wound care guidelines

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WOUND CARE GUIDELINES

March 2008


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BOLTON PRIMARY CARE NHS TRUST&

BOLTON HOSPITALS NHS TRUST

WOUND CARE GUIDELINES

CONTENTS

A INTRODUCTION ................................................................................................................................................. 2 B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES ......... ........... .......... ........... ... 5 B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES ( CONTINUED ) .......................6 B:2 P RESSURE ULCERS : DRESSING SELECTION ............................................................................................................. 7 C: 1 LEG ULCERS: THE FACTS (AETIOLOGY) ..................................................................................................... 8 C2 LEG ULCERS : DRESSING SELECTION ....................................................................................................................... 9 D: DIABETIC FOOT ULCERS...............................................................................................................................10

E: W OUND I NFECTION .................................................................................................................................................. 11 F: W OUND BED PREPARATION & D RESSING SELECTION .............................................................................................. 12 G: M INOR WOUNDS D RESSING SELECTION .............................................................................................................. 13 H: CELLULITIS.......................................................................................................................................................... 14 I: WOUND COMPLICATIONS:............................................................................................................................... 15 I:1 O VERGRANULATION ............................................................................................................................................15 I:2 - H YPERTROPHIC / K ELOID SCARS .......................................................................................................................... 15 I: 3 - F UNGATING WOUNDS ...........................................................................................................................................16 J: WOUND CLASSIFICATION................................................................................................................................ 17 K MECHANISMS OF WOUND HEALING ......................................................................................................... 18 L WOUND ASSESSMENT ................................................................................................................................... 18

Wound Bed..................................................................................................................................... ...19Wound Measurement ............................................................................................................................19

Exudate .................................................................................................................................................19 Infection................................................................................................................................................20 Pain.. ...............................................................................................................................20 Surrounding Skin ..................................................................................................................................21

M FACTORS DELAYING WOUND HEALING............ ........... .......... ........... .......... ........... .......... ........... .......... ... 21 N NUTRITIONAL ASPECTS OF WOUND HEALING............ ........... .......... ........... .......... ........... .......... ........... . 23 O WOUND MANAGEMENT ................................................................................................................................ 26

i. Wound Cleansing...................................................................................................................................26 ii. Choice of Dressings..............................................................................................................................27

P: FORMULARY OF PRODUCT GROUPS WITH R ECOMMENDATIONS FOR USE ............................................................ 29 REFERENCES.31 APPENDICES:............................................................................................................................................................35

1. Clinical Evidence Grading Criteria ......................................................................................................35

2. Wound Care Assessment Tool ...............................................................................................................35

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A INTRODUCTION

The wound care guidelines have been developed by clinicians who are treating patients with wounds.They reflect current research and evidence based expert opinion.

The guidelines are intended for use as a resource for wound management and should be available to allmedical,nursing and therapist caring for patients with wounds in Bolton Primary Care NHS Trust andBolton Hospitals NHS Trust,Bolton Hospice and The Beaumont Hospital. Evidence basedrecommendations are included and a formulary of wound care products is included to promote rational

prescribing.

These guidelines have been produced for use by any member of the healthcare team.They are notintended as a substitute for professional judgement but are in support of the practitioner making aninformed decision relating to the management of the patient,in accordance with individual professionalcompetence.

The guidelines have been developed incorporating available evidence of best practice. Where evidenceof best practice is not available, expert opinion has been sought and consensus agreement between themulti-professional team has been reached.

Acknowledgement to the patients who are part of the leg ulcer service who gave valuable commentsand advice on leg ulcer management.

They will be reviewed annually and updated every two years. Comments from users of the guidelinesare welcomed.

Authors:

Jacqui Ashton Consultant Nurse Tissue Viability Nicky Morton Tissue Viability Specialist NurseSusan Beswick Podiatrist Bolton Hospitals NHS TrustVivienne Barker Tissue Viability Podiatrist Bolton PCTFreda Blackburn Sister Beaumont HospitalCarolyn Wright Dietetics Manager Bolton Hospitals NHS TrustLisa Turner Pharmacist Bolton Hospitals NHS TrustKathryn Morton Dietitian Bolton PCT

Andrea Jennings District Nurse



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Reviewers:

Hannah Dobrowolska Assistant Chief Executive Bolton PCTMr. G Ferguson Consultant Vascular SurgeonMr. G Shepard Consultant Orthopaedic Surgeon

Mr. R Hopkins Consultant ObstetricianJackie Solomon Deputy Director of Nursing Bolton Hospitals NHS TrustPeter Hilton Manager Podiatry Bolton PCTIrene Pennington Podiatry Manager Bolton Hospitals NHS Trust



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Summary of Conclusions and Grading of Recommendations :

Recommendation Grade ofEvidence

Holistic assessment of the patient is an essential part of the wound care process C

All patients with wounds will have their wounds assessed by nursing staff within24 hours of admission to an episode of care

C

Optimal nutrition facilitates wound healing, maintains immune competence anddecreases the risk of infection.

B

It is essential to consider the nutritional status of all patients with wounds.Referral to the dietitian should then be made where appropriate

B

Wound cleansing(where necessary) should be carried out by irrigation with sterilenormal saline warmed to body temperature

C

For chronic wounds such as leg ulcers, ordinary tap water can be used B

Antiseptics are toxic to human tissue and may delay wound healing B

Topical antibiotics are frequent sensitisers and should be used with caution B

Systemic antibiotics should be used to treat clinical wound infections A

Wound dressings should: maintain a moist environment at the wound/dressing interface.

(The only possible exceptions are peripheral necrosis secondary to arterial disease). be able to control (remove) exudate. A moist wound environment is good, a wet

environment is not beneficial not stick to the wound and cause trauma on removal protect the wound from the outside environment aid debridement if there is necrotic or sloughy tissue in the wound (caution with

ischaemic lesions) keep the wound close to normal body temperature be acceptable to the patient be cost-effective Diabetes choose a dressing that will allow frequent inspection

B

Please refer to Appendix 2 for Evidence Grading Criteria.

NB For wounds failing to respond to treatment according to the guidelines please refer to theTissue Viability Servic.Tel No 01204 360005/2



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B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES

INDICATOR /DESCRIPTOR

ACTION

Grade 1Non-blanchable

erythema of intact skin.Discolouration of the skin,warmth, oedema, induration orhardness may also be used asindicators, particularly onindividuals with darker skin.

Must relieve pressure, regular skin inspection Do not cover area easy visual inspection Adhesive dressing could cause tissue damage Re-position patient 2 4 hourly. Turning ch Appropriate pressure relieving equipment m

patient 2 4 hourly Assess nutritional needs

Grade 2 Partial thic kness skin lossinvolving epidermis, dermis, orboth.The ulcer is superficial andpresents clinically as anabrasion or blister .

Relieve pressure, observe frequently, do not c Small blisters may resolve without interventi If partial skin loss protect area with a thin f Assess nutritional needs

Large blistered area Drain blister large blisters will not resolve wreleasing the fluid with a sterile needle, until dispersed

Non adherent foam dressing Relieve the pressure, observe at least daily

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B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES (continued)

INDICATOR /DESCRIPTOR

Grade 3

Full thickness skin lossinvolving damage to or necrosisof subcutaneous tissue that mayextend down to, but not throughunderlying fascia .

