wound mgmt guidelines sept

7/25/2019 Wound Mgmt Guidelines SEPT

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DOCUMENT REFERENCE NO:

Type: GUIDELINE

Sus

Relevant to: All PCT Clinical Staff

Produced by: Tissue Viability CommitteeResponsible 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 ofPublication

Sectionno:

Sub Folder: File:

Wound Management Guidelines

Signed ChiefExecutive


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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


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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 Intention2.2 Healing by Secondary Intention2.3 Wound Bed Preparation

2.3.1 Tissue2.3.2 Infection2.3.3 Moisture2.3.4 Edges

3. FACTORS AFFECTING THE HEALING PROCESS Pages 18-21

3.1 Factors that can delay healing3.2 Diet

3.2.1 Identification of patients at Risk3.3 Pain

3.3.1 Using opiates on wounds

4. CLASSIFICATION OF WOUND TISSUE Pages 22-23

4.1 Epithelialising Tissue4.2 Granulating Tissue4.3 Sloughy Tissue4.4 Infected Tissue4.5 Necrotic Tissue4.6 Malignant Tissue

5. WOUND ASSESSMENT Pages 23

5.1 Wound Assessment Form

6. WOUND CARE Pages 25-31

6.1 Wounds healing by First Intention6.2 Wounds healing by Secondary Intention6.2.1 Epithelialising wounds6.2.2 Granulating wounds6.2.3 Sloughy Wounds6.2.4 Infected Wounds6.2.5 Necrotic Wounds

6.3 Malignant/Fungating Wounds6.4 Criteria for Removing/Changing Dressings6.5 How to take a swab for culture6.6 How to treat overgranulating tissue


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TVS Guidelines: Wound Management/ Sept 2011

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7. PRINCIPLES OF WOUND IRRIGATION Pages 33-34

7.1 Cleansing Solutions7.1.1 Sodium Chloride 0.9% solution7.1.2 Chlorhexidine with cetrimide7.1.3 Protosan

7.1.4 Iodine

7.1.5 Stellisept

8. WOUND BED PRODUCT INFORMATION Pages 35-38

8.1 Semi Permeable Film dressing8.2 Hydrocolloids8.3 Alginates8.4 Foam Dressings8.5 Hydrogels8.6 Dressings containing charcoal8.7 Dressing containing antimicrobial

8.7.1 Honey

8.8 Protease Modulating Therapy (PMT)8.9 Larva Therapy/Biosurgery8.10 Topical Negative Pressure8.11 Topical Antibiotic

9. WOUND DRAINAGE Page 41

10. ASEPTIC NON TOUCH TECHNIQUE Page 41

11. WOUND COMPLICATIONS Page 43

11.1 Infection with/without Exudate11.2 Wound Dehiscence

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

12.1 Definition of Debridement12.2 Scope12.3 Contra-indications for versajet or sharp debridement12.4 Criteria for sharp debridement12.5 Criteria for versajet debridement12.6 Procedure of communication with other disciplines

prior to stop debridement12.7 Procedure for debridement

13. MONITORING OF ADHERENCE TO GUIDLEINES Page 50

14. EDUCATION Page 50

LIST OF TABLESTable 1 - Stages of Healing Process Page 6Table 2 - The TIME principles of Wound Bed Preparation Page 9Table 3 - Characteristics of Healthy and Unhealthy Page 10

Granulating TissueTable 4 - Signs and Symptoms of superficial and deep infection Page 14Table 5 - Types of exudates and management Page 17Table 6 - Conditions and interventions known to delay Page 18

Wound healingTable 7 - Comparison of commonly used antimicrobials Page 34Table 8Procedure for aseptic non touch technique Page 42


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

Figure 3- Numerical pain rating scale Page 20Figure 4 -Factors causing delayed wound healing Page 21Figure 5 - Wound Assessment Form Page 24Figure 6 - Wound Care Plan Form Page 32

APPENDICES

Appendix 1 Nutrition Assessment (MUST) Pages 51 -55

Appendix 2 TVS Referral Form Page 57TNP Referral Form (VAC) Page 58Care Pathway for Patient with a Wound Page 59Care Pathway for MRSA infected Wound Page 60

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 allcircumstances. A limitation of a guideline is that it simplifies clinical decision-making.

1Decisions 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.

1Shiffman 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 WestEssex Locality regarding the management of acute and chronic wounds.

1.1.2 This guideline aims to simplify the decision making regarding woundmanagement while ensuring that patients are provided with the bestevidence based care. To that end this guideline must be used to ensurethat all patients have been assessed and managed holistically and thatcare is supported with completed care plans and assessments inconjunction with the following guidelines:

SEPT West Essex Locality Infection Control Guidelines

SEPT West Essex Locality Pressure Ulcer Prevention andManagement Guidelines.

SEPT West Essex Locality Dressing Formulary Guidelines

Nursing and Midwifery Council (NMC) The Code: Standards ofconduct, 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 managementof patients with wounds within SEPT West Essex Locality, NHS WestEssex and NEPT, ensuring fair and equitable access to the best care andadvice regardless of whether care is provided by NHS providers or privatenursing homes providers. It is intended that adherence to theseguidelines will facilitate all patients with non healing wounds being givenaccess to the Tissue Viability Department if clinically appropriate asillustrated in the Care Pathway available in Appendix 2

1.1.4 This guideline was written by the Tissue Viability Committee, which is aproperly 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 ViabilityService, The Leg Ulcer Service, Community and Inpatient NursingServices, the Medicines Management Department, Infection Control,Dietetics and the Foot Health Department. This guideline does not serveto advise on the management of Burns and Plastics, Dermatology, orDiabetic Foot Ulcers. Clinicians requiring support on such issues shouldseek advice from the appropriate Burns and Plastics, DermatologyServices or Foot Health Department.

