Wound Update Target 2018
Learning Outcomes • Factors affecting wound healing • Wound assessment • Choosing correct dressing • Management of over-granulation • Managing infection/sepsis • Wound Types
The Stages of Wound Healing There are four stages of wound healing: Adult Services • Vascular response • Inflammation • Proliferation • Maturation (Flanagan M, 1997)
Factors affecting wound healing INTRINSIC Adult Services • Presence of systemic • PH of wound surface disease • Dehydration (local and • Nutritional status systemic) • Smoking • Presence of infection • Medication • Wound temperature • Adequate skin perfusion • Psychological factors • Age of individual and wound
Factors affecting wound healing EXTRINSIC Adult Services • Poor wound care • Wound location • Dressings • Mechanical stress (pressure, friction and • Hygiene shear) • Social problems • Presence of foreign • Radiotherapy bodies • Ability to elevate the limb • Extent of tissue loss and type of tissue involved
Wound Assessment When How Adult Services • Baseline • Wound assessment template • Deterioration • Map/measure • At least monthly • Photograph
The Ideal Wound Environment • Moist environment at the • Absorption of toxins wound/dressing interface • Insulation from low Adult Services • Gaseous exchange able temperature to take place • Free from other particles • Impermeable to micro- and other contaminants organisms • Protection from trauma • Absorption of excess exudate
Adult Services
Epithelialising wound Adult Services
Epithelialising Wounds Treatment aim - to protect new fragile tissue Adult Services • Hydrocolloids • Films • Low absorbent foams • NA Dressings
Granulating Wounds Adult Services
Adult Services
Granulating Wounds Treatment aim: to maintain a healthy wound bed for epithelialisation Adult Services Low Exudate High Exudate • • Hydrocolloids Hydrofibres • • NA dressings Alginates • • Low absorbent foams Foams • High absorbent pads
Sloughy Wound Adult Services
Sloughy Wound Adult Services
Sloughy Wounds Treatment aim: to remove slough and provide clean base for granulation tissue Adult Services Low Exudate High Exudate • Hydrogels – with caution • Hydrofibres contact TVN • Alginates • Hydrocolloids • Foams • Low absorbent foams • High absorbent pads
Necrotic Wound Adult Services
Adult Services
Necrotic Wounds Most necrotic/sloughy wounds auto-debride naturally. NB: Diabetic/ischaemic foot wounds – keep dry to Adult Services minimise risk of infection and consider referral to WPMS Nurse or vascular Dressing choices: • N/A Dressing • Hydrocolloids • Absorbent dressings • Films
Cavities Adult Services
Adult Services
Cavity Wounds • Cavities should not routinely be packed in order to allow free drainage of exudate • Given the lack of high quality evidence, decisions to pack may be based on local Adult Services practices or patient preferences. Guideline for the Treatment of Wounds Healing by Secondary Intention including Sinuses and Cavities. Leeds Health Pathways (2017) • http://nww.lhp.leedsth.nhs.uk/common/guidelines /detail.aspx?ID=5239
Overgranulating Wounds Adult Services
Overgranulation • Occurs at the proliferation stage of wound healing Adult Services • Granulation tissue continues to be laid down and stands proud of the rest of the skin • Possibly related to wound infection/inflammation, or friction from tubing or excess exudate • It prevents epithelial cells from spreading across the wound surface delaying the final stage of wound healing
Overgranulation – Management and Prevention • Foam dressings – with a topical antiseptic Adult Services underneath, e.g. povidone or cadexomer iodines • Corticosteroid cream- Haelan Cream/Tape (Liciensed) 1% Hydrocortisone cream – not licensed for this purpose • Silver Nitrate pencil 95% - as last resort can cause trauma to healthy tissue (Nelson A, 1999)
Adult Services Infection
Signs of Local Infections • Abscess/pus • Cellulitis/excessive inflammation Adult Services • Erythema • Oedema • Heat • Unexpected pain/tenderness • Malodour • Dehiscence
