK Harrogate. 254

Leak K, Johnson S, (2007) Versajet in “out of theatre” debridement: improving costs and clinical outcomes. Poster presentation Wounds UK Harrogate. 255

Fraccalvieri M, et al. (2011) Surgical debridement with Versajet: An analysis of bacteria load of the wound bed pre- and post treatment and skin graft taken. A preliminary pilot study. International Wound Journal Vol 8 No 2 pg 155-161


44

In SEPT WEL sharp debridement by nurses will only be performed on devitalised tissue, which is necrotic or sloughy. No removal or cutting of healthy tissue with a blood supply will occur. No debridement of ischaemic digits will be performed. No perforation of vessels should occur during the procedure. Blood loss as a result of contact with granulating tissue during the procedure will be minimal. Versajet debridement of slough, soft necrosis, senescent cells, biofilm and devitalised tissue can be performed by the TVS within competency.

12.3 Contra-indications for Versajet or Sharp Debridement256

257

Densely adherent necrotic tissue.

No visual evidence of a demarcation line between viable and non-viable tissue.

Patients with impaired clotting mechanisms.

Ischaemic limbs with ulcers where tissue perfusion is inadequate to support healing.

Cellulitis.

Diabetic foot ulceration. (Unless under supervision of Vascular Team or Foot Health Department)

Fungating malignant wounds

Where wounds are near, vascular structures, Dacron grafts, prosthesis, dialysis fistula, hands face or feet with the exception of the heel.

Necrotic toes or fingers

12.4 Criteria for sharp debridement

Sharp debridement of necrotic or sloughy tissue may take place if; the nurse wishing to undertake the procedure, working in accordance with the NMC code of professional conduct and in line with Trust Policy believes that sharp debridement offers the greatest advantage for the patient above other methods of debridement or in cases where other methods of debridement have been unsuccessful.

12.5 Criteria for Versajet debridement

Versajet debridement may take place if the Tissue Viability Nurse Specialist undertaking

the procedure working in accordance with the NMC code of professional conduct and in line with Trust Policy believes that it offers the greatest advantage for the patient above other methods of debridement.

12.6 Procedure of communication with other disciplines prior to Versajet or sharp

debridement.

The nurse wishing to undertake sharp debridement must ensure that:

Procedure Rationale

The intention to debride should be discussed with the responsible medical team and should be documented in the patient’s medical notes. If the medical team involved hold an objection to such debridement this should be written clearly in the patients notes in advance of any debridement taking place.

The proposed procedure is discussed with the patient and is documented in line with Trust Consent Policy.

To gain the opinion of the medical staff regarding sharp debridement, and to ensure they agree and support the decision to sharp debride.

To inform the patient of their condition and provide them with insight into the options available and reasons why sharp debridement has been chosen and to gain consent for the procedure.

12.7 Procedure for debridement258

256

Doughty D. (1992) Principle of wound healing and wound management. In Bryant R.A (ed) Acute and Chronic wounds: Nursing Management. St. Louis, MO: Mosby 257

O Brien M, (2003) Debridement : ethical, legal and practical considerations. Wound Care March 2003


45

Procedure Rationale

Routine procedures to ensure patient comfort and safety will be followed.

Routine analgesic normally provided for the individual concerned prior to dressing changes will be provided. However to ensure patient comfort and allay anxiety additional analgesia may be prescribed by Medical Staff or Independent Prescribers if required.

Aseptic technique and a sterile debridement pack /Versajet pack will be used.

An additional nurse will be present to comfort the patient throughout the procedure and assist the debridor.

Additional gauze and bandages will be at hand in case of accidental haemorrhage.

Good seating and lighting will be available for the debridor.

No callous or chronic ulceration tissue with a blood supply will be removed by sharp debridement. Suspected Biofilm or devitalised granulating tissue can be debrided using Versajet Debridement

Necrotic eschar and sloughy tissue only will be removed via sharp debridement.

If accidental cutting of viable tissue should occur, direct pressure will be applied with sterile gauze until bleeding ceases. A haemostatic pressure dressing can also be used.

259

If direct pressure fails to control bleeding within 15 minutes medical staff will be contacted for immediate assistance.

In all cases of accidental bleeding an entry to detail the extent of the situation will be made in the medical notes.

To ensure the patient is comfortable and safely positioned for the procedure.

As debridement of necrotic issue only will take place, there should be no reason to cause increased pain and thus no requirement for additional or stronger analgesia however holistic patient assessment may indicate that additional analgesia may enhance the patient experience and ensure an improved outcome.

To prevent cross infection.

To comfort the patient and ensure that the debridor is assisted when necessary.

To ensure immediate control of any accidental bleeding.

To promote optimum visualisation of the area to be debrided.

The purpose of debridement is to remove necrotic, sloughy tissue only and in the case of versajet biofilm and senescent devitalised tissue only.

To remove devitalised tissue and facilitate proliferation of the wound bed.

To ensure accidental blood loss is minimal and that no haemodynamic instability occurs.

To obtain expert assistance in curtailing blood loss.

To ensure patient records provide evidence of the event and the action taken to minimise patient harm

If accidental cutting of healthy tissue occurs medical staff will be contacted to discuss the possibility of prophylactic antibiotics.

All patients who have undergone sharp debridement or Versajet debridement should be monitored for signs of bleeding or pyrexia following the procedure.

The patient’s notes will be updated giving full details of the extent of debridement and providing instructions for aftercare. Together with date of review by the Debridor. Versajet handset serial

numbers will be place in the notes.

A registered nurse will inspect the wound after 24 hours and any deterioration reported to the

If medical staff feels there might be a risk of septicaemia as a result of incident, prophylactic antibiotics may be provided to reduce the risk.

To detect any signs of complications as a result of the procedure and to ensure prompt action should such events take place.

To provide good record of the procedure and ensure good communication will all staff regarding aftercare.

To check that the wound is healthy and to detect any complication. Should complication

258

Doughty D (1992) Principles of wound healing and wound management. In Bryant R.A (ed) Acute and Chronic Wounds: Nursing Management. St.Louis MO: Mosby 259

Vowden K R ( 1999) Wound debridement, Part 2: Sharp techniques. JWC Vol 8 No 6 291-293


46

debridor and medical staff immediately. occur the debridor and medical staff will provide advice regarding action to be taken.

