THE CARE OF WOUNDS
A GUIDE FOR NURSES
THIRD EDITION
CAROL DEALEY PhD MA BSc (Hons) RGN RCNT
Research Fellow
University Hospital Birmingham NHS Trust, and
School of Health Sciences
University of Birmingham
© 2005 Blackwell Publishing Ltd
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First published 2005 by Blackwell Publishing Ltd
Library of Congress Cataloging-in-Publication Data
Dealey, Carol.
The care of wounds : a guide for nurses / Carol
Dealey. – 3rd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-1-4051-1863-7 (pbk. : alk. paper)
ISBN-10: 1-4051-1863-6 (pbk. : alk. paper)
1. Wounds and injuries – Nursing.
[DNLM 1. Wounds and Injuries – nursing.
2. Wound Healing – physiology. WO 700 D279c
2005] I. Title.
RD93.95.D43 2005
617.1 – dc22
2005001740
ISBN 10: 1-4051-1863-6
ISBN 13: 978-14051-1863-7
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Contents
iii
Contents
Preface
vii
Chapter 1 The Physiology of Wound Healing
1.1 Introduction
1.2 Definitions associated with wounds
1.3 The structure of the skin
1.3.1
Dermis
1.3.2
Epidermis
1.4 Wound healing
1.4.1
Inflammation
1.4.2
Reconstruction
1.4.3
Epithelialisation
1.4.4
Maturation
1.5 Impaired wound healing
1.5.1
Hypertrophic scars
1.5.2
Keloids
1.5.3
Contractures
1.5.4
Acute to chronic wounds
1.6 Conclusion
1
1
1
2
2
2
3
4
6
8
9
9
9
10
10
10
11
Chapter 2 The Management of Patients with Wounds
2.1 Introduction
2.2 Physical care
2.2.1
Nutrition
2.2.2
Infection
2.2.3
Smoking
2.2.4
Diabetes mellitus
2.2.5
They physical effects of stress
2.2.6
Pain
2.2.7
Sleeping
2.2.8
Hypothermia
2.2.9
Steroids
2.2.10 Radiotherapy
2.3 Psychological care
2.3.1
Anxiety
2.3.2
Motivation and education
2.3.3
Body image
2.3.4
Other psychological problems
2.4 Spiritual care
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23
25
26
27
30
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34
35
35
37
39
41
43
iv
The Care of Wounds
Chapter 3 General Principles of Wound Management
3.1 Introduction
3.2 Wound assessment
3.2.1
Wound classification
3.2.2
The position of the wound
3.2.3
The environment of care
3.2.4
M = measure
3.2.5
E = exudate
3.2.6
A = appearance
3.2.7
S = suffering
3.2.8
U = undermining
3.2.9
R = re-evaluate
3.2.10 E = edge
3.3 Managing wounds
3.3.1
Moist wound healing
3.3.2
Wound bed preparation
3.3.3
Pain management
3.4 Documentation
3.5 Evaluating the dressing
56
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56
57
58
58
61
62
69
70
70
71
72
72
72
76
77
78
Chapter 4 Wound Management Products
4.1 Introduction
4.2 The development of dressings through the ages
4.2.1
Early days
4.2.2
The Dark Ages and early Middle Ages
4.2.3
Late Middle Ages and Renaissance
4.2.4
The seventeenth, eighteenth and early nineteenth centuries
4.2.5
Mid-nineteenth and early twentieth century developments
4.2.6
The British Pharmaceutical Codices
4.3 Traditional techniques
4.4 The use of lotions
4.4.1
Antiseptics
4.4.2
Antibiotics
4.4.3
Honey
4.4.4
Saline 0.9%
4.4.5
Tap water
4.5 Clinical effectiveness of wound management products
4.5.1
Providing an effective environment
4.5.2 The handling qualities of an effective wound
management product
4.6 Modern wound management products
4.7 Advanced technologies
4.7.1
Growth factors
4.7.2
Protease-modulating wound management products
4.7.3
Hyaluronan-based products
4.7.4
Hyperbaric oxygen
83
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85
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89
90
91
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95
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97
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98
99
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105
105
106
107
Contents
v
4.7.5
Topical negative pressure
4.7.6
Tissue culture
4.7.7
Tissue engineering
4.8 Alternative therapies and wound management
108
110
110
112
Chapter 5 The Management of Patients with Chronic Wounds
5.1 Introduction
5.2 The prevention and management of pressure ulcers
5.2.1
The cost of pressure ulcers
5.2.2
The aetiology of pressure ulcers
5.2.3
Prevention of pressure ulcers
5.2.4
Management of pressure ulcers
5.3 The management of leg ulcers
5.3.1
The epidemiology of leg ulcers
5.3.2
The cost of leg ulcers
5.3.3
The causes of leg ulcers
5.3.4
Venous ulceration
5.3.5
Arterial ulcers
5.3.6
Ulcers of mixed aetiology
5.3.7
Malignant leg ulcers
5.3.8
Leg ulceration in rheumatoid arthritis
5.4 Diabetic foot ulcers
5.4.1
Aetiology
5.4.2
Prevention
5.4.3
Management
5.5 Fungating wounds
5.5.1
Aetiology and incidence
5.5.2
Management of fungating wounds
5.6 Lymphoedema
5.6.1
Lymphoedema management
5.7 Conclusion
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128
138
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145
152
155
156
157
158
158
159
160
162
163
163
165
166
168
Chapter 6 The Management of Patients with Acute Wounds
6.1 Introduction
6.2 The care of surgical wounds
6.2.1
Management of surgical wounds
6.2.2
Managing complications
6.3 Traumatic wounds
6.3.1
Minor traumatic wounds
6.3.2
The management of specific types of traumatic wounds
6.4 The burn injury
6.4.1
Aetiology
6.4.2
Incidence
6.4.3
The severity of the injury
6.4.4
Burn oedema
6.4.5
First aid treatment of burns
6.4.6
The management of burn injuries
179
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186
194
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196
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200
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201
203
203
205
vi
The Care of Wounds
6.5 Radiation reactions
6.5.1
Aetiology
6.5.2
The classification of radiation reactions
6.5.3
Preventive skin care
6.5.4
Managing radiation reactions
6.5.5
Care of the patient
209
210
210
210
211
212
Chapter 7 Clinically Effective Wound Care
7.1 Introduction
7.2 Evidence-based practice and clinical effectiveness
7.3 Searching and appraising the literature
7.3.1
Appraising the literature on wound care
7.4 Developing clinical guidelines
7.4.1
Guidelines in wound care
7.5 The clinical audit cycle
7.5.1
Auditing clinical practice
7.5.2
Dissemination of audit findings
7.6 Conclusions
218
218
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222
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224
224
225
225
Chapter 8 The Organisation of Wound Management
8.1 Introduction
8.1 Managing wounds in the community
8.2.1
Nurse prescribing
8.2.2
Community leg ulcer clinics
8.3 Nurse specialists in wound care
8.4 The management of pressure-redistributing equipment
8.4.1
Equipment stores
8.4.2
Total bed management
8.5 Wound-healing centres
8.6 Conclusions
228
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230
232
232
232
233
234
Index
236
Preface
vii
Preface
This is an exciting time in wound care and there have been many new developments in the last few years, including new approaches as well as systematic
reviews and guidelines. Much of this is reflected in this third edition of The Care
of Wounds and as a result, several of the chapters have been rewritten rather
than updated. I also believe that many of those involved in caring for patients
with wounds are more sophisticated in their approach to the subject. I hope
that I have managed to reflect this in the text.
I would like to thank all those people who have encouraged me to produce
this new edition and for their kind remarks about the usefulness of the last
edition. I hope they find it to be relevant to their clinical practice and that nurses
especially will find it useful when caring for patients with wounds.
Carol Dealey
Dedication
To my husband for his endless patience
The Physiology of Wound Healing 1
Chapter 1
The Physiology of Wound Healing
1.1 INTRODUCTION
Wound healing is a highly complex process. It is important that the nurse has
an understanding of the physiological processes involved for several reasons.
䊉
䊉
䊉
䊉
Understanding the physiology of skin assists in understanding the healing
process.
An understanding of the physiology of wound healing makes it possible to
recognise the abnormal.
Recognition of the stages of healing allows the selection of appropriate
dressings.
Understanding of the requirements of the healing process means that appropriate nutrition can, as far as is possible, be given to the patient.
1.2 DEFINITIONS ASSOCIATED WITH WOUNDS
Any damage leading to a break in the continuity of the skin can be called a
wound. There are several causes of wounding.
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䊉
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䊉
Traumatic – mechanical, chemical, physical
Intentional – surgery
Ischaemia – e.g. arterial leg ulcer
Pressure – e.g. pressure ulcer
In both traumatic and intentional injury there is rupture of the blood vessels,
which results in bleeding, followed by clot formation. In wounds caused by
ischaemia or pressure, the blood supply is disrupted by local occlusion of the
microcirculation. Tissue necrosis follows and results in ulcer formation, possibly with a necrotic eschar or scab.
Wounds in the skin or deeper have been labelled in various ways. Some of
them can be described as follows.
Partial- and full-thickness wounds
䊉
䊉
A partial-thickness wound is one where some of the dermis remains and
there are shafts of hair follicles or sweat glands.
In a full-thickness wound all the dermis is destroyed and deeper layers may
also be involved.
2
The Care of Wounds
Healing by first and second intention
These definitions were first described by Hippocrates around 350 bc.
䊉
䊉
Healing by first intention is when there is no tissue loss and the skin edges
are held in apposition to each other, such as a sutured wound.
Healing by second intention means a wound where there has been tissue loss
and the skin edges are far apart, such as a leg ulcer.
Open and closed wounds
These are the same as healing by second and first intention respectively.
1.3 THE STRUCTURE OF THE SKIN
The skin is the largest and one of the most active organs of the body. It is composed of two layers – the epidermis and dermis – with the epidermis forming
the outer surface of the body and the dermis forming the deeper layer of the
skin. The main structures of the skin can be found in the dermis. Figure 1.1
shows a cross-section of the skin.
1.3.1 Dermis
Dermis is composed of connective tissue, both collagen and elastic fibres, which
is both elastic and resilient and provides support for the structures in the
dermis. Within the dermis can be found blood vessels, lymph vessels, sensory
nerve endings, sweat and sebaceous glands and hair follicles. The ducts of the
glands and hair shafts pass through the epidermis to the skin surface. Sweat
glands have their own ducts opening on the skin surface but sebaceous glands
open onto the hair follicles. The base or bulb of hair follicles is sited deep into
the dermis. They are lined with epithelial cells and can play a role in the healing
of partial-thickness wounds.
The surface of the dermis where it interlocks with the epidermis is irregular,
with projections of cells called papillae. The base of the dermis is less clearly
defined as it blends into subcutaneous tissue, which contains both connective
tissue and adipose tissue and helps to anchor the skin to muscle and bone.
1.3.2 Epidermis
The epidermis comprises several layers of cells. The deepest layer is the stratum
basale and it is constantly producing new cells by cell division. These cells are
gradually pushed towards the skin surface, taking about seven weeks to reach
the surface. The stratum spinosum contains bundles of keratin filaments, which
hold the skin together. The top three layers of epidermis are the stratum granulosum, which produces the precursor to keratin, the stratum lucidum and the
stratum corneum. As they move through the strata, the cells gradually flatten
The Physiology of Wound Healing 3
Fig. 1.1
A cross-section of the skin. Reproduced from www.nurseminerva.co.uk with permission.
and the protoplasm becomes replaced with keratin. The cells in the stratum
corneum are flat with no nucleus and are essentially dead cells. They are constantly worn away and replaced by new cells moving to the surface.
In addition, the epidermis has cells called melanocytes containing melanin,
which gives skin its colour. A high concentration of melanin produces a dark
skin colour. Ultraviolet light increases melanin production. This may occur
naturally by sunlight, resulting in a sun tan, or artificially such as a treatment
in dermatology.
1.4 WOUND HEALING
The wound-healing process consists of a series of highly complex interdependent and overlapping stages. These stages have been given a variety of names
but are described here as:
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inflammation
reconstruction
epithelialisation
maturation.
4
The Care of Wounds
The stages last for variable lengths of time. Any stage may be prolonged
because of local factors such as ischaemia or lack of nutrients. The factors that
can delay healing are discussed in more detail in Chapter 2.
1.4.1 Inflammation
The inflammatory response is a non-specific local reaction to tissue damage
and/or bacterial invasion. It is an important part of the body’s defence mechanisms and is an essential stage of the healing process. The signs of inflammation were first described by Celsus, in the first century ad, as redness, heat, pain
and swelling. The factors causing them are shown in Table 1.1.
When there is traumatic or intentional injury that causes damage to the blood
vessels, the first response is to stop the bleeding. This is achieved by a combination of factors: first by vasoconstriction, which reduces the blood flow, and
second, by the release of a plasma protein called von Willebrand factor from
both endothelial cells and platelets, resulting in platelet aggregation and formation of a platelet plug. The third factor is the initiation of the clotting cascade
and the development of a fibrin clot to reinforce the platelet plug.
Hageman factor (factor XII in the clotting cascade) triggers both the complement and kinin systems. The complement system consists of plasma proteins
which are inactive precursors. When activated, there is a cascade effect that
leads to the release of histamine and serotonin from the mast cells and results
in vasodilation and increased capillary permeability. The complement system
also assists in attracting neutrophils to the wound. The complement molecule,
C3b, acts as an opsonin. That is, it assists in binding neutrophils to bacteria.
Five of the proteins activated during the cascade process form the membrane
attack complex, which has the ability to directly destroy bacteria.
The effect of the complement system is enhanced by the kinin system which,
through a series of steps, activates kininogen to bradykinin. Kinins attract neutrophils to the wound, enhance phagocytosis and stimulate the sensory nerve
endings. The apparent delay in feeling pain after injury is explained by the short
time lag taken for the kinin system to be activated.
Table 1.1
The signs of inflammation.
Signs and symptoms
Physiological rationale
Redness
Vasodilation results in large amount of blood in the area
Heat
Large amount of warm blood and heat energy produced by metabolic
reactions
Swelling
Vasodilation and leakage of fluid into the wound area
Pain
May be caused by damage to nerve ends, activation of the kinin system,
pressure of fluid in the tissues or the presence of enzymes, such as
prostaglandins, which cause chemical irritation
The Physiology of Wound Healing 5
As the capillaries dilate and become more permeable, there is a flow of fluid
into the injured tissues. This fluid becomes the ‘inflammatory exudate’ and contains plasma proteins, antibodies, erythrocytes, leucocytes and platelets. As
well as being involved in clot formation, platelets also release fibronectin and
growth factors called platelet-derived growth factor (PDGF) and transforming
growth factor alpha and beta (TGFa and TGFb). Their role is to promote cell
migration and growth at the wound site.
Growth factors are a subclass of cytokines, proteins that are used for cellular
communication (Greenhalgh, 1996). The particular role of growth factors is to
stimulate cell proliferation. There are a number of growth factors involved in
the healing process and they are listed in Table 1.2. Some growth factors have
been isolated and used as a treatment for chronic wounds. This will be discussed in more detail in Chapter 4.
The first leucocyte to arrive at the wound is the neutrophil. Wagner (1985)
has described the role of fibronectin in relation to neutrophils. It attracts neutrophils to the wound site, a process known as chemotaxis. Neutrophils squeeze
through the capillary walls into the tissues by diapedesis; again this ability is
enhanced by fibronectin. Within about an hour of the inflammatory response
being initiated, neutrophils can be found at the wound site. They arrive in large
numbers, their role being to phagocytose bacteria by engulfing and destroying
them. Neutrophils decay after phagocytosis as they are unable to regenerate the
enzymes required for this process. As the numbers of bacteria decline, so too
do the numbers of neutrophils.
Table 1.2
Growth factors involved in the healing process.
Growth factor
Abbreviation
Action
Platelet-derived growth factor
PDGF
Chemotactic for neutrophils,
fibroblasts and, possibly, monocytes
Encourages proliferation of
fibroblasts
Transforming growth
factor alpha
TGFa
Stimulates angiogenesis
Transforming growth
factor beta
TGFb
Chemotactic for monocytes (macrophages)
Encourages angiogenesis. Regulates
inflammation
Fibroblast growth factor
FGF
Stimulates fibroblast proliferation and
angiogenesis
Epidermal growth factor
EGF
Stimulates the proliferation and migration
of epithelial cells
Insulin-like growth factors
IGF-I, IGF-II
Promote protein synthesis and fibroblast
proliferation. Work in combination with
other growth factors
6
The Care of Wounds
TGFb attracts monocytes to the wound where they differentiate into
macrophages. Fibronectin binds onto the surface receptors on the cells,
promoting diapedesis and phagocytosis. Oxygen is vital to this process and
macrophages can be inactivated and their ability to undertake phagocytosis
reduced if the partial oxygen pressure falls below 30 mmHg (Cherry et al., 2000).
Macrophages are larger than neutrophils and so are able to phagocytose larger
particles, such as necrotic debris, as well as bacteria. The lifespan of the
neutrophil can be a few hours or a few days. When they die, they are also
phagocytosed by the macrophages.
T lymphocytes also migrate into the wound, although in smaller numbers
than macrophages (Martin & Muir, 1990). They influence macrophage phagocytic activity by the production of several macrophage-regulating factors. They
also produce colony-stimulating factors that encourage the macrophage to
produce a range of enzymes and cytokines. These include prostaglandins which
maintain vasodilation and capilliary permeability and can be produced on
demand to prolong the inflammatory response if required. A study by Martin
and Muir (1990) found that both macrophages and lymphocytes are present in
wounds from day 1, with macrophages peaking between days 3 and 6 and lymphocytes between days 8 and 14.
Inflammation lasts about 4–5 days. It requires both energy and nutritional
resources. In large wounds the requirements may be considerable. If this stage
is prolonged by irritation to the wound, such as infection, foreign body or
damage caused by the dressing, it can be debilitating to the patient as well as
delaying healing.
1.4.2 Reconstruction
The reconstruction phase is characterised by the development of granulation
tissue. This consists of a loose matrix of fibrin, fibronectin, collagen and
hyaluronic acid and other glycosaminoglycans. Within this matrix can be
found macrophages and fibroblasts and the newly formed blood vessels.
Macrophages play a major role in this phase of healing. They produce PDGF
and fibroblast growth factor (FGF), which are chemotactic to fibroblasts, attracting them to the wound and stimulating them to divide and later to produce
collagen fibres. Fibronectin also seems to play a role in enhancing fibroblast
activity (Orgill & Demling, 1988). Collagen has been seen in a new wound as
early as the second day. Collagen fibres are made up of chains of amino
acids in a triple helix formation. There are a number of different types of collagen characterised by different formations of amino acids. Type III is present
in the healing wound in greater proportions than would normally be found
in skin. Over time, this proportion reduces in favour of higher levels of type I
collagen.
Fibroblasts are key cells in this phase of healing (Harding et al., 2002). As well
as being responsible for the production of collagen, they also produce the extra-
The Physiology of Wound Healing 7
cellular matrix, which is seen visually as granulation tissue. As new extracellular matrix is synthesised, the existing matrix is degraded by enzyme systems
such as matrix metalloproteinases (MMPs). There are a number of MMPs, in
particular MMP1, MMP2 and MMP9, involved in the healing process, although
their role is imperfectly understood at present.
The activity of fibroblasts depends on the local oxygen supply. If the tissues
are poorly vascularised the wound will not heal well. The wound surface has
a relatively low oxygen tension, encouraging the macrophages to produce TGFb
and FGF, which instigate the process of angiogenesis, the growth of new blood
vessels. Undamaged capillaries beneath the wound, sprout buds, which grow
towards the surface and loop over and back to the capillary. The loops form a
network within the wound, supplying oxygen and nutrients. At this stage, a
high oxygen tension promotes the continued growth of the capillary loops
because collagen is required in their formation (Cherry et al., 2000).
Some fibroblasts have a further role as they are involved in the process of
contraction. The exact mechanism is not clearly understood and there are currently two theories postulated: cell contraction and cell traction. The theory of
cell contraction is based on specialised fibroblasts known as myofibroblasts
(Gabbiani et al., 1973), which have a contractile apparatus, similar to that in
smooth muscle cells. In in vitro models, they have been shown to cause contraction of the wound. Tomasek et al. (1989) found a higher level of contractile
forces when a high level of myofibroblasts was present. The concept of cell
traction was put forward by Stopak and Harris (1982), who demonstrated
that fibroblasts could contract collagen gels by a physical pull, resulting in a
rearrangement of the extracellular matrix. It must be noted that all these studies
were undertaken in vitro and there is no certainty that they could be repeated
in vivo.
Whatever the actual process, contraction may start at around the fifth or sixth
day. It considerably reduces the surface area of open wounds. Irvin (1987) suggests that contraction could be responsible for as much as 40–80% of the closure.
It is certainly of considerable importance in large cavity wounds. However, in
shallower wounds with a large surface area such as burns, contraction may lead
to contractures. Myofibroblasts disappear after healing is completed.
In wounds healing by first intention, little can be seen of this stage of healing
but in those healing by second intention, the granulation tissue can be seen as
it gradually fills the wound cavity. Figure 1.2 summarises cellular activity
during reconstruction as the macrophage completes clearance of cellular debris
and produces growth factors that will instigate angiogenesis and also attract
fibroblasts to the wound site.
As the wound fills with new tissue and a capillary network is formed, the
numbers of macrophages and fibroblasts gradually reduce. This stage may have
started before the inflammation stage is completed and prolonged inflammation can result in excessive granulation with hypertrophic scarring. The length
of time needed for reconstruction depends on the type and size of wound but
may be about 24 days for wounds healing by first intention.
8
The Care of Wounds
Phagocytosis
Production of
TGFB & FGF
instigates
angiogenesis
Production of
PDGF & FGF
chemotactic to
fibroblasts
MACROPHAGE
Fig. 1.2
The process of reconstruction.
1.4.3 Epithelialisation
This is the phase in which the wound is covered with epithelial cells.
Macrophages release epidermal growth factor (EGF), which stimulates both the
proliferation and migration of epithelial cells. Keratinocytes at the wound
margins and around hair follicle remnants synthesise fibronectin, which forms
a temporary matrix along which the cells migrate. The cells move over the
wound surface in a leapfrog fashion, the first cell remaining on the wound
surface and forming a new basement membrane. When cells meet, either in the
centre of the wound, forming islets of cells, or at the margin, they stop. This is
known as contact inhibition. Epithelial cells only move over viable tissue and
require a moist environment (Winter, 1962). In sutured wounds, epithelial cells
also migrate along the suture tracks. They are either pulled out with the sutures
or gradually disappear.
Once the cells stop moving on the wound surface, they start to reconstitute
the basement membrane, which is essential in order for the epidermis to ‘fix’
The Physiology of Wound Healing 9
to the dermis. Until the basement membrane is fully reconstituted, it is easy for
epithelial cells to be sheared off the wound surface by mechanical forces
(Cherry et al., 2000).
Epithelialisation commences as early as the second day in closed wounds.
However, in open wounds it is necessary for the wound cavity to be filled with
granulation tissue before it can commence. There is a very variable time span
for this stage.
1.4.4 Maturation
During maturation the wound becomes less vascularised as there is a reduction in the need to bring cells to the wound site. The collagen fibres are reorganised so that, instead of being laid down in a random fashion, they lie at right
angles to the wound margins. During this process, collagen is constantly
degraded and new collagen synthesised. The highest level of activity in this
process occurs between days 14 and 21 (Cherry et al., 2000). The scar tissue
present is gradually remodelled and becomes comparable to normal tissue after
a long period of time. The scar gradually flattens to a thin white line. This may
take up to a year in closed wounds and very much longer in open wounds.
Tensile strength gradually increases. This is a way of describing the ability of
the wound to resist rupture or dehiscence. Forester et al. (1969) found that at
ten days an apparently well-healed surgical incision has little strength. During
maturation it increases so that by three months the tensile strength is 50% that
of normal tissue. Further work by Forester et al. (1970) compared surgical incisions where the skin edges were held together by tape with those where sutures
were used. The findings showed that, when tape was used, the wounds
regained 90% strength of normal tissue whereas sutured wounds only regained
70% strength.
1.5 IMPAIRED WOUND HEALING
Although the majority of wounds heal without problem, impaired healing may
sometimes occur. Some of the different types of impaired healing are described
here. Their management will be discussed elsewhere.
1.5.1 Hypertrophic scars
Hypertrophic scars occur when there is an excessive fibrous tissue response
during the healing process resulting in excessive deposition of collagen and a
thick wound scar (Munro, 1995). Cherry et al. (2000) suggest that the ratio of
type I to type III collagen is lower than in normal skin. Hypertrophic scars are
more common after traumatic injury, especially large burns. They occur shortly
after the injury or surgery and remain limited to the area of the injury. They
will generally flatten out with time, about one to two years.
10
The Care of Wounds
1.5.2 Keloids
Keloids are similar to hypertrophic scars in that they are also the result of an
excessive fibrous response but this time, the ratio of type I to type III collagen
is much higher than in normal skin. Another difference is that keloids take some
time to form and may occur years after the initial injury. They can range in size
from small papules to large pendulous growths (Munro, 1995). Keloids more
commonly occur in individuals aged between 10 and 30 (Cosman et al., 1961)
and in those with a darker skin (Placik & Lewis, 1992). Unfortunately, unlike
hypertrophic scars, keloids do not gradually flatten out.
1.5.3 Contractures
Wound contraction is part of the normal healing process but occasionally contraction will continue after re-epithelialisation has occurred, resulting in scar
contraction (Tredget et al., 1997). Engrav et al. (1987) describe how this type of
scar contracture can lead to joint contracture with subsequent loss of mobility,
functional loss, delay in return to work and a poor cosmetic result, any of which
may necessitate surgery.
1.5.4 Acute to chronic wounds
Wounds may be called ‘chronic’ because their underlying aetiology makes
healing a very long process. A good example is the venous leg ulcer. However,
some chronic wounds may have originally been acute wounds that have failed
to heal over a long period of time, perhaps years. The original factor delaying
healing may have been related to infection or local irritation, perhaps caused
by a suture. Once these problems have been resolved, the wound still fails to
heal, causing considerable misery to the patient.
The differences between acute and chronic wounds are still imperfectly
understood. However, work by Phillips et al. (1998) did shed some light on the
problem. They used cultured fibroblasts from human neonatal foreskin as a
plated laboratory model and treated them with either chronic wound fluid
(CWF) or bovine serum albumen (the control). They found that CWF inhibited
the growth of the fibroblasts quite dramatically. The researchers concluded that
this study gave some indication of how the microenvironment has a negative
effect on the healing wound. As result of this work, other research groups have
looked at wound exudate in more detail.
Trengrove et al. (1999) used wound fluid from venous leg ulcers at both nonhealing and healing stages to measure MMP levels. They found elevated levels
of MMPs at the non-healing stage, which decreased significantly as the ulcers
started to heal (p = 0.01). The levels of MMPs in the healing ulcers were similar
to those in acute wounds, thus suggesting that failure to heal may be linked to
excessive matrix degradation. Ladwig et al. (2002) collected wound fluid from
56 pressure ulcers and found lower levels of MMP9 in those ulcers that went
on to heal well compared with those that healed poorly.
The Physiology of Wound Healing 11
Trengrove et al. (2000) undertook further studies of wound exudate from nonhealing and healing leg ulcers. They found significantly higher concentrations
of a number of proinflammatory cytokines or growth factors in the non-healing
ulcers. They consider that wound healing is delayed in chronic wounds because
of an impairment of inflammatory mediators rather than by any deficit of
growth factors.
Premature ageing of fibroblasts may also be a problem. Mendez et al. (1998)
investigated the characteristics of fibroblasts cultured from chronic venous
ulcers and found signs of accelerated ageing or senescence in these cells. Senescent fibroblasts have reduced mobility, are less able to replicate, have abnormal
protein production and do not respond well to growth factors. A small study
of seven patients by Stanley and Osler (2001) compared the senescence rates in
fibroblasts from chronic venous ulcers with fibroblasts from punch biopsies
taken from the proximal thigh of the same patient. They found a significantly
higher senescence rate in the fibroblasts from the leg ulcers (p = 0.0001).
1.6 CONCLUSION
This chapter has described ‘normal’ physiology. However, not all wounds heal
without complication or delay and some of the differences between acute and
chronic wound healing have been discussed. But many factors can affect the
healing process and they will be considered in more detail in Chapter 2.
FURTHER READING
Cherry, G.W., Hughes, M.A., Ferguson, M.W.J., Leaper, D.J. (2000) Wound healing, in
(eds) Morris, P.J., Wood, W.C., Oxford Textbook of Surgery, 2nd edn. Oxford
University Press, Oxford.
Vander, A., Sherman, J., Luciano, D. (1998) Human Physiology, 7th edn. McGraw-Hill,
Boston.
REFERENCES
Cherry, G.W., Hughes, M.A., Ferguson, M.W.J., Leaper, D.J. (2000) Wound healing, in
(eds) Morris, P.J., Wood, W.C., Oxford Textbook of Surgery, 2nd edn. Oxford University Press, Oxford.
Cosman, B., Crikelair, G.F., Ju, M.C. et al. (1961) The surgical treatment of keloids. Plastic
and Reconstructive Surgery, 27, 335–358.
Engrav, L.H., Covey, M.H., Dutcher, K.D. et al. (1987) Impairment, time out of school
and time out of work after burns. Plastic and Reconstructive Surgery, 79, 927.
Forester, J.C., Zederfeldt, B.H., Hunt, T.K. (1969) A bioengineering approach to the
healing wound. Journal of Surgical Research, 9, 207.
Forester, J.C., Zederfeldt, B.H., Hunt, T.K. (1970) Tape-closed and sutured wounds: a
comparison by tensiometry and scanning electron microscope. British Journal of
Surgery, 57, 729.
12
The Care of Wounds
Gabbiani, G., Hajno, G., Ryan, G.B. (1973) The fibroblast as a contractile cell: the
myofibroblast, in (eds) Kulonen, E., Pikkarainen, J., The Biology of the Fibroblast.
Academic Press, London.
Greenhalgh, D. (1996) The role of growth factors in wound healing. Journal of Trauma,
41 (1), 159–167.
Harding, K.G., Morris, H.L., Patel, G.K. (2002) Healing chronic wounds. British Medical
Journal, 324, 160–163.
Irvin, T.T. (1987) The principles of wound healing. Surgery, 1, 1112–1115.
Ladwig, G.P., Robson, M.C., Liu, R., Kuhn, M.A., Muir, D.F., Schultz, G.S. (2002) Ratios
of activated matrix metalloproteinase-9 to tissue inhibitor of matrix matelloproteinase-1 in wound fluids are inversely correlated with healing in pressure ulcers.
Wound Repair and Regeneration, 10 (1), 26.
Martin, C.W., Muir, I.F.K. (1990) The role of lymphocytes in wound healing. British
Journal of Plastic Surgery, 43, 655–662.
Mendez, M.V., Stanley, A.C., Phillips, T.H., Murphy, M., Menzoian, J.O., Park, H.Y. (1998)
Fibroblasts cultured from venous ulcers display cellular characteristics of senescence. Journal of Vascular Surgery, 28, 1040–1050.
Munro, K.J.G. (1995) Hypertrophic and keloid scars. Journal of Wound Care, 4 (3), 143–148.
Orgill, D., Demling, R.H. (1988) Current concepts and approaches to wound healing.
Critical Care Medicine, 16 (9), 899–908.
Phillips, T.J., Al-Amoudi, H.O., Leverkus, M., Park, H-Y. (1998) Effect of chronic wound
fluid on fibroblasts. Journal of Wound Care, 7 (10), 527–532.
Placik, O., Lewis, V.L. (1992) Immunological associations of keloids. Surgery, Gynaecology and Obstetrics, 175, 185–193.
Stanley, A., Osler, T. (2001) Senescence and the healing rates of venous ulcers. Journal of
Vascular Surgery, 33, 1206–1210.
Stopak, D., Harris, A.K. (1982) Connective tissue morphogenesis by fibroblast traction.
1. Tissue culture observations. Developments in Biology, 90 (2), 383–398.
Tomasek, J.J., Haaksma, C.J., Eddy, R.T. (1989) Rapid contraction of collagen lattices by
myofibroblasts is dependent upon organised actin microfilaments. Journal of Cell
Biology, 170, 3410.
Tredget, E.E., Nedelec, B., Scott, P.G., Ghahary, A. (1997) Hypertrophic scars, keloids and
contractures. Surgical Clinics of North America, 77 (3), 701–730.
Trengrove, M.K., Stacey, M.C., McCauley, S. et al. (1999) Analysis of the acute and chronic
wound environments: the role of proteases and their inhibitors. Wound Repair and
Regeneration, 7 (6), 442–452.
Trengrove, N.J., Bielefeldt-Ohmann, H., Stacey, M.C. (2000) Mitogenic activity and
cytokine levels in non-healing and healing chronic leg ulcers. Wound Repair and
Regeneration, 8 (1), 13–25.
Wagner, B.M. (1985) Wound healing revisited: fibronectin and company. Human Pathology, 16 (11), 1081.
Winter, G.D. (1962) Formation of the scab and the rate of epithelialisation of superficial
wounds in the skin of the domestic pig. Nature, 193, 293.
The Management of Patients with Wounds 13
Chapter 2
The Management of Patients with Wounds
2.1 INTRODUCTION
This chapter looks at assessment of the patient with a wound and how appropriate care may be planned and evaluated. When caring for patients with
wounds of all types, it is important to take a holistic approach, considering
physical, psychological and spiritual care as they are inextricably linked. There
are many factors that can affect the healing process. If they are taken into
account when taking a history and assessing the patient, it may be possible to
mitigate some of the effects. Nursing intervention is not able to resolve every
problem (for example, age) but where nursing intervention can be effective,
appropriate strategies are suggested.
2.2 PHYSICAL CARE
2.2.1 Nutrition
The precise relationship between wound healing and nutrition remains uncertain (Williams & Barbul, 2003). There is increasing evidence that nutritional
deficit impairs healing, such as the study by Wissing et al. (2001) which
followed up patients with leg ulceration identified in a previous study. Those
patients whose ulcers were still open had significantly lower nutritional status
compared with those whose ulcers had healed. A number of other studies have
identified the impact of malnutrition on the healing of surgical wounds, burns
and pressure ulcers (Andel et al., 2003; Haydock & Hill, 1986; Mathus-Vliegen,
2004). The importance of nutrition in relation to pressure ulcer prevention and
management is highlighted by the development of nutrition guidelines by the
European Pressure Ulcer Advisory Panel (EPUAP, 2003).
Malnutrition is a pathological state that results from a relative or absolute
deficiency or excess of one or more essential nutrients. As protein or carbohydrates are used in the largest quantities, they are usually the deficient nutrients.
This is referred to as protein energy malnutrition or PEM. In her Notes on
Nursing, What it is and What it is Not, Florence Nightingale (1974) said: ‘Every
careful observer of the sick will agree in this, that thousands of patients are
annually starved in the midst of plenty, from want of attention to the ways
which alone make it possible for them to take food’. More than a century later
this statement is still true. McWhirter and Pennington (1994) assessed the nutri-
14
The Care of Wounds
tional status of 500 acutely ill patients and found 40% were undernourished on
admission to hospital. Gallagher-Allred et al. (1996) reviewed studies involving
1327 patients which showed that 40–55% were malnourished and 12% were
severely malnourished. Edington et al. (1996) surveyed community patients and
found that 10% of cancer patients and 8% of those with chronic diseases were
malnourished.
Overall, malnutrition is seldom recognised in hospital patients although it
has a major impact on morbidity and mortality (Pablo et al., 2003). Correia and
Waitzberg (2003) undertook multivariate analysis of the impact of malnutrition
on adult hospital patients and found mortality increased to 12.4%, compared
with 4.7% in the well nourished. Hospital costs increased up to 308.9%. Older
patients are at particular risk of malnutrition. Guigoz et al. (2002) identified malnutrition in 20% of hospitalised patients in a survey of more than 10 000 Swiss
elderly people in the community, nursing homes and hospitals. Similar results
were found in a Spanish study of hospital patients – 18.2% of patients had
severe malnutrition (Cereceda et al., 2003). Fortunately, politicians have been
alerted to the importance of food and nutritional care in hospitals. The Council
of Europe Committee of Ministers passed a resolution in 2003 that each member
state should have national recommendations that encompass all aspects of
nutritional care (Resolution RESAP(2003)3) (Committee of Ministers, 2003).
Nutritional status
The initial causes of malnutrition may be related to debilitating disease,
especially of the gastrointestinal tract, old age, poverty or ignorance. Once
admitted to hospital, other factors become relevant. An early study by
Hamilton Smith (1972) found that patients were starved for up to 12 hours prior
to surgery and for varying lengths of time afterwards. Chapman (1996) found
little had changed in over 20 years. She found that patients fasted for periods
ranging from 4 to 29 hours. A long period of preoperative starvation serves to
compound the effects of trauma and surgery, both of which cause marked catabolism. This catabolic state usually lasts between 6 and 18 hours. Following this,
the basal metabolic rate rises, leading to increased energy requirements. Unless
adequate protein and carbohydrate are taken in to supply these needs, further
tissue breakdown occurs, resulting in muscle wasting and a negative nitrogen
balance. Lee (1979) suggests that the consequences of a negative nitrogen
balance include poor wound healing, impaired immunocompetence and
susceptibility to infection.
Whilst some patients will return to a normal diet fairly quickly and so redress
the balance, others will receive only intravenous fluids. A litre of dextrose 5%
contains approximately 150 calories. Normal saline does not contain any at all.
These fluids obviously do not provide adequate calories to meet the body’s
requirements.
Burn patients are particularly at risk and may continue to be so for as long
as four weeks (Sutherland, 1985). Trauma, burns and pain increase the metabolic rate, further diminishing the patient’s nutritional status (Arturson, 1978).
The Management of Patients with Wounds 15
Zinc, in particular, is burned up in large amounts during emotional or physical stress. Taylor (1999) studied 106 burn patients who received enhanced
enteral nutrition (50% of energy and nitrogen requirements). There was a significantly greater incidence of infection and length of hospital stay when there
was a delay of 24 hours in commencing the enhanced nutrition treatment. Zhou
et al. (2003) randomly allocated severely burned patients to additional enteral
glutamine (an amino acid) and found a 19% improvement in wound healing
compared to controls, who had received standard feeds.
It is the responsibility of the nurse to see that patients have an adequate
diet. Many patients have their mealtimes disrupted by medical ward rounds
or being away from the ward undergoing investigations, although there is
increased awareness of the need to have protected mealtimes. Older et al. (1980)
saw food being placed beyond the reach of a patient and then removed later
without the patient ever having the chance to actually eat any of it. Delmi et al.
(1990), in their study of a group of elderly patients with fractured neck of femur,
found that inadequate amounts of food were consumed. It should also be noted
that 80% of patients in the study were malnourished on admission. Lewis et al.
(1993) studied the diet of a small group of elderly patients with leg ulcers and
found their intake was below the estimated average requirement for their age
group and did not meet the requirements for healing their ulcers. A similar
study by Sitton-Kent and Gilchrist (1993) of elderly hospitalised patients with
chronic wounds found that they did not consume adequate levels of nutrients
and in some instances had inadequate quantities on their plates. Many things
can affect the appetite such as anxiety, altered mealtimes, cultural differences
or malaise. It is obvious that a nutritional assessment of all patients should be
made on admission and at regular intervals afterwards.
The Better Food Programme (DoH, 2001c) was introduced to try and address
some of the problems described above. The Essence of Care document (DoH,
2001a) has provided best practice standards against which healthcare providers
can benchmark their practice. It includes statements such as the following.
䊉
䊉
Patients/clients receive the care and assistance they require with eating and
drinking.
Food that is provided by the service meets the needs of individual
patients/clients.
Age
The cell metabolic rate slows with advancing years. There is also an increased
risk of malnutrition. Exton Smith (1971) divided the causes of this into primary
and secondary. Primary causes included ignorance, social isolation, physical
disability, mental disturbance, iatrogenic disorder and poverty. Secondary
causes were impaired appetite, masticatory inefficiency, malabsorption, alcoholism, drugs and increased requirements.
16
The Care of Wounds
Disease
Many patients suffering from malignant disease have a reduced nutritional
status. Stubbs (1989) found that one in four cancer patients experienced alterations in taste perception that affected their appetite and eating habits.
Drugs
Several drugs affect the nutritional status of patients. Methotrexate has an antivitamin effect which means that the enzyme that would normally bind a
vitamin binds the drug instead. Methotrexate competes with folic acid and
causes it to be excreted, thereby inhibiting DNA synthesis and cell replication
(Holmes, 1986). Neomycin reduces the absorption of vitamins K and D. Paraaminosalicylic acid (PAS) and colchicine reduce the absorption of vitamin B12.
A number of drugs can cause loss of appetite, which may lead to a diminished
nutritional status. Examples are phenformin, metformin, indomethacin, morphine, digoxin and cancer drugs.
It should also be noted that patients not deemed to be at risk of undernutrition may fail to eat adequately. Brown (1991) studied the intake of patients who
were considered to have no special dietary requirements. She found that 68%
had intakes of less than 1000 kcal and large deficits of a range of vitamins and
minerals. The deficit was caused by failure to eat the food provided. Adequate
monitoring of patients’ diets is essential as this group of patients are often
missed.
It is important to identify those who are malnourished in order that appropriate steps can be taken to improve their nutritional status. A number of
screening tools have been developed and some have been widely validated.
One such is the Mini-Nutritional Assessment Tool (MNA), which has been used
to assess elderly patients with leg ulceration (Wissing & Unosson, 1999). The
first part of the MNA is a screening tool that identifies those who require more
detailed assessment. The second part allows the assessor to identify those at
risk of malnutrition and those who are actually malnourished, allowing the
healthcare professional to develop an appropriate plan of care.
The British Association for Parenteral and Enteral Nutrition (BAPEN)
launched the MUST screening tool in 2003 (Elia & Stratton, 2004). It is a fivestep tool that has been validated for use with adults of all ages in both hospital and community settings. It allows the assessor to determine if a patient is
at low, medium or high risk of malnutrition and provides appropriate management guidelines, depending on whether the patient is in hospital, a care
home or the community. The guidance also provides information on how to
calculate height for a patient who cannot be measured in the usual way. Further
information can be obtained from www.bapen.org.uk.
Hunt (1997) and her colleagues have devised a nutritional assessment tool
that considers various factors that can affect nutritional status. Patients are
assessed according to their mental condition, weight, appetite, ability to eat, gut
function, medical condition, including chronic wounds, and age. The tool provides a score that indicates whether the patient is nutritionally at risk. Use of a
The Management of Patients with Wounds 17
screening tool can be helpful in identifying those less obviously at risk of poor
nutritional status than those discussed above.
䊉
Nursing assessment
䊉
On admission:
䊉
䊉
䊉
䊉
identify those at special risk using an appropriate screening tool.
take a dietary history.
observe for obvious signs of obesity, emaciation or muscle wasting.
Nursing intervention
䊉
Problem: Reduced nutritional status
Goal: The patient will consume sufficient nutrients for his daily needs
The nutritional needs for each individual vary according to their age, sex, activity and the severity of any illness. If a patient has been assessed as having a
reduced nutritional status or falls into a high-risk category, then his nutritional
intake should be very carefully monitored. Each patient requires sufficient
nutrients to support his basal metabolic rate, his level of activity and the metabolic response to trauma. Patients with heavily exuding wounds, such as fistulae or leg ulcers, may lose large amounts of protein without it being realised.
Table 2.1 shows the nutrients required for wound healing and their sources.
The dietician will be able to help in assessing individual needs, so that very
specific goals can be set. The goal set at the beginning of this section is of necessity broad but needs to be more clearly defined for each individual. If a patient
is being cared for at home, the carer must also be involved. Many patients will
eat better at home, where they can eat what they want, when they want to.
The elderly may have special problems or needs. Penfold and Crowther
(1989) have provided helpful guidelines for assisting the elderly to maintain a
good diet. One problem may be developing disability. The occupational therapist can give guidance on adapting cooking equipment. Another problem may
be lack of education as to what constitutes a ‘good’ diet. An even simpler
problem may be poorly fitting dentures. A new set of teeth may be all that is
needed to allow an elderly person to maintain an adequate nutritional status.
For many people, the short period of starvation during surgery followed by
a rapid return to an adequate diet will not be harmful and the body will quickly
adapt. However, nurses need to be aware of the amount of food their patients
actually eat. These days the plated meal system is widely used in hospitals and
there has been little monitoring of the amount of food which patients actually
eat. It is to be hoped that the benchmarking process discussed earlier will assist
in resolving this problem. When assisting a patient to plan appropriate menus,
it is helpful to bear in mind the sources of the nutrients particularly required
for wound healing (see Table 2.1).
Some critically ill patients will not have an adequate intake without artificial
feeding. This may take the form of a supplement or total nutrition, either by
enteral or parenteral feeding. Enteral feeding is the more desirable way of providing nutrition but if the gastrointestinal tract is not functioning, then total
18
The Care of Wounds
Table 2.1
The nutrients required for healing.
Nutrient
RDA*
Food source
Contribution
Carbohydrates
1600–3350 kcals
Wholemeal bread, wholegrain
cereals, potatoes (refined
carbohydrates are seen as
‘empty’ calories)
Energy for leucocyte,
macrophage and
fibroblast function
Protein
42–84 g
Meat, fish, eggs, cheese,
pulses, wholegrain cereals
Immune response,
phagocytosis,
angiogenesis, fibroblast
proliferation, collagen
synthesis, wound
remodelling
Fats
1–2% kcals
Dairy products, vegetable oil,
oily fish, nuts
Provision of energy,
formation of new cells
Vitamin A
750 mg
Carrots, spinach, broccoli,
apricots, melon
Collagen synthesis and
cross-linking, tensile
strength of wound
B complex
3 mg
Meat (especially liver), dairy
products, fish
Immune response,
collagen cross-linking,
tensile strength of wound
Vitamin C
30 mg
Fruit and vegetables (but
easily lost in cooking)
Collagen synthesis,
wound tensile strength,
neutrophil function,
macrophage migration,
immune response
Vitamin E
Vegetable oils, cereals, eggs
Appears to reduce tissue
damage from free radical
formation
Copper
Shellfish, liver, meat, bread
Collagen synthesis,
leucocyte formation
Iron
10–12 mg
Meat (especially offal), eggs,
dried fruit
Collagen synthesis,
oxygen delivery
Zinc
12–15 mg
Oysters, meat, whole cereals,
cheese
Enhances cell
proliferation, increases
epithelialisation,
improves collagen
strength
* These recommended daily amounts are the requirements in health and may need to be
increased (see text).
The Management of Patients with Wounds 19
parenteral nutrition is necessary. Zainal (1995) discussed the issues around the
feeding of critically ill patients and stressed the importance of starting feeds
early. However, this must be done with caution as overfeeding the critically ill
can cause major metabolic problems. Further problems may be caused by persisting with enteral feeding for a patient in septic shock with reduced splanchnic blood flow. The nutrition team should be involved in managing these
patients.
Decision trees can also be used in planning care. They can be particularly
helpful in providing guidance for less experienced staff and for setting a standard for care. The European Pressure Ulcer Advisory Panel has developed a
decision tree to use alongside their nutrition guideline (Fig 2.1) which maps the
essential elements of the guideline (Clark et al., 2004).
䊉
Evaluation
䊉
Evaluation may be achieved by regular weighing of the patient and reassessment using a nutritional screening tool. Gazzotti et al. (2003) used weighing and
the MNA in a randomised trial to determine the effectiveness of nutritional
supplements in preventing malnutrition.
2.2.2 Infection
Consideration of infection must include both systemic and localised wound
infection. Systemic infection affects healing as the wound has to compete with
more widespread infection for white cells and nutrients. Wound healing may
not take place until after the body has dealt with the infection. Systemic
infection is frequently associated with pyrexia which causes an increase in the
metabolic rate, thus increasing catabolism or tissue breakdown.
All wounds are contaminated with bacteria, especially open wounds. This
does not affect healing but clinical infection will certainly do so. Infection prolongs the inflammatory stage of healing as the cells combat the large numbers
of bacteria. It also appears to inhibit the ability of fibroblasts to produce collagen (Senter & Pringle, 1985).
Infection in a burn wound increases the metabolic rate and thereby increases
the period of negative nitrogen balance. Kinney (1977) has shown that there
may be a loss of 20–30% of the initial body weight in the presence of major
sepsis. Infection also causes pain, which raises the metabolic rate (Arturson,
1978).
A number of factors have been found to increase the risk of developing a
wound infection. They are identified below.
Age
Moro et al. (1996) used logistical regression to identify factors associated with
increased risk of surgical wound infection. They found that age greater than 85
years was a significant factor. A study using multivariate analysis (de Boer
et al., 1999) found age over 74 years to be the most important independent risk
20
The Care of Wounds
Patient at risk of developing pressure ulcer
or with a preassure ulcer
In association with all other appropriate
interventions according to guidelines
Regular
nutritional
follow-up
BMI (kg/m2) <20
% weight loss > 10% in 6 months
of >5% in 1 month
High-risk score from screening tool
Nuritional assessment
This should be done preferably by a qualified
member of a nutritional team
Not at risk of malnutrition
Nutritional screening
· Clinical judgement
· Weight (kg), height (m), BMI (kg/m2)
· Screening tool (e.g. MUST)
At risk or with malnutrition
Steps
Nutritional intervention
Plan includes patient’s choice and
expected outcome
It is possible to achieve adequate oral intake with normal diet?
First
No
Yes
Can it be achieved using (specific)
supplements in addition to normal diet?
Second
No
Yes
Can adequate intake be achieved by partial or total enteral feeding?
Third
No
Yes
Did this plan meet the goals set with the patient?
No
Yes
Refer to the nutrition team or reset the goals with the patient
Fig. 2.1 Decision tree on nutrition in pressure ulcer prevention and treatment (reproduced by kind
permission of the European Pressure Ulcer Advisory Panel).
The Management of Patients with Wounds 21
factor for infection in over 10 000 orthopaedic patients. Pavlidis et al. (2001) compared local and systemic factors in 89 patients with abdominal wound dehiscence with a control group and found age over 65 years to be a significant factor.
Obesity
Martens et al. (1995) found obesity to be a significant factor in wound infection
following caesarean section. These findings are supported by Moro et al. (1996),
who found obesity to be a significant factor for infection in a wide range of surgical cases, and also by He et al. (1994) and Birkmeyer et al. (1998). Researchers
in these latter two studies found a significantly higher incidence of sternal
wound infection following bilateral internal mammary artery grafting and
coronary artery bypass surgery respectively.
Nutritional status
Poor nutrition increases the infection risk. McPhee et al. (1998) found preoperative protein depletion to be a significant factor for wound infection in patients
undergoing spinal surgery. (See also under Nutrition heading above.)
Diabetes
Borger et al. (1998) found diabetes to be a predictor of deep sternal wound infection for patients undergoing cardiac surgery. (See also under Diabetes Mellitus
heading, p. 25.)
Special risks
Irradiation, steroids and immunosuppressive drugs cause greatly increased
infection rates (Bibby et al., 1986). Chmell and Schwartz (1996) found that preoperative chemotherapy was a significant factor in wound infection following
musculoskeletal sarcoma resections.
Length of preoperative stay
The longer anyone is in hospital, the more chance there is that the patient’s skin
will become colonised by bacteria against which the patient has no resistance.
A preoperative stay over four days was found to be an independent risk factor
by de Boer et al. (1999).
Shave
It is impossible to carry out a shave without causing injury to the skin. Bacteria flourish and multiply rapidly in these minute cuts. Mishriki et al. (1990) and
Moro et al. (1996) found shaving to be a significant factor in the development
of infection. Mishriki et al. suggest that this is particularly so when contaminated and dirty procedures are undertaken and bacteria are shed on the skin.
It is generally recommended that if a patient needs to be shaved preoperatively,
it should be done just prior to surgery.
22
The Care of Wounds
Type of surgery
Infection rates are much higher in some types of surgery than others. This is
discussed in more detail in Chapter 6. The appearance of infected wounds will
be discussed in Chapter 3.
䊉
Nursing assessment
䊉
Identify those at risk.
Assess wound (see Chapter 3).
Monitor temperature regularly.
䊉
䊉
䊉
Recently neural network analysis has been used to predict outcomes and identify those at higher risk of developing an infection. Lammers et al. (2003) undertook a study of a cohort of 1142 uncomplicated traumatic wounds. Clinicians
undertaking the initial treatment of the wound were asked to estimate the likelihood of subsequent infection. Staff blinded to this prediction followed the
wounds until the sutures were removed. Independent predictors were identified and used in the neural network analysis as input variables; infection was
the output variable, in order to arrive at an equation for the analysis model.
The researchers were able to use this as a diagnostic test for wound infection
in this group of wounds. This type of data analysis has potential for the future
as neural network analysis becomes more widely used.
䊉
Nursing intervention
䊉
Problem: Actual/potential risk of infection
Goal: Prevention or early detection
The prevention of infection is the responsibility of all healthcare professionals.
There are both general and specific measures that can be taken. Most health
authorities have infection control policies that provide guidelines both to
prevent infection and to reduce the risk of cross-infection. The infection control
team, especially infection control nurses, can give advice and support.
Much has been written on the prevention of infection. The UK Department
of Health developed guidelines entitled Standard Principles for Preventing Infections in Hospitals together with guidelines for preventing hospital-acquired
infections (HAI) associated with the use of short-term indwelling urethral
catheters in acute care and with central venous catheters in acute care (DoH,
2001b). It is intended that these guidelines are incorporated into local protocols.
Within the first part of the guideline there are four standard principles.
䊉
䊉
䊉
䊉
Hospital environmental hygiene.
Hand hygiene.
The use of personal protective equipment.
The use and disposal of sharps.
The spread of infection is mostly by people from people. Thus, the simplest and
most effective measure to prevent infection is good handwashing. A review by
Larson and Kretzer of the period 1984–1994 found that researchers consistently
The Management of Patients with Wounds 23
reported that whilst the action of handwashing was carried out mostly at the
appropriate times, the methods used were ineffective (Larson & Kretzer, 1995).
Gould (1992) also supports this view but she suggests that there has been a
failure to consider the reality of the situation in the clinical area. One example
cited is that compliance is unlikely if the designated cleanser makes hands
sore. Adequate facilities for handwashing are also necessary although alcohol
handrub may be a useful alternative.
Tibballs (1996) observed doctors to obtain their handwashing rates and then
asked a sample for their estimated frequency of handwashing prior to patient
contact. There was a considerable difference between the estimated rate of 73%
(range 50–90%) and the observed rate of 9%. It is also interesting to note that
an editorial in the British Medical Journal by the Handwashing Liaison Group
(1999) provoked 21 letters to the editor from seven different countries, not all
of them in support of handwashing.
The DoH guideline recommendations for handwashing include either the
use of soap and water or the use of alcohol-based handrub. Hands that are
obviously soiled or could be grossly contaminated must be washed in soap and
water. Handwashing is defined as having three stages: preparation, washing
and rinsing, and drying. It is important to ensure that the soap or handrub
touches all the surfaces of the hands. The guidelines also recommend regular
use of an emollient hand cream in order to reduce skin dryness.
Identification of patients at risk of infection means that appropriate measures
can be taken. Some particularly vulnerable patients may require extra measures. These may include the use of a single room with a positive pressure
filtered air system, providing protective isolation, prophylactic drugs or
special operating techniques such as a Charnley Howarth tent for orthopaedic
procedures.
A more controversial prevention method is the use of supplemental oxygen.
Greif et al. (2000) randomly allocated 500 patients undergoing colorectal surgery
to one of two regimes of supplemental oxygen. They found that provision of
supplemental oxygen during surgery and for two hours afterwards halved the
infection rate. This approach seems promising but Gottrup (2000) suggested
that the optimal treatment period has not been finally determined.
䊉
Evaluation
䊉
Careful monitoring of vulnerable patients is essential. Monitoring a patient’s
temperature is a useful means of evaluation as a rise in temperature is often the
first indication of infection. The use of clinical audit will identify areas where
cross-infection may be a regular problem.
2.2.3 Smoking
Smoking causes vasoconstriction and is associated with Buerger’s disease, a
condition causing intermittent claudication and gangrene. Smoking may also
act as an appetite depressant. Smokers have been found to be deficient in
vitamins B1, B6, B12 and C. Smoking reduces subcutaneous oxygen tension
24
The Care of Wounds
significantly for up to 30–45 minutes after each cigarette. Synthesis of type I collagen has also been found to be reduced in smokers (Jorgensen et al., 1998). A
review of the effects of smoking on wound healing by Siana et al. (1992) found
that nicotine affected macrophage activity and reduced epithelialisation and
wound contraction. There is increasing evidence that smoking is associated
with poor wound healing and increased complications. However, most studies
undertaken in this area have looked at surgical wounds and there is little information regarding smoking and chronic wound healing (Sorensen, 2003).