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

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


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2. PROCESS OF HEALING4

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

STAGE PROCESS CLINICAL EFFECTS IMPLICATIONS

IMMEDIATE Haemostasis

Vasoconstriction

Activation ofendothelial cells,

platelets and clottingcascade.

Haemorrhagecontrolled or reduced.

Clot forms in wound.

Dress with a securepressure bandage.

Seek medical adviceif blood loss is

excessive persistent.

INFLAMMATION Mediator release

Vasodilatation

Increased capillarypermeability

Chemotaxis

Phagocytosis

Initiation of Repair

Cell stimulation/inhibition.

Bradykinin &histamines produced.Blood vessels dilateand become morepermeable.

Increased blood flow

Protein cells and fluid

leak from capillaries.

Mediators attractphagocytes(Neutrophils first,then Macrophages).

Neutrophils andmacrophages removedebris and bacteria.

Macrophagesproduce growthfactor.

Inflammatory processinitiated.

Pain

Skin becomes red hot

Swelling

Exudate production

Contribute toexudates andswelling

Crust, pus orsloughing

No Clinical effectsvisible

Observe the following:

Swelling anddiscoloration

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

PROLIFERATION Granulation

Angiogensis

Collagen production

Epithelialisation

Contraction

Endothelial buddingor marginal capillaries

Fibroblasts migrate tothe scene andsecrete collagen

Epithelial cellmultiplicating andmigration oversurface

Possible due tospecialized fibroblastaction.

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

Red, vascular tissueappears in wound

Smooth marginalzone or islands ofepithelium seen inwound

Size of defectreduced

The nurse must ensure:

The patient receiveda nutritious diet, highin vitamin C and

protein. Movement is

encouraged toprevent DVT andcontractures

Physical support ofthe wound area andpain relief

The patient iseducated regardingany physicalrestriction andprovision of healing

MATURATION Collagen remodelling

Capillary regression

Type III collagenconverted to Type I,

increasing strength Reduction in numberof vessels, reducingblood flow.

ECM developsdensity

Scar flattens andsoftens

Scar pales, itchingsubsides.

The nurse needs to adviseon:

Scar tissue

2

Protection of the scarfrom friction

Encourage normalactivity

Camouflaging after 1 monthdepending on the extent ofthe wound if appropriate.

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

6

4Kingsley A (2003) Wound healing and potential therapeutic options. Professional Nurse. Vol 17 No 9 539-5445The Wound Programme (1992) Centre for Medical Education. Dundee

6Wicks 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 bysuturing, steristrips, clip, staples or glue.

Acute wounds usually follow a well-defined process as illustrated in Table 1. Thesestages 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 woundwill have formed a natural barrier against invasion by pathogenic bacteria.

78

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 thewritten 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, legulcers. (These guidelines do not cover the management of Leg Ulceration. Please referto the Leg Ulcer Guidelines)

In the past, the acute wound-healing model has been applied to chronic wounds, but it isnow known that chronic wound healing is different from acute wound healing.

10Chronic

wounds become stuck in the inflammatory and proliferative phases of healing, delayinghealing.

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

hyperproliferation at the wound margins, which interferes with normal cellular migrationover 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 andother macromolecules scavenge growth factors and other molecules involved inpromoting 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 repairprocess. Chronic wound fluid is also bio chemically distinct from acute wound fluid; itslows down, or even blocks the proliferation of cells such as keritinocytes, fibroblasts andendothelial cells, which are essential for the wound-healing process.

1516

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

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

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

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

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

S16-S2311

Ennis WJ, Meneses P (2000) Wound healing at the local level. The stunned wound. Ostomy Wound Manage 46: 39S48S12

Schultz G, Sibbald G, Falanga V et al (2003) Wound bed preparation: a systemic approach to wound management.Wound Repair Regen 11(2): 1-2813

Falanga V, Grinnell F, Gilchrist B, Maddox YT, Moshell A (1994) Workshop on the pathogenisis of chronic wounds. JInvest Dermatol 102(1): 125-714

Falanga V (2000) Classification for wound bed preparation and stimulation of chronic wounds. Wound Repair Regen 8:347-5315Schultz G, Sibbald G, Falanga V et al (2003) Wound bed preparation: a systemic approach to wound management.Wound Repair Regen 11 (2): 1-2816

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 apractical tool to assist practitioners when assessing and managing patients with wounds.

171819

Itis 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 possiblecause of the problem.

WBP involves the application of the principles of Tissue, Infection, Moisture and Edge (TIME) to awound bed in order to enable the practioner to make a systematic interpretation of the observablecharacteristics 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 theunderlying cellular abnormalities, and the effects of clinical interventions at a cellular level. The firstcolumn lists the clinical signs of a non-healing wound. As growth factors, senescent cells orfibroblasts cannot be seen with the naked eye; the clinician needs clear, visible signs that can beassessed at the bedside. The second column highlights the proposed pathophysiology of thatclinical observation. Column three and four suggest the clinical actions that need to be taken andthe effects of these actions. The final column is for clinical outcomes, which are objective and

measurable.22

17Benbow 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 casestudy. JWC Vol 16 No 9 pg 373-37619

Sibbald RG Woo K, Ayello E, (2007) Increased bacterial burden and infection:NERDS and STONES. Wounds Uk 2007Vol 3 No 2. pg 25-4620

Dowsett C Newton H (2005) Wound bed preparation: TIME in practice. Wounds UK Vol 1 issue 3. 58-7021

Dowsett C, Claxton K (2006) Reviewing the evidence for wound bed preparation. JWC Vol15 No 10 439-44222Dowsett C, Ayello E ((2004) TIME principles of chronic wound bed preparation and treatment. BJN Vol 13, No 15 pgS16-S23