DEBRIDEMENT PORTFOLIO


47

PATIENT DETAILS NAME: ADDRESS: DATE OF BIRTH: HOSPITAL NUMBER: CONSULTANT:

BRIEF MEDICAL DETAILS

DETAILS OF AREA TO BE DEBRIDED

RESULTS OF PROCEDURES OF RELEVENCE

TECHNIQUE TO BE USED INCLUDING SERIAL NUMBER OF VERSAJET HANDSET

DESCRIPTION OF PROCEDURE

EVALUATION OF DEBRIDEMENT

FOLLOW UP VISIT

BRIEF DESCRIPTION OF ANY COMPLICATIONS AND TREATMENT

MEDICAL EVALUATION OF END RESULT NAME: SIGNATURE:

TRAINING RECORD


48

COURSES

DATE & VENUE COURSE TITLE

RECORD OF CLINICAL OBSERVATION

CLINICAL AREA OBSERVED

INDIVIDUAL

PROCEDURES

OBSERVED

DATE


49

13 MONITORING OF ADHERANCE TO GUIDELINE It is the responsibility of clinical teams to regularly audit wound care practice as part of their audit cycle. Appendix 4 provides an audit tool which has been developed to facilitate the review of practice relative to these guidelines. It is recommended that clinical teams incorporate wound management into their audit cycle as a regular occurrence and action plan to achieve continuous improvement.

14 EDUCATION This guideline has been compiled to facilitate the continuous education of clinical groups. In addition the Tissue Viability Service provides regular training sessions to support these guidelines. Detail of planned training can be obtained from the Trust Education Directory available on the Intranet


50

Appendix 1

The MUST Nutrition Risk Score


51

“MUST” FOR COMMUNITY HOSPITALS AND RESIDENTIAL

/NURSING HOMES

“MUST” FOR THE COMMUNITY

“MUST” SCORE RECORDING SHEET


52

STEP 1 + STEP 2 + STEP 3 BMI Score * Weight loss score Acute disease effect score

STEP 4 - Overall risk of malnutrition

Add scores together to calculate overall risk of malnutrition

Score 0 = Low risk Score 1 = Medium risk Score 2 or more = High risk

STEP 5 - Care Plan

MUST = 0 (LOW RISK) (If BMI is greater than 30 kg/m2 then include a healthy eating plan)

ROUTINE CARE: -

Repeat MUST score weekly in Community Hospitals and monthly in Residential/Nursing Homes

MUST = 1 (MEDIUM RISK)

OBSERVE: -

Observe intake using food chart and fluid chart

If oral intake is poor encourage oral intake, offering high calorie snacks and meals – implement

“Food First”

If there is no improvement then there is clinical concern – implement nutrition care plan

If improved/adequate oral intake then there is little clinical concern – continue routine care

Repeat MUST weekly in Community Hospitals, and monthly in Residential/Nursing Homes or more

frequently if clinical condition deteriorates

MUST = 2 or More (HIGH RISK)

TREAT: - (Unless detrimental or no benefit is expected from nutritional support e.g. terminal phase of illness)

Observe intake using a food chart and fluid chart

Implement nutrition care plan

Aim to improve and increase oral intake. This could be done by offering high calorie snacks

and meals and nutritional supplements. Implement “Eat Well Tray System” and/or “Food First”

If no improvement after 7 days (Hospital) or 4 weeks (NH), consider referral to the dietitian

Also refer to dietician if MUST is 3 or more and BMI < 18.5 kg/m2

Monitor and review care plan weekly in Community Hospitals and monthly in Res/Nursing Homes

*If height, weight or BMI cannot be obtained due to strict bed rest, the following criteria can assist your

professional judgement of the patient’s nutritional risk: -

a) BMI

Clinical impression – thin; acceptable weight; overweight. Obvious wasting (very thin) and obesity

(very over weight) can also be noticed.

b) Unplanned weight loss

Clothes and/jewellery have become loose fitting

History of decreased food intake, reduced appetite or swallowing problems over 3 – 6 months,

and underlying disease or psycho-social/physical disabilities are likely to cause weight loss

BMI kg/m2 Score =

> 20 0

18.5 – 20 1

< 18.5 2

Unplanned weight loss in past

3 – 6 months

% Score =

< 5 0

5 -10 1

> 10 2

If the patient is acutely ill

AND there has been or is

likely to be NO nutritional

intake for > 5 days

Score 2

MALNUTRITION UNIVERSAL SCREENING TOOL (MUST)

FOR COMMUNITY HOSPITALS and

RESIDENTIAL/NURSING HOMES


53

STEP 1 + STEP 2 + STEP 3

BMI Score * Weight loss score Acute disease effect score

STEP 4 - Overall risk of malnutrition

Add scores together to calculate overall risk of malnutrition

Score 0 = Low risk Score 1 = Medium risk Score 2 or more = High risk

STEP 5 - Care Plan MUST = 0 (LOW RISK) (If BMI is greater than 30 kg/m

2 then include a healthy eating plan)

ROUTINE CARE: -

Repeat MUST score annually for at risk patients e.g. those over 75 yrs

People with neurological degenerative diseases need to be monitored every 4 months

MUST = 1 (MEDIUM RISK)

OBSERVE: -

Observe intake using food chart and fluid chart

If oral intake is poor encourage, offering high calorie snacks and meals – implement

“Food First”

If there is no improvement then there is clinical concern – implement nutrition care plan

If improved/adequate oral intake then there is little clinical concern – continue routine care

Repeat MUST at least every 2 – 3 months

MUST = 2 or More (HIGH RISK)

TREAT: - (Unless detrimental or no benefit is expected from nutritional support e.g. terminal phase of illness)

Observe intake using a food chart and fluid chart

Implement nutrition care plan

Aim to improve and increase oral intake. This could be done by offering high calorie snacks

and meals and nutritional supplements. Implement “Food First”

If no improvement after 4 weeks refer to the dietitian

Also refer to dietician if MUST is 3 or more and BMI < 18.5 kg/m2

Monitor and review care plan monthly

*If height, weight or BMI cannot be obtained due to strict bed rest, the following criteria can assist your

professional judgement of the patient’s nutritional risk: -

a) BMI

Clinical impression – thin; acceptable weight; overweight. Obvious wasting (very thin) and obesity

(very over weight ) can also be noticed

b) Unplanned weight loss: -

Clothes and/jewellery have become loose fitting

History of decreased food intake, reduced appetite or swallowing problems over 3 – 6 months, and

Underlying disease or psycho-social/physical disabilities are likely to cause weight loss

BMI kg/m2 Score =

> 20 0

18.5 – 20 1

< 18.5 2

Unplanned weight loss in past

3 – 6 months

% Score =

< 5 0

5 -10 1

> 10 2

If the patient is acutely ill

AND there has been or is

likely to be NO nutritional

intake for > 5 days

Score 2

MALNUTRITION UNIVERSAL SCREENING TOOL

(MUST)