Sorensen et al. (2002) studied the impact of smoking compared with nonsmoking on 425 patients undergoing breast surgery. They found smoking was
significantly associated with wound infection, skin flap necrosis and epidermolysis. The same group studied the impact of abstinence from smoking on
healing of experimental incisional wounds in healthy individuals. They compared never-smokers with smokers randomised to either continue smoking or
abstain from smoking for a four-week period. They found a significantly higher
incidence of wound infection in the smokers compared with the never-smokers
(12% versus 2%, p < 0.05). They also found there was a significant reduction
in infection in the abstinent smokers compared with continuous smokers
(Sorensen et al., 2003). Manassa et al. (2003) undertook a retrospective study of
132 patients undergoing abdominoplasty and compared outcomes for smokers
and non-smokers. They found a significant incidence of wound complications,
including wound dehiscence (47.9% versus 14.8%, p < 0.01).
In reviewing the evidence on smoking and problems in wound healing,
Sorensen (2003) suggests that there is a need for research into the impact of
smoking on chronic wound healing. Further research is also required to determine the impact of abstinence on collagen production and delayed healing.
䊉
Nursing assessment
䊉
Early identification of patients who smoke, especially prior to surgery.
䊉
Nursing intervention
䊉
Problem: Patient who smokes about to undergo surgical intervention
Goal: Patient to abstain from smoking for a four-week period, two weeks before and
two weeks after operation
Nurses can play a significant role in both educating patients about the harmful
effects of smoking on a healing wound and encouraging them to abstain over
the perioperative period. Prescription of nicotine patches may be helpful for
some patients and additional support from helplines and other agencies may
also be beneficial.
䊉
Evaluation
䊉
Monitoring abstinence (or otherwise) may not be easy. It requires both honesty
from the patient and respect from the nurse, whatever the outcome. Even if
there are lapses, nurses should continue to encourage their patients to refrain
from smoking.
The Management of Patients with Wounds 25
2.2.4 Diabetes mellitus
Both Type I and Type II diabetes have been shown to be associated with delayed
healing. King (2001) suggested that the most frequently quoted reason for
delayed healing is infection as high glucose levels encourage proliferation of
bacteria. McCampbell et al. (2002) found higher infection rates in 181 diabetic
patients with burn injuries compared with 190 non-diabetic burn patients.
There are, however, a number of other problems that may be encountered
through each stage of the healing process in diabetics with deep wounds such
as surgical incisions.
䊉
䊉
䊉
䊉
䊉
䊉
䊉
Signs of inflammation may be limited because a thickened basement
membrane causes a rigidity that prevents vasodilation (Renwick et al.,
1998).
In addition, high glucose levels make erythrocytes, platelets and leucocytes
more adhesive and they tend to stick together, filling the vascular lumen
(Alberti & Press, 1992).
There is decreased phagocytosis and poor chemotactic response in neutrophils although the precise reason is uncertain (King, 2001).
Chbinou and Frenette (2004) found reduced levels of neutrophils,
macrophages and angiogenesis in a diabetic animal model.
Several studies have demonstrated that diabetics have abnormal fibroblasts
with reduced capacity for proliferation and collagen synthesis. This results
in abnormal cross-linking of collagen and reduced wound contraction,
further prolonging the healing process (Hehenberger et al., 1998; Leaper &
Harding, 1998; Loots et al., 1999).
Also, diabetics deal with the stress of wounding (trauma or surgery) by producing increased levels of glucagons, cortisol and growth hormone, leading
to raised levels of blood glucose and an increased need for insulin. If this situation is not corrected the patient can become catabolic. The body will start
to break down proteins and fats, ultimately resulting in a state of negative
nitrogen balance (Rosenberg, 1990).
Nursing assessment
䊉
Regular checks of blood glucose levels, the frequency depending on patient
condition.
䊉
Nursing intervention
䊉
Actual/potential problem: Unstable glycaemic control increases potential for poor
wound healing and infection in diabetic patients with surgical or traumatic wounds
Goal: Effective glycaemic control and uncomplicated wound healing
In planned procedures it is possible to ensure that the patient is adequately prepared and the diabetes well controlled. Obviously, this is not possible when a
patient suffers traumatic injury. In either event, during any period of fasting
the greatest risk is from hypoglycaemia and it may be necessary to commence
a dextrose intravenous infusion. In the immediate postoperative or postinjury
26
The Care of Wounds
period the patient is at considerable risk of hyperglycaemia as a result of the
stress of the event.
Perkins (2004) discussed this problem in relation to critically ill patients, in
particular the danger of intensive insulin therapy resulting in hypoglycaemia.
She proposed that effective interventions could only be achieved by multiprofessional teamwork and agreement of planned actions or protocols. Such an
agreement would need to consider the frequency of monitoring for blood
glucose and the level at which insulin therapy would be commenced. Perkins
describes the regime that was set for the critically ill trauma patient: two-hourly
monitoring with insulin therapy set to commence if blood glucose levels rose
above 7 mmol/l. Insulin was to be administered according to a sliding scale in
order to ensure titration. Obviously, this degree of intervention is not necessary
or appropriate for every patient but the principle of team working and developing agreed, planned action can be applied to any situation where diabetic
control is challenged because of stress.
䊉
Evaluation
䊉
Regular monitoring of blood glucose levels will determine the effectiveness of
care.
2.2.5 The physical effects of stress
Stress has a physiological effect. Stimulated by the release of adrenalin, a
primary biochemical change in stress is an increased secretion of adrenocorticotrophic hormone (ACTH), which stimulates production of adrenal cortex hormones. In particular, ACTH regulates production of glucocorticoids, cortisol
and hydrocortisone. Glucocorticoids cause the breakdown of body stores to
glucose, raising the blood sugar, and reduce the mobility of granulocytes and
macrophages, impeding their migration to the wound. In effect, this suppresses
the immune system and reduces the inflammatory response. Glucocorticoids
also increase protein breakdown and nitrogen excretion, which inhibits the
regeneration of endothelial cells and delays collagen synthesis.
Kiecolt-Glaser and colleagues researched the effects of psychological stress
on 13 women and found it significantly slowed the rate of healing when compared with a group matched for sex, age and income (Kiecolt-Glaser et al., 1995).
There would also seem to be an increased risk of wound infection in a stressed
patient (Kiecolt-Glaser et al., 2002). An animal model study found a significantly
higher incidence of opportunistic infection compared with the control group as
well as a 30% rate of delayed healing (Rojas et al., 2002). Cole-King and Harding
(2001) measured stress levels in 53 patients with leg ulcers that had been present
for no more than three months. They found that of the 16 patients identified as
having clinical anxiety, 15 had delayed healing and that all 13 patients with clinical depression also had delayed healing.
A great number of factors can cause stress and they will be discussed
throughout the rest of this chapter.
The Management of Patients with Wounds 27
2.2.6 Pain
Pain and stress are closely related because pain can increase stress and stress
increases pain (Augustin & Maier, 2003). Hayward (1975) showed that preoperative information to reduce stress and anxiety resulted in less postoperative
pain. Fear of pain can cause much anxiety to patients. Pracek et al. (1995) found
that procedural pain experienced by burn patients in the early stages of their
admission could be a causal factor in their ability to adjust after discharge. The
greater the pain levels, the poorer the adjustment.
There has been increasing recognition of the effect of pain on patients with
chronic wounds, especially leg ulceration (Ebbeskog & Ekman, 2001). Nemeth
et al. (2003) surveyed leg ulcer patients for the prevalence of pain and found
that approximately half of them suffered from pain to the extent that it impacted
on their quality of life. Gibson and Kenrick (1998) graphically described the
impact that the pain from a chronic condition (peripheral vascular disease) can
have on the sufferer and the resulting sense of powerlessness.
There is a wealth of evidence that lack of adequate pain control is common.
Carr (1997) described four barriers to effective pain control.
Lack of knowledge and inappropriate attitudes of healthcare professionals
A large study by the Royal College of Surgeons and College of Anaesthetists
(1990) on pain after surgery found that nurses had insufficient commitment to
providing adequate pain control and a lack of relevant knowledge; as a result
up to 75% of patients experience moderate to severe postoperative pain. Field
(1996) found that nurses consistently underestimated the pain suffered by their
patients. Closs (1992) found that patients’ sleep was disturbed by pain. In her
study of 100 surgical patients, 49 said the pain was worse at night.
It is not only patients undergoing surgery who experience unrelieved pain.
A study was undertaken by Chan et al. (1990) to determine the prevalence of
chronic pain in diabetics. They found that chronic pain was more common in
those suffering from diabetes than in those who did not. The pain was most
commonly reported to be in the lower limbs. The researchers noted that there
seemed to be little recognition of the problem or facilities to help resolve it.
Hitchcock et al. (1994) surveyed over 200 individuals who suffered from chronic
pain. They found that on average, the respondents suffered pain 80% of the
time and 50% reported that their prescribed analgesia was inadequate.
Patients expect pain and patients may minimise their pain
Yates et al. (1995) studied older patients in long-term residential care. They
found that these patients were resigned to having pain and expected that they
would just have to tolerate it. They also reported being reluctant to discuss their
pain for fear of being labelled a complainer. Carr and Thomas (1997) found
similar results when they interviewed postoperative patients. Ward et al. (1996)
discussed cancer patients’ perceptions of pain and noted that many feared that
they would become addicted to their analgesia. Others do not complain because
28
The Care of Wounds
they believe that ‘good’ patients should not complain. Also, pain to the cancer
patient indicates further progression of the disease and the patient may be
reluctant to report increased pain.
The organisation may inhibit the provision of good pain relief
Fagerhaugh and Strauss (1977) considered the organisational structure within
which pain management takes place. They suggested that workload in the clinical area, lack of accountability and the complexity of the nurse–patient relationship were all factors that resulted in poor pain management. The acute pain
team can play a major role in improving the standards of assessment and organisation of analgesia which result in improved pain control (Harmer & Davies,
1998). However, there can also be problems. Carr and Thomas (1997) suggest
that ward nurses still fail to recognise their responsibilities for pain management and may abdicate their role to the pain management team. They also
found that nurses tended to assume that ‘high-tech’ equipment, such as patientcontrolled analgesia, automatically abolished pain and therefore pain assessment was not necessary.
Parsons (1992) gave an overview of studies of cultural aspects of pain and
concluded that definitions of pain by both the sufferer and carer are shaped by
cultural beliefs. In some cultures, free expression of feelings of pain is expected
whereas in others it is unacceptable. There needs to be recognition of these cultural differences in order to manage pain successfully.
䊉
Nursing assessment
䊉
Holzman and Turk (1986) describe pain as a unique experience for each individual. It therefore follows that only the patient can describe its presence and
severity. Pedley (1996) reviewed some of the assessment tools that have been
developed. She recommends the use of a visual analogue scale such as that in
Figure 2.2. However, elderly people do not always find such a concept easy to
use. Verbal analogue scales may be more suitable. This type of scale uses
descriptions ranging from no pain through mild, moderate and severe to
unbearable pain. Simons and Malaber (1995) considered the problem of patients
who cannot communicate by speech and developed a method of assessing
behaviour and body language.
䊉
Nursing interventions
䊉
Problem: Inadequate pain control
Goal: The patient will be able to express feelings of comfort and relief from pain
Pain management is a big topic and can only be addressed briefly here. Pain at
dressing change will be addressed in Chapter 3. Modern systems of drug delivery, such as slow-release drugs or intravenous pumps, provide constant pain
relief that is more effective than the use of injections that have a bolus effect.
Spinal infusion has been found to be effective for a small group of terminally
ill patients for whom other methods failed (Hicks et al., 1994).
The Management of Patients with Wounds 29
Numbers corresponding
to severity of pain
Excruciating pain
(no control)
10
9
Extreme pain
(disabling) – prevents
you doing your usual
activities
8
7
6
Moderate pain
5
Words to describe pain
Match the word(s) that apply to
your pain with a number in the
ruler which corresponds to the
severity of your pain.
Draw an arrow from the word to the
number or tell the nurse.
tender
crushing
squeezing
stabbing
sharp
burning
feels like an electric shock
throbbing
cramping
dull
sore
aching
gnawing
feels like a weight pressure
a discomfort
4
3
2
Slight pain
1
No pain
0
Fig. 2.2
A pain chart.
Music has been used as a distraction therapy to help reduce a patient’s perception of pain in the immediate postoperative period (Taylor et al., 1998).
Relaxation has been successfully used as a technique to reduce pain in cancer
patients (Sloman et al., 1994) and in older men undergoing hip replacement
(Parsons, 1994). Other strategies may be used to assist in pain relief. Measures
such as turning, lifting or massage may be very comforting. Simple aids such
as a bed cradle to reduce the weight of the bed clothes can be very effective.
30
The Care of Wounds
䊉
Evaluation
䊉
Regular use of a pain chart allows constant evaluation of the effectiveness of
pain relief.
2.2.7 Sleeping
Most people consider sleep to be important as it provides a sense of refreshment and well-being. In recent years there has been considerable research on
sleep and its effects. Sleep deprivation causes people to become increasingly
irritable and irrational (Carter, 1985). They may complain of lassitude and loss
of feelings of well-being. The sleep–activity cycle is part of the circadian
rhythm. During wakefulness, the body is in a state of catabolism. Hormones
such as catecholamine and cortisol are released. They encourage tissue degradation to provide energy for activity; in particular, protein degradation occurs
in muscle.
Growth hormone is secreted from the anterior pituitary during sleep and
stimulates protein synthesis and the proliferation of a variety of cells, including fibroblasts and endothelial cells (Lee & Stotts, 1990). Rose et al. (2001)
reviewed the impact of burn injury on the sleep patterns of children and the
need to aggressively treat growth hormone insufficiency. They speculate
that improved sleep would improve growth hormone levels. However,
Brandenberger et al. (2000) argue that the body is able to compensate during
the day and the levels of growth hormone secreted over 24 hours remain much
the same, regardless of any sleep deprivation.
There has been some reliance on animal studies to determine the impact of
sleep deprivation and the surrogate measure, noise, on wound healing.
Wysocki (1996) measured the impact of noise on wound healing and found that
wounds healed more slowly compared with controls. Landis and Whitney
(1997) studied the impact of 72 hours of sleep deprivation and found that there
was no difference between experimental and control groups. It should be noted
that these studies were undertaken on basically healthy animals and the findings may not be transferable to sick humans. Further studies, especially clinical studies, are needed to clarify the matter.
There is much evidence that sleep patterns are disturbed in hospital. Hill
(1989) suggested that ward routines, such as early morning waking, prevent the
patient getting adequate sleep. Also, many patients are disturbed during the
night, especially in the intensive care unit. Woods (1972) observed cardiac
surgery patients and noted that they were disturbed as many as 56 times during
the first postoperative night. Morgan and White (1983) found that intensive care
nurses were aware of the importance of sleep but failed to recognise when they
were disturbing their patients unnecessarily.
Freedman et al. (1999) surveyed 203 patients immediately after discharge
from different types of intensive care units and found that poor sleep quality
was common to all units. They also found that sleep disruption was caused by
human interventions, diagnostic testing and environmental noise. A further
The Management of Patients with Wounds 31
study from the same research centre investigated the impact of environmental
noise on sleep. The sleep patterns of 22 medical patients in an intensive care
unit were monitored for 24–48 hours continuously. Patients were found to sleep
for short periods throughout a 24-hour timeframe with a mean number of sleep
periods of 41+/-28 and the mean length of a sleep bout was 15+/-9 minutes.
Overall, environmental noise was responsible for only 17% of sleep disturbances (Freedman et al., 2001).
Other factors may also disturb sleep, as shown in a survey by Southwell and
Wistow (1995) of 454 patients and 129 nurses across a variety of wards in three
hospitals. Half the patients had difficulty in sleeping through the nights and
did not get as much sleep as they wished. Many of the patients complained that
the ward was too hot and the mattresses were uncomfortable and they disliked
having plastic covers on both mattresses and pillows. Pain and worry were also
likely to make sleeping more difficult. A variety of factors were found to disturb
sleep including: other patients making a noise, nurses attending other patients,
telephones ringing, lights in the ward, nurses talking to each other or to
patients, having treatment including medication, toilets flushing or commodes
being used, nurses’ shoes making a noise. Patients on surgical wards reported
more disturbances than other ward specialties. The authors of this study considered that nurses should be more aware of the need to ensure that patients
get a good night’s sleep.
䊉
Nursing assessment
䊉
Compare ‘normal’ with present patterns of sleep.
Assess the ward environment – is it conducive to sleeping?
Consider ward routines – do they allow the patient to follow any aspect of
their usual routines or are they too rigid?
䊉
䊉
䊉
䊉
Nursing intervention
䊉
Problem: Disruption of normal sleeping patterns
Goal: Patients are able to sleep a number of hours at night and state that they feel
well rested
McMahon (1990) suggested four types of sleeplessness:
䊉
䊉
䊉
䊉
difficulty getting to sleep.
waking regularly during the night.
waking early in the morning.
sleeping for the normal length of time but not waking refreshed.
Various strategies can be employed to help patients resolve their specific
problems. The provision of a milky drink can be beneficial, especially if the
patient normally has one at bedtime. Some people may become hungry after
having supper between 1700 and 1800 hours. They may ask their visitors
to bring them in a snack. Whilst there is no evidence that food can induce
sleep, it is difficult to sleep when hungry. Most people have specific routines
that they follow each night. As much as possible, this same routine should be
32
The Care of Wounds
followed in hospital which can introduce a feeling of normality into a strange
situation.
Some people find their sleep disrupted because of pain. This may be acute
pain following trauma or surgery or a more chronic pain relating to a longstanding illness or condition. Adequate pain control is essential. Pain is a resolvable problem (see also section 2.2.6). The position of patients may affect their
comfort so it is helpful to ensure that the patient is in a comfortable position,
with a bell close to hand.
During the night, many fears that are suppressed during the day come to the
surface. Sleep may be disturbed because of a particular anxiety. Nighttime is a
quieter time on the ward so the nurse may have an opportunity to sit and listen
and allow patients to express their fears and anxieties. Once this has happened,
the patient may be able to return to normal sleep patterns.
Hospital routines can disrupt normal sleep patterns. The lights of a ward may
go off late, around 2300 hours, and come on again at 0600 hours (Southwell &
Wistow, 1995). Patients are woken for their drugs and a drink. It seems reasonable for more flexibility to be introduced, with a reduction of the 0600 drug
round to the minimum and an arrangement not to wake those who would
prefer to sleep later. Jarmon et al. (2002) experimented with flexible morning
and evening medication times and found that patients were able to sleep for
longer. Haddock (1994) found some patients benefited from using earplugs but
they are not suitable for everyone. It should be possible, with careful planning,
to provide an environment that is conducive to sleep, and a comfortable patient
who is able to benefit from it.
䊉
Evaluation
䊉
Patient questionnaires are a useful way of establishing the success or otherwise
of the above plan.
2.2.8 Hypothermia
Anaesthesia for major surgery can lead to hypothermia as a result of decreased
metabolic rate and impaired thermoregulation (Sellden, 2002). Recently, there
has been increased understanding of the impact that even mild levels of intraoperative hypothermia can have on postoperative recovery. Schmied et al.
(1996) randomised 60 patients undergoing total hip arthroplasties to either normothermia (36.6°C) or mild hypothermia (35°C). They found that blood loss
was significantly higher in the hypothermic group compared with the normothermic patients.
Kurz et al. (1996) proposed that mild hypothermia increased the risk of
wound infection because of vasoconstriction decreasing the level of tissue
oxygen and impacting on neutrophil activity. To investigate this further, they
undertook a double-blind randomised study of 200 patients undergoing colorectal surgery. Patients were randomised to either the normothermic group
(37°C) or the hypothermic group (34.4°C). They found that patients in the
hypothermic group were three times more likely to develop a postoperative
The Management of Patients with Wounds 33
wound infection and had significantly longer hospital stay. Their sutures were
also removed later than those in the normothermic group.
Mahoney and Odom (1999) reviewed the outcome costs for mildly hypothermic patients compared with normothermic patients undergoing a range of
operations. They were able to pool the findings of the studies and undertake a
meta-analysis. They found that mildly hypothermic patients were more likely
to require blood transfusions and to develop wound infections and the cost of
these adverse outcomes ranged between $2500 and $7000.
Plattner et al. (2000) tested an experimental warming bandage system and
compared it with conventional gauze with elastic adhesive in 40 normothermic
patients following elective abdominal surgery. The experimental bandage consisted of an adhesive shell and a foam frame surrounding a clear window. A
heated card was inserted into the frame approximately 1 cm above the wound
surface and left in situ for two hours at a time. Oxygen tension was measured
via a probe inserted 2–3 cm laterally to the incision. Their results were unexpected. They found that the oxygen tension was considerably lower in those
with a conventional dressing because of the pressure exerted by the elastic
strapping. The warming device did not appear to benefit normothermic
patients particularly, although it had potential for use for hypothermic patients.
Perioperative hypothermia is associated with a higher incidence of wound
infection. This is of particular relevance in surgery where there is already a
high risk of infection such as abdominal surgery. It is less likely to be important in surgery with a low risk of infection, such as neurosurgery. There are
also procedures when cooling the patient is appropriate, such as during
craniotomy.
2.2.9 Steroids
Glucocorticoids or corticosteroids are widely used in the treatment of inflammatory diseases. Although they produce effective anti-inflammatory outcomes,
this can have a serious impact on wound healing. A review by Anstead (1998)
highlighted the fact that glucocorticoids affect every stage of the healing
process. This includes overall effects such as the increased risk of infection and
dehiscence in surgical wounds, although this is probably dose dependent.
Grunbine et al. (1998) studied 73 patients who had had a steroid injection following surgery to the foot or ankle and compared the outcome with those who
did not. The use of a single dose of steroids made no difference to healing rates.
Anstead (1998) summarised the effects of glucocorticoids on wound healing
as follows.
䊉
䊉
䊉
Inflammation is suppressed because of a reduction in the numbers of neutrophils and macrophages and an impaired ability to digest phagocytosed
material.
Wound contracture is poor as a result of inhibition of fibroblast proliferation.
Reduced wound strength, as collagen structure and cross-linking are
affected.
34
The Care of Wounds
䊉
Epithelialisation is delayed and the cells are thin, producing a weak wound
covering.
When there is planned wounding, such as surgery, it may be beneficial to
reduce the level of glucocorticoids, especially preoperatively. Pollack (1982)
suggests that doses of prednisolone greater than 40 mg/day have the greatest
effect on wound healing. However, it may not be possible to change dosage
levels and there has been considerable interest in the potential of vitamin A to
counteract the unwanted side effects of glucosteroids. Vitamin A has been
found to restore a normal inflammatory response (Ehrlich et al., 1972) and also
epithelial regeneration, fibroblast proliferation and collagen content (Talas et al.,
2003). However, although there have been a number of animal studies, there is
a need to test the use of vitamin A clinically using controlled trials to determine
what might be an appropriate dose and also to ensure that its use does not
adversely affect the beneficial systemic outcomes of glucocorticoids (Anstead,
1998).
2.2.10 Radiotherapy
Radiation effectively destroys cancer cells as they are more radiosensitive than
normal cells. A dosage high enough to kill cancer cells does not affect the surrounding cells. However, if the dosage has to be increased there is increased
risk of normal tissue necrosing. Radiation has the potential to impact on wound
healing and it would seem that the worst outcomes occur when radiotherapy
is given before surgery.
Hillmann et al. (1997) found preoperative irradiation was an influencing
factor in postoperative complications for patients with Ewing’s sarcoma.
Sassler et al. (1995) found major wound complications in patients undergoing
head and neck surgery following an initial regime of chemotherapy and
irradiation. They reported a 77% incidence of complications in patients
undergoing surgery within one year of the regime compared with a 20%
incidence after one year. Lin et al. (2001) found that a history of radiotherapy
was a factor in wound-healing complications of breast reconstruction. Similar
results were found by Wang et al. (2003) and O’Sullivan et al. (2002), when comparing pre- and postoperative radiotherapy. Both studies found a significantly
higher rate of wound-healing complications when radiotherapy was given
preoperatively.
Radiation may affect the healing of an existing wound or it may cause
changes to the skin so that any later wound will heal slowly. The skin may show
signs of damage from the radiation during treatment. This is known as a radiation reaction and will be discussed in Chapter 6.
Levenson et al. (1984) investigated the use of vitamin A supplements to counteract the effects of radiation on wound healing. In the animal model, they
found that giving vitamin A supplements was effective. Good results were
obtained if the supplementation was started prior to radiotherapy or up to two
days after treatment.
The Management of Patients with Wounds 35
2.3 PSYCHOLOGICAL CARE
Nurses have always excelled at the physical care of patients. It is only recently
that the emotional needs of patients have been considered. Many situations
may cause psychological distress, which may be described as stress. The physiological effects of stress and its effect on wound healing have already been
described in section 2.2.5. Factors causing psychological distress may be defined
as stressors. Those that may be particularly associated with wounded patients
will be discussed in this section. It should be noted that other factors, not
addressed here, can also act as stressors.
2.3.1 Anxiety
Lazarus and Averill (1972) stated that ‘Anxiety results when a person is unable
to fully comprehend the world around him’. This could be considered in relation to ill health. A further quotation from Frankenhaeuser (1967) adds to this:
‘Information is necessary for comprehension, but the perception of this information can be modified by the expectations of the subject’. Many nurses will
have seen patients who have not heard or have misunderstood what has been
said to them because of their degree of anxiety.
Admission to hospital, whether planned or unplanned, can be a very stressful experience.
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Nursing assessment
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Zigmond and Snaith (1983) designed a simple questionnaire, known as the Hospital Anxiety and Depression Score or HAD Score, that can identify the degree
of stress being suffered and can be completed by patients. The questionnaire
comprises a series of questions such as whether an individual is worried or able
to relax and enjoy watching television. There is a choice of four answers to each
question, such as ‘most of the time’ or ‘seldom’. Most patients find it simple to
use. Cole-King and Harding (2001) used the HAD Score to identify stress in 53
patients with leg ulcers and found it to be a useful research tool.
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Nursing intervention
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Problem: Anxiety related to hospital admission
Goal: Patients will be able to express their specific anxieties
Many patients find their admission to hospital a very anxious time. Gammon
(1998) compared the impact of hospital admission on patients with that of isolating a patient because of infection. All patients were assessed using the HAD
Score and two other assessment tools to measure self-esteem (the Self-Esteem
Scale) and a sense of control (the Health Illness (Powerlessness) Questionnaire)
(Rosenburg, 1965; Roy, 1976). The isolated patients had significantly higher
levels of anxiety and depression and lower levels of self-esteem and sense of
control than the routine admission patients. However, results for all patients
36
The Care of Wounds
showed them to be outside normal levels, indicating that they were all suffering above normal levels of stress.
Communication is essential to address this problem. The initial assessment
should provide both information and an opportunity for the patient to ask questions and express their feelings and concerns. Not everyone will always be able
to discuss their anxieties immediately so there may be an ongoing process of
building up a relationship over a period of time.
A study by McCabe (2004) investigated patients’ experiences of nurse–patient
communication. She noted that all the patients in the study frequently stated
that nurses did not provide them with enough information and seemed to be
more interested in tasks than in talking to patients. This was then excused by
saying that the nurses were too ‘busy’. McCabe analysed the findings from her
study in terms of patient-centred communication and task-centred communication. Patient-centred communication involves attending behaviour and the
patients in the study described this in terms of: giving time and being there,
open/honest communication, genuineness, empathy and friendliness and
humour. McCabe considered that nurses could have been using friendliness
and humour as a means of maintaining a superficial level of communication
to avoid the need to address emotional or difficult issues. She also considered
that the culture of the organisation tended to discourage patient-centred
communication.
Active listening is not a very safe occupation. The consequences may be emotionally painful to the nurse because of the difficult questions that may be
asked. Many may feel inadequate or too inexperienced. Koshy (1989) describes
active listening as ‘the process of receiving and assimilating ideas and information from verbal and non-verbal messages and responding appropriately’.
Tschudin (1991) emphasises the importance of not making assumptions. It is
too easy for nurses to assume that they not only know the problem but also
have the answers for dealing with it.
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Evaluation
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Repetition of the assessment will enable the nurse to identify any reduction in
stress levels.
Problem: Anxiety related to surgery
Goal: The patient’s anxiety will be reduced by adequate preoperative preparation
There is now much greater awareness of the importance of providing good
preoperative information. A Department of Health circular (1990) makes it clear
that all patients have the right to understand their treatment and the risks
involved. The role of the nurse is to ensure that each patient receives appropriate preoperative information about the surgery and what to expect in the
postoperative period. Radcliffe (1993) has considered how a suitable strategy
can be implemented. She suggests that oral information is reinforced with
written leaflets, which can be a source of reference for both patients and
relatives.
The Management of Patients with Wounds 37
Doering et al. (2000) assessed the impact of providing a videotape of a patient
undergoing a hip replacement from time of admission to discharge, purely from
a patient’s perspective. One hundred patients were randomly allocated to either
the preparation group (shown the videotape) or a control group. They were
assessed for levels of anxiety and pain for four days post surgery. The
researchers found significantly lower levels of anxiety in the preparation group
as well as a lower intake of analgesia, although there were no differences in the
amount of pain. They considered that this was an effective method of providing information to patients.
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Evaluation
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The patient should be able to describe the likely course of events in the perioperative and postoperative period.
Alternative therapies
Some alternative therapies have been successful in assisting patients to reduce
anxiety. Marshall (1991) described the use of aromatherapy and relaxation techniques to reduce stress in dermatology patients. Dossey (1991) used case studies
to discuss the benefits of guided imagery. This is a method of relaxation that
encourages the patient to use their imagination to first identify the health
problem and then to visualise how the treatment will work effectively. This may
involve favourite scenes, music or other audiotapes. Ultimately patients have to
visualise themselves in the final healed state. This technique should be used over
a period of time, such as for two weeks prior to surgery, for it to be effective.
It is easy to dismiss such a concept as ‘mumbo-jumbo’ because it is alien to
many healthcare professionals. However, Holden-Lund (1988) randomly allocated cholecystectomy patients to either guided imagery or period of quiet and
those receiving guided imagery had significantly lower anxiety levels, cortisol
levels and surgical wound erythema compared to the control group.
Therapeutic touch has been used in the USA for a number of years to reduce
anxiety levels. Heidt (1981) used matched patient groups in a cardiovascular
unit to receive therapeutic touch, casual touch or no touch. Those receiving therapeutic touch had significantly lower levels of anxiety compared with the other
groups.
2.3.2 Motivation and education
Bentley (2001) discussed the importance of working in partnership with chronic
wound patients in their own care. Such an approach can help to reduce the
sense of powerlessness and loss of control felt by many patients. Bentley uses
a case example of a patient with both pressure ulcers and a chronic leg ulcer to
support her arguments. Rivera et al. (2000) used a similar approach to demonstrate how a model of behaviour modification was utilised to motivate and
educate a patient with a diabetic foot ulcer. Such papers provide support for
the importance of patient education. Unfortunately, there is limited research
38
The Care of Wounds
evidence of effective outcomes, mainly because of poor methodological quality,
as demonstrated by the Cochrane review of the benefits of patient education in
preventing diabetic foot ulceration (Valk et al., 2003). The authors concluded
that it appeared that patient education may reduce the incidence of ulceration
and amputation but randomised controlled trials were needed to provide conclusive evidence.
Involving patients in their own care can reduce the risk of non-compliance
and therefore it is useful to have a greater understanding of compliance and
non-compliance. Nyatanga (1997) reviewed psychosocial theories of non-compliance and divided them into the following categories.
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Perceptual theory – people interpret the world based on what they already
know. They may have pre-existing theories about their treatment.
Value clarification – patients may consider the choices in relation to their
treatment and choose whether to comply. An example would be a man
choosing not to give up smoking despite knowing it increases his risk of leg
amputation.
Attribution theory – this relates to the locus of control. Patients who feel in
control of their treatment or who see a link between their treatment and the
healing of their wound are more likely to be compliant.
Cultural theories – all individuals have a cultural understanding of their
wound, its meaning and the treatment. This may lead them to decide not to
follow all the treatment requirements, such as not wishing to take analgesia.
Health belief model – patients may choose to engage in health-related behaviour if they believe that the benefits in terms of health gain outweigh the
costs. For example, a leg ulcer patient may choose to wear a four-layer
bandage that she finds hot and uncomfortable because she believes that it
will heal her ulcer.
More recently, it has been recognised that the term ‘compliance’ does not reflect
the move to increased patient autonomy and ‘concordance’ is now seen as a
more accurate word to use. Moffatt (2004) has discussed concordance in relation to leg ulcer management and emphasised the importance of understanding the reasons why patients may not be concordant with their treatment plan.
Physical reasons, such as bodily pain that reduces tolerance to treatment, or
psychosocial issues, such as a patient’s expectations of care, can have an impact
on concordance. It is important to understand the patient’s perspective when
planning care so that they can truly become engaged in the healing process.
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Nursing assessment
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Simple questioning can determine the level of relevant knowledge that a patient
possesses.
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Nursing intervention
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Problem: A lack of understanding of the care needed to promote wound healing
Goal: Patients demonstrate the ability to be self-caring and are able to explain their
plan of care
The Management of Patients with Wounds 39
In the climate of early discharge from hospital, many patients will return home
with a wound that still requires dressing. If it is practicable, it is helpful to teach
patients to undertake their own dressing. Monitoring and supervision by the
district nurse or practice nurse would still be necessary. A planned education
programme using short-term goals is the most effective. Information about
allied care such as diet or exercise can also be incorporated into the programme.
Patients with chronic wounds should be given information about their causes
and possible prevention.
Some patients will have little motivation to carry on the plan of care once
they have been discharged from hospital. Recognition of the reasons for the lack
of motivation and good communication with the community staff may be of
some help. A few patients will still fail to respond. It is necessary to accept that
every patient has the right to choose not to comply with the care recommended
by the healthcare team.
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Evaluation
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The ability of the patient to undertake management of the wound will provide
adequate evaluation of the effectiveness of the nursing care.
2.3.3 Body image
Body image is the mental picture that people have of themselves. Body image
is also closely associated with self-esteem. Shipes (1987) suggests that selfesteem can be defined as the sum total of all we believe about ourselves. All
patients with wounds have an altered body image which can have a profound
effect on the person’s self-esteem and motivation. Obvious types of wounds
that can have these effects are those resulting in disfigurement, such as burns,
head and neck surgery, mastectomy, amputation and ostomies. Many patients
will also be suffering from anxiety about their prognosis. Chronic wounds can
also affect body image, as shown in a study by Ebbeskog and Ekman (2001)
who found that leg ulcer patients were embarrassed by their ulcer and bandages and hid them with clothing. The resultant stress can be so overwhelming that the patient may be unable to take in information, to share their feelings
or to commence rehabilitation.
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Nursing assessment
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Neil (2001) developed an assessment tool called the Stigma Scale to measure
body image in relation to the skin. Users are asked to judge a series of 11 statements using a five-point Likert scale. This is a promising approach but a major
limitation is that, as yet, the scale has been validated only by educated, mainly
white, women and further work is required.
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Nursing intervention
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Problem: Loss of self-esteem related to altered body image
Goal: Patients acknowledge change in body image and express their feelings about
this change
40
The Care of Wounds
In the early stages, following the circumstances that led to an altered body
image, some patients appear to be quite euphoric. This is due to simple relief
at having survived. After a while the patient’s attitude is likely to change.
Common problems that can occur include:
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a sense of loss, similar to bereavement.
anxiety related to diagnosis, especially if it is cancer.
loss of sexual function, which may be related to type of surgery or trauma
or to either of the previous problems.
withdrawal from social relationships with family or significant others, possibly due to a malodorous wound or any of the previous problems.
The role of the nurse is to assist the patient to develop a reintegrated body
image (Burgess, 1994). This may be achieved in a variety of ways. Perhaps the
most important is accepting patients as they are, at whatever stage they have
reached. Allowing patients to express their feelings and providing them with
matter-of-fact information, such as an honest appraisal of the progress of the
wound, is beneficial. It is also essential to include family and/or significant
others in the patient’s care and in any education programme. Good management of the wound should prevent odour or leakage, which helps to boost confidence. Burgess also suggests that if patients are having difficulty coping, it
may be necessary to emphasise the importance of the surgery for the health of
the individual and the fact that it does not change them as a person.
As already discussed under Anxiety (section 2.3.1), preoperative information
and counselling are most important. Kelly (1989) studied 67 patients who had
undergone head and neck surgery. Generally, they said they were more anxious
before surgery than after but 42% of men and 21% of women would have liked
more information. Another study by Elspie et al. (1989) found that 41% of
patients suffered psychological stress following major surgery for intraoral
cancer.
In many areas, specialist nurses are employed to give help and support to
patients, such as colorectal nurses or breast care nurses. They can build up a
relationship with their patients which can give patients the confidence to
express their feelings freely. In other circumstances, it may be a nurse who
already has a good relationship with a patient who is able to provide this
service.
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Evaluation
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Regular evaluation of progress is important for patients with an altered body
image. Learning to cope with the new image may take time and strategies may
have to be changed along the way. This may be particularly true for those
undergoing a series of plastic surgery operations who may have to cope with
a constantly changing body image.
The Management of Patients with Wounds 41
2.3.4 Other psychological problems
Fear
Fear is a common human experience that may be transitory or longer lasting.
Illness may release many fears: fear of hospitalisation, fear of illness, fear of a
life-threatening condition, fear of loss of affection of loved ones, fear of the
mutilation of surgery. Such fear creates great stress within the sufferer. This may
be made worse by the healthcare team failing to recognise when patients are
experiencing fear and so not allowing them to express their feelings.
Grief
Grief is a normal process that allows adaptation to some major loss in a person’s
life. The wounded patient may have to come to terms with skin damage from
burns, the loss of a limb or breast or other types of mutilating surgery (see also
Body Image, section 2.3.3.). Kubler-Ross (1969) described various stages in the
grief process. She related them to dying but they can be applied to all types of
grief. The stages are: denial, isolation, anger, bargaining, depression and acceptance. Each person will progress through some or all of these stages at a different rate and not necessarily in the same sequence. By listening to the patient
and accepting without judgement, the nurse can assist in this process and thus
reduce the amount of stress suffered. This may be particularly difficult during
the stage of anger as the aggression expressed by the patient is often directed
at the main caregivers. Understanding of the cause of the aggression will help
the nurse deal with this stage of grief.
Powerlessness
Taylor and Cress (1987) describe powerlessness as the ‘perception of loss of
control over what happens to oneself and one’s environment’. This is a feeling
experienced by many hospital patients as they are placed in the subservient
‘patient role’. Even simple decisions such as when to eat or go to bed are taken
away from the individual. There is pressure to conform and be a ‘good’ patient.
Stockwell (1972) describes very graphically the fate of the unpopular patient
who did not conform to the role the nurses desired from him. A ‘good’ patient
will submit without question to treatment and will not ask too many questions.
Although it is to be hoped that nursing has moved forward since 1972, many
patients are still aware of their loss of status once they are in hospital. Some
may feel depressed because of their feelings of learned helplessness. Others
may feel quite euphoric to have survived, which may also be misinterpreted as
a lack of compliance.
In a society where independence is prized, dependence on others may
produce feelings of anger and frustration. Many patients remark that they feel
a nuisance because they cannot care for themselves. It may also reduce feelings
of self-worth. A common attitude of elderly people when asked to participate
in a research project is that they will do so – because it will help others. Such a
42
The Care of Wounds
contribution is important to them as they feel that, despite their physical limitations, they can still make a contribution to the good of society.
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Nursing assessment
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Although the precise problem may vary, the assessment is the same.
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Observe body language – does the patient look relaxed, tense, fidgety, withdrawn, hypoactive or hyperactive? Do they avoid eye contact?
Conversation – does the patient talk excessively, not talk to anyone, ask
questions?
Do any of these terms describe the patient? Angry, confused, aggressive, confident, demanding, distrustful, anxious, fearful, critical, passive, depressed,
euphoric, disorientated.
Katona and Katona (1997) proposed that a slightly different approach is
required for assessing older people. They recommended the use of four simple
questions.
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Are you basically satisfied with your life?
Do you feel that your life is empty?
Are you afraid that something bad is going to happen to you?
Do you feel happy most of the time?
The patient would score a point for replying ‘no’ to the first and last questions
and for replying ‘yes’ to the middle two. Anyone with a score of two or more
is probably depressed.
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Nursing interventions
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Although nurse training is providing improved knowledge of psychological
care, it may be more appropriate for the patient to have further help from others
such as a clinical psychologist, a psychiatric trained nurse, a chaplain or a
trained counsellor.
Problem: Fear due to separation from loved ones or related to unfamiliarity
Goal: Patients identify the source(s) of their fear and are able to describe their
feelings
Once the nurse recognises that the patient is very frightened, then strategies
can be developed to allow the patient the opportunity of expressing their specific fears. Time may have to be set aside for ‘casual’ conversation, especially if
the patient has few visitors. Assigning the same nurses to care for the patient
can build up confidence. Involving the patient and, possibly, the family in all
aspects of planning may be helpful. Patients with any sort of sensory loss will
need orientation to the new surroundings.
Problem: Grieving related to loss of or disfigurement to a body part
Goal: Patients will allow themselves to experience the grieving process
A variety of strategies can be adopted to help the patient move through the
grief process. Setting aside time to allow the patient to talk is very important.
The Management of Patients with Wounds 43
However, it may be constructive to set time constraints as it can be exhausting
for both the patient and the nurse. Patients may prefer to know that they have
the undivided attention of the nurse for a set period of time each day, rather
than an indeterminate amount of time occasionally. For some individuals, it
may be appropriate for others to assist the patient in recognising and talking
through their grief. In those situations, the nurse should be there to support
and encourage.
Problem: Powerlessness related to feelings of loss of control of the environment
Goal: The patent will express feelings of having a sense of control and will participate in the planning of care
Many healthcare workers fail to recognise the degree to which the ‘system’
takes charge of the individual once they pass through the doors of a hospital.
Whilst in an emergency situation there may be some alteration of priorities,
every patient is entitled to be treated with respect. Nurses can play an important role in assisting their patients to remain in control of as many areas of their
lives as possible. Patient education not only promotes compliance but also
allows the patient to participate in care, thus having a degree of control. Discussing with the patient when particular treatment should be given and involving them in planning care will reduce feelings of powerlessness.
A study by Efraimsson et al. (2003) demonstrates graphically how this can go
wrong. They undertook a case study of discharge planning for an elderly
patient. The patient and some of her family were invited to participate in the
case conference. Observation showed that the clinical staff talked about rather
than with the patient, using technical language, and they failed to answer questions posed by the patient or her children. In an interview with one of the
researchers later, the patient revealed that she felt like on object during the discharge planning meeting and that she felt powerless. It is pointless to involve
patients in the discharge planning process if we do not give them time and
space to express their own feelings and desires.
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Evaluation
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Evaluation of psychological care is not easy. Some indication can be obtained
by repeating the assessment and by talking to the patient.
2.4 SPIRITUAL CARE
In recent years there has been increasing awareness of the importance of spiritual care within healthcare. Although much of it has centred around palliative
care, as is evidenced in the NICE guideline Improving Supportive and Palliative
Care for Adults with Cancer (NICE, 2004), it is seen to be wider than that, as discussed in the paper NHS Chaplaincy: meeting the religious and spiritual needs of
patients and staff (DoH, 2003). A survey by King et al. (1999) of 250 patients
admitted to a London teaching hospital found that 79% of patients professed
some form of spiritual belief, although not all engaged in a religious activity. A
44
The Care of Wounds
survey undertaken of 1.75 million patients in American hospitals found that
emotional and spiritual care was seen as largely ineffective and as an area that
was in considerable need of improvement (Clark et al., 2003).
NICE (2004) suggests that healthcare professionals frequently fail to recognise when patients need spiritual support. Spirituality is a concept that many
nurses find difficult to define and they may feel unsure of what is required.
Spirituality should not just be put into the framework of religion. Everyone,
whether they believe in a God or not, has spiritual needs. Spirituality can be
defined as that within us that responds to the infinite realities of life.
Narayanasamy (1996) listed some indicators of spirituality which provide
further clarity: a sense of purpose, hopefulness, creativity, joy, enthusiasm,
courage, reverence, serenity, humour, providing meaning in struggle and
suffering.
If the spiritual needs of individuals are not met or they experience a catastrophic event in their lives, the result is spiritual pain or distress. This acts as
a stressor and thus can impact on wound healing. Kohler (1999) defined spiritual distress as the lack of meaning in one’s life. In her study of French AIDS
and cancer patients, Kohler found that nearly all of them expressed feelings of
‘ill being’ and raised questions about the meaning of life, death, pain or illness.
Kawa et al. (2003) studied palliative care patients in Japan and described spiritual distress as consciousness of the gap between an individual’s aspirations
and their current situation. The patients in the study were distressed by the gap
between their current situation and how they wanted to live or how they
wanted to die or how they wanted to maintain relationships with others.
Despite the cultural differences between the patient groups in these studies,
there are obvious similarities in the factors causing their spiritual distress.
Cressey and Winbolt-Lewis (2000) worked with a group of chaplains and lay
people to determine areas of potential distress where the patient can be left with
feelings of isolation, fragmentation or despair. They are listed in Table 2.2. In
the context of spiritual distress, acceptance also has significance. A patient may
need reassurance that others, particularly family and friends, will accept them
in the new role as a patient, especially if having to come to terms with a disfiguring wound. Finlay et al. (2000) suggest that patients perceive that healthcare professionals are too busy to discuss spiritual matters and so only disclose
their distress when it becomes severe.
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Nursing assessment
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Peterman et al. (2002) have developed a validated assessment tool to measure
spiritual well-being, called the Functional Assessment of Chronic Illness
Therapy – Spiritual Well-Being (FACIT-sp). This measures a sense of meaning
and peace and also the role of faith in illness. However, it has only been validated with cancer patients. King et al. (2001) took a different approach and
developed an assessment questionnaire that consistently differentiates between
patients with high and low spiritual beliefs.
Villines and Harrington (1998) suggested a number of signs indicative of spiritual distress.
The Management of Patients with Wounds 45
Table 2.2
2000).
Potential causes of spiritual distress (based on Cressey & Winbolt-Lewis,
Potential cause
Explanation
Being valued
Individuals need to feel loved and valued and have a
sense of belonging. If this is not present, patients can feel
isolated and fragmented
Finding meaning
Illness and suffering challenge preconceived ideas of the
meaning of life and often provoke a search for further
meaning. Until this is found the patient will suffer
Having hope
Hope is a major motivator and powerful life force.
The loss of hope results in misery and melancholy
Emotions
Emotions are part of everyday life but the distressed
patient may express feelings of fear, doubt or despair
Having dignity
Loss of privacy and dignity can be very distressing as
can a failure to respect aspects of the many different
cultures in today’s society
Truth and honesty
Everyone is entitled to truth and honesty but this needs
to be expressed with compassion and insight. Denying
patients this right may result in tensions within their
family and a ‘conspiracy of silence’
Good communication
Failures of communication can cause distress and even
offence
Death, dying, bereavement
and loss
This often links to the need to find meaning and patients
may ask ‘why me?’
Religion
Patients can be very distressed by the lack of opportunity
to follow their usual religious observances
Culture
For some, cultural observances are intertwined with their
religious beliefs, yet we often fail to recognise them
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Crying.
Expressions of guilt: ‘I must have been very wicked to have to suffer all this’.
Sleeping a great deal/not sleeping (afraid of not waking).
Disrupted spiritual trust.
Feeling remote from God or the higher power.
Showing anger towards God/others.
Loss of meaning and purpose in life: ‘Why is this happening to me?’
Challenged belief or value system.
The signs of spiritual despair include:
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loss of hope.
refusal to communicate with loved ones.
loss of spiritual belief.
46
The Care of Wounds
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death wish.
severe depression.
Nursing interventions
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Problem: Spiritual distress related to separation from religious or cultural ties or from
a challenged belief or value system
Goal: The patient will be able to identify the cause of spiritual distress and specify
the assistance required to alleviate it
Cavendish et al. (2003) suggest that provision of spiritual care is part of nursing
care, although nurses may not always be comfortable with the concept. Nurses
are not always able to recognise the difference between spiritual needs and religious needs. Cressey and Winbolt-Lewis (2000) describe spiritual care as conveying to patients that they have value and are unconditionally regarded for
who they are, regardless of illness, colour or creed.
The chaplaincy team is very much part of the multiprofessional network and
can give much support to both the patients and staff by listening, comforting
and counselling when necessary. However, nurses need to have some understanding of the range of spiritual care activities. There can be no standardised
spiritual care as there is with postoperative physical care. In this situation, each
patient must be cared for in the light of their unique needs. Fish and Shelly
(1985) proposed the following activities: listening, empathy, vulnerability,
humility and commitment.
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Listening – this is active listening, giving the patient full attention and noting
all the non-verbal as well as verbal cues.
Empathy – this allows the nurse to share the feelings of the patient
without losing objectivity. This is essential to enable the patient to consider
alternatives.
Vulnerability – as nurses enter into and share patients’ feelings, they become
vulnerable. This may be painful but can also be rewarding.
Humility – this is not easy. Few people want to admit that they do not have
the answers in their particular field. A sense of humility will enable nurses
to see that they can learn from their patients. Humility also allows nurses to
accept themselves and their patients in all their human frailty.
Commitment – being with a patient through all the difficult times, sharing the
pain as well as the joys, involves considerable commitment.
Several studies have investigated spiritual coping mechanisms. Dein and
Stygall (1997) undertook a review of religion and chronic illness and found that
religion was a positive coping mechanism. A qualitative study using grounded
theory found that 13 Christian patients undergoing open heart surgery sought
comfort through prayer. They used two strategies: praying themselves and
enlisting others to pray for them, especially for the times when they were
unable to pray (Hawley, 1998). Narayanasamy (2002) interviewed 15 chronically sick people (nine Christians, two Hindus and four with no religious affiliation) and also found that prayer brought comfort as it gave both a sense of
The Management of Patients with Wounds 47
connectedness to God and also a sense of hope, strength and security. However,
the author only found this sense of connectedness to God (or Hindu deities)
amongst the Christians and Hindus in his sample.
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Evaluation
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Just as spiritual assessment is very difficult, so too is evaluation of the outcomes
of care. Narayanasamy (1996) suggests that spiritual integrity is one outcome
that may be demonstrated as relief from spiritual pain or by restoration of the
life principle. Resolution of the signs of spiritual distress or despair would indicate a positive outcome, as would an improved FACIT-sp score.
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56
The Care of Wounds
Chapter 3
General Principles of Wound Management
3.1 INTRODUCTION
This chapter will discuss, in broad detail, the general principles of wound management. Specific care of chronic and acute wounds will be considered in later
chapters. The products mentioned in this chapter will be described in more
detail in Chapter 4.
The ability to make an accurate assessment of a wound is an important
nursing skill. It should be carried out in conjunction with an assessment of the
patient as discussed in Chapter 2. The aim of the assessment is twofold. It will
provide baseline information of the state of the wound, so that progress can be
monitored, and will also ensure that an appropriate selection of wound management products is made. Keast et al. (2004) consider that accurate and comprehensive wound assessment requires meticulous and consistent clinical
observation. To that end, they have proposed a mnemonic, ‘MEASURE’, to
provide a framework for assessment (see Table 3.1). In addition, wound classification, the position of the wound and the environment of care also need to be
determined. These factors provide the framework for wound assessment and
will be discussed next, followed by the MEASURE framework.
3.2 WOUND ASSESSMENT
3.2.1 Wound classification
Wounds can be classified as chronic, acute and postoperative wounds.
Chronic wounds have been described as being of long duration or frequent
recurrence (Fowler, 1990). Typical examples are pressure ulcers and leg ulcers.
Patients may have multifactorial problems that affect their ability to heal their
wounds.
Acute wounds are usually traumatic wounds. They may be cuts, abrasions,
lacerations, burns or other traumatic wounds. They usually respond rapidly to
treatment and heal without complication.
Postoperative wounds are intentional acute wounds. They may heal by first
intention, where the skin edges are held in approximation. Sutures, clips or tape
may be used. Some surgical wounds are left open to heal by second intention,
usually to allow drainage of infected material. Donor sites are also open
wounds.
General Principles of Wound Management
Table 3.1
M
E
A
S
U
R
E
57
MEASURE: a framework for wound assessment (from Keast et al., 2004).
Parameter
Parameter content
Measure
Exudate
Appearance
Suffering
Undermining
Re-evaluate
Edge
Length, width, depth and area
Quantity and quality
Wound bed, tissue type and amount
Pain type and level
Presence or absence
Monitoring all parameters regularly
Condition of wound edge and surrounding skin
There may be related factors to be considered when managing each of these
types of wounds, such as the relief of pressure for pressure ulcers. The care of
chronic wounds will be considered in Chapter 5 and of acute wounds in
Chapter 6.
Traditionally, some wounds have been classified according to depth. This
type of classification is widely used in the USA but is generally only used to
describe burns or, occasionally, pressure ulcers in the UK. Wounds are described
in relation to the tissues that are damaged or destroyed. Figure 3.1 illustrates
the different depths of tissue damage.
Erosion is the term used to describe the loss of one or two layers of epithelial cells. There is no depth to this type of wound.
Superficial wounds are wounds where the epidermis has been damaged.
Partial-thickness wounds occur when the epithelium and part of the dermis
are destroyed. Hair follicles and sweat glands are only partially damaged. This
type of wound is sometimes subdivided into partial-thickness and deep partialthickness wounds. When these wounds have a large surface area, hair follicles
and sweat glands produce epithelial cells during the epithelialisation stage
which form islets of cells on the wound surface, thus speeding the healing
process.
Full-thickness wounds have all of the epidermis and dermis destroyed.
Deeper tissues such as muscle or bone may also be involved. Healing may take
longer to establish in these wounds.
3.2.2 The position of the wound
The position of a wound should be noted as part of the assessment. It may be
an indicator of potential problems, such as risk of contamination in wounds in
the sacral region or problems of mobility caused by wounds on the foot.
Another aspect to consider is the fact that a dressing may stay in place very
well on one part of the body but not on another.
58
The Care of Wounds
Fig. 3.1 The degree of tissue damage in
wounds of differing depth. (a) A partialthickness wound: islets of living epithelium
remain around hair shafts and sweat ducts. (b)
A full-thickness wound: no living epithelia
remain in the injured area.
3.2.3 The environment of care
Consideration must be given to the environment in which care is to be given.
Harding (1992) proposed a wound-healing matrix which includes consideration of the environment and carer. The management of a wound can be affected
by the circumstances of the patient. For example, the timing of a dressing
change may not be particularly important for a patient in hospital but for a
patient at home, perhaps a young mother with children to get to school, timing
may be critical. Flexibility may be important for a patient with a long-standing
wound who has to return to work. It may be helpful to arrange for the occupational health nurse in the patient’s place of employment to carry out the
dressing change, thus reducing the frequency of clinic attendance.
Not all wound management products are available in the community. Hospital nurses need to ensure that the product selected can be continued after discharge home. If a non-skilled person is to provide some of the wound care for
a patient, adequate time must be allowed for teaching the individual appropriate routines. Adequate monitoring of care must also be established.
3.2.4 M = Measure
The size and shape of a wound may alter during the healing process. In the
early stages as necrotic tissue and/or slough are removed, the wound appears
General Principles of Wound Management
59
to increase in size because the actual extent of the wound was originally masked
by the necrotic tissue. Monitoring of wound shape is important to guide dressing selection. A cavity wound requires a different dressing to a shallow wound.
Some dressings are not appropriate for use if there is a sinus present. Accurate
nursing records are essential for monitoring progress.
This section considers the various ways in which measurement of a wound
may be undertaken. Some of them are not really appropriate for use in busy
areas but may have value in a research study. Others are very expensive and
beyond the budget of most nurses. Whatever type of measurement is used, it
should be undertaken on a regular basis, the frequency depending on the type
of wound. Chronic wounds should be measured every 2–4 weeks as little
change is likely to be seen by more frequent measurement. However, acute
wounds progress much more rapidly so measurement should be done at each
dressing change.
Simple linear measurement
The very simplest method of measuring a wound is to measure it at its greatest length and breadth and to measure the depth if appropriate. If a wound is
a relatively regular shape, such as the example shown in Figure 3.2, then this
can be a fairly successful method. It is also likely to be more accurate if the
wound edges are marked to indicate the measurement points. A probe can be
used if the wound is a very irregular shape or has sinus formation.
There are several drawbacks to using this type of measurement. Goldman
and Salcido (2002) suggest that the method has limited sensitivity to changes
in wound size and it also provides limited information about the shape of a
wound. The more people involved, the greater the risk of the measurement not
being on the same spot each time. Even if the same person does the measurement each time, it still may not be replicated accurately; this is known as sampling error. If necrotic tissue or slough is present, the true wound size will
become apparent as debridement occurs. Wound measurement will show that
the wound has increased in size and can give a misleading picture of wound
progress. Measurement gives no indication of wound appearance. Despite these
drawbacks, Kantor and Margolis (1998) found a significant correlation between
simple wound measurements and measurement using planimetry, except for
Fig. 3.2
Measurement of a regular-shaped wound.