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

CLINICAL

OBSERVATIONS

PROPOSED

PATHOPHYSIOLOGY

WBP CLINICAL

ACTIONS

EFFECT OF WBP

ACTIONS

CLINICAL

OUTCOME

TISSUE NON-VIABLE OR

DEFICIENT

Defective matrix andcell debris impairhealing

Debridement (episodicor continuous)Autolytic, sharp surgical,enzymatic, mechanicalbiological agents

Restoration of woundbase and functionalextracellular matrixproteins

Viable woundbase

INFECTION OR

INFLAMMATION

High bacterial counts orprolonged inflammation

inflammatorycytokines

protease activitygrowth factor activity

Remove infected fociTopical/systemic: -antimicrobials anti-inflammatories

Protease inhibition

Low bacterial countsor controlledinflammation:

inflammatory

cytokinesprotease activity

growth factoractivity

Bacterialbalance andreducedinflammation

MOISTURE

IMBALANCE

Dessication slowsepithelial cell migration

Excessive fluid causesmaceration of wound

margin

Apply moisture-balancing dressings

Compression, negativepressure or other

methods of removingfluid

Restored epithelialcell migration,desiccation avoided.Oedema, excessivefluid controlled,

maceration avoided

Moisturebalance

EDGE OF WOUND

NON ADVANCING

OR UNDERMINED

Non-migratingkeratinocytes

Non-responsive woundcells and abnormalitiesin extracellular matrix

or abnormal proteaseactivity

Re-assess cause orconsider correctivetherapies: -

DebridementSkin graftsBiological agents

Adjunctive therapies

Migratingkeratinocytes andresponsive woundcells. Restoration ofappropriate proteaseprofile

Advancingedge of wound

23Schultz G, Sibbald G, Falanga V et al (2003) Wound Bed Preparation: a systemic approach to wound management.

Wound Repair Region 11 (2): 1-28


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2.3.1 Tissue

Monitoring the type of tissue in a wound is the mainstay of wound assessment in clinicalpractice, 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 delayedhealing.

25It 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 orliquefying in consistency. If necrotic tissue dries out, and is hard and leathery it is morecommonly described as eschar.

26Necrotic tissue when grouped with the clinical problems

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

Sloughmay be creamy in appearance because of large amounts of leukocytes present.

28

Alternatively, a tendon may be exposed, signifying wound deterioration, presenting asstriated, 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 todifferentiate between healthy and unhealthy tissue.

31(See Table 3)

The surface or the texture of tissue can yield useful clues, for example if granulationtissue 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 tissuehas 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 infact 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

24Flanagan M, (2003) Wound measurement: can it help us to monitor progression to healing. JWC 12: 189-94

25Flanagan M, (1997a) Wound Management. Churchill Livingstone, London

26Bale S, (1997) A guide to wound debridement. JWC 6: 179-82

27Falanga V, (2002) Wound bed preparation and the role of enzymes: a case for multiple actions of therapeutic agents.

Wounds 14: 47-5728

Flanagan M. (1997b) A practical framework for wound assessment 2: methods. Br J Nurs 6:6-1129

Edwards R, Harding KG (2004) Bacteria and wound healing. Curr Opin Infect Dis 17: 91-630

Cutting K, Harding K (1994) Criteria for identifying wound infection. JWC 3: 198-20131

Harker J, Moore K ( 2004) Tissue management and wound pathophysiology,. A Journey through TIME. Wound bedpreparation in practice BJN32

Edmonds M, Foster A (2004) the use of antibiotics in diabetic foot. Am J Surg 187 (5A): 25S-28S33

Young, T (1995) Common problems in wound care: overgranulation. Br J Nurs 4:169-70.34Chraibi H (2004) The diagnosis and treatment of carcinomas occurring at the sites of chronic pressure sores. JWC Vol13. No 10 447-44835

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


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

36 The

European Wound Management Association Algorithm illustrated in Figure 1 illustrates thedifferent stages of wound infection. The spectrum of interaction between the microbialcommunity and host may gradually reach a point at which wound healing process isimpaired 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

Woundcolonisation is the presence of replicating micro organisms adhering to the wound withouta host reaction. If mixtures of potential pathogens are multiplying, this may lead to a delayin wound healing and the critical colonisation stage is reached.

3940

41

Unsuppressed, thenatural progression from this stage is to wound infection. This is when the sum of thebacterial 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 activatedmacrophages, 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 havebeen eliminated.

4647

48

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

49

50 They include antibiotics (which act on specific cellular

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

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

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

36Dowsett C, (2008) Using the TIME framework in wound bed preparation. Wound Care UK June pg S15-D2037

EWMA (2006) Position Document. Management of wound infection38Ayton M (1985) Woundscare: wounds that wont heal. Nursing Times 81 (Suppl 46): 16-1939

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: 50-841

Schultz G, Sibbald G, Falanga V et al (2003) Wound bed preparation: a systemic approach to wound management.Wound Repair Regen 11 (2): 1-2842

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 UKVol 4 No 4.44

EWMA (2005) Position Document: Identifying criteria for wound infection45

Cooper R, Okhiria O (2006) Biofilms. Wound infection & the issue of control. Wounds UK Vol 2 No 3 48-5646

EWMA (2006) Position Document. Management of wound infection. . London MEP Ltd. www.ewma.org47

Rhoads DD (2008) Biofilms in wounds: management strategies. JWC Vol 17 No11 Nov pg 502-50748

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 272-28149

Cooper R, Jenkins L, Rowlands R. (2011) Inhibition of biofilms through the use of manuka honey. Wounds Uk Vol 7 No1 pg 24-3250

Butcher M (2011) Introducing a new paradign for bioburden management. JWC/BSN supplement May. Pg 4-951

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


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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; woundappears 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 threateningSigns 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


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When bacteria proliferate they form micro colonies that become attached to the woundbed 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 andclinical observation, with microbiological data used to supplement the clinical diagnosis.Quantification of bacteria by wound biopsy has been considered the gold standard, butsurface sampling cost less and is easier to carry out.