Must relieve pressu Avoid packing if sa

further pressure to t Assess nutritional n Assess patient for a

equipment accordinetc

If known peripheraldebride heel presViability

Otherwise, refer to wound managemen

Grade 4

Full thicknessExtensive destruction, tissuenecrosis, or damage to muscle,bone, or supporting structureswith or without full thickness skinloss.

Must relieve pressu Avoid packing if sa

further pressure to t Assess nutritional n Assess patient for a

equipment accordinetc

If known peripheraldebride heel pres

Viability Otherwise, refer to wound managemen

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C2 Leg Ulcers: Dressing Selection

Tissue Type Indicator/Descriptor

Managementaims

Partial thickness Full thickness

Necrotic Identified bypresence ofpredominantlyblack / browntissue

To rehydrateeschar andreduce risk ofinfection

Primary dressing:Hydrogel

Secondary Dressing:Semi-permeable film dressing to

occlude the area


Secondary DressinSemi-permeable filmdressing

Sloughy Identified byformation ofviscous,predominantlyyellow tissue

To remove alldebris andpromoteautolysis


Secondary Dressing:Non-adherent foam if heavyexudates or Non adherentcontact dressing light/moderateexudate


Secondary DressinNon-adherent foamIf slough persists concadexomer iodine

Granulating Wound hasgranularappearance, looksred and bleedseasily

To promoteangiogenesisand aid woundhealing

Non-adherentwound co ntact layer

Non-adherentwound co ntact lay

Epithelialising Wound is pink inappearance, tissuevery fragile andneeds to be keptmoist

To protect newtissue and allowfinal stage ofhealing

Non-adherentwound co ntact layer

Non-adherentwound co ntact lay

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E: Wound Infection According to the most recent figures wound infection in the UK accounts for 10.7% of all hospital-acquired infections and 0.7% of comminfection. Extra costs include in-patient stay, diagnostic procedures, cost of treatment, nursing time, pain, anxiety and quality of life. Wounbe used as a key quality indicator but care should be taken to compare criteria for definition between centres.

TYPE Indicator / Descriptor Management aims Treatment Options

Colonised Exudate leNo Low M

Multiplications oforganisms with, asyet, no host reactionPositive swab/biopsy

Prevent infectionReduce bacterialnumbersPrevent bacterialproliferation

PrimaryDressing:Hydrogel

SecondaryDressingThin Foam

PDH

SDF

Critically Colonised Sufficient organismspresent to interferewith healing but not

invading surroundingtissue, therefore noinflammationCharacteristics:Pain, excess exudate, Dull,dark red granulation tissue,wound is static and delayedhealing

Reduce bacterialnumbersPrevent bacterial

infectionRemove barriers tohealing


SecondaryDressingThin Foam

PDC

SDF

Clinically infected Deposition andmultiplication ofbacteria with host

reactionCharacteristics ofinfectionPain, Erythema,Inflammation, Pyrexia, Pus,Odour, Heavy exudate,Non-healing

Resolve deepinfection usingsystemic antibiotics

Reduce bacterialnumbersTreat symptomsPrevent septicaemiaRemove Barriers tohealing


SecondaryDressing:Thin foam

PDC

SDF

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F: Wound Bed Preparation & Dressing Selection

This is simply the removal of local barriers to healing. Modern wound dressings provide excellent healing rates but there are still a certain pchronic wounds that fail to heal. If the wound bed is properly prepared this may yield faster healing rates from existing products and hence effectiveness.

Type Indicator/ Descrip tor Management Aims Treatment Options OtheNecrotic / Sloughy Identified by presence of

black non-viable / yellowviscous tissue

To rehydrate eschar andremove the physicalbarriers to healing

Primary Dressing:Hydrogel

Secondary Dressing: Adhesive Foam Dressing

High bacterial Count Identified by a chronicwound not healing, with orwithout clinical signs of

infection

To reduce the bacterialnumbersPrevent bacterial

proliferationRemove barriers to healing

Primary Dressing:Cadexomer Iodine


Chronic Exudate Copious amounts of woundexudateMaceration of surroundingskinLack of wound healing andcell proliferation

Control the wound exudatewhilst avoiding dessicationof wound bedKeep surrounding skin drywhilst maintaining a moistwound environment

Primary Dressing:Hydrofibre


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G: Minor Wounds Dressing SelectionThe minor injuries market consists of: cuts, abrasions, minor burns/scalds, skin flaps, sprains and strains. Such wounds are classified as thoto the epidermis or superficial damage has occurred. These wounds are characterised by redness, minor bleeding and skin abrasion and are commonly seen from day to day

Tissue Type Indicator/Descriptor

Managementaims

Broken Shallow

Necrotic Identified bypresence ofpredominantlyblack / browntissue

To rehydrateeschar and reducerisk of infection


Secondary Dressing:Film or adhesive foam


Secondary DressinFilm or adhesive fo

Sloughy Identified byformation of

viscous,predominantlyyellow tissue

To remove alldebris and promote

autolysis


Secondary Dressing:Film or adhesive foam


Secondary DressinFilm or adhesive fo

Granulating Wound hasgranularappearance,looks red andbleeds easily

To promoteangiogenesis andaid wound healing

Non-adherentwound con tact layer

Non-adherentwound con tact la

Epithelialising Wound is pink inappearance,tissue very fragile

and needs to bekept moist

To protect newtissue and allowfinal stage of

healing

Non-adherentwound con tact layer

Non-adherentwound con tact la

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H: CELLULITISCellulitis of the lower limb can usually be managed in the community with appropriate antibiotics if recognised at an early stage. Where celluantibiotics may be required and can, in most cases be administered at home via the Rapid Response Team. Very occasionally cellulitis of the loadmission.Antibiotics are the essential basis for therapy in these cases and they will rarely require a Tissue Viability Referral.

TYPE Indicator / Descripto r Management aims Treatment Options Ot

Cellulitis of theLower Limb

The extent of the Erythema shouldbe marked as soon as it is i dentifiedthen monitored to determinewhether the cellulitis isincreasing or resolving withantibiotic therapy.

Exudate levels

No Low Mod - High

The patient w illcomplain of feelingunwell with flu likesymptoms.