FOR THE COMMUNITY


54

MUST Score Recording Sheet

Name: Usual weight (kg)

Location: Height (m)

Date Weight A = Actual

E = Estimated U =

Unable to weigh –

with rationale

Step 1

BMI Score

Step 2

Weight loss score

Step 3

Acute disease score

Step 4

MUST score

=

1+2+3

Risk

0 = Low

1 = Medium

2 = High BMI kg/m

2 Score Weight

loss %

Score Print and sign name

Date Step 5: Action taken Review Date


55

Appendix 2

TVS Referral Form

TNP Referral Form

Care Pathway for a Patient with a Wound

Care Pathway for MRSA infected Wound


56

Tissue Viability Department

1st Floor Birchwood House

St Margaret’s Hospital The Plain

Epping Essex, CM16 6TN

Tel: 01992 561 666 Ext 5551 Fax: 01279 827178

TISSUE VIABILITY PATIENT REFERRAL FORM Ward referrer to complete sections 1 to 6 fax no 01279 827178. All Sections must be completed before TVS will accept referral.

Sssss Date of Referral:

Section 1: Referrer’s Details:

Name: Contact Tel No: Name of Hospital/ G.P. Practice/Clinic

Section 2: Patients Details:

Name: D.O.B Address: Tel No: G.P and G.P Base: Consultant:

NHS No

Is the Patient eligible for NHS care Yes No

Section 3: Consent:

Patient consents to being assessed by TVN? Yes No

Section 4: Referral Details:

Wound Management Pressure Ulcer Category/Grade 1 Surgical 2 for all Category 2 & above Traumatic 3 please provide Burn 4 incident form no -------------------- Malignant Other Duration: Waterlow Score Must Score Has a SET SAF 1 Form been completed, please give date -----------------------------------------

Has TNP Therapy been requested Yes No

Pressure Reducing/ Relieving Mattress: Propad □ Alpha x cell □ Auto x cell □

Eclipse □ Nimbus 2 □ Nimbus 3 □ Biwave □ Airwave □ Other □ State:

Section 5: Wound Details

Site: Sacrum Trochanter Buttocks Heels: Left Right Both Head Other State:

Tissue Appearance: Necrotic %, Sloughy %, Granulating %, Epithelialising %

Current Wound Management (State):

Please attach copy of current Wound Assessment Form and TV Care Plans:

Medical History/ Diagnosis/ is patient taking Steriods / Nsaids

Section 6

Is the Patient Diabetic YES / NO CBG------------ HbA1c -------------- Urinalysis ----------

Tissue Viability Department 1

st Floor Birchwood House


57

St Margaret’s Hospital The Plain

Epping Essex, CM16 6TN

Tel: 01992 561 666 Ext 5551 Fax 01279 827179

TISSUE VIABILITY TNP REFERRAL FORM Referrer to complete sections 1 to 5 and fax no 01279 827178

Sssss Date of Referral:

Section 1: Referrer’s Details:

Name: Contact Tel No: Name of Hospital/ G.P. Practice/Clinic

Section 2: Patients Details:

Name: D.O.B Address: Tel No: G.P and G.P Base: Consultant: NHS No

Is the Patient eligible for NHS care Yes □ No □

Section 3: Reason TNP Required

Hospital Acquired Pressure Ulcer: Yes/No Category/Grade: Which Hospital? Community Pressure Sore: Sore present on admission to Acute Trust Yes/No District Nurse or Practice Nurse involved: Yes/No District Nurse or Practice Nurse Name: Acute Wound: Reason required: Surgeons Name: Chronic Wound: Reason required:

Section 4: Ordering TNP

When was TNP Therapy commenced: Who requested commencement: How long will TNP be required: Should funding be refused what other treatment could be used: If TNP is used what is the potential reduction in length of stay: State method of TNP: (Gauze or Foam)………….. Canister in use ……………Dressings in use ……………

Section 5: Wound Details:

Site: : Sacrum Trochanter Buttocks Heels: Left Right Both Head Other State:

Tissue Appearance: Necrotic %, Sloughy %, Granulating %, Epithelialising % Please attach copy of current Wound Assessment Form:

Brief Medical History/Diagnosis

Section 6: N.B Tissue Viability Nurse to complete Section 6

Appointment Made: Date…………………. Time………………am/pm

Tissue Viability Nurse: Name……………………….. Signature……………….


58

Care Pathway for a Patient with a Wound

Acute Wound less then

6 weeks old.

Chronic Wound more than 6 weeks old

Is the wound healing well without complications.

YES NO

Continue normal post

operation plan

Refer to Tissue

Viability Team for

assessment

Has the G.P / Medic/ Surgeon been

informed?

Is the wound healing well, and likely to be healed

within 12 weeks

GP, Medic, Surgeon to be contacted

for advice/ review

& consideration for referral to

Tissue Viability Service

NO YES

NO YES

Consider a review of

management by Tissue

Viability Team to check

that care is optimum

Follow advice given & make Tissue

Viability referral concurrently for

collaborative care

Tissue Viability Service to be involved, collaborating with Surgeon

to support patient in primary care.


59

Care Pathway for MRSA Infected Wound

All MRSA infected wounds must be referred to the Tissue Viability Service, the Leg Ulcer Service or Podiatry (According to Type of Wound) within 72 hours of diagnosis.

YES

Wound Dressing Options

Iodoflex

Actilite Honey

Physiotulle Ag

Sorbisan Silver flat

Allevyn AG

Wound Dressing Options

Iodoflex

Algivon

Aquacel AG

Sorbisan Silver packing

Suprasorb X Plus PHMB

Larval Tharapy

TNP Therapy

NO

Heavy Exudate?

MRSA Colonised Antibiotics not required

Treat according to condition of wound bed and TIME.

MRSA Locally/systemically infected. Treat with antibiotics as per SEPT WEL Guidelines

Holistic Wound Assessment and complete SEPT WEL WAF

Identify wound aetiology and develop care plan for appropriate treatment


60

Appendix 3

Proforma Care Plans

These care plans are available electronically and

must be amended and tailored electronically to

each individual patient wound before printing. Please speak to your team leader or ward manager for access or contact The Tissue Viability Dept on

EXT 5551


61

WOUND CARE PLAN

Patient’s Name:

Address:

G.P Details: D.O.B: Hosp. No:

DATE/TIME

PATIENT PROBLEM/NEED RGN SIGNATURE REVIEW DATE

Patient has a clean epithelialising flat wound (State where and cause) If the wound is a leg ulcer refer to the leg ulcer guidelines. Patient understands nature of problem and consents to treatment.