54 The European Wound

Management Association Algorithm for Managing Wound Infection as illustrated in Figure1

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 arephysically removed by irrigation with saline. Increasing the frequency of dressing changesmay also be useful particularly as infected wounds often produce copious amounts of

exudate, which may promote bacterial growth causing further tissue breakdown andmaceration of the surrounding skin. There is clearly a need to link the I element of WBPto the M element for intervention to be successful.

56

MRSA

MRSA stands for meticillin-resistant Staphylococcus aureus. It is sometimes known as asuper bug. There are various subtypes (strains) of S. aureusand some strains areclassed 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 infectionsdescribed above.

Most S. aureusinfections can be treated with commonly used antibiotics. However MRSA

infections are resistant to an antibiotic called meticillin and also to many other types ofantibiotics. MRSA strains of bacteria are no more aggressive or infectious than otherstrains of S. aureus. However, infections are much more difficult to treat because manyantibiotics do not work against MRSA. Infections with MRSA can sometimes becomemore severe than they may otherwise have been if the cause of the MRSA infection is not

52Enoch S, Harding KG, (2003) wound bed healing: the science behind the removal of barriers to healing. Wounds 15:

210-53

Dowsett C, Edwards-Jones V, Davies S, (2004) Infection control for wound bed preparation A Journey through TIME.Wound bed preparation in practice BJN.54

Dowsett C, Edwards-Jones V, Davies S, (2004) Infection control for wound bed preparation A Journey through TIME.Wound bed preparation in practice BJN.55EWMA (2006) Position Document. Management of wound infection56

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

SuperficialNon-healing wound

Friable granulation tissue

Exuberant bright red granulation

Increased exudates

Erythema/cellulitis around wound edgeDeepPain

Increased size

Warmth

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

Odour

Probes/exposed bone


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14

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

For this reason itis vital that all MRSA positive wounds are referred to either Tissue Viability, Leg UlcerServices 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 thatmust be based on the clinical findings of an experienced clinician. Figure 1 provides EWMAguidance 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 antisepticsdelivered from a sustained-release dressing formulation therefore represent the first linetreatment, as they provide a high antimicrobial concentration at the site of infection.

60 Some

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

6162

Topical antiseptics have the additional advantage that they donot interfere with the remainder of the protective bacterial flora in other parts of the body andare also less likely to produce an allergic reaction.

In the case of biofilms the mainstay is frequent removal of the wound surface either withsharp 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 besuppressed with multiple strategies. This will include wound cleansers, topical antimicrobialsand advanced primary dressings. Since biofilms adapt to selective stresses a rotating regimeof 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 topicalor systemic agents. Given the evidence that improvements in wound healing have previouslybeen associated with the elimination of malodour-causing anaerobes and that mixedanaerobes appear to play some synergistic role in preventing wound healing, the use of ametronidazole gel may then be considered

66under the instruction of the TVS.

Topical antimicrobials are most appropriate when used to decrease the bacterial burden inchronic 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 asubstitute for debridement or systemic antibotics. Increased antimicrobial resistance meansthese agents should not be used for an extended period of time and should be followed by anappropriate dressing once the bacterial burden has been reduced. Where infection hasextended beyond the level that can be managed by local therapy, systemic antibiotics shouldbe used in conjunction with antimicrobial products.

57MRSA. (2011)http://www.patient .co.uk/health/mrsa. sourced 4/8/11

58EWMA 2006) Position Document. Management of wound infection

59Bowler PG, Duerden BI, Armstrong DG (2001) wound microbiology and associated approaches to wound management.

Clin Microbiol Rev 14: 244-6960

White RJ, Cooper RA, Kingsley A (2001) Wound colonisation and infection. Br J Nurs 10: 563-7861

Lawerence JC (1998) The use of iodine as an antiseptic agent. J Wound Care 7:421-562

Sibbald RG, Brown AC, Coutts P, queen D (2001) Screening evaluation of ionised nanocrystalline silver dressings inchronic wound care. Ostomy Wound Manag 47: 38-4363

Wolcott R D. (2009) Regular debridement is the main tool for maintaining a healthy wound bed in most chronicwounds. 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 502-50766

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


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2.3.3 Moisture67

68

Exudate.Exudate contains a variety of substances including water, electrolytes, nutrients,inflammatory mediators, white cells, protein-digesting enzymes (eg matrixmetalloproteinases MMPs), growth factors and waste products. In the healing woundexudate 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. Theexudate contains elevated levels of inflammatory mediators and activated MMPs.

69

One of the most significant challenges faced by nurses is the efficient and cost effectivemanagement of excessive wound exudates which causes extreme distress and negativelyimpacts 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 maintainingthe 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, theresultant 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 monitoredit is preferable that the same nurse reassesses a wound in order to aid comparison withserial assessments. Colour and consistence are considered in Table 5 with someguidance 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 compression3. 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 woundedges 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 timetowards closure are perhaps the clearest sign of all that a wound is failing to heal. Woundmeasurement provides baseline information while continuous measurement helps topredict 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 asign of critical colonisation or infection. The use of cytotoxic agents and cortiocosteroidscan 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 inprotease activity, which degrade extra cellular matrix as soon as it is formed.