Infected Wounds Adult Services
Anti-microbial dressings • Four main categories: • Silver – should only be used when symptoms or signs Adult Services of clinical infection are present. There is some evidence to suggest they delay wound healing (BNF 2015) • Honey – osmosis promotes autolytic debridement, should not be used on patients with allergies to bee products, diabetic patient should be monitored (BNF 2015)
• Iodine – cadexomer-iodine releases free iodine when exposed to wound exudate - povidone-iodine knitted viscose Adult Services dressing facilitates diffusion of the iodine but is rapidly deactivated by wound exudate • PHMB Dressings – impregnated with polyhexamethylene biguanide • DACC dressing (dialkycarbamoyl chloride)
Signs of Systemic Infection • Pyrexia/fever Adult Services • Flu-like symptoms • Sweats and chills • Unexplained confusion • Blood results = > CRP / > WCC • Unstable blood sugar in diabetics
Sepsis Screening • Acute confusion, disorientation, reduced conscious level • Blood glucose non diabetic >7.7 Adult Services • Temperature >38.3 or <36 • Respiratory rate > 20 per min >25 per min • Heart rate >90 per min >130 per min • Systolic B.P. <90mmHg, • Oxygen sats <91% • Purpuric rash
Adult Services
When to Swab • Enlarging of the wound • Abnormal bleeding Adult Services • Increased pain • Increasing Odour or exudate • Cellulitis • Pyrexia • To check effectiveness of current antibiotic therapy
Adult Services Types of wounds
Leg Ulcers Adult Services
Venous leg ulcer Adult Services
The Evidence Compression vs no compression More patients heal with compression than without (Cullum et al 2001) Results of VenUs 4 Compared 4 layer compression bandaging system with 40mmHg treatment hosiery kits Treatment hosiery had similar healing rates to those randomised to compression bandages. Quality of life improved for patients wearing hosiery Promotes self care and independence
Venous Leg Ulcer Myth Busters Best Practice Statement: Management of Venous Leg Ulcers 2017
Lower Leg Injury • Complete doppler within two weeks of initial assessment if no signs of improvement • 0.8 – 1.3 Suitable for full compression • >1.3 ? calcification – refer to WPMS or vascular • 0.6 - 0.8 = Mixed aetiology – refer to WPMS • <0.6 Refer to vascular team • < 0.4 Urgent referral to vascular team
Frequency of Doppler 3 Monthly ABPI below < 0.8 and > 1.3 in hosiery/bandages Active foot/leg ulceration Change in medical condition History of unstable dopplers over 12 months 6 Monthly No ulcer ABPI within range 0.8-1.3 History of recurrent lower limb ulceration/lymphoedema Multiple co-morbidities with an established regime Diagnosed with new condition which affects circulation 12 Monthly No Ulcer ABPI within range 0.8 – 1.3 Stable lymphoedema/ oedema Healed ulcer and no recurrence in 12 months Limited or well controlled co-morbidities (Stephen-Hayes, 2015) adopted by LCHT for leg ulcer guidelines 2016
Compression Hosiery Contact your local company reps to arrange a training session. BSN Medical (Jobst) Jo Whittaker-Cox: 07850 659 658 Activa Rose Richardson: 07973 862 780 Medi UK Adam Hopkinson: 07469 858 357
In Summary • Doppler lower leg wounds as soon as possible • Start compression if safe. • Refer to Wound service if no improvement
Further Info: Wounds UK Best Practice Statements: Venous Leg Ulcers Compression Hosiery • Local Leg Ulcer Guidelines on Leeds Health Pathways
Pressure Ulcers Adult Services
Pressure Ulcers Adult Services
Pressure Ulcer Risk Factors • Immobility • Existing pressure ulcer • Previous pressure damage • Perfusion Adult Services • Diabetes • Nutrition • Sensory perception • Moisture Pain!
Foot Ulcers Adult Services
Non Diabetic Foot Adult Services
Diabetic Foot Adult Services
How to access referrals on LHP Click: -Leeds Health Pathways -Referral Pathways -Referral Pathways and Forms “Diabetic Limb salvage “Non Diabetic feet – Service – Urgent” screening and referral pathway” “Community Diabetes Team: Foot Protection Service”
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