DATE/TIME

GOAL RGN SIGNATURE REVIEW DATE

Maintain patients involvement and concordance. Ensure patients pain is controlled.

T: Promote epithelialisation

I: Reduce inflammation and maintain bacterial balance


E: Measure advancing edges

DATE/TIME

NURSING ACTION/INSTRUCTION RGN SIGNATURE REVIEW DATE

Discuss progress with patient, explaining changes and maintaining concordance.

Wound Assessment Form (WAF) completed:

Date:

The WAF must be completed at each dressing

change.

If a pressure ulcer, develop a care plan to prevent deterioration and development of new sores.

Provide analgesia 30 minutes prior to dressing change if required, record pain rating on WAF. Establish a pain care plan if required.

If wound is clean no cleaning is required. Sterile saline should be used if cleaning is required to remove dressing debris.

Minimal exudate: Use semi -permeable film

Low/moderate exudates: Non - adherent or low adherent dressing

Moderate exudate: Hydrocolloid sheet

DATE/TIME

FREQUENCY OF DRESSING CHANGE RGN SIGNATURE REVIEW DATE

Follow manufacturers guidelines regarding frequency of dressing changes and state this on this plan

Change dressing every ……………..Days. However all dressings should be changed when strike through occurs or if the dressing is soiled from other sources.

Refer to the Tissue Viability Service if wound is failing to progress.

DATE/TIME

OTHER INSTRUCTIONS: RGN SIGNATURE REVIEW DATE

Care plan discussed and agreed with patient Patient signature:………………………


62

WOUND CARE PLAN

Patient’s Name:

Address:

G.P Details: D.O.B: Hosp/NHS. No:

DATE/TIME


Patient has a granulating cavity wound (State where and cause) If the wound is a leg ulcer refer to the leg ulcer guidelines. Patient understands nature of problem and consents to treatment.

DATE/TIME


Maintain patients involvement and concordance.

Ensure patients pain is controlled.




E: Prevent closure of edges before would base heals Measure advancing edges and base of wound.

DATE/TIME




Date:

The WAF must be completed at each dressing change.

If a pressure ulcer develop a care plan to prevent deterioration and development of new sores.



Minimal exudate: use Hydrocolloid paste. Cover with adhesive N/A dressing.

Moderate exudate: Alginate rope or Hydrofibre rope. Cover with adhesive non adherent dressing.

High exudate: High absorbent Alginate or Hydrofibre. Cover with Foam or Hydrocolloid sheet.

TNP Therapy will manage a high amount of exudate and accelerate healing from the base of the wound.

DATE/TIME

FREQUENCY OF DRESSING CHANGE: RGN SIGNATURE SIGNATURE

Follow manufacturer’s guidelines regarding frequency of dressing changes and state this on this plan.

Change dressing every……………..Days. However all dressings should be changed when strike through occurs or if the dressing is soiled from other sources.

Refer to TVS if wound is failing to progress.

DATE/TIME OTHER INSTRUCTIONS: RGN SIGNATURE REVIEW DATE


WOUND CARE PLAN


63

Patient’s Name:

Address:


DATE/TIME


Patient has a granulating non-cavity wound (State where and cause) If the wound is a leg ulcer refer to the Leg Ulcer Guidelines Patient understands nature of problem and consents to treatment.

DATE/TIME








DATE/TIME




Date:


change.




Minimal exudate: use Hydrocolloid adhesive sheet.

Moderate exudate: Hydrocolloid fibre covered with Hydrocolloid sheet.

High exudate: High absorbent Alginate or Hydrofibre. Cover with a Foam or sheet. A gauze pad may also be used for additional absorbancy as an outer layer.

DATE/TIME


RGN SIGNATURE REVIEW DATE


Change dressing every……………..Days. However all dressings should be changed when strike through occurs or if the dressing is soiled from other sources.


DATE/TIME

OTHER INSTRUCTIONS: RGN SIGNATURE SIGNATURE


WOUND CARE PLAN

Patient’s Name:


64

Address:


DATE/TIME


Patient has an infected wound. (State where and cause) If the wound is a leg ulcer refer to the Leg Ulcer Guidelines. Patient understands nature of problem and consents to treatment.

DATE/TIME




T: Debridement of sloughy and necrotic tissue

I: Reduce inflammation and control bacterial balance


E: Measure advancing edges and base of wound

DATE/TIME


Discuss progress with patient, explaining changes

and maintaining concordance. Provide analgesia 30 minutes prior to dressing change, record pain rating on WAF.


Date: The WAF must be completed at each dressing change.



Clean with sterile saline 0.9%, Stellisept wash or povidine iodine solution if an antiseptic is required to remove dressing debris

Minimal exudate: use a Hydrogel held in place with a N/A Pad.

Moderate exudate: use an Alginate or Hydrofibre held in place with a non-adherent Pad.

High exudate: use an Alginate or Hydrofibre held in place with a foam dressing.

Do not use occlusive dressings on infected

wound until antibiotic therapy has controlled the

infection.

DATE/TIME




Change dressing every………………….days. However all dressings should be changed when strike through occurs or if the dressing is soiled from other sources.


DATE/TIME



WOUND CARE PLAN

Patient’s Name:

Address:


65


DATE/TIME


Patient has a hard necrotic eschar covering a wound. (State where and cause) If necrotic area is a toe or hand do not debride, seek advice from medical staff or Tissue Viability Service If the wound is a leg ulcer refer to the Leg Ulcer Guidelines Patient understands nature of problem and consents to treatment.

DATE/TIME




T: Debride necrotic tissue




DATE/TIME




Date:


change.


Provide analgesia 30 minutes prior to dressing change if required, record pain rating on WAF. Establish pain care plan if required.

Refer patient to a clinician who can sharp debride wound OR use debridement agents such as

Hydrocolloid sheet:

Hydrogel:

Secure primary dressing with non-adherent dressing where required

DATE/TIME






DATE/TIME




66

WOUND CARE PLAN

Patient’s Name:

Address:


DATE/TIME


Patient has a sloughy wound ( Cavity) (State where and cause) If the wound is a leg ulcer refer to the Leg Ulcer Guidelines Patient understands nature of problem and consents to treatment.

DATE/TIME


Maintain patients involvement and concordance. Ensure patients pain is controlled.

T: Debride Slough




DATE/TIME


Discuss progress with patient, explaining changes and maintaining concordance


Date:


change.