60
The Care of Wounds
wounds larger than 402 cm, and suggested that simple measurements could be
used to monitor wound progress.
Simple measurement is best used on small, surgically induced cavities that
are regular in shape and should heal rapidly. More comprehensive data would
be obtained if used in conjunction with a nursing chart.
Measurement of surface area
Flanagan (2003a) reviewed the varying methods of wound measurement and
found that measuring true surface area and monitoring the percentage reduction of wound surface area over time are the most useful methods. The most
frequently used system for surface area measurement is that of tracing a wound.
A variety of materials may be used, the commonest being acetate paper. One
presentation of acetate paper is the lesion measure, samples of which are supplied by several dressing manufacturers. They are usually fairly small sheets
with a series of circles on them. The centre circle is 1 cm in diameter and is surrounded by concentric circles that increase in size by 2 cm increments. This
gives some estimate of measurement in the tracing.
The surface area of a wound can be calculated quite accurately by placing
the tracing over squared paper and counting the number of whole squares or
by using computerised planimetry. Successive tracings can be compared to
show any difference in wound size. If necrotic tissue or slough is present then
an initial increase in size will occur as debridement progresses.
More recently, sophisticated computerised methods have been developed
that can measure surface area. Lagan et al. (2000) compared planimetry and
digitising and found that digitising based on wound tracings gave a significantly higher level of repeatability than planimetry. Keast et al. (2004) described
a portable digital tablet (VisitrakTM) that can be used in conjunction with wound
tracings. A tracing can be placed on the digital tablet and a special stylus used
to trace over the wound outline. The system calculates the surface area and percentage reduction in wound size from previous measurements. Clinical evaluation of the digital tablet is in progress.
Another system is a specialised computer software package for use with a
digital camera (Verge VideometerTM [VeV]). A photograph is taken and downloaded onto a computer where the program calculates the wound surface area.
Thawer et al. (2002) compared tracings and planimetry with VeV and found
excellent intrarater and interrater reliability in 45 chronic wounds. However, it
must be noted that there is potential for inaccuracy when using a system involving a digital camera if the wound is over a curved part of the body such as the
leg.
Flanagan (2003a) noted that errors can occur when undertaking wound tracings, particularly in identifying the wound margin. She suggested that establishing a simple protocol could help to improve accuracy. As with wound
measurement, the tracing will show the increase or decrease in size without
any explanation, as it does not provide information on wound appearance or
depth.
General Principles of Wound Management
61
If the acetate sheet is placed in direct contact with the wound, it will need
cleansing with alcohol spray or similar. Some centres use plastic bags so the
underside can be discarded and the side with the tracing retained. Some
acetates are provided with disposable backing paper.
Tracing is best used on fairly straightforward shallow wounds. Ideally it
should be used in combination with an assessment chart. Lucas et al. (2002) recommend using both tracings and photography to monitor wound healing.
Measuring volume
When wounds are deep, it may be useful to measure wound volume. Theoretically, it is possible to calculate the volume by measuring the wound depth
(using a sterile swab) and multiplying by the surface area. However, there are
inherent errors in this method (Goldman & Salcido, 2002). Deep wounds are
rarely cuboid in shape, may not have a uniform depth, and sinus formation or
undermining may be present. If the base of the wound is filled with necrotic
debris, it must first be cleansed from the wound before undertaking any measurements (Keast et al., 2004). Various methods have been used to measure
wound volume but they are not simple, valid or reliable (Keast et al., 2004).
The most practical method of monitoring changes in wound volume is to
measure and record the depth at the deepest part of the wound and to note the
amount of dressing required to fill the cavity.
3.2.5 E = Exudate
The amount of wound exudate varies during the healing process. In a normally
healing wound, there is considerable exudate at the inflammatory stage and
very little at epithelialisation. A copious exudate may indicate a prolonged
inflammatory stage or infection. In their review of the role of exudate in the
healing process, Vowden and Vowden (2003) consider the differences between
acute and chronic wound exudate and conclude that chronic wound exudate
has the potential to become a barrier to healing. Unfortunately, it is not possible to assess a wound and immediately determine if wound exudate is an actual
barrier to healing.
Keast et al. (2004) suggest that exudate can be measured in terms of quantity,
quality and odour. Falanga (2000) proposed a scoring system for wound
exudate quantity that provides some qualification with the aim of achieving
standardisation. Thus:
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1 = minimal (dressings last up to one week).
2 = moderate (dressings changed every 2–3 days).
3 = heavy (dressings changed at least daily).
An alternative method to quantify exudate was used by Browne et al. (2004a)
in a multicentre study assessing dressing performance in the presence of heavy
exudate (called the WRAP Study). The research team used the TELER® system
of clinical indicators (Le Roux, 1993) to measure exudate leakage. A clinical indi-
62
The Care of Wounds
Table 3.2 Exudate leakage using TELER indicator (from
Browne et al. (2004a). Reproduced by kind permission of TELER
Ltd).
Code
Exudate leakage
5
No leakage between routine/planned dressing change
4
Exudate leakage within 2 hours of next dressing change
3
Exudate leakage within 8 hours of next dressing change
2
Exudate leakage within 24 hours of dressing change
1
Exudate leakage within 8 hours of dressing change
0
Exudate leakage within 2 hours of dressing change
cator is an ordinal measuring scale with six reference points that measure
change. Each reference point is clinically significant, with 0 being the worst possible outcome and 5 the best. Table 3.2 shows the clinical indicator for exudate
leakage when the planned frequency of dressing change is every two days.
Exudate is considered to leak if it strikes through the outer bandage or strapping. Although this system measures exudate leakage rather than exudate
amount, it still has clear clinical relevance.
Falanga (2000) considered that there is little benefit in scoring the quality of
wound exudate. However, there may be some benefit in using clearly defined
terminology to describe exudate quality. It may be of particular importance in
postsurgical wounds where there is a potential risk of postoperative bleeding.
Therefore the terms ‘serous’, ‘serosanguinous’, ‘sanguinous’, ‘seropurulent’ and
‘purulent’ may be useful.
Odour is much more difficult to measure in any objective way. Odour may
be indicative of infection but wound odour also increases as necrotic tissue
debrides by autolysis. Some dressings such as hydrocolloids may produce a
foul-smelling odour when they are removed. It must also be remembered that
many patients are distressed by wound odour and may feel embarrassment,
disgust or shame (Hack, 2003). In a further paper on the WRAP project, Browne
et al. (2004b) describe a clinical indicator to quantify odour (see Table 3.3).
Browne et al. (2004b) used it in conjunction with a patient-focused indicator to
determine the impact of odour on the patient, thus making it an even more
powerful tool.
3.2.6 A = Appearance
The appearance of the wound gives an indication of the stage of healing that it
has reached or of any complication that may be present. Open wounds or
wounds healing by second intention can be categorised as:
General Principles of Wound Management
63
Table 3.3 TELER indicator to quantify odour (from Browne
et al. (2004b). Reproduced by kind permission of TELER Ltd).
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䊉
䊉
䊉
Code
Odour
5
No odour
4
Odour is detected on removal of the dressing
3
Odour is evident on exposure of the dressing
2
Odour is evident at arm’s length from the patient
1
Odour is evident on entering room
0
Odour is evident on entering house/ward/clinic
necrotic.
infected.
sloughy.
granulating.
epithelialising.
Some wounds may fit into more than one category and so present as ‘mixed’
wounds. Before assessing a wound, the nurse should ensure that all the old
dressing has been removed. Many modern dressings form a gel, which may
give a misleading impression of the wound unless it is first cleaned away.
Necrotic wounds (see Fig. 3.3)
When an area of tissue becomes ischaemic for any length of time, it will die.
The area may form a necrotic eschar or scab which can be black or brown in
colour. Some necrotic tissue may present as a thick slough that can be brown,
grey or off-white. When assessing these wounds it is important to remember
that the wound may be more extensive than is apparent. The eschar or slough
masks the true size of the wound. Intervention is needed for these wounds to
heal.
Infected wounds (see Fig. 3.4)
All wounds are colonised with bacteria. This does not delay healing or mean
that wounds will automatically become infected. If infection occurs, the clinical signs of infection will usually be present which are pain, heat, swelling, erythema and pus. The signs may vary slightly according to the bacteria causing
the infection. Usually there is localised erythema or redness which may be
restricted to just one part of the wound, such as at one end of a suture line, or
may spread to a large area around the wound. Associated with the erythema
is heat in the adjacent tissue that will also feel hotter than the skin at a distance
from the wound. Oedema or swelling around the wound is also present. The
64
The Care of Wounds
Fig. 3.3
A necrotic wound.
Fig. 3.4
An infected wound.
colour of the exudate and the slough on the wound surface depend on the bacteria causing the infection. There is usually a heavy exudate as the body rushes
extra neutrophils and macrophages to the affected area and also tries to ‘wash’
the bacteria away. The exudate may have an offensive odour and can be the
first indication of infection. Patients may also complain of increased pain.
However, chronic wounds do not always have such clear clinical signs.
Cutting and Harding (1994) proposed additional criteria to those discussed
above.
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䊉
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䊉
䊉
Delayed healing (compared with expected rate, may be for other reasons).
Discolouration: relates to wound bed.
Friable granulation tissue that bleeds easily.
Unexpected pain or tenderness.
Pocketing or bridging at the base of the wound.
Abnormal odour.
Wound breakdown.
General Principles of Wound Management
Fig. 3.5
65
A sloughy wound.
Cutting (1998) studied the use of these criteria and compared his clinical
opinion with microbiological cultures on the wounds of 40 patients attending
a wound clinic. He found that eight times out of nine, his decisions about infection were corroborated by the microbiological culture and also on the 31 occasions when he deemed infection was not present. This study demonstrates the
potential value of using these criteria in clinical practice, although it must also
be acknowledged that the researcher is both knowledgeable and experienced
and this undoubtedly had an impact on the outcome.
Gardener et al. (2001a) further developed these signs and symptoms into a
checklist with definitions for each sign and symptom. The checklist was submitted to a panel of six experts in chronic wounds for content validation and
then tested for reliability using two nurses to assess 36 chronic wounds in three
healthcare sites, using different nurses on each site. Perfect agreement using
kappa statistics was achieved for increased pain, oedema, wound breakdown,
delayed healing and friable granulation tissue; substantial agreement was
achieved for erythema, purulent exudate, serous exudate, discolouration; only
moderate agreement was achieved for foul odour and heat; pocketing was not
observed. In a further aspect to the study, they also undertook microbiological
cultures from the wounds (Gardener et al., 2001b). They found the signs proposed by Cutting and Harding to be better indicators of chronic wound infection than the classic signs. However, increasing pain and wound breakdown
were both sufficient indicators for infection without the other symptoms and
have good interrater reliability.
Sloughy wounds (see Fig. 3.5)
Slough is typically a white/yellow colour. It is most often found as patches on
the wound surface, although it may cover large areas of the wound. It is made
up of dead cells that have accumulated in the exudate. It can be related to the
end of the inflammatory stage in the healing process. Neutrophils have only a
short lifespan and may die faster than they can be removed. Given the right
66
The Care of Wounds
Fig. 3.6
A granulating wound.
environment for healing, the macrophages are usually capable of removing the
slough and it disappears as healing progresses. Harding (1990) refers to a
yellow fibrinous membrane that develops on the surface of some wounds. It is
not stuck fast but can be easily removed. The membrane has no effect on healing
and recurs if removed. He describes it as a variant on the normal.
Granulating wounds (see Fig. 3.6)
Granulation tissue was first described by John Hunter in 1786. It relates quite
well to the stage of reconstruction in the healing process. The wound colour is
red. The tops of the capillary loops cause the surface to look granular, hence
the name. It should be remembered that the walls of the capillary loops are very
thin and easily damaged, which explains why these wounds bleed easily.
Regular, careful measurement will show a reduction in wound volume as the
cavity fills with new tissue and contracts inwards.
Epithelialising wounds (see Fig. 3.7)
As the epithelia at the wound margins start to divide rapidly, the margin
becomes slightly raised and has a bluey-pink colour. As the epithelia spread
across the wound surface, the margin flattens. The new epithelial tissue is a
pinky-white colour. In shallow wounds with a large surface area, islets of
epithelialisation may be seen. The progress of epithelialisation may be easily
identified as the new cells are a different colour from those of the surrounding
tissue.
Recording wound appearance
Wound appearance can be recorded in a number of ways. The simplest is the
written word but this is also likely to be the most subjective and open to misuse
and misinterpretation. Common examples are ‘wound healing well’ or ‘wound
a bit sloughy’. Neither of these assessments has much value when trying to
monitor wound progress accurately. In an attempt to overcome this problem,
General Principles of Wound Management
Fig. 3.7
67
An epithelialising wound.
some investigators use percentages to determine the quantity of each tissue
type on the wound surface. This method has not been thoroughly tested but
although still subjective, it is more precise than the previously described
method.
Romanelli (1997) described the use of a colour reflectance analyser to determine the levels of granulation tissue in a wound. In a study evaluating methods
of debridement in 32 patients with sloughy venous leg ulcers, he found chromatic measurement of the wound bed to be a reliable measurement tool. It was
able to accurately measure the percentages of slough and granulation tissue in
the wound. However, this type of equipment is not readily available in most
clinical areas and it takes time to set up and use.
The old adage ‘A picture is worth a thousand words’ may not be strictly true
in relation to photographs of wounds but photography does address some of
the criticisms of the previous methods. A photograph provides clear evidence
of the appearance of a wound and some suggestion of its size, especially if a
rule is incorporated to provide a scale. Houghton et al. (2000) investigated the
validity and reliability of using photography to assess wound status in comparison to a pressure ulcer assessment tool. They concluded that it was a valid
and reliable tool for assessing wounds on the trunk and lower extremities.
When managing chronic wounds, regular photographs can provide real encouragement to both patients and carers. It should be remembered that the
depth of a wound is not demonstrated in a photograph, as it does not accurately record wounds on curved surfaces.
There are three types of camera in use for medical purposes: 35 mm camera,
Polaroid camera and digital camera. Generally, it is hospital photographers who
use 35 mm cameras rather than individual clinicians. Nechala et al. (1999) compared 35 mm cameras with Polaroid and digital cameras and found that the 35
mm camera produced the highest quality hard copies. Kokoska et al. (1999)
found similar results in their comparison of 35 mm and digital cameras. Nechala
et al. (1999) also found the 35 mm camera was the most economical per hard
copy. The main disadvantage of the 35 mm camera is that it takes much longer
68
The Care of Wounds
to generate a photograph than the other camera types. Another disadvantage
is that it is not possible to be certain of the quality or accuracy of an individual
photograph until the film is developed. It is also important to determine how
individual patients will be identified if using a film with large numbers of exposures. One issue many nurses have to consider if planning to purchase a camera
is the need for an ongoing budget to pay for films and development.
Polaroid cameras have been very popular with nurses, especially in the community. The major advantage of this camera is that the hard copy is produced
immediately and can be shown to the patient and immediately placed in the
notes (Nechala et al., 1999). Whilst the quality may not be as good as more powerful cameras, it is adequate for most needs, especially if a light lock lens is used
to enable close-ups. There is still an ongoing cost for the purchase of films.
Increasingly, digital cameras are being used in clinical practice. They are
gradually improving in quality and becoming cheaper. After initial training has
been given, they have been found to be easy to use and focus and to transfer
to computer to provide digital images. There are no ongoing costs as the filmcard can be reused many times. However, access to a computer with a large
memory on the hard drive is necessary, as the images require a large storage
capacity. Once downloaded, the images can be utilised to produce hard copies,
which can be displayed on the screen for teaching purchases or incorporated
into a PowerPoint presentation. Galdino et al. (2000) monitored the costs of converting a large plastic surgery to digital photography rather than using the hospital photographic department. All the medical staff, including junior doctors,
were supplied with their own camera and film-card. Over a five-year period,
the authors estimated they would save $63 950. The main disadvantages of
digital cameras are the initial training to use them successfully and that it is
possible to manipulate the image and to falsely enhance the results (Nechala et
al., 1999).
Hayes and Dodds (2003) successfully incorporated use of a digital camera
into clinical practice in a hospital vascular clinic. They utilise a shared electronic
patient record to communicate with primary care teams via the NHSnet, so that
all involved can see the digital images. They recommend using standardised
lighting and background and using the same patient position and that patient
identification codes, the date and a calibration scale should be included within
the digital image.
Not all nurses have access to a camera. It may be possible to obtain one on
a short-term loan if a dressing trial is being undertaken.
Several factors need to be considered if the purchase of a camera is planned.
Nechala et al. (1999) considered that it was important to determine the reason
for requiring a camera before making a choice of camera type. If high-quality
hard copies are required, a 35 mm camera is the best option. If speed is important then a Polaroid camera should be chosen and if digital images are required,
then a digital camera is best. Other questions to answer are as follows.
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䊉
Who will pay for films and developing?
Is the proposed camera capable of taking close-up pictures?
General Principles of Wound Management
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69
Who will be using the camera?
How can pictures be taken from the same angle and distance each time?
How will patient consent be recorded? Some hospitals have a consent form
for photography, others accept that implied consent is sufficient for routine
photography.
How will the images be stored to protect patient confidentiality?
Photographs provide good visual evidence of wound appearance. If a camera
is not readily available, photography is best only considered for complicated
or unusual wounds.
3.2.7 S = Suffering
Moffatt (2002) suggested that within chronic wound management, there is a
need to focus on the patient, particularly their pain control. Unfortunately, pain
assessment is rarely part of routine wound assessment despite the fact that
many wounds are associated with pain (Krasner, 1995). Increased pain may be
an indicator of infection and this must always be excluded in the first instance.
Pain has been discussed in Chapter 2 and pain assessment should part of the
overall patient assessment. This section will focus on local wound factors in
relation to pain.
Dressing change and wound management activities such as debridement
may cause pain. An international survey of practitioners was undertaken across
11 countries to investigate their views on wound pain (Moffatt et al., 2002).
Dressing removal was identified as the time of greatest pain, with adherent
dressings being seen as a major contributing factor. Szor and Bourguignon
(1999) surveyed 32 patients with pressure ulcers for pain using the McGill Pain
Questionnaire. They found that 28 (87.5%) had pain at dressing change and 12
(42%) had continuous pain both at rest and during dressing changes. Sadly, only
two patients were receiving analgesia.
It is well recognised that burn patients suffer considerable pain at dressing
change (Latarjet, 2002). Nagy (1999) investigated the impact on nurses of having
to inflict pain on burn patients during dressing changes. She found that the
commonest strategy was distancing by the nurse, which had the side effect of
the nurses becoming less concerned about controlling pain. But if nurses developed a strategy of engaging with the pain, they saw it as a challenge to ensure
good pain control. Taal et al. (1999) undertook a validation study of a pain
anxiety scale specifically for burn patients. The scale included items such as ‘I
find it impossible to relax when my burns are being treated’ and ‘I am frightened of the pain during and/or after the treatment’. They found high levels of
reliability and internal consistency and suggest that the scale could be used as
a method of assessing therapeutic interventions.
Senecal (1999) stresses the importance of assessment and that it should
include the type of pain and pain intensity. Krasner (1995) put forward a model
of chronic wound experience that divides wound pain into three types: noncyclical acute wound pain, such as sharp debridement; cyclical acute wound
70
The Care of Wounds
pain, such as dressing changes; chronic wound pain, which is persistent and
constant. Pain intensity can be measured by means of a variety of visual analogue scales as discussed in Chapter 2. It may also be useful to identify any
factors related to dressing change, such as dressing type, that may impact on
pain levels. The frequency of reassessment should also be identified.
3.2.8 U = Undermining
In this part of their assessment framework, Keast et al. (2004) discuss assessment of the internal wound area. This is relevant in cavity wounds and it is
important to identify any undermining, tunnelling or sinus tracts. A sterile
swab can be used to probe under the wound edges to measure the extent of
undermining. If it is extensive it may be helpful to mark the area on the surface
of the skin using a pen. This will facilitate future assessments and assist in
evaluating any change.
3.2.9 R = Re-evaluate
The purpose of re-evaluating a wound is to check for any signs of complications and to monitor progress towards achieving short-term goals, such as
debridement and the overall goal of healing. This may be achieved by checking the wound for complications such as infection at each dressing change and
regularly assessing selected wound parameters such as reduction in wound
size. The frequency of assessment will vary according to wound type but for
most chronic wounds, it should be every 1–2 weeks. Acute wounds may need
to be assessed more frequently.
Flanagan (2003b) reviewed the methods for measuring wound healing and
concluded that percentage reduction in size was the most useful indicator of
wound progress as this can differentiate between healing and non-healing
wounds in the first few weeks of treatment. Kantor and Margolis (2000) measured percentage reduction in wound size for 104 patients with venous leg
ulcers and found that percentage change in the first four weeks of treatment
predicted the healing outcome at 24 weeks. In a small study of nine patients
with grade 4 pressure ulcers, Brown (2000) found that healing did not progress
in a linear fashion and suggested that plotting wound-healing curves could be
useful; that is, multiple measurements of percentage reduction in wound area
from baseline, measured over time.
This type of accurate measurement may not be necessary for everyday clinical practice but it has considerable value in research. Specialist centres may be
able to invest in some of the digitised systems that can provide this type of
information very easily, as discussed in section 3.2.4, but they are not available
to all. In general clinical practice, wounds should be regularly assessed every
1–4 weeks and progress towards treatment goals evaluated.
General Principles of Wound Management
71
3.2.10 E = Edge
This final stage of the MEASURE assessment process refers to the need to assess
the wound margins and the surrounding skin. The wound margin provides
useful information indicative of both aetiology and healing status. For example,
a punched-out appearance and a sharp margin is indicative of an arterial ulcer.
A raised edge of epithelial cells on a wound with residual slough, such as can
be seen in Figure 3.7, is indicative of a wound that is starting to heal, whereas
Figure 3.4 shows no indication of any activity on the wound margin.
Nurses often neglect to assess the skin surrounding a wound and yet much
useful information can be obtained. Erythema and heat may be indicative of
infection. Erythema alone may be caused by allergy to the dressing (contact dermatitis), as shown in Figure 3.8. Induration may indicate further pressure
damage around an existing pressure ulcer. Maceration can occur in the presence of heavy uncontrolled exudates; if this situation persists over time, irritant
dermatitis may develop (Fig. 3.9). Fragile skin must be treated with caution and
is at risk of damage if dressings and tapes are selected unwisely. Dry scaly skin
should also be identified as scales can build up around the wound and cause
problems.
Comment
Wound assessment is highly complex and is an important clinical skill. The use
of uniform concepts and terms can assist in ensuring a consistent approach to
the subject.
Fig. 3.8
Contact dermatitis.
Fig. 3.9
Irritant dermatitis.
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The Care of Wounds
3.3 MANAGING WOUNDS
A great deal has been written about wound management but in order to make
sense of what is proposed, it is helpful to understand the competing theories
of wound management. They are moist wound healing and wound bed
preparation.
3.3.1 Moist wound healing
The concept of moist wound healing was first introduced by George Winter in
1962. He compared the effect of leaving superficial wounds exposed to form a
scab with the effect of applying a vapour-permeable film dressing, using an
animal model (Winter, 1962). Epithelialisation was twice as fast in those wounds
covered with a film dressing; this was because the dressing maintains humidity on the wound surface and the epithelial cells are able to slide across the
surface of the wound. In contrast, epithelial cells in the exposed wounds had
to burrow beneath the scab, dried exudate and layers of dessicated cells to find
a moist layer to allow movement across the wound.
Little notice was taken of Winter’s work until the 1980s when a number of
clinical studies confirmed his findings and identified other benefits as well.
Local wound pain was found to be considerably reduced in a moist environment (Eaglstein, 1985; May, 1984). The moist environment was also shown to
enhance natural autolytic processes, thus aiding the breakdown of necrotic
tissue (Freidman & Su, 1983; Kaufman & Hirshowitz, 1983).
Following these studies, there was a dramatic change in the methods of
wound management and many new occlusive wound management products
have been developed such as alginates, foams, hydrocolloids and hydrogels.
Schultz et al. (2003) summarised the benefits of a moist wound environment
as follows:
䊉
䊉
䊉
䊉
assists epidermal migration.
promotes alterations in pH and oxygen levels.
maintains an electrical gradient.
retains wound fluid on the wound surface.
However, although these outcomes are of undoubted benefit to acute wounds,
questions were being raised as to their usefulness in chronic wound management. Much of the research into the moist wound environment has been undertaken on acute, superficial wounds and does not address all the issues
presented by chronic wounds, which tend to be deeper, with larger amounts of
exudate and a greater bacterial burden. Thus a further wound management
theory was required.
3.3.2 Wound bed preparation
The theory of wound bed preparation (WBP) has developed in part because of
increasing understanding of the differences between acute and chronic wound
General Principles of Wound Management
73
exudate and the potentially harmful constituents of chronic wound fluid (see
Chapter 1) and in part following clinical experience of using bio-engineered
skin products. Falanga (2000) proposed that it was inappropriate to utilise
expensive, sophisticated products on a poorly prepared wound. As a minimum,
a wound should have a well-vascularised wound bed, minimal bacterial
burden and little or no exudate before an effective outcome can be achieved.
Further debate has led to a consensus paper (Schultz et al., 2003), which has
provided the following definition:
‘Wound bed preparation is the management of the wound to accelerate
endogenous healing or to facilitate the effectiveness of other therapeutic
measures.’
WBP has four aspects: debridement, management of exudate, resolution of bacterial imbalance and undermined epidermal margin (Schultz et al., 2003).
Falanga (2004) has utilised the work of Schultz et al. (2003) to develop a framework called TIME to provide a comprehensive approach to chronic wound care.
The terms in the framework have been modified by the European Wound Management Association WBP Advisory Board to maximise their use in different
languages (Box 3.1). Figure 3.10 shows how the TIME framework can be used
within a holistic approach to care.
Tissue management
This aspect of the TIME framework refers to the need to debride necrotic and
sloughy tissue. Debridement may be achieved in a number of ways.
䊉
䊉
䊉
Autolytic debridement utilises the ability of macrophages to phagocytose
debris and necrotic tissue. Hydrocolloids and hydrogels are widely used to
promote autolytc debridement as they provide a moist environment that
enhances macrophage activity. Alginates are also used in the presence of
moisture.
Biosurgery or larval therapy has recently regained popularity and is widely
used in the UK. Sterile maggots of the fly Lucilia sericata secrete enzymes that
break down necrotic tissue to a semi-liquid form that the maggots can ingest,
leaving only the healthy tissue (Thomas, 2001).
Enzymatic debridement also ensures autolysis through the use of enzymes
such as elastase, collagenase and fibrinolysin. These enzymes cleave through
the collagen holding necrotic tissue to the wound bed, thus debriding the
Box 3.1 The TIME framework (based on Falanga, 2004).
T
I
M
E
= Tissue management
= Inflammation and infection control
= Moisture balance
= Epithelial (edge) advancement
Reproduced by kind permission of Radical Education Partnership.
74
The Care of Wounds
Continue present
therapy
Basic wound
management
Re-evaluate time
Immediate
considerations,
e.g. surgical
debridement
Healing
wound
Non-healing
wound
Implement
advanced
therapies
Ongoing
assessment
Preliminary
diagnosis,
e.g. treat
underlying
cause
Patient wound
assessment
Follow-up assessment
Healed uncomplicated
wound
Non-healed
wound
TIME
Tissue
management
Inflammation
and infection
control
Moisture
balance
Epithelial
(edge)
advancement
Healed
wound
Fig. 3.10 Pathway showing how wound bed preparation is applied to practice (from Falanga 2004,
reproduced by kind permission of Medical Education Partnership Ltd).
䊉
䊉
wound (Douglass, 2003). Although widely used in North America and mainland Europe, enzymes are rarely used in the UK.
Mechanical debridement has been more popular in North America than elsewhere. Methods include wet-to-dry dressing, high-pressure wound irrigation and whirlpool baths. There is little evidence to support their use and
they have the potential to cause harm. Wet-to-dry dressings are salinesoaked gauze swabs that are allowed to dry out and stick to the wound. They
lift off slough and eschar when removed but also cause pain to the patient
and may damage newly formed tissue. High-pressure irrigation can actually
drive bacteria deeper into a wound rather than washing it off. Whirlpool
footbaths can potentially spread infection elsewhere on the foot and may be
difficult to decontaminate between patients (Schultz et al., 2003).
Sharp or surgical debridement is the fastest method. It is of particular benefit
when managing diabetic foot ulcers in preventing the build-up of callus.
However, it is not suitable for all situations. As there is potential for harm,
such as excessive bleeding, it should be undertaken by a competent, trained
professional (Fairbairn et al., 2002).
Inflammation and infection control
Chronic wounds are always colonised with bacteria but if the numbers increase
this may ultimately result in infection. Sibbald (2001) described the importance
General Principles of Wound Management
75
of maintaining a bacterial balance where the wound may be contaminated or
colonised but this does not impact on healing. He also discussed the issue of
deep and superficial infections. If healing does not result from topical therapy,
systemic antibiotics may be necessary, especially if a deep infection is present.
Schultz et al. (2003) emphasise the importance of debridement as it can reduce
the bacterial burden by removing devitalised tissue, which is a focus for bacteria, and creating a more active wound. Using maggots for debridement is particularly useful, as they have been found to ingest and destroy bacteria,
including MRSA (Thomas, 2001). Topical antiseptics such as slow-release silver
and iodine have been shown to be beneficial but should only be used for two
weeks (Edmonds et al., 2004; Moffatt et al., 2004). Topical antibiotics are not recommended because of the risk of bacterial resistance.
Moisture balance
A major criticism of the moist wound-healing theory is that there is no information about what constitutes the correct level of moisture on the wound
surface. Wounds can produce widely varying quantities of exudate. Heavily
exuding wounds may cause maceration of the surrounding skin as well as
soggy dressings and a very distressed patient. On the other hand, wounds with
little or no exudate may become dessicated. A balance between the two is
required. Moisture balance in the presence of heavy exudate can be achieved
in a variety of ways.
䊉
䊉
䊉
䊉
Use of highly absorbent dressings. There are a number of highly absorbent
dressings available and selection depends on the type, position and size of
the wound and the wound bed status. Alginates, foams and hydrofibre dressings are widely used; they absorb exudate and may also have moisture
vapour transmission capability. Capillary action dressings are multilayered
and able to conduct exudate away from the wound surface.
The use of appliances such as ‘bag systems’. This may be by means of a stoma
bag or a specialist wound appliance. These systems are useful in wounds
that constantly seep but they only contain the problem, rather than solving
it. However, they may be more effective and comfortable for the patient than
bulky dressings that frequently leak (Vowden & Vowden, 2003).
Compression is an effective method of controlling wound exudate in leg
ulceration as compression reduces chronic venous hypertension. It can be
achieved by the use of compression bandages or by intermittent compression therapy. This treatment is limited to leg ulcers where there is a venous
component and will be discussed further in Chapter 5.
Topical negative pressure therapy (TNP) is increasingly being applied to
heavily exuding wounds of all types. It has also been suggested that use of
TNP can reduce the bacterial burden of a wound (Morykwas et al., 1997).
Whatever method of moisture balance is used, it is important to care for the
skin surrounding the wound. Excessive moisture can cause maceration or irritant dermatitis (Cutting & White, 2002). Various strategies may be used,
76
The Care of Wounds
depending on the method used to manage the exudate. Creams containing zinc
provide an effective barrier and are frequently used with heavily exuding leg
ulcers. They are soothing to macerated skin but would be inappropriate where
adhesive strapping is used close to the wound margin, such as with TNP. Skin
sealants are particularly useful under adhesive dressings as they protect the
skin from the adhesives as well as the exudate. Another strategy is to use a
hydrocolloid dressing, first cutting a hole the shape of the wound in the dressing wafer and then applying it as a border around the wound, as is used in
biosurgery.
Epithelial (edge) advancement
A healing wound not only has a wound bed filled with healthy granulating
tissue but also evidence of epithelialisation at the wound margins. For many
wounds, achieving debridement of necrosis and slough and bacterial and moisture balance will stimulate the wound to heal. However, Falanga (2004) suggests that the problems of impaired MMP metabolism or cell senescence
(discussed in Chapter 1) may prevent this last phase of healing, although there
is need for more research in this area. As shown in Figure 3.10, this may be the
time to re-evaluate the wound and to consider the implementation of advanced
therapies such as growth factors or tissue-engineered products (Schultz et al.,
2003).
Comment
Both these theories of wound management have moved our understanding
forward. It is too simplistic to suggest that moist wound-healing theory should
be used for the management of acute wounds and WBP for chronic wounds.
Nurses should have an understanding of the underlying principles of both concepts and utilise them appropriately following a comprehensive patient and
wound assessment.
3.3.3 Pain management
As discussed in section 3.2.7, pain management is often neglected in wound
care. Accurate assessment will determine the type and intensity of pain, allowing appropriate strategies to be developed. Senecal (1999) proposed incremental steps to determine suitable analgesia and stressed the importance of regular
administration. However, many patients are reluctant to take regular analgesia
and may need to be encouraged to do so. Latarjet (2002) discussed the difference between background pain and procedural pain in burn patients. He considered that it is possible to achieve zero background pain but this is difficult
during dressing changes. If additional medication is given before dressing
changes, sufficient time must be allowed for the analgesia to take effect. If pain
is not controlled, it may be useful to involve the pain team.
General Principles of Wound Management
77
Briggs and Torra i Bou (2002) discussed additional strategies to reduce pain.
They emphasise the importance of reducing anxiety and spending time explaining to the patient what will happen and the level of pain to expect. It is also
important to select appropriate dressings that will maintain moisture balance
and minimise pain and trauma on removal. If dressings have adhered to the
wound, then it may be necessary to soak them off. If dressings persistently
adhere to the wound, an alternative dressing should be considered.
3.4 DOCUMENTATION
In order to judge the progress of a wound, it is essential to keep accurate
records. Good documentation will help to ensure continuity of care. Poor documentation has been implicated in frequent alterations of dressing type, according to the whim of individual nurses, as shown in a study by Rundgren et al.
(1990). They followed the progress of 101 patients with a variety of wounds
over a five-month period. They found that from week to week about 30% of the
patients were receiving a different treatment; 65% of the wounds did not heal
and were having treatment for the whole of the study period. They concluded
that this lack of continuity was related to poor documentation, impatience and
a lack of understanding of the healing process.
The European Tissue Repair Society (ETRS) has produced several statements
in relation to wound management, including one on documentation (ETRS,
2003). This statement is given in full below.
䊉
䊉
Adequate and accurate documentation of all patients with wounds should
take place. This should include core information with additional information
recorded depending on wound type.
Core information should be recorded at least monthly and include:
a) Wound size by:
i) Tracing.
ii) Measurement.
iii) Photography.
b) Wound bed colour (black, green, yellow, pink, red)
i) Percentage of wound bed.
ii) Photography.
c) Wound depth, using grading scale of initial assessment and detailing
tissue at wound base
d) Surrounding skin:
i) Healthy.
ii) Unhealthy.
e) Exudate – composition and volume:
i) Nil.
ii) Normal.
iii) Excessive.
f) Pain – continuous/dressing change/occasional
78
The Care of Wounds
g) An evaluation of treatment effect with the outcome graded as wound:
i) Healing.
ii) Static.
iii) Deteriorating.
h) The reason for non-healing indicated, e.g. infection, and the reason for
treatment changes documented
3.5 EVALUATING THE DRESSING
Nurses should be prepared to objectively evaluate the dressings they use, particularly if they are using new dressings, although traditional dressings should
not be exempt from evaluation. When evaluating a dressing, various aspects
need to be considered.
䊉
䊉
䊉
䊉
Patient comfort.
Ease of application.
Effectiveness.
Cost.
Patient comfort is of primary importance for any wound management product.
It can be very distressing for a patient when the application of a dressing
is painful. Eusol is a well-known example of a lotion which causes pain on
application (see Chapter 4).
Other products may adhere to the wound and cause discomfort to patients
when they move and pain when the dressing is removed. A dressing that fails
to provide sufficient absorbency and allows leakage of exudate can cause considerable inconvenience, as well as promoting feelings of insecurity in the
patient. Although different nurses may carry out the dressing, the patient is
always present. Any evaluation should involve the patient. Many like to take
an interest and can provide valuable information on new products.
Ease of application means that a dressing can be applied easily and so will
stay in place. When using any new product, it may take a little practice to
develop the most effective method of application. The nurse should be prepared
to try a dressing over a period of time on a variety of wounds (unless contraindicated) and on different parts of the body. This will allow a more comprehensive evaluation.
Effectiveness is most important. If a product does not promote healing, then
it does not matter if it is comfortable or easy to apply. Before a product becomes
available for general use, it should have undergone stringent laboratory tests
to check for safety. The ETRS (2003) has developed standards for clinical trials
in wound healing that can guide the development of study protocols. Nurses
may find particular difficulties in undertaking a clinical trial. Hunt (1983) suggested that these included a lack of control over the admission and discharge
of patients, staffing patterns, the large numbers of nurses involved in patient
care and the variations in patterns of care across healthcare providers. If nurses
are to evaluate the effectiveness of any dressing they use, they need to be aware
General Principles of Wound Management
79
of any research that has been published and any relevant systematic reviews.
This will be discussed further in Chapter 7.
Cost is an important factor in all aspects of care and should be considered
when evaluating any dressing. However, not only the unit cost is relevant. The
overall costs should be considered. One example is a study by Thomas and
Tucker (1989) who compared the use of paraffin tulle and an alginate
(SorbsanTM) and found a reduced overall cost using SorbsanTM, despite the fact
that the unit cost is greater than that of tulle.
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in (eds) Cherry, G.W., Harding, K.G., Ryan, T.J., Wound Bed Preparation. Royal
Society of Medicine Press, London.
Szor, J.K., Bourguignon, C. (1999) Description of pressure ulcer pain at rest and at
dressing change. Journal of Wound, Ostomy and Continence Nursing, 26 (3), 115–
120.
Taal, L.A., Faber, A.W., van Loey, N.E.E., Reynders, C.L.L., Hofland, H.W.C. (1999) The
abbreviated burn specific pain anxiety scale: a multicentre study. Burns, 25, 493–
497.
Thawer, H.A., Houghton, P.E., Woodbury, G., Keast, D., Campbell, K. (2002) A comparison of computer-assisted and manual wound size measurement. Ostomy and
Wound Management, 48, 46–53.
Thomas, S. (2001) Sterile maggots and the preparation of the wound bed, in (eds) Cherry
G.W., Harding K.G., Ryan T.J., Wound Bed Preparation. Royal Society of Medicine
Press, London.
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Thomas, S., Tucker, C.A. (1989) Sorbsan in the management of leg ulcers. Pharmaceutical Journal, 243, 706–709.
Vowden, K., Vowden, P. (2003) Understanding exudate management and the role of
exudate in the healing process. British Journal of Nursing, 12 (20) (suppl), 4–13.
Winter, G.D. (1962) Formation of the scab and the rate of epithelialisation of superficial
wounds in the skin of the domestic pig. Nature, 193, 293.
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Chapter 4
Wound Management Products
4.1 INTRODUCTION
There are many wound management products available and much conflicting
advice on how they should be used. Many nurses have a great interest in this
subject and take a justifiable pride in the acquired skills that facilitate dressing
change. Recent developments have demonstrated a need to change or adapt
traditional practices.
Wound management products include topical agents as well as dressings and
also what have been described as ‘advanced dressings’. A topical agent is one
which is applied to a wound. A dressing is a covering on a wound that is
intended to promote healing and protect from further injury. Advanced products are much more sophisticated dressings compared to those in everyday
practice. The Department of Health divides dressings into primary and
secondary. A primary dressing is that which is used in direct contact with the
wound. A secondary dressing is superimposed over the primary dressing. The
use of all these products will be discussed in this chapter.
4.2 THE DEVELOPMENT OF DRESSINGS THROUGH THE AGES
In L’Ingenue (1767) Voltaire described history as a ‘tableau of crimes and misfortunes’. A study of the dressings used through the ages suggests that there
may be some truth in this. Some of the treatments used on the wounded were
bizarre, if not horrific, whilst others are still familiar today.
4.2.1 Early days
The earliest record of any dressing can be found on the Edwin Smith Papyrus.
Edwin Smith was an American Egyptologist who bought the papyrus from a
trader in Luxor in 1862. He was unable to translate it and its contents were
unknown until a complete translation was published in 1930 (Zimmerman &
Veith, 1961). The papyrus is dated at around 1700 bc but it is a copy of original manuscripts that date back to around 3000–2500 bc. A variety of dressings
are mentioned including grease, honey, lint and fresh meat, which was valued
for its haemostatic properties. Adhesive strapping was made by applying gum
to strips of linen (Forrest, 1982).
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As the power of Ancient Egypt waned, the Greek civilisation gradually developed. Amongst the men who made their mark at this time was Hippocrates.
He lived from about 460 to 377 bc. Hippocrates laid the basis for scientific
medicine with his emphasis on careful observation. For the most part,
Hippocrates considered that wounds should be kept clean and dry. He recommended tepid water, wine and vinegar for cleansing wounds. If a wound
showed signs of inflammation, he suggested applying a cataplasm or poultice
to the area around the wound to soften the tissues and to allow free drainage
of pus (Zimmerman & Veith, 1961). Hippocrates also used propolis, a hard
resinous material produced by bees, to help in the healing of sores and ulcers
(Trevelyn, 1997). Hippocrates gave the first definition of healing by first intention, where the skin edges are held in approximation to each other, and secondary intention where there is tissue loss and the skin edges are far apart.
Some of these concepts can also be found in the writings of Sushruta, an
Indian surgeon who lived some time between the sixth century bc and the sixth
century ad. His surgical textbook, the ‘Sushruta Samhita’, was used as a basis
by later writers. Sushruta described 14 different types of dressings made from
silk, linen, wool and cotton (Zimmerman & Veith, 1961). He also placed great
emphasis on the importance of cleanliness. Meade (1968) describes Sushruta’s
recommendations for the management of wounds involving the intestines. First
black ants were applied and then the intestines were washed in milk and lubricated with clarified butter before they were returned to their normal position.
He differed from Hippocrates on the matter of the most appropriate diet for
patients. Sushruta considered meat, normally forbidden to Hindus, an important factor whereas Hippocrates recommended the restriction of food and gave
his patients only water to drink (Zimmerman & Veith, 1961).
The influence of Greek physicians continued on into the time of the Roman
Empire. Oil and wine were commonly applied to wounds. Reference to this was
made by the Gospel writer Luke, when he was recording the parable of the
Good Samaritan (Luke, Ch.10, v.34, New Testament). Luke describes the Good
Samaritan pouring oil and wine onto the wounds and then applying bandages.
Celsus compiled a history of the development of medicine from the time of
Hippocrates to the first century ad, with great detail of the practices of his time.
Although it is believed that Celsus was not a physician, he was the first to give
a definition of inflammation. He listed the cardinal signs as redness, heat, pain
and swelling. He advocated the cleansing of wounds to remove foreign bodies
before suturing. He also expected wounds to suppurate; that is, to form pus
(Meade, 1968). A Roman scholar, Pliny, described the use of propolis to soften
induration and reduce swelling. He also wrote that it healed sores when healing
seemed impossible (Trevelyn, 1997).
It is, however, Galen who stands out as the person whose work had lasting
impact. Galen (129–199 ad) was surgeon to the gladiators in Pergamun and later
physician to the Emperor Marcus Aurelius. He wrote many books, some of
which survived him and were seen as the ultimate in medical knowledge for
many centuries. He is particularly known for his theory of ‘laudable pus’ (pus
bonum et laudabile), which holds that the development of pus is necessary for
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healing and should, therefore, actively be promoted. Galen found the application of writing ink, cobwebs and Lemnian clay to wounds to be efficacious
(Forrest, 1982). When reviewing his achievements, Duin and Sutcliffe (1992)
considered that although in some ways Galen considerably expanded medical
knowledge, he also held it back for a thousand years.
4.2.2 The Dark Ages and early Middle Ages
After the fall of the Roman Empire, cultural influence moved eastwards and
the Arab doctors of Islam further developed medical knowledge. However,
their wound care was based on Galenic teaching. A number of doctors, such as
Rhazes and Albucassis, translated Galen’s writings into Arabic but the most
famous was Ali Ibn Al-Husain-al-Sina (980–1037), also known as Avicenna to
the Western world. Avicenna wrote the Canon Medicina, translating Galen’s
work and adding his own commentary (Dealey, 2002). Ultimately it was translated into both Hebrew and Latin and became the foremost medical textbook
in the Middle East, North Africa and Europe up until the seventeenth century
(Guthrie, 1945). Avicenna proposed treating pressure ulcers with white lead
ointment, covering the bed with salix leaves and preventing the patient from
sleeping on his back (Kanal, 1975). He also advised the use of astringents such
as cooked honey and myrrh to reduce the amount of exudate in wounds with
tissue loss.
Medical knowledge swept across the Middle East, through North Africa and
into Spain and southern Italy with the spread of Islam and the Islamic Empire.
Thus the teaching of the Arab doctors influenced many of the developments
in Europe, including reinforcing the pre-eminence of Galen. It must also be
recognised that during this time the Church supplied most of the healthcare
provision outside the home, resulting in the Church having control over many
aspects of medicine, such as giving support to Galenic teaching.
Salerno in southern Italy was the first European university to have a medical
school, which was founded in the ninth century (Forrest, 1982). Unlike most
other universities of the time, Salerno was not under ecclesiastical control and
so was able to incorporate surgery into the curriculum at a time when the clergy
were prohibited from practising it (Zimmerman & Veith, 1961). Salerno was the
leading centre for surgical training in the eleventh century and during this time
the Surgery of Roger was written. It was translated into 15 other languages and
was used up to the sixteenth century (Paterson, 1988). Roger advocated the use
of lard in head wounds, either applied directly or soaking cloth in molten lard
for deep wounds. He did not recommend cleaning wounds but used dressings
made from eggs and water, tow and salt and bandages of fine linen cloth
(Paterson, 1988).
One of the expert surgeons who graduated from Salerno was Hugo of Lucca
(1160–1257). He went on to found the School of Surgery at Bologna University
(Dealey, 2003). Although none of his writings have survived, he was considered to be a very innovative surgeon. His famous pupil, Theodoric (also known
at Teodrico Borgognoni) (1205–1296?), completed his Chirurgia or surgical text-
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book in 1267, which he stated was based in Hugo’s teaching. Theodoric disagreed with the concept of ‘laudable pus’ as he considered that it prolonged
healing. He advocated cleaning a wound with wine, debriding it and removing all foreign matter, approximating the wound edges and holding them in
place using compresses of lint soaked in warm wine and then binding them in
place. The dressing was then to be left in situ for 5–6 days, unless there was
excessive heat or pain (Borgognoni, 1955). He proposed that chronic wounds
should be cleansed with honey mixed with wine and water of holm-oak or vine
ashes; alternatively, sea water could be used to cleanse and dry a wound. Unfortunately, his ideas were discredited and gradually disappeared until the
twentieth century when they were again discovered in Italy (Popp, 1995).
One of the people influenced by Theodoric’s teaching was Henri de
Mondeville (1260–1320). He was a French doctor who trained in Paris and
Montpellier as a physician, before going to Bologna to learn surgery from
Theodoric (Gerster, 1910). He was highly respected as a man of profound erudition and moral character and became surgeon to King Phillippe le Bel of
France in 1301. De Mondeville also wrote a Chirurgie, which drew on the work
of Avicenna for anatomy and Theodoric for wounds. Unfortunately, de
Mondeville was not a tactful person and he commenced his treatise on wounds
by first describing and then condemning the common practices of the day that
promoted ‘laudable pus’. Unsurprisingly, he failed to influence his contemporaries who tried to put pressure on him to abandon his treatment (Dealey, 2004).
A close successor to de Mondeville was Guy de Chauliac (1300–1368). He
followed a similar pattern to de Mondeville, training in Toulouse, Montpellier
and Paris before travelling to Bologna to study anatomy (Johnson, 1989). It was
when de Chauliac was in Bologna that he became strongly influenced by
Galen’s writing. This is reflected in his Grande Chirurgie in which he quoted
Galen 890 times (Johnson, 1989). When writing about wound care, he rejected
the ideas of Theodoric and de Mondeville and proposed treatments such as the
use of tents (drains) and meshes (packing) to hold wounds open and oily salves
to promote pus formation. De Chauliac’s book was highly successful, having
numerous editions and translations, and it became the primary surgical textbook for 200 years. He had so great an influence that his critics consider that
he set back progress in wound management for up to six centuries, although
not every commentator takes such a harsh view (Johnson, 1989).
4.2.3 Late Middle Ages and Renaissance
Kirkpatrick and Naylor (1997) have described the contents of a surgical treatise
dated 1446 and believed to be the work of Thomas Morstede (1380–1450) who
was a London surgeon. The work provides detailed information about the classification of ulcers and their treatment. The step-by-step approach describes
how to enlarge the mouth of the ulcer, then the processes of mortification
(debridement), mundification (cleansing) and fleshing (encouragement of
granulation tissue). Recipes for the various topical applications are provided
for the reader. They include items such as sage leaves, wormwood, white
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Gascony wine, alum and honey for mundification. The recipe for a treatment
for fleshing involved stirring the mixture for the length of time it took to say
two Creeds (articles of belief for Christian faith).
Ambroise Paré (1510–1590) was the most famous surgeon of the Renaissance
period (Zimmerman & Veith, 1961). He rose from a poor background with
little education to become surgeon to four successive French kings, ultimately
gaining the titles Premier Chirurgien and Conseiller du Roi. However, it is as
a military surgeon that Paré is best known. With the discovery of gunpowder,
warfare changed. Gunshot wounds were believed to be poisonous. In order to
treat them, surgeons began to undertake more amputation of limbs. The standard practice was to use boiling oil to cauterise the stump. Paré is famous for
using a mixture of egg yolks, oil of roses and turpentine instead. He is also well
known for his saying ‘Je le pensait, Dieu le guarist’, which is generally translated as ‘I dressed him, God healed him’ (Zimmerman & Veith, 1961). Paré
proposed using a dressing composed of rock alum, verdigris, Roman vitriol,
rose honey and vinegar, boiled together to form a paste, on traumatic wounds
(Linker & Womack, 1969). He treated a severe pressure ulcer by encouraging
the patient, feeding him, providing pain relief and sleep-inducing medication
and pressure relief by means of a small pillow (Levine, 1992). Paré wrote
numerous books, all in the vernacular rather than Latin. Some of his later writings are considered to be classics.
4.2.4 The seventeenth, eighteenth and early nineteenth centuries
Another doctor worthy of mention is the German surgeon Lorenz Heister
(1683–1758). Heister was exceedingly well educated in languages and the
humanities as well as medicine and surgery at a time when most of his colleagues had little education or training and charlatans abounded (Zimmerman
& Veith, 1961). He developed his skills working as a military surgeon and
became a professor of anatomy and surgery at the University of Helmstadt
in 1719. He wrote a General System of Surgery in three parts on the doctrine
and management of: I) Wounds of all kinds, II) Several operations, and III)
Bandages (Heister, 1768). Heister used lint dressings dipped in alcohol or oil of
turpentine to treat haemorrhage or spread with a sound digestive ointment or
balsam to heal wounds. He suggested that wound edges should not be closed,
in order to allow pus to drain. He believed that all bandages should be made
from clean linen that had been softened by repeated use (Bishop, 1959). His
book was translated into numerous languages, including English, and ran to
ten editions.
Many of the developments in wound management seem to be associated
with wounds from battles. One development was that of debridement,
possibly originated by Henri Francois LeDran (1685–1770) in order to relieve
the constriction of soft tissues, believed to be caused by inflammation following gunshot wounds (Helling & Daon, 1998). However, other surgeons across
Europe suggested caution in its use. John Hunter (1728–1793), the famous
English surgeon, disagreed with the practice as he did not believe that wounds
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should be made larger in order to remove extraneous matter. He thought that
suppuration would bring it to the surface (Zimmerman & Veith, 1961). During
the Napoleonic wars, several French surgeons advocated the use of debridement, particularly in the care of gunshot wounds (Helling & Daon, 1998).
However, its use was sporadic and most wounds were not explored and
after the fall of Napoleon and his empire, the concept was almost entirely
forgotten.
4.2.5 Mid-nineteenth and early twentieth century developments
The Crimean War led to a huge demand for dressings. Various types of dressings were produced in the workhouses, which were a source of cheap labour.
Charpie was made from unravelled cloth. Oakum was old rope which had been
unpicked and teased into fluff; it became popular with doctors during the
American Civil War as they considered it to be very absorbent (Bishop, 1959).
Tow was made from broken, ravelled flax fibres. Lint is linen that has been
scraped on one side. The production of this dressing was mechanised. All of
these dressings were washed and reused many times so they gradually became
quite soft but they were not very absorbent.
Sheets of cotton wool retained by cotton bandages were used during the
Franco-Prussian wars, but Joseph Sampson Gamgee (1828–1886) was the
person who further developed its use. He noted that cotton wool could be made
absorbent by removing the oily matter within it. He then conceived the idea of
covering the cotton wool with unbleached gauze to make dressing pads or
Gamgee tissue (Lawrence, 1987). Gamgee tissue is still available today.
In 1867, Lister introduced the use of carbolic acid and revolutionised surgery
and surgical wound management. When he realised that carbolic caused skin
irritation, he developed a method of impregnated carbolic gauze that became
the first antiseptic dressing (Bishop, 1959). The use of antiseptics and concept
of asepsis spread rapidly across Europe.
During the course of the First World War, severely wounded soldiers had to
wait several days before receiving more than a simple field dressing. As a result,
many wounds became infected and gangrenous. Antiseptics were developed to
help resolve this problem. In particular, two similar antiseptic solutions came
into use: Eusol (Edinburgh University Solution of Lime) and Dakin’s solution.
Other antiseptics such as iodine, carbolic acid and mercury and aluminium
chloride were also available.
Sinclair and Ryan (1993) have reviewed some of the medical literature of
1915 to identify thinking at that time on the use of antiseptics. Bond (1915)
considered that it was important to apply a ‘germicide’ as early as possible to
wounds that were almost certain to be infected. British soldiers were advised
to carry tincture of iodine so that they could apply it immediately to any
gunshot wounds (Mayo-Robson, 1915). However, Herzog (1915), writing of the
German experience in the battlefield, reported that he had seen a number of
soldiers suffering from dermatitis of the skin around the wound as a result of
the indiscriminate use of iodine.
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Deparge, a Belgian surgeon of note, recognised that merely introducing
antiseptics into war wounds was insufficient and he revived the concept of
wound debridement (Helling & Daon, 1998). He believed that such devastating wounds, often covered in mud and dirt and receiving only minimal surgery,
encouraged the development of soft tissue infections. He formulated a set of
principles for managing them that involved exploring the wound and excision
of all contaminated and contused tissue, followed by leaving the wound open
and irrigating it with Dakin’s solution. He also favoured the use of delayed
primary closure or secondary closure if bacteria were present. Deparge’s use
of debridement has had a major impact on trauma surgery (Helling & Daon,
1998).
At this time, Lumiere devised a dressing called tulle gras, a gauze impregnated with paraffin. Sphagnum moss was also used as it was found to be twice
as absorbent as cotton wool. It could also be impregnated with antiseptics and
sterilised. Eupad was a dressing designed for use on leg ulcers. It was a Eusol
preparation, made up with a mixture of boracic and bleach. Another popular
type of dressing was Emplastrums which were made of white leather spread
with a plaster mass, to which some type of medication was often added (Turner,
1986).
During the Second World War an American neurosurgeon called Eldridge
Campbell was with a field hospital in Italy. In 1943 there was a great deal
of heavy fighting and many casualties. Some of the Italian doctors caring for
these patients proposed a method of wound care that involved cleansing and
debriding the wound and then suturing it. This was contrary to the current
practice of the day, which recommended packing with Vaseline gauze and
immobilisation. Campbell was impressed by this method of healing and
eventually traced its origins back to the thirteenth century and Theodoric. In
describing this fascinating piece of medical history, Popp (1995) concludes
that it demonstrates the problems of entrenched views that are not questioned,
such as the teachings of Galen, and the dangers of summarily dismissing new
ideas.
4.2.6 The British Pharmaceutical Codices
The first British Pharmaceutical Codex was published in 1907. It provided information on all the drugs and medicinal preparations in common use throughout the British Empire. Turner (1986) has reviewed the dressings listed in the
earliest British Pharmaceutical Codices and compared them with more recent
lists of dressings in the British Pharmacopoeia. He found that the list from 1923
contains much that is familiar today. Table 4.1 compares the 1923 list with the
1980 list, showing that little had changed in the intervening years. Gauzes,
cotton wool pads and bandages can be seen as very popular methods of wound
care. Turner suggests that it is only in the last 30 years that any attempt has
been made to design materials that are actually functional. Prior to that, dressings were made from materials that happened to come to hand.
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Table 4.1
Comparison of surgical dressings 1923 and 1980.
1923
Gauzes, medicated and unmedicated
Cotton wools, medicated and unmedicated
Tows, medicated and unmedicated
Lints, medicated and unmedicated
Gauze and cotton tissues
Jaconet, oiled silk, etc.
