wound management guidelines

7/30/2019 Wound Management Guidelines

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Guidelines for the Assessment andManagement of Wounds

Date of Guideline July 2004 1 Date of review July 2006


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Contents Page

Summary 3

1. Guidelines for the Assessment & Management of Wounds 51.0 Definition 52.0 Classification 53.0 Aim of Assessment 53.1 Assessment 53.2 Additional Assessment techniques for clients with Leg Ulcers 63.3 Computer based 63.4 Wounds healing 63.5 Assessment 63.51 Measurement may be by 63.6 Skin assessment 73.7 Client opinion 74.0 Wound Management 7

4.1 Aims of Management 74.2 Primary Treatment objectives 74.3 Frequency of dressing changes 84.4 Swab taking 84.5 Dressing Characteristics which influence choice 84.6 Choice of dressing 94.7 Features of the ideal dressing 95.0 Debridement 105.1 Surgical debridement 105.2 Sharp debridement 105.3 Other methods of debridement 105.4 Rationale for debridement 105.5 Choice of debridement 11

5.6 Contraindications to sharp debridement 115.7 Assessment for debridement should include 115.8 Training for sharp debridement 116.0 Specific types of wound management 126.1 Leg Ulcers 126.2 Pressure Ulcers 126.3 Vacuum Assisted Wound Closure 126.4 Larva therapy 127.0 Documentation of Wounds 128.0 Client Information 139.0 Infection Control 1310 Appendix 1 1411 Appendix 2 15

12 References 16



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Summary

Summary guidelines for wound assessment and managementThis summary to be read in conjunction with South Gloucestershire PCT Guidelines for the

Assessment and Management of Wounds.

All wounds will be assessed within

6 hours of admission to episode of

care

Refer to pressure ulcer riskassessment & preventionGuidelines

Clinical signs ofinfection evident:Swab only if present

Leg Ulcersuspected:Dopplerassessment,considerVascular referral

Follow Avon Leg UlcerProtocol

Wound Management: all wound will have documented management plans, with evidence ofongoing review & evaluation, using PCT wound evaluation frameworks

Primary treatment objectivesCleansing: is it needed? Does dressing absorb exudates? Tap water or Normal Saline may beused as appropriate as an irrigation agent. Consider water quality. Use at body temperature.

Debridement / desloughment, Control bleedingControl exudates Reduce bacterial burdenReduce odour Minimise effects of infectionMinimise pain at dressing changes Optimise healing potentialOnce the primary treatment objective /intended outcome is achieved,reassessment is needed to identify next objective

Actual pressure ulcer

or vulnerable to

pressure areas

MeasurementAcetate tracingsPhotogrphy (valid informed consent required)Specialist assessment: deep tracks / sinusesChronic wounds will betraced / measured at leastevery 4 weeks and re-evaluated each time a

dressing is applied and / or if it gives rise forconcern (Royal Marsden 2000)

Skin assessmentErythematousExcoriatedInduratedMacerated

All wounds will be assessed using the PCT wound

assessment framework:a) Siteb) Sizec) Wound historyd) Condition of the wound

Bed

Edge

Surrounding skine) Evidence of infectionf) Odourg) Painh) Fluid; exudate / pus / serous fluidi) Intrinsic or extrinsic factors affecting healing (see

NICE & EPUAP Guidelines on Pressure Ulcers)j) Previous related wound management regimes,

including success / failures & how long they wereused

k) Patients perception of their wound

Effective handwashing techniques & attention to Infection

Control guidance will be adhered to at all times



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Assessment for debridement should

include:Nature / extent of necrotic tissueRisk infection / use antibioticsUnderlying disease processesExtent existing ischeamiaLocation of woundClient consentPain controlPossible complications

(Leaper 2002)

Debridement

Removal of dead or foreign materialust above the level of viable tissue.Sharp :conservative approach: requirestraining from specialist TVnurse. Validinformed consent is essential.Surgical: excision / resection necroticmaterial