Clean with Sterile Saline to remove debris.

Minimal Exudate: Hydrogel, & non adherent dressing

Moderate Exudate: Hydrogel and non adherent pad.

High Exudate: Hydrocolloid fibre rope and foam dressing. A gauze pad can be used as an outer dressing if additional absorbency is required.

DATE/TIME

FREQUENCY OF DRESSING CHANGE: RGN SIGNATURE REVIEW DATE



Refer to the Tissue Viability Service if wound is failing to progress

DATE/TIME




67

WOUND CARE PLAN

Patient’s Name:

Address:


DATE/TIME PATIENT PROBLEM/NEED RGN SIGNATURE

REVIEW DATE

Patient has a sloughy wound (Non Cavity) (State where and cause) If the wound is a leg ulcer refer to the Leg Ulcer Guidelines) Patient understands nature of problem and consents to treatment.

DATE/TIME


Maintain patient involvement & concordance. Ensure patients pain is controlled

T: Debride Slough




DATE/TIME


Discuss progress with patient, explaining changes and maintaining concordance. .


Date: The WAF must be completed at each dressing

change.



Clean with Sterile Saline to remove debris

Minimal Exudate: Hydrocolloid sheet

Moderate Exudate: Hydrocolloid fibre dressing and Non adherent pad.

High Exudate: Alginate and foam dressing. A gauze pad can be used as an outer layer if additional absorbency is required

DATE/TIME


Follow manufacturer’s guidelines regarding frequency of dressing changes and state this

on this plan. Change dressing every

………..Days. However all dressings should be changed when strike through occurs or if the dressing is soiled from other sources.

Refer to the TVS if failing to progress.

DATE/TIME



68

WOUND CARE PLAN

Patient’s Name:

Address:


DATE/TIME PATIENT PROBLEM/NEED RGN SIGNATURE REVIEW DATE

Patient has a uncomplicated post surgical wound (State where ) Patient understands nature of problem and consents to treatment.

DATE/TIME


Maintain patient involvement &concordance. Ensure patients pain is controlled.





DATE/TIME




Date:

The WAF must be completed at each

dressing change.


If wound is clean no cleaning is required. Sterile saline should be used if cleaning is required to remove debris.

Leave wound exposed after 48 hours or cover with semi-permeable film dressing.

DATE/TIME



Change dressing every………….. Days. However all dressings should be changed when strike through occurs or if the dressing is soiled from other sources.

DATE/TIME

OTHER INSTRUCTIONS RGN SIGNATURE REVIEW DATE


69

Appendix 4

Wound Management Audit Tool

Staff questionnaire

Questionnaire answers

Patient questionnaire

Audit tool

70

WOUND MANAGEMENT STANDARD STAFF QUESTIONNAIRE

CODE

QUESTION

ANSWERS

P1

1. Name five factors which impair wound healing in patients?

a) b) c) d) e)

P2

What factors can promote wound healing? (Include two local

and two systemic factors)

Systemic a)

b)

local a) b)

S5 &

S10

What would be the cleaning solution for a granulating wound

(non- infected)?

S5 &

S10

What would be the dressing for a granulating wound with:- a) minimum exudate b) low exudate c) moderate exudate d) heavy exudate

a) b) c) d)

S5 &

S10

What would be the cleaning solution for a sloughy wound (non-

infected)?

71

CODE

QUESTION

ANSWERS

S5 &

S10

What would be the dressing for a sloughy wound with:-

a) low exudate b) moderate exudate c) heavy exudate

a) b) c)

P3 What does the acronym TIME stand for?

S10 &

P4

Give an example of the following dressings:- a) Semipermeable b) Alginate c) Hydrocolloid d) Hydrogel e) Foam

a) b) c) d) e)

S3 &

P4

Where would you commence a wound care plan?

S3 &

P4

When would you photograph or trace/illustrate a wound?

S8A What is the basic procedure that minimises the risk of cross

infection?

S8

B&C

Name two means by which bacteria is transferred: a) b)

S8 If you are concerned about cross infection, where would you

obtain advice?

a) b)

72

WOUND MANAGEMENT STANDARD STAFF ANSWERS

CODE

QUESTION

ANSWERS

P1

Name five factors which impair wound healing in patients?

Hypoxia Sleep deprivation Low blood flow Drugs eg Steroids Pain Reduced immunity Stress Jaundice Infection Uraemia Poor nutrition Length and type of operation Abnormal blood sugar levels

P2

What factors can promote wound healing? (Include two local

and two systemic factors)

Systemic Nutrition Analgesia Sleep Adequate blood supply to wound Antibiotics Adequate oxygenation

Local Maintenance of high humidity between wound and dressing Removal of excess exudate and toxic components Thermal insulation Dressing impermeable to bacteria Freedom from particles and toxic wound contaminants A traumatic removal of dressings Maintenance of a physiological pH and promotion of O2 delivery to wound surface

S5 &

S10

What would be the cleaning solution for a granulating wound

(non- infected)?

Sodium Chloride 0.9%

73

CODE

QUESTION

ANSWERS

S5 &

S10

What would be the dressing for a granulating wound with:-

a) minimum exudate b) low exudate c) moderate exudate d) heavy exudates

a) Non-adherent or semi occlusive/semipermeable b) Hydrocolloid c) Foam d) Alginate or Hydrocolloid fibre

S5 &

S10

What would be the cleaning solution for a sloughy wound (non-

infected)?

Sodium Chloride 0.9%

S5 &

S10

What would be the dressing for a sloughy wound with:-

a) low exudate b) moderate exudate c) heavy exudate

a) Hydrocolloid sheet or Hydrogel b) Hydrocolloid fibre c) Alginate and Foam

P3 What does the acronym TIME stand for?

Tissue, Infection, Moisture, Edges

S10 &

P4

Give an example of the following dressings:- a) Semipermeable b) Alginate c) Hydrocolloid d) Hydrogel e) Foam

a) C View, Episil Film. b) Kaltostat, Sorbsan. c) Granuflex, Comfeel. d) Activheal Gel, Nugel e) Allevyn, Lyofoam, Biatain

S3 &

P4

Where would you commence a wound care plan?

Where a wound exists

74

CODE

QUESTION

ANSWERS

S3 &

P4

When would you photograph or trace/illustrate a wound?

All wounds should be measured as part of the wound assessment process, see WAF. Photographs can also be taken, however they must be calibrated with a ruler and consent must be obtained

S8A

What is the basic procedure that minimises the risk of cross

infection?