Characteristics:BlisteringPain,

Erythema,Inflammation,Pyrexia,Pus,Odour,Heavy exudate,Non-healing

Resolve deep inf ectionusing systemicantibiotics

Drain blister large blisterswill not resolve withoutaseptically releasing thefluid with a sterile needle,

until all the fluid isdispersed

Reduce bacterial numbersTreat symptomsPrevent septicaemiaRemove Barriers to healing

As the blisters and woundsdry out, rehydrate dry legsby washing the legs inwarm water with Aqueouscream

PrimaryDressing:Non Adherentdressing

SecondaryDressingWool and crepetoe to knee

Primary Dressing: Absorbent pads

Secondary DressingWool and crepe toe toknee

Change regularlyaccording to exudate

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I: WOUND COMPLICATIONS:

I:1 Overgranulation

Type Indicator / Descrip tor Management aims Treatment Options Overgranulation occurs at

the proliferative stage ofwound healing. It presentsclinically as granulationtissue raised above thelevel of the surroundingskin

To reduce further

development of granulationtissueTo promoteepithelialisation over thesurface of the woundTo effectively managewound exudateTo provide a dressing thatis comfortable andacceptable to the patient

Foam dressing mus

non adhesiveShort term Hydrocort1% to be applied to aof 3mm daily

Seek advice from tissviability service if noimprovement within tweeks

I:2 - Hypertrophic / Keloid scars

Type Indicator / Descrip tor Management aims Treatment Options Other CoHypertrophic Red/dark raised scar within the

boundary of the original woundand can be very itchy orpainful.

Typical causes: Following anyinjury. Result of an imbalancein production of collagen in ahealing wound.More common in the young.

To flatten and fade scar and toimprove function and mobilityover a joint

Silicone gel sheet

Keloid As above.Keloid scars are most commonin dark skinned people

To flatten and fade scar and

to improve function andmobility over a joint

Silicone gel sheet

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I: 3 - Fungating woundsFungating wounds are caused by a local tumour infiltrating the skin, or by metastatic spread from the primary tumour. Both ulceration and pmalignant growth may be present and consequently may require a number of planned interventions to control the exudate and odour, minimiprevent maceration of the surrounding skin. Although the separate indicators are listed below and described more fully in the sub-sections, fungating wounds (as with other complex wounds) is often by a combination of therapies.

Type Indicator /

Descriptor

Management aims Treatment O

Wound exudate Manage excessexudatesControl slough/necroticdebrisKeep moist

Alginate modHydrofibre Hexudate

Odour Control odourCheck for infection

Irrigate withmetronidazole Topical applicaMetrotop gel

Maceration Keep skin as dry aspossible to protect frombreakdown

Charcoal dressprotective barrifor surrounding

Difficult sizes and sites Dress with appropriateproduct

Foam dressing

Pain Use an appropriateprimary dressing thatcan be left in place forup to 7 days

Silicone dressi

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J: WOUND CLASSIFICATION

A wound may be defined as a defect or break in the skin that results from physical, mechanical orthermal damage, or that develops as a result of the presence of an underlying medical or

physiological disorder (Thomas, 1990)

Abrasions (grazes) are superficial wounds, generally caused by friction as a result of glancing ortangential contact between the skin and a harder or rougher surface. Abrasions are generallyconfined to the outer layers of the skin.

Lacerations (tears) are more severe than abrasions and involve both the skin and the underlyingtissues.

Penetrating wounds may be caused by knives, bullets, or may result from accidental injuriescaused by any sharp or pointed object. Internal damage can be considerable depending upon thesize and depth of penetration, and/or the velocity of the bullet or missile.

Bites caused by animals or humans may become infected by a range of pathogenic organismsincluding spirochetes, staphylococci, streptococci, and various gram positive bacilli. If untreated,these infections may have very serious sequelae, involving fascia, tendon and bone.

Burns and chemical injuries There are several different types of burns: thermal, chemical, electrical, and radiation. Thermalinjuries are the most common. Burns and scalds (thermal) may be classified into three typesdepending upon the degree of tissue damage.

Superficial (first degree) burns involve only the epidermis and superficial layers of the dermis andusually result from exposure to prolonged low intensity heat.

Deep dermal (second degree) burns, in which most of the surface epithelium is destroyed togetherwith much of the dermal layer beneath. Only some isolated epidermal elements in the deeper layerremain visible such as those within hair follicles and sweat glands.

Full thickness (third degree) burns, in which all the elements of the skin are destroyed.

Chronic Ulcerative Wounds

Ulcers can be divided into different types depending upon their underlying cause.

Pressure ulcers are usually caused by the sustained application of surface pressure over a bony prominence, which inhibits capillary blood flow to the skin and underlying tissue. If the pressure is not relieved it will ultimately result in cell death followed by tissue necrosis and breakdown.

Leg or foot ulcers, which may be venous, ischaemic, mixed venous and ischaemic or traumaticin origin.



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Diabetic foot ulcers Ulcers associated with certain systemic infections. Ulcers resulting from radiotherapy. Ulcers resulting from malignant disease.

K MECHANISMS OF WOUND HEALING

Irrespective of the nature or type of wound, the same basic biochemical and cellular procedures arerequired to bring about healing.

The following types of wound healing are generally recognised.

PRIMARY CLOSURE. Most clean surgical wounds and recent traumatic injuries are managed by primary closure. Thesurgeon approximates the edges of the wound and individually sutures the different layers of tissue

together.

OPEN GRANULATION. In wounds that have sustained a significant degree of tissue loss as a result of surgery, trauma orchronic ulceration, it may be undesirable or impossible to bring the edges of the wound together.The wound is left to heal by secondary intention.

DELAYED PRIMARY CLOSURE. Delayed primary closure is carried out when, in the opinion of the surgeon, primary closure may beunsuccessful (due to the presence of infections, a poor blood supply to the area, or the need for theapplication of excessive tension during closure). In these circumstances, the wound is left open for

about three to four days before closure is affected.

GRAFTING AND FLAP FORMATION. A skin graft is a portion of skin (composed of dermis and epidermis) that is removed from oneanatomical site and placed onto a wound elsewhere on the body. If successful, grafting will ensurethat the wound will heal rapidly, thus reducing the chance of infection. The disadvantage of thistechnique is that the patients finishes up with two wounds instead of one, and the donor site can bemore painful than the original injury.

L WOUND ASSESSMENT

Guideline Statement

Holistic assessment of the patient is an essential part of the wound care process.

All patients with wounds will have their wounds assessed by nursing staff within 24hours of admission to an episode of care (hospital or community).



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To link in with the wound assessment tool, classification by wound bed tissue type is used inaddition to the following factors:Wound measurement, exudate, presence of infection, pain and condition of surrounding skin.

Wound Bed

Necrotic Wound containing dead tissue. It may appear hard, dry and black. Dead connective tissue mayappear grey. Eschars with time may soften by autolysis and bacterial liquefacation. The presence ofdead tissue in wounds delays healing.

Sloughy Slough is formed by an accumulation of dead cells in the wound exudate. It is light yellow incolour and must not be confused with infected tissue and pus.

Granulating Healthy red tissue, which occurs during the proliferative phase of healing. Firbroblasts migrate tothe wound to produce collagen fibres. The tissue is well vascularised and bleeds easily.

Epithelializing Process by which the wound surface is covered by new epithelium, this begins when the wound hasfilled with granulation tissue. The tissue is pink, almost white, and only occurs on top of healthygranulation tissue.

Wound Measurement

Wound measurement is a vital aid to examining the healing process within a wound. Chronicwounds should be measured 4 weekly (diabetic foot ulcers weekly).