Bandages
Emplastrums
1980
(23)
(15)
(14)
(8)
(2)
(4)
(9)
(32)
Gauze products
Cotton wool pads (eye)
Dressing pads
Impregnated gauze
Gauze and cotton tissues
Ribbon gauze
Bandages
Adhesive pads
Foams
Contact layers
Absorbent cotton
Medicated bandages
(11)
(1)
(2)
(3)
(2)
(3)
(15)
(2)
(3)
(2)
(2)
(4)
Numbers in parentheses indicate number of different types available within each category.
4.3 TRADITIONAL TECHNIQUES
Today nurses expect to perform the vast majority of dressings, other than
simple first aid treatments applied in the home or workplace. But this was not
always the case. Originally, dressing changes were undertaken by doctors.
Eventually, medical students, particularly on surgical wards, were trained to
change dressings. By the 1930s, the task was given to experienced sisters and
ultimately, it became a recognised nursing task.
During the 1930s and 1940s, as the care of wounds gradually came into the
nursing domain, much mystique became attached to the subject. This was
exaggerated with the development of an aseptic, usually non-touch, technique.
Merchant (1988) has reviewed the literature on this subject and concluded that
the procedure developed in the 1940s was still being used at the time she was
writing, despite the change to a central sterile supply system. Most hospitals
had changed to this system by the early 1970s.
In the early days, large water sterilisers were used for preparing the equipment for an aseptic procedure. One was usually found on every ward. It was
the task of the night nurses to boil all the metal bowls, receivers and gallipots,
ready for the morning dressing round. The dressings were packed in drums
and sent to a central point for sterilising. It was left to the ward sister to choose
what went into the drum. Commonly, gauze squares, cotton wool balls and
wadding were used. In many hospitals nurses wore masks and gowns, a practice that gradually disappeared. Usually two nurses carried out the dressing,
a clean nurse and a dirty nurse. Much attention was paid to the position
of the equipment on top of the trolley and to the frequency and timing of
handwashing.
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All wounds were redressed once or twice daily. The wound was thoroughly
cleaned using cotton wool balls and forceps. The method of wiping across the
wound surface varied from hospital to hospital. The Hippocratic principle of
keeping wounds clean and dry became adapted to ‘allowing wounds to dry
up’. Mostly gauze preparations were used but gradually all sorts of dubious
practices crept in. There have been reports of Marmite, eggs and even toast used
on wounds (Dobrzanski et al., 1988; Johnson, 1987).
A wide variety of pharmaceutical preparations have also been applied
without any recognition of the need for evidence-based care. Murray (1988)
found that within her health authority, an amazing selection of pharmaceutical
products were in use: 18 different cleansing agents, 53 substances left in contact
with open wounds and 24 products used for packing wounds. Millward (1989)
found 19 different substances being used on pressure ulcers within one hospital. Walsh and Ford (1989) have discussed the rituals in nursing, much of which
can be applied to wound care. The common reasons for choosing a dressing
could be listed as:
䊉
䊉
䊉
We always do it that way here.
Sister said so.
I have used this dressing for the last 30 years, why should I change?
Many older nurses will have been trained to use these ritualistic methods. It is
only recently that there has been a critical evaluation of these methods and
changes made to a more evidence-based approach.
4.4 THE USE OF LOTIONS
A variety of lotions are used in wound care, primarily for wound cleansing.
The aims of wound cleansing are to remove any foreign matter such as gravel
or soil, to remove any loose surface debris such as necrotic tissue and to remove
any remnants of the previous dressing. A study by Thomlinson (1987) considered the various ways in which swabs could be wiped across the wound
surface. The results showed that the action of cleansing did not reduce the
number of bacteria on the wound surface but simply redistributed them.
4.4.1 Antiseptics
After saline, the commonest type of lotion in use is an antiseptic. An antiseptic
can be defined as a non-toxic disinfectant, which can be applied to skin or living
tissues and has the ability to destroy vegetative compounds, such as bacteria,
by preventing their growth. If antiseptics are simply used to wipe across the
wound surface, they will have little effect. They need to be in contact with bacteria for about 20 minutes before they actually destroy them (Russell et al., 1982).
In some instances they can be applied in the form of soaks or incorporated into
dressings, ointments or creams.
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Research using experimental wounds in the animal model has demonstrated
that antiseptics have toxic effects that need to be weighed against any advantages obtained from their use. In the late 1980s and early 1990s there was considerable debate about antiseptics and their widespread use dramatically
reduced. Since the introduction of the concept of wound bed preparation (discussed in Chapter 3), antiseptics have made something of a comeback as they
are seen to have a place in achieving bacterial balance (Schultz et al., 2003).
Each of the common antiseptics will be listed in turn and their advantages
and disadvantages discussed.
Cetrimide
Cetrimide is useful for its detergent properties, particularly for the initial
cleansing of traumatic wounds or the removal of scabs and crusts in skin
disease. It should not be used in contact with the eye. It is rapidly inactivated
by organic material. Two dangers should be noted: it can cause skin irritation
and sensitivity, and, it is very easy for it to become contaminated by bacteria,
especially Pseudomonas aeruginosa. It is mostly only used in accident and
emergency departments for initial cleansing of wounds rather than as a routine
cleanser. It is available as a cream or as a lotion in combination with chlorhexidine. Morgan (1993) suggests that cetrimide should be used with caution in
restricted circumstances rather than as a general cleanser.
Chlorhexidine
Chlorhexidine is used in a variety of aqueous formulations. It is effective
against Gram-positive and Gram-negative organisms. Brennan et al. (1986)
found that it has a low toxicity to living cells. Tatnall et al. (1990) undertook a
similar study to identify the toxicity of several antiseptics when used on cultured keratinocytes (used for grafts). They found chlorhexidine to be the least
toxic but considered that antiseptics should not be used over these graft sites.
Kearney et al. (1988) found that chlorhexidine could maintain its antimicrobial
levels for a period of time when impregnated into a dressing. However, its
efficacy is rapidly diminished in the presence of organic material such as
pus or blood (Reynolds, 1982). Mengistu et al. (1999) tested chlorhexidine in
different strengths against a range of Gram-negative bacteria and found that a
significant number were only inhibited by high concentrations of chlorhexidine.
They concluded that it was more suitable for disinfection and hospital hygiene
rather than wound care.
Hydrogen peroxide
Hydrogen peroxide 3% (10 vols) has an oxidising effect that destroys anaerobic bacteria. However, it loses its effect when it comes in contact with organic
material such as pus or cotton gauze. Lineaweaver et al. (1985) showed that
hydrogen peroxide was cytotoxic to fibroblasts unless diluted to a strength of
0.003%. This dilution is not effective against bacteria. O’Toole et al. (1996) found
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that even in concentrations 1000-fold less than 3% dilution, it inhibits
keratinocyte migration and proliferation. Bennett et al. (2001) found that 3%
hydrogen peroxide significantly reduced neodermal regeneration and fibroblast proliferation compared to controls (untreated wounds) in an animal model
study. There is also a report of an incident where an air embolism occurred after
irrigation with hydrogen peroxide (Sleigh & Linter, 1985). Rees (2003) reviewed
the evidence on hydrogen peroxide and concluded that it was unsuitable for
use in cleaning wounds in A&E. Hydrogen peroxide is no longer widely used
as there is no evidence to demonstrate its efficacy and there are a number of
other more suitable alternatives.
Iodine
Iodine is a broad-spectrum antiseptic and is available as an alcohol and an
aqueous solution. The aqueous solution is used in wound care, usually as povidone iodine 10%, which contains 1% available iodine. It is used as a skin disinfectant and to clean grossly infected wounds. McLure and Gordon (1992) and
Michel and Zach (1997) found it to be effective against methicillin-resistant
staphylococcus aureus.
Several studies have questioned the value of using povidone iodine. It is cytotoxic to fibroblasts unless diluted to 0.001%, retards epithelialisation and lowers
the tensile strength of the wound (Lineaweaver et al., 1985). Brennan and Leaper
(1985) found that povidone iodine 5% damaged the microcirculation of the
healing wound but a 1% solution was innocuous. In contrast, Bennett et al.
(2001) found that povidone iodine significantly increased fibroblast proliferation and slightly increased neodermal regeneration and epithelialisation.
Becker (1986) reported that when operating on contaminated head and neck
cases, he irrigated 18 with povidone iodine and 17 with isotonic saline; 28%
of wounds became infected, all of which had been irrigated with povidone
iodine.
Povidone iodine has been used within the wound bed preparation model of
wound management. Consequently, Selvaggi et al. (2003) reviewed and reappraised the role of iodine and concluded that most of the evidence is confusing, especially as a mixture of in vitro and animal models have been used as
well as different preparations. They conclude that povidone iodine has been
shown to be an effective antibacterial that is superior to other products and
seems to have no problem with resistance. Zhou et al. (2002) proposed that a
slow-release form of iodine might overcome the toxicity problems. They tested
cadexomer iodine using both in vitro methods and a variety of chronic wounds.
They found no evidence of toxicity in the in vitro study. After 2–3 weeks of
treatment, all 16 chronic wounds showed increased debridement, decreased
exudate, increased granulation tissue and reduced wound size.
Povidone iodine is available in ointment, spray and powder form and
impregnated into dressings. Iodine should not be used for patients with thyroid
disease or those who are sensitive to the product.
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Potassium permanganate
Potassium permanganate 0.01% is mostly used on heavily exuding eczematous
skin conditions, generally associated with leg ulceration. It is most easily used
in the form of tablets. One tablet dissolved in four litres of water provides a
0.01% solution. The affected limb is generally placed in a container holding the
fluid for approximately 15 minutes. It is mildly deodorising and has slight disinfectant properties. It has been found to cause staining of the skin. There is
little evidence to demonstrate its efficacy (Anderson, 2003).
Proflavine
Proflavine has a mild bacteriostatic effect on Gram-positive organisms but not
on Gram-negative bacteria. There has been little research to demonstrate its
value. Although it is available as a lotion it is mostly used as an aqueous cream.
However, proflavine is not released from the cream into the wound so has no
effect on the bacteria. Foster and Moore (1997) compared the use of proflavinesoaked gauze packs with cellulose-based fibre dressing in surgical cavity
wounds. They found that the proflavine packs were significantly more painful
to remove and patients required analgesia prior to removal.
Silver
Silver has been used as an antiseptic in wound care for many years in the form
of silver nitrate. It is still used in this format in some burns units in North
America. However, it is extremely caustic, stains the skin black and prolonged
use causes hyponatraemia, hypokalaemia and hypocalcaemia. To overcome
these problems, a cream, silver sulphadiazine, was developed and has been
very successful in controlling burn wound infections (Lansdown, 2004).
However, the combination of cream and exudate makes dressing removal
messy so it is usually undertaken in a hydrotherapy unit, which can be a source
of cross-infection (Tredget et al., 1998). As a result, there is increasing interest in
the use of silver-coated dressings of varying types.
Wright et al. (1998a) tested the bactericidal effect of silver in three modalities:
liquid (silver nitrate), cream (silver sulphadiazine) and a silver-coated dressing.
All products were effective at killing bacteria. The silver-coated dressing
was the most efficacious against a wider range of bacteria and silver nitrate
the least efficacious. Tredget et al. (1998) compared a silver-coated dressing,
changed daily, with the standard procedure of covering a burn with gauze
and moistening it with 0.5% silver nitrate every two hours. They found that
the silver-coated dressing caused significantly less pain on removal and
had substantially less infection. Also, the wound only required attention
every 24 hours and could have been left for 48 hours, reducing dressing and
nursing time costs. Silver dressings will be discussed in more detail in section
4.6.
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Sodium hypochlorite
Sodium hypochlorite comes in several forms, the commonest being Eusol,
Dakin’s solution and Milton. It was originally used on heavily infected wounds
during the First World War. Dakin suggested that to be effective, it should be
used in large volumes (Thomas, 1990).
Several research studies have been undertaken which suggest that the
hypochlorites may have few beneficial effects and do much harm. Bloomfield
and Sizer (1985) found they cause irritation to both the wound and the surrounding skin. They were found to have a cumulative effect, causing redness,
pain and oedema, and to prolong the inflammatory stage of healing. They are
cytotoxic to fibroblasts, unless diluted to a strength of 0.0005%, and retard
epithelialisation (Lineaweaver et al., 1985). Brennan and Leaper (1985) found
that they caused considerable damage to the microcirculation of the wound.
The antiseptic effect is lost when the solution comes in contact with organic
material such as pus or gauze. A study describing the use of Eusol and liquid
paraffin on leg ulcers was undertaken by Daltrey and Cunliffe (1981) who found
no significant evidence of antibacterial activity. Bennett et al. (2001) found
that half-strength sodium hypochlorate had a mixed effect on wound repair,
with no impairment of fibroblast proliferation but decreased vascular density.
However, at that strength it was ineffective as an antimicrobial.
Carneiro and Nyawawa (2003) randomly allocated Eusol or phenytoin
powder to treat 102 leg ulcers. They found that there was a significant reduction in pain, exudate levels and wound size in the phenytoin group compared
with the Eusol group. This study was undertaken in Tanzania and many of the
ulcers were due to animal bites. These ulcers were found to heal fastest. The
authors concluded that phenytoin was more suitable than Eusol, especially as
it is cheap and easily applied.
Humzah et al. (1996) surveyed 124 plastic surgeons in the UK regarding their
views on the use of Eusol. They had responses from 95 (77%) of the surgeons.
Analysis of the responses found that 82% still used Eusol when it was available and the majority (88%) used it for sloughy wounds. Since this survey was
undertaken, the use of Eusol has reduced even further. It is interesting to consider that where alternatives have replaced Eusol, its use has not been missed
at all. Overall, Eusol is an outmoded product whose disadvantages far outweigh any slight advantage there may be in its use.
4.4.2 Antibiotics
A range of antibiotics is available in topical form. They are potentially
hazardous and they are not always absorbed into the wound. There is considerable risk of sensitisation to the patient as well as the development of resistant organisms. Systemic antibiotics are the treatment of choice when treating
infected wounds because the infection may be too deep for topical antibiotics
to penetrate.
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D’Arcy (1972) recommends that any antibiotic that is used systemically
should not be applied to the skin. However, antibiotics that are not appropriate for systemic use may be developed for use on the skin or in wound care.
This means that creams, gels, ointments or impregnated dressings containing
gentamicin, tetracycline, fusidic acid or chlortetracycline hydrochloride should
not be used as these antibiotics are used systemically. Neomycin is no longer
used systemically but topical use may cause systemic side effects such as
ototoxicity.
One preparation which would seem to be of benefit in wound care is
mupirocin. Mupirocin is used predominantly for treating methicillin-resistant
Staphylococcus aureus (MRSA) either in skin infections or for nasal colonisation.
Several studies have demonstrated its efficacy in treating MRSA in burn
wounds (Deng et al., 1995; Rode et al., 1989; Trilla & Miro,1995). However,
Cookson (1998) warns of the potential dangers of resistance and cites a number
of reported cases of mupirocin-resistant bacteria to support his arguments. He
proposes that prolonged and widespread use of mupirocin should be stopped
and a more judicious approach to its usage be adopted.
4.4.3 Honey
As was discussed earlier, honey has been used in wound care since ancient
times and there has been a recent resurgence of interest in its use, particularly
manuka honey (Flanagan, 2000). A review by Molan (1999) discussed the role
of honey and considered that it had the following properties.
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Antibacterial action, as shown in laboratory studies and case studies,
although, Kingsley (2001) did not find this in two case studies.
Deodorising action, as demonstrated by Dunford and Hanano (2004) in a
study of 40 patients with recalcitrant venous leg ulcers.
Debriding action, as found by Ahmed et al. (2003).
Anti-inflammatory action, as shown in histological studies.
Stimulation of wound healing, as shown in several studies (Dunford &
Hanano, 2004; Misirlioglu et al., 2003; Subrahmanyam, 1998; Vandeputte &
Van Waeyenberge, 2003;).
Pain relief was not listed by Molan (1999) but was demonstrated by Dunford
and Hanano in their study (Dunford & Hanano, 2004).
A systematic review by Moore et al. (2001) found that although honey appeared
to be an effective treatment, many of the studies reviewed were of poor quality.
There is a need for larger randomised controlled trials to determine the most
effective use for honey. There is also an issue about frequency of dressing
change, as Molan (1999) suggested that up to three times daily may be necessary initially. This is very labour intensive and may not be acceptable to the
patient (Kingsley, 2001).
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4.4.4 Saline 0.9%
This is the only completely safe cleansing agent and is the treatment of choice
for use on most wounds. Manufacturers recommend that it is used in conjunction with many of the modern wound management products. Saline is presented in sachets, small plastic containers that allow the saline to be squirted
onto the wound and also in aerosols. These last two presentations are more
widely used in the community.
4.4.5 Tap water
Tap water is being used more frequently on a variety of wounds, in particular
on areas already colonised such as wounds following rectal surgery or leg
ulcers. Many patients may bath or shower prior to dressing change so there
seems to be little point in then ‘cleansing’ the wound. However, the bath or
shower should be thoroughly cleaned afterwards to avoid cross-infection. A
recent systematic review found that using tap water to clean wounds did not
differ from using sterile normal saline in respect of wound infection and healing
rates (Fernandez et al., 2002). This would therefore suggest that either saline
or water can be used, selection being based on practicality and individual
circumstances.
4.5 CLINICAL EFFECTIVENESS OF WOUND
MANAGEMENT PRODUCTS
Originally dressings were seen merely as coverings that could provide some
protection to the wound. The range of products currently available are much
more sophisticated. There are so many products to choose from that it can cause
considerable confusion. There is no single perfect dressing but an ‘identikit’ list
of criteria can be established. A specific wound may not need all of the criteria
listed. Selection can be assisted if the nurse has:
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assessed the wound and identified the specific objectives for the wound at
that time.
an understanding of what can be reasonably expected from a dressing.
access to information regarding the characteristics and effectiveness of the
range of dressings available.
The characteristics of a clinically effective wound management product are
considered below. Dressings are generally considered in relation to their
performance and their handling qualities. Performance relates to the ability to
promote healing.
4.5.1 Providing an effective environment
The qualities that will promote an effective environment for healing were discussed in Chapter 3 under theories of wound management. They are:
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ability to maintain a moist environment.
antibacterial properties.
fluid-handling properties.
4.5.2 The handling qualities of an effective wound
management product
These qualities can be listed as:
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easy to apply
conformability
easy to remove
comfortable to ‘wear’
does not require frequent dressing change.
Easy to apply
A major advantage of many of the modern products is that they are very simple
and quick to apply. Realistically, this has helped to promote their use with the
nurses who regularly provide wound care.
Conformability
A dressing that conforms well to the shape of the wound is likely to assist in
maintaining a moist environment and also provide an effective barrier for
bacteria.
Easy to remove
If a dressing is easy to remove it is less likely to damage the newly formed tissue
in the wound. It is also less likely to be painful for the patient.
Comfortable to ‘wear’
Another advantage of many modern products is that they are comfortable for
the patient when they are in situ. This means that the patient is more likely to
want to comply with the treatment regime. In any case, there is no need for
patients to suffer unnecessary pain or discomfort.
Does not require frequent dressing change
The majority of modern products can be left in place for several days, depending on the wound and, particularly, the amount of exudate. This not only saves
nursing time and reduces costs but also reduces the amount of interference with
the wound. Reduction in the frequency of dressing change helps to reduce the
opportunities for a drop of temperature on the wound surface. This can potentially occur at each dressing change. Myers (1982) studied 420 patients and
found that, after wound cleansing, it took 40 minutes before the wound
regained its original temperature. Furthermore, he found that it took three
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hours for mitotic activity to return to its normal rate. Patients also find less frequent dressing changes beneficial. Some patients find dressing change an ordeal
and others, especially community patients, an inconvenience which disrupts
their life.
Comment
It should be recognised that no one dressing provides the optimum environment for the healing of all wounds. Equally, it may be necessary to use more
than one type of dressing during the healing of a wound. Many dressings will
fulfil some of the criteria and they should be selected following careful assessment of the wound (see Chapter 3).
4.6 MODERN WOUND MANAGEMENT PRODUCTS
In order to make sense of all the dressings that are available, they will be
divided into different categories. Dressings can also be considered in terms of
their suitability as a primary or secondary dressing on open wounds. In the UK,
not all the dressings are freely available in the community as government
restrictions control which dressings can be prescribed. This may considerably
affect continuity and quality of care between hospital and community.
This section aims to describe the different categories of wound management
products and some proprietary examples will be mentioned.
Absorbent pads
There are many versions of this type of dressing. Most are in the form of an
absorbent core, which is covered by a sleeve of gauze or synthetic material.
These dressings are not suitable as a primary dressing on open wounds but
make an excellent secondary dressing, particularly when there is a heavy
exudate. They are generally very cheap.
Absorbent cellulose dressings
Exu-dryTM and MesorbTM are one-piece multilayer dressings that are highly
absorbent and able to wick exudate away from the wound surface. They may
be used in direct contact with the wound and are intended for use on heavily
exuding wounds of all types.
Adhesive island dressings
These dressings consist of a central pad which is covered with a wider band of
adhesive backing. They are lightweight and usually remain in position satisfactorily. There is little absorbent capacity in these dressings. They are widely
used on postsurgical wounds, which are healing by first intention, but are not
suitable for open wounds as a primary dressing.
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Alginates
Alginate dressings contain calcium or sodium alginate, which is derived from
seaweed. There are several types of alginate including Algisite MTM, AlgosterilTM, CurasorbTM, KaltostatTM, SorbalgonTM, SorbsanTM and TegagenTM. These
dressings are interactive because as they react with the wound, their structure
alters. As the dressing absorbs exudate, it changes from a fibrous structure to
a gel. Some dressings allow removal in one piece, others have to be flushed
from the wound. These dressings are available in a variety of formats: flat dressings, rope or ribbon, extra-absorbent versions and with an adhesive backing.
They are appropriate for moderate or heavily exuding wounds and may require
a secondary dressing. They should not be used on wounds with no or low
exudate.
Antibacterials
MetrotopTM is a gel containing metronidazole. It reduces odour and anaerobic
bacteria and is licensed for use as a deodoriser for fungating tumours. However,
it has been used successfully on other wound types. Like all products of this
type, it should not be used indiscriminately.
Antibiotics
See section 4.2.2.
Antiseptics
See section 4.2.1.
Barrier film dressings
Barrier film dressings have developed to protect the skin. Some films, such as
ClinishieldTM and Skin PrepTM, were originally developed for use around stoma
sites. Others, such as CavilonTM and Comfeel Skin CareTM, have been more
specifically marketed for protecting the skin around a wound. The film is wiped
on using an applicator such as an impregnated towel and dries to form a film
barrier, protecting the skin from adhesives as well as moisture and resistant to
urine and faeces.
Biosurgery
Biosurgery is another name for maggot or larval therapy. The often inadvertent
use of maggots in wounds has been recognised for centuries. Morgan (1995)
chronicled the use of maggots by Maya Indians through to the 1930s. He
considered that it fell into disrepute with the advent of antibiotics and aseptic
wound care and also noted the attendant aesthetic problems. However, larval
therapy is enjoying a resurgence of popularity at present. Thomas et al. (1996)
suggest this return in popularity might be in part because of the problems
caused by resistant bacteria such as MRSA.
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The larvae for biosurgery are packed in sterile containers directly from the
supplier. They may be ‘free range’ within a small plastic container or sealed
within a porous bag. Before applying the larvae, a hydrocolloid dressing should
be applied around the wound to protect the skin from the proteolytic enzymes
produced by the maggots (Sherman, 1997). Once placed in the wound, the freerange maggots are retained by means of a small net, taped in place; those in a
bag are simply placed in the wound and held in place with tape. Once the larvae
are removed from the wound, they are disposed of in the same way as all used
dressings. They are used to debride necrotic, sloughy and infected tissue from
a wound.
Cadexomer bead dressings
These dressings are composed of hydrophilic beads containing iodine. As they
absorb exudate, the beads swell and the iodine is released slowly into the
wound. They come in the form of a powder (IodosorbTM) and an ointment
(IodflexTM). This dressing is intended for heavily exuding necrotic, sloughy or
infected wounds. It should not be used for more than three months at a time
and is not suitable for people with iodine sensitivity or thyroid problems.
Capillary wound dressings
VacutexTM is the only dressing in this category. It is a non-interactive, threelayered dressing made from polyester filaments and polycotton fibres. It
absorbs exudate into the middle layer and wicks it laterally in a capillary action.
It may be cut to shape to fit a cavity and is suitable for all types of heavily
exuding wounds.
Foams
Foam dressings are made from polyurethane. They are either available as a flat
foam dressing, such as AllevynTM, BiatainTM, Cutinova HydroTM, LyofoamTM or
TielleTM, or as a filler for cavity wounds, such as Allevyn Cavity Wound DressingTM. Allevyn, Lyofoam and Tielle come in a range of presentations such as
shaped dressings, varying absorbent capacity, tracheostomy dressings and
adhesive dressings. Allevyn Cavity Wound is a preformed foam stent, which
comes in two shapes and two sizes in each. Cavi-CareTM is also a foam stent but
it has to be mixed with a catalyst and then poured into the wound cavity where
it sets in the shape of the wound. Foam dressings are best used on granulating
or epithelialising wounds with some exudate.
Hydrocapillary and multilayered absorbent dressings
The dressings within this category all have a slightly different action, depending on their construction. They are Alione HydrocapillaryTM, TransorbentTM and
VersivaTM. AlioneTM has a non-adherent wound contact layer, a hydrocapillary
pad that absorbs exudate and distributes it horizontally and an outer lowfriction film. TransorbentTM is a multilayer dressing containing a film, foam and
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hydrogel. VersivaTM also comprises three layers: a wound contact layer of
perforated hydrocolloid adhesive, a central absorbent layer of sodium
carboxymethylcellulose fibres and an outer layer of polyurethane foam. These
dressings can be left in place for several days. They are not suitable for dry
wounds.
Hydrocolloids
Hydrocolloids are a development from stoma products. They are interactive
dressings consisting of a hydrocolloid base made from cellulose, gelatins and
pectins and a backing made from a polyurethane film or foam. The technology
has progressed since the original hydrocolloid dressings were introduced and
a second generation of products is now available which have greater
absorbency and hold exudate more effectively within the dressing. Examples
of hydrocolloid dressings include Comfeel PlusTM, Cutinova HydroTM, GranuflexTM (known as DuodermTM outside the UK) and TegasorbTM. Several come
in a wide range of sizes and shapes and variations such as a thinner than
standard dressing. No secondary dressing is necessary. Cutinova HydroTM has
a greater absorptive capacity than other hydrocolloids. CombidermTM is another
variation of hydrocolloid technology. It is composed of several layers including a thin hydrocolloid and an island pad containing polyacrylate granules
which hold the exudate within the pad. Cutinova CavityTM is suitable for cavity
wounds; it is a flat sheet which can be folded or cut into a ribbon shape. Initially it should only fill half the cavity because it swells as it absorbs exudate
and moulds to the shape of the cavity. It is suitable for moderate to heavily
exuding cavity wounds.
Hydrocolloids can be used on a wide range of wounds but generally are most
effective on the moderate to low exuding wounds.
Hydrofibres
Hydrofibre dressings are made from hydrocolloid fibres that gel in the presence
of exudate. They are highly absorbent. AquacelTM comes as a flat dressing in a
range of sizes and also a ribbon for cavity wounds. They are not suitable for
use over dry necrotic wounds.
Hydrogels
These dressings are made from insoluble polymers and have a high water
content. The amorphous gel, such as GranugelTM, Intrasite GelTM, Nu-GelTM or
SterigelTM, may be used on a wide variety of wounds. They have the ability to
either absorb exudate or hydrate dry wounds such as necrotic eschar, thus
encouraging debridement. They can be used on wounds with moderate to low
exudate and in small cavities. The gel sheets such as 2nd SkinTM or VigilonTM
are best used on granulating moderate to low exuding wounds. They all require
a secondary dressing.
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Low-adherent dressings
These types of dressing are low adherent rather than non-adherent. They have
little if any absorbent capacity and are best on wounds with little exudate. They
may be used to ‘carry’ a dressing such as an amorphous hydrogel and mostly
need to be used in combination with an absorbent pad. They do not provide
a moist wound environment. Examples of this type of dressing are MelolinTM,
N-A UltraTM, ReleaseTM, TelfaTM and TricotexTM.
Low-adherent dressings (medicated)
InadineTM is a low-adherent dressing that is impregnated with water-soluble
povidone iodine. It is suitable for moderate to low exuding infected wounds or
for prophylaxis in minor traumatic wounds. It is not suitable for patients with
iodine sensitivity or thyroid problems. Activon TulleTM is a low-adherent dressing impregnated with manuka honey.
Non-medicated and medicated tulles
Tulles are also called paraffin gauze and were originally known as tulle gras.
They are made of open weave cotton or rayon impregnated with soft paraffin.
Although the paraffin makes the dressing less adherent, it readily becomes
incorporated into granulation tissue. A pattern can be seen on the wound
surface when it is removed. It does not maintain a moist wound environment
and has no absorbent capacity. It is widely used on minor burns and traumatic
injuries. Examples are JelonetTM, ParanetTM, ParatulleTM and UnitulleTM. A
secondary dressing is required with these dressings.
Some types of tulles are impregnated with either antiseptics or antibiotics.
The commonest type of antiseptic is chlorhexidine which is present in BactigrasTM, ChlorhexitulleTM and SerotulleTM. These dressings are useful for superficial infected wounds. Two tulles are impregnated with antibiotics (Fucidin
IntertulleTM and Sofra-TulleTM). The use of these dressings is not recommended
because of the problems of sensitivity and resistance of bacteria.
Paste bandages
These are cotton bandages impregnated with medicated paste. The use of paste
bandages has largely been superseded by more modern products but they are
still used for leg ulceration, particularly when the surrounding skin is eczematous or inflamed. Whilst they are an effective form of treatment, many patients
develop allergies to the contents of the paste so it is wise to patch test the patient
before applying a bandage. There are several types of bandage with different
pastes such as zinc paste with ichthammol or zinc paste with calamine. A
secondary bandage is required.
Silicone wound dressings
Silicone products have a number of uses. Silicone gel sheets such as CicaCareTM, SilgelTM and Sil-K FilmTM help with scar management as they are able
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to soften and flatten scars. Silicone N-ATM is similar to a low-adherent dressing
as it is made from a knitted viscose material impregnated with silicone to allow
easy removal and is virtually non-adherent. MepitelTM is suitable for painful
wounds or where there is macerated or fragile skin as it is very easy to remove.
Exudate passes through the dressing to the secondary pad. The outer pad may
be changed more frequently than the Mepitel, which can be left in place for up
to ten days.
Silver and charcoal dressings
These dressings incorporate silver into their structure and some also contain
activated charcoal cloth. Silver is an effective antibacterial and charcoal has been
found to be effective in absorbing the chemicals released from malodorous
wounds. Infected, necrotic or fungating wounds may have a very unpleasant
odour. Actisorb Plus 25TM or Actisorb Plus 220TM are both in the form of a charcoal pad impregnated with silver; they are used with a primary dressing and
require a covering pad. ArglaesTM contains alginate powder and a mixture of
inorganic polymer and ionic silver. As the alginate gels, the silver is gradually
released. Aquacel AgTM acts in a similar fashion. ActicoatTM, Acticoat 7TM and
Contreet AgTM are made from polyethylene or polyurethane coated with
silver. Dressings such as CarbonetTM, ClinisorbTM or Lyofoam CTM are a combination of dressing and charcoal. Most of these dressings require a secondary
dressing.
TenderWet
TenderWetTM is a multilayer dressing with a central core of polyacrylate, which
is activated by soaking the dressing with an appropriate volume of Ringer’s
solution. The Ringer’s solution is delivered to the wound surface for up to 12
hours and helps to soften necrotic tissue. It is able to absorb exudate but should
be changed daily.
Vapour-permeable films
There is a wide range of these film dressings available. They provide a moist
healing environment but have no absorbency. They should not be used on
infected wounds. The method of application varies according to make. Most
require a certain amount of skill and practice in application. Examples include
BioclusiveTM, CutifilmTM, MefilmTM, OpraflexTM, OpsiteTM and TegadermTM.
Vapour-permeable membranes
TegaporeTM allows exudate to pass through the dressing and can be left in place
for several weeks whilst the outer dressings are changed. It is non-adherent and
will protect delicate skin.
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4.7 ADVANCED TECHNOLOGIES
As with any other aspect of healthcare, new developments in wound care are
regularly announced. Sometimes they are variations on an older form of treatment and sometimes they are new developments. This section seeks to identify
these innovations and consider the evidence to support their use.
4.7.1 Growth factors
Growth factors have been used for some time in wound care. In the USA, the
use of growth factors was primarily via the establishment of wound care centres
that provided a comprehensive programme of full assessment and planned
care. Many of the patients treated in these centres have leg or foot ulcers such
as demonstrated in a randomised controlled trial undertaken by Knighton et al.
(1990). They found a significantly higher rate of healing in those treated with
growth factor solution compared with a blinded placebo.
The use of growth factors has not had the results that were initially expected.
Spencer et al. (1996) suggested that whilst the results of clinical trials have so
far been disappointing, the interest in the use of growth factors has led to
a greater understanding of the physiological make-up of different types of
chronic wound. Falanga (2000) suggested that part of the reason for this apparent failure may be because the concept of wound bed preparation (WBP) was
imperfectly understood at the time of many of the trials and there was a failure
to prepare the wound adequately before applying the growth factor. It is interesting to note that the only growth factor product licensed in both the UK and
the USA is becaplermin (RegranexTM) (platelet-derived growth factor), specifically for diabetic foot ulcers. It has been long understood that sharp debridement of neuropathic diabetic foot ulcers is an essential aspect of good practice
(Brem et al., 2004). Ladin (2000) suggested that there is a direct correlation
between debridement prior to becaplermin application and healing rates.
It is not just the preparation of the wound that needs to be considered; the
method of delivery of a growth factor to the wound surface may also affect the
outcome (Robson et al., 1998). There is increasing interest in the idea of using
gene transfer as a delivery system. Skin gene therapy has the potential to facilitate delivery of a number of different growth factors (Guarini, 20003). Galeano
et al. (2003) have demonstrated that it is possible to deliver a virus vectormediated vascular endothelial growth factor (VEGF) gene transfer to a burn
wound, using an animal model. This model of delivery has considerable potential and, combined with WBP, may reinvigorate the use of growth factors.
However, there is still some way to go before this can become a clinical reality.
4.7.2 Protease-modulating wound management products
As discussed in Chapter 1, excessive levels of proteases such as matrix metalloproteinases (MMPs) have been shown to be a factor in delayed healing of
chronic wounds. Relatively recent additions to the range of dressings are two
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products designed to reduce the harmful effects of MMPs: PromogranTM and
DermaxTM. These products are dissimilar in their structure and do not act in the
same way. PromogranTM is made from collagen and oxidised regenerated cellulose and is able to bind MMPs, thus negating their harmful effects. DermaxTM
is made from ethylene vinyl acetate mesh fabric impregnated with oak bark
extract that downregulates MMP production, thus promoting healing. As yet,
there is limited published evidence for their use.
Veves et al. (2002) undertook a randomised study comparing PromogranTM
with standard care in the USA (moistened gauze) in 276 patients with diabetic
foot ulcers. Overall, there was no statistical difference between the two groups
at 12 weeks. However, there was borderline significance in favour of PromogranTM in a subset of patients with ulcers that had been present less than six
months. Vin et al. (2002) randomly allocated 73 patients with venous leg ulcers
to either PromogranTM or AdapticTM (a low-adherent dressing impregnated with
petrolatum emulsion) and followed their progress for 12 weeks. Although more
ulcers healed with PromogranTM than with AdapticTM, this did not achieve
significance. There was, however, a significant reduction in ulcer size in the
PromogranTM group. A cost modelling study was undertaken by Ghatnekar
et al. (2002) to determine the cost-effectiveness of PromogranTM for treating
diabetic foot ulcers, using costs from France, Germany, Switzerland and the UK.
Based on the assumption that within the first three months of treatment, 26%
of ulcers were treated with PromogranTM and 20.7% were treated with standard
practice, the authors calculated both recurring and non-recurring costs. They
estimated that there was potential for cost savings in each country, there being
considerable variation due to overall treatment costs.
To date, there is only a small pilot study showing the clinical use of DermaxTM
in the public domain. Karim et al. (2002) studied the impact of using DermaxTM
on four non-healing chronic wounds over six weeks. They found an increase in
fibroblast activity and a decline in the levels of MMP2. Further clinical trials are
in progress and the results are required before the value of this product can be
clearly determined.
4.7.3 Hyaluronan-based products
Hyaluronan is an important component of the extracellular matrix and it plays
a role in regulating the inflammatory response, stimulation of cell proliferation
and angiogenesis and also epithelialisation (Taddeucci et al., 2004). HyalofillFTM is a non-woven fleece dressing made from HYAFF, an esterified benzyl ester
of hyaluronic acid. There are as yet limited studies of its efficacy.
Boyce et al. (1997) undertook a randomised study of pilonidal sinus wounds
comparing Hyalofill-FTM placed under a foam stent with the foam stent alone.
An interim analysis was undertaken after 41 patients had been recruited that
showed a dramatic reduction in wound size in the Hyalofill-FTM group during
the first two weeks. Unfortunately, no statistical analysis was undertaken and
there have been no further reports on this study.
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Hollander et al. (2000) undertook two case studies to evaluate the use of
Hyalofill-FTM in patients with traumatic wounds with healing difficulties and
found a rapid reduction in wound size within two weeks. They called for
further randomised studies to determine the most effective use of this product.
Vazquez et al. (2003) undertook a non-comparative pilot study of 36 patients
with diabetic foot ulcers to provide data for a future randomised, controlled
trial. They achieved a 75% healing rate within the 20-week study period. The
mean healing time for this group was 10.0 ± 4.8 weeks. Unsurprisingly, they
found that superficial ulcers healed more quickly than deep ulcers.
Two studies have been reported of the use of Hyalofill-FTM in the treatment
of venous leg ulcers. Colletta et al. (2003) undertook a non-comparative pilot
study of non-healing venous ulcers, using the dressing in combination with
compression bandages. The 19 ulcers were followed for eight weeks. They
found that four ulcers healed completely with a mean healing time of 24.5 days.
The mean percentage reduction of the remaining ulcers was 53% during the
study period. The research team noticed a rapid reduction in ulcer size during
the first two weeks of treatment. Taddeucci et al. (2004) compared Hyalofill-FTM
with paraffin gauze (standard treatment in Italy) for the treatment of 24 venous
ulcers. At eight weeks, they found a significant reduction in ulcer size and rate
of epithelialisation in the experimental group. There was also a significant
reduction in maceration in this group. Overall, the research team considered
that the product had been shown to be effective in treating chronic venous
ulcers.
This product looks to be a useful tool but larger studies are needed to determine its most effective use.
4.7.4 Hyperbaric oxygen
Hyperbaric oxygen chambers have been used for many years in recompression
of divers with the bends or decompression illness. More recently, they have also
been used for non-healing wounds. Hyperbaric oxygen (HBO) treatment has
been defined as “the patient breathing in 100% oxygen intermittently at a point
higher than sea level pressure” (British Medical Association Board of Science
and Education, 1993). It is delivered by placing a patient inside a pressure
chamber, which may be designed for one or more people. The length of time
over which treatments are given varies according to the condition being treated.
There have been two systematic reviews of the use of HBO therapy for
chronic wounds. Kranke et al. (2004) undertook a Cochrane review of five randomised studies using HBO. Four of the studies were of diabetic foot ulcers (a
total of 147 patients). The authors were able to pool the results of three studies
and found a reduction in the risk of major amputation with HBO therapy compared to controls. A numbers needed to treat analysis showed that four patients
would need to be treated in order to prevent one amputation in the long term.
Kranke et al. (2004) also reviewed a study of 16 venous ulcer patients. Although
there was a significant reduction in ulcer size in the HBO group, the numbers
are very small. They conclude that overall, the reviewed studies were of poor
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quality and inadequately reported. There seems to be a benefit for diabetic foot
ulcers but there is a need for adequately powered, randomised studies that
include an economic evaluation.
Wang et al. (2003) undertook a more inclusive review that included randomised, controlled trials, cohort studies and case series of at least five patients.
They found a total of 57 studies involving more than 2000 patients. The authors
considered that HBO could potentially provide improved outcomes for
non-healing diabetic foot ulcers, compromised skin grafts, wounds damaged
by radiotherapy and gas gangrene. Wang et al. (2003) also concluded that the
quality of the studies that they reviewed was poor and that there is insufficient
evidence to provide guidance on when it would be appropriate to commence
HBO or which patients would benefit most. Kalani et al. (2002) followed 38 diabetic foot ulcer patients for three years to monitor long-term outcomes of using
HBO and found improved outcomes in the HBO group, but also expressed a
desire for more studies to be undertaken to clearly determine the role of HBO
within the wound management armamentarium.
It is obvious that there is only a limited case for the use of hyperbaric oxygen
at present. However, for most nurses the argument is academic as they are not
likely to have access to such equipment.
4.7.5 Topical negative pressure
Topical negative pressure (TNP) therapy or vacuum-assisted closure (VAC) is
a device which applies a universal negative pressure to a wound, encouraging
blood flow and faster granulation (Baxandall, 1996). It comprises a foam sponge
to fit into the wound, tubing to connect the foam to the pump via a canister to
collect exudate. The sponge is covered with a film dressing to create an airtight
seal (Fig. 4.1). Pressure can be applied continuously or intermittently.
Argenta pioneered the development of TNP therapy. He described successful outcomes in 296 of 300 cases of chronic, acute and subacute wounds
Fig. 4.1
VAC therapy in situ.
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(Argenta & Morykwas, 1997). Subsequently, there have been numerous reports
of its use, many of which have been case series or case studies. Some of the
benefits of TNP can be described as follows.
䊉
䊉
䊉
䊉
䊉
䊉
䊉
Reduction of tissue oedema. Although this is particularly difficult to
measure, Banwell (1999) suggests that this action could be very useful in the
management of crush injuries or burns.
Reduction of bacterial load. There are mixed reports of the impact of TNP
on bacterial colonisation. Morykwas et al. (1997) found a significant reduction in bacterial counts in the animal model. Banwell (1999) reported the
same outcome, whereas Moues et al. (2004) and Weed et al. (2004) found a
variable outcome with reduction of some bacteria and an increase in others.
However, both the latter studies still reported good healing rates. There are
also consistent reports of beneficial outcomes in infected wounds such as for
deep sternal wound infection following open heart surgery (Gustaffson et al.,
2003; Luckraz et al., 2003).
Management of chronic wound fluid. TNP can be a useful method of collecting and managing wound exudate. Banwell (1999) suggested that TNP
may be able to reduce the levels of MMPs within the wound.
Removal of slough and promotion of granulation tissue. TNP has been
demonstrated to be effective in removal of slough (Gustaffson et al., 2003;
Loree et al., 2004; Luckraz et al., 2003).
Promotion of wound healing. Numerous cohort or uncontrolled studies have
concluded that TNP is effective. However, a Cochrane review (Evans & Land,
2004) was only able to identify two small randomised, controlled trials of
chronic wounds with a total of 34 patients up until November 2002. These
studies showed weak evidence of efficacy but the numbers are too small for
any firm conclusions to be drawn.
Improved take in skin grafts. Blackburn et al. (1998) reported using VAC
therapy prior to skin grafting of large complex open wounds and found that
they were able to get a minimum of a 95% take.
Cost effectiveness of TNP. The unit costs of using TNP are high but a review
by Neubauer and Ujlaky (2003) investigated the treatment costs using data
derived from three studies and concluded that TNP has the potential to make
cost savings of up to $9000 per patient through a faster healing time.
However, they also emphasise the need for further prospective studies in
order for firm conclusions to be obtained.
TNP therapy is gradually being used more widely, especially as a portable
version is now available. However, it can potentially be harmful if used inappropriately and skill is needed in its application. Birchall et al. (2002) describe
how one acute trust developed a centralised system for the use of TNP, along
with guidelines to ensure appropriate use and a competency-based education
programme for nurses. The whole system was both clinically- and costeffective as well as being more efficient.
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4.7.6 Tissue culture
Tissue culture describes the process whereby a small full-thickness section
of skin is harvested from a patient or donor and then cultured in the
laboratory to form large sheets of cells (cultured keratinocytes). The sheets
of cells are then grafted onto a granulating wound completely free of any
necrotic material. Autologous tissue (that taken from the patient) has been
found to be more effective than allogenic tissue (that taken from a donor).
However, it can take more than a month to prepare (Kakibuchi et al., 1996).
Tissue culture has become well established since the early 1980s when the
first clinical reports of its use appeared. Kumagai et al. (1997) followed up
38 patients who had received autologous cultured keratinocyte grafts for over
two years. They concluded that cultured tissue has site specificity even
after grafting and therefore, where possible, the maxim “closer is best”,
which is applied to conventional skin grafting, should also be used for tissue
cultures.
Wright et al. (1998b) describe the use of a polyurethane foam dressing as a
carrier for cultured keratinocytes. They found it to be a useful vehicle but there
was slow proliferation of cells. They suggest that cells should be expanded
using the standard methods and then seeded onto the dressing. Myers et al.
(1997) tested a hyaluronic membrane delivery system for cultured keratinocytes
on an animal model and found that it gave a superior keratinocyte take. The
researchers suggest that this system requires further investigation and clinical
evaluation. Caravaggi et al. (2003) used a similar product in the treatment of
diabetic foot ulcers, comparing it with paraffin gauze (standard treatment in
Italy). The results from 79 patients showed greater numbers of healed ulcers in
the experimental group but this difference failed to reach statistical significance,
possibly because the study was underpowered. The ulcers were subdivided
into those on the plantar surface or dorsum. There were a significantly higher
number of healed ulcers in the experimental group on the dorsum of the foot
but the precise significance of this is uncertain.
Generally, cultured keratinocytes have been used by plastic surgeons particularly for treating burn patients. However, they have also been used for treating
leg ulcers that have not responded to other forms of treatment. In reviewing
this, Kakibuchi et al. (1996) consider that it has not been an unqualified success
as grafts have only shown a 10–20% take. Tissue culture is an important therapy
for burn patients and it may have potential for a wider use, but needs some
further development.
4.7.7 Tissue engineering
Tissue engineering takes tissue culture a step forward. It uses human dermal
fibroblasts and cultures them on a biosynthetic scaffold. The fibroblasts proliferate and secrete proteins and growth factors, resulting in the generation of a
three-dimensional human dermis that can then be used to graft over wound
sites. Two brands are currently available, ApligrafTM (also known as Graftskin)
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and DermagraftTM, and they can be described as cultured human skin equivalent (HSE).
Falanga et al. (1998) studied the effect of using a HSE (ApligrafTM) on patients
with venous ulcers in a multicentre trial. A total of 240 patients were randomised to HSE and compression or compression therapy alone. They found
a significantly faster healing rate in the HSE group. In those patients (n = 120)
whose ulcer had been open for more than a year, HSE was significantly more
effective in achieving healing. Falanga and Sabolinski (1999) investigated the
results from this last group of patients in more detail. They found that 47% of
those treated with HSE were healed by six months compared with 19% of controls. They suggest that HSE is particularly useful in the treatment of ulcers of
long duration. Omar et al. (2004) undertook a pilot study using DermagraftTM
for venous ulcers. Eighteen patients were randomised to either the HSE and
compression or compression alone and followed up for 12 weeks. Five patients
in the HSE group and one of the controls were healed at 12 weeks, but this did
not achieve significance. However, there was a significant reduction in ulcer
size and in the linear rate of healing in the HSE group.
Brem et al. (2001) discussed the success of two centres in the use of HSE
(ApligrafTM) for 33 patients with 54 venous ulcers that had been present for
more than a year. They considered that their results were better than those
reported in an earlier trial (Falanga et al., 1998; Falanga & Sabolinski, 1999) as
they were able to achieve healing rates of 70% in six months. The authors
suggest that this was due to improved wound bed preparation, particularly in
the use of antiseptics to reduce wound exudate prior to commencement of HSE
therapy. They also meshed the HSE prior to application to allow excessive
exudate to escape. Schonfeld et al. (2001) undertook an economic analysis of the
use of HSE (ApligrafTM) in hard-to-heal venous ulcers using a semi-Markov
model. They calculated that as ulcers would heal faster using HSE compared
with compression alone, the overall treatment costs were lower ($20 141
compared with $27 493 over a 12-month period).
HSE has also been used to treat diabetic foot ulcers. Gentkow et al. (1996)
carried out a randomised, controlled, single-blinded trial of 50 patients with
diabetic foot ulcers. Patients were allocated to four groups: three different
dosages of HSE (DermagraftTM) or a control group. They found that all three of
the treatment regimens were significantly better than the control. Furthermore,
after 14 months’ follow-up there were no recurrences in the HSE patients. The
authors considered this fact to be significant, quoting recurrence rates from
other studies of 19.6–46% in times less than 12 months. Hanft and Surprenant
(2002) compared HSE (DermagraftTM) with moistened gauze in 28 patients with
diabetic foot ulcers. They found that there was a significant difference in the
healing rate in the HSE group by week 12 and in the overall rate of healing.
A larger multicentre randomised study of 245 diabetic foot ulcers compared
DermagraftTM with conventional therapy (Marston et al., 2003). A significantly
higher number of patients in the HSE group were healed by 12 weeks. This
group also experienced significantly fewer ulcer-related adverse events. Veves
et al. (2001) reported a multicentre study of 208 neuropathic diabetic foot ulcers
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comparing HSE (ApligrafTM) with moistened gauze. All patients had surgical
debridement prior to treatment and adequate foot off-loading. There were significantly more ulcers healed in the HSE group at 12 weeks and the median
time to healing was 65 days compared with 90 days for the controls (p = 0.0026).
Newton et al. (2002) studied the microvascular blood flow in seven fullthickness diabetic foot ulcers before and after application of DermagraftTM.
They found that by eight weeks, there was a 72% increase of blood flow in five
of the seven ulcers and that they were healed by 12 weeks. The other two ulcers
reduced in size by 25%.
Allenet et al. (2000) used a Markov model to undertake an economic evaluation of the costs of using HSE (DermagraftTM) compared with standard treatment for diabetic foot ulcers over a 52-week period. The overall treatment costs
were lower for the HSE because of a faster healing rate (53 522FF compared with
56 687FF). Redekop et al. (2003) undertook a similar exercise comparing
ApligrafTM with general wound care for diabetic foot ulcers. They found that
there was a 12% reduction in costs using HSE.
It would seem that the use of HSE has considerable potential in the treatment
of wounds that have failed to heal with other methods. Although the economic
evaluations described above indicate that cost savings can be made using HSE,
it should be remembered that this is only the case in those wounds that are not
healing. Other methods should be used first, before considering HSE.
4.8 ALTERNATIVE THERAPIES AND WOUND MANAGEMENT
Alternative or complementary therapies have been defined as those therapies
that usually lie outside the official health sector (WHO, 1983). Trevelyn and
Booth (1994) divided them into three categories in relation to their potential
links to nursing (see Box 4.1). Although there is much written in the literature
Box 4.1 Categories of alternative therapies related to nursing.
Category 1: can be incorporated into nursing care
•
•
•
•
Massage
Reflexology
Aromatherapy
Therapeutic touch
Category 2: can be used to some extent by nurses with relevant training
• Homeopathy
• Herbal medicine
Category 3: not usually practised as part of nursing care
• Acupuncture
• Osteopathy
• Chiropractic
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regarding these therapies, there is a paucity of research evidence to demonstrate
their place in patient care. Gates (1994) and Vickers (1997) have discussed this
problem and suggested the need for a critical appraisal of the literature on the
subject.
One such review has been undertaken by Finch (1997), who appraised the
therapy of therapeutic touch, healing by laying on of hands, in relation to
wound healing. Its use in nursing was introduced in the USA in the 1970s. It is
based on the principle that human beings are energy fields and illness is the
result of an imbalance in the energy field. Therapeutic touch focuses on redirecting the energy to restore balance. Finch reviewed five studies of therapeutic touch and wound healing carried out on healthy volunteers by the same
researcher. She concluded that therapeutic touch was unreliable and generally
ineffective when used to treat wounds. A Cochrane review by O’Mathuna and
Ashford (2004) considered the use of therapeutic touch in healing acute
wounds. They concluded that there was insufficient evidence to show whether
it had a role in healing acute wounds. However, it has been shown to be
beneficial in treating anxiety (see Chapter 2).
Aromatherapy involves the use of essential oils that are applied to the skin.
A variety of oils can be used, depending on the effect required. Unfortunately,
there are a number of inconsistencies found in the literature with a variety of
contradictory properties being given to the same oil (Vickers, 1997). A study by
Kite et al. (1998) suggests that aromatherapy is effective in reducing anxiety and
stress. They assessed 58 cancer patients using a HAD score before and after six
sessions of aromatherapy and found a significant reduction in anxiety and
depression at the end of the course of treatment. Asquith (1999) undertook a
review of the literature and reported a number of case studies that found lavender and tea tree oils beneficial in healing a variety of wounds. Asquith also identified studies that improved other aspects of patient care such as sleep patterns.
She concluded that there was little evidence to show a direct benefit to wound
healing.
There is no doubt that some patients find alternative therapies helpful.
Whether these types of therapies have a role in wound healing remains questionable. There is a real need for the development of high-quality research
methodologies to explore the multifaceted nature of these treatments.
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The Management of Patients with Chronic Wounds 121
Chapter 5
The Management of Patients with Chronic Wounds
5.1 INTRODUCTION
Fowler (1990) defined a chronic wound as one where there is tissue deficit as
the result of long-standing injury or insult or frequent recurrence. Despite
medical or nursing care, they do not heal easily. They are more likely to occur
in the elderly or those with multisystem problems. This section will consider
the care of patients with pressure ulcers, leg ulcers, diabetic foot ulcers and fungating wounds.
Chronic wounds cause much discomfort and pain for the many people who
have to suffer them. A multidisciplinary approach is needed for their management and prevention. Nurses can play an important role in the team as they
usually have the most contact with the patient. An essential part of this role is
communication and co-operation across the disciplines. Healing is not possible
for all chronic wounds and in those cases, the goal is to assist the patient to
achieve the maximum independence and function possible.
It cannot be denied that the treatment of chronic wounds is costly. Harding
(1998) suggests that chronic wounds cost the National Health Service (NHS)
about £1 bn a year. The Department of Health calculates the costs for inpatient
treatments by category. Although there is no specific category for chronic
wounds, they fit within the category of ‘skin ulcers’. The costs for skin ulcers
for the year 2000 were nearly £4.5 million and the average length of stay was
21 days. In comparison, inpatient treatment for diabetes was just under £2.5
million. These figures are very limited as they only include costs for inpatients
with skin ulcer as a primary diagnosis and they do not include community
costs, which can be considerable as many of these patients are primarily cared
for in the community.
5.2 THE PREVENTION AND MANAGEMENT OF
PRESSURE ULCERS
Pressure ulcers are also called pressure sores, bed sores and decubitus ulcers.
A pressure ulcer can be described as localised damage to the skin caused by
disruption of the blood supply to the area, usually as a result of pressure, shear
or friction or a combination of any of these. There has not been a national survey
of pressure ulcer prevalence in the UK but a series of surveys by O’Dea (1999)
of hospital patients in 35 acute care hospitals, carried out between 1992 and
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1998, provides some information. O’Dea found a gradual decline in pressure
ulcer prevalence rates from 18.6% in 1992 to 10% in 1997–1998. The fifth national
survey in the USA was undertaken in 356 acute care hospitals in 1999 (Amlung
et al., 2001). The researchers found a pressure ulcer prevalence of 14.8%, an
increase on previous surveys. They also found a nosocomial rate of 7.1%.
Kaltenthaler et al. (2001) compared prevalence and incidence data of surveys
undertaken in the UK, USA and Canada and found large variations in methods,
patient groups and prevalence, making comparisons difficult. They noted one
unexpected finding – none of the studies undertaken during the period
1976–1997 had a prevalence rate below 5%. They suggested that there may be
a point beyond which it is difficult to reduce prevalence rates further.
Prevalence surveys have been undertaken in a number of other countries, with
variable results. Bours et al. (2002) report on a national survey in the Netherlands
that showed a prevalence rate of 23.1% whereas a national survey in Iceland
found a prevalence rate of 8.9% (Thoroddsen, 1999). A survey across 18 rural hospitals in Australia identified a rate of 6% (Pearson et al., 2000) and in Sweden a
similar survey identified 3.75% of patients with pressure ulcers (Lingren et al.,
2000). It is difficult to draw conclusions from this wide range of prevalence rates,
mostly because of the variation in methods. However, the fact that they have
been carried out at all demonstrates the increasing interest in the topic.
For many years pressure ulcers were seen as a failure of care, in particular as
the result of bad nursing. Florence Nightingale (1861) considered that good
nursing could prevent them whereas a very influential French doctor called
Jean-Martin Charcot (1825–1893) believed that doctors could do nothing about
pressure ulcers. As a result, pressure ulcers became a very emotive issue and
were only discussed by doctors as ‘a nursing problem’ and by nurses with comments like ‘we do not have pressure ulcers here’.