76

67Cutting 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): 1-3669

WUWHS (2007) Principles of best practice: Wound exudate and the role of dressings, a consensus document. London:MEP Ltd.70Benbow M, Stevens J (2010) Wxudate, infection and patietn quality of life. BJN TV Supplement) Vol 19 No 20 pg S 31-S3671

Vowden K, Vouden P (2003) Understanding exudate management and the role of exudate in the healing process. TheExudate 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 SocietyPublication.73

Gethin G (2006) The importance of continuous wound measuring. Wounds Uk Vol 2 No 2 60-6874

Dowsett C, (2008) Using the TIME framework in wound bed preparation. Wound Care UK June pg S15-D2075


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


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

Colour Consistency Type of wound Probable cause Management

Clear/strawcolour

Watery Leg ulcer Oedema/lymph oedema(sudden increase inexudate may indicateinfection)

Compression orelevation of thelimb

Clear/strawcolour

Watery Surgical Heart failure/oedemacaused by fluid overload

Diuretics

Clear/strawcolour

Serous fluid Acute: traumaticor surgical

Normal inflammatoryexudate

Dressings ofappropriateabsorbency

Blood stained Serous fluid Acute: traumaticor surgical

Slight bleeding fromvessel in wound bed

Localisedpressure or use ofa haemostaticdressing

Blood Viscous Surgical Bleeding vesselpostoperative

Excessivebleeding shouldbe referred backto surgeon

Blood Viscous Any Trauma from dressing Traumaticbleeding can bestopped with local

pressure orhaemostaticdressing. Re-consider dressingchoice

Yellow Slightly viscous(may appearpurulent, maycontain fattyglobules, usuallyprofuse)

Any sloughywound

Autolytic debridement ofnon-viable tissue

Appropriatedressing ordrainage system

Yellow or brown Purulent orhaemopurulent

Abscess orinfected wound

Bacteria Systemicantibiotics,possibly topicalantiseptics andappropriatedressing

Green Very viscous,mucus-like

Leg ulcer, burnwound

Bacteria especiallyPseudomonasaeruginosa

Topical antiseptic(systemicantibiotic ifcellulitis present)

Clear green Watery or slightlyviscous

Upperabdominalwound

Fistula to upper intestine Refer back tosurgeon

Brown, faecal Viscous Lowerabdominalwound

Fistula to lower bowel Refer back tosurgeon

Grey or Blue Viscous or watery any Related to silvercontaining dressings

Avoid prolongedused of silver

77Scanlon E. (2004) Moisture balance and exudate control. Clinical review. A Journey through TIME. Wound BedPreparation in practice. BJN78

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


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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 andcan 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 healingSource: 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, uncontrolledvasculitis or pyoderma gangrenosum.

Inadequate or poor nutrition

Diabetes88

89

Smoking

9091

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 supplementsshould also be provided to all patients with established wounds where deficiency is knownparticularly 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

79Jones P.L. Millman A (1990) Wound Healing and the Aged Patient. Nursing Clinic of North America. 25: pg 263-77

80Descai H (1997) Ageing and Wounds Part 2. Healing in Old Age. Journal of Wound Care. May Vol. 6 No.5 Pg 237-239

81Harding, K (1999) Wound Management : Theory and Practice. Nursing Times Publications. Pg 96-107.

82Robson M et al. (1991) Wound healing alterations caused by infection. Clinics in Plastic surgery. 17: 3, 485-492/

83Bland 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 78284

Siang J.E. (1992) The effect of smoking on tissue formation JWC July/Aug. Vol 1 No 2 pg 37-4185

Winter, GD. (1962) Formation of scab and rate of epithelialisation of superficial wounds in the skin of a young domesticpig. 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 JournalVol 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-S2591

Kean J (2010) The effects of smoking on the wound healing process. JWC Vol 19 No 1 pg 5-892

Ng M (2010) Cachexiaan intrinsic factor in wound healing. Int Wound Jr . Vol 7 No 2 pg 107-11193

Heyman H, Van de Looverbosch DE, Meijer EP, Schols JMGA (2008) Benefits of an oral nutritional supplement onpressure ulcer healing in long term care residents. JWC Vol 17 No 11 Nov pg 476-48094

Mandal A (2006) Do malnutrition and nutritional supplementation have an effect on the wound healing process. JWCVol 15 No 6 254 -25795

Bradbury S (2006) Wound healing: is oral zinc supplementation beneficial. Wounds UK Vol 2 No 1. 54-6196

Frias Soriano L et al. (2004) The effectiveness of oral nutritional supplementation in the healing of pressure ulcers. TheJournal of wound Care Vol 13, No8 319-32297

Lansdown A (2004) Nutrition 1: a vital consideration in the management of skin wounds. BJN (Tissue Viabilitysupplement) Vol 13 No 19 S22-S2898

Lansdown A (2004) Nutrition 2: a vital consideration in the management of skin wounds. BJN Vol 13 No 20, 1199-121099

Lewis B (1996) Zinc and Vitamin C in the Aetiology of Pressure Sores. The Journal of Wound Care. Nov. Vol 5 No 10483-481100

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.


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

3.2.1. Identification of Patients Risk

Nutritional assessment should be carried out in line with the MUST NutritionalAssessment 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 accurateassessment, 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 woundshould have an individual pain management plan including regular ongoing assessment

which should be performed each time a dressingrelated procedure is carried out.120

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

121122

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

102Ronaghy HA. (1987) The role of zinc in human nutrition. World Review of Nutrition and Dietetics. 54: 237-54.

103Casey, G. (1998) The Importance of Nutrition in Wound Healing. Nursing Standard: 13:3 (supplement) 51-56.