The wound should be measured at its greatest length and breadth: The two measurements are thenmultiplied to give an approximate wound area in CM 2. This method can be unreliable wheredifferent professionals are assessing the same wound and also where the shape of the wound isquite irregular.

Exudate

Exudate is produced by all acute and chronic wounds (to a greater or lesser extent) as part of thenatural healing process but may become more viscous and malodorous in infected wounds. It playsan essential part in the healing process in that it:

Contains nutrients, energy and growth factors for metabolising cellsContains high quantities of white blood cells



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Maintains a moist environment for wound healing

Uncomplicated exudate should ideally be left undisturbed on the wound surface, however thesurrounding skin may require some cleansing in order to reduce odour and prevent maceration.

With leg ulcers, excessive exudate may be produced as a result of venous hypertension and in thiscase the patient should be referred to the appropriate leg ulcer clinic for holistic assessment anddoppler studies to determine suitability for compression.

Infection

Wound infection may be defined as the presence of bacteria or other organisms, which lead to ahost reaction. A host reaction can present as any one or combination of the following signs:(Adapted from: Cutting & Harding, 1994)

Redness (erythema) around the woundThe production of large amounts of exudate or pusA change in exudate colour

MalodourA raised systemic temperatureLocalised painLocalised heatLymphangitisDelayed or abnormal wound healingWound breakdownThe appearance of fragile tissues which may bleed easily when touched or at the time of adressing change.

Guideline Statement

Systemic antibiotics should be used to treat clinical wound infections

ntiseptics are toxic to human tissue and may delay wound healing

Pain

The pain associated with chronic wounds is often underestimated. In over 50% of cases, nursesrecording of patients pain differed from self-reporting. In most of these cases, the nurses had

underestimated the patients pain. Pain assessment tools have many advantages:Patient has a more active role in dealing with their painThe patient may feel that their pain is being taken seriouslyThe tool often prompts more effective pain relieving measures, as documented evidence exists.

In wound care, accurate assessment of pain is essential with regard to choice of the mostappropriate dressing. Assessment of pain before, during and after the dressing change may

provide the nurse with vital information for future wound management.



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Exceptions: Patients with peripheral neuropathy (often diabetic patients) who may have lostsensation in the foot and therefore are unable to feel pain in the foot.

In general, pain experienced by patients with chronic wounds, (although extremely subjective andvariable from patient to patient) falls into the following categories:

A deep, dull constant painA superficial, burning-type painA neuralgic type painAn ischaemic type painThe pain resulting from cellulitis

Whatever the cause of the pain, the patients perception of their pain should be acknowledged, andappropriate action taken to alleviate suffering.

Surrounding SkinSurrounding tissues may present as:

healthymacerateddry/flakyeczematous

blue/black discolourationoedemaerythemacellulitis

The surrounding skin should be examined carefully as part of the process of assessment andappropriate action taken.

M FACTORS DELAYING WOUND HEALING

A number of local and systemic factors are well recognised causes of delayed or impaired woundhealing. Foreign bodies introduced deep into a wound at the time of injury can, if not removed,cause a chronic inflammatory response and delay healing or lead to the formation of a granulomaor abscess. Long standing wounds that heal by epithelialisation, such as burns and leg ulcers, maydevelop Marjolins ulcer, an uncommon slow-growing squamous cell carcinoma.

Other major factors that have an important effect upon the rate of healing include the age and thenutritional status of the patient; underlying metabolic disorders such as diabetes or anaemia; theadministration of drugs that suppress the inflammatory process; radiotherapy; arterial diseasewhich may be aggravated by smoking; and the presence of slough and necrotic tissue. (Thomas,1990)



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Factors that may affect the healing process:

Increasing age

Nutrition

Dehydration

Blood Supply

Infection

Disease

Stress

Lack of Sleep

Adverse conditions at the wound site

Inappropriate wound management

Iatrogenic causes

Patient compliance/motivation

Unrelieved pressure



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N NUTRITIONAL ASPECTS OF WOUND HEALING

Nutritional status plays a critical role in the wound healing process. Neglecting the nutritionalhealth of the individual may totally compromise all wound management to be carried out.(Wallace, 1994)Optimal Nutrition Helps To Maintain Immune Competence.

THE ESSENTIAL NUTRIENTS FOR WOUND HEALING

Protein, Vitamin C, B Complex and A, Zinc, Iron and Copper are essential for wound healing.

In addition to these nutrients, it is essential that adequate energy/calories are obtained from fats andcarbohydrates to prevent tissue protein being used as a source of energy.

PROTEIN

Requirements: 1.2 2.0g protein/kg/24h

Protein is required for healing tissues. Without adequate protein normal protein synthesis andwound healing are inhibited. The immune response is diminished and there is a delay in matrixformation.

Protein Sources:- Meat, fish, eggs, milk, cheese, yoghurt, pulses and nuts. Nutritional sip feeds will provide important sources of protein andother nutrients if dietary intake is inadequate.

ENERGY

Requirements: 30-40 Kcal/kg/24h

An adequate energy/calorie intake is essential in order to prevent dietary and tissue protein beingused as a source of energy rather than for wound healing.

An excessive intake of energy, leading to obesity, also gives rise to problems with wound healing decreased mobility, increased weight bearing and vascular insufficiency may precipitate woundcomplications and increase the risk of pressure sores (Wells, 1994).

For obese patients during recovery from major surgical or trauma wounds, a strict weight-reducing

diet during this time is inappropriate, good quality nutrition is vitally important.

It is important to remember that overweight does not necessarily mean well nourished.Malnutrition is a widespread problem (Edington, et al., 1996) which affects obese and underweight

patients.

Energy Sources:- All foods provide energy and preserve tissue protein.Carbohydrate sources bread, potatoes, breakfast cereal, rice and pasta, oils,



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spreads, butter, margarine, fried foods.Fat sources oils and fats, butter, margarine, fried foods.

VITAMINS

Vitamin C

Requirements: A minimum of 60mg vitamin C. Vitamin supplements from 200 mg 1g per day aresometimes recommended [Taylor, 1974], however excessive doses may cause renal stones[Morton, 1995].

Vitamin C is required for collagen synthesis and aids iron absorption.

Vitamin C is not stored in the body with patients rapidly becoming deficient. Supplements may benecessary.

Vitamin C Sources:- Citrus fruits and juices, blackcurrant juice drinks and fruit squashes fortifiedwith vitamin C tomato juice, all fruit and vegetables.

Vitamin A

Promotes epithelialization and granulation of healing wounds.

Vitamin A Sources:- Liver, dairy products, oily fish, carrots, dried fruits.

Vitamin B Complex

Co-factor for enzyme systems in protein, fat and carbohydrate metabolism.

Vitamin B Complex Sources: Liver, kidney, meat, poultry, fortified breakfast cereals, wholemeal bread, yeast extract, eggs, and green vegetables.

Vitamin E

Controversial role. Some research states that it is beneficial, while others consider it detrimental(Mazzotta, 1994).

Vitamin K

Indirect role in wound healing, needed for normal blood coagulation.Vitamin K sources Green vegetables, potatoes, tomatoes, liver, soya beans.