This attitude is changing. A document published by the Department of
Health stated that pressure ulcers should be considered a key indicator of the
quality of care provided by a hospital (DoH, 1993). There is a much greater
awareness that all healthcare professionals need to be involved in pressure ulcer
prevention (Culley, 1998). A number of multidisciplinary societies have been
formed, such as the Tissue Viability Society and the European Pressure Ulcer
Advisory Panel, with the intent of expanding knowledge and supporting good
practice and there are now NICE guidelines available. As all topics for guideline development have to be agreed by the Secretary of State for Health, this
indicates the level of interest in the Department of Health.
5.2.1 The cost of pressure ulcers
A recent cost-model for pressure ulcers undertaken in the Netherlands calculated that the cost of treatment ranged from $362 m to $2.8 bn and potentially
used 1% of the total Dutch healthcare budget (Severens et al., 2002). Bennett et
al. (2004) also used a cost-model to calculate the cost of treating pressure ulcers
in the UK. They found the costs to be even greater than those in the Netherlands, as they ranged from £1.4 bn to £2.1 bn annually, which represented about
4% of NHS expenditure. It is less easy to measure the cost to either the indi-
The Management of Patients with Chronic Wounds 123
vidual or the state in terms of loss of earnings and state support and no figures
are currently available to determine the overall cost.
Other studies have addressed the measurement of costs in other ways.
Allman et al. (1999) measured hospital costs and length of stay in patients developing pressure ulcers in a university teaching hospital. After adjusting the costs
for admission characteristics and hospital complications, they found that the
mean cost of patients who developed pressure ulcers was $1877 greater than
those who did not and their length of stay was 4.0 days longer. Lapsley and
Vogels (1996) looked at the cost of pressure ulcers in patients who had undergone surgery either for hip replacement or coronary artery bypass graft. They
found a significantly longer stay for those patients who developed pressure
ulcers compared with those who did not. Stordeur et al. (1998) also studied
patients undergoing cardiovascular surgery. They found that total length of stay
was longer by a mean of six days for those who developed pressure ulcers.
A classic study by Hibbs (1988) calculated that the cost of treating one patient
with a deep sacral pressure ulcer was £25 905.58. This patient was in hospital
for 180 days. A further calculation looked at the opportunity costs, which
describe what has been foregone because of specific circumstances. For
example, because of the extended stay in hospital of this patient, the opportunity to carry out 16 routine hip or knee replacements was lost. Similar calculations can also be made looking at standard days and standard costs. A critique
of this work was undertaken by two economists, nine years later (Brookes &
Thompson, 1997). They support Hibbs’ approach and regret that there have
been few economic appraisals in relation to pressure sore prevention.
Another cost that has to be taken into consideration is that of litigation. Tingle
(1997) described a number of legal cases where the patient or their families were
awarded damages ranging from £3500 to £12 500. More recently, McKeeney
(2002) described two cases in which the settlements were £32 000 and £14 000.
In all of these cases there is a chronicle of incompetence and negligent care. In
some instances the pressure ulcer directly contributed to the patient’s death.
Allied to this, there is often inadequate assessment and poor documentation.
Compliance with clinical guidelines could, potentially, reduce the level of litigation, as discussed by Goebel and Goebel (1999) in an analysis of the situation
in the USA. However, not all patients wish to comply with a guideline-derived
treatment plan (McKeeney, 2002). Patients have a right to refuse treatment if
they wish but it is incumbent upon the nurse to clearly explain the possible
risks and record the matter in detail.
5.2.2 The aetiology of pressure ulcers
Pressure ulcers are caused by a combination of external factors and factors
within the patient.
Extrinsic factors
There are three extrinsic factors that can cause pressure ulcers either on their
own or in any combination of the three. They are pressure, shear and friction.
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Pressure is the most important factor in pressure ulcer development. When
the soft tissue of the body is compressed between a bony prominence and a
hard surface, causing pressures greater than capillary pressure, localised
ischaemia occurs. The normal body response to such pressure is to shift position so the pressure is redistributed. When pressure is relieved a red area
appears over the bony prominence. This is called reactive hyperaemia and is
the result of a temporarily increased blood supply to the area, removing waste
products and bringing oxygen and nutrients. It is a normal physiological
response.
Capillary pressure is generally described as being approximately 32 mmHg,
based on the research of Landis (1931). His research was carried out on young,
healthy students. He found the average arteriolar pressure was 32 mmHg but
the average pressure in the venules was 12 mmHg. There is also a certain amount
of tissue tension that resists deformation. It is not uncommon for interface
pressures of around 30–40 mmHg to be seen as ‘safe’ but this is not always
correct. Ageing causes a reduction in the numbers of elastic fibres in the tissues,
resulting in reduced tissue tension. In situations where the blood pressure is artificially lowered, such as during some types of surgery, capillary pressure is also
likely to be lower. In these circumstances, very little pressure is required to cause
capillary occlusion. Ek et al. (1987) found that a pressure of only 11 mmHg was
necessary to cause capillary occlusion in some hemiplegic patients.
If unrelieved pressure persists for a long period of time, tissue necrosis will
follow. Prolonged pressure causes distortion of the soft tissues and results in
destruction of tissue close to the bone. A cone-shaped ulcer is created, with the
widest part of the cone close to the bone and the narrowest on the body surface.
Thus, the visible ulcer fails to reveal the true extent of tissue damage. The bony
prominences that are most vulnerable to pressure ulcer development are sometimes referred to as the pressure areas. They include the sacrum, ischial
tuberosities, trochanters, heels and elbows (see Fig. 5.1).
Some authors have discussed the possibility that pressure damage actually
results from repeated ischaemia-reperfusion injury (Houwing et al., 2000;
Mustoe, 2004). In simple terms, this suggests that the precipitating factor in
pressure ulcer development is repeated periods of ischaemia followed by
repeated periods of reperfusion that trigger a series of cellular events. These
events result in a lack of tissue perfusion (no-reflow phenomenon) that occurs
in reperfusion injury. Mustoe (2004) suggests that the elderly (or their aged
cells) are less able to cope with this situation than those younger, so that
repeated ischaemia-reperfusion injury results in a cycle of inflammation and
protease and oxidant injury leading to tissue necrosis. Two research groups
have been able to demonstrate this cycle of events using an animal model
(Houwing et al., 2000; Peirce et al., 2000).
Gebhardt (1995) argues that pressure is rarely applied uniformly and that the
subsequent distortion leads to shearing. Shear forces can deform and disrupt
tissue and so damage the blood vessels. Shearing may occur if the patient slides
down the bed. The skeleton and tissues nearest to it move but the skin on the
buttocks remains still. One of the main culprits of shearing is the backrest of
The Management of Patients with Chronic Wounds 125
Fig. 5.1
The bony prominences.
the bed which encourages sliding. Chairs that fail to maintain a good posture
may also cause shearing. Friction occurs when two surfaces rub together. The
commonest cause is when the patient is dragged rather than lifted across the
bed which causes the top layers of epithelial cells to be scraped off. Moisture,
which exacerbates the effect of friction, may be found on a patient’s skin as a
result of excessive sweating or urinary incontinence.
Intrinsic factors
The human body is frequently subjected to some or all of the extrinsic factors
but does not automatically develop pressure ulcers. The determining factor(s)
come from within the patient.
General health is important as the body can withstand greater external pressure in health than when sick. Bliss (1990) suggested that the acutely ill are particularly vulnerable. Although the reasons for this are not certain, Bliss listed
some precipitating factors including pain, low blood pressure, heart failure, the
use of sedatives, vasomotor failure, peripheral vasoconstriction due to shock
and others. Margolis et al. (2003) studied 75 168 older adults on the UK General
Practitioner Research Database and identified those with pressure ulcers
(1.61%). They found a number of medical conditions that were significantly
associated with pressure ulcers: Alzheimer’s disease, congestive heart failure,
chronic obstructive pulmonary disease, cerebral vascular accident, diabetes
mellitus, deep venous thrombosis, hip fracture, hip surgery, limb paralysis,
lower limb oedema, malignancy, malnutrition, osteoporosis, Parkinson’s
disease, rheumatoid arthritis and urinary tract infections. It is interesting to note
that many of these conditions are also on the list put forward by Bliss (1990),
based on her extensive clinical experience.
Age is a major factor in the development of pressure ulcers, as shown by early
studies such as those of David et al. (1983), Nyquist and Hawthorn (1987) and
also Thoroddsen (1999). Bergstrom et al. (1996) studied a sample of 843 patients
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The Care of Wounds
in a variety of care settings over a period of four weeks for the incidence of
pressure ulcers. They found that those who developed pressure ulcers were significantly older than those who did not.
As people age, their skin becomes thinner and less elastic. In part, this is
because the collagen in the dermis reduces in quantity and quality. Collagen
provides a buffer that helps to prevent disruption of the microcirculation
(Krouskop, 1983). There may be wasting of the overall body mass, resulting in
loose folds of skin. There is also an increased likelihood of chronic illness or
disease developing, many of which may also predispose to pressure ulcer
development. Once an ulcer occurs it is much harder to heal in an older person
than a young one (see Chapter 2).
Reduced mobility can affect the ability to relieve pressure effectively, if at all.
It also predisposes to shearing and friction if the patient is confined to bed or
chair. General prevalence surveys, such as those of David et al. (1983), Nyquist
and Hawthorn (1987) and Bergstrom et al. (1996), found reduced mobility to be
a factor for many patients with pressure ulcers. In their study of 109 long-term
care facilities, Horn et al. (2002) also found reduced mobility to be a significant
factor for those who developed pressure ulcers. In a similar study of 2015
patients in long-term care facilities, Baumgarten et al. (2003a) also found immobility to be a factor. A classic study by Versluysen (1986) studied 100 patients
over the age of 60 years with a fractured femur and found an incidence of 66%.
Much attention has subsequently been paid to the management of this group
of patients and a study by Baumgarten et al. (2003b) of elderly patients with hip
facture has a pressure ulcer incidence rate of 8.8%.
Exton-Smith and Sherwin (1961) studied the number of movements made by
50 elderly patients during the night. A strong relationship was found between
those with reduced movement and the development of pressure ulcers.
Reduced movement during sleep may be associated with a variety of drugs
such as hypnotics, anxiolytics, antidepressants, opioid analgesics and antihistamines. Berlowitz and Wilking (1989) studied a variety of factors in patients
with pressure ulcers and patients developing pressure ulcers and found that
reduced mobility was significantly associated with pressure ulcers in both
groups. Brandeis et al. (1994) also found reduced mobility to be a significant
factor in a study involving nursing home patients.
Another aspect of reduced mobility is that of the patient undergoing major
surgery. Operations may last many hours whilst the patient lies immobile on
the operating table. Mobility may be reduced in the immediate postoperative
period because of the effects of the anaesthetic, pain, analgesia, infusions or
drains. Today very sophisticated surgery is carried out, often on the older
patient. The risks of pressure ulcer development associated with such surgery
are consequently increased. Schoonhoven et al. (2002a) observed 208 patients
undergoing surgery lasting at least four hours and found that 44 (21.2%) developed pressure ulcers within two days of surgery. The research team also identified possible risk indicators in these surgical patients and found that the only
predictor of pressure ulcer development was length of surgery (Schoonhoven
et al., 2002b). This outcome replicates the finding of Aronovitch (1999) who
The Management of Patients with Chronic Wounds 127
found that the incidence of pressure damage increased with the length of
surgery.
Neurological deficit may be associated with reduced mobility, such as in a
patient with paraplegia, but this is not always so. The diabetic may suffer from
neuropathy without loss of mobility. Neurological deficit may be associated
with strokes, multiple sclerosis, diabetes and spinal cord injury or degeneration. Loss of sensation means the patient is unaware of the need to relieve pressure, even if he is able to do so. Dealey (1991a) found that neurological deficit
was a common factor in those patients with pressure ulcers in a survey of a
teaching hospital. Kabagambe et al. (1994) compared ten patients with spinal
cord injury with 11 healthy subjects. They found an impaired reactive hyperaemia response in those with spinal cord injury.
Reduced nutritional status impairs the elasticity of the skin. In the long term,
it will lead to anaemia and a reduction of oxygen to the tissues. Poor nutrition
has long been considered to be a factor in pressure ulcer development although
research results are inconsistent (Langer et al., 2003; Mathus-Vliegen, 2001).
Some studies, such as those of Berlowitz and Wilking (1989), Brandeis et al.
(1994) and Williams et al. (2000), found impaired nutritional intake to be a factor
in pressure ulcer development. Guenter et al. (2000) found that newly hospitalised patients with grade 3 or 4 pressure ulcers had malnutrition. The factors
that may lead to malnutrition are discussed in Chapter 2.
Body weight should also be considered. Very emaciated patients have no
‘padding’ over bony prominences and so have less protection against pressure.
On the other hand, very obese patients are difficult to move. Unless great care
is taken, they may be dragged rather than lifted in the bed. Another problem
of the obese patient is that moisture from sweating may become trapped
between the rolls of fat, causing maceration. Both of these types of patient may
also have a poor nutritional status.
Incontinence of urine can contribute to maceration of the skin and thus
increase the risk of friction. Constant washing because of either urinary or faecal
incontinence removes natural body oils, drying the skin. Urinary incontinence
may be caused by the use of diuretics or sedatives. Diarrhoea may cause incontinence in the elderly or immobile patient and is a side effect of some antibiotics. There is no clear evidence as to whether incontinence is a risk factor for
pressure ulcer development or not. Baumgarten et al. (2003a) found faecal
incontinence to be a risk factor whereas Reed et al. (2003) did not. Other studies
have found both urinary and faecal incontinence to be risk factors (Ferrell et al.,
2000; Schue & Langemo, 1999).
Poor blood supply to the periphery lowers the local capillary pressure and
causes malnutrition in the tissues. It may be caused by disease, such as heart
disease, peripheral vascular disease or diabetes. Bergstrom et al. (1996) found
cardiovascular disease to be a significant predictor of pressure ulcer development. Drugs, such as beta-blockers and inotropic sympathomimetics, may
cause peripheral vasoconstriction. These drugs may be used following cardiac
surgery when the patient is already suffering from reduced mobility. Blood flow
may also be affected during surgery. Sanada et al. (1997) measured blood flow
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The Care of Wounds
during surgery in the skin over the iliac crest and sacrum. They found a 500%
increase in flow in those patients who did not develop pressure sores but a drop
in flow in those who later developed pressure sores. Spittle et al. (2001) measured the incidence of pressure ulcers in patients who had undergone lower
limb amputations for either ischaemia or neuroischaemia and found an incidence rate of 55% in those who had had major amputations and 20% in minor
amputees. They suggest that the presence of peripheral vascular disease may
have been a risk factor for these patients.
External factors
Dealey (1997) cited a number of external factors that can exacerbate the factors
discussed above. They include:
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inappropriate positioning, which may increase pressure or shear.
restrictions to movement, such as lying for long periods on a trolley.
lying for long periods in one position on hard surfaces, such as the X-ray
table.
poor lifting and handling techniques which increase the risk of friction and
shear.
poor hygiene that leaves the skin surface moist from urine, faeces or sweat.
drugs such as sedatives that make the patient drowsy and less likely to move.
5.2.3 Prevention of pressure ulcers
Whilst it is a truism, as far as pressure ulcers are concerned, prevention is better
than cure. Waterlow (1988) suggested that 95% of all pressure ulcers could be
prevented. Although this concept was based on opinion, it has been supported
by a study undertaken in Japan (Haglsawa & Barbenel, 1999) that observed the
outcome of providing preventive care for at-risk patients admitted to an internal medicine ward. The researchers found an incidence rate of 4.4% in the 240
patients they studied. They suggest that this may approach the lowest rate
achievable in very ill patients.
In response to the development of evidence-based guidelines, most hospital
and primary care trusts use them as a framework from which a local policy
may be developed. The most recent pressure ulcer prevention guidelines are
those published by the National Institute for Clinical Excellence (NICE, 2003).
The guidelines can be divided into sections on risk assessment, pressure ulcer
prevention, education and training and they will be used to provide a framework for this next section. They are also summarised in a useful poster that can
be downloaded from www.nice.org.uk.
Identify individuals vulnerable to or at elevated risk of pressure ulcers
Too often, risk assessment is just seen as using a risk calculator to determine
the patient’s score and then following a ‘recipe’ of care. The first part of the
assessment guidance is listed in Box 5.1 and describes some of the issues about
The Management of Patients with Chronic Wounds 129
Box 5.1 NICE Clinical Guideline 7: pressure ulcer prevention. Assessment of patients to
determine risk of pressure ulcer development.*
• Assessing an individual’s risk of developing pressure ulcers should involve both informal
and formal assessment procedures.
• Risk assessment should be carried out by personnel who have undergone appropriate training to recognise the risk factors that contribute to the development of pressure ulcers and
know how to initiate and maintain correct and suitable preventive measures.
• The timing of risk assessment should be based on each individual case. However, it should
take place within six hours of the start of admission to the episode of care.
• If an individual is not considered to be vulnerable to or at elevated risk of pressure ulcers
on initial assessment, reassessment should occur if there is a change in an individual’s condition that increases risk.
• All formal assessments of risk should be documented/recorded and made accessible to all
members of the interdisciplinary team.
*(reproduced from the NICE Clinical Guideline 7: pressure ulcer prevention (2003), with
permission)
the type, timing and documentation relating to assessment. Assessment should
include identifying risk factors such as: reduced mobility, sensory impairment,
acute illness, level of consciousness, extremes of age, vascular disease, severe
chronic or terminal illness, previous history of pressure damage, malnutrition
and dehydration (NICE, 2003). The guidelines also state that risk assessment
tools or risk calculators should only be used as an aide mémoire and should not
replace clinical judgement.
There are a number of risk calculators available. The earliest that was developed was the Norton Score (Norton et al., 1975). Probably the most widely used
within UK hospitals is the Waterlow Score (Waterlow, 1985) which considers a
wider range of variables than the Norton. The scoring is also reversed so that
the higher the score, the higher the risk. It has the advantage of dividing the
degree of risk into categories: at risk, high risk and very high risk. These can
be useful when considering the use of appropriate support systems. Waterlow
included suggestions for preventive measures on the reverse of the card. The
Braden Scale (Bergstrom et al., 1985) is widely used in the USA and elsewhere.
It has been demonstrated to have greater sensitivity and specificity than other
scales but only if used by registered nurses (Bergstrom et al., 1987).
Risk calculators have been judged according to their sensitivity and specificity. Sensitivity relates to the percentage of patients predicted to develop pressure ulcers, who have gone on to develop them. Specificity is defined as the
percentage of patients deemed not to be at risk who do not develop pressure
ulcers (Anthony, 1996). Bridel (1993) found that the Waterlow Score had a high
sensitivity but a lower specificity whereas the reverse was true for the Braden
Scale. However, the effect of nursing care may be responsible, rather than
failure of the calculator. Deeks (1996) suggests that where sensitivity and specificity appear to be poor, it is often in settings where effective prevention
methods are being used.
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The Care of Wounds
Schoonhoven et al. (2002b) compared the Norton, Braden and Waterlow
scores for 1229 patients admitted to one of two acute hospitals and found that
none of them was able to satisfactorily predict all patients who developed pressure ulcers. They suggest that this is because the components of the calculators
are based on clinical observation rather than prognostic research. Papanikolaou
et al. (2002) undertook secondary analysis of data collected for a prospective
study of 213 inpatients and determined that a modified version of the Waterlow Score was more accurate than the original but only in the case of the specific patient group on whom it was tested. The researchers suggest that larger
studies of high-quality data are necessary in order to finally determine more
accurately the most relevant factors to include in a risk calculator.
Despite the criticisms that can be made of the risk calculators, there is benefit
in using a systematic method of assessing and identifying patients at risk of
pressure ulcer development. Flanagan (1997) stresses the importance of regular
assessment of patients rather than just doing one initial assessment. It should
also be noted that once a patient is identified as being at risk, appropriate preventive action must follow. Failure to do so would be a failure in the duty of
care that all nurses have to their patients.
Skin inspection
There is a natural resilience in skin that enables the healthy individual to overcome many of the problems of friction or shear met in everyday life. It makes
sense to utilise these properties and to enhance them where possible. Skin
assessment should be undertaken daily for the at-risk patient. The NICE guidelines on skin inspection can be seen in Box 5.2. Where possible, the patient
and/or carer should be involved in this process. Any alterations in skin status
should be recorded immediately. Unqualified staff should be alerted to the need
to inform a qualified nurse as a change in the plan of care may be required.
Skin assessment is important in two ways. It provides baseline data of the
initial skin status at the beginning of a care episode and it provides ongoing
information of the effectiveness of the prevention plan. Skin inspection should
encompass the following.
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䊉
䊉
Assessment of the bony prominences, remembering that emaciated patients
may develop sores in uncommon areas, e.g. ribs.
Skin status should be identified – areas of dryness, fragility, erythema or
maceration are all vulnerable to tissue damage.
Skin colour – dark skin is more difficult to assess for early signs of tissue
damage; watch for dryness, cracking or induration.
Pressure ulcer prevention
Positioning
Relief of pressure is the main strategy used in the prevention of pressure
ulcers. The commonest method is that of repositioning the patient. Clark (1998)
undertook a systematic review of the literature to determine the evidence
The Management of Patients with Chronic Wounds 131
Box 5.2 NICE Clinical Guideline 7: pressure ulcer prevention. Skin inspection.*
• Skin inspection should occur regularly and the frequency determined in response to
changes in the individual’s condition in relation to either deterioration or recovery.
• Skin inspection should be based on an assessment of the most vulnerable areas of risk for
each patient. These are typically: heels; sacrum; ischial tuberosities; parts of the body
affected by antiembolic stockings; femoral trochanters; parts of the body where pressure,
friction or shear is exerted in the course of an individual’s daily living activities; parts of
the body where there are external forces exerted by equipment and/or clothing; elbows;
temporal region of the skull; shoulders; back of head and toes. Other areas should be
inspected as necessitated by the patient’s condition.
• Individuals who are willing and able should be encouraged, following education, to inspect
their own skin.
• Individuals who are wheelchair users should use a mirror to inspect the areas that they
cannot see easily or get others to inspect them.
• Healthcare professionals should be aware of the following signs, which may indicate incipient pressure ulcer development: persistent erythema; non-blanching hyperaemia previously identified as non-blanching erythema; blisters; discolouration; localised heat; localised
oedema; and localised induration. In those with darkly pigmented skin: purplish/bluish
localised areas of skin; localised heat that, if tissue becomes damaged, is replaced by coolness; localised oedema; and localised induration.
• Skin changes should be documented/recorded immediately.
*(reproduced from the NICE Clinical Guideline 7: pressure ulcer prevention (2003), with
permission)
demonstrating the effectiveness of repositioning as preventive strategy. He concluded that not only was there little evidence to determine the appropriate frequency of repositioning, there was little evidence to show its effectiveness in
preventing pressure ulcers, despite it being an internationally used nursing
strategy. More recently, Defloor et al. (2005) undertook a study to measure the
effectiveness of a range of turning regimes on two types of mattress. They were:
turning every two hours or every four hours on a standard hospital mattress,
and turning every four hours or every six hours on a viscoelastic polyurethane
foam mattress. They found a significantly lower incidence of pressure ulcers in
the group that received the pressure-reducing mattress and four-hourly turning
compared with two-hourly turning on a standard mattress.
An alternative to traditional side-to-side turning of patients is the 30° tilt. This
method of positioning patients was developed in a younger disabled unit
(Preston, 1988). The position is achieved by placing pillows in such a manner
that the patient is tilted as shown in Figure 5.2. Once in position, there is no
pressure on the sacrum or heels. The interface pressure on the buttock is around
25 mmHg. Colin et al. (1996a) compared the effect of the 90° lateral position with
the 30° tilt and found significant hypoxaemia over the trochanter in the former
position but none in the latter.
In the 30° tilt, patients can be left for increasingly longer periods without
turning, although careful observation must be made of all vulnerable areas.
Once patients have become accustomed to using the 30° tilt, they may be left
The 30° tilt is a useful method for
positioning patients who are difficult to
turn or are not able to lie on their side.
Patients may be safely left for long periods
in this position but the pressure areas
should be carefully monitored to establish
an appropriate time for each patient.
1
Place the patient in the centre of the
bed with sufficient pillows to support
the head and neck.
2
3
Fig. 5.2
Place a pillow at an angle under one
buttock; thus tilting the pelvis by 30°.
Check with a flattened hand that the
sacrum is just clear of the mattress.
The patient may be turned by removing the
pillow under the buttock and placing it under
the other buttock.
Place a pillow lengthways under
each leg so that the heels are
lifted clear of the bed.
The 30° tilt position.
This can be done by two nurses rolling the
patient slightly. No lifting is necessary.
The Management of Patients with Chronic Wounds 133
for up to eight hours without turning. Not only does this allow a patient to
have an undisturbed night’s sleep but also it is of great benefit for use in the
community. This method of positioning is not suitable for all patients, as shown
by Young (2004) who randomised 46 elderly acutely ill patients to either 30° or
90° lying. She found that many of the patients were unable to maintain the 30°
position and questioned the value of the widespread advice to use it. It seems
reasonable to conclude that further evidence is needed to determine when it
may best be used. In the meantime, nurses should know how to use the position but should recognise that it probably has limited value for the acutely ill,
conscious patient.
The use of correct positioning and repositioning techniques, as well as appropriate methods for transferring patients from one surface to another, will reduce
both friction and shear forces. Incorrect positions in either bed or chair can
cause patients to slide. Regular moving of patients puts nurses at risk of back
injury. The European Community directive on the moving and handling of
heavy loads states that all healthcare institutions must have a policy for manual
handling and staff should have regular training on correct methods of moving
patients. Hoists, slides and other aids for moving patients should be available.
The RCN (2003) code of practice suggests that manual handling should be
eliminated in all but exceptional or life-threatening situations. All nurses
have a responsibility to take reasonable care for their own safety and that of
patients and colleagues.
Seating
䊉
Chairs
䊉
Most of the research in relation to pressure-redistributing equipment has
involved mattresses and beds rather than seating and yet sitting vulnerable
patients in armchairs is part of the routine rehabilitation process for many
(McCafferty et al., 2000). In many instances, hospital armchairs have been purchased without any reference to clinical staff or the varied needs of patients
(Collins, 1999; McCafferty et al., 2000). Once ill patients start to sit out of bed,
they are perceived to be ‘mobile’ and so may be left in a chair for long periods
of time without being moved. The NICE guidelines suggest that patients at risk
of pressure ulcer development should not be sat in a chair for more than two
hours at a time (NICE, 2003).
Many hospital armchairs are in a poor state and fail to give any pressure relief
or maintain a good posture (Dealey et al., 1991). Chairs should be checked and
replaced or repaired in the same way as mattresses. Many chairs have a reclining back of between 15° and 40° that puts the patient in a semi-reclining posture.
This may make it more difficult for the patient to stand. Ideally, a chair should
have a recline of not more than 10°, enabling the patient to move more freely.
Although cushions may be added to chairs to improve pressure relief, they
should not make the chair so high that the patient’s feet cannot touch the floor.
Collins (1999) undertook a comparative study of an armchair with an integral
pressure-relieving cushion and standard hospital armchairs. She found a sig-
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The Care of Wounds
nificantly lower incidence of pressure ulcers in the experimental group compared with the control group. Conventional seating is not suitable for everyone. Some patients have severe seating problems due to contractures, deformity
or infirmity. Specialised seating must be considered for these people.
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Cushions
䊉
Most of the research on cushions has been on those for use in wheelchairs.
Wheelchairs have a canvas base, which Rithalia (1989) found exerted pressures
in the region of 226 mmHg. It is essential that a cushion should always be used
in a wheelchair. For those people who become wheelchair bound because of
disability, special assessment should be made to identify the cushion most
suited to the specific needs of the patient (NICE, 2003). Many physiotherapists
and occupational therapists have developed specialist skills in assessment.
There are many cushions available but there is insufficient evidence to demonstrate whether any cushion outperforms the others and so no specific recommendation can be made (NICE, 2003).
䊉
Use of aids
䊉
The NICE guidelines specifically state that water-filled gloves and doughnuttype devices should not be used (NICE, 2003).
Pressure-relieving devices (beds, mattresses and overlays)
In 1995, an Effective Health Care Bulletin (1995) on pressure ulcer prevention
recommended that pressure-relieving foam mattresses should be used for atrisk patients rather than the standard mattress. Since then many hospitals have
replaced worn-out standard hospital mattresses with this type of mattress. In
the NICE guidelines, this type of mattress is seen as a minimum provision for
those at risk of pressure ulcer development (NICE, 2003).
There is an ever-increasing range of pressure-redistributing equipment available for use. They range from overlays to highly sophisticated beds and can be
divided into high-tech and low-tech categories (Cullum et al., 2001a). Low-tech
devices conform to the shape of the body, thus ‘spreading the load’ and reducing the pressure over bony prominences, whereas high-tech devices are
dynamic systems with various modes of action. Examples of both high- and
low-tech devices are given in Box 5.3.
The NICE guidelines suggest that selection of a device should be based on a
holistic assessment that includes:
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䊉
䊉
identified levels of risk.
skin assessment.
patient comfort.
general health state.
lifestyle and physical and mental abilities.
critical care needs.
acceptability of the proposed device to both patient and carer.
The Management of Patients with Chronic Wounds 135
Box 5.3 Examples of high-tech and low-tech pressure redistributing devices.
Low-tech
High-spec foam (overlay, mattress)
Gel (overlay, mattress)
Fluid (overlay, mattress)
Fibre (overlay)
Air (overlay, mattress)
High-tech
Alternating air (overlay, mattress, bed)
Low air loss (overlay, mattress, bed)
Air fluidised (mattress, bed)
Turning beds (manual controls, motorised)
Whilst a risk assessment calculator may form part of the assessment, equipment selection should not be based on the score alone (NICE, 2003).
The Effective Health Care Bulletin (1995) examined the evidence regarding
the range of product types available and considered that it was not possible to
recommend any one product as a best buy. Sadly, this situation is unchanged
and the current NICE guidelines are still unable to make specific recommendations. However, the guidelines do acknowledge that there is professional consensus that high-tech devices should be used:
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䊉
䊉
as a first-line preventive strategy for those patients seen to be at high risk of
pressure ulcer development.
if the patient’s previous history in relation to pressure ulcer prevention or
current clinical condition indicates that a high-tech device would be more
suitable.
if there are indications of pressure damage when on a low-tech device.
Jay (1997) suggested that cost, patient comfort, clinician satisfaction, safety and
reliability and logistical factors need to be taken into consideration as well as
efficacy.
䊉
Additions to the bed
䊉
Pressure relief can be enhanced by the use of simple measures. The use of bed
cradles can lift the weight of the bed clothes off the patient. Backrests are widely
used but it should be remembered that they cause the patient to slide down the
bed, risking damage by shearing. Strategic placing of pillows can relieve pressure on bony prominences such as heels, malleoli and knees.
䊉
Other hospital equipment
䊉
Vulnerable patients may spend time lying or sitting on very hard surfaces such
as operating tables, X-ray tables, trolleys and some types of wheelchair. Very
little consideration has been given to the need to provide some sort of pressure
relief in these circumstances. Versluysen (1986) undertook a study of 100 con-
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The Care of Wounds
secutive elderly patients admitted with a fractured femur. The interface pressures were measured on the casualty trolleys and operating tables. The casualty trolleys with a 5 cm deep foam mattress showed pressures of 56–60 mmHg
at the sacrum and 150–160 mmHg at the heels. The operating table had interface pressures of 75–80 mmHg at the sacrum and 60–120 mmHg at the heels.
NICE (2003) states that all patients undergoing surgery who are identified as
being at risk of pressure ulcer development should be placed on a highspecification foam theatre mattress or similar.
䊉
Organisation of delivery of devices
䊉
It is not practical for every clinical area to maintain their own stock of pressureredistributing devices and many hospital and primary care trusts have some
form of equipment store to ensure effective provision and use of devices. NICE
(2003) states that there should be a co-ordinated approach to the acquisition,
allocation and management of equipment and that prevention strategies or
policies should have a specified standard time between assessment and
allocation of equipment. NICE also provides guidance on auditing the use of
equipment (NICE, 2003).
Every patient at risk of pressure ulcer development should have an individualised written plan of care. It is important to document all assessments and
the care given. This will enable staff to monitor the effectiveness of the plan and
to identify any early signs of tissue damage. It should also ensure effective use
of equipment as patients may be moved to less sophisticated equipment when
they no longer have need of the high-tech equipment or vice versa.
Additional prevention strategies not mentioned in the NICE guidelines
䊉 Skin care 䊉
Traditionally, skin care involved rubbing patients’ pressure areas at regular
intervals. A variety of lotions and potions were used. A review of the literature
by Buss et al. (1997) considered the effects of massage or rubbing on pressure
sore prevention. They concluded that this practice could not be recommended.
When the practice of rubbing was discontinued most nurses developed a reluctance to use any type of cream over the pressure areas. Whilst this is generally
appropriate, there may be exceptions in the case of very dry or very moist skin.
Emollients should be considered when caring for patients with very dry skin,
either in the bath or an emollient cream. Creams should be applied gently to
the affected area. If the skin is moist, the source of the moisture should be identified and dealt with if possible. A barrier cream may be needed to protect the
skin from the harmful effects of moisture.
Frequent cleansing using soap and water for incontinent patients can cause
excessive drying of the skin. Dealey and Keogh (1998) found a significant
improvement in skin status using a cleanser and barrier cream compared to
soap and water in elderly incontinent patients at risk of pressure sore development. Cooper and Gray (2001) undertook a similar study comparing soap
and water with a combination cleanser and emollient in 93 elderly nursing
The Management of Patients with Chronic Wounds 137
home residents. They found borderline significance (p = 0.05) in favour of the
combination cleanser and emollient. Use of these types of products provides
better protection for the skin than soap and water.
䊉
Nutrition
䊉
If nutritional assessment suggested that a patient had reduced nutritional status
then an appropriate plan of care must be developed. Chapter 2 discusses this
in more detail.
䊉
Mobility
䊉
As has already been noted, pressure ulcers may be associated with acute illness.
As the patient’s general condition improves, so their levels of mobility and
activity should increase. Some patients may require considerable rehabilitation
to optimise their mobility levels. It is important that patients achieve as
great a level of mobility and activity as is practical for each individual which
has the additional benefit of enabling an individual to relieve pressure by
movement.
䊉
Education and training
䊉
There is little point in developing a policy for pressure ulcer prevention if no
attempt is made to provide relevant education for healthcare professionals and
assistants, patients and carers. A number of authors have described the beneficial outcomes of educational programmes. O’Brien et al. (2000) found a reduction in the biannual prevalence rate following an educational programme.
Regan et al. (1995) and Danchaivijitr et al. (1995) found a reduction in pressure
ulcer incidence following the introduction of a prevention programme supported by staff education. All healthcare professionals should receive education
and training on pressure ulcer risk assessment and prevention (NICE, 2003).
Box 5.4 lists the topics identified within the NICE guideline that should be
included in an education programme. However, it is not just healthcare professionals who need education. Patients and carers also require information and
this should be provided both verbally and in a written format. Information for
patients and carers that is written in appropriate language can be obtained from
www.nice.org.uk.
Summary
The various aspects of pressure ulcer prevention can be summarised as follows.
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Assessment: identify those at risk, assess and monitor the skin, especially
bony prominences, identify continence problems.
Plan appropriate preventive measures.
Evaluate outcomes by maintaining vigilant skin assessment.
Monitor all support systems, establishing replacement or maintenance
programmes where appropriate.
Ensure that staff have an adequate knowledge of the causes and prevention
of pressure ulcers.
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The Care of Wounds
Box 5.4 NICE Clinical Guideline 7: pressure ulcer prevention. Recommended education
programme content.*
•
•
•
•
•
•
•
•
•
•
•
•
•
Risk factors for pressure ulcer development
Pathophysiology of pressure ulcer development
The limitations and potential applications of risk assessment tools
Skin assessment
Skin care
Selection of pressure-relieving equipment
Use of pressure-relieving equipment
Methods of documenting risk assessments and prevention activities
Positioning to minimise risk
Shear and friction damage, including the correct use of manual handling devices
Roles and responsibilities of interdisciplinary team members in pressure ulcer management
Policies and procedures regarding transferring individuals between care settings
Providing education and information to patients
*(reproduced from the NICE Clinical Guideline 7: pressure ulcer prevention (2003), with
permission)
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Establish a teaching programme for long-term at-risk patients and their
carers.
Monitor outcomes of prevention strategies by measuring the prevalence and
incidence of pressure ulcers.
Audit the quality of care by utilising the benchmarking system known as the
Essence of Care (DoH, 2003). Birchall et al. (2004) found it a useful tool after
it had been adapted to meet local needs.
5.2.4 Management of pressure ulcers
If a pressure ulcer occurs, preventive measures should still be continued. The
precise cause of the ulcer and the effectiveness of any prevention plan must be
evaluated. Any necessary changes must be made, such as using a different
support system or increasing proteins and vitamins in the diet. The European
Pressure Ulcer Advisory Panel (EPUAP) has developed guidelines for the treatment of pressure ulcers (EPUAP, 1999) The guideline includes assessment,
assessing complications, managing tissue loads, use of pressure ulcer prevention devices and wound management. Managing tissue loads and use of
devices has been discussed in the previous section and the principles of wound
management can be found in Chapter 3. The rest of the guideline will be used
as a framework for this section.
Assessing the pressure ulcer
The EPUAP guideline states that pressure ulcers should be assessed for location, grade, size, wound bed, exudate, pain and status of surrounding skin. Also
any undermining or sinus formation should be identified (EPUAP, 1999).
The Management of Patients with Chronic Wounds 139
Elbows 8.8%
Sacrum 32.6%
Trochanter 8.3%
Buttocks 11.4%
Ankles 9.1%
Fig. 5.3 The common position of pressure ulcers
(based on Clark et al., 2003).
Heels 29.7%
The location of pressure ulcers
Some bony prominences are more prone to pressure ulcers than others. Clark
et al. (2003) reported a pressure ulcer prevalence survey of nearly 6000 patients
in five European countries and noted the position of the 1630 ulcers. Figure 5.3
shows the range of positions with the percentages found in each. There are
some specific aspects of care that need to be considered.
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Sacrum – dressings must be chosen with care, as many tend to ruckle up as
the patient moves. Chair sitting must be strictly regulated as to type of chair
and length of time seated in it.
Buttocks – as for sacrum.
Heels – ideally dressings must not be too bulky as this may impede mobility. Dressings may need to be ‘tailored’ in order to fit correctly around the
heel. If footwear is being worn, care must be taken to ensure that it is not too
tight or this will exert pressure on the foot. Ensure there is adequate pressure relief when in bed.
Trochanters – some dressings may ruckle up so select carefully.
140
The Care of Wounds
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Elbows – these pressure ulcers are usually caused by friction from moving
about the bed. Consider ways of reducing friction – use of a monkey pole,
pads or semipermeable film dressings.
Trunk – ulcers here are uncommon; try and identify source of pressure and
remove or modify it.
Grading of pressure ulcers
The use of a recognised system of grading pressure ulcers can be helpful, as it
provides an objective description and gives a more accurate picture of the
amount of tissue damage than comments such as ‘a deep ulcer’. It should be used
in conjunction with other descriptive tools such as measuring or tracing the ulcer
and describing its appearance. The EPUAP uses the following grading system.
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Grade 1 – non-blanchable erythema of intact skin. Discolouration of the skin,
warmth, oedema and induration may be used as indicators, especially for
dark skin.
Grade 2 – partial-thickness skin loss involving epidermis and/or dermis. The
ulcer is superficial and may be seen as a blister, abrasion or crater.
Grade 3 – full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia.
Grade 4 – extensive destruction, tissue necrosis or damage to muscle, bone
or supporting structures with or without full-thickness skin loss.
Figure 5.4 shows examples of each of these grades of pressure ulcer.
There are a number of issues that need to be considered when utilising any
grading system: accurate identification of grade 1 ulcers, incontinence lesions,
reverse grading and interrater reliability.
Grade 1 pressure ulcers are often found to account for approximately 50% of
all ulcers in prevalence surveys (Halfens et al., 2001). However, there are problems with both over- and underreporting. Overreporting may occur if nurses
fail to differentiate between blanching and non-blanching erythema. Alternatively, underreporting may occur because of the difficulties in identifying erythema on dark skin (Scanlon & Stubbs, 2004). Attempts have been made to
provide additional descriptors to the definition, as can be seen above. However,
there is a need to undertake further research to identify a truly accurate method
of assessment that overcomes skin colour.
Incontinence lesions are sometimes mistaken for pressure ulcers (Defloor &
Schoonhoven, 2004). Incontinence can cause erythema, excoriation and maceration of the skin and thus an incontinence lesion may have a similar appearance
to a grade 2 or 3 pressure ulcer. Care should be taken to determine the precise
position of any lesion/ulcer in incontinent patients. If a lesion is not over a bony
prominence, it is more likely to be due to incontinence than pressure.
Reverse grading is the practice of describing a healing pressure ulcer as
moving from a grade 4, through grade 3 and then to grade 2 as the grade 4
cavity heals and becomes shallower. The American National Pressure Ulcer
Advisory Panel (NPUAP) debated this topic and produced a position statement
that can be found at www.npuap.org. This states that as pressure ulcers heal,
The Management of Patients with Chronic Wounds 141
Grade 1
Grade 2
Grade 3
Grade 4
Fig. 5.4
Pressure ulcer grades.
they fill with granulation tissue that is not the same as the tissue it replaces;
therefore reverse staging should not be used. A grade 4 pressure ulcer should
therefore be described as a healing grade 4 ulcer.
Interrater reliability is the term used to describe the frequency with which
different individuals achieve the same score; in this case, the same grade when
grading pressure ulcers. The level of interrater reliability of different grading
systems has been tested by using either photographs of pressure ulcers (Defloor
& Schoonhoven, 2004; Russell & Reynolds, 2001) or actual patients with pressure ulcers (Pedley, 2004) and asking healthcare professionals to determine the
grades. The methods and findings of these studies vary, making it difficult to
compare the findings and ascertain the most effective scoring system.
Wound bed
Wound bed has been discussed in detail in Chapter 3. The same principles can
be applied to pressure ulcers. A pressure ulcer should be assessed for its appear-
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The Care of Wounds
ance as well as its grade. For example, grades 3 and 4 ulcers can be necrotic,
infected, sloughy or granulating in appearance. Accurate assessment is necessary in order to select a suitable wound management product.
Patient assessment
The EPUAP guidelines suggest that pressure ulcers need to be assessed in the
context of the patient’s overall condition (EPUAP, 1999) This has been discussed
in detail in Chapter 2.
Assessing complications
The EPUAP guidelines identify nutrition, pain and psychosocial factors as
potential areas of complication; again, these factors have been discussed in
Chapter 2.
Selection of wound management products
A variety of wound management products can be used when treating pressure
ulcers. The range of wound management products available is discussed in
Chapter 4. At present, there is insufficient evidence to determine which dressing is the most appropriate for each grade of pressure ulcer (Bradley et al., 1999).
It is, of course, entirely possible that such prescriptive wound care would never
be appropriate and that a range of products is needed in order to address individual situations. Many of the studies compare two products and find little or
no difference in performance. This may be because there truly is no difference
or because the sample size is too small to detect any differences. Some examples of clinical trials are given below.
Colin et al. (1997) compared a film dressing with a thin hydrocolloid dressing for the management of grade 1 and 2 pressure ulcers (n = 40). They found
no difference in healing rates but there was a significantly greater reduction in
wound size in the film group compared to the thin hydrocolloid group. Teot et
al. (1998a) compared two thin hydrocolloids on grade 1 and 2 pressure ulcers
and found no differences in outcome (n = 41). Both film and thin hydrocolloid
dressings would seem to be suitable for this grade of ulcer.
Several studies have considered appropriate products for grade 2–4 pressure
ulcers. Teot et al. (1998b) compared a hydrofibre dressing with a traditional tulle
dressing (n = 62). The hydrofibre dressing produced a better healing rate and a
greater reduction in wound size. However, these results were not significant.
Sopata (1997) compared a gel dressing with an adhesive foam dressing and
found no differences in performance between the two (n = 34). Seeley et al.
(1998) found no difference in healing rates in a comparison of a hydrocolloid
and an adhesive hydrocellular foam dressing (n = 40). A similar study in the
UK of the same dressings produced the same results (n = 61) (Bale et al., 1997).
However, the researchers found a high drop-out rate (26%), unrelated to the
dressings, mainly due to patient discharge or death. They proposed that future
study designs should include larger patient numbers. Thomas et al. (1997) com-
The Management of Patients with Chronic Wounds 143
pared a hydropolymer foam dressing with a hydrocolloid dressing (n = 99) and
found no differences in outcome.
Several researchers have investigated the management of sloughy or necrotic
pressure sores. Colin et al. (1996b) compared a hydrogel with a dextranomer
paste (n = 135). They found a significant reduction in wound size at 21 days in
the hydrogel group. The hydrogel treatment costs were also significantly lower
than those of the dextranomer paste. The other studies compared two different
hydrogels and found no difference in healing rates (Bale et al., 1998; Bale &
Crook, 1998; Young et al., 1997). Hydrogels are effective products for managing
sloughy pressure sores but there is no evidence to indicate which is best.
The use of plastic surgery
The healing time of a large cavity pressure ulcer can be considerably reduced
by plastic surgery. However, this is not appropriate for all patients. Their condition may be too poor or the ulcer may be healing rapidly. Sorensen et al. (2004)
suggest that only a small proportion of patients are suitable candidates,
generally those with spinal cord injury and deep grade 3 or 4 ulcers. Khoo
and Bailey (1990) have described the principles of reconstructive surgery.
Underlying infected bone also indicates a need for surgery. The first stage of
reconstruction is debridement followed by either simple closure or use of a flap.
If a wound is heavily colonised, it is best to undertake reconstruction in two
separate stages, so that there is an opportunity to reduce the bacterial count
(Sorensen et al., 2004).
The major problem with reconstruction surgery is the high rate of recurrence.
Tavakoli et al. (1999) found a recurrence rate of 62% when monitoring outcomes
over an eight-year period. However, Kierney et al. (1998) found that such rates
could be reduced by working collaboratively with colleagues in the Department
of Physical Medicine and Rehabilitation. In a longitudinal study of 158 patients,
they found a recurrence rate of 25%. They considered their success was related
to improved patient selection combined with a protocol for rehabiliation following surgical repair.
5.3 THE MANAGEMENT OF LEG ULCERS
Leg ulcers are a very common type of chronic wound that has been recognised
for many years. Those following the Hippocratic view, that disease was the
result of imbalance of the four bodily humours, believed that a leg ulcer allowed
the bad humours to leach out. In some areas, this belief still persists – the ulcer
lets the ‘bad’ out and if it heals, the person will die. Hopefully, this type of old
wives’ tale will gradually disappear.
Until recently there was little interest amongst doctors in the treatment of this
condition. Their views seemed to coincide with that of an eighteenth-century
physician who described the care of leg ulcers as ‘an unpleasant and inglorious
task where much labour must be bestowed and little honour gained’ (Loudon,
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The Care of Wounds
1982). Modern developments in wound management have revitalised those
caring for patients with leg ulcers.
5.3.1 The epidemiology of leg ulcers
Briggs and Closs (2003) undertook a review of leg ulcer prevalence surveys performed before March 2003, and the various methods used. Using the most reliable estimates from studies undertaken in Europe, Australia and the USA, they
concluded that the prevalence of open ulcers is around 0.11–0.18%. They also
found that those suffering from recurrent leg ulceration were about 1–2% of the
population. These figures should not be extrapolated to other parts of the world
where the prevalence rates may be entirely different.
Moffatt et al. (2004) have undertaken a leg ulcer prevalence survey in a large,
inner London borough and found a prevalence rate of 0.45/1000 population.
They compared their findings with two earlier UK surveys (Callam et al., 1985;
Cornwall et al., 1986) that had found prevalences of 1.48/1000 population and
1.79/1000 population. The authors suggested that this reduction could partly
be explained by the improvements in leg ulcer care in the last 15–20 years,
although the large numbers of patients from ethnic minority groups may also
have influenced the outcome.
One of the problematic features of leg ulcers is the length of time they can
take to heal and the frequency of recurrence. Baker and Stacey (1994) found that
24% had had their ulcers open for more than a year, 35% for more than five
years and 20% of leg ulcer suffers had had ten or more episodes of ulceration.
They also noted that 45% of the leg ulcer population were so immobile as to be
housebound. The more recent survey by Moffatt et al. (2004) found 55% of
patients had had their ulcers for more than a year and 35% had had them for
more than 18 months.
5.3.2 The cost of leg ulcers
As has already been shown, leg ulcers can be a long-standing and recurrent
problem. Inevitably, they are also very expensive. The majority are cared for in
the community and so require home visits or to be taken to clinics; the worst
cases may be admitted to hospital. Gruen et al. (1996) analysed the cost of hospitalisation for leg ulcer patients over a two-year period and found that patients
were admitted for a mean of 44.2 days at a total cost of A$2 750 000. What was
even worse was that less than 50% of patients (n = 119) had any documented
improvement on discharge. Tennvall et al. (2004) calculated the cost of treating
venous ulcers in Sweden based on existing epidemiological data. They found
the annual cost to be €73 million. Kumar et al. (2004) undertook a similar study
in New Mexico, USA, using retrospective data from the Medicaid health insurance system. They found the cost of treating venous ulcers for a five-year period
was $588 413 but gave no indication of the number of ulcers treated.
Several centres have established community leg ulcer clinics and costed the
outcomes. Ellison et al. (2002) undertook a study to compare the cost and out-
The Management of Patients with Chronic Wounds 145
comes of leg ulcer care provision in two large health authorities. They found
that in one health authority there was a 65% reduction in costs with the introduction of the clinics. Even so, 156 patients cost £212 707.84 to treat over a threemonth period in 1999.
None of the studies quoted above considers the cost to the patient but several
other researchers have investigated this cost. Persoon et al. (2004) undertook a
review of the literature to determine the impact of leg ulceration on daily life.
They included 37 studies, with both qualitative and quantitative methodologies. The common problem identified in all studies was pain and a number
also identified disturbed sleep associated with pain; for example, Hofman et al.
(1997) interviewed 94 patients with venous ulcers and found that 64% had
severe pain, 38.3% had continuous pain and 63.8% were woken by pain.
Another problem identified by the reviewers is impaired mobility. Some of the
qualitative studies also found that heavily exuding malodorous ulcers resulted
in limitations in patients’ work and leisure activities and often resulted in poor
self-esteem and social isolation. The reviewers conclude that leg ulceration has
a major impact on the life of the sufferer.
5.3.3 The causes of leg ulcers
There are a variety of causes of leg ulcers, the commonest being venous disease
and arterial disease. O’Brien et al. (2000) surveyed a health district in Ireland
and found that 81% of ulcers were venous in origin and 16.3% were due to
arterial disease.
Increasingly, more complex aetiologies are being identified, perhaps because
of increasing age and also improved management of the straightforward cases.
A recent survey within London found uncomplicated venous ulceration was
still the commonest cause (43%), but 35% of the ulcers in the survey had
complex aetiologies: lymphoedema (42%), mixed venous and diabetes (35%)
and rheumatoid arthritis (26%) (Moffatt et al., 2004).
5.3.4 Venous ulceration
Aetiology
Chronic venous insufficiency is the main cause of venous leg ulcers. Initially,
thrombosis or varicosity causes damage to the valves in the veins of the leg.
The deep vein is surrounded by muscle. When the leg is exercised, the calf
muscle contracts and squeezes the veins, encouraging the flow of blood along
the vein. This is often referred to as the calf muscle pump.
Normally blood flows from the superficial veins to the deep veins via a series
of perforator vessels. The valves in the vessels ensure that blood moves from
the capillary bed towards the heart. If some of the valves become damaged then
blood can flow in either direction. The backflow of blood towards the capillary
bed leads to venous hypertension. As a result, the capillaries become distorted
and more permeable. Larger molecules than normal are able to escape into the
146
The Care of Wounds
extravascular space, for example fibrinogen and red blood cells. The haemoglobin is first released from the red blood cells and then broken down, causing
eczema and a brown staining in the gaiter area. Ultimately there is fibrosis of
the underlying tissues, giving the leg a ‘woody’ feeling. This condition is called
lipodermatosclerosis. The slightest trauma to the leg and an ulcer will develop.
Common examples of trauma are knocking the leg on the corner of a piece of
furniture or a fall, injuring the lower leg.
The lymphatic system may also be affected. The lymphatics are responsible
for removing protein, fat, cells and excess fluid from the tissues. Ryan (1987)
has described how the superficial lymphatics in the dermis disappear. This
results in waste products accumulating in the tissues, which can cause fibrosis
and further oedema.
Management
Assessment
Full assessment of the patient is essential as many factors can delay the healing
of chronic wounds (see Chapter 2). A medical assessment may be necessary to
ensure accurate diagnosis. The leg ulcer guidelines developed by the Royal
College of Nursing (RCN, 1998) suggest a number of factors that may be specifically indicative of venous ulceration and those that are indicative of other
aetiologies. They can be seen in Box 5.5. Other factors that may need to be
particularly considered include nutritional status, mobility, sleeping, pain,
psychological effects of leg ulceration and the patient’s understanding of the
disease process. A comprehensive assessment of the affected leg must be made,
as it is important to rule out arterial disease. The treatments for these two types
of ulcer are not compatible.
Box 5.5 Factors to include in assessment of patients with leg ulceration (based on RCN,
1998).
Factors indicative of venous ulceration
Family history
Varicose veins
Proven DVT in affected leg
Phlebitis in affected leg
Suspected DVT
Surgery/fractures to the leg
Episodes of chest pain, haemoptysis, history of pulmonary embolus
Factors indicative of non-venous ulceration
Family history of non-venous ulcers
Heart disease, stroke, TIA
Diabetes mellitus
Ischaemic rest pain
Cigarette smoking
Rheumatoid arthritis
Peripheral vascular disease/intermittent claudication
The Management of Patients with Chronic Wounds 147
First, look at the legs. The characteristic staining of lipodermatosclerosis is
usually clearly seen in the gaiter area. Ankle flare may also be present; this is
distension of the network of small veins situated just below the medial malleolus. Oedema may be present but can also be found in arterial ulceration.
Theoretically, the leg and foot should feel warm to touch but if the weather is
cold, this may not be the case. The skin surrounding the ulcer may be fragile
and eczematous.
Typically, venous ulcers are found on or near the medial malleolus. They tend
to be shallow and develop slowly over a period of time. It should also be noted
that pain will be increased if there is any infection in the ulcer. The ulcer appearance should be assessed as in Chapter 3. Many venous ulcers have a heavy
exudate. Figure 5.5 shows a typical venous ulcer with staining in the gaiter area.
Differential diagnosis between venous and arterial ulcers can be achieved by
assessing the blood supply to the leg, ideally by means of Doppler ultrasound.
This procedure should be undertaken by healthcare professionals who have
received relevant training. Doppler ultrasound is used to compare the blood
pressure in the lower leg to the brachial pressure. It is usually presented in the
form of a ratio, the ankle brachial pressure index (ABPI), which is calculated
by the following formula:
Ankle systolic pressure
= Ankle brachial pressure index
Brachial systolic pressure
An ABPI of 0.9 or above indicates a normal arterial supply to the leg. If it
is below 0.9 then some ischaemia is present. Compression therapy should
not be used if the ABPI is below 0.8. If there is any doubt about the presence
of arterial disease, further medical opinion should be sought.
Planning
There are three aspects to the management of venous ulcers: improving the
drainage of the leg, skin care and the use of appropriate wound management
products. Any one of these alone will not be truly effective without the others.
Fig. 5.5
An example of a venous ulcer.
148
The Care of Wounds
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Drainage of the legs
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The drainage of the legs can be improved in several ways: exercise, compression and elevation. The use of exercise stimulates the calf muscle pump, promoting drainage. Allen (1983) recommends that patients should walk as much
as they are able and, if standing still, they should move from one foot to the
other. He also suggests that frequent ankle exercises should be performed when
sitting. Obviously exercise should be tailored to the abilities of the patient.
Regular encouragement will be needed to ensure patients persist with their
exercises.
Compression works with exercise to aid drainage from the superficial veins.
It should be graduated so that there is a higher pressure at the ankle than at
the calf. It can be achieved by the use of either bandages or stockings. Bandages
are probably easiest to use in the early stages when the dressings may be rather
bulky. Some remain in situ day and night whilst others may be removed at
night. Reapplying bandages is best done before rising when the leg has the least
amount of oedema.
The commonest type of compression bandage used in the UK is elastic,
whereas in the rest of Europe inelastic or short-stretch bandages are used. In
many instances, three or four different types of bandage are used to achieve
a multilayer system comprising three or four layers. This may involve
orthopaedic padding, crepe, elastic bandage and a cohesive layer (four-layer)
or orthopaedic padding, crepe and high compression bandage (three-layer).