104Lewis, 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, 87-90106

Wallace, E. (1992) Feeding the Wound: Nutrition and Wound Healing. Br J Nursing; 3: 13,662-667107

Foster A. Greenhill M.T Edmonds ME (1994) Comparing 2 dressings in the treatment of diabetic foot ulcers JWC Vol 3 No 5 Pg224-228108

Capper C.J. (1994) The Management of Pressure Sores in a patient with Diabetes Mellitus. JWC Vol 3 No 8 pg 360-362109

McIlwaine C (2003) Importance of holistic nutritional assessment in wound healing. JWC Vol 12 No 8 285-288110

WUWHS (2004) Principles of best practice: Minimising pain at wound dressing-related procedures. A consensusdocument. London: MEP Ltd111

Hofman D ((2006) Practical steps to address pain in wound care. BJN Supplement. Vol 15 No 21, pg10-15112

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

Sibbald R G, Katchky A, Queen D (2006) Medical management of chronic wound pain. Wounds UK Vol 2 No 4 pg 74-89114

Young S Hamption S (2005) Pain management in leg ulcers using ActiFormCool. Wounds UK Vol 1 Issue 3. 94-101115

Fletcher J (2010) managing wound pain during application and removal of dressings BJN TV Supplement Vol 19 No 20S4-S6116

Taylor Alison ( 2010) Principles of Pain Assessment. Wound Essentials Vol 5 Pg 104-110117

Briggs M, Ferris F D, Glynn C, et al (2004) Assessing pain at wound dressing-related procedures. Nursing Times Vol100 No 41 56-57118

European Wound Management (2002) Position Document: Pain at wound dressing changes. London MEP Ltd.www.ewma.org119


Solowiej K et al (2010) Psychological stress and pain in wound care. Part 2:management. JWC Vol 19 No 4 pg 153-155121


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


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3.3.1 Using Opiates on wounds123

124

Topical opiates act centrally and peripherally and can be alternative or concurrent formsof 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 woundA foam dressing can be used to secure the hydrogel. The effective dose concentration is10mgs morphine opiate to 1gram hydrogel. Application should be daily or as requiredbasis.There are minimum adverse effects however it is preferable to keep certain wounds suchas 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 5 434-439124

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

0 1 2 3 4 5 6 7 8 9 10

None Mild Moderate Severe


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TVS Guidelines: Wound Management Sept 2011

20

Adverse Local Conditions

At the Wound Site

Inappropriate WoundManagement 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 4Factors causing delayed wound healing


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4. CLASIFICATION OF WOUND TISSUE

The Wound Healing Stage Classification as described below is recommended as itfacilitates simple and consistent verbal and written description of the appearance of thewound bed. This is a different classification to the pressure ulcer classification. (SeePressure 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 orreminents of hair follicles, sebaceous or sweat glands

The epithelial cells rapidly multiply and migrate across granulation tissue, until theyform 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 raisedbody temperature may be present. It is thus recommended that temperature, pulse, BPand respiratory observations are taken and recorded if there is suspicion of woundinfections.

125Garrett B (1998) Re-Epithelialisation. Journal of wound Care; 7:7, 358-359

126Flanagan, M .(1999) Wound Management: theory and practice. Nursing Times Publication. pg 14-20

127Harding, K., Cutting, K. (1994) Criteria for identifying wound infection. JWC. 3:4, 198-201

128Cutting. K.F. (1996) Definition of Terms. JWC. Resource File. London Macmillan.


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4.5 Necrotic Tissue129

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 itis 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 necessaryto state the grade (see Pressure Ulcer Guidelines)

5. WOUND ASSESSMENT.

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

130131

Wounds should be assessed using the principles of WBP and application of the acronymTIME illustrated in Table 2. Tissue observed should be classified according to the WoundTissue Classification described in Section 4. The Wound Assessment Form (Figure 5)

which incorporates the principles of WBP (TIME) should be completed at every dressingchange as documentation is as essential as the assessment itself.

132

The use of the WAF and a comprehensive care plan ensures that registered nurses arefulfilling 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 iscrucial that wound assessment forms and care plans are completed on all patients whohave wounds. These records must be clearly written, signed and regularly updated.

133 An

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

129Cutting K..F. (1996) Definition of Terms. Journal of Wound Care Resource File. London Macmillan

130Dowsett C, (2008) Using the TIME framework in wound bed preparation. Wound Care UK June pg S15-D20131

Briggs M (1996) Documenting Wound Management JWC Vol 5 No 5 Pg 229 - 231132

Oldfield A (2010) Assessing the Open Surgical Wound. Wound Essentials Vol 5 pg 48-55133

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


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

Patients 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 (cm )

Undermining

Cavity: Depth cm

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

Insert generic dressing code number

Staff Signature

GenericDressing

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.


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6 WOUND CARE

A holistic assessment of the patient is essential before choosing a wound dressing.134

Acareplan should be drawn up using the information gathered in the WAF and directed by theTIME WBP Clinical Actions illustrated in the Timetable. (Table 2)Many wounds will be a combination of some of the already mentioned classifications identified insection 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 byproviding 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 beremoved by irrigating with sterile sodium chloride 0.9%Dressing: Wounds can be left exposed after 48 hours or coveredwith 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 orsuperficial wounds where granulation tissue has been replacede.g. skin donor sites, superficial burn, and granulated pressureulcer.

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

GOALS: T: Promote epithelialsation

I: Reduce inflammation and maintain a bacterial balance.M: Achieve moisture balance


CARE PLAN: Analgesia to control pain.Does not require cleaning if exudate is minimal. If cleaning isrequired use sterile sodium chloride 0.9%

Dressing: Minimal exudate Semi-permeable film

Low/moderate N/A Dressing

Moderate Hydrocolloid sheet

134Morris C (2006) Wound management and dressing selection. Wound Essential. Vol 1 178-183

135NICE (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. 204-205137

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


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6.2.2 Granulating Wounds

EXAMPLES: Clean cavity pressure ulcers

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

GOALS: T: Promote viable granulation from the wound base

I: Reduce inflammation and maintain a bacterial balance.


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

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

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

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

High exudate High absorbency Alginate or Hydrocolloid Fibreand a Foam or Hydrocolloid Sheet.

TNPwill manage exudate and accelerate healing from the baseof the wound.

6.2.3 Sloughy Wounds

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

PROBLEM: Excessiveexudate or odour due to bacteria and necrotic tissue.

Slough and necrotic tissue may encourage growth of bacteriaand this may delay healing.