MINERALS



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ZincDeficiency is associated with poor wound healing.Zinc is required for collagen synthesis, epithelialization and cell proliferation.Zinc supplements have been found to improve the healing of leg ulcers where zinc deficiency isidentified.However, where there is no deficiency excess zinc can impair healing (Wells, 1994).Zinc sources:- Liver, meat, fish, eggs, pulses including baked beans, wholegrain cereals.

Iron

Blood losses during injury or inadequate dietary intake, anaemia will result in decreased transportof oxygen to damaged tissue and may delay wound healing.Iron is required for collagen formation.Iron Sources:- Liver, meat, poultry, oily fish, egg yolk, pulses, dried fruits.

Copper

Required for collagen formation and essential for red blood cells formation.Copper Sources:- Meat, fish, cereals and pulses, green vegetables.

FLUIDS

Requirements:- 30-65 ml/kg/24h

Adequate fluids are required to prevent skin dehydration and essential with high protein diets.

Fortification of foods with energy/calories and/or protein supplements can enhance the quality ofthe diet.

Supplementary drinks such as Build-up, Complan or Vitafood provide an important source of allnutrients if dietary intake is inadequate.

Nutritional assessment .

Identification of high risk individuals allows prompt employment of nutritional support andoptimal use of resources to improve wound healing and reduce complications. [Ward et al., 1998].

Guideline Statement

Optimal nutrition facilitates wound healing, maintains immune competence and decreases the risk of infection.

It is essential to consider the nutritional status of all patients with wounds. Referral to the dietitian should then be made where appropriate.



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O WOUND MANAGEMENT

i. Wound Cleansing

Most of the research on wound cleansing examines the efficacy of wound cleansing on removal of bacteria from the wound. It is widely accepted that chronic wounds are heavily colonized with bacterial skin flora and that attempts to remove these bacteria from a chronic wound are futile.(Thomlinson, 1997)

Wound cleansing should not be undertaken to remove normal wound exudate. There is extensiveevidence to support the fact that exudate is beneficial to the wound, containing growth factors andnutrients, which actually support the healing process (Leaper, 1986)

Excessive wound exudate may require removal and may also cause local maceration of the skin.Some cleansing may be required in this case, however if the exudate is clear, enabling accuratewound assessment the surrounding skin may be cleansed leaving the wound untouched.

The following criteria for wound cleansing are recommended in accordance with recent research:

Criteria for wound Cleansing

1. To remove visible debris after a wound has initially occurred and to aid assessment2. To remove excess slough and exudate in order to aid patient comfort3. To remove remaining dressing material

(Miller & Gilchrist, 1998)

In cases where wound cleansing is necessary, warm normal saline should be used. Cell mitosis isinhibited by cooling the wound and may actually delay healing (Lock, 1980).

Irrigation is the method of choice for cleansing wounds. This may be carried out utilising asyringe in order to produce gentle pressure in order to loosen dressing debris etc., but to preventsplashback of irrigation fluid.

Gauze swabs, cotton wool etc. should not be used for cleansing the wound surface, but may be used

to wipe away excess saline/exudate from the surrounding skin following irrigation. Mechanicaldamage to new tissue and the shedding of fibres from gauze swabs/cotton wool delays healing(Wood, 1976)

26

Guideline StatementWound cleansing (where necessary) should be carried out by irrigation with sterile normal

saline warmed to body temperature.

For chronic wounds such as leg ulcers, ordinary tap water can be usedNurswc001 Review Date: March 2010


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Other Solutions Used for Wound Cleansing:The following solutions should not be routinely used in the cleansing of wounds. They shouldonly be used where the risk of infection outweighs the reported detrimental effects of the solutionand should only be used further to Consultant, Microbiological or Pharmacological advice:

Povidone Iodine only licensed as a skin antiseptic and not for use on open wounds

Chlorhexidine 0.5% shown to inhibit epithelialization and granulation of tissue (Neider &Scoph, 1986). If used on traumatic wounds with a high risk of infection, then 0.05% inaqueous form should be used.

Potassium Permanganate: No research traced relating to benefits, toxicity or allergies. BNFstates that it may be irritant to mucous membranes. Sometimes used under instructions ofdermatologist, vascular surgeon or General Practitioner for weeping eczema.

Hydrogen Peroxide: Not recommended for wound cleaning except in exceptionalcircumstances. There have been unsubstantiated reports of air emboli resulting from its use incavity wounds. (Sleigh & Winter, 1985)

Guideline Statement

Systemic antibiotics should be used to treat clinical wound infections

ntiseptics are toxic to human tissue and may delay wound healing

ii. Choice of Dressings

It should be recognised that a wound will require treating differently at various stages of itshealing. No dressing is suitable for all wounds.Following careful selection of the appropriate management plan for the patient, the wound

assessment tool should be used to monitor the progress of the wound through to its healing stage.

Guideline statement

Criteria for Choosing a Dressing In Order of Importance (Miller & Collier, 1997)

1. Choose a dressing that maintains a moist environment at the wound/dressing interface. (The only possibleexceptions are peripheral necrosis secondary to arterial disease.

2. Choose a dressing that is able to control (remove) exudate. A moist wound environment is good, a wetenvironment is not beneficial

3. Choose a dressing that does not stick to the wound and cause trauma on removal4. Choose a dressing that protects the wound from the outside environment5. Choose a dressing that will aid debridement if there is necrotic or sloughy tissue in the wound (caution with

ischaemic lesions)6. Choose a dressing that will keep the wound close to normal body temperature7. Choose a dressing that is acceptable to the patient8. Choose a dressing that is cost-effective9. Diabetes choose a dressing that will allow frequent inspection



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Dressings Supplies

Methods for wound management should be re-assessed at each dressing change. However, thefollowing list is issued as guidance to minimise wastage of prescribed dressings as the woundchanges.

Wound Type / Suggested Duration of Supply *

Black/Necrotic 7 days Sloughy 7 - 10 days

Low or no exudate >10 days Medium to high exudate 2 - 4 weeks Granulating 2 - 4 weeks

Epithelialising 2 - 4 weeks

* The amount supplied depends on the frequency of dressing changes.

Manufacturers instructions are provided with all products and these must be read and followed atall times.



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P: Formulary of Product Groups With Recommendations for Use

Alginates Formulary choice:Kaltostat (Convatec)

Sorbsan Plus (Unomedical)

Indicated in the management of moderately to heavily exuding wounds Calcium alginate with sodium alginate Active haemostatic dressing Fibres convert to a hydrophillic gel (biodegradable) when in contact with exudates

NB. Use Sorbsan Plus for very heavy exudate only

Use placed on the surface of the wound. Alginate rope can be used in cavity wounds or sinuses but do not pack tightly

Cover with film dressing or adhesive foam dressing Change every 1 - 7 days depending on amount of exudate Removal:

Kaltostat - remove with forceps once moistened with saline. At dressing changes the fibre in contact with the surface should have formed a gel. If dressingmoist but not gelled, increase interval between dressing changes. If dressing has gelled and driedout, use of a more occlusive dressing may be appropriate.