The benefit of the orthopaedic padding is that it helps to absorb excess exudate
and can provide extra padding over bony prominences.
A system called Unna’s boot (a non-compliant plaster-type bandage) is used
in North America.
Clark (2003) described the British Standard 7505 for bandages. Elastic compression bandages are defined as type 3 and divided into four categories:
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3A providing up to 20 mmHg pressure.
3B providing 21–30 mmHg pressure.
3C providing 31–40 mmHg pressure.
3D providing 41–60 mmHg pressure.
All the above measurements are based on the sub-bandage pressure achieved
when applying the bandage to a leg with a 23 cm ankle and with a 50% overlap
in the bandage layers. In a normal-shaped leg, if the bandage is applied with
constant tension and overlap, the pressure will automatically become lower as
the bandage is applied up the leg (Clark, 2003). This concept is based on
Laplace’s Law and has been described in detail by Thomas (2003).
Inelastic or short-stretch bandages provide a rigid layer over the limb that
does not ‘give’ when the wearer is mobilising, thereby providing increased
compression during walking. They are applied in a combination of figure of
eight and spirals and achieve a multilayered effect. The pressures tend to
drop during periods of immobility and the bandages become loose as oedema
reduces. This bandage is not suitable for immobile patients.
The Management of Patients with Chronic Wounds 149
The level of compression needed for venous ulceration is around 40 mmHg
(Stemmer, 1969). Therefore, the high compression bandages are generally suitable. However, these pressures are dependent on the size of the limb. A large
limb, swollen with oedema, would require a higher compression bandage than
a thinner limb in order to achieve an adequate level of compression. There is
also a need to ensure protection over bony prominences as there is the potential risk of pressure damage, especially if the bandage is poorly applied.
A systematic review of clinical trials of compression bandaging found that
multilayered bandage systems were more effective than single-layer and high
compression better than low compression (Cullum et al., 2001b). There were no
clear differences to dermine the most effective type of high compression. Since
this review a number of studies have been published that provide further
evidence. Two studies compared the four-layer bandage system with a shortstretch bandage and both found that the four-layer system gave a faster healing
rate (Iglesias et al., 2004; Ukat et al., 2003). The research teams also found the
four-layer system was less expensive to use, mostly because the short-stretch
bandages needed to be reapplied more frequently than the four-layer system.
One study compared a three-layer paste bandage system with four-layer and
found the paste system gave a significantly faster healing rate (Meyer et al.,
2003). A small study by Polignano et al. (2004) compared the four-layer system
with Unna’s boot and found no difference in healing rates. Overall, the multilayered systems such as the four-layer bandage would seem to provide the most
effective compression.
Unfortunately, not all patients can tolerate high compression bandage systems
and a pragmatic approach to the problem may be necessary. Tubular bandages
may be better tolerated by some patients and can be used to provide some compression. There is a shaped tubular bandage that can be most useful as it is relatively easy to apply. This type of compression may be the easiest to pull on for
someone with arthritic hands. Bale and Harding (2003) studied 28 patients
unable to tolerate high compression and found that using three layers of graduated tubular bandage was effective in healing (n = 14) or reducing the ulcer.
The tubular bandage was applied in gradually reduced lengths: layer 1 = toe to
knee; layer 2 = toe to calf; layer 3 = toe to malleolus. The authors concluded that
whilst using this type of bandage system cannot be recommended for routine
care, it is a possible alternative for those unable to tolerate therapeutic compression. It should be noted that the straight variety of tubular bandage does
not give appropriate compression as pressure is higher at the calf than the ankle.
Another method of applying compression that can be used, particularly if
oedema is present, is pneumatic compression. It may be applied once or twice
a day for periods of up to an hour. Initially the time should be shorter and
gradually increased. Whilst this may be a useful form of treatment, it is difficult in the community where there is limited access to such equipment. The use
of pneumatic compression should be seen as an addition to the treatment
regime rather than an alternative. A Cochrane review found limited evidence
of the benefits of pneumatic compression and concluded that further research
is required to determine whether it increases healing rates (Mani et al., 2004).
150
The Care of Wounds
Elevation of the legs allows gravity to aid venous return. However, many
people tend to place their feet on a low stool, which is of no benefit whatsoever. To be effective, the feet should be higher than the heart. If there is an acute
exacerbation of the ulcer with oedema and heavy exudate, it may be worth
admitting the patient to hospital to allow a short period of bedrest. Bedrest with
elevation of the foot of the bed can significantly reduce oedema and improve
venous return but it should not be considered as a long-term measure because
the ulcer will merely break down again once the patient is up and about. It may
also seriously affect the mobility of older patients. A more practical method is
to raise the foot of the bed at home so that the legs are elevated at night. This
may be achieved by the use of bricks or blocks of wood.
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Skin care
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Management of the ulcer involves cleansing and a suitable topical application.
Consideration must be given to the presence of eczema, scaling on the legs
around the ulcer, any allergies to treatment and wound infection. Cleansing is
an important factor as many patients may have been told in the past that they
must never get their ulcer wet. As a result, they may not have had a bath for
years. Footbaths are very useful as they allow the patient the opportunity to
give the affected leg a good soak. Plain tap water is suitable for most patients.
Attention needs to be paid to the adequate cleansing of the footbath after use
in order to prevent cross-infection.
One skin complication associated with 37–44% of venous ulcers is gravitational or varicose eczema (Patel et al., 2001). It presents as skin excoriations
with a diffuse edge, dryness, scaling and weeping and the patients may complain of itching, burning or stinging (Patel et al., 2001). Quartey-Papafio (1999)
discussed the importance of being able to differentiate between gravitational
eczema and cellulitis and suggested that the most important sign in gravitational eczema is the presence of scaling or crusting. Potassium permanganate
1 : 10 000 solution may be used for heavily weeping eczema for short periods,
in conjunction with a steroid cream. Otherwise, emollients and topical steroids
may be used and care taken to avoid any irritants that may aggravate the
eczema.
When taking an initial history, any reported allergies should be noted. Many
long-term leg ulcer sufferers develop allergies to their treatment. Cameron
(1998) reviewed the problems of allergic contact dermatitis or contact sensitivity. Substances which have been found to cause sensitivities include lanolin,
neomycin, framycetin, emulsifiers such as cetyl alcohol, rubber, parabens and
colophony. Cameron recommends avoiding the use of any products containing
potential irritants. Bland emollients such as a 50/50 mixture of soft white paraffin and liquid paraffin should be applied following cleansing of the leg. This
can be massaged gently into the skin, helping to lift the skin scales that rapidly
build up on the leg. Machet et al. (2004) reviewed changes in sensitivities
reported in France since 1990 and found an 8.5% increase in sensitivity rates.
There was a slight decrease in sensitivity to lanolin and a marked increase in
sensitivity to balsam of Peru.
The Management of Patients with Chronic Wounds 151
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Wound management
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Management of the ulcer depends on the assessment and the factors previously
discussed. Selection of suitable dressings is discussed in Chapter 4. There have
been of number of clinical trials of modern products on leg ulcers, many of
which have been of small size or inconclusive. Overall, there is insufficient
evidence to recommend one product over another. Alginates, foams, hydrocolloids, hydrogels and low-adherent dressings may be particularly effective.
Marston and Vowden (2003) suggest that dressing selection should be based on
the status of the ulcer and surrounding skin. It should be remembered that
whilst the ulcer may be new to the nurse, the patient could have lived with it
for some time. There may be a credibility gap as the patient starts yet another
course of treatment which will ‘definitely resolve the problem’.
Paste bandages have been widely used in the treatment of leg ulcers in the
past, although less frequently now. They are cotton bandages impregnated with
different types of paste according to the manufacturer. They are particularly
useful for sore, eczematous legs as they are soothing and will also lift off some
of the scales that tend to form around the ulcer. Paste bandages do not provide
compression but they enhance the effect of the compression bandages used over
the top. Paste bandages have to be applied in such a way as to allow for any
swelling of the leg. This may be achieved by making a pleat on each turn at the
front of the leg. An alternative method is to overlap each turn and cut the
bandage. Paste bandages can be left in place for up to a week.
Skin grafts are used in some centres to promote faster healing. Either mesh
grafts or pinch grafts may be used but the former requires hospital admission.
Grafting should be used in conjunction with compression therapy. A Cochrane
review assessed the benefits of skin grafts, including tissue culture and tissueengineered products (artificial skin) (Jones & Nelson, 2001). The authors concluded that there was limited evidence of the benefits of using artificial skin
and further research is needed. Margolis et al. (2000) suggested using a simple
prognostic model to identify those patients who would not heal with a simple
dressing plus compression bandaging within 24 weeks. Those identified could
be considered for more sophisticated treatment, such as artificial skin.
Evaluation
Regular assessment of the ulcer may be done by the use of tracings or
photographs which are essential to monitor the progress of the ulcer. If there
appears to be no progress over a period of 2–3 months, the ulcer should be
reassessed and any ischaemia or infection ruled out. Patient assessment will
identify any relevant factors such as loss of appetite. Skin care should be continued as the skin is likely to remain scaly.
Below-knee compression stockings are widely used as the ulcer improves and
after healing. Some manufacturers also produce compression socks for men that
look like ordinary socks. For many patients, socks and stockings are easier to
apply than bandages. Jones and Nelson (1998) have reviewed the use of compression stockings.
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The Care of Wounds
The British Standards Institute has specified three classes of stockings available on prescription which provide different ranges of compression at the ankle.
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Class I has pressures of 14–18 mmHg.
Class II has pressures of 18–24 mmHg.
Class III has pressures of 25–35 mmHg.
It is very important that the patient should be correctly fitted for stockings.
Class II may be appropriate for many patients. If Class III stockings are required
but the patient is unable or unwilling to pull them on, it may be better to use
two layers of Class I stockings. Fentem (1986) has shown that this would
provide the same level of compression. A systematic review of the use of compression hosiery for preventing ulcer recurrence found only two trials to report
(Nelson et al., 2004). The reviewers noted that both studies found that not
wearing compression was strongly associated with leg ulcer recurrence,
although this is circumstantial evidence as this condition was not being tested
in either trial.
Some authors have discussed the benefits of surgery to correct venous reflux.
Ghauri et al. (1998) found that the introduction of superficial venous surgery
reduced one-year recurrence rates from 23% to 9% within a vascular-led specialist clinic service. They followed this with a randomised, controlled trial that
found that surgery plus compression was significantly more effective than compression alone (Barwell et al., 2004).
Patients still need to be seen regularly once the ulcer is healed in order to
provide encouragement and to ensure that the preventive care is understood.
They should also be given information on how to get further help if the ulcer
recurs. The sooner that appropriate care can be given, the sooner the ulcer will
heal. Poore et al. (2002) monitored the impact of a healed ulcer clinic over a twoyear period. Of the 110 patients studied, 14 patients did not attend after the first
year, 75 (78%) remained healed and 21 (22%) had recurrence. The authors examined the medical records to determine the actual length of time the healed ulcers
had remained healed. The commonest length of time was three years (32%) with
a range of 1.5 to 19 years.
Prevention is obviously better than cure. Ruckley et al. (2002) undertook a
cross-sectional survey of adults aged 18–64 years randomly selected from 12
general practices. They found a 9.4% prevalence of chronic venous insufficiency
in men and 6.6% in women. However, the rate rose steeply with age to 21.2%
in men and 12% in women over 50 years. The research team suggests that as
about a third of the subjects had damage to the superficial veins, it would be
worth advocating surgical treatment to prevent leg ulceration developing at a
later date.
5.3.5 Arterial ulcers
Aetiology
Arterial ulcers are the result of inadequate tissue perfusion to the feet or legs.
This is due to complete or partial blockage of the arterial supply to the legs and
The Management of Patients with Chronic Wounds 153
the underlying condition is often referred to as peripheral vascular disease. This
is a general term used to encompass disease which reduces the blood supply
to the periphery. The commonest disease is arteriosclerosis in which the artery
walls become thickened. It is usually found in combination with atherosclerosis, the formation of plaques on the inner lining of the vessels. The lumen of
the vessels gradually narrows, causing ischaemia in the surrounding tissue and
ultimately resulting in necrosis. This type of arterial insufficiency is most commonly found in men over the age of 50.
Buerger’s disease is another type of disease affecting the peripheral arteries.
Inflammation of the vessels results in thrombus formation and occlusion of the
vessels. It is associated with heavy smoking and is found most commonly in
men between the ages of 20 and 35 years. Ulceration associated with necrosis
and gangrene may develop.
Management
Assessment
Assessment of the patient may reveal pain particularly associated with walking
which is relieved by resting; this is called intermittent claudication. Pain may
also occur at night when the patient is in bed and can be relieved by hanging
the legs down. Past medical history may reveal known peripheral vascular
disease or arterial surgery. A past or present history of smoking should also be
noted.
When the legs are examined they may feel cold to touch and have a shiny,
hairless appearance. The toe nails may be thickened and opaque. The legs
become white when elevated and a reddish/blue colour when dependent.
Pedal pulses are diminished or absent. Doppler examination will reveal the
presence of ischaemia with an ABPI below 0.9. If the patient has intermittent
claudication, the ABPI is likely to be between 0.5 and 0.9. Rest pain and an ABPI
below 0.5 are indicative of critical ischaemia. The patient should be referred to
a vascular surgeon.
Arterial ulcers may occur anywhere on the leg or foot but are most commonly
found on the foot. The ulcer has a punched-out appearance and may be deep,
involving muscles or tendons. Necrosis is often present and there is often far
less exudate than in venous leg ulcers (see Fig. 5.6). Table 5.1 compares venous
and arterial ulcers (Dealey, 1991b).
Planning
Arterial ulcers are notoriously difficult to heal and arterial surgery to improve
the blood supply may be necessary before an ulcer will heal. Early referral for
reconstructive surgery is ideal. Ray et al. (1995) found that percutaneous transluminal angioplasty was effective in promoting healing in all those with ulcers
in their study (n = 14). The standard surgical procedure is a bypass graft.
Sieggreen and Kline (2004) discussed the advantages and disadvantages of
both bypass grafts and percutaneous procedures and concluded that appropriate patient selection is the key to successful outcomes. Unfortunately, for
some patients, despite treatment, there is considerable risk of the onset of gan-
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The Care of Wounds
Fig. 5.6
An arterial ulcer
Table 5.1
A comparison of venous and arterial ulcers.
Sign/symptom
Venous ulcer
Arterial ulcer
Site
On/near medial malleolus
May be on toes, foot, heel or lateral
aspect of leg
Development
Develops slowly
Develops rapidly
Appearance of ulcer
Shallow margin; deep tissues
not affected
Often deep with involvement of
tendons or muscles
Appearance of leg
Brown, varicose staining, and
eczema, warm to touch
Shiny skin, cold to touch, white on
elevation, may become blue when
dependent
Oedema
Present – usually worse at
end of day
Only present if patient immobile –
stasis oedema
Pain
Level and time of pain varies
Very painful – worse at night. Relieved
by hanging leg over side of bed
Medical history
DVT, phlebitis, varicose veins
Peripheral vascular disease, ischaemic
heart disease,
ABPI
0.9 and above
Below 0.9
grene and even septicaemia, and amputation of the limb may be the only
solution.
If a patient has severe resting pain, good pain control is an essential part of
the management. The patient should also be encouraged to give up smoking
as failure to do so will further compromise the blood supply to the leg. Gentle
exercise will help to encourage the development of a collateral supply to the
limb, thus improving tissue perfusion. The limbs should be kept warm as cold
may precipitate pain.
The major aim of ulcer management is to remove necrotic tissue and to
prevent infection. Selection of appropriate wound management products
The Management of Patients with Chronic Wounds 155
depends on the ulcer appearance, the amount of exudate and the position of
the ulcer (see Chapter 4). A Cochrane review found only one small trial of a
topical agent for arterial ulcers and concluded that there was insufficient evidence to determine whether the choice of dressing affects the healing of arterial ulcers (Nelson & Bradley, 2003).
Any dressing needs to be effectively retained and yet not so bulky as to
restrict mobility unduly. Areas such as the toes are not at all easy to dress. Bandages are often needed to hold the dressing in place. Compression bandages
should not be used on arterial ulcers. Comfortable retention bandages such as
cotton conforming bandages are suitable. Lightweight tubular bandages can be
very useful, particularly on toes. It is important to ensure that, whatever
bandage is used, it does not constrict the blood supply.
Evaluation
The progress of both the patient and the ulcer should be evaluated. The effectiveness of pain control can be ascertained using a pain ruler (see Chapter 2).
When monitoring the progress of the ulcer, attention should be paid to any indications of infection.
5.3.6 Ulcers of mixed aetiology
Some patients will have both an arterial and a venous component to their ulcer.
It is important to define the predominant factor, so that appropriate treatment
may be given.
Management
Assessment
Doppler assessment and assessment of the leg will provide an indication of the
mixed aetiology. A full assessment in a vascular laboratory may be of benefit.
Planning
If the main factor is venous, moderate graduated compression should be worn
during the day. The degree of compression should be based on patient tolerance. The International Leg Ulcer Advisory Board has provided a care pathway
that gives guidance on the levels of compression that should be used for different levels of arterial insufficiency in a mixed ulcer as well as for venous ulcers
(Stacey et al., 2002). Figure 5.7 shows this section of the pathway. Most patients
will need to remove the compression garment at night when elevation of the
legs is likely to increase ischaemic pain. Butcher (2002) suggests that shortstretch bandages may be particularly useful, as they do not exert pressure when
the limb is resting. Bowering (1998) achieved reduced compression by omitting
the elastic third-layer bandage from the four-layer system and achieved 67%
healing. Arthur and Lewis (2000) used reduced compression on 24 mixed aetiology ulcers and achieved 74% healing (n = 19). However, it must also be noted
that two patients were unable to continue this therapy as their limbs became
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The Care of Wounds
Assessment
Non-invasive diagnostics
∑ Ankle-brachial pressure
index (ABPI)
∑ Confirmation of venous
disease
∑ Investigations to exclude
other disorders
Diagnosis
Recommendations
for treatment
Mixed arterial and venous
ulcer
Arterial insufficiency
(ABPI 0.5–0.8)
Reduced compression
(15–25 mmHg)
Refer to vascular specialist
particularly if continuing rest
pain
Mixed arterial and venous
ulcer
Severe arterial insufficiency
(ABPI <0.5)
Refer to vascular specialist
No compression
Fig. 5.7 Guidance on levels of compression for mixed aetiology ulcers from the treatment pathway
developed by the International Leg Ulcer Advisory Board (adapted from Stacey et al., 2002).
too ischaemic. Care and careful monitoring must be exercised if using compression for these patients. When arterial disease predominates, a vascular
opinion must be sought. However, exercise and short periods of limb elevation
can be encouraged, within the limits of patient toleration.
Evaluation
If healing is very slow, further advice from a vascular surgeon should be
obtained. Butcher (2002) emphasised the importance of regular reassessment to
monitor any changes in the level of arterial insufficiency. The RCN leg ulcer
guidelines suggest that this should be every three months (RCN, 1998).
5.3.7 Malignant leg ulcers
A small number of leg ulcers may be malignant or become malignant. Voisard
et al. (2001) reported on patients attending a vascular clinic between 1991 and
1999 where they found six cases of squamous cell carcinoma and four with
Marjolin’s ulcer. The authors observed that they did not see any existing leg
ulcers become malignant in their series. Yang et al. (1996) monitored patients
attending a specialist leg ulcer clinic and found 43 patients with 55 malignant
lesions, an incidence of 4.4%. In this group 75% were basal cell carcinoma and
25% squamous cell carcinoma. They concluded that malignant changes are
common in chronic leg ulcers. Over a 12-month period, Taylor (1998) found 12
patients in a cohort of less than 200 patients attending a community leg ulcer
clinic.
Hayes and Dodds (2003) discussed the identification and diagnosis of malignant ulcers and suggested that there are a number of clinical signs of
malignancy.
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Irregular nodular appearance on the wound surface.
A raised or rolled edge.
The Management of Patients with Chronic Wounds 157
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Raised granulation tissue on the ulcer bed with firm surrounding skin.
Islets of epithelialisation that do not persist.
Apparently healthy granulation tissue that is exuberant, translucent, shining
and rolls over the wound margins.
Yang et al. (1996) suggest that any ulcer that fails to heal when treated appropriately should rouse suspicion. Walsh (2002) discussed the importance of
taking a biopsy from atypical ulcers or non-healing ulcers and of early referral
for specialist advice.
Treatment of malignant ulcers is by excision and skin grafting when caught
at a reasonably early stage. Amputation may be necessary for large ulcers.
Although only a small percentage of leg ulcers are malignant, it is important
for nurses to be aware of the possibility and alert to the need to obtain biopsies
of any atypical ulcers.
5.3.8 Leg ulceration in rheumatoid arthritis
It has been noted that patients with rheumatoid arthritis (RA) are more vulnerable to leg ulceration and that the aetiology is frequently multifactorial
(McRorie, 2000). In their leg ulcer survey, Moffatt et al. (2004) found that 35%
of ulcers were multifactorial and of these, 26% were associated with rheumatoid arthritis. This indicates a significant minority of patients who require
careful assessment and management.
Oien et al. (2001) studied 20 patients with chronic leg ulcers and RA in order
to determine the ulcer aetiology. They found that three patients had vasculitis
as well as both venous and arterial components; five had both vasculitis and
venous disease; two had vasculitis and diabetes; seven had venous disease
alone; one had vasculitis alone; one had arterial disease alone; one had neither
vasculitis nor venous or arterial problems. The research team also noted that
the ulcers were very painful.
Management
Assessment
A specialist rheumatology assessment as well as a vascular assessment is
required for these patients. McRorie (2000) also suggests that nutritional assessment and assessment of footwear should be undertaken.
Planning
Management of these patients is complex and depends on the underlying aetiologies. Compression can be used with caution where venous disease is the
dominant factor, particularly if peripheral oedema is present. A small study of
15 patients by Hafner et al. (2000) found that vein or arterial surgery was effective in achieving healing in 9/15 patients and markedly improving the ulcers
of 5/15. They suggest a prospective trial was needed to confirm these results.
Oien et al. (2001) used pinch grafts to treat the patients in their study group.
They achieved healing in 8/20 patients, the ulcers in these patients being much
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The Care of Wounds
smaller (range 0.4–13.2 cm2) than the unhealed ulcers (range 6.7–356.6 cm2).
They also found a significant reduction in pain in 18/20 patients following the
pinch grafting.
Evaluation
Regular monitoring of these patients is essential, especially as arterial disease
may be accelerated in patients with RA (McRorie, 2000).
5.4 DIABETIC FOOT ULCERS
Ulceration of the foot is a serious complication of diabetes mellitus, which can
lead to disability and possible amputation of the affected limb. Jeffcoate and
Harding (2003) reviewed current data on surveys of foot ulcers and noted that
5.3% (type 2 diabetes) and 7.4% (type 1 and 2 combined) have either an active
ulcer or have previously had an ulcer. The lifetime risk for people with diabetes
developing an ulcer is about 15%. The incidence of major amputation is 0.5–5.0
per 1000 people with diabetes and the perioperative mortality rates associated
with amputation have been found to range from 9% to 15% (Jeffcoate &
Harding, 2003).
Girod et al. (2003) evaluated the direct and indirect costs of treating foot ulcers
in diabetic patients. They monitored the cost of 239 patients cared for by 80
physicians and found the average monthly cost was €2287.96. This gives a total
monthly cost for treating the 239 patients of €546 822.44.
5.4.1 Aetiology
The underlying causes of diabetic ulcers are peripheral neuropathy and peripheral vascular disease. Infection is an ever-present risk for the diabetic and can
exacerbate the development of ulceration and increase the risk of amputation.
Peripheral neuropathy affects the peripheral sensory, motor and autonomic
nerves of the leg. This has a twofold effect of causing a loss of sensation and
compromising the biomechanics of the foot. Muscle atrophy in the foot, particularly over the arch of the foot, causes a transfer of body weight and reactive callus formation on the plantar surface. Ultimately, deformities of the foot,
such as claw toes or Charcot foot, may occur along with alterations in gait.
Walters et al. (1993) found foot ulceration was significantly associated with foot
deformity. Poorly fitting shoes or a foreign body within the shoe can cause
undetected injury, resulting in ulcer formation. The patient may be completely
unaware of the ulcer for some time.
Vascular disease in diabetics primarily affects the smaller arterioles within
the foot. Intermittent claudication is unlikely, as larger arteries are not usually
occluded. As with all types of vascular disease, it is exacerbated by smoking.
Gangrene of the toes can be caused by thrombosis in the artery supplying the
affected digit. Pressure from poorly fitting shoes is the commonest cause of
ischaemic ulceration.
The Management of Patients with Chronic Wounds 159
Microvascular dilation plays a significant role in the healing of minor
wounds. The ability of these vessels to dilate can be measured by using a laser
Doppler to test the response to heat. A study by Sandeman et al. (1991) measured the ability to respond to heat by vasodilation in insulin-dependent (ID)
diabetics, non-insulin dependent (NID) diabetics and a control group of healthy
individuals. A significantly worse response was found in the NID diabetics than
in the other two groups.
5.4.2 Prevention
Given the grave implications of ulceration, prevention is very important. The
main methods used in prevention are patient education and adequate monitoring of the patient by the healthcare team. Litchfield and Ramkissoon (1996)
monitored the outcome of providing an educational footcare video for diabetics. They found that whilst most patients were aware of the need for good footcare, there was a lack of compliance with the recommended care. NICE has
produced guidelines for the prevention and management of foot problems in
diabetics (NICE, 2004). The guidelines include guidance on the content of any
education programmes to be targeted at those with low risk of developing foot
ulcers, those at high risk and those with foot ulcers. The guidelines also state
that effective prevention and care involves a partnership between patients and
professionals (NICE, 2004).
Regular monitoring of diabetic feet is essential and should occur at least
annually. Assessment should include testing of foot sensation, palpation of foot
pulses, inspection for any foot deformity and inspection of footwear (NICE,
2004). Assessment allows the classification of foot risk as follows:
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low current risk (normal sensation, palpable pulses).
increased risk (neuropathy or absent pulses or other risk factor).
high risk (neuropathy or absent pulses plus deformity or skin changes or
previous ulcer).
ulcerated foot (NICE, 2004).
Once patients have been identified as being at risk, they should be made aware
of their responsibilities for prevention of foot problems. Feet should be washed
daily and dried carefully. They should be inspected for any red areas or swelling
and cracked or broken skin. Toe nails should be cut straight across. Socks should
be changed daily and not wrinkle. Shoes should be well fitting. They should be
checked before wearing for any foreign bodies. New shoes should be properly
fitted and feet carefully observed for signs of rubbing. Patients should not wear
sandals or go barefoot. Those with poor vision may need assistance. Those who
smoke should be encouraged to stop.
At each attendance at the diabetic clinic, the patient should have a full foot
check. This may involve the doctor, diabetic nurse specialist and chiropodist/podiatrist. Treatment of callus formation and management of any
fungal infections is usually carried out by the chiropodist/podiatrist. If the
patient has any deformity of the feet it may be helpful for the orthotist to assess
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The Care of Wounds
for suitable footwear. If the patient has other pathology requiring treatment,
other health professionals should be vigilant in identifying any potential foot
problems.
5.4.3 Management
Ideally, the care of patients with diabetic foot ulcers should be within the
context of a multidisciplinary footcare team comprising podiatrists, orthotists,
nurses and diabetologists, all of whom should have specialist expertise in this
area.
Assessment
When assessing the patient, there may be an indication of the type of ulcer. A
history of pain associated with the ulcer, for example, almost certainly indicates
ischaemia. Deformities of gait are indicative of neuropathy. Assessment of the
diabetic state is important because of the increased risk of infection in the presence of hyperglycaemia.
Assessment of the leg and foot will provide objective evidence of the presence of either ischaemia or neuropathy or both. Table 5.2 indicates the differences between the two types of ulcers. However, both pathologies may be
present in many patients. A survey of diabetic foot ulcer management in secondary healthcare found that 33% were neuropathic, 40% were neuroischaemic
and 20% were ischaemic (Jude et al., 2003). Vascular assessment using Doppler
Table 5.2 A comparison of signs of peripheral neuropathy and peripheral vascular disease in
the diabetic foot.
Sign/symptom
Neuropathic ulcer
Ischaemic ulcer
Deformity of the foot
Present as claw toe, hammer
toe, Charcot foot or other
Not present
Skin temperature of foot
Warm
Cold
Colour of foot
Normal
White when elevated or cyanotic
Toe nails
Atrophic
Atrophic
Pedal pulses
Present
ABPI below 0.9 (false high
readings if small vessels calcified)
Pain
Present in some – associated
with numbness and
diminished sensation
Present, relieved by hanging
legs down
Callus formation
Present, especially on plantar
surface
Not present
Ulcer site
Commonly on plantar surface
of foot
Commonly on toes and the edges
of the foot
The Management of Patients with Chronic Wounds 161
ultrasound can help to determine the level of ischaemia. However, it is important to be aware of the potential for a falsely elevated ABPI because of calcification of the arteries. If this is suspected, the patient should be referred for more
intensive vascular assessment. An important aspect of assessment is to identify
the precipitating factor. Careful assessment of footwear and the precise position of the ulcer can provide clues. It is essential to identify the cause of the
ulcer or further ulceration may occur.
Neuropathic ulcers may be surrounded by callus and have a punched-out
appearance (see Fig. 5.8). Ischaemic ulcers are usually covered by necrotic
tissue. Neither type of ulcer generally has much exudate. The ulcer should be
carefully observed for any indication of infection.
Wagner (1981) devised a scale for assessing diabetic ulcers.
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Grade 0 – at-risk foot.
Grade 1 – superficial ulcer, not clinically infected.
Grade 2 – deeper ulcer, often infected, no osteomyelitis.
Grade 3 – deeper ulcer, abscess formation, osteomyelitis.
Grade 4 – localised gangrene (toe, forefoot or heel).
Grade 5 – gangrene of whole foot.
Ulcers graded 0–3 tend to be predominantly neuropathic, whereas in those
graded 4 or 5 ischaemia is the main factor.
Fig. 5.8
A neuropathic ulcer.
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The Care of Wounds
Planning
Adequate control of the diabetic state is the primary goal when managing
patients with foot ulceration. Pain control may also be necessary. Management
of the ulcer depends on the causative factors. On the whole, neuropathic ulcers
should be referred to the chiropodist/podiatrist as the callus needs to be
removed before the ulcer can heal. Pressure must also be removed from the
ulcer and this can be achieved in several ways such as use of extra-depth
insoles, Scotchcast boot, Aircast boot, Total Contact Cast or even the use of
crutches. Ischaemic ulcers may be resistant to treatment. Necrotic tissue must
be debrided by use of appropriate wound management products (as discussed
in Chapter 3). Any infection should be treated with systemic antibiotics and the
application of suitable dressings (see Chapter 4). Compression bandages should
not be used but, if necessary, a simple retention bandage can be used to hold
the dressing in place.
Some patients may benefit from revascularisation and should have a prompt
referral for a vascular opinion (NICE, 2004). Faries et al. (2004) discussed the
role of arterial reconstruction and noted that in centres of excellence, 70% of
surgical bypass grafts will still be patent after five years and the associated fiveyear limb salvage rate was greater than 80%.
Evaluation
Measurement of the ulcer by tracing may not provide adequate information as
the surface area may not appear to alter greatly. A photographic record may be
of more value. Careful assessment for any indication of infection should be
made at each dressing change. Failure to respond to treatment can result in
osteomyelitis. Surgical treatment is necessary to eradicate the infection. The
NICE guidelines state that patients should be referred to a multidisciplinary
foot clinic within 24 hours if there is a new ulcer, new swelling or new discolouration of the foot (NICE, 2004).
Once the ulcer is healed, preventive measures need to be instigated.
5.5 FUNGATING WOUNDS
Malignant fungating wounds are particularly difficult wounds to manage. They
are distressing for both the sufferer and the nurse. A major problem is that there
has been very little research into the management of this type of lesion. It is
interesting to note that what little research there is has predominantly been
undertaken within the UK (Schiech, 2002). A postal survey (Thomas, 1992) has
provided some information about current practice in radiotherapy centres
across the UK. Thomas noted that several respondents commented on the lack
of published data and the generally unscientific approach to the management
of fungating wounds. Little has changed in the years since that survey was
undertaken. It is undoubtedly a difficult area to research but it is an important
area to tackle, not least in order to improve the quality of life for these patients.
The Management of Patients with Chronic Wounds 163
5.5.1 Aetiology and incidence
Fungating lesions occur when a cancerous mass invades the epithelium, thus
ulcerating through to the body surface. It has been estimated that between 5%
and 10% of patients with metastatic cancer will develop a fungating wound
(Haisfield-Wolfe & Rund, 1997). It most commonly occurs with cancer of the
breast but may also be found in cancers of the skin, head and neck, vulva and
bladder (Dowsett, 2002). Fungating wounds not only develop at the site of the
primary tumour but if the nodes of the groin or axilla are affected, ulceration
may also occur at that site.
Fungating lesions are often associated with neglect; that is, the patient delays
seeking medical help. This is commonly seen in patients with breast cancers. A
typical example is the lady who ‘ignores’ her breast lump for several years and
only seeks help when her family notice the offensive odour.
5.5.2 Management of fungating wounds
Management of the patient
This is a vital part of the management of these wounds. Many factors within
the patient can affect the progress of the wound. Naylor (2001) discussed the
issue of wound pain for patients with fungating wounds and the need to
address the psychological, social and spiritual aspects of pain. Chapter 2 discusses patient care in greater detail.
Management of the wound
Chapter 3 covers the general principles of wound management. This section
will address the specific problems related to fungating wounds.
Assessment
When assessing the wound, the following factors need to be considered.
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Fungating lesions are often necrotic, sloughy or infected.
There are usually copious amounts of exudate, which may have an offensive
odour.
Many of these wounds become malodorous as a result of bacterial invasion.
This causes distress to the patient, relatives and visitors and may be very difficult to control.
The position of the wound obviously depends on the type of cancer.
However, it may spread along the trunk or limbs, sometimes in the form of
isolated nodules. Applying a dressing to protect such a spread-out lesion can
be very difficult and requires considerable nursing skill.
Capillary bleeding may occur as the cancer increases in size and erodes blood
vessels. It may be sufficiently heavy or frequent as to cause anaemia.
Removal of the old dressing must be done with great care in order to avoid
loosening any clots.
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The Care of Wounds
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Lymphoedema may be present with cancers of the breast, cervix or vulva.
This is a chronic swelling of the adjacent limb(s) due to a failure of lymph
drainage. It may be associated with loss of function of the affected limb. (See
also section 5.6.)
Planning
It is essential to identify patient problems rather than nurse problems. Whilst
in many instances they may be the same, they are not always. In her studies,
Grocott (1998, 2000) reported the impact of fungating wounds on the patients,
quoting patients using words such as ‘revulsion’ and describing the constant
washing of soiled clothing and bedclothes. She concluded that an efficient
dressing system that would cope with the exudate was essential to allow
patients to cope with their disease (Grocott, 2000).
Once the specific problems have been identified, the treatment options have
to be planned in the light of the patient’s condition. If the expected outcome is
very poor, then totally palliative care with the minimum need to dress the
wound must be the treatment of choice. For others, a more aggressive approach
can be used. A course of radiotherapy may be prescribed to help reduce the size
of the lesion. It should be remembered that many patients find dressing change
a major ordeal that leaves them feeling very tired.
As previously noted, copious exudate is a problem that concerns patients.
Very absorbent dressings are necessary to provide comfort and dryness for the
patient. Alginates and hydrocellular foams can be effective in controlling
exudate. Grocott (1997, 1998) has undertaken a longitudinal multiple case study
design to monitor the outcomes when using different dressings to manage
exudate. She considered that the factor of greatest importance is fitting conformable dressing materials to the wound, thus reducing the risk of leakage.
Dressing bulk can be reduced by the use of outer dressings with high moisture
vapour transfer rates.
Odour causes great distress to patients. It is mostly due to bacterial invasion,
although exuding necrotic wounds may also be offensive. A wound swab will
identify the invading bacteria, so that appropriate systemic antibiotics can be
prescribed. Topical agents can also be used. Clark (2002) reviewed the use of
metronidazole for malodorous wounds and concluded that there was a lack of
evidence to determine the best method of delivery, the dose and the optimum
length of treatment. However, it is widely used to reduce odour. Silver sulphadiazine cream can be used for Pseudomonas aeruginosa infections. Honey and
other types of silver dressings may be useful for odour reduction.
If the odour cannot be reduced or whilst action is being taken to reduce
odour, other steps can be taken. The aim is to mask the smell which can be
achieved in a variety of ways. Activated charcoal dressings can be effective in
absorbing odour (Lawrence et al., 1993) and are often used in conjunction with
other dressings. Air fresheners can help and stoma therapists can give advice
on the use of deodorant solutions used by ostomists.
When aggressive treatment is suitable, wound debridement is an option.
Removal of necrotic or sloughy tissue can reduce odour and exudate. The
The Management of Patients with Chronic Wounds 165
quickest method is surgical debridement which must be done by a skilled
surgeon because of the distorted anatomy and the risk of capillary bleeding.
Surgical debridement is not a suitable option for patients with a history of capillary bleeding into the wound. A variety of wound management products can
be used, depending on the amount of exudate. Alginates can be used on heavily
exuding wounds. When there is moderate to low exudate, an amorphous
hydrogel and occasionally hydrocolloids can be used. The position, size and
spread of the lesion can affect dressing choice.
Capillary bleeding can be frightening for both the patient and the nurse.
When there is a history of capillary bleeding, great care should be taken when
removing the old dressing. If the dressing is adherent, it should be soaked with
saline before removal is attempted. It may also be necessary to remove the
dressing slowly in stages. It is better to take a long time to remove a dressing
than to start bleeding which is difficult to control.
Adrenaline can be applied directly to the wound to control profuse bleeding.
However, it should be used with caution, under medical supervision. Alginate
dressings are useful when there is oozing and can be removed easily by
washing away with saline. If there is persistent bleeding, the haemoglobin
should be checked regularly. Blood transfusions may be necessary to treat
anaemia.
If the lesion is being treated with radiotherapy, attention must be given to
dressing selection. A variety of dressings have been found to be suitable: charcoal dressings, alginates and an amorphous hydrogel. Dressing retention may
be a problem. Ideally, the dressing should not be too bulky because it makes
the wearing of clothes difficult and the patient becomes very self-conscious.
Bandages and tubular net and tubular gauze are probably the most versatile
means of dressing retention. Tape should be used with care as the skin may
become sore with repeated dressing change. If the patient is undergoing a
course of radiotherapy to the lesion, it may be necessary for the outer dressing
to be removed for treatment. Again, the skin may become sore. ‘Garments’
made from tubular net allow easy access to the wound and will not further
damage the skin.
Evaluation
Evaluation of the management of fungating wounds should always consider
whether the predetermined goals have been attained. Good documentation can
be used to maintain a record of effective care, thus providing guidelines for the
management of other patients. Managing a fungating wound and providing
care for the patient require considerable nursing skills. More research is needed
in order to be able to identify the most effective care.
5.6 LYMPHOEDEMA
Lymphoedema occurs when there is absence, obliteration or obstruction of the
lymph vessels, which results in accumulation of fluid distal to the damage as
166
The Care of Wounds
the transporting capacity of the system is reduced. Although associated with
cancer, lymphoedema can be either primary or secondary. To date, no cause
of primary lymphoedema has been identified (BLS, 2001). Secondary lymphoedema is primarily seen to be a consequence of cancer or cancer treatment
but it may also be caused by low-grade infection or inflammation, trauma or
filariasis (Board & Harlow, 2002a). Filariasis is a parasitic invasion of the lymph
system, enabled by mosquitoes, and is estimated to affect more than 120 million
people worldwide (WHO, 2001).
5.6.1 Lymphoedema management
Although there is much greater awareness of lymphoedema management than
there used to be, some patients with lymphoedema may have been told that
nothing can be done to reduce the swelling. This is not true. Whilst it is not
possible to cure lymphoedema, it can be controlled. Ideally, patients should be
referred to a specialist treatment centre to ensure the most effective care. Within
Europe, especially Germany, Austria and the UK, there are a number of centres
available that offer this treatment (Board & Harlow, 2002b).
Assessment
Board and Harlow (2002a) list the clinical features that need to be considered
as part of an assessment.
䊉
䊉
䊉
䊉
䊉
䊉
Identify the cause of the lymphoedema and any associated medical conditions,
in conjunction with the medical team.
Oedema – assess the extent of the oedema. Does it affect one or more limbs?
Has it spread to the trunk? Measure limb size by taking measurements every
4 cm along both the affected and the unaffected limb.
Skin status – the skin may become dry, scaly and rough or it may be taut and
shiny. Eventually skinfolds and crevices occur because of the severe oedema
and will result in hyperkeratosis.
Acute inflammatory episodes – the presence of lymphoedema makes an individual more vulnerable to infection from small breaks in the skin. Cellulitis
can spread rapidly through the affected limb (Mortimer, 2001).
Lymphorrhoea – the leakage of lymph through small breaks in the skin; this
can be seen as fluid constantly trickling down the affected limb.
Mobility – has the oedema affected movements of the limb? What impact has
this had on activities of daily living? Is there associated pain with the heaviness of the limb?
Management
Board and Harlow (2002b) suggest that treatment should be offered in three
categories: intensive, in order to reduce moderate or severe oedema; maintenance, to provide long-term control of oedema; and palliative, to alleviate
symptoms in the final stage of life. Any treatment plan needs to be developed
in partnership with the patient and it may also need to involve family members.
Treatment comprises skin care, compression, massage and exercise.
The Management of Patients with Chronic Wounds 167
Skin care is a vital aspect. Williams and Venables (1996) describe the need for
daily washing and careful drying, especially between the digits. Emollient
creams should be applied to prevent the skin drying out and cracking and the
development of hyperkeratosis. Care should be taken to prevent the swollen
limb getting burnt by the sun. Cuts and scratches can be a source of infection
and should be treated with antiseptic cream. Gloves should be worn for protection when working in the kitchen or garden. Jeffs (1993) has reviewed the
effects of infection in lymphoedema. She suggests that Streptococcus is generally the causative organism. The infection should be treated with appropriate
antibiotics.
Compression can be provided by means of multilayer bandages or compression hosiery, such as a sleeve (Board & Harlow, 2002b). In the initial stages of
treatment, bandages assist in reducing limb size. In severe cases the digits as
well as the hand and arm, or foot and leg, should be bandaged. Once the limb
has been reduced to a reasonable size, compression hosiery can be used to maintain limb reduction. Intermittent pneumatic compression may be of use for
some patients, in addition to massage and not as an alternative. The most effective type of compression is the multichamber sequential pump. The best effect
is obtained by clearing fluid from the trunk before commencing treatment.
Massage is an important aspect of lymphoedema management and may be
in the form of manual lymphatic drainage or simple massage. The former
should be undertaken by a healthcare professional who has received training
in the technique but the latter may be taught to patients or their relatives.
Massage encourages the flow of lymph away from the limb. Occasionally, the
swelling may have spread beyond the limb into the trunk. Massage should start
on an area of the trunk free of lymphoedema before moving to a lymphoedematous area (Regnard et al., 1997). This creates a space for the lymph in the
swollen limb to flow into. The massage then continues down the affected limb.
The massage technique should be gentle, so that it does not stimulate blood
flow into the limb and increase congestion. It may need to be a little firmer
when tissue fibrosis is present. Board and Harlow (2002b) recommend that
patients/relatives be advised to spend 20 minutes each day undertaking
massage. Patients and relatives often find that undertaking this massage creates
a sense of closeness that may be of particular benefit for those who are terminally ill.
Ko et al. (1998) monitored the effects of treatment for 299 patients over a 12month period. They found a 59.1% size reduction in arms and 67.7% reduction
in legs after initial treatment averaging 15.7 days. This was maintained in 88%
of compliant patients. The non-compliant patients regained 33% of the initial
reduction. McNeely et al. (2004) randomised 50 patients with lymphoedema
associated with breast cancer to compression bandaging or compression bandaging plus manual lymphatic drainage. They found that all patients achieved
a significant reduction in arm volume after four weeks but those with mild lymphoedema in the combination treatment group had a significantly larger reduction in limb volume. However, these numbers are small and a larger study is
needed to confirm this finding.
168
The Care of Wounds
Exercise assists in improving drainage of lymph from the limb. Muscle movement alters tissue pressure and has a massaging effect on the lymph vessels.
The best effect is obtained if the exercises are carried out when the patient is
wearing compression bandages or hosiery. Exercise also prevents or reduces
stiffness of the joints. Passive movements should be carried out if the limb is
paralysed. All patients should be encouraged to move as much as possible but
lifting and carrying heavy weights should be avoided. It is important to provide
encouragement to the patient to persevere with all aspects of this plan as
none of these treatments is effective in isolation. Significant reduction of a
swollen limb can only be achieved when all aspects of the treatment plan are
implemented.
Evaluation
Reduction in limb size, improvements in skin status and greater limb mobility
are all desirable outcomes that can easily be measured.
5.7 CONCLUSION
The management of chronic wounds is complex and requires skilled care that
is best undertaken by a multiprofessional team. Fortunately, there is increasing
access to specialist services that have made a major impact on improvement in
patient care.
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The Management of Patients with Acute Wounds 179
Chapter 6
The Management of Patients with Acute Wounds
6.1 INTRODUCTION
Acute wounds can be defined as wounds of sudden onset and of short duration. They include surgical wounds and traumatic wounds such as burns. Acute
wounds can occur in people of all ages and generally heal easily without complication. This section will consider the specific care needed for patients with
acute wounds.
6.2 THE CARE OF SURGICAL WOUNDS
Surgical wounds are, by their very nature, premeditated wounds. This allows
the surgeon to attempt to reduce any risks of complication to a minimum.
However, as increasingly sophisticated surgery is performed, often on relatively
elderly patients, complications are still a hazard. One aspect of nursing care is
to monitor the progress of the wound, so that there is early identification of any
problems.
6.2.1 Management of surgical wounds
Patient assessment
This is essential to identify any factors that might affect healing. This topic is
covered in more detail in Chapter 2.
Wound assessment
This should identify the method of closure, note the use of any drains and
observe for any indication of complication. Westaby (1985) described the main
aim of surgical wound closure as the restoration of function and physical
integrity with the minimum deformity and without infection. The method of
wound closure is selected in order to achieve this aim and it will vary according to the surgery performed. There are three methods of closure: primary
closure, delayed primary closure and healing by second intention.
Primary closure
Hippocrates (460–377 bc) was the first to describe this method of wound
closure. He called it healing by first intention. The skin edges are held in
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approximation by sutures, clips, staples or tape. In these wounds the skin edges
seal very quickly, first with fibrin from clot formation and then as epithelialisation occurs. Within 48 hours the wound should be totally sealed, thus preventing the ingress of bacteria.
Nursing care
The care of wounds healing by first intention is generally straightforward. A
simple island dressing is commonly used to cover the wound at the end of the
operation. Several studies have shown that the dressing can be removed
after 24–48 hours and need not be replaced, (Chrintz et al., 1989; Cruse &
Foord, 1980; Weiss, 1983). Some surgeons prefer to cover the wound with a
film dressing and leave it in place until the sutures are removed. Whichever
method is used, normal hygiene can be resumed and the patient may bathe or
shower.
Some more recent studies have been able to add further information. Wikblad
and Anderson (1995) randomised 250 heart surgery patients to an island dressing, a hydrocolloid dressing or a hydroactive dressing. They found that overall,
the island dressing outperformed the other dressings in terms of being less
painful to remove and causing less redness to the wound site and skin changes
to surrounding skin. Significantly more wounds healed under the standard
dressing than the hydroactive (57% compared with 27%). Fifty percent of the
wounds in the hydrocolloid group healed, there being no significant difference
with the standard dressing group. Despite requiring more dressing changes
over five days, the island dressing was considerably cheaper than the
comparators.
Allen (1996) also studied the care of sternal wounds following heart surgery.
After an initial observation study of 100 patients to observe the impact of using
gauze immediately after surgery and removing it on the first postoperative day,
it was concluded that there was actually an increased risk of infection in these
patients. Subsequently three dressings were trialled successively: in week 1, 73
patients received Duoderm Extra ThinTM; in week 2, 75 patients had OpraflexTM;
and in week 3, 77 patients had Opsite Post-OpTM. The author found that
Opsite Post-OpTM remained in place longer than the other dressings and
bathing was easier. It was also easier to remove as it did not pull on the sutures.
There was no real difference in infection rates compared with the observational
study.
Holm et al. (1998) compared a standard island (control) dressing with a
hydrocolloid dressing on 73 patients following clean abdominal surgery, the
dressings remaining in place until suture removal. Unfortunately, 29 patients
withdrew from the study, leaving a relatively small number to complete the
study. The incidence of wound infection was higher in the control group (5/17)
compared with the hydrocolloid group (1/26). There were no other differences
in respect of leakage, dressing detachment and cosmetic appearance. The
authors noted that the patients seemed to find the hydrocolloid more comfortable and mobilising was easier. This finding seems to support the results from
the next study to be discussed.
The Management of Patients with Acute Wounds 181
Briggs (1996) undertook a small study where 30 patients undergoing
hysterectomy were randomised to either a dry dressing removed after 48 hours
or a film dressing left in place until suture removal. She found a significant
difference in pain on day 3 after the dry dressing had been removed. Those
with no dressing had sufficient pain to require analgesia.
A much larger study compared three dressings used on sternotomy wounds:
an island dressing, a film dressing and a thin hydrocolloid dressing (Wynne et
al., 2004). A total of 737 patients were randomised to one of the three dressings.
The authors found no difference in the incidence of wound infection or healing
rates. The island dressing was seen to be the most comfortable and cost
effective of the three dressings. It seems reasonable to conclude that although
there may not be a need for a dressing over a surgical incision to prevent
infection, use of a dressing is more comfortable for the patient. A simple island
dressing appears to be comfortable to wear and remove as well as being
relatively cheap.
Surgical wounds should be monitored daily for any indication of
complication.
Removal of sutures or other types of wound closure is usually carried out
under medical supervision.
Delayed primary closure
This method of closure is used when there has been considerable bacterial contamination. Initially, any body cavity is closed and the remaining tissue layers
are left open to allow free drainage of pus. After about five days, these layers
are closed and the wound will heal as any primarily closed wound. Wound
drains may be used to assist in the removal of any fluid remaining at the wound
base. Cohn et al. (2001) demonstrated that delayed primary closure was an effective method of treatment for dirty abdominal surgical wounds compared with
primary closure. There was a significantly higher incidence of infection in the
primary closure group (11/23 – 48%) compared with the delayed primary
closure group (3/26 – 12%).
Nursing care
The aim of management of these wounds is to allow free drainage of any pus.
This may be achieved by loose packing of the cavity. As the wound will be
sutured at about day 5, the promotion of granulation is not a major aim. If
ribbon gauze is used, it should be kept moist and changed regularly to prevent
it drying out and adhering to the wound. Alginate rope may also be used, as
it is very absorbent and can be removed without pain to the patient. Once the
wound is sutured, it should be treated as a wound healing by first intention.
Healing by second intention
Healing by second intention describes a wound that is left open and heals by
granulation, contraction and epithelialisation. This method may be used for a
variety of reasons.
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The Care of Wounds
䊉
䊉
䊉
There may be considerable tissue loss, e.g. radical vulvectomy.
The surgical incision is shallow but has a large surface area, e.g. donor sites.
There may have been infection; for example, a ruptured appendix or an
abscess may have been drained and free drainage of any pus is essential.
Nursing care
The care of varying types of surgical wounds will be described here.
䊉
Surgical cavities
䊉
Surgical cavities are generally clean wounds with a healthy bed that would be
expected to heal without complication. Harding (1990) suggests that surgical
cavities should be boat-shaped in order to heal rapidly without premature
surface healing. Simple wound measurement is usually sufficient to monitor
healing rates (see Chapter 3). These wounds should also be observed for indications of infection.
Selection of a suitable dressing depends on the position of the wound and
the amount of exudate. Traditionally, ribbon gauze packing, often soaked in
antiseptic solutions, has been used in these wounds. Ricci et al. (1998) compared
iodine-soaked gauze with a foam stent in patients following pilonidal sinus
excision and found the foam stent to be more effective. Healing time was faster
– median 33.5 days compared with 73 days. The patients with the foam stent
were able to return to work after 12 days compared with 23 days. Far fewer
dressing changes were required: 20 foam stents compared with 868 gauze
packs. In addition, the foam stent group had pain-free dressing changes
whereas the gauze group found the dressing change painful and bleeding
occurred. This small study clearly demonstrates the problems found with gauze
packing.
Most of the studies have been small studies like the one described above.
Vermeulen et al. (2004) undertook a systematic review of dressings and topical
agents used to manage surgical wounds healing by secondary intention. They
concluded that the studies were too small to provide guidance on the treatment
of choice. However, they found that foam had been most frequently studied as
an alternative to gauze and that it seemed to be preferable in respect of pain
reduction, patient satisfaction and nursing time. Further large studies are
required to provide clear evidence as to the most effective treatment regimes.
䊉
Skin grafts
䊉
Skin grafts are widely used in reconstructive surgery following trauma or
burns. They may also be used to repair chronic wounds such as pressure sores
or leg ulcers. Skin grafting is a technique that permits the transfer of a portion
of skin from one part of the body to another. There are several ways of classifying skin grafts. They can be divided into:
䊉
䊉
䊉
autografts – a graft of the patient’s own skin
allografts – a graft taken from another individual
xenografts – a graft taken from another species.
The Management of Patients with Acute Wounds 183
Grafts can be described according to their thickness. This depends on the
amount of dermis that is included in the graft. A full-thickness graft includes
the epidermis and all the dermis. A partial or split-thickness graft includes the
epidermis and some dermis. This type of graft can be cut to varying thickness
depending on need. The graft can also be meshed in order to cover a larger
surface area.
Other types of graft are flaps or pedicle grafts, pinch grafts and tissue cultures. Flaps may include other tissue besides skin and one part of the graft is
still attached to original site. This provides a blood supply to the graft until a
new blood supply has been established. It is particularly useful in areas where
the blood supply is poor and for areas of the face. An example is a gluteal rotation flap to cover the cavity of an ischial pressure sore.
Pinch grafts are small pieces of skin that have been obtained by pinching the
area with forceps or lifting with a needle and slicing off with a knife. They have
been used as a method of treating leg ulcers but there is limited evidence as to
their success in long-term healing of leg ulcers.
Tissue culture has been developed primarily in burns units, where repeated
grafting from the same donor site may be necessary for patients with large
surface area burns. A small sample of skin about 2 cm in diameter can be used
to culture epithelial sheets many times this size. One of the early studies using
this method was carried out by Gallico et al. (1984) on two children who had
burn injuries affecting more than 95% of their body surface area. Tissue culture
provided effective grafts for more than 50% of the body surface. When such
extensive burns occur, autografting is very limited because of the lack of appropriate donor sites. Allografts are also used but they do not always take. Tissue
culture can reduce the need for frequent surgery to take further grafts.
Grafts may be sutured or stapled in position or just laid in place. The graft
may be left exposed or covered with a dressing to help anchor it in place. The
graft must be observed carefully for any indication of infection, oedema or
haematoma. It may also be necessary to immobilise the area so that the graft
does not slip out of position. Tension over the graft must also be avoided as it
may damage the vulnerable blood supply.
Gauze dressings and paraffin gauze have been used to cover grafts but there
is no evidence to determine their effectiveness. Davey et al. (2003) described the
use of HyperfixTM in a paediatric burns unit over a 15-year period. It was used
for over 700 grafts and found to be an effective covering, with only 18 patients
(2%) requiring repeat grafts. Peanut oil was routinely applied to the strapping
two hours before dressing change in order to facilitate its removal without
damage to the graft.
Some small studies have been undertaken to investigate the use of a silicone
net dressing. Vloemans (1994) used the silicone dressing on 45 split-thickness
skin grafts and found that no grafts were lost. However, the main advantage
was that dressing removal was painless, unlike the standard treatment of either
a non-adherent dressing or paraffin gauze. Platt et al. (1996) undertook a small,
randomised trial comparing the use of a silicone net dressing with paraffin
gauze. There was no difference in graft take between the two groups. However,
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The Care of Wounds
the silicone net group had significantly less pain at dressing change and the
dressing was easier to remove than the paraffin gauze. Although there have
been no further published studies, there is widespread use of silicone net as a
fixative material.
A small study investigated the use of topical negative pressure therapy (TNP)
as a fixative for split-thickness skin grafts (Moisidis et al., 2004). Twenty-two
patients were recruited and the donor sites divided into two halves and then
each half randomised to either TNP or standard treatment of silicone net,
proflavine wool and foam sponge. A narrow bridge of several layers of hydrocolloid separated the two treatments. The authors found that there was no significant difference in graft take between the two treatments but quality of the
graft take was significantly better in the TNP group. However, this is a very
small study and a larger study is required to determine a definitive outcome.