138

GOAL: T: Debridement of sloughy and necrotic tissue

I: Reduce inflammation and maintain a bacterial balance


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

CARE PLAN: 1) If wound infection is suspected, take a swab and send for

microscopy and culture. Inform Medical Staff and record vitalsigns.2) Clean with sterile sodium chloride 0.9%

Dressing: (Non cavity sloughy)

Minimal exudate Hydrocolloid sheet

Moderate exudate Hydrocolloid Fibre Dressing andN/A padHigh Exudate Alginate and Foam Dressing

139

Versajet debridement can be performed by the TVS.

138Haury 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 229-240139

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


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Larvae therapy can expedite the removal of slough fromwounds on advice from the TVS.

Antibacterial dressing can be used if infection issuspected.TNPon advice from TVS will contain exudate, acceleratehealing 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 onceantibiotic 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 andinflamed 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.M: Achieve moisture balance

E: Measured advancing edges and base of wound

Identify the organism causing the infection and eradicatewith systemic antibiotics. Promote healing by providingan optimum local environment.

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

Dressing: Minimal exudate Hydrogel held insitu withN/A Pad.

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

143

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

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

144

Do not occlude clinically infected wounds until antibiotictherapy is established and infection controlled.

Change dressings daily while infected or more frequentlyif strike through occurs. If malodour is a problem seesection 6.3

140Cutting K.F (1994) Criteria for identifying Wound Infection. JWC. Vol 3. No 4. Pg 198-210

141Grey J.E. (1998) Cellulitis Associated with Wounds. JWC, July Vol 7 Pg 338-339

142Heggers J.P. (1998) Defining Infection in Chronic WoundsDoes it Matter? JWCCare. Sep. Vol 7 No 8 Pg 389-392143

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


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6.2.5 Necrotic Wounds

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

PROBLEM: Extensive cavity wound is hidden beneath the necrotictissue.

GOALS: T: Debridement of necrotic tissue

I: Reduce inflammation and maintain a bacterialbalance.



CARE PLAN: Surgical debridement:Sharp debridement is the quickest means of removingeschar. Nurses wishing to pursue this form ofmanagement must be clinically competent to do so.

Versajet debridement can be performed on soft necrotictissue by the TVS

Medical debridement:Dressings: Hard dry eschar will need to be hydrated ifmedical debridement is to occur.

Hydrocolloid sheets will trap the bodies humidity andfacilitate debridement

Hydrogels will actively hydrate escharBio Surgical debridement:

Larvae therapy will effectively and efficiently debrideslough and soft eschar.

6.3 Malignant/Fungating Wounds145

146

147

148

EXAMPLES: External tumour wounds

PROBLEM: Odour, incipient bleeding, pain, exudate

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

I: Reduce inflammation and attempt to maintain abacterial balance.


E: Awareness of advancing wound edges andminimising such advancement where possible

through control of I andM.

145Grocott P (1998) Exudate management in fungating wounds. Journal of Wound Care. Oct. Vol 7 No 9 Pg 445-448

146Grocott P (1995) The Palliative management of fungating malignant wounds. Journal of Wound Care. May. Vol 4 No

5. Pg 240-242147

McDonald A, Lesage P (2006) Palliative management of pressure ulcers and malignant wounds in patients withadvanced illness. Jr Palliative Medicine, April 9 (2): 285-295148

Hampton S, (2008) Malodorous fungating wounds: how dressings alleviate symptoms. Wound care June 2008 pgS31- S38


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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 151152

Establish the cause of the odour by sending a wound swab for microscopy andculture.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 silvercan help to reduce odour.

153 Metronidazole gel can be used following a doctors

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 andsupport.Small amounts of hydrogel can minimise adherence in dry wounds.Good provision of analgesia is crucial, particularly prior to dressing changes.

Exudate155

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 followingevents.

wet contamination from external sources

strike through (when exudate has leaked through the dressing)

offensive smell156

pain or prolonged tenderness at wound site

unexplained pyrexia

inflammation at site

removal of drain/clips/sutures

allergic reactions.

149Alexandra 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 456-465150

Piggin C, Jones V (2009) Malignant fungating wounds: and analysis of the lived experience. JWC Vol 18 No 2 pg 57-64151

Van Toller S (1994) Invisible Wounds: The effects of skin ulcer malodour. JWC Vol 3 No 2 Pg 103-105152

Morris C (2008) Wound odour: principles of management and the use of Clinisorb. BJN (TV Supplement) Vol17 No 6pg153

Hack A (2003) Malodourous woundstaking the patients perspective into account. JWC Vol 12 No 8 319-321154

Hamilton S (1999) Wound Management theory and practice. Nursing Times Books. Pg 119155Thomas S (1997) Assessment and Management of Wound Exudate. Journal of Wound Care. July Vol 6 No 7 Pg 327-330156

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


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

157

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

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 duringcleansing 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 medium161

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 Tissue164

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 firstchoice. If overgranulation persists nurses should discuss the situation with the TVS or theresponsible physician to exclude undiagnosed malignancy as the underlying cause.

The reduction of hypergranulation/over-granulation may be achieved through the use ofthe 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 linemeasure. Morison (1991) cited in Hampton S and Collins

168 found silver nitrate to be

caustic with potential to initiate methaemoglobinaemia and metabolic disturbance. Silvernitrate 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 beremembered that topical steroid preparations are not licienced for the treatment ofovergranulation and therefore responsibility for its use lies with the prescriber.