EnzymaticAutolytic:moist wound environment,hydrocolloid / hydrogel dressing

Mechanical:wash wound / adherentdressing

Bio-surgical:sterile maggotsChemical: not recommended

Debridementneeded surgicalwoundsSee NICE Guidelineson Debr

iding agents

(2001)

Choice of agent shouldbe based on:ComfortOdour controlClient acceptabilityType & location of

woundTotal costs(NICE 2001)

Evidence supporting onemethod of debridementover another is lacking(Leaper 2002)

Training for sharp debridementRNs must have attended accredited woundmanagement course & min. 1-day sharpdebridement study day. Assessment ofcompetence by TV specialist Nurse


Training needs for wound managementPressure ulcer prevention: all RNs / HCAsBasic wound management: all RNs / HCAsCommunity Equipment Prescribing: all RNsLeg Ulcer Management: 2-day course & mandatory follow up &assessment of competence. All RNs as required

Complex wound management: all RNs as requiredSharp debridement: all RNs as required & assessment ofcompetenceVacuum assisted wound closure: all RNs as requiredLarva therapy: all RNs as required

ALL WOUNDS

Dressing SelectionPlease refer to typology onlaminated card & in woundguidelines

Features of ideal dressingComfortable & mouldableProtectivePrevent contamination withparticles / toxic substances(Hallet & Hampton 1999)Allows gaseous exchangeKeep wound moist(Hollingworth 2002)Keep wound warm (drop intemp below 37 degreesdelays mitotic activity)(Torrence 1986. Myers1982)

Dressing ChangesSurgical Wounds:Leave min 48 hours. If no infectionevident, leave as long as possible upto 10 days

Non-surgical woundsAvoid frequent changes unlessclinically indicated (Baker 1997).Change when leakage / strikethrough evident.Avoid soaking dressings adheredto wound: exacerbates maceration(Hollingworth 2002)

Evaluation of WoundsAll wounds will be evaluatedusing the PCT evaluationframeworks. Chronic wounds,stuck in any stage of thehealing process for 6 weeksor more, should be evaluated

using the chronic woundevaluation forms.

Consideration in choice ofdressingsPrimary treatment objectives &clinical effectivenessFunction of dressingEase of application / removalVariety of size / shape &

alternatives availableLength of time it will be usedHow secured?Cost effectiveness


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Guidelines for the Assessment and Management of Wounds

This guideline should be used in conjunction with the following SouthGloucesterhsire PCT documents: Clinical Nursing Policy (2004), InfectionControl Policy (2004), Nurse Prescribing Policy, Principles of Care (2003,Avon Leg Ulcer Protocol (2004), NICE Guidelines on Pressure Ulcer RiskAssessment and Management (2004) , Community equipment PrescribingStrategy.

1.0 Definition.A wound can be defined asan abnormal break in the normally intact covering of the body theskin (Collier 2002)

it may beACUTEwounds that are healing as anticipated (Collier 2002)

orCHRONIC wounds that are failing to heal as anticipated or that have becomefixed in any one stage of wound healing for a period of six weeks(ibid)

2.0 Classification Mechanical eg Surgical / Traumatic

Chronic eg Leg Ulcers / Pressure Ulcers

Burns Chemical or thermal injuries

Malignant Primary lesions such as melanoma

3.0 Aim of Assessment Improve documentation and communication (NMC (UKCC) 1998)

Define the problem and identify appropriate therapeutic regime

3.1 AssessmentAll clients with wounds will have a documented woundassessment using the PCT assessment framework.This should include:

a) Siteb) Sizec) Wound historyd) Condition of the wound

Bed

Edge

Surrounding skine) Evidence of infectionf) Odour



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g) Painh) Fluid; exudate / pus / serous fluidi) Intrinsic or extrinsic factors affecting healing (see NICE &

EPUAP Guidelines on Pressure Ulcers)j) Previous related wound management regimes, including

success / failures & how long they were used

NBT 2001, Dowsett 2002, Collier 2002, NICE 2001, EPUAP1998

3.2 Additional assessment techniques for clients with Leg Ulcers Doppler Ultrasound

Duplex scanning

Photoplethysmography (PPG)

(Moffat & Harper 1997)

3.3 Computer based assessment systemsmay assist with objectivemeasurement of all wound types, since these can assess maximumdimensions of wounds plus depth & volume of them. Referrals to theTissue Viability specialist nurse should be made as required.