Hand washing before patient contact and between each patient contact

S8

B&C

Name two means by which bacteria is transferred: a) dust particles b) droplet nuclei

S8 If you are concerned about cross infection, where would you

obtain advice?

a) The Infection Control folder b) The CNS, Infection Control

75

WOUND MANAGEMENT STANDARD

QUESTIONS TO ASK THE PATIENT

CODE

QUESTIONS

P12

Do you know how the wound will be dressed (Dressing name)?

P12 & O5

Do you know how often you wound will be redressed?

O6A

Do you find the dressing painful?

O6B If yes, were you given painkillers before the dressing?

76

AUDIT PROTOCOL FOR TISSUE VIABILITY WOUND CARE STANDARD

Audit Objective: To check that patient receive care in line with ratified guidelines on wound management

Sample: Two patients and their notes

Time Frame: Annually

Auditor(s): Tissue Viability Nurse or Nursing Staff responsible for patient

Audit Criteria

Structure

Process

Outcome

Method of

Data

Collection

Points allocated

(yes=1) (no = 0)

STRUCTURE

1. Has the patient and the wound been assessed by a registered Nurse within 24 hours of admission or the time agreed on the patients wound care plan?

Check

2. Is there access to a copy of the SEPT WEL Guidelines on Wound Management (2011)

Check

3. Is a) the Wound Assessment Form (WAF) available on the ward for each patient with an open wound? b) Have all wounds present on admission been traced or photographed with written consent c) Is TVS/LUS/Podiatry involved if wound is MRSA positive?

Check

4. Is the pre printed Wound Care Plan template available electronically or in paper.

Check

5. Is (a) Sterile Normal Saline for wound cleansing available and (b) Dressing products available to dress the wound?

Check

6. Are dressing packs available? Check

7. Is a ruler/instrument to measure the wound available? Check

8. Can nurses describe the principles of preventing cross infection in relation to: (a) handwashing (b) instruments (c) dust particles and droplet nuclei

Nurse Questionnaire

9. Are the following multidisciplinary staff available by phone or in person to give advice on wound management: (a) Tissue Viability Nurse Specialist (b) Pharmacist (c) Medical Staff

Check

10. Can nursing staff involved in application of solutions and dressings emonstrate knowledge of the therapeutic and adverse effects of dressings and solutions used?

Check

77

Audit criteria

Structure

Process

Outcome

Method of

Data

collection

Points allocated

(yes=1) (no = 0)

Comments

PROCESS

1. Is the patient assessed and factors which delay wound healing identified within 24 hours of admission or the agreed time frame on the care plan?

Documentation & Nurse Question

2. Are actions instituted to minimise delaying factors? Documentation & Nurse Question

3. Is the patient’s wound assessed according to the TIME Acronym using the WAF?

Documentation

4. Is a care plan developed which identifies appropriate: (a) solutions (b) dressing products for wound type

Documentation & Nurse Question

5. Is the wound cleansed using solutions identified on the care plan?

Documentation & observation

6. Is the wound dressed using products identified on the care plan?

Documentation & observation

7. Is the wound dressing product applied correctly?

Observation

8. Do the prescription chart and care plan name the same dressing if appropriate?

Documentation

9. Are the principles of preventing cross infection adhered to? Observation & Nurse Questionnaire

10. Is the wound evaluated at each dressing change or and recordings made on the WAF

Documentation

11. Is the care plan revised as the wound classification changes?

Documentation

12. Is the patient informed of the nature of: (a) wound dressing ? (b) how often it will be changed?

Ask Patient & Check documentation

13. Is the patient assessed for pain and discomfort, and are analgesics offered?

Ask Patient & Check documentation

78

Audit Criteria

Structure

Process

Outcome

Method of

Data

collection

Points allocated

(yes=1) (no = 0)

Comments

OUTCOME

1. Has the patient and the wound been assessed by a registered Nurse within within 24 hours of admission or within the time frame agreed on the care?

Documentation

2. Is the cleansing solution appropriate for the classification of the wound?

Documentation

3. Is the dressing product used appropriate for the classification of wound?

4. Is TVS/LUS/Podiatry involved in all cases of MRSA infection

Documentation

5. Is there evidence that the wound is healing (eg reduction in size, depth or improved classification)?

Documentation

6. Does the patient know (a) the frequency of dressing changes (b) The name of the dressing (c) that they feel involved in their care

Ask Patient

7. Does the patient find: (a) the wound dressing painful and (b) were they offered analgesics

Ask Patient

79

THE AUDIT RESULTS FOR

WOUND CARE STANDARDS

KEY FINDINGS

RESULTS

TOTAL POINTS

POINTS OBTAINED

PERCENTAGE

ACHIEVED

%

80

ACTION PLAN

PROBLEM IDENTIFIED

SUGGESTED ACTION

STAFF

RESPONSIBLE

Proposed

Completion

Date

Actual

Completion

Date

WECHS /TVS/WCP/Competencies Band 5 and above. Sept 2011

Adapted from Queens Medical Centre Nottingham competence framework and acquired

via Tina Chambers at Hampshire Primary Care Trust. Further additions made by Cathy

Malone Senior CNS TVS WECHS April 2010, & Sept 2011

81

Appendix 5

Competency Assessment

Self Assessment Competency Statement

Clinical Competency framework for Wound Assessment and Management





82

Self-Assessment Competency Statement

Wound Assessment and Dressing Selection

Surname: Forename(s):

Dept & Ward / Unit:

Job title / designation:

Self-verification of competence is undertaken by assessment against the statements below. These statements are designed to indicate competence to undertake this skill. If you are in any doubt regarding your competence, you should seek education or advice (consider self-directed learning, clinical experts coaching and formal training) to bring about improvement. Your statement of competence will provide evidence towards the following dimensions in the knowledge and skills framework: Core dimension 1: Communication: Level 3 a,b,c,e,f Core dimension 3: Health, Safety and Security: Level 3 a, b, c, d, e Core dimension 5: Quality: Level 2 a, b, e, f Health and Well Being: HWB1 Level 1: HWB2 Level 3: HWB5 Level 3: HWB6 Level 2 Carry out an initial assessment. You must be able to answer ‘Yes’ to all the questions before considering yourself to be competent. If you are not competent, instigate learning and then repeat self-verification

Ask yourself the following questions.

Initial

assessment

date:

Final

assessment

date:

Have I read the Trusts guidelines for Wound

Management; Pressure Ulcer and Leg Ulcer

Management?

Yes / No Yes / No

Can I explain the need for a holistic patient

assessment in conjunction with a wound

assessment?