Antiseptics Formulary Choice:Cadexomer Iodine: Iodosorb &Iodoflex (Smith & Nephew)

Inadine (Johnson and Johnson)

Cadexomer Iodine is the product of choice within Bolton PCT as it releases Iodine slowly into thewound at a controlled rate.

Inadine contains 10% povidone iodine with 1% available iodine, which imparts pronounced(though short-term) antibacterial activity to the dressing (Thomas, 1990). Inadine adheres to thewound bed and is deactivated by wound exudate (in some cases in only a few hours). Absorptionof iodine occurs and therefore it is contraindicated in patients on Lithium or thyroxine therapy. Itshould NOT be used on children as it often causes trauma on removal.

The debate on the use of iodine continues at National and European levels (Gilchrist, 1997) andtherefore the use of these (and other iodine) dressings should remain restricted until clear guidanceis available.



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Foam Dressings Formulary Choice:Allevyn thin, adhesive and non-adhesive (Smith & Nephew)

Indicated for medium exuding wounds Exudate absorbed horizontally across the hydrophillic surfaceUse

Place on wound surface Secure with adhesive tape (if non-adhesive) Change every 1 - 7 days depending on volume of exudate Low adherence

Hydrocolloids Formulary Choice:Hydrocoll basic, Hydrocoll border, Hydrocoll thin film(Hartmann)

Indicated for light / medium exuding wounds Interactive with the wound exudate, slowly absorbing fluid leading to a change in the physicalstate of the dressing.

The dressing provides an environment for rapid debridement and an initial increase in the sizeor depth of the wound therefore often occurs.

Use Dressing should extend at least 2 cm beyond the edge of the wound Dressings should be changed every 3 - 7 days depending on the amount of exudate

Hydrofibre Formulary Choice:

Aquacel(Convatec)

Indicated for medium/heavy exuding wounds Interactive with the wound exudate, slowly absorbing fluid leading to a change in the physical

state of the dressing. The dressing provides an environment for rapid debridement and an initial increase in the size

or depth of the wound therefore often occurs.Use There is minimal lateral wicking therefore it can overlap healthy skin slightly When packing a wound with the ribbon, it must be very lightly packed to avoid further trauma

Hydrogel Formulary ChoicePurilon (Coloplast)

Suitable for wound debridement and for light to medium exuding wounds Dressing allows either the release of water to rehydrate surrounding tissues or the absorbtion



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of exudate from the woundUse Apply to the wound Requires a secondary dressing which will encourage occlusion (eg film or adhesive foam

dressing)

Film Dressings Formulary Choice:Mefilm (Molynlycke)

Suitable for flat/shallow low exudate wounds Sterile, thin, waterproof, self adhesive film Can be used as a retention dressing aid alone Some patients may be allergic to the adhesive

Odour Absorbing Formulary Choice:Dressings Actisorb Plus (Johnson &Johnson)

Carboflex (Convatec)

Actisorb Plus is a primary dressing and is designed to be placed directly onto a wound and coveredwith a secondary dressing. It contains 0.15% Silver, which provides antimicrobial properties, andtherefore this product, should only be used for malodorous and infected wounds.

Carboflex has an alginate wound contact layer and carbon layer for odour absorption. It is a particularly useful dressing for fungating malignant wounds.

Polysaccharide Pastes Not Available in Bolton Formulary(eg. Sugar Paste)

Unfortunately most of the evidence supporting use of sugar paste is anecdotal (Thomas, 1990),however its use for rapid debridement of slough/eschar and reduction in bacterial contaminationare frequently reported. Wounds treated with sugar paste should be redressed daily, and may causesevere pain therefore use of sugar paste is not advocated in Bolton.

Tulle Dressings Formulary Choice

Jelonet

Although this is cited as a non-adherent dressing, this dressing often adheres to the wound bed.There has also been evidence of granulation tissue protruding through the dressing, thus increasingadherence. The dressing should therefore be changed frequently to avoid this and a double layer ofthe product should be used to reduce adherence.

Antibiotic Not advised in Bolton Formulary



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ImpregnatedDressings (eg Sofra-tulle, Fucidin-Intertulle)

Due to increasing numbers of resistant strains of micro-organisms and also sensitivity reactions, theuse of antibiotic dressings is not recommended. Wherever possible antibiotics should be

administered orally, NOT by dressings applied to the wound.

Topical Negative PressureAlso known as Vacum-assissted closure (VAC KCI Medical Ltd). This is a treatment that sub-atmospheric pressure to a wound via a computerised therapy unit (Mendez Eastman 2001). Thisdevice removes excess exudates, which is collected in a canister, reduces oedema, improves themicro-circulation, decreases bacterial load and stimulates both new tissue formation and woundcontracture (Ballard and Baxter 2002). It has been shown to be effective in a variety of wounds,

particularly surgical dehiscence, pressure ulcers, leg ulcers, diabetic foot ulcers and skin grafts(Baxandall 1997:Collier 1997:Ballard and Baxter 2002).The Tissue Viabiltiy Team MUST be involved in the initial assessment for Vac therapy. Vactherapy does have a cost implication. The funding has to be agreed by a department prior toan order being placed. The Tissue Viability service does not have a budget for this treatment.

Important Note: A single product is unlikely to be suitable for a particular wound throughout the wound healing process. Regular re-assessment of the wound is essential together with documentation to supportrationale for change of dressing.Communication between the acute/community setting and joint visits with other disciplines aidholistic assessment and promote multidisciplinary team approach to wound care.

Guideline Statement

Wounds which are being managed in accordance with wound care guidelines but are deteriorating should be referred to Tissue Viability Team.

Wounds failing to respond to treatment within a four to six week period can be referred to theTissue Viability Team for review.

Please also refer to specific referral and wound management criteria for leg ulcers & diabetic oot ulcers within specific guidelines.



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Bibliography

Ballard K,Baxter H (2002) Developments in wound care for difficult to manage wounds In:WhiteR Ed Trends in Wound Care.Mark Allen Publishing:Salisbury,Wiltshire UK.

Baxandall T (1997) Healing cavity wounds with negative pressure.Elderly care 9 (1):20-2.

Burton A and Burton M., (1981) The Management and prevention of Pressure SoresLondon, Faber and Faber,

Collier M (1997) Know How:Vacuum-assisted closure (VAC).Nursing Times 93(5):32-3.

Cutting K. F., Harding, K. G. (1994) Criteria for identifying wound infection. Journal of WoundCare 3: 4, 198-201

Dealey C (1994) The Care of Wounds. Blackwell Scientific Publications, Oxford.

Duckworth, C Ed. (1996) Guide to the Research Base to Support a Wound Care Policy

Edington J., Kon P, Martyn CN. Prevalence of Malnutrition in Patients in General Practice.Clinical Nutrition, Vol 15, 1996, Pp 60-63.

Feller N. and Lurie A., The early care of wounds caused by human and animal bites,Fam Physn, 1977, 7, 29-30.

Gilchrist B.(1996) Wound infection: sampling bacterial flora: a review of the literature.