As the graft becomes vascularised, it turns approximately the same colour as
the donor site. In Caucasians, the ideal colour is pink. It is more difficult to
assess the vascularity of a graft in darker skins. Coull and Wylie (1990) suggest
the use of a colour code along with an assessment chart to monitor the progress
of skin flaps. Once a graft has taken, it still needs to be handled very carefully
as the tissues are still fragile. It should be protected against any extremes of
temperature and sunlight. Once the graft is healed, the skin should be massaged twice daily with a bland moisturising cream. This helps to improve the
suppleness of the skin, as it is likely to be less well lubricated than normal.
A graft may fail to take for a variety of reasons. If there is an inadequate blood
supply to the graft bed the microcirculation will fail to grow into the graft and
it will necrose from lack of oxygen. Equally, haematoma formation will cause
separation of the graft. If the graft slides out of position it will cause separation
of some or all of the graft and lead to failure.
Infection, especially from Pseudomonas aeruginosa and beta-haemolytic streptococcus, will also cause failure. Infection will cause pain, odour, itching and
redness around the edges of the graft and a low-grade fever (Francis, 1998). It
is most likely to occur between the second and fourth postoperative days.
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Donor sites
䊉
Ideally, skin grafts are taken from a part of the body where the skin provides a
good match for the recipient site. The colour, texture and hair-bearing properties of the skin have to be considered. One of the commonest areas for a donor
site is the thigh, from which a large area of skin can be obtained.
Donor sites are often described as being more painful than the skin graft for
which the removed skin has been used. This is probably, in part, because of the
large number of exposed nerve endings. Initially, a donor site is a raw haemorrhagic area. Pressure is needed to stop the bleeding and the wound should
be checked regularly in the immediate postoperative period. Analgesia is also
necessary and may be needed for several days.
Traditionally, donor sites have been dressed with paraffin gauze, covered
with ordinary gauze, wrapped in wool roll or gamgee and held in place with
bandages (Wilkinson, 1997). The dressing is left in place for about ten days and
The Management of Patients with Acute Wounds 185
then removed. This is often a very painful experience as the dressing has dried
out and adhered to the wound. The patient may have to sit in the bath in order
to soak the dressing off. Damage to the newly formed tissue can occur as
the dressing is pulled away. The newly epithelialising wound may be quite
sore and dessicated. Aqueous cream or a similar emollient may be applied as
a moisturiser.
A systematic review by Wiechula (2003) examined the use of dressings for
the management of donor sites. The outcomes of using all types of moist wound
and non-moist products were compared using meta-analysis. It showed a significant benefit of moist wound products such as films, foams and hydrocolloids compared with non-moist dressings such as paraffin gauze in terms of
healing, pain and wound infection. The author also compared different types
of products with paraffin gauze. Hydrocolloids were significantly better in
terms of healing, pain and wound infection. Films also outperformed paraffin
gauze in terms of healing, pain and wound infection. There were insufficient
studies of good quality to determine the relative effectiveness of alginates.
Since this review was undertaken, two studies of interest have been published. Misirlioglu et al. (2003) compared honey-impregnated gauze with paraffin gauze, saline soaks and a hydrocolloid in 88 patients with donor sites. They
found the honey gauze performed significantly better than the paraffin gauze
and the saline soaks in respect of healing, pain and wound infection. There was
no difference in the results when compared with the hydrocolloid. A smaller
study by Barnea et al. (2004) compared AcquacelTM with paraffin gauze on 23
donor sites, each dressing being randomly applied to half of the site. The
AcquacelTM sites healed significantly faster and caused less pain to the patient.
Dressing changes were also easier.
Donor site management seems to be one area where there is reasonably clear
evidence that modern products outperform paraffin gauze. It is difficult to
understand, therefore, why this outdated product is still in use.
Once the donor site has healed, the skin should be kept supple. Emollients
may be of assistance and should be applied two or three times a day. The patient
should be advised to avoid extremes of temperature. If it is not possible to avoid
exposing the site to sunlight, sun blockers should be used to cover the area.
Donor sites remain susceptible to sunburn for up to a year after healing (Fowler
& Dempsey, 1998). A tubular bandage may be applied to donor sites on a lower
limb to provide support and to prevent hypertrophy of the scar.
Wound drains
Wound drains are inserted to provide a channel to the body surface for fluid
that might otherwise collect in the wound. The fluid may be blood, pus, serous
exudate, bile or other body fluids. There are several different types of drains,
which can be divided into open and closed drains. Open drains may be tubes,
corrugated rubber or plastic, or soft tubes filled with ribbon gauze to provide
a wicking effect. Open drains originally drained into the dressing, causing considerable discomfort to the patient. They also increased the risk of infection as
186
The Care of Wounds
the drain provided an open channel for bacteria. As a result of the classic
research by Cruse and Foord (1973, 1980), which demonstrated the infection
hazard posed by open drains, they are rarely used these days.
Closed drains consist of the drain, connection tubing and the collecting receptacle. They usually provide a vacuum and so have a suction effect. Chest drains
are closed drains that work rather differently. The purpose of this type of system
is to allow air to escape from the chest cavity and bubble into the water in the
container. Closed drains are usually inserted through a stab wound adjacent to
the incision.
The use of drains is essential to prevent the collection of fluid in the wound.
This is more important with some types of surgery than others. Several studies
have investigated the use of drains, some finding them of value and others not.
Varley and Milner (1995) randomly allocated 177 patients undergoing surgery
for proximal femoral fracture to receive wound drainage or no drainage. Twice
as many patients (13.2%) in the undrained group developed wound infections
compared to the drained group (7%). However, this difference did not reach
statistical significance, possibly because the numbers of infections were small.
Perkins et al. (1997) randomised 222 patients undergoing face-lift surgery to
drains or no drains and found a significant reduction in the formation of
seromas in the group that received drainage. There was also a reduction of
haematoma formation in this group but the difference did not reach statistical
significance. Holt et al. (1997) randomised 136 patients undergoing total knee
arthroplasty to the use of drains or no drain. They found a significant difference between the two groups, with the undrained requiring greater dressing
reinforcement and developing a greater level of ecchymosis.
Conversely, the use of drains was shown not to have any particular advantage in the following studies. Maharaj et al. (2000) randomised 440 women
undergoing emergency caesarean section to either drainage or non-drainage.
They found no significant difference between the two groups in terms of wound
inflammation, wound infection, haematoma formation or length of stay.
Purushotham et al. (2002) randomised women undergoing surgery for breast
cancer to either drains or no drains and found no difference in surgical outcomes. However, they did find that the no drains group had a significantly
shorter hospital stay (3.75 days versus 5.23 days). Brown and Brookfield (2004)
studied the impact of drain usage in a randomised study of 83 patients undergoing extensive spinal surgery and found no difference between the two groups
in a range of measures including infection rates, haematoma and length of stay.
It seems reasonable to conclude that with improving surgical techniques and
materials, drains do not need to be used as frequently as they have been in the
past. However, they are still of benefit in some types of surgery, especially some
types of orthopaedic and plastic surgery procedures.
6.2.2 Managing complications
A variety of complications may occur following surgery. Only those related to
the wound will be discussed here.
The Management of Patients with Acute Wounds 187
Haemorrhage
This may occur during surgery, in the immediate postoperative period and up
to ten days afterwards. It is sometimes categorised as primary, intermediary
and secondary haemorrhage. The main cause of both primary and intermediary haemorrhage is poor surgical technique due to failure to control bleeding
during surgery or poorly tied blood vessels. As the blood pressure returns to
normal levels, the clots and ties get pushed off the end of the blood vessel(s),
resulting in bleeding. Secondary haemorrhage is invariably associated with
infection.
Taylor et al. (1987) studied the effects of haemorrhage on wound strength.
They found that perioperative bleeding caused a weaker suture line, which was
associated with impaired fibroblast function. The researchers suggest that nonabsorbable or long-lasting sutures should be used if haemorrhage occurs during
surgery.
The bleeding may be brisk and rapidly seen or more insidious. Blood may
be seen on the wound dressing or it may drain into a drainage bag. If the bleeding is internal, signs of shock may be the first indication of its presence. If there
is only a little bleeding, the blood may ooze into the superficial tissues and
show as bruising around the suture line. Slow seeping of blood may lead to
haematoma formation when the blood collects in a ‘dead space’ around the
operative site and then clots.
If there is heavy bleeding, further surgery may be needed to find and control
the bleeding point. In many cases the bleeding is monitored closely to see if
further clotting will resolve the problem. When a haematoma forms it is a
potential breeding ground for bacteria. It is sometimes possible to remove a
suture in order to evacuate the haematoma.
Infection
Despite considerable improvement in standards of asepsis, postsurgical wound
infection still occurs. In a national survey undertaken in the UK, surgical wound
infection was found to account for 10.7% of all hospital-acquired infections
(Emmerson et al., 1996). These findings are not dissimilar to those of national
surveys undertaken in Switzerland, which found an infection rate of 10.1% in
1999 and 8.1% in 2002 (Sax, 2004). Measuring infection rates is one method used
in evaluating standards of care for surgical audit. Recently surveys have tended
to involve only those undergoing a particular type of surgery. For example,
Harrington et al. (2004) undertook a survey of 4475 patients undergoing heart
surgery in five hospitals. Of these patients, 310 (6.9%) developed 346 infections:
191 sternal infections, 89 saphenous vein site infections and 66 radial artery site
infections. Using multivariate analysis, the study team also found obesity, diabetes and age to be independent predictors of surgical site infection. Herruzo
et al. (2004) monitored trauma patients who required more than two days in
hospital and found a 2% clean wound infection rate.
However, the patients in both of these studies were not followed up after discharge and therefore the total numbers of infections may be underestimated. A
188
The Care of Wounds
study by Jonkers et al. (2003) followed patients undergoing cardiac surgery for
90 days and divided infections into sternal wound infections (SWI) and donor
site infections (DSI). They found that considerably more infections were diagnosed at 30 days compared with those identified during hospital admission:
SWI rose from 4.7% to 6.8% at 30 days and DSI rose from 1.5% to 4.6% during
the same period. They had risen further by 90 days to 9% (SWI) and 7.3% (DSI).
The authors concluded that accurate surveillance should include follow-up
after discharge.
Wilson et al. (1990) have produced a scoring system for infections that they
found to be reproducible. The ASEPSIS wound scoring system, with the
grading for the severity of infection, is shown in Figure 6.1. The authors compared this system with other methods when assessing 1029 surgical patients.
Further work by Wilson et al. (1998) reports a comparative study of four
different methods of assessing wounds for infection. Patients were assessed
during their hospital stay and followed up after discharge. The authors found
that the infection rate depended on the definition being used.
It is important to remember that it is not always possible to make direct comparisons between different surveys because of the varying methods of data collection. The criteria used for defining wound infection may also vary. Crowe
and Cooke (1998) instigated a debate on case definitions of surgical wound
infections and listed several definitions used by a variety of researchers. They
hoped that the ensuing debate would result in consensus on which definition
should be used for national and international surveys.
When measuring the incidence of surgical wound infections, it is essential to
understand the potential causes. The causes of infection can be divided into
factors related to the environment, the patient and the surgery; they are summarised in Box 6.1. The first two factors have already been discussed in Chapter
2 so only those relating to the surgery will be considered here. One of the most
important aspects is the type of surgery being undertaken. Cruse and Foord
(1973, 1980) categorised operations into clean, clean-contaminated, contaminated and dirty, a method that has become widely recognised and used in other
studies. Box 6.2 explains these categories and shows the infection rates found
by Cruse and Foord (1980). There is a quite dramatic difference in infection rates
between clean and dirty surgery. The clean wound infection rate is usually used
as a baseline for monitoring other factors that may affect infection rates. KampHopmans et al. (2003) also found different infection rates in different specialties over a five-year period, with 1.8 per 100 operations in a thoracic surgery
ward, 4.6/100 operations in an orthopaedic ward, 5.3/100 in a gynaecology
ward and 5.4/100 in the general surgery and vascular wards.
Probably the most important factor to consider is surgical technique. Cruse
and Foord (1980) found that meticulous attention to detail was essential to keep
clean wound infection rates low. Israelsson (1998) surveyed 1013 patients who
underwent a midline laparotomy and found the individual surgeon’s infection
rates ranged from 0% to 27%. The length of surgical experience of the surgeons
did not affect the complication rate in this study. Reilly (1997) audited the infection rates within a district general hospital and found a direct correlation
The Management of Patients with Acute Wounds 189
TABLE A
Proportion of wound affected (%)
Wound characteristic
Serous exudate
Erythema
Purulent exudate
Separation of deep tissues
0
<20
20–29
40–59
60–79
>80
0
0
0
0
1
1
2
2
2
2
4
4
3
3
6
6
4
4
8
8
5
5
10
10
TABLE B
Criteria for allocation of additional points to ASEPSIS Score
Criterion
Additional treatment:
Antibiotics
Drainage of pus under local anaesthetic
Debridement of wound (general anaesthetic)
Serous discharge
Erythema
Purulent drainage
Separation of deep tissues
Isolation of bacteria
Stay as inpatient prolonged over 14 days
Points
Daily
Daily
Daily
Daily
10
5
10
0–5
0–5
0–10
0–10
10
5
Score Table A daily for first week, add points fromTable B for any criteria satisfied in first 2
months after surgery.
Category of infection: total score 0–10 = satisfactory healing; 11–20 = disturbance of healing;
21–30 = minor wound infection; 31–40 = moderate wound infection; >40 = major wound infection.
Fig. 6.1 The ASEPSIS wound score (from Wilson et al., 1990, reproduced with kind permission of
Academic Press Ltd).
between the grade of surgeon and infection rates. The more junior the doctor,
the poorer the technique is likely to be.
Another factor that has been shown to have some relevance to the development of infection is the length of operations. Cruse and Foord (1980) found that
the clean wound infection rate doubled for every hour of surgery. They suggest
four possible reasons for this increase: wound cells are damaged by drying out
when exposed to air; the total amount of bacterial contamination increases with
time; the longer the operation, the more sutures and electrocoagulation are
used; longer surgery may be associated with shock and/or blood loss, thus
reducing resistance to infection. Whilst it is not possible to eliminate all these
factors, the numbers of bacteria in the air can be reduced. Although air
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The Care of Wounds
Box 6.1 Factors increasing the incidence of surgical wound infection (based on Dealey,
1991).
Environment
Lengthy preoperative hospitalisation
High bed occupancy
Poor standards of asepsis within the theatre suite
Unsuitable layout within the theatre suite
Inadequate ventilation in the operating theatre
Patient
Age
Obesity
Malnutrition
Diabetes
Steroids
Immunosuppressive drugs
Additional lesions, e.g. pressure sore (form reservoir of bacteria)
Shaving
Wounds
Type of surgery
Length of surgery
Time of surgery
Poor surgical technique
Position of drains
Box 6.2 Classification of surgical wounds (based on Cruse & Foord, 1980).
Clean
Surgery where there was no infection seen, no break in asepsis and hollow muscular organs
not entered. Could include hysterectomy, cholcystectomy or appendectomy ‘in passing’ if no
evidence of inflammation.
Infection rate: 1.5%
Clean-contaminated
Where a hollow muscular organ was entered but only minimal spillage of contents.
Infection rate: 7.7%
Contaminated
When a hollow organ was opened with gross spillage of contents, acute inflammation without
pus found, a major break in asepsis or traumatic wounds less than four hours old.
Infection rate: 15.2%
Dirty
Traumatic wounds more than four hours old. Surgery where a perforated viscus or pus is
found.
Infection rate: 40%
The Management of Patients with Acute Wounds 191
filtration systems can be used, Cruse and Foord suggested that the same results
could be obtained by taking some fairly simple measures, such as reducing
conversation and the amount of movement in and out of the theatre, and
excluding anyone with a skin infection.
The timing of surgery also affects infection rates. Cruse and Foord (1980)
found that when clean and clean-contaminated surgery was carried out at
night, there was almost double the infection rate of procedures in the day. This
is most likely to be due to weariness in the surgical team leading to imperfect
surgical technique.
Nursing care
Early identification of signs of infection is important (see also Chapter 3).
Dehiscence
Dehiscence means the breaking down, or splitting open, of all or part of a
wound healing by first intention. Complete dehiscence may involve evisceration of the gut, a condition that is commonly known as a ‘burst abdomen’. If
the skin remains intact when the muscle and fascia layers break down, an
incisional hernia occurs which may not become obvious for some months
following surgery.
Dehiscence can occur because of systemic and local factors. Several studies
have looked at the effect of surgical wound closure techniques. Gislason et al.
(1995) randomised 599 patients to three different closure types and found that
there was no difference between the groups. Dehiscence occurs more frequently
in those undergoing emergency surgery, those having intestinal resections with
stoma formation and following wound infection. Those patients whose wounds
broke down were also significantly older. Brolin (1996) found that a continuous
suture was more effective for closing midline incisions following surgery for
morbid obesity than an interrupted suturing technique.
Westaby (1985) considered that surgical technique may be a factor in dehiscence. Securing sutures too tightly so that they cut into the tissues can result in
dehiscence. Tight suturing also affects the vascularity of the skin edges, with
areas of necrosis around the sutures. Occasionally failure of the suture material may occur although this is less common with non-absorbable sutures.
Perkins (1992) suggested that dehiscence can be divided into early dehiscence,
related to suture failure and/or surgical technique, and late dehiscence, which
is more likely to be the result of infection.
Nursing care
If a surgical wound starts to break down, the potential cause(s) should be identified and rectified where possible. The wound should be carefully assessed for
indications of infection. If major dehiscence, such as a burst abdomen, occurs,
the wound will require resuturing. Most wounds are treated conservatively and
allowed to heal by granulation and contraction. This is particularly so when
infection is present as all purulent material should be allowed free drainage.
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The Care of Wounds
Fig. 6.2 An example of a dehiscent wound with
complete breakdown of the suture line.
When this is associated with complete dehiscence of a suture line with some
necrosis, as can be seen in Figure 6.2, topical negative pressure therapy may
be effective in removing the wound debris and preparing the wound for late
resuturing.
The wounds may be necrotic or sloughy with a heavy exudate. NICE (2001)
has provided guidance on the management of these wounds. The guidance concluded that there is no clear evidence as to the most effective method of debridement or the most appropriate dressing. However, modern products were seen
to be more effective than gauze in respect of pain, odour control and exudate
management. As a result, the guidance recommends that selection of the
method of debridement and the use of dressings should be based on patient
acceptability, comfort, odour control, the type and location of the wound and
total costs.
If there is only a partial dehiscence of the suture line with little exudate and
necrosis then an amorphous hydrogel is appropriate. An alginate or hydrofibre
is more appropriate in the presence of heavy exudate or greater dehiscence of
the suture line. These dressings cause far less trauma than using traditional
methods such as ribbon gauze. Once any cavity is filled with granulation tissue
and there is no indication of lingering infection, foam cavity fillers may also be
used.
In a few instances the exudate may be excessive and not controlled by dressings. In this situation it may be helpful to consult a colorectal nurse specialist
who may suggest that an appliance similar to a drainage bag be used. It has an
adhesive backing that can be cut to fit over the wound, whilst protecting the
surrounding skin. The front of the appliance has a hinged lid that allows access
to the wound and saves frequent removal. There is usually a tap that allows
drainage. The amount of exudate can be measured accurately which is important for fluid balance. Good management of a wound following dehiscence
should promote healing and permit the patient to be discharged home for care
in the community.
The Management of Patients with Acute Wounds 193
Sinus formation
A sinus is a track to the body surface from an abscess or some material that is an
irritant and becomes a focus for infection. A common irritant is suture material.
Dressing material, such as ribbon gauze, may also be retained and prevent
healing. Sinuses can become chronic if the causative factor is not resolved. A
sinogram will show the extent of a sinus and help to identify the root problem.
Surgical excision or laying open of the sinus is usually the most effective form
of management. Once the focus for infection has been removed and free drainage
can occur, the remaining cavity will heal by granulation and contraction.
Although wide excision is the most appropriate method of managing a sinus,
it is not always possible. If the sinus is very deep the opening may be fairly
narrow in relation to the sinus size. Butcher (1999) suggests that a sinus should
be regularly irrigated with saline to prevent the accumulation of pus and
exudate. Traditionally ribbon gauze was used in sinuses but it is painful to
insert and remove and may act as a plug, preventing the drainage of exudate.
The easiest dressing to apply is a hydrogel as it can easily be inserted into the
sinus via the applicator. Butcher (1999) warned of the danger of maceration of
the surrounding skin when using hydrogels for prolonged periods of time in
the presence of heavy exudate. It is therefore advisable to use a protective skin
wipe to protect the skin.
Fistula formation
A fistula is an abnormal track connecting one viscus with another viscus or
a viscus with the body surface. It may develop spontaneously or following
surgery. Common examples are:
䊉
䊉
䊉
rectovaginal – connecting the rectum and vagina
biliary – allowing leakage of bile to the surface following surgery on the gall
bladder and/or bile ducts
faecal – allowing leakage of faecal fluid through the wound, often associated
with infection.
Persistent leakage of fluid indicates the possible presence of a fistula. Examination of the fluid will usually provide information to indicate the source of the
fistula. Any associated infection must also be treated.
Nursing care
The management of fistulae involves care of the surrounding skin, containing
and measuring the output and nutritional support. The skin can be protected
by the use of ostomy pastes and protective skin wafers. Drainage bags can be
applied to collect the output from the fistula. The colorectal nurse specialist may
have the greatest skill in applying a suitable drainage bag over the fistula and
protecting the skin.
Once the output from the fistula is contained, it can be accurately measured.
This enables the correct amount of fluid to be given to replace what has been
lost. Output may be considerable, sometimes a litre per day. In hospitals where
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The Care of Wounds
there is a nutrition team, they can also be involved in the care of these patients.
When it is possible, enteral feeding should be given. If the fistula is high in the
gastrointestinal tract then it will be necessary to give parenteral nutrition.
Nienhuijs et al. (2003) reported on the management and outcomes for 17
patients with enterocutaneous fistulae. They followed the treatment described
above until spontaneous healing but ten patients had skin erosion and required
frequent dressing changes. Consequently topical negative pressure (TNP) was
applied to these wounds. Patients were given TNP for a median of 25 days
(range 14–161 days). Four patients went on to heal spontaneously after a
median of 73 days, five patients had surgery to correct the fistula and one
patient died, due to extensive metastasis. The four patients who healed spontaneously were discharged home with TNP therapy. Despite the high costs of
using TNP, the authors calculated that the cost was cheaper than conventional
treatment (€290 394 versus €428 311). They noted that as these figures were calculated retrospectively, they should be treated with caution. Undoubtedly, the
patients in the study were very satisfied with the use of TNP and preferred it
to the conventional treatment that they had been given previously.
Evaluation
Regular monitoring of surgical wounds is essential in order to identify any
potential complications as early intervention may prevent further problems.
Therefore good documentation is essential. Birchall and Taylor (2003) described
the development of a benchmarking tool based on The Essence of Care (DoH,
2001). The project involved determining best practice (in the absence of any
national guidelines) and improving wound assessment documents and then
benchmarking practice against it. The motivation for undertaking this work
was an unrelated audit that had identified that out of 40 surgical wounds, only
one had a documented assessment. Projects such as this improve awareness of
the need to maintain accurate records of each wound and its progress.
6.3 TRAUMATIC WOUNDS
Traumatic injuries can range from a simple cut to a major crushing injury. Major
traumatic injury is beyond the remit of this book. It requires surgical intervention and specialised nursing care. Most nurses will be required to care for minor
traumatic wounds from time to time. Their care will be considered here.
6.3.1 Minor traumatic wounds
Assessment
Initial assessment should identify any life-threatening problems such as airway
obstruction, haemorrhage or shock. Vital signs should be recorded. Any of these
problems should be addressed before treating the wound. If possible, a history
should be obtained of when, where and how the injury occurred. A medical
The Management of Patients with Acute Wounds 195
history can highlight any factors that may affect healing of the wound or the
type of treatment prescribed to manage the wound.
The wound should be assessed for any bleeding. Haemorrhage may be
resolved by pressure or require surgical intervention. The presence of any
foreign bodies should be noted and the extent and severity of the injury. Cleansing of the wound may be necessary before a full assessment can be made. Loose
particles may easily be washed off but other debris may be more difficult to
remove. Bianchi (2000) reviewed the limited evidence available as to the best
methods of cleansing traumatic wounds. She concluded that pain assessment
and management were essential prior to the procedure, especially for children.
Unfortunately, there is insufficient evidence to determine the best methods of
cleansing and cleansers to use. Some accident and emergency departments use
Clingfilm to cover a wound until seen by the doctor. This has the advantage of
keeping the wound warm and moist and allowing easy observation.
Nursing intervention
Medical assessment and prescription may be necessary before the wound can
be dressed. Whilst many nurses are competent to dress minor injuries the following guidelines should be considered. Patients should be examined by a
doctor if:
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the nature and extent of the injury are uncertain.
there is persistent bleeding.
suturing is required.
a foreign body is present.
tetanus prophylaxis may be necessary.
the injury occurred to a hospital patient.
the nurse is uncertain of the appropriate management.
it is required by nursing policies.
Prior to dressing, the wound should be thoroughly cleaned using saline. Any
loose devitalised tissue should be removed. In some instances it may be necessary to shave the area around the wound, if there are hairs that may interfere
with the healing process. An appropriate dressing can then be applied. Tetanus
prophylaxis will be required if the patient has not had a complete course of
tetanus toxoid or if no booster dose has been given for more than five years.
Depending on the cause of the wound, the doctor may also prescribe a course
of antibiotics.
If the person is not a patient in hospital, they and any carer will require information about the management of the wound. Information should also be given
concerning whom to contact if any complication occurs. Potential complications
such as fever, swelling around the wound, excessive pain or offensive discharge
should be described to the patient. Ideally, this information should also be given
in written form so that the patient has it for future reference.
Traumatic injuries occur primarily to the young and the elderly. Whilst most
young people will heal easily, this is not necessarily true for the older people.
196
The Care of Wounds
They may need to be admitted to hospital for further care. Wijetunge (1992) has
provided a useful overview of a management plan for soft tissue injuries.
Evaluation
The aim of any treatment is uncomplicated healing of the wound with restoration of function and minimal scarring (Brunner & Suddarth, 1988). Patients may
return to be reviewed by those who made the original assessment or they may
be referred to the family practitioner. The majority of these wounds will heal
without complication.
6.3.2 The management of specific types of traumatic wounds
Abrasions
An abrasion is a superficial injury where the skin is rubbed or torn and it may
be extremely sore. It may occur as a result of falling on a gritty surface. Abrasions should be cleaned carefully to ensure that there are no foreign bodies
embedded in the wound. In the case of extensive abrasions a general anaesthetic may be required in order to allow adequate cleansing. Failure to remove
all the debris may result in unsightly ‘tattooing’ (Evans & Jones, 1996).
Selection of a suitable dressing depends on the extent and depth of the injury.
These wounds are often very sore. Occlusive dressings have been found to
reduce the pain, possibly because they keep the nerve endings from drying out.
If the abrasion is superficial a film dressing or a thin hydrocolloid can be
applied. Deeper wounds, with a heavier exudate, can be treated with hydrocolloids, foams or alginates.
Lacerations
A laceration is a wound that penetrates the skin and has a torn and jagged edge.
They can be caused by blunt injury which produces shear forces or by a sharp
object such as glass (Singer et al., 1997). The aim of treatment is to achieve
uncomplicated healing with a functional and cosmetically acceptable scar.
It is important to remove all debris from the wound and any devitalised
tissue. This procedure is sometimes called surgical toilet. The best way to
manage these wounds is to bring the skin edges together to heal by first intention. This may be achieved by the use of sutures, adhesive strips or tissue adhesive. The choice of material depends on the position of the wound, its extent
and the condition of the damaged skin. Suturing is recommended around joints
or on the hand where movement is involved. Farion et al. (2004) reviewed the
use of tissue adhesives for traumatic lacerations in both children and adults.
They found no difference in cosmesis between adhesives and standard closures
but tissue adhesives could be applied more quickly and were less painful to
use. The authors of the review also noted that there was a small but significant
increased rate of dehiscence with tissue adhesives compared with standard
closure methods.
The Management of Patients with Acute Wounds 197
One of the commonest positions for a laceration is the pretibial area. Davis
et al. (2004) undertook an audit of A&E departments in a heavily populated
region of the UK and found that the mean incidence of estimated patients with
pretibial laceration was 5.2/1000 A&E attendances. The extent of the injury can
vary and Dunkin et al. (2003) proposed a method of classifying these wounds.
I
II
III
IV
Laceration.
Laceration or flap with minimal haematoma and/or skin edge necrosis.
Laceration or flap with moderate to severe haematoma and/or necrosis.
Major degloving injury.
Dunkin et al. (2003) have also provided a useful algorithm for the management
of each type of laceration. Fairly obviously, types III and IV require surgical
intervention. Type I lacerations should have the skin edges opposed and then
held together with short, wide adhesive strips. The wound is covered with a
non-adherent dressing and a crepe bandage applied from toe to knee. It may
be appropriate to place a wool bandage under the crepe bandage in order to
provide additional protection. Patients should be encouraged to mobilise and
to elevate their leg when sitting in order to reduce any oedema. Type II is also
managed with use of adhesive strips and supportive bandages, after any
haematoma has been evacuated, the non-viable wound edges trimmed and the
wound edges apposed. Both these type of lacerations should heal without complication. Failure to do so indicates that the injury is more serious than originally thought (Dunkin et al., 2003).
If there is any risk of infection as a result of severe contamination of the
wound at the time of injury, primary closure is not appropriate. Conservative
treatment with antibiotics and dressings such as an amorphous hydrogel is
preferable. An iodine-impregnated low-adherent dressing may also be used for
a short period of time. Once the wound is clean, skin grafting is the fastest
method of wound closure.
Finger tip injuries
Crushing finger tip injuries are very common in children, mainly caused by
fingers being caught in house or car doors. Buckles (1985) suggested that 14%
of children below the age of 13 years suffer from this type of injury. Cockerill
and Sweet (1993) described the procedure of trephining to remove a haematoma
from the nail bed. They also suggest that an X-ray may be necessary to identify any fracture. Prophylactic antibiotics may be needed if a fracture is present.
The use of adhesive tapes over the finger tip can be an effective way of
holding the wound edges together and then protecting the finger by applying
a tubular bandage. Collier (1996) suggests that it is important to use dressings
that will not stick to the wound as adherent dressings will cause pain and
further trauma at dressing change. Given that many of the patients are children, this is an important consideration. Suitable dressings might be hydrocolloids or adhesive foams which can be retained without bulky dressings or
strapping.
198
The Care of Wounds
Mammalian and human bites
Patients presenting with mammalian bites account for 1% of visits to A&E
departments (Medeiros & Saconato, 2004). As many as 74% of bites are from
dogs; other animals causing problems include cats, rats, squirrels and, occasionally, snakes. As well as animal bites, patients also present with human bites,
usually as a result of physical violence such as a punch to the mouth which
causes injury to the knuckles (Higgins et al., 1997).
The major problem with any type of bite injury is the risk of infection or the
transmission of diseases such as HIV or hepatitis B from human bites. Higgins
et al. (1997) stress the importance of not underestimating these wounds. After
reviewing the evidence for the use of prophylactic antibiotics after mammalian
bites, Medeiros and Saconato (2004) concluded that there was some evidence
that they were beneficial after human bites but not after dog or cat bites. They
called for further research on the subject.
Careful cleansing is essential in order to assess the extent of the injury. Saline
or an antimicrobial such as povidone iodine should be used. Surgical debridement or exploration may be necessary to remove devitalised tissue, skin tags
or any foreign bodies. Large cuts and facial wounds need suturing. Delayed
primary closure may be used for some wounds. Chen et al. (2000) monitored
outcome for 145 mammalian bite wounds that were treated by primary closure.
They found there was an infection rate of 5.5% and considered that this was
an acceptable risk for wounds where a good cosmetic result was essential.
However, they also noted that appropriate selection of patients was important.
Puncture wounds should be left open because of the risk of infection. The
wound should be protected. An iodine-impregnated low-adherent dressing
may be suitable, unless there is a moderate to heavy exudate. Higgins et al.
(1997) suggest that patients with human puncture wounds should be admitted
for surgical exploration and irrigation. So, too, should those with bites involving joints or tendons or any indication of spreading infection. Patients with bite
wounds should be followed up to ensure that there has been uncomplicated
healing and the patient has regained full function of the affected area.
Skin tears
Skin tears are caused either by friction or by a combination of friction and shearing associated with thin, fragile skin. Thomas et al. (1999) suggest that up to 1.5
million people living in care institutions in the USA suffer a skin tear each year.
A survey of 154 nursing home residents revealed that they occurred mostly on
the arms in the very elderly who were frail, had limited mobility, poor appetite
and ecchymosis (McGough-Csarny & Kopac, 1998). Skin tears can be classified
according to severity using a classification system devised by Payne and Martin
(1993), given in Table 6.1.
There is limited evidence to determine the best method for managing skin
tears. Sutures are not an option as the skin is too fragile and they would cause
further damage. Adhesive strips may be used for category I tears but care must
be taken to ensure that they do not cause damage on removal.
The Management of Patients with Acute Wounds 199
Table 6.1
Skin tear classification (based on Payne & Martin, 1993).
Category
Subcategory
Definition
I
Linear type
Epidermis and dermis pulled in one layer from supporting
structures, resulting in skin tear in a straight line
The epidermis and dermis are separated but the epidermal
flap covers the dermis to within 1 mm of the wound margin
Flap type
II
Scant loss of tissue
Large loss of tissue
III
An actual loss of tissue no greater than 25% of flap size
Loss of tissue where more than 25% of the flap has been lost
Entire loss of tissue, either at the time of injury or later
following necrosis of the flap
Meuleneire (2002) reported on 88 patients with category I or II (scant tissue
loss) who were managed using a silicone-coated net dressing, MepitelTM. The
same protocol was followed for all wounds. The flap and wound bed were
irrigated and the flap gently returned to as close approximation as possible.
The wound was covered with MepitelTM, a secondary low-adherent dressing
applied and then a light compression bandage applied to reduce any oedema.
The secondary dressing was changed daily for three or four days and then left
in situ until day 7 when all dressing layers were removed. The wound was then
protected using a low-adherent dressing for a further 4–5 days. A total of 83%
of the wounds had healed by day 8. The remaining 17% did not heal in this
time because of either bleeding or infection. The infection was a consequence
of delay in initial treatment as all the infected wounds were treated six hours
or more after the injury.
Edwards et al. (1998) undertook a pilot study to compare four dressings: a
film, a thin hydrocolloid, a foam and a combination of adhesive strips and lowadherent dressing on skin tears (no indication of severity was given). Fifty-four
patients were recruited to the study but 24 cases were withdrawn, 14 of these
(12 film dressing and two hydrocolloid) because the wound was not progressing or it was infected. Of the 30 that completed the study, only 13 had healed
by day 7 and a further 12 by day 14 while five remained unhealed. The combination dressing performed better than the other dressings as about two-thirds
had healed by day 7 and the remainder by day 14. However, these numbers are
very small and no real conclusions can be drawn, other than the need for further
research.
6.4 THE BURN INJURY
Burns are traumatic wounds but because of the specialised care required, they
need to be considered separately from other traumatic wounds. Burns are
measured in terms of the percentage of total body surface area (TBSA) that is
200
The Care of Wounds
affected and they are divided into complex and non-complex burns. In the UK,
there are national criteria for the referral of complex burns to a specialist burn
care unit (NBCRC, 2001). They include:
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patients aged under five years or over 60 years.
full-thickness burns involving more than 10% TBSA in adults or 5% in
children less than 16 years of age.
burns of the face, hands, perineum, feet or flexures of the body such as neck
or axilla.
circumferential deep dermal or full-thickness burns of torso, limbs or neck.
inhalation injuries.
suspicion of non-accidental injury.
The burn care required by these patients is beyond the remit of this book.
6.4.1 Aetiology
A burn is an injury caused by excessive heat. It primarily damages the skin,
causing tissue destruction and coagulation of the blood vessels of the affected
area. Burn damage consists of three areas or zones (Hettiaratchy & Dziewulski,
2004a). The central zone is the zone of coagulation and at this point there is coagulation of the tissue proteins and thus irreversible damage and tissue loss. The
zone of stasis surrounds the zone of coagulation and there is decreased tissue
perfusion in this zone. However, if tissue perfusion is increased promptly it is
possible to prevent the tissue damage extending into this zone. The third and
outer zone is the zone of hyperaemia and here tissue perfusion is increased. Generally this area will recover unless the burn becomes severely infected or there
is prolonged hypoperfusion.
Burns can be divided into four categories depending on their cause.
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Thermal – caused by flame, hot water or steam, other hot liquids and hot surfaces. Smoke inhalation injuries may be associated with fire casualties.
Chemical – caused by spillage of strong acids, alkalis or other corrosive substances. These are usually industrial injuries. Damage to vital organs can
occur if the chemicals are absorbed into the blood supply.
Electrical – caused by an electrical current passing through the body. The
internal damage may be considerably greater than is obvious from the skin
appearance. Such burns may also be associated with thermal injury.
Radiation – due to overexposure to industrial ionising radiation or following
radiotherapy treatment. (Reactions to radiotherapy are covered in more
detail in section 6.5.)
Although burn injuries are usually described as accidental, it has been suggested that some individuals are more likely to suffer from them than others
(Hettiaratchy & Dziewulski, 2004b).
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Young children – 20% of all burn injuries are in young children, predominantly
boys. Most of these injuries (70%) are due to scalds.
The Management of Patients with Acute Wounds 201
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Children aged 5–14 years – 10% of burns occur in this group and may be due
to illicit activity such as playing with fireworks or petrol or misuse of
electrical equipment.
Adults of working age – around 60% of burns occur in this group, generally as
a result of flame injury. About a third of the burns in this group are due to
work-related injury.
Elderly people – 10% of burns occur in this group, often as a result of infirmity or disability.
Additional factors – within all age groups there are other predisposing factors
that can increase the risk of burn injury. They include medical conditions
such as epilepsy, psychiatric illness, alcoholism and social conditions such
as poor housing, including faulty wiring and overcrowding.
6.4.2 Incidence
It is estimated that around 250 000 people suffer burn injury each year in the
UK (NBCRC, 2001). Out of this group, around 175 000 people attend A&E as a
result of their injury and for 13 000 it is sufficiently severe as to require admission to hospital. About 1000 people, half of whom are children under 12 years,
have such severe burns that they require fluid resuscitation. It should also be
noted that 300 people on average will die from their burns each year.
The figures for burn injury in the UK are similar to those in other developed
counties (Hettiaratchy & Dziewulski, 2004b). However, in developing countries
they are likely to be much higher; for example, it is thought that 2 million of
the 500 million people in India have suffered a burn injury. Mortality rates are
also likely to be higher in countries with a high level of poverty. Poor housing,
overcrowding and the use of open fires for cooking are likely factors in the high
incidence of fires in developing countries.
Staff should be aware of the possibility of non-accidental injury to children.
Gordon and Goodwin (1997) suggest that around 10% of paediatric burns are
the result of child abuse. This view is supported by work by Andronicus et al.
(1998) who reviewed 507 paediatric burn cases. They found that 8% of injuries
were considered to be as a result of abuse or neglect. The staff believed that the
family’s social or emotional situation was likely to have been a major factor in
causing the burn injury of a further 6% of children. Andronicus et al. (1998)
provide a list of features that may indicate abuse or neglect. They include a
delay between the incident and presentation, an inconsistent history of events,
a history of previous accidents and presentation for treatment by someone other
than the parent. Most A&E departments have specific procedures to follow if
an injury is suspected to be non-accidental.
6.4.3 The severity of the injury
The skin is the organ of the body that usually suffers the greatest damage from
a burn injury. Depending on the extent of the injury, several layers may be
202
The Care of Wounds
9%
FRONT 18%
BACK 18%
9%
9%
1%
18% 18%
Fig. 6.3
The Rule of Nines.
affected. It is common to describe the severity of a burn according to its depth
and extent. Burns are divided as follows.
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Superficial burns – only the upper strata of the epithelium are damaged. The
stratum basale is unaffected.
Superficial dermal burns – these burns extend beyond the epidermis into the
top layers of the dermis. They are associated with blistering.
Deep dermal burn – the burn extends into the deeper layers of the dermis and
may involve hair follicles or sweat glands.
Full-thickness burns – there is full destruction of the epidermis and dermis.
The damage extends into the subcuticular layer and may involve muscle and
bone.
The extent of the burn is determined by the measurement of the surface area
of the affected part, excluding erythema. This is described in terms of a percentage of the whole body. Various methods of achieving this have been
described. An ad hoc method is to measure the area using the palm of the hand.
The palmar surface of the patient is equal to 1% of the body surface area in
adults and 1.5% in children. When making the initial assessment of a burninjured patient, it is most common to use the ‘Rule of Nines’ (Wallace, 1951).
Figure 6.3 shows how the body is divided into sections, each measuring 9% of
the whole, or multiples of 9%. The percentages for each affected area are then
totalled. Thus, if one arm and the front of the trunk were affected, this would
be described as 27% burns.
The Management of Patients with Acute Wounds 203
However, the Rule of Nines may overestimate the extent of the injury. Once
the initial emergency treatment has been carried out, a reassessment of the
extent of the injury is usually made. A more accurate picture can be obtained
using a Lund and Browder chart (see Fig. 6.4). Lund and Browder (1944) developed a system for assessing burn injury that not only divides the body into
smaller areas but also considers the age of the patient. Body proportions alter
during childhood, so that the front of the head is 8.5% of the whole in a child
of one year but only 4.5% of the whole in a 15 year old. Patient management
may need to be adapted once this reassessment has been made.
6.4.4 Burn oedema
Almost immediately after injury, oedema starts to collect beneath the damaged
tissue. This is typically maximal within 24 hours of the injury but can last for
up to three or four days. As plasma continues to leak into the tissues, there is
a risk of hypovolaemia developing. Without treatment, burns shock can
develop and is potentially fatal. If the burn is on the face, neck or chest, the
swelling from the oedema may cause obstruction of the airway. Patients with
facial burns are admitted for 24 hours as a precaution. Treatment must ensure
that the effects of burn oedema are minimised.
6.4.5 First aid treatment of burns
The British Burn Association has published recommendations for the first aid
treatment of burns (Lawrence, 1987). Box 6.3 is based on these recommendations. The principal treatment is to remove the injured person from the source
of heat and pour cold water over the affected area. Lawrence and Wilkins (1986)
demonstrated that the subcutaneous temperature continues to rise after the
burn injury occurs. Thus, if a burn injury at 100°C lasts for ten seconds, the
affected tissue will take three minutes to return to normal body temperature.
Application of cold water within ten seconds of the injury can reduce the ‘burn
time’ to 30 seconds.
There are occasions when cold water is not readily available and other alternatives must be used. Lawrence (1996) tested a mousse containing a mixture of
Box 6.3 The first aid treatment of burns (based on Lawrence, 1987).
•
•
•
•
•
•
•
•
•
Remove the person from the source of heat.
Turn off the electricity in the case of electric burns.
Apply copious amounts of water to the affected area.
Do NOT try to remove clothing if the burns are extensive.
Put wet compress on any exposed areas.
Wrap Clingfilm around wet compress to hold in place.
Seek qualified help quickly, especially if the burn is extensive.
If no tap water, use bottled/mineral water or milk.
Do not use solutions such as bleach, butter or oil.
204
The Care of Wounds
CHART FOR ESTIMATING SEVERITY OF BURN WOND
NAME
AGE
WARD
ADMISSION WEIGHT
NUMBER
DATE
LUND AND BROWDER CHARTS
IGNORE
SIMPLE ERYTHEMA
A
A
1
1
2
2
2
121
121
2
13
13
Partial thickness loss
(PTL)
Full thickness loss
(FTL)
121
121
%
121
121
1
121
221
221
B
B
B
B
C
C
C
C
143 143
143
143
REGION
HEAD
NECK
ANT.TRUNK
POST.TRUNK
RIGHT ARM
LEFT ARM
BUTTOCKS
GENITALIA
RIGHT LEG
LEFT LEG
TOTAL BURN
121
PTL FTL
RELATIVE PEROENTAGE OF BODY SURFACE AREA
AFFECTED BY GROWTH
AREA
A=1/2 OF HEAD
B=1/2 OF ONE THIGH
C=1/2 OF ONE THIGH
Fig. 6.4
Lund & Browder chart.
AGE 0
91/2
23/4
21/2
1
81/2
31/4
21/2
5
61/2
4
23/4
10
51/2
41/2
3
15
41/2
41/2
31/4
ADULT
31/2
43/4
31/2
The Management of Patients with Acute Wounds 205
paraffin oils and waxes in the laboratory and found that it gave local cooling
for at least ten minutes. The same product was tested at a fire service college
on 108 casualties with a variety of burns or scalds (Dunn, 1996). All subjects
found immediate pain relief after application of the mousse. When the mousse
fell off, a thin film remained over the burn site, obviating the need for a dressing unless there was skin loss. This product would appear to be a useful first
aid treatment but further clinical evidence is required to support its use. An
alternative is a cooling gel pad that can both cool the wound and relieve some
of the initial wound pain (Hudspith & Rayatt, 2004).
6.4.6 The management of burn injuries
When considering the management of burns, the extent of the injury must be
defined as the treatment varies drastically between complex and non-complex
burns. Non-complex burns may be treated in the outpatient department but
anyone with complex burns must be admitted to hospital.
Complex burns
Depending on the circumstances, it may be necessary to provide initial resuscitation before transferring a patient to a burn care unit. Gordon and Goodwin
(1997) describe the importance of the primary ABCDEF assessment of the
patient.
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A = airway, B = breathing. Check airway. Endotracheal intubation may be
needed if there are deep burns to face, neck or mouth or any indication of
respiratory distress.
C = circulation. Check pulse. May be absent or show signs of dysrhythmias
following electric burn.
D = disability or neurological deficit. Identify any associated trauma. Signs of
mental confusion or disorientation may be an indication of pre-existing conditions, hypoxia or unrecognised injury.
E = exposure and evaluation. All jewellery or clothes should be removed from
the burn-injured area because of the risk of constriction when burn oedema
develops. This also allows for a rapid assessment of the full extent of the
injury, using the Rule of Nines. The patient should be kept warm; a space
blanket is ideal.
F = fluid resuscitation. Establish an intravenous infusion – this is essential for
all burns greater than 15% TBSA in adults and 10% in children. Blood
samples may be taken at the same time. Catheterise the bladder if the burns
are 25% or more TBSA; urinary output will indicate inadequate rehydration
as well as renal function.
Analgesia may also be required, especially for those with superficial burns as
they are very painful (Hettiaratchy & Papini, 2004).
It is also important to obtain a full history of cause of the injury from patient,
relative or ambulance crew. This may provide information indicating potential
206
The Care of Wounds
complications such as smoke inhalation. Inhalational analgesia or systemic
analgesia may be given depending on the condition of the patient.
When the patient’s condition has been stabilised by the above measures,
urgent transfer to the burn care unit can take place. Once in the care of a burns
team, a more detailed assessment of the patient and the extent of the burn injury
using a Lund and Browder chart is undertaken. Essentially, the extent of
damage is assessed visually. However, Mileski et al. (2003) found that a Doppler
flowmeter could be a useful tool to measure tissue perfusion, thus allowing
easier differentiation between the different zones of the burn injury. They found
that serial measurements had a positive predictive value of 81% for identifying
non-healing wounds.
Non-complex burns
Managing minor burns requires assessment of both the patient and the wound,
as in any other type of wound. Assessment of the patient has been discussed
in Chapter 2 and wound assessment and management in Chapter 3. Specific
aspects of the care of minor burns are discussed here.
Patient assessment
Burn aetiology. Discover the cause of the injury. Non-accidental injury must
be considered if the history seems inconsistent with the burn appearance. The
risk of infection is always present in the burn-injured patient.
Pain. Analgesia may be required for pain.
Nutrition. Nutritional status should be identified. Advice on nutrition may
be necessary as there will be increased nutritional demands on the body.
Sleep. Pain or anxiety may affect sleep patterns.
Early psychological care. Many patients will be very frightened. It is important to provide reassurance and explanation to the patient and the family.
Later psychological care. A burn injury can be extremely disfiguring. Body
image may be profoundly altered, causing distress and loss of self-esteem.
Many patients may have fears of disfigurement or disability. Some may fear
loss of loved ones as a result of the scarring. Specific fears should be identified
and addressed.
Wound assessment
Initial assessment of a burn injury includes the extent and depth of the burn.
The use of a Lund and Browder chart has already been described. The zone of
hyperaemia should not be included when calculating the burn area. Identifying the depth of a burn is not always easy to do, especially as a burn injury
may have varying depths. Table 6.2 shows how it is possible to differentiate
between the different wound depths.
A burn injury differs from other types of wounds in several important
respects (Bayley, 1990). There are frequently large areas of devitalised tissue.
The wound may have a large surface area and take some time to heal. As a
result, the burn wound is rapidly colonised by bacteria. There is considerable
The Management of Patients with Acute Wounds 207
Table 6.2
Identifying burn wound depth (from Fowler, 2003).
Depth of burn
Skin structures affected
Indicators
Superficial
Upper strata of epithelium
• Skin intact, red and very painful
• Blanches under fingertip pressure
• Usually no blisters but may form
in the 48-hour period after injury
Superficial dermal
Epidermis and upper layers
of dermis
• Blisters form immediately with a
pink/red wound bed below
• Wound areas may be red and
moist and exuding
• Easily observable brisk capillary
refill
• Painful and sensitive to skin
changes
Deep dermal
Epidermis down to deep layers
of dermis, possibly hair follicles
and sweat glands
•
•
•
•
Full thickness
Complete destruction of
epidermis and dermis; may
involve muscle or tendon
• Burn appears waxy white, cherry
red, grey or leathery
• Little or no pain – but may be areas
on the edges of the burn that are
not so deep and therefore painful
Burn creamy/white
May have large blisters
Initially burn has little moisture
Slight pain with insensate areas
not sensitive to pinprick
risk of infection in complex burns but this is much less likely in non-complex
burns. Lawrence (1989) quotes an incidence of about 1% but this may vary
between centres. Nonetheless, the wound should be observed carefully for any
indication of infection.
Wound management
Superficial burns may be very painful and require analgesia. Fowler (2003) suggested treating them like minor sunburn with aloe vera gel or other aftersun
lotions. Aloe vera gel is soothing and feels cooling and thus helps to alleviate
the pain.
Superficial dermal burns require careful cleansing with warm saline or tap
water to remove all loose debris in the first instance. They have traditionally
been treated with paraffin gauze dressings or silver sulphadiazine cream and
covered with gauze and a bandage. Whilst healing will occur with this regime,
it has several disadvantages. The dressings are bulky and hinder washing
around the affected area. They may also be painful to remove, although it may
not be necessary to remove the wound contact layer until the wound is healed
and it separates spontaneously.
208
The Care of Wounds
Modern products are easier to use and are also more comfortable for patients,
especially when being removed. There is limited evidence to determine best
practice but what evidence is available seems to favour modern products.
Thomas et al. (1995) undertook a randomised study comparing a hydrocolloid
alone, a hydrocolloid with silver sulphadiazine cream and a medicated paraffin gauze dressing in 50 patients with 54 non-complex burns. The hydrocolloid
group required significantly fewer dressings than the other two groups. The
hydrocolloid group also had significantly faster healing than the hydrocolloid
with cream group. The researchers concluded that hydrocolloid dressings alone
are useful for the management of non-complex burns.
Two studies by Subrahmanyam (1991, 1998) investigated the use of honey for
partial-thickness burns compared with silver sulphadiazine. The 1991 study
compared these products on 104 patients with less than 40% partial-thickness
burns. Patients were randomly assigned to one of the two treatments. The
author found a significantly lower infection rate in the honey group. The study
in 1998 followed the same procedure as the previous study but monitored
healing outcomes of 50 patients (25/group). The results showed that 84% of
wounds in the honey group showed evidence of granulation and epithelialisation by day 7 compared with 72% in the silver sulphadiazine group. By day 21
all patients in the honey group (n = 25) and 21/25 in the silver sulphadiazine
group were healed, a significant difference in favour of the honey group (p =
0.05).
Other dressings that can be used on minor burns include flat foam dressings,
silicone net dressings and hydrogels. The foam dressings are comfortable and
can be held in place with tape or a tubular net. Hydrogels can give a cooling
sensation when applied, which may be comforting to the patient. Silicone net
dressings are widely used as they can be left in place for 7–14 days and the
secondary dressing changed when necessary.
Whatever dressing is used, the patient and wound should be reviewed at
between 48–72 hours when the local oedema has subsided (Fowler, 2003). This
review is especially important for patients who are being managed at home and
attending the outpatient department.
Deep dermal and full-thickness burns generally require early excision of
necrotic tissue and skin grafting for speedy healing.
Burns of the hands are best treated with silver sulphadiazine. Once the cream
is applied, the hand should be covered with a plastic bag. This will allow free
movement and help to prevent contractures. The hand should be kept elevated
for the first 48–72 hours to reduce swelling (Fowler, 1996). There are several disadvantages with the use of plastic bags. They cause considerable maceration of
the whole hand as large quantities of exudate accumulate in the bag. The bag
becomes heavy and pulls the wrist into flexion. Once full of fluid, the bag tends
to leak or tear, necessitating dressing change. Terrill et al. (1991) compared the
use of Gore-TexTM bags with plastic bags. Gore-TexTM has the property of water
vapour permeability. Although there was no difference in healing times, there
was a considerable reduction in skin maceration and accumulation of exudate
when using Gore-TexTM. Improved hand function was also noted. Witchell and
The Management of Patients with Acute Wounds 209
Crossman (1991) compared the use of these bags over silver sulphadiazine with
paraffin gauze for children with burns of the hands. They found that use of
Gore-TexTM bags increased child activity and reduced the length of time of
dressing change. More significantly, there were considerably fewer unscheduled visits to the accident and emergency department because of problems with
the dressing.
Evaluation
Evaluation of the burn wound involves monitoring of the wound as it progresses towards healing and of the healed wound. Any non-complex burn that
fails to heal within three weeks should be referred to a specialist unit. Once the
wound is healed, special care needs to be taken of the newly formed epithelia.
Bayley (1990) suggests cleansing with a mild soap and then applying waterbased cream several times a day. The patient should be warned to avoid any
possibility of sunburn. Fowler (2003) recommends use of total sunblock for the
first year and then gradually reducing to factor 15.
Potential problems that can develop are contractures and hypertrophic scarring. Myofibroblasts contract and shorten the wound, causing the collagen
fibres to become coiled. The scar develops a hard, red, raised appearance. If the
burn injury is over a joint, as the myofibroblasts contract this causes flexion of
the joint. Unless measures are taken to splint the joint, it will become contracted.
A programme of exercise and splinting can help to counteract this problem.
Hypertrophic scarring is often managed by the use of pressure garments that
the patients will have to wear for about a year. However, a randomised study
by Chang et al. (1995) found that pressure garments made no difference to the
degree of scarring. An alternative treatment, a silicone gel sheet, has been used,
initially in Australia. Poston (2000) undertook a review of the use of silicone gel
sheeting in the management of hypertrophic and keloid scars and concluded
that it appears to improve the appearance of these scars, but there is insufficient evidence to determine its usefulness in restoring mobility and function
when scarring is associated with contractures.
A few patients will develop permanent pigmentation changes. This is possibly because of damage to the melanocytes in the basal layer of the epidermis.
It can present as either apigmentation or hyperpigmentation. It is not possible
to predict when it will occur.
6.5 RADIATION REACTIONS
Radiation treatment or radiotherapy is the mainstay of cancer treatment. It has
been estimated that nearly 20% of people in Western countries will receive
radiotherapy at some point in their lives (Porock et al., 1999). Radiation reaction is the reaction of the skin to the effects of radiotherapy and is limited to
the treatment field or its exit point. Strictly speaking, a radiation reaction is not
a wound. However, the skin reaction is akin to a superficial burn and has the
210
The Care of Wounds
potential for ulceration. There is limited research into the management of what
can be a very painful problem.
6.5.1 Aetiology
Ionising radiation or radiotherapy is the mainstay of cancer treatment. Treatment is usually given in a series of doses, ranging from daily to weekly,
although a small number of patients will receive just one dose. A course of treatment may last up to eight weeks. Radiation reactions are most likely to occur
when the treatment field is close to the body surface, such as the head or neck,
or if it includes the axillae, under the breasts, perineum or groin. The reaction
is dose dependent; that is, the more frequent the treatment or the higher the
dose, the more likely the reaction. A reaction may occur during a course of treatment or after it is completed. Within six weeks of completion of treatment, all
but the most severe reactions have disappeared.
6.5.2 The classification of radiation reactions
The severity of radiation reactions is generally classified using the grading
system developed by the Radiation Therapy Oncology Group (RTOG) (Cox et
al., 1995) and recommended by the College of Radiographers in the UK.
0
1
2a
2b
3
4
No change over baseline.