3.4 Wounds healing by primary intention or minor wounds may not besubject to lengthy or formal wound assessment although the principlesof this should be applied.All woundswill be documented and amanagement plan implemented, reviewed and evaluated.

3.5 AssessmentShould be documented using the PCT assessment framework andreviewed & evaluated regularly.

3.51 Measurementmay be by Acetate tracings.

Surface area of the wound may be calculated by tracing over asquare grid (preferably 0.5cm). Cling film should be applied tothe wound prior to the tracing to prevent contamination of theacetate and cross infection of client notes. (Pudner 2002)

PhotographyInformed valid consent is required to demonstrate the client

understands the purpose of the photo and what will be donewith it. This includes storage & transmission of images now, &in the future. (Pudner 2002, Collier 2002)

Where photographs are to be used for research, education ortraining purposes, a signed consent should be obtained.

A grid should be included so that an accurate calculation of thewound area may be made. It may be less accurate on curvedwounds. Position of client for photograph should be recorded.



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Wounds involving sinuses / tracks may require further specialistmeasurement.

Chronic wounds will be traced / measured at least every 4 weeks andre-evaluated each time a dressing is applied and / or if it gives rise for

concern(Royal Marsden Clinical Nursing Procedures 2000)

3.6 Skin assessmentSkin surrounding the wound may be described as

Erythematous ie red as a result of a hyperaemic response.Result of pressure or infection (Collier 1999)

Excoriatedi.e. stripping of upper layers of dermis as a result ofprolonged exposure to toxins on the surface of the skin;dependent on the nature rather then volume of fluid present.

(Collier 2002) Induratedie change in the texture rather than colour of the skin

(less supple / hardened) (Collier 2002)

Maceratedie softening / sogginess of the skin due to retentionof excessive moisture (Cutting 1999)

3.7 Client opinionClient perception of the wound should be included & recorded in theassessment and ongoing evaluation of wound healing.

4.0 Wound Management

The registered nurse will complete a baseline assessment of wound inorder to promote successful wound management, facilitate continuityand consistency of care and meet the professional legal requirementfor record keeping (Sterling 1996)

4.1 Aims of managementOverall aim of wound management includes

Promotion of speedy healing, free of complication.

Cost effective and evidence based use of products.

Optimal concordance with patients.

Eradication or minimising of extrinsic factors and the control of

intrinsic factors which affect healing. Prevention of occurrence.

4.2 Primary Treatment objectiveswill be dependent on signs &symptoms associated with that wound. Typical objectives may include:

a) Cleansing of woundConsider; is this required at all?The irrigation of a wound should onlybe performed to remove excessive exudate, pus, or particles ofdressing.Many dressings take up excess exudate, and so on their removal, ordressing change, cleansing is not required.



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Tap water or Normal Saline may be used as appropriate as anirrigation agent however the quality of the tap water available should beconsidered before it is used. Cooled boiled water or distilled water maybe used if necessary. (Fernandez R. Griffeths R. Ussia C. 2002)

b) To debride / deslough the wound(See NICE guidelines for difficult to heal surgical wounds 2001)This may be achieved by

Mechanical (sharp) debridement

Autolytic (rehydration of the tissues)

Ensymatic (maggots)(Collier 2002)

c) To control associated bleedingd)To control wound exudatese) To decrease bacterial burden present within a woundf) To reduce associated wound odourg) To minimise effects of wound infection

(Ayton 1986, Beldon 2001)h)To minimise client pain experienced at time of dressing changes

(Hollingworth & Collier 2002)i)To optimise clients own healing potential

NB Rememberonce theprimary treatment objective / intendedoutcome has been achieved, the assessment process should berepeatedin order to identify the next treatment objective and so on,until the wound has healed (Collier 2002).