Yes / No Yes / No

Can I explain the different wound types and the

stages of healing? Yes / No Yes / No

Can I identify slough, necrotic, granulating and

epithelial tissue? Yes / No Yes / No

Can I identify when taking a wound swab is

appropriate? Yes / No Yes / No

Do I know which dressings are in the Trust

Formulary? Yes / No Yes / No

Can I undertake a wound assessment and

complete the relevant assessment form? Yes / No Yes / No

Can I identify the types of dressings which are

suitable for different wound types and / or

symptoms?

Yes / No Yes / No

Can I explain to the patient my rationale for the

chosen treatment regime? Yes / No Yes / No

Do I understand the need to gain consent and

maintain privacy and dignity throughout the

wound assessment and procedure?

Yes / No Yes / No

Do I know:

- When an aseptic or clean technique should be

undertaken? Yes / No Yes / No





83

- What solution should be used to clean acute

and chronic wounds? Yes / No Yes / No

- What the indications and contraindications are

for hydrocolloids, hydrogels, films, and

antimicrobial dressings?

Yes / No Yes / No

- How to apply and remove each dressing

according to the manufacturer’s

recommendations to avoid trauma and

discomfort?

Yes / No Yes / No

- How to use Topical Negative Pressure,

including application, removal, trouble shooting

and cancellation of pump

Yes / No Yes / No

- Which dressings may alleviate pain and / or

odour? Yes / No Yes / No

- How long a treatment regime should be

adhered to before the treatment is stopped or

changed?

Yes / No Yes / No

- How to identify a clinical infection? Yes / No Yes / No

- The difference between contamination,

colonisation and infected wounds? Yes / No Yes / No

- Do I know when to initiate and stop

antimicrobial dressings?

- Do I know how to treat and protect skin

surrounding a wound? Yes / No Yes / No

-Do I know when and how to refer to the Tissue

Viability Service Yes / No Yes / No

Who to involve in all cases of MRSA Wound

infection? Yes / No Yes / No

TVS/TCS/ WCP Competency Framework Form June 2010

84

STATEMENT OF COMPETENCE I certify that I am aware of my professional responsibility for continuing professional development and that I am accountable for my actions. With this in mind I make the following statement:

I am competent to undertake wound assessment and management without

further training Signature: Date: My Team Leader is aware of my competency and evidence of my competency is included within my annual Appraisal. Team Leader Signature & Name …………………………………………….

I require further training or supervision before I can undertake wound assessment and management in a competent manner

Signature & Name …………………………………………………………… Date:………………………. My Team Leader is aware of my competency deficits and my annual appraisal identifies learning needs to be addressed within the next 6 months through training and clinical supervision opportunity within my Team or with the Tissue Viability Service. The Clinical Competency Framework for Wound Assessment and Management will be the method used to direct and record that training and supervision has taken place. Team Leader Signature & Name……………………………Date:…………………………….

Keep this form in your personal portfolio or training record. Ensure your manager has seen the form

when completed.

A new self-assessment competency statement must be completed each year for Personal Development

Review.

Indicate how you plan to meet your learning needs:

By when:


85

Clinical Competency Framework for Wound Assessment and Management

The aim of this clinical competency framework is to demonstrate that supervised correct wound assessment, application of

dressings and completion of an individualised holistic patient wound care plan has been achieved in a productive clinical

learning environment.

Name of Student…………………………………….. Clinical Base assessment undertaken:…………………….

Completion of the clinical competencies should be within 2 months from attending SEPT West Essex ½ day training and action any areas identified in the Self Assessment Competency Statement.

Successful completion of competencies has been assessed by: Name & Signature of clinical assessor……………………………………….…………………………... Date..…. /…/… (Primary assessor of wound assessments, application of dressing and completion of care plan) Name & Signature of clinical assessor……………………………………………………………...…Date..…. /…/… (Secondary assessor, a student may have one or two assessors) Name & Signature of Team leader………………………………………….………………………..….….Date…../…/….

Name & Signature of Assessee……………………………………………………………..…………….…. ..Date …./…/….. Name & Signature of TVS Lecturer on Wound Management ½ day…………..……………………..…Date…./…./… ( Please attach certificate of Attendance to Competency form)

The Assessee is expected to undertake 2 wound assessments, and complete 2 wound care plans specific to the wound and the patient’s

holistic needs assessment. This may be repeated if the student requires further support. The assessor must ensure that each individual assessment is signed of at the top of each page. The assessor must also initial each box relating to the performance criteria of each individual assessment undertaken. There is a space at the end of each assessment for the student to add comment s relating to their performance whilst undertaking each

wound assessment and dressing and how they overcame any difficulties they encompassed during the procedure. Adapted from competency frameworks of Lynfa Edwards and used with permission of @Lynfa Edwards

Developed further be Cathy Malone CNS TVS For WECHS WCP MAR 2010 & Sept 2011


86

Competence Performance

Criteri

Evaluation method Assessment

1

Date… ……

Assessors Name &

Signature……………

Assessment

2

Date… ……

Assessors Name &


Assessee

Comment relating

to performance.

How they

overcame any

difficulties? 1. Has knowledge of

underlying medical

conditions & holistic

assessment of patient and

ability to link all these factors

with wound healing

1.1 Demonstrates an ability to communicate and explain to patient the rationale for assessment and wound care management.

Questioning &

Direct observation

1.2 Demonstrates understanding of the importance of a Consistent Assessor in wound management and how this translates in practice by frequent reassessments by the Care Plan Initiator for each patient, ensuring continuity of care and adding value and benefit to the level of assessment and care provided.

Questioning &

Direct observation

1.3 Explores patients lay and health beliefs in order to determine ability to adhere and comply with chosen wound management care plan including obtaining patient consent. Identifies other co-morbidities within assessment documentation. Is aware of pain levels and takes action to address pain within care plan.

Questioning &

Direct observation

2. Assesses patients wound

taking action to ensure safe

practice, Traces wound, WAF

completion and care plan

production

2.1 Identifies type of wound including classification of tissue, explaining the desired outcome and effect of treatment within the wound management care plan. Correctly completes the wound assessment form (WAF)

Questioning &

Direct observation

2.2 Correctly chooses a dressing product including demonstration of understanding as to why and when a wound needs redressing.

Questioning &

Direct observation

2.3 Correctly applies dressings adhering to infection control practices and completes notes.

Questioning &

Direct observation

2.4 Demonstrates understanding of the use of Advanced Wound Care Products such as Topical Negative Pressure & antimicrobials. Demonstrates the skill of how to apply such treatment including trouble shooting a, resolution of therapy problems and cancellation of pump.