157Lock A.M.(1980) The effect of temperature at the edge of experimental wounds, Symposia on wound healing, plastic

surgical and dermalogical aspects. Pg 103-109158

Cutting K. Harding K. (1994) Criteria for identifying wound infection in Wounds. Essential Vol 1 2006159

RDNS Research Unit (2002) The Pursuit of Excellence. Promoting Evidence-Based Nursing PracticeWoundSwabbing. ISSN 1449-44X Issue No 11. Sept160

Community & primary Care Infection Control Manual. (2006) EFPCT Ref GUI00062/HP161

Microbiology advice from PAHT162Patten H (2010) Identifying wound infection: Taking a swab. Wound Essentials Vol 5 pg 64-66163

Patten H (2010) Identifying wound infection: Taking a swab. Wound Essentials Vol 5 pg 64-66164

Hampton S. Collins F (2004) Tissue Viability, Ch 3 Pg 96. Whurr publishers. ISBN 1 88156 237 3165

Dunsford C (1999) Hyperegranulation Tissue. JWC Vol 8 No 10 pg 506-507166Young 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 3168

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


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

169170

169Johnson, S (2007) Haelan Tape for the treatment of overgranulation tissue. Wounds Uk Vol 3 no 3 pg 70 -74170

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


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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 thatregistered nurses are fulfilling their obligations under the NMCCode

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

Trust to the risk of litigation. It is crucial that wound assessmentforms and care plans are completed on all patients who havewounds. These records must be clearly written, signed,dated andtimed and are regularly updated. The WAF must be completedafter every dressing change.

171NMC (2008) The Code, Standards of conduct, performance and ethics for nurses and midwives


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7 PRINCIPLES OF WOUND IRRIGATION172

173

The purpose of wound irrigation is to help create optimum local conditions of healing. Itshould remove wound debris. It should be performed in an atraumatic method, so thatepithelialising and granulation tissue is not damaged. The method used to do this shouldbe based upon an assessment of the wound and the patients general condition.

Clean epithelialising/granulating wounds do not benefit from mechanical irrigation, whichremoves exudate containing valuable healing factors. These wounds should be leftundisturbed for as long as possible to enhance the rate of healing. Wiping may damagenew granulation tissue. Chronic wounds with excess exudate may benefit fromirrigation.(See section 2.3.3)Irrigation using a syringe or by showering is often preferred providing that the pressureachieved 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 (assupplied in dressing packs) be used in conjunction with either a gloved hand or forceptechnique.

Some methods of mechanical wound cleaning can result in the redistribution of bacteriarather 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. Whena surgical wound has separated or has been surgically opened to drain pus, then the useof 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 thatstaff 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 withcetrimide) are quickly rendered ineffective by body fluids and pus. The potentialdisadvantages of using such antiseptics should be weighed against any possible benefitsbefore 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 tosupport their use.

178 Some studies have indicated that Fungi and Yeasts are more

important wound pathogens than previously reported and thus antimicrobial products mustbe 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% solutionThis isotonic solution does not cause chemical damage to cells and is thepreferred irrigating agent for wounds. Sodium chloride 0.9% does not require aprescription; all the other solutions do need a prescription.

7.1.2 Chlorhexidine with cetrimide

172Lawrence J.C. (1997) Wound Irrigation JWC Jan Vol 6 No 1 Pg 23-26

173Gilcrist B (1999) Wound Management, Theory and Practice. Nursing Times Books. Pg 104-105

174Thomlinson D (1987) To clean or not to clean, Nursing Times, Journal of Infection Control Nursing. 4 March Vol 83.5

175NICE (2008) . Surgical site infection. Guideline no 74 . October 2008

176Lawrence 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 44-47177

NICE (2008) Surgical site infection. Guideline no 74 . October 2008178Cutting K F (2010) Addressing the challenge of wound cleansing in the modern era. BJN (TV Supplement) Vol 19 No11 pg S25-S28179

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


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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 productsare easily contaminated and any remaining in a container after opening should bediscarded.

7.1.3 Prontosan

Prontosan Wound Irrigation Solution and Gel are ready to use products forcleansing, moisturising and decontamination of acute and chronic wounds. They

contains unique ingredients that have a double effect on the wound bed to createa wound environment optimal for healing. Betaine a gentle effective surfactant topenetrate, clean and remove wound debris andbiofilm.Polyhexanide (PHMB) apowerful antimicrobial agent that can reduce bioburden. This product is not onthe Dressing Formulary and should only be prescribed on the instruction of theTissue Viability Service

7.1.4 IodineIodine is active against a wide range of organisms including Gram-negative andGram-positive bacteria, fungi and bacterial spores. If an antiseptic solution isrequired Iodine is the solution of preference. Cadexomer Iodine has in studiesbeen shown to produce a marked decrease in MRSA, and it is recognised ashaving 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 StelliseptIf a wound is colonised or infected with MRSA it can washed using Stellisept atdressing changes.

182 The wound should subsequently be redressed using an

antimicrobial dressing according to its classification and in adherence with theEWMA Algorithm as illustrated in Figure 1.

Table 7 Comparison of commonly used antimicrobials183

Antimicrobial properties

Gram+ve Gram -

ve

Fungi Endospores Viruses Resistance

Chlorhexidine

184

185

+++ ++ + 0 + +

Honey110, +++ +++ +++ 0 + 0

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

Maggots186

187

188

189

190

+++ ++ ND ND ND 0

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

ND= No data

180Mertz. P Davis S Brewer L (1994) Can Antimicrobials be effective without impairing healing

181Marshall C, Queen J Manjooran J (2005) Honey Vs povidone iodine following toenail surgery. Wounds UK May Vol 1

Issue 1: 10-17182

Olivo, S. (2011) SEPT Internal communication on management of MRSA in Wounds. 3/8/11183

European Wound Management Association (EWMA) position Document: Management of wound infection. LondonMEP Ltd 2006184

McDonnellG RussellAD. Antiseptics and disinfectants:activity, actions and resistance. Clin Microbiol Rev 1999:12 (1):147-79185

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 preliminarystudy. J tissue Viability 9:127-32187

Beasley WD, Hirst G. (2004) Making a meal of MRSAthe role of biosurgery in hospital acquired infection. J Hospinfect: 56:6-9188

Horobin AJ, ShakesheffKM, Woodrow S et al. Maggots and wound healing: an investigation of the effects ofsecretions

wound mgmt guidelines sept

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