4.3 Frequency of dressing changes

It takes 48 hours for a surgical wound to form its own optimalhealing environment; therefore removal of the dressing beforethis time increases the risk of infection and damage to thewound. In the absence of any signs of infection, surgical wounddressings should be left for as long as possible up to ten days.

The frequency of dressing changes of non-surgical wounds willdepend on the type of dressing used and the type of wound.

Frequent dressing changes should be avoided unless clinicallyindicated (Baker 1997)

Dressings should be changed when leakage / strike through isevident

Soaking to remove adhered dressings is not recommendedsince this may exacerbate effects of maceration (Hollingworth2002)

4.4 Swab Taking Wounds should be swabbed only if there is evidence of clinical

infection

4.5 Dressing Characteristics which influence the choice of dressings1.Primary treatment objectives2.The function of the dressing



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3.Easiness of application and removal, including prevention of tissuetrauma4.Variety of size/shape, whether similar alternatives available5.Length of time dressing may be used6.How is it secured, is a secondary dressing necessary?

7.Cost effectiveness

4.6 Choice of dressingThe Nurse prescribing treatment must be able to state her rationalfor the choice made

Type ofwound

Aim Deep Wound Shallow Wound Heavy/ModerateExudate

Necrotic Rehydrate/debride Intrasite Gel Hydrocolloid Alginate

Infected ReducecolonisationContain exudate

AlginateIntrasite GelMetronidazole

AlginateCharcoalIodoflex

Alginate

Sloughy Remove slough/Debride

AlginateIntrasite Gel

AlginateIntrasite GelInadineHydrocolloid

AlginateHydrocolloid

Granulating Keep MoistManage Exudate

FoamsIntrasite Gel

Alginate

HydrocolloidIntrasite Gel

AlginateSemi-permeablemembranes

Epithelising To keep moist HydrocolloidSemi-permeablemembranes

AlginateFoamHydrocolloid

4.7 Features of the ideal DressingThe following features should be considered:

1. To be comfortable and mouldable

2. To protect the wound3. To ensure the wound is not contaminated with particles or toxic

substances which can act as a foci for infection (Hallet & Hampton1999)

4. To allow gaseous exchange5. To keep the wound moist (Hollingworth 2002)6. To keep the wound warm; a drop in temperature below 37c delays

mitotic activity for up to 4 hours (Torrence 1986, Lock 1979, Myers1982)

7. To assist the removal of exudate and necrotic tissue. Excessiveexudate can macerate healthy tissue around wound margin.



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8. To be impermeable to micro-organisms. Strike thorugh of exudatesallows passage for bacteria in / out of wound (Dealey 1994, Hallet &Hampton 1999)

9. To allow monitoring of the wound10. To be non- toxic, non-sensitising and hypoallergenic

11. To allow removal without causing trauma.

5.0 Debridementthe removal of necrotic or foreign material from and around a wound tooptimise healing (Leaper 2002)

5.1 Surgical debridementInvolves surgical excision or wide resection of necrotic tissue.

5.2 Sharp debridement

Removal of dead or foreign material just above the level of viabletissue. Nurses should adopt a conservative approach to this andshould only undertake it when trained to do so.(Fairbairn et al 2002,Leaper 2002)(See 4.84)

5.3 Other methods of debridement include

Enzymatic (Bacterial derived collagenases may promote healingalso)

Autolytic (by use of moist wound environment, hydrocolloid orhydrogel dressings)

Mechanical (washing the wound or adherent dressings*) Bio-surgical (sterile maggots)

Chemical (not recommended)(NICE 2001, Leaper 2002)

*see 4.3 above

Evidence supporting one method of debridement over anotheris lacking(Leaper 2002)