Questioning &

Direct observation


87

Competence Performance

Questioning &

Direct observation Assessment

1

Date… ……

Assessors Name &


Assessment 2

Date… ……

Assessors Name &


Assessee

Comment relating

to performance.

How they

overcame any

difficulties

3. Identifies and

establishes action to

protect areas of further

risk including pressure

injury risk, infection

risk, nutrition risk,

moving & handling etc

3.1 Care plan and notes reflect adherence and action to address additional risk factors

Questioning &

Direct observation

4. Demonstrates an

understanding

of the theory of wound

types, classification and

grading. Knowledge on

how identify wound

infection

4.1 Aware of Trust wound care, pressure area and leg ulcer guidelines and knows how to access. Aware of NICE guidelines and how to access

Questioning &

Direct observation

4.2 Knowledge of WECHS Dressing Formulary and how to access. Ability to identify generic dressing types

Questioning &

Direct observation

4.3 Ability to diagnose wound infection, acting appropriately including taking of swab and amending care plans to address the infection

4.4 Aware of involving TVS/LUS/Podiatry for all cases of MRSA infection

Questioning &

Direct observation


88

Appendix 6

Wound Care Bundle


89

WOUND CARE BUNDLE

WOUND CARE ACTIONS

1. Hygiene Hands are decontaminated immediately before and after each patient contact, using correct hand hygiene technique.

260

2. Personal Protective Equipment Disposable apron and gloves are worn and disposed of following use and between each patient

261

3. Risk Assessment Holistic assessment of patient including wound and pain assessment, in line with SEPT West Essex Locality Wound Care Guidleines occurs with all patients with wounds.

4. Dressings All wounds are dressed in line with SEPT West Essex Locality Wound Care Guidelines

262 and Dressing Formulary Guidelines.

5. Documentation All wound assessments are documented, dated and signed in patient notes within 6 hours of care provision

263 All wound care is supported with a detailed care plan which

is reviewed weekly and updated as the wound progresses.

6. Patient Information All patients provided with information on their wound care including frequency of changes and types of dressings in use.

264

7. Referral to other Health Care Specialists Referrals are made to relevant clinicians such as Tissue Viability or Leg Ulcer Services as appropriate where there is failure to progress or when clinically indicated and especially

265 266

to surgical teams when relevant or podiatrists in the case of diabetic foot ulceration.

8. Diabetes Optimal glucose control is maintained in patients with diabetes. Referral to the patients GP or Physician should be made to assess control and treat as required. Referral to the Specialist Community Diabetes Service may be made for Type 1 and

260

Pratt RJ, Pellowe CM, Wilson JA et al (2007) epic 2: Nastional evidence-based guidelines of r preventing

healthcare-associated infections in NHS hospitals in England. Jr Hosp Infetion. 65:S1-S64 261

Pratt RJ, Pellowe CM, Wilson JA et al (2007) epic 2: Nastional evidence-based guidelines of r preventing healthcare-associated infections in NHS hospitals in England. Jr Hosp Infetion. 65:S1-S64 262

WECHS 2009) Wound Care Guidelines. www.wepct.uk 263

NMC (2008) The Code, Standards of Conduct, performance and ethics for nurses and midwives. 264

NICE (2005) Prevention and Treatment of Pressure Ulcers: Guidance for patients, public, cnd carers www.nicw.org. 265

Diabetes uk (2009) Putting feet first; Commissioning specialist services for the management and prevention of diabetic foot disease in hospitals. www.diabetes.org.uk/Documents/Reports/putting Feet First 010709.pdf 266

NICE (2008) Surgical site infection: prevention and Treatment of Surgical Site Infection. CG74 www.nice.org.uk/nicemedia/pdf/CG74FullGuideline.pdf

http://www.wepct.uk/

http://www.diabetes.org.uk/Documents/Reports/putting


90

Type 2 diabetics on insulin who are socially/psychologically compromised (ie house bound/care home) if control is suboptimal following GP agreement.

267 268

269

9. Off loading Any wound on the foot or pressure point should be off loaded including providing appropriate footwear and insoles, this is particularly the case if the patient is diabetic.

270

10. Pressure Ulcers All Patients placed on minimum of high specification foam mattress within 2 hours of admission, upgraded to dynamic system if high risk or signs of any pressure ulcers or wounds on pressure points within 6 hours of admission.

271 272

11. Communication of Infection status Clear communication of patients known to be infected or colonised with pathogenic organisms including MRSA, is given to all relevant healthcare providers involved in patient’s care.

273

Observation Care

Action

1

Care

Action

2

Care

Action

3

Care

Action

4

Care

Action

5

Care

Action

6

Care

Action

7

Care

Action

8

Care

Action

9

Care

Action

10

Care

Action

11

All

Actions

1

Y N Y Y Y Y Y Y Y Y Y N

2

Y Y N Y N Y N Y N Y N N

3

Y Y N/A Y N/A Y N/A Y N/A Y N/A Y

4

Y Y Y Y Y Y Y Y Y Y Y Y

5

Y Y Y Y Y Y Y Y Y Y Y Y

Total number

of times an

individual

action was

compliant

5 4 4 5 4 5 4 5 4 5 4 3

% when

action of care

was compliant

100% 80% 80% 100% 80% 100% 80% 100% 80% 100% 80% 60%

267

Tadman J (2011) Input on guidelines email communication. 23/8/11 268

Bongiovanni C (2006) Nonsurgical Management of Chronic Wounds in patients with Diabetes. The Journal of Vascular Ultrasound 30 (4):215-218 269

NICE (2008) Surgical site infection: prevention and Treatment of Surgical Site Infection. CG74 www.nice.org.uk/nicemedia/pdf/CG74FullGuideline.pdf 270

Donnelly J, Winder J, Kernohan W G (2011) An RCT to determine the effect of a heel elevation device in pressure ulcer prevention post hip fracture. JWC Vol 20 No 7 pg 309-318 271

NICE (2005) The prevention and treatment of pressure ulcers. www.nice.org.uk/CG029 272

WECHS (2011) Prevention and Management of Pressure Injury. www.wepct.uk 273

DOH (2008) The Health and Social Care Act: Code of Practice on the prevention and control of infection and related

guidance> DOH, London. http://www.dh.gov.uk/en/Publicationsandstatistics/Publication/PublicationsPolicyAndGuidance/DH

122604

http://www.dh.gov.uk/en/Publicationsandstatistics/Publication/PublicationsPolicyAnd