Gilchrist B (1997) Should iodine be reconsidered in Wound Management? Journal of Wound Care6: 3, 148-150

Harding K. and Jones V. (1996)

Lock, P.M. The effects of temperature on mitotic activity at the edge of experimental wounds. In:Sundell, B. (ed) Symposia on wound healing; plastic surgical and dermatological aspects. Molndal;Switzerland: Lindgren, A. & Soner, A. B., 1980

Mazzotta M. Nutrition and Wound Healing. Journal American Podiatr. Medical Association, Vol84 (9), 1994, pp 456-462.

Mendez-Eastman S (2001) Guidelines for using negative pressure wound therapy. Adv SkinWound Care 14 (6):314-325

Miller & Collier, (1997)Understanding Wounds. Professional Nurse Supplement

Miller & Gilchrist, (1998) Understanding Wound Cleansing and Infection. Professional Nurse



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Supplement

Moffatt C.J. et al, (1992) Community Clinics for Leg Ulcers and Impact on healing.BMJ 1992 305`3989-1392.

Morrison MJ, (1992) A Colour Guide to the Assessment and Management of Leg Ulcers,2nd Edition Mosby, London.

Morton, K. Nutrition and wound care. (1995) 5 th European Conference on advances in woundmanagement proceedings. 21-24 November 1995, pp 31 34

Owen-Smith M., Wounds caused by weapons of the war, in Wound Care, Westaby S. (ed), LondonHeinemann Medical, 1985, 110-120.

RCN (1998) Clinical Practice Guidelines.The Management of Patients With Venous Leg Ulcers.

SIGN (1998) The Care of Patients With Chronic Leg Ulcer.A National Clinical Guideline.ScottishIntercollegiate Guidelines Newtwork.

Sims R and Fitzgerald V (1985) Community Nursing Management of Patients withUlceration/Fungating Malignant Breast Diseases. Oncology Nursing Society London.

Taylor A. D., Taylor R. and Marcuson RW, (1998) Prospective comparison of healing rates andtherapy costs for conventional and four-layer high-compression bandaging treatments of venous legulcers. Phlebology 13:20-24

Thomas S. (1990) Wound Management and Dressings. The Pharmaceutical Press.

Thomas B. (Ed). Dietetic management of acute trauma.In Manual of Dietetic Practice, Blackwell Scientific Publications, Oxford, 1994, p 637.

Thomlinson, D. (1997) To Clean or Not To Clean? Nursing Times; 83: 9, 71-75

Wallace E. Feeding the Wound: nutrition and wound care. British Journal of Nursing Vol 3(13),1994, pp 662-667.

Ward, J. et al., Development of a screening tool for assessing risk of undernutrition in patients inthe community. Journal of Human Nutrition and Dietetics, Vol.11, No 4, 1998, pp 323 -330.

Wells L. The Importance of Nutrition in Wound Management. Professional Nurse, Vol 9, 1994, pp525-530.



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APPENDICES:

1. Wound Care Assessment Tool(a) Hospital(b) Community

2. Clinical Evidence Grading Criteria

3. Summary of Recommendations and supporting graded evidence



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Bolton Hospitals NHS TrustWOUND ASSESSMENT CHART

Date of InitialAssessment ..

Known Patient Allergies

SIZE OF WOUNDSWOUND

1WOUND

2WOUND

3

WidthLength

TYPE OF WOUNDSWOUND

1WOUND

2WOUND

3SurgicalPressure Ulcer / GradeDiabetic foot ulcerLeg UlcerOther (eg. Fungating)

POSSIBLE DELAYED HEALING DUE TO:TICK ONE OR MORE IF APPLICABLEAge 75+ Anorexia Dehydration Bedbound Chairbound Cachexia Anaemia Diabetes Vasc Disease

Oedema Incontinence Steroids Infection Other please state: If 4 or more factors consider impact on healing and try to correctfactors if possibleDate..

Name:AddressGPConsultant

Refer on to appropriate teams below ONLY if significant complication or deterioration in wound:

Infection Control (if complications) Date .. Sign .Tissue Viability Nurse (if wound deteriorating) Date .. Sign .Dietitian (if required following nutritional assessment) Date .. Sign .Pain Nurse (eg Uncontrolled pain at dressing) Date .. Sign .Podiatrist (for complex foot ulcers , footwear etc) Date .. Sign .Other (Please state) Date .. Sign .



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WOUND PROGRESS AND TREATMENT RECORDThis record should be used in conjunction with the patients care plan

Ongoing Wound Assessment:

Date

Wound NumberDESCRIPTION

Necrotic (Black) %age

Sloughy (Yellow / Green) %age

Granulating (Red) %ageEpithelialising (Pink) %ageCondition of surrounding skinEg fragile, dry etcEXUDATEExudate present (Yes or No)Odour None

SlightOffensive

Colour clearStraw

BloodPurulentAmount (Mild/ Mod/ excessive)PAINNone/mild/moderate/ severeINFECTION

Spreading ErythemaExcessive InflammationGreen Slough / ExudatePyrexiaPus (take a sample for C & S)If clinical signs of infection obtain awound swab (Date)

37 Nurswc001


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Bolton Primary Care NHS TrustWOUND ASSESSMENT CHART

Date of InitialAssessment ..

If skin tear or laceration in a residential / nursing home, please ensure that you have seendocumented evidence that the home has completed an accident / incident report prior to accepting

patient on caseloadEvidence of completed Accident / Incident Report seen Signature Date Known Patient Allergies

38

SIZE OF WOUNDSWOUND

1WOUND

2WOUND

3

WidthLength

TYPE OF WOUNDSWOUND

1WOUND

2WOUND

3SurgicalPressure Ulcer / GradeDiabetic foot ulcerLeg UlcerOther (eg. Fungating)

Name:AddressGPConsultant

Refer on to appropriate teams below ONLY if significant complication or deterioration in wound:

Infection Control (if complications) Date .. Sign .Tissue Viability Nurse (if wound deteriorating) Date .. Sign .Dietitian (if required following nutritional assessment) Date .. Sign .Pain Nurse (eg Uncontrolled pain at dressing) Date .. Sign .Podiatrist (for complex foot ulcers , footwear etc) Date .. Sign .Other (Please state) Date .. Sign .

POSSIBLE DELAYED HEALING DUE TO:TICK ONE OR MORE IF APPLICABLEAge 75+ Anorexia Dehydration Bedbound Chairbound Cachexia Anaemia Diabetes Vasc Disease Oedema Incontinence Steroids Infection Other please state: If 4 or more factors consider impact on healing and try to correct factorsif possibleDate..

Nurswc001 Review Date: March 2010


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WOUND PROGRESS AND TREATMENT RECORDThis record should be used in conjunction with the patients care plan

Ongoing Wound Assessment:

Date

Wound NumberDESCRIPTION

Necrotic (Black) %age

Sloughy (Yellow / Green) %age

Granulating (Red) %ageEpithelialising (Pink) %ageCondition of surrounding skinEg fragile, dry etcEXUDATEExudate present (Yes or No)Odour None

SlightOffensive

Colour clearStraw

BloodPurulentAmount (Mild/ Mod/ excessive)PAINNone/mild/moderate/ severeINFECTION

Spreading ErythemaExcessive InflammationGreen Slough / ExudatePyrexiaPus (take a sample for C & S)If clinical signs of infection obtain awound swab (Date)

39 Nurswc001


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Appendix 1

Levels of Evidence

This hierarchy is for use by Guideline and Pathway authors when preparing their work. It

should be used to help analyse individual items of evidence used.