Follicular, faint or dull erythema.
Tender or bright erythema with/without dry desquamation.
Patchy, moist desquamation, moderate oedema.
Confluent wet desquamation, pitting oedema.
Ulceration, haemorrhage, necrosis.
It is considered that 90–95% of patients undergoing radiotherapy will have
some degree of reaction (Porock et al., 1999). However, in a study of 126 women
treated for breast cancer, less than 10% had moist desquamation (Porock &
Kristjanson, 1999). Thus it seems reasonable to assume that most patients are
likely to have erythema, possibly associated with soreness and itching. In a
review of the subject, Porock et al. (1999) noted that women being treated for
breast cancer were particularly vulnerable if they smoked, were overweight
and/or had large breast size or had required axillary lymphocoele drainage
prior to treatment, whereas younger patients were more vulnerable than older
patients in those having treatment to the sternum.
6.5.3 Preventive skin care
There is a body of evidence available to guide practice, in the form of best practice statements (NHS Quality Improvement Scotland, 2004), a summary of key
research findings for breast cancer (National Breast Cancer Centre, 2004) and
the clinical guidelines issued by the UK College of Radiographers (2001). Box
6.4 provides a summary of the recommended skin care. Unfortunately, despite
The Management of Patients with Acute Wounds 211
Box 6.4 Summary of recommendations for skin care during radiotherapy treatment.
•
•
•
•
•
•
•
•
•
•
Wash treatment site daily using mild unperfumed soap.
Avoid having a very hot shower, especially if the water jets are powerful.
Pat area dry with soft towel, avoiding friction.
Do not apply deodorants, perfume or aftershave to the treatment site.
Apply a mild emollient twice daily, ensuring emollient is at room temperature.
For men having radiotherapy to face or neck, use an electric razor rather than a wet shave.
If the axilla is part of the treatment site, do not shave during treatment.
If swimming, wash off chlorinated water as it is drying to skin and apply emollient.
Wear loose clothing over treatment site to avoid friction.
Avoid sun exposure where possible and use sunblock if it is unavoidable.
this guidance, there is considerable variation in the advice given to patients concerning how the skin within the treatment field should be managed whilst
radiotherapy is in progress (Faithfull et al., 2002).
Wells and colleagues reviewed the findings of their study of 357 patients
undergoing radiotherapy and concluded that levels of skin discomfort were
lower than they had expected (Wells et al., 2004). They concluded that consistent advice, skin hygiene and regular assessment were major factors in reducing problems. It is interesting to postulate that a reason for previous reports of
severe skin problems may have been the advice given some years ago that
patients should not wash the treatment area. Happily, that advice is now seen
as outdated.
6.5.4 Managing radiation reactions
The basic principles of managing radiation reactions are as follows.
RTOG score 1 and 2a
A simple moisturiser such as aqueous cream can be soothing applied to the area
twice daily. If aqueous cream is not effective an alternative cream may help.
There is much anecdotal evidence of the benefits of using aloe vera gel and
Heggie et al. (2002) undertook a study of 225 patients undergoing treatment for
breast cancer comparing aloe vera gel with aqueous cream. They found that
aqueous cream was significantly better than aloe vera gel in reducing dry
desquamation and pain. However, Wells et al. (2004) did not find this to be the
case when comparing aqueous cream with either sucralfate cream or no cream.
They concluded that patients should be given the choice to use a cream or not.
RTOG score 2b and 3
There is insufficient evidence to suggest a definitive treatment for wet desquamation. The main goal is to choose a dressing that is comfortable for the patient
and promotes healing. Depending on the level of exudate, this could include
212
The Care of Wounds
hydrocolloids, hydrogels and silicone dressings (National Breast Care Centre,
2004).
RTOG score 4
There is no information in the literature about the management of this grade of
radiation reaction but it would seem logical to treat them following the basic
principles of wound management as described in Chapter 3.
6.5.5 Care of the patient
The most important aspect of care of any patient undergoing radiotherapy must
be communication. Written information can be used to reinforce verbal explanations. This provides the patient with a permanent record that can be shared
with others. Although UK radiotherapy centres provide written information for
their patients, not all of this is evidence based (Faithfull et al., 2002). As hospitals seek to improve the information given to patients, it is hoped that this
situation will improve.
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Wilson, A.P.R., Helder, N., Theminimulle, S.K., Scott, G.M. (1998) Comparison of wound
scoring methods for use in audit. Journal of Hospital Infection, 39, 119–126.
Witchell, M., Crossman, C. (1991) Dressing burns in children. Nursing Times, 87 (36),
63–66.
Wynne, R., Botti, M., Stedman, H., Holsworth, L. (2004) Effect of three wound dressings
on infection, healing comfort and cost in patients with sternotomy wounds: a
randomised trial. Chest, 125 (1), 43–50.
218
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Chapter 7
Clinically Effective Wound Care
7.1 INTRODUCTION
Most nurses want to give their patients high-quality care. In the last few years
there has been considerable emphasis on the importance of ensuring that clinical practice is based on research. Evidence-based care is a major component of
clinical governance, the framework used by the UK Department of Health to
ensure high standards of care within the NHS (DoH, 1997).
Alongside the move to identify clinically effective practice has been the
development of clinical guidelines. In turn this links to clinical audit. Research
is an essential component underpinning each one. This chapter will address the
issues in relation to developing clinically effective practice in wound care.
7.2 EVIDENCE-BASED PRACTICE AND
CLINICAL EFFECTIVENESS
Providing clinically effective evidence based care involves:
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identifying current research and ‘best’ practice.
utilising appropriate national guidelines, protocols or standards where
available.
where guidelines are not available, critically appraising the available literature and evaluating its value to the proposed care setting.
implementing guidelines or protocols, changing practice where necessary.
undertaking clinical audits to measure outcomes and ensure patient care is
clinically effective.
sharing this knowledge with others within the clinical care setting and
elsewhere.
7.3 SEARCHING AND APPRAISING THE LITERATURE
With the advent of electronic databases, literature searches have become more
sophisticated. It is no longer adequate for individuals to simply use those articles that they have stored in the filing cabinet. They are likely to be out of date
and coincide with the point of view of the individual. Electronic databases such
as MEDLINE or CINAHL can assist in rapidly identifying relevant information
Clinically Effective Wound Care
219
Box 7.1 Examples of different kinds of wound care journals.
General wound care journals
Advances in Skin and Wound Care
International Wound Journal
Journal of Tissue Viability
Journal of Wound Care
Ostomy and Wound Management
Journals that cover specific types of wounds
Burns
Diabetic Foot Journal
Journal of Burncare Rehabilitation
Journal of Hospital Infection
Surgery
on a specific topic. It is also important to have access to library facilities in order
to retrieve the relevant journal papers.
Wound care research can be found in a wide range of journals as evidenced
in the reference lists within this book. There are also a number of specialist journals that focus wholly on tissue viability or very specific types of wounds. Box
7.1 lists some examples. Hand searching these journals may also provide further
information.
Other sources of information include the Cochrane Library, in particular the
Cochrane Wounds Group, which is based at the University of York in the UK.
The Cochrane Wounds Group is responsible for overseeing systematic reviews
that follow the same specific methodology and format for presentation of
the findings as any other Cochrane review on a wide range of topics relating
to wounds. Another source of evidence is the Health Technology Assessment
Programme in the UK. This programme has funded both primary (randomised
controlled trials) and secondary (systematic reviews) research in wound care.
The relevant reports are freely available on the website. It is also sometimes
useful to be aware of research studies that are in progress. This information
can be found on the Controlled Trials website, which also contains the
meta Register of Clinical Trials. Details of all these resources can be found in
Table 7.1.
Once a literature search is completed, the identified studies need to be critically appraised. All healthcare professionals should be able to critically review
a piece of research in order to judge the value of a study and whether the findings have implications for their clinical practice. Unfortunately, not everyone
has had training to develop this skill. In the UK, the Critical Appraisal Skills
Programme (CASP) has been developed to assist large numbers of healthcare
professionals in developing these skills. There are also useful proformas to
guide appraisal of studies using different research methods. The broad issues
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Table 7.1
Useful web-based sources of education and evidence.
Source
Type of evidence
Internet address
Cochrane Collaboration
Systematic reviews
www.cochrane.org
Cochrane Wound Group
Systematic reviews relating to
wound care
www.york.ac.uk/healthsciences/
gsp/themes/woundcare/Wounds
Health Technology
Assessment Programme
RCTs and systematic reviews
relating to wound care + wide
range of other studies
www.ncchta.org.
Meta-Register of Clinical
Trials
Wide range of information
about current trials
www.controlled-trials.com/mrct
Critical Appraisal Skills
Programme (CASP)
Details of programme for
developing skills in literature
searching and critical appraisal,
including e-learning
www.phru.nhs.uk/casp
that the appraisal tool helps to identify for most quantitative methods such as
randomised controlled trials or cohort studies are:
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is the trial valid?
what are the results?
will the results help locally?
whereas for an economic evaluation, the overall questions of relevance are:
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is the economic evaluation likely to be useable?
how were the costs and consequences assessed and compared?
will the results help in purchasing services for local people? (Milton Keynes
Primary Care Trust, 2002)
The proformas are designed to guide the user through the process in a very systematic way. Further information can be found in Table 7.1.
Searching the literature is very time-consuming as there is a wealth of information available. Not everyone has the time or resources to undertake such a
task in relation to all aspects of patient care. Systematic reviews of the literature can assist the healthcare professional by integrating existing information.
A systematic review has been defined by Mulrow (1994) as ‘the methodological and critical exploration, evaluation, collation and analysis of information
from related research studies to draw conclusions about the variables and outcomes included in the studies’. Systematic reviews generally only include randomised controlled trials as they are considered to be the best research method
for measuring the effectiveness of different treatments. Within the review, the
results of several studies can be grouped together by means of a type of statistical analysis called meta-analysis, which can give a more conclusive result than
each of the studies may do on their own (Cook et al., 1997a). The websites where
relevant wound care systematic reviews may be found are detailed in Table 7.1.
Clinically Effective Wound Care
221
7.3.1 Appraising the literature on wound care
The literature pertaining to all aspects of wound care is very large, as demonstrated by the many examples that have been given in other chapters of this
book. It is therefore important for the nurse to be aware of how to identify both
the strengths and the weaknesses of the wound care evidence. Some of the
issues are addressed here.
Study size
Early studies of modern dressings tended to compare them with gauze. As the
differences between the two groups were so great, only relatively small
numbers of patients were needed in a study. However, the differences are much
smaller when comparing two modern products and therefore much larger
numbers are needed. It may be difficult for one centre to recruit sufficient
patients, so several centres may be required. This may introduce other variables
if there are variations in local management patterns (Freak, 1995). High-quality
research will indicate that it has sought to reduce this problem by using a power
calculation to identify the required sample size and also addressing the issue
of standardisation between centres.
Endpoints
Another issue to consider when appraising the wound care literature is endpoints. In other words, at what point a patient should be considered to have
completed a study. Freak (1995) suggests that complete healing is not always
the most suitable endpoint, although Bradley et al. (1999) argue that assessing
the proportion of wounds healed is the most objective assessment currently
available. They also propose that if reduction in wound size is used as an endpoint then both the percentage and absolute change in surface area should be
measured.
Length of study
There has been considerable debate regarding the length of time that is reasonable for a trial of effectiveness of treatment, especially if time to healing is
used as an endpoint. Lengthy studies are costly to undertake and there is a risk
that patients may be lost to follow-up during the time of the study. Nelson
(1998) suggests that healing rates for leg ulcers should be measured at intervals
over time, probably more than 12 weeks. However, other authors have not
always supported this view. Kantor and Margolis (2000) studied 104 venous leg
ulcers and found that percentage change in area at four weeks was an indicator of healing at 24 weeks. Similarly, Sheehan et al. (2003), using 203 patients
found the percentage change in diabetic foot ulcer area at four weeks is a robust
indicator of healing at 12 weeks. There is obviously some disparity in
the expected healing time between the two studies quoted, indicating the
importance of not trying to extrapolate the findings directly to another
wound type.
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7.4 DEVELOPING CLINICAL GUIDELINES
Clinical guidelines are recommendations on the appropriate treatment and care
of people with specific diseases and conditions (NICE, 2004a). They have a
number of uses: to guide the care of individuals; to develop standards against
which clinical practice can be measured; for education and training; and to help
patients make informed choices (NICE, 2004a). Generally, guidelines consist of
a series of statements around a particular topic with a rationale for each statement. The rationale relates to the evidence, usually obtained from systematic
reviews, underpinning the statement. Many guidelines use a hierarchy to
measure the quality of the evidence that they use and then grade the recommendation, as demonstrated in the NICE guidelines. For example, within the
hierarchy of evidence, level I indicates evidence obtained from meta-analysis
of randomised controlled trials or at least one randomised controlled trial;
a statement based on this evidence would be graded as a grade A statement.
Table 7.2 shows the grading system used in the NICE guidelines on prevention
and management of foot problems in patients with type 2 diabetes (NICE,
2004b).
Preparation and publication of a guideline are not enough to ensure that it
is implemented. Any national guideline tends to be written in broad terms. It
needs to be adapted to include more operational detail for local use and may
include policies and protocols. The implementation team should be multidisciplinary, reflecting all key personnel including representatives from purchasing authorities (Effective Health Care, 1994). Richens et al. (2004) undertook a
review of the literature on guideline implementation and made several useful
observations based on their findings.
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Guidelines and any local adaptation of guidelines should contain recommendations that are clear, specific and relevant to both practitioners and
practice.
Ownership and adoption of guidelines are more likely to occur if there is a
partnership between the guideline developers, users and implementers.
Guideline implementation can be improved by use of dedicated ‘change
agents’ to work with individuals, teams and organisations in the clinical
setting.
The use of clinical audit is an essential aspect of guideline implementation.
Those responsible for implementing guidelines need to be aware of organisational factors, especially linking in to the organisation’s strategy and
resource commitments.
7.4.1 Guidelines in wound care
There are a great number of guidelines available that relate to various aspects
of wound care. A survey undertaken by the Tissue Viability Society in 2002
found that there appeared to be a major shift over a five-year period from the
use of locally developed guidelines to the use of national and international
Clinically Effective Wound Care
223
Table 7.2 Evidence grading scheme used within the NICE guideline: Type 2 Diabetes,
Prevention and Management of Foot Problems (NICE, 2004)*
Recommendation grade
Evidence
A
Directly based on category I evidence
B
Directly based on:
• category II evidence or
• extrapolated recommendation from category I evidence
C
Directly based on:
• category III evidence or
• extrapolated recommendation from category I or II evidence
D
Directly based on:
• category IV evidence or
• extrapolated recommendation from category I, II or III evidence
NICE 2003
Recommendation drawn from the NICE 2003 technology appraisal
of patient education models for diabetes
Evidence category
Source
I
Evidence from:
• meta-analysis of randomised controlled trials or
• at least one randomised controlled trial
II
Evidence from:
• at least one controlled trial without randomisation or
• at least one other type of quasiexperimental study
III
Evidence from non-experimental descriptive studies such as
comparative studies, correlation studies and case control studies
IV
Evidence from expert committee reports or opinions and/or clinical
experience of respected authorities
*(reproduced by kind permission of NICE).
guidelines (Clark, 2003). Many of these guidelines have been published in the
wound care literature and others are freely available via the Internet.
At present, there is insufficient high-quality research to provide all grade A
recommendations in guidelines for either pressure ulcers or leg ulcers. For
example, the NICE guidelines for pressure ulcer prevention contains ten statements, of which one is grade B and the remainder grade D, demonstrating the
weak evidence on which the guideline is based (NICE, 2003). Cook et al. (1997b)
suggest that where the evidence supporting a guideline is not strong, the impact
of implementation needs to be rigorously audited.
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7.5 THE CLINICAL AUDIT CYCLE
Audit has been defined as:
‘a clinically-led initiative which seeks to improve the quality and outcome of
patient care through structured peer review whereby clinicians examine their
practices and results against agreed explicit standards and modify their practice where indicated’ (NHS Executive, 1998).
Burnett and Winyard (1998) suggest that clinical audit is at the heart of clinical
effectiveness. Some guidelines also include an audit tool against which it is possible to measure the effectiveness of implementation. Examples can be found
in the NICE guidelines on pressure ulcer prevention and the diabetic foot
(NICE, 2003, 2004b).
One of the benefits of audit is that it can be used to measure the outcomes of
everyday practice to provide baseline information before introducing clinical
guidelines. A repeat of the audit enables the guideline team to monitor any
health gains associated with the implementation of more effective practice as
well as monitoring whether the guidelines are being adhered to. Clinical staff
are more likely to be willing to adhere to guidelines if they can see a beneficial
outcome. Providing information for staff about performance levels is an essential aspect of the audit process.
7.5.1 Auditing clinical practice
Audit provides data both for initial baseline information and to measure the
outcomes of guideline implementation. In many instances this information is
obtained by means of prevalence surveys and incidence monitoring. This is particularly true of pressure ulcers where there has been much debate on the most
effective methods for collecting this information and on its value.
Prevalence can be defined as: ‘The number of persons with a specific disease
or condition as a proportion of a given population measured at a specific point
in time’ (Dealey, 1997), whereas incidence is defined as: ‘The number of people
developing a specific condition as a proportion of the local population measured over a period of time’ (Dealey, 1997).
An example of a baseline pressure ulcer audit is one undertaken across
France by Barrois et al. (1997). They found an overall prevalence of 8.7% as well
as considerable detail about the characteristics of pressure ulcers in France. This
provided a very informative baseline prior to introducing a range of prevention strategies. Incidence rates are often used to evaluate the effectiveness of
prevention policies. Data collection for incidence measurement is more complicated than for prevalence surveys and subject to inaccuracies (Bridel et al.,
1996). However, Dealey (1997) suggests that the main benefit of incidence rate
measurement is to demonstrate improvements over time.
Lindholm et al. (1998) and Dealey (1998) undertook prevalence surveys of leg
ulceration prior to instigating education and training and the implementation
Clinically Effective Wound Care
225
of management guidelines. Audit of the effectiveness of this strategy concentrated on changes in practice, nursing knowledge and healing rates (Dealey,
1998). Feedback of the results to the staff provided encouragement that adherence to the guidelines was ensuring increased healing rates. Stevens et al. (1997)
also used healing rates to monitor the outcomes of a project establishing leg
ulcer guidelines within two acute hospitals and the surrounding community.
Over time they were also able to measure recurrence rates and compare them
favourably with the rate from another study previously reported in the
literature.
Audit of surgical wounds is usually undertaken as a surveillance of wound
infection rates. This may be in the form of either prevalence or incidence. Prevalence surveys have been used in national surveys to provide a snapshot of the
situation (Briggs, 1996). Incidence rates can be used to monitor the performance
of individual surgeons. Frequently this type of surveillance measures the incidence of surgical wound infection (SWI) in clean surgery. Incidence may be
used with case control studies or with cohort studies. Case control studies retrospectively compare a group of patients with SWI with a control group in
order to determine any risk factors associated with SWI. Cohort studies are
prospective and follow a group of patients over time to see who develops a
SWI. Potential risk factors are determined at the beginning of the studies and
then monitored for the outcome. For example, in their ten-year study, Cruse
and Foord (1980) considered diabetes to be a potential risk factor and so monitored the clean wound infection rate for diabetics and found it to be considerably higher than that for non-diabetics. The findings from this type of audit can
be used to improve patient care.
7.5.2 Dissemination of audit findings
As well as sharing audit results with those directly involved, it is important to
discuss them with a wider audience. This may be in the form of a report for the
executive board of a hospital trust or the local purchasing authority or it may
be a conference presentation or a publication. There are a number of benefits.
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Internal dissemination allows other areas in the organisation to benefit from
the audit findings.
Healthcare professionals working in similar clinical areas can apply the
lessons learned from the audit.
Those involved in the audit will develop skills in writing and undertaking
presentations.
7.6 CONCLUSIONS
At present, the quality of the evidence available to support clinically effective
wound care is very variable. Systematic reviews can be used to determine the
gaps so that future research can be directed to the area where it is most needed.
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REFERENCES
Barrois, B., Allaert, F., Urbinelli, R., Colin, D. (1997) National survey in France: pressure
sores in hospital institutions in 1994, in (eds) Cherry, G.W., Gottrup, F., Lawrence,
J.C., Moffat, C.J., Turner, T.D., Proceedings of the 5th European Conference on Advances
in Wound Management. Macmillan Magazines Ltd, London.
Bradley, M., Cullum, N., Sheldon, T. (1999) The debridement of chronic wounds: a systematic review. Health Technology Assessment, 3 (17), Part 1, 1–78.
Bridel, J., Banks, S., Mitton, C. (1996) The admission prevalence and hospital-acquired
incidence of pressure sores within a large teaching hospital during April 1994 to
March 1995, in (eds) Cherry, G.W., Gottrup, F., Lawrence, J.C., Moffat, C.J., Turner,
T.D., Proceedings of the 5th European Conference on Advances in Wound Management.
Macmillan Magazines Ltd, London.
Briggs, M. (1996) Epidemiological methods in the study of surgical wound infection.
Journal of Wound Care, 5 (4), 186–191.
Burnett, A.C., Winyard, G. (1998) Clinical audit at the heart of clinical effectiveness.
Journal of Quality and Clinical Practice, 18 (1), 3–19.
Clark, M. (2003) Barriers to the implementation of clinical guidelines. Journal of Tissue
Viability, 13 (2), 62–72.
Cook, D.J., Mulrow, C.D., Haynes, R.B. (1997a) Systematic reviews: synthesis of best evidence for clinical decisions. Annals of Internal Medicine, 126 (5), 376–380.
Cook, D.J., Greengold, N.L., Ellrodt, A.G., Weingarten, S.R. (1997b) The relation between
systematic reviews and practice guidelines. Annals of Internal Medicine, 127 (3),
210–216.
Cruse, P.J.E., Foord, R. (1980) The epidemiology of wound infection: a 10-year prospective study of 62 939 wounds. Surgical Clinics of North America, 60, 27–40.
Dealey, C. (1997) Managing Pressure Sore Prevention. Mark Allen Publishing Ltd, Salisbury.
Dealey, C. (1998) The importance of education in effecting change in leg ulcer management, in (eds) Leaper, D., Dealey, C., Franks, P.J., Hofman, D., Moffatt, C.J., Proceedings of the 7th European Conference on Advances in Wound Management. EMAP
Healthcare Ltd, London.
Department of Health (1997) The New NHS: Modern, Dependable. Department of Health,
London.
Effective Health Care (1994) Implementing clinical practice guidelines. Effective Health
Care Bulletin no. 8. University of Leeds, Leeds, pp. 1–12.
Freak, L. (1995) Evaluating clinical trials. Journal of Wound Care, 4 (3), 114–116.
Kantor J., Margolis D. (2000) A multicentre study of percentage change in venous leg
ulcer area as a prognostic index of healing at 24 weeks. British Journal of Dermatology, 142, 960–964.
Lindholm, C., Tammelin, A., Bergsten, A., Berglund, E. (1998) The Uppsala experience:
implications for developing educational strategies, in (eds) Leaper, D., Dealey, C.,
Franks, P.J., Hofman, D., Moffatt, C.J., Proceedings of the 7th European Conference on
Advances in Wound Management. EMAP Healthcare Ltd, London.
Milton Keynes Primary Care Trust (2002) Critical Appraisal Skills Programme. Milton
Keynes Primary Care Trust, Milton Keynes.
Mulrow, C.D. (1994) Rationale for systematic reviews. British Medical Journal, 309 (6954),
597–599.
National Institute for Clinical Excellence (2003) Clinical Guideline 7: the use of pressurerelieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in
primary and secondary care. NICE, London.
Clinically Effective Wound Care
227
National Institute for Clinical Excellence (2004a) About Clinical Guidelines. Available
online at: www.nice.org.uk.
National Institute for Clinical Excellence (2004b) Clinical Guideline 10: type 2 diabetes: prevention and management of foot problems. NICE, London.
Nelson, E.A. (1998) The evidence in support of compression bandaging. Journal of Wound
Care, 7 (3), 148–150.
Richens, Y., Rycroft-Malone, J., Morrell, C. (2004) Getting guidelines into practice: a literature review. Nursing Standard, 18 (50), 33–40.
Sheehan, P., Jones, P., Caselli, A., Giurini, J.M., Veves, A. (2003) Percentage change in
wound area of diabetic foot ulcers over a 4-week period is a robust predictor of
complete healing in a 12 week prospective trial. Diabetes Care, 26 (6), 1879–1882.
Stevens, J., Franks, P.J., Harrington, M. (1997) A community/hospital leg ulcer service.
Journal of Wound Care, 6 (2), 62–68.
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Chapter 8
The Organisation of Wound Management
8.1 INTRODUCTION
The organisation of the delivery of wound care has undergone great change in
the last few years. This chapter explores some of the aspects of wound care
delivery that have had a great impact on nurses and nursing, both in the hospital and in the community. Overall, these changes have ensured that patients
receive more effective care.
8.2 MANAGING WOUNDS IN THE COMMUNITY
In most healthcare systems there are some restrictions on which wound management products are available in the community. In the UK, available products
are listed on the Drug Tariff. Today this list is regularly reviewed and new products added to it but this was not always the case. Less than ten years ago, there
were considerable restrictions on the range of products available, particularly
dressings for cavity wounds and compression bandages. Dealey (1997) reported
a survey undertaken by the Tissue Viability Society to gain information about
how cavity wounds were managed in the community. The overall response rate
was poor but the results showed that nearly one-fifth of the dressings used were
obtained by illegal means such as obtaining a prescription for one product and
doing a ‘swap’ with the pharmacist for another, more suitable product. Happily
a great deal has changed since then. As well as an increase in the products available, nurses are now allowed to prescribe from a limited formulary.
8.2.1 Nurse prescribing
Nurse prescribing has followed a rocky road since Julia Cumberlege first put
forward the idea in a report for the Department of Health (DHSS, 1986). The
concept was seen as a way of reducing time wasting for both community nurses
and general practitioners (GPs) and reducing delays in treatment. Typically a
nurse would see a patient with a leg ulcer at home and decide on a particular
course of treatment. The nurse would have to go to the surgery to see the GP
and request a prescription for the treatment. The patient, or a representative,
would then collect the prescription from the surgery. In the case of housebound, elderly patients, nurses would sometimes obtain the prescription and
deliver it to the pharmacist for the patient.
The Organisation of Wound Management 229
Initially it was only qualified district (community) nurses and health visitors
who were able to prescribe, once they had undertaken the relevant three-month
training course. Since 2000, this has widened and there are now a variety of
ways in which a wide range of nurses can potentially undertake prescribing
using the Nurse Prescriber’s Formulary.
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Independent prescriber – person who is responsible for both assessment and
treatment of a range of specific conditions. This group includes doctors and
dentists as well as nurses but there are obviously greater limitations to the
range of conditions that nurses can treat. However, they do include skin and
wound care and minor injuries.
Supplementary prescriber – this type of prescribing is most frequently of benefit
when caring for patients with long-term conditions. A doctor will draw up
a plan of care including the range of medication that can be used and when
to refer the patient back to the doctor (Dimond, 2003). The supplementary
prescriber can vary the dosage, keeping within the prescribed treatment
range. This type of prescribing means that supplementary prescribers can
legally prescribe from a wider range of medications than can be found in the
nurse’s formulary and this is generally more useful within specialist multidisciplinary teams (Hay et al., 2004).
Patient Group Directions (PGD) – these are documents that make it legal for
specific medicines to be given to patients without an individual prescription.
However, they only relate to the supply or administration of a medicine,
rather than its prescription (Baird, 2003). Each PGD has to be developed
locally. Although initially intended for situations such as the treatment of
mass casualties, they have also been used for walk-in centres and nurse-led
clinics.
Thus far, nurse prescribing would seem to be relatively successful in the UK
and around 23 000 district nurses and health visitors have been trained to prescribe so far. Latter and Courtney (2004) reviewed the literature for evaluations
of nurse prescribing and found that, overall, the outcome was positive with evidence of improvements in time saving and convenience. White and Biggs (2004)
conducted a postal survey of health visitors and district nurses in three trusts.
They found variation in the level of confidence as a prescriber and in the frequency of prescribing. There was also a strong association between prescribing
more than three times a week and wound care products and elastic hosiery,
indicating wound care has particularly benefited from nurses’ ability to prescribe. However, as discovered by other writers (Banning, 2004; Lewis-Evans
& Jester, 2004), the authors of this study found that the nurses desired greater
education in applied pharmacology, both in the initial education programme
and as part of their ongoing professional development.
8.2.2 Community leg ulcer clinics
Another development has been that of nurse-led leg ulcer clinics in the community. These clinics have gradually increased in number during the last ten
230
The Care of Wounds
years, encouraged by the work of Moffatt et al. (1992) and the development of
leg ulcer courses for nurses, such as the N18 validated by the now defunct
English National Board (Moffatt & Karn, 1994). Many clinics have been established under the auspices of clinical nurse specialists in tissue viability or leg
ulcer nurse specialists. The rationale for establishing leg ulcer clinics is the possibility of concentrating resources and skilled nurses at the clinic to ensure that
all patients have a full assessment, including a Doppler assessment, and access
to appropriately applied compression bandages. However, it is the outcomes
of care that are most important.
Simon et al. (1996) found a 38% reduction in costs after establishing leg ulcer
clinics in a health authority alongside a 13-week healing rate that increased
from less than 25% to 42% in the first 12 months. They compared these outcomes with a control group in a neighbouring health authority where there
were no clinics and found no improvement from baseline in this group. In a
later phase of this project, the project team monitored the continuing progress
of the clinics as well as new clinics established in the neighbouring health
authority (Ellison et al., 2002). They found the new clinics showed a similar
improvement in outcome but the longer established clinics did not totally maintain their initial level of improvement, most probably because of the loss of the
leg ulcer nurse specialist between the two phases of the project.
Morrell et al. (1998) undertook a randomised, controlled trial to compare outcomes for patients randomised to a leg ulcer clinic compared with usual care
at home by a district nurse. They found a trend towards greater healing in the
clinic group (p = 0.03) and a slightly greater cost per patient compared with the
controls. The authors concluded that clinics provide better outcomes than
homecare. However, in a critique by Thurlby and Griffiths (2002), the authors
suggest that the study was biased towards the clinic group as there was poor
provision of compression bandages with less than half the homecare patients
receiving them. It is also possible that the nurses were less skilled in leg ulcer
care.
Despite these criticisms, there seems to be a general view that leg ulcer clinics
are an effective method of proving care for patients with leg ulcers. Some
patients find the social aspect important as many have poor mobility that
restricts their lifestyle. A study by Liew et al. (2000) found an improvement in
quality of life over an average of eight weeks of clinic attendance. In particular, patients had a significant reduction of pain, better sleep and greater mobility. Overall, leg ulcer clinics have more supporters than critics, although it may
be that involvement of a nurse specialist is crucial in maintaining beneficial
outcomes.
8.3 NURSE SPECIALISTS IN WOUND CARE
Specialist nurses in wound care have a variety of titles but the most common
in the UK is clinical nurse specialist in tissue viability (TVN). They straddle
The Organisation of Wound Management 231
both hospital and community as TVN may be found in both community and
hospital trusts. It is a relatively new nursing specialty developed in the late
1980s and the numbers have grown rapidly. The precise number is difficult to
determine as there is no formal register but Finnie (2004) suggests that there
are now around 500 in post as well as a few nurse consultants.
Education is an essential prerequisite for the recognition of any specialty.
Fletcher (1998) found that there are a variety of courses available within the
UK. They comprise short courses at diploma level as well as degree and Masters
level programmes. Fairbairn (2001) discussed the potential for a clinical doctorate for TVN as an alternative to undertaking a PhD following the more traditional route. He suggested that this option is more flexible, allowing the
student to utilise aspects of existing work. A more recent development has been
that of a competency framework devised for TVN in Scotland but it is intended
for wider use (Finnie & Wilson, 2003). It involves six domains: clinical problem
solving, professional practice, teamwork, reflective practice, empowerment and
leadership.
Austin (2002) undertook a survey of TVN in one region of the UK and found
several clearly defined aspects of the role.
䊉
䊉
䊉
䊉
䊉
Clinical role – all the TVN had direct clinical contact with patients, receiving
referrals predominantly from nurses.
Educator role – this is an important aspect of the role. The survey found that
TVN mostly taught nurses but also taught other disciplines such as doctors,
allied health professionals and social workers.
Leadership role – all respondents had a remit that extended across their
organisation, involving advice on purchasing or commissioning resources
(94%), standards or guideline development (93%), audit of care provision
(83%).
Research role – 57% had participated in research, predominantly product evaluations. This aspect of the role generally requires further development (Gray,
2004).
Management role – respondents indicated that this involved managing a team
(39%) and/or holding the service budget (42%) or influencing the budget
expenditure.
Austin’s survey provides a picture of TVN activity that is fairly representative.
She also noted that the role is poorly understood by others. Flanagan (1996)
described some of the difficulties that the TVN may face. They include unrealistic objectives or targets, role ambiguity, responsibilities across large geographical areas or multiple sites, constant pressure to reduce the cost of the
tissue viability service and often having to work with insufficient resources
with limited professional support. Despite the constraints, the role of the TVN
still presents the post holder with considerable opportunities to enhance
nursing practice and the personal satisfaction of seeing wounds healing and
patients’ quality of life improve.
232
The Care of Wounds
8.4 THE MANAGEMENT OF PRESSURE-REDISTRIBUTING
EQUIPMENT
As noted above, many TVN have a major role in relation to the management
of equipment, especially pressure-redistributing equipment. Most trusts have
some type of budget for equipment but there is considerable variety in how it
is used and the ways in which distribution and maintenance are organised.
Several authors have reported that ad hoc ordering of rental equipment or
unplanned purchasing on a ward-by-ward basis is both expensive and inefficient and results in ineffective care (Birchall, 2001; Fox & Delve, 1994; Newton
2001). One alternative is an equipment store or equipment library.
8.4.1 Equipment stores
This method of control and delivery of pressure-redistributing equipment is
most commonly found in the hospital setting but there are also a few within
primary care trusts. Birchall (2001) described the development of an equipment
store across an acute trust of 1100 beds on two sites, taking two years to become
fully established. The store contained a mixture of purchased and rental equipment. The cost savings from the previous ad hoc rental system covered the cost
of the equipment, including maintenance and repair, cost of the staff running
the store, an annual foam mattress replacement programme and a five-year
replacement programme for the alternating air mattresses.
Newton (2001) found similar problems in her trust. In particular, there were
problems with staff attitudes as they were careless with equipment, unwilling
to share equipment with other wards, kept patients on dynamic systems for
longer than necessary and tended to order rental equipment as an easy option,
rather than seeking out trust-owned equipment. As a result, rental expenditure
was spiralling out of control. After implementing an equipment library, Newton
found a marked change in staff attitudes and a more appropriate and costeffective use of equipment.
Both Birchall (2001) and Newton (2001) implemented improved education
programmes for staff that covered not only the appropriate use of equipment
but also how to set it up. The use of a central database is also an essential aspect
of this type of service as it enables the store staff to determine the whereabouts
of every piece of equipment, making it easier to monitor usage.
8.4.2 Total bed management
An alternative to the establishment of an equipment store is the use of total bed
management (TBM). This concept means that a trust and a contractor enter into
partnership, with the contractor supplying the trust with all its tissue viability,
manual handling and bed therapy needs (Preece, 1999). Obviously, this type of
contract means that the equipment is supplied at a reduced cost. Preece (1999)
described similar problems as those described above. In addition, there was
also a major problem with existing bed frame stock as 492 bed frames failed at
The Organisation of Wound Management 233
least one of five assessment criteria; also 389 of them were a manual handling
risk. An audit of the foam mattresses showed that 75% needed replacement.
There was also an excessive use of low air loss systems. The implementation
of TBM enabled the trust to replace the worn-out bed frames with electric
bed frames, which they found reduced both the manual handling risks and
also the need for low air loss beds. The foam mattresses were replaced
with high-specification foam mattresses and a suitable range of other pressureredistributing equipment was included in the contract.
8.5 WOUND-HEALING CENTRES
Wound care falls into the remit of a great many specialist areas: vascular
surgery, dermatology, diabetology, plastic surgery, geriatrics and so on. This has
resulted in considerable fragmentation of services and lack of ownership in
many areas. Bennett (2000) suggested that unless wound care is able to establish its own unique national profile, it is in danger of being subsumed into other
specialties such as those listed above. There is also little awareness of the benefits of providing a multiprofessional specialist centre for non-healing wounds.
The one exception seems to be diabetic foot ulcers as the NICE guidelines state
that patients should have access to a multidisciplinary footcare team (NICE,
2004); even then, it only refers to the one wound type. There are a number of
centres of excellence caring for one wound type, such as leg ulcers or diabetic
foot ulcers, but very few that provide care for wounds of all aetiologies.
Four wound-healing centres will be discussed: two in the UK and two in
Denmark. All of these centres are based within the national healthcare systems
of the two countries and there is no charge associated with attendance. This is in
contrast with the wound-healing centres in the USA that are commercially run.
Despite the fact that nurses have led much of the work in improving wound
care provision, it is doctors who have pioneered the concept of wound-healing
centres. In the case of the two centres in the UK, one centre was established by
a general practitioner, although it is based in a department of surgery in a university hospital, and the other by a geriatrician (Bennett, 2000; Harding, 2001)
and in Denmark, the two wound-healing centres were established by a surgeon
(Gottrup, 2004). Although the centres all function differently, they have a
number of common features:
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䊉
䊉
The staff working in wound-healing centres include physicians from different specialisms, as well as a variety of other healthcare professionals, including nurses. The range of professionals varies from centre to centre.
They are based within teaching hospitals and provide education programmes of varying types.
They treat both inpatients and outpatients, referred from both the primary
and secondary healthcare sectors, although the number of inpatient beds
may be limited.
All the wound-healing centres are involved in research programmes.
234
The Care of Wounds
Beyond this common ground, the centres all function differently, due to the circumstances in which they were developed. The centres in Denmark have been
fully integrated into the national health service, allowing for country-wide
referrals. Gottrup (2004) suggests that for Denmark, with its 5.2 million inhabitants, only one or two clinics are necessary. Obviously, larger or more densely
populated countries would require more centres to provide the same levels of
care provision.
Wound-healing centres have a great deal to offer in terms of specialised care
for problem wounds, educational opportunities to increase the numbers of
clinical staff with specialist knowledge and an important research function to
assist in developing the evidence base for this important subject.
8.6 CONCLUSIONS
Wound care is increasingly being recognised as an important aspect of nursing
care and it is becoming ever more sophisticated. Despite this, there are still areas
of poor practice and patients who receive less than optimum care. It is hoped
that these variations in practice will decrease as more evidence and more guidelines become available to guide the practitioner.
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Preece, J. (1999) Total bed management: the way forward in pressure sore prevention.
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Thurlby, K., Griffiths, P. (2002) Community leg ulcer clinics vs home visits: which is more
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236
The Care of Wounds
Index
Page numbers in italics refer to figures or tables.
absorbent pads and cellulose dressings, 99
Acquacel, 185
Acticoat, 104
Actisorb Plus, 104
active listening, 36
Activon Tulle, 103
adhesive island dressings, 99
adrenaline, 165
advanced technologies, 105–12
growth factors, 105
hyaluronan-based products, 106–07
hyperbaric oxygen, 23, 107–08
protease-modulating products, 105–06
tissue culture, 110
tissue engineering, 110–11
topical negative pressure (TNP) therapy, 75,
108–09
age factors and risk, 15, 19, 21, 125–6
air filtration systems, 189, 191
alginates, 73, 75, 100, 165
Algisite M, 100
Alione Hydrocapillary, 101
Allevyn, 101
aloe vera gel, 211
alternative therapies, 37, 112–13, 211
antibacterial dressings, 100
antibiotics, 75
topical forms, 95–6
antiseptics, 75, 88–9
types, 92–5
anxiety management, 35–7
Apligraf (Graftskin), 110–12
Aquacel, 102
Aquacel Ag, 104
Arglaes, 104
aromatherapy, 37, 113
arterial leg ulcers, 151–5, 154
artificial skin, 110–11, 151, 183
ASEPSIS wound scores, 188, 189
assessment see wound assessment
auditing clinical practice, 224–5
autolytic debridement, 73
Bactigras, 103
‘bag systems’, 75, 192
barrier film dressings, 100
Better Food Programme (DoH 2001), 15
Biatain, 101
Bioclusive, 104
biosurgery see larval therapy
bites, 198
body image problems, 39–40, 206
body temperature, and wound healing, 32–3
British Pharmaceutical Codices, 89, 90
Buerger’s disease, 23, 153
burn injuries, 9, 199–209
aetiology and incidence, 200–201
classification and assessment, 201–03, 204, 206,
207
first aid treatment, 203, 205
management, 205–09
complex burns, 205–06
non-complex, 206–09
non-accidental, 200, 201
and oedema, 203
cadexomer bead dressings, 101
capillary bleeding, 163, 165
see also haemorrhage
capillary wound dressings, 75, 101
carbolic acid, 88
Carbonet, 104
carcinomas
and leg ulcers, 156–7
see also fungating wounds
catheter use, and infection control, 22
Cavi-Care, 101
Cavilon, 100
cell traction, 7
cetrimide, 92
charcoal dressings, 104, 164
Charnley Howarth tent, 23
chlorhexidine, 92, 103
Chlorhexitulle, 103
chronic wounds, 10–11
defined, 56
diabetic foot ulcers, 158–62, 161
economic costs, 121, 122–3
and infection control, 64–5, 74–5
pressure ulcers, 121–43
types
fungating wounds, 162–5
leg ulcers, 143–58
CicaCare, 103
clinical guidelines development, 222–3
see also NICE guidelines
clinical trials, 78–9, 219–21
Clinishield, 100
Clinisorb, 104
Cochrane reviews, 219, 220
collagen, 6–9, 24, 209
Combiderm, 102
Comfeel Skin Care, 100
communication needs see patient communication and
education
community wound management regimes, 228–34
Index
complement system, 4
compression, 75, 148–50, 167
bandage systems, 138–9
pneumatic, 149
socks and stockings, 151–2
see also TNP (topical negative pressure) therapy
computer-assisted wound measurement, 60
concordance (compliance), 38
contact dermatitis, 71, 71
contact inhibition, 8
continuity of care, 42
contractures, 7, 10
Contreet Ag, 104
Critical Appraisal Skills Programme (CASP), 219–20,
220
Curasorb, 100
cushions, 134
cutifilm, 104
Cutinova Cavity, 102
Cutinova Hydro, 102
cytokines, 5
Dakin’s solution, 88–9, 95
debridement, 73–4
history of use, 86, 87–8, 89
types
autolytic, 73
enzymatic, 73–4
larval therapy, 73, 75, 100–101
mechanical, 74
surgical, 74, 164–5
dehiscence, 191–2
delayed primary closures, 56, 181
depression, 26, 35–6
Dermagraft, 111–12
dermatitis, 71, 71
Dermax, 106
dermis, 2, 3
diabetes mellitus, 25–6
complications
foot ulcers, 158–62, 161
infection risk, 21, 225
leg ulcers, 145
neuropathic vs. ischaemic ulcers, 160–61, 160
pain, 27
diet see nutrition management
digital photography, 60, 67–8
discharge planning
availability of dressings, 58
involving patients, 43
documentation, 77–8
see also measurement of wounds
donor sites, 184–5
Doppler ultrasound/flowmeters, 147, 160–61, 206
dressings
background history, 83–90
dark ages and middle ages, 85–6
late middle ages and renaissance, 86–7
seventeenth to early nineteenth centuries, 87–8
mid-nineteenth and twentieth centuries, 88–9
traditional techniques, 90–91
costs, 79
environmental considerations, 97–8
evaluation, 78–9, 97–9
handling qualities, 98–9
and moisture balance, 75
timing and frequency, 58
types, 92–6, 99–104
see also advanced technologies
237
education see patient communication and education;
training and education
EGF (epidermal growth factor), 5
enteral feeding, 17–19
enzyme debridement, 73–4
epidermis, 2–3, 3
epithelialisation (wound healing), 8–9
epithelialising wounds, 66, 67
equipment stores, 136, 232
erosion, 57
erythema, 63, 71
European Pressure Ulcer Advisory Panel, 122
decision ‘tree’ nutrition guidelines, 19, 20
on grading and assessment, 138, 140
European Tissue Repair Society (ETRS), on documentation,
77–8
Eusol, 78, 88–9, 95
evaluation of treatments, 70
donor sites, 184–5
dressing efficacy, 78–9
foot ulcers, 162
fungating wounds, 165
leg ulcers, 144, 151, 155, 156, 158
primary closure dressings, 180–81
skin grafts, 182–4
surgical cavities, 182
see also clinical trials; measurement of wounds; wound
assessment
evidence-based practice, 218–25
clinical audit cycles, 224–5
clinical guidelines development, 222–3, 223
literature searches and appraisal, 218–21
Exu-dry, 99
exudate
assessment and classification, 61–2, 62
burn injuries, 208
and chronic wounds, 10–11
FGF (fibroblast growth factor), 5, 6, 8
fibroblasts, 6–7, 8
and burns, 209
and chronic wounds, 10–11
and diabetes, 25
finger tip injuries, 197
fistula formation, 193–4
foam dressings and cavity fillers, 101, 192
foam stents, 182
food standards in hospitals, 15
see also nutrition management
footwear, 159–60
friction, 125
full-thickness wounds, 1, 57
fungating wounds, 162–5
aetiology, 163
management, 163–5
Galen (Roman surgeon), 84–5
glucocorticoids, 26, 33–4
Gore-Tex bags, 208–09
Granuflex (Duoderm), 102
Granugel, 102
granulating wounds, 66, 66
granulation tissue, 7
grief reactions, 41
growth factors, 5–6, 5, 11, 105
guided imagery, 37
haemorrhage, 187
Hageman factor, 4
238
The Care of Wounds
handwashing, 22–3
healing see wound healing
healing by second intention, 2, 56, 181–2
heart surgery, 180
high-pressure wound irrigation, 74
honey, 83–7, 96, 164, 185, 208
Hospital Anxiety and Depression (HAD) Score, 35
hospital trolleys, 135–6
hospital-acquired infections (HAIs) see infection control
Hyalofill-F, 106–07
hyaluronan-based products, 106–07
hydrocapillary and multilayered absorbent pads, 101–02
hydrocolloids, 73, 102, 185, 196, 208
odour, 62
hydrofibres, 102
hydrogels, 73, 102, 197, 208
hydrogen peroxide, 92–3
hyperbaric oxygen, 23, 107–08
hypertrophic scars, 9, 209
hypothermia, 32–3
IGF-I/II (insulin-like growth factors), 5
Inadine, 103
incontinence lesions, 140
infection control, 19–23, 63–5, 64, 74–5
during and following surgery, 187–91
interventions and assessment, 22–3, 74–5
air filtration systems, 189, 191
antibiotics/antiseptics, 91–5, 95–6
handwashing, 22–3
larval debridement, 73, 75, 100–101
protective isolation, 23
supplemental oxygen, 23, 107–08
use of honey, 83–7, 96, 164, 185, 208
key risk factors, 19, 21–2
inflammation (wound healing), 4, 4–6, 5
insulin therapy, 26
Intrasite Gel, 102
iodine and products, 88–9, 93, 101, 103, 197
Iodosorb/flex, 101
irritant dermatitis, 71, 71
ischaemic ulcers, vs. neuropathic ulcers, 160
Jelonet, 103
Kaltostat, 100
keloid scars, 10
keratinocyte grafts, 110
kinin system, 4–5
Laplace’s Law, 148
larval therapy, 73, 75, 100–101
leg ulcers, 143–58
aetiology and epidemiology, 144–5
economic costs, 144–5
management, 146–51, 153–5, 157–8
community clinics, 229–30
evaluation, 144, 151, 155, 156, 158
types
arterial ulceration, 152–5
malignant, 156–7
mixed aetiologies, 155–6, 156
ulcers and rheumatoid arthritis, 157–8
venous ulceration, 145–52
lifting and handling patients, 131–3
lint dressings, 88
listening skills, 36
locus of control, 41–2, 43
lotion use (wound cleansing), 91–7
low-adherent dressings, 103
lymphoedema, 164, 165–8
Lyofoam/C, 101, 104
maceration, 71
maggots see larval therapy
margins of wounds, 71
massage, 167
mattresses, 135
and TBM (total bed management) systems, 232–3
and turning regimes, 131–3
maturation processes (wound healing), 9
measurement of wounds, 58–61
and documentation, 77–8
frequency, 59
linear measures, 59–60
surface area, 60–61
volume of deep cavities, 61
recording methods, 66–9
colour reflectance analyser, 67
photographs, 60, 67–8
use of percentages, 66–7, 70
MEDLINE, 218–19
Mefilm, 104
melanocytes, 3, 209
Melolin, 103
Mepitel, 104, 199
Mesorb, 99
methotrexate, and nutritional status, 16
metronidazole, 164
Metrotop, 100
microvascular dilation assessment, 159
MMPs (matrix metalloproteinases), 7, 10, 105–06
mobility and exercise, 126, 137, 168
moist wound healing theory, 72
motivation and education, 37–9
MRSA (methicillin-resistant Staphyloccus aureus), 96
mupirocin, 96
music, and pain management, 29
MUST screening tool, 16
N-A Ultra, 103
necrotic wounds, 63, 64
neomycin, 16, 96
neutrophils, 5–6, 65–6
NICE guidelines, 222, 223
foot care in diabetics, 159, 233
palliative care, 43–4
pressure ulcer prevention, 129, 133, 134, 138
non-compliance, 38
Norton Score, 129–30
Nu-Gel, 102
nurse prescribing, 228–9
nurse specialists, 230–31
nutrition management, 13–19
interventions and assessment, 17–19, 20
daily nutrient requirements, 18
enteral feeds, 17, 19
monitoring and evaluation, 19
screening tools, 16–17
key risk factors, 14–17
obesity
and infection risk, 21, 190
suture techniques, 191
odour, 62
fungating wounds, 164
oedema, burn injuries, 103
operating tables, 135–6
Index
Opraflex, 104
Opsite/Post-Op, 104, 180
osteomyelitis, 162
oxygen see subcutaneous oxygen tension; supplemental
oxygen regimes
pain management, 27–30, 76–7
barriers to control, 27–8
interventions and assessment, 28–9, 29, 69–70, 76–7
dressing changes, 69–70
positioning, 32
monitoring and evaluation, 29, 30
palliative care, psychological and spiritual needs, 43–7
papillae, 2
paraffin gauze, 103, 183–4, 184–5, 207
Paranet, 103
Paratulle, 103
partial-thickness wounds, 1, 57
PAS (para-aminosalicylic acid), and nutritional status, 16
paste bandages, 103, 151
patient communication and education, 37–9
use of leaflets and videotapes, 36–7
Patient Group Directives (PGD), 229
PDGF (platelet-derived growth factor), 5, 5, 6, 8
peanut oil, 183
pedicle grafts, 183
percutaneous transluminal angioplasty, 153–4
photographic records, 67–8
and computer-assisted measurements, 60
plastic surgery, 143
pneumatic compression, 149
positioning, 130–33
30 degree tilt, 131–3, 132
pain relief, 32
potassium permanganate, 94
powerlessness, 41–2, 43
prayer, 46–7
pressure ulcers, 121–43
aetiology, 123–8
costs, 122–3
grading, 140–41, 141
locations, 139–40, 139
prevention, 128–38
equipment and aids, 133–6
positioning, 130–33
skin care, 136–7
treatment and management, 138–43
and plastic surgery, 143
pressure-relieving devices, 134–5, 135
cushions, 134
management of equipment, 232–3
primary closures, 179–81
proflavine, 94
Promogran, 106
prostagladins, 6
protease-modulating wound management products, 105–06
psychological problems
anxiety and fear, 35–7, 41, 42
grief reactions, 41, 42–3
loss of power/control, 41–2, 43
motivation and concordance, 37–9
poor body image, 39–40, 206
radiation reactions, 34, 165, 209–12
classification, 210
skin care regimes, 210–11, 211
reconstruction processes (wound healing), 6–7, 8
recording wound observations, 66–9, 77–8
colour reflectance analyser, 67
239
importance of documentation, 77–8
photographs, 67–8
use of percentages, 66–7, 70
Regranex, 105
Release, 103
religious needs, 43–7
rheumatoid arthritis, and leg ulcers, 157–8
Ringer’s solution, 104
RTOG (Radiation Therapy Oncology Group) scores, 210,
211–12
saline solutions, 97
scar tissues, remodelling processes, 9
seating, 133–4
self-care, motivation and education needs, 39
Serotulle, 103
shaving, and infection risk, 21
shear forces, 123–4
silicone wound dressings, 103–04, 183–4, 208, 209
silver and silver-coated dressings, 94, 164, 208
sinus formation, 70, 193
2nd Skin, 102
skin care regimes, 136–7
burns, 209
leg ulcers, 150
radiotherapy, 210–11
skin flaps, 183
skin gene therapy, 105
skin grafts, 151, 182–4
skin inspection, 130, 132
Skin Prep, 100
skin structure, 2–3, 3
skin tears, 198–9, 199
sleep problems, 30–32
sloughy wounds, 65–6, 65
smell see odour
smoking, 23–4, 154
sodium hypochlorite, 95
Sorbsan, 100
spiritual care, 43–7
Sterigel, 102
steroids, 26, 33–4
Stigma Scale, 39
stress management, 26
see also anxiety management
subcutaneous oxygen tension, 6, 7
and smoking, 23–4
supplemental oxygen regimes, 23
and hyperbaric oxygen therapy, 107–08
surgical cavities, 182
surgical debridement, 74, 164–5
surgical wounds, 56, 179–94
cavities, 182
closure types, 179–82
complications, 186–94
dehiscence, 191–2, 192
fistula formation, 193–4
haemorrhage, 187
infection, 187–91, 189–90
sinus formation, 193
donor sites, 185–6
grafts, 182–4
use of drains, 185–6
sutures
and dehiscence, 191
and epithelialisation processes, 8
lacerations, 196
SWI (surgical wound infection) studies, 187–91,
225
240
The Care of Wounds
tap water, 97
TBM (total bed management), 232–3
Tegaderm, 104
Tegagen, 100
Tegapore, 104
Tegasorb, 102
TELERr system, 61–2, 63
Telfa, 103
TenderWet, 104
TGFs (transforming growth factors), 5–6, 5
Theodoric, 85–6
therapeutic touch, 37, 113
Tielle, 101
TIME framework, 73–6, 74
tissue culture, 110, 151, 183
tissue engineering, 110–11, 151
Tissue Viability Society, 122, 228
TNP (topical negative pressure) therapy, 75, 108–9, 184, 194
training and education
equipment use, 232
pressure ulcer prevention, 137
Transorbent, 101–2
traumatic wounds, 194–9
general management principles, 194–6
types
abrasions, 196
bites, 198
finger tip injuries, 197
lacerations, 196–7
skin tears, 198–9, 199
Tricotex, 103
tulles, 89, 103
Vacutex, 101
vapour-permeable films and membranes, 104
varicose eczema, 150
venous leg ulcers, 10–11, 145–52, 154
aetiology, 145–6
management, 146–51
compression, 75, 148–9
leg elevation, 150
skin care, 150
skin grafts and surgery, 151–2
risk factors, 146
Versiva, 101–2
Vigilon, 102
vitamin A, 18, 34
wheelchair users
cushions, 134
skin inspection, 131
wound assessment, 56–71
classification and definitions, 1–2, 56–7, 58
epithelialising, 66, 67
granulating, 66, 66
infected, 63–5, 64
necrotic, 63, 64
sloughy, 65–6, 66
environmental considerations, 58
position, 57–8
recording observations, 66–9
use of MEASURE framework, 56, 57, 58–71
see also burn injuries; chronic wounds; radiation
reactions; surgical wounds; traumatic wounds
wound bed preparation (WBP) theory, 72–6
wound closures see surgical wounds
wound drains, 185–6
wound healing
key stages, 3–9
inflammation, 4–6
reconstruction, 6–7, 8
epithelialisation, 8–9
maturation, 9
key theories and requirements
environmental considerations, 58, 97–8
moist wound healing, 72
nutritional needs, 18
wound bed preparation, 72–6
management frameworks, 72–6
problems and impairments, 9–10
chronic wounds, 10–11, 123–8
contractures and scarring, 7, 9–10
surgical wounds, 186–94
risk factors
diabetes, 25–6, 225
hypothermia, 32–3
infections, 19, 21–2, 63–5, 74–5, 187–91
malnutrition, 13–17, 18, 20, 127
positioning, 130–33
radiotherapy, 34, 165, 209–12
sleep problems, 30–32
smoking, 23–4, 154
steroid use, 26, 33–4
stress, 26
surgery, 187–91, 225
see also advanced technologies; dressings
wound-healing centres, 233–4
WRAP project, and odour indicators, 62
Waterlow Score, 129–30
wet-to-dry dressings, 74
zinc, nutrition needs, 15, 18
zinc creams and paste, 76, 103
unitulle, 103
Unna’s boot, 148