Any staff using the Guidelines and Pathways should be able to see easily what type ofevidence is informing the document they refer to. Guideline and Pathway authors shouldmake this clear in their document. Good examples of this type of presentation are NICEGuidelines ( www.nice.org.uk )

1++ High quality meta analyses, systematic reviews of RCTs, or RCTs with a very low riskof bias

1+ Well conducted meta analyses, systematic reviews of RCTs, or RCTs with a very lowrisk of bias

1- Meta analyses, systematic reviews of RCTs, or RCTs with a high risk of bias

2++

High quality systematic reviews of case control or cohort or studies High quality case-control or cohort studies with a very low risk of confounding, bias, or chance and ahigh probability that the relationship is causal

2+ Well conducted case control or cohort studies with a low risk of confounding, bias, orchance and a moderate probability that the relationship is causal

2- Case control or cohort studies with a high risk of confounding, bias, or chance and asignificant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series4 Expert opinion

Grading

Grading is done by Guideline and Pathway authors when preparing their work for submission to the ClinicalEffectiveness Group. An overall single grading for the Guideline/Pathway should be stated on the document proformasubmitted for ratification.

A At least one meta analysis, systematic review, or RCT rated as 1 ++, and directlyapplicable to the target population; orA systematic review of RCTs or a body of evidence consisting principally of studiesrated as 1 +, directly applicable to the target population, and demonstrating overallconsistency of results

B A body of evidence including studies rated as 2 ++, directly applicable to the target population, and demonstrating overall consistency of results; orExtrapolated evidence from studies rated as 1 ++ or 1 +

C A body of evidence including studies rated as 2 +, directly applicable to the target

population and demonstrating overall consistency of results; orExtrapolated evidence from studies rated as 2 ++

D Evidence level 3 or 4; orextrapolated evidence from studies rated as 2

level of evidence and grading, August 2003



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Appendix 3

Evidence Ratings Used Within Guidelines

Recommendation Grade ofEvidence

Evidence to support recommendation

Holistic assessment ofthe patient is anessential part of thewound care process

All patients withwounds will havetheir wounds assessed

by nursing staff within24 hours of admissionto an episode of care

C 1. Van Rijswijk L (1996) Wound assessment anddocumentation. Chronic Wound Previews 8 (2)57-68

2++

Optimal nutritionfacilitates woundhealing, maintainsimmune competenceand decreases the riskof infection.

B 1. Albina JE (1994) Nutrition and wound healing.Journal of Parenteral and Enteral Nutrition 16:367-376

2. Martin MTM, (1998) In: Leaper D (ed)Proceedings of the 7 th European Conference on:Advances in Wound Management. London:EMAP Healthcare Ltd 129-133

3. Sitton-Kent L, Gilchrist B (1993) The intake ofnutrients by hospitalized pensioners with chronicwounds. Journal of Advanced Nursing 18: 12,1962-1967

2-

2++

2++

It is essential toconsider thenutritional status of all

patients with wounds.Referral to thedietitian should then

be made whereappropriate

B 1. Albina JE (1994) Nutrition and wound healing.Journal of Parenteral and Enteral Nutrition 16:367-376

2. Martin MTM, (1998) In: Leaper D (ed)Proceedings of the 7 th European Conference on:Advances in Wound Management. London:EMAP Healthcare Ltd 129-133

3. Sitton-Kent L, Gilchrist B (1993) The intake ofnutrients by hospitalized pensioners with chronicwounds. Journal of Advanced Nursing 18: 12,1962-1967

2-

2++

2++

Woundcleansing(wherenecessary) should becarried out by

C 1. Lock PM The effect of temperature on mitoticactivity at the edge of experimentalwounds.(1980) IN: Lundgren A , Soner AB (eds)Symposia on Wound Healing: Plasitc surgical

2++



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irrigation with sterilenormal saline warmedto body temperature

and dermatologic aspects. Sweden: Molndal

For chronic woundssuch as leg ulcers,ordinary tap water can

be used

B 1. Angeras MH, Brandberg A, Falk A, Seeman T.Comparison between sterile saline and tap waterfor the cleaning of acute traumatic soft tissuewounds. (1992) European Journal of Surgery158: 33, 347-350

1+

Antiseptics are toxicto human tissue andmay delay woundhealing

B 1. OMeara S M, Cullum NA, Majid M, SheldonTA (2001) Systematic review of antimicrobialagents used for chronic wounds. British Journalof Surgery 88, 4-21

2. Brennan SS and Leaper D J (1985) The effect ofantiseptics on the healing wound: a study usingthe rabbit ear chamber

3. Tatnall FM, Leigh IM, Gibson JR (1990)Comparative study of antiseptic toxicity on basalkeratinocytes, transformed human keratinocytesand fibroblasts. Skin pharmacology 3, 3, 157-163

1++

2++

2+

Topical antibiotics arefrequent sensitisersand should be usedwith caution

B 1. OMeara S M, Cullum NA, Majid M, SheldonTA (2001) Systematic review of antimicrobialagents used for chronic wounds. British Journalof Surgery 88, 4-21

1++

Systemic antibiotics

should be used to treatclinical woundinfections

A 1. OMeara S M, Cullum NA, Majid M, Sheldon

TA (2001) Systematic review of antimicrobialagents used for chronic wounds. British Journalof Surgery 88, 4-21

1++

Wound dressingsshould:

maintain a moistenvironment at thewound/dressing interface.(The only possibleexceptions are peripheral

necrosis secondary toarterial disease).

be able to control (remove)exudate. A moist woundenvironment is good, a wetenvironment is not

beneficial

not stick to the wound and

B 1. Winter GD (1962) Formation of the scab and therate of epithelialisation of supervicial wounds inthe skin of the young domestic pig Nature 193:293-294

2. Hinman, CD, Maibach H (1963) Effect of airexposure and occlusion on experimental skinwounds. Nature 200: 377-378

3. Dyson M, Young S, Pendle CL, Webster DF,Lang SM (1988) Comparison of the effects ofmoist and dry conditions on dermal repair.Journal of Inversitgative Dermatology 91; 5,435-439

4. Lock PM The effect of temperature on mitoticactivity at the edge of experimentalwounds.(1980) IN: Lundgren A , Soner AB (eds)

2+

2++

2++



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cause trauma on removal

protect the wound from theoutside environment

aid debridement if there isnecrotic or sloughy tissuein the wound (caution withischaemic lesions)

keep the wound close tonormal body temperature

be acceptable to the patient

be cost-effective

Diabetes choose adressing that will allowfrequent inspection

Symposia on Wound Healing: Plasitc surgicaland dermatologic aspects. Sweden: Molndal

wound care guidelines

Documents