5.4 Rationale for debridementThis process assists wound healing in that it:

Reduces infection

Inhibits phagocytosis

Inhibits epithelial cell migration

Enables accurate assessment of extent & condition of woundbed

Reduces number of microbes & toxins in wound bedAntibiotic therapy is less effective topically if devitalised tissue ispresent (Fairbairn et al 2002, Leaper 2002)



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5.5 Choice of debriding agent for difficult to heal surgical wounds should bebased on

Comfort

Odour control

Client acceptability

Type & location of wound Total costs

(NICE 2001)

5.6 Contraindications to sharp debridement by nurses(Fairbairn et al2002, Leaper 2002))

Ischaemic digits

Blood clotting disorders

Fungating / malignant wounds

Necrotis tissue near / involving vascular structures. Dacron

grafts / prosthesis Underlying vascular disease

Dialysis fistula

Debridement of the foot (excluding the heel )

Hands & face

Caution should be exercised for the following

Ischaemia of the lower limbs

Clienrs on long term anti coagulant therapy

Achilles tendon area

Infected wounds

5.7 Assessment for debridement should include1.Nature & extent of necrotic tissue2.risk of spreading infection & use of antibiotics3.possibility if underlying disease processes4.extent of existing ischeamia5.location of the wound in relation to surrounding anatomy6.client consent7. pain control8. possible complications

(Leaper 2002)

5.8 Training for sharp debridementRNs must have undertaken an accredited education course in woundmanagement and a minimum of a one-day sharp debridement studyday.Competency should be assessed by a Tissue Viability NurseSpecialist, Podiatrist or Surgeon. Valid, informed client consent isessential.



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6.0 Specific types of wound management6.1 Leg Ulcers

Please refer to Avon Leg Ulcer Management Protocol

6.2 Pressure Ulcers

Please refer to NICE guidelines (2003) and South Gloucestershire PCTCommunity Equipment Prescribing Strategy (2004).

Assessment of risk will be undertaken using the Waterlow AssessmentTool and clinical judgement based on holistic patient assessment. (seeappendix 1)Classification of pressure ulcers will be undertaken using the SterlingScale (see appendix 1).

Equipment prescribing: will be in accordance with SouthGloucestershire PCT Community Equipment Prescribing Strategy.

6.3 Vacuum Assisted Wound ClosureNurses must notundertake this treatment unless they have receivedappropriate training from an approved trainer with professional nursinginput.Please refer to PCT guidelines on Vacuum Assisted Wound Closure (inprogress)

6.4 Larva TherapyNurses must not undertake this treatment unless they have received

approved training.

7.0 Documentation of WoundsNB Client documentation, includingphotographyshould informactions.

Ensure there is a documentedpaper assessment

This should be available to all health care professionals involvedin the management of the wound as an importantcommunication tool

Use ofPCT assessment frameworkshould include allparameters of the wound (see 3 above)

Primary treatment objectives (see 4.3) should be evident on theplan of care and evidence on ongoing reassessmentdocumented

Changes to planned wound care must be documented, includingrationale for the change.



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8.0 Client InformationSupporting client information should be given in an appropriate formatand a record of this should be made e.g. health advice, potentialcomplications, equipment use, emergency contact details, preventativestrategies etc.

9.0 Infection ControlThe key measures that can help prevent wound infection/colonisationinclude:

. Hand hygiene before and after handling wounds and dressingsusing either soap and water or alcohol hand rub/gel (only use alcoholhand rub/gel on hands that are not visibly soiled)

. Wearing gloves when handling wounds

. Wearing apron and if appropriate eye protection

. Using a wound dressing that is appropriate to the wounds

. Changing dressings when indicated and whenever thebarrier- effect has been impaired (e.g. wet)

. Selecting a dressing that will promote healing

Low risk waste (dressings, incontinence pads etc.)

In the home situation any clinical waste that has been assessed as lowrisk (e.g. dressings, incontinence pads) must not be placed in a yellowbag. The primary container should not be a yellow clinical waste bag orlabelled clinical waste. Where possible it should be a white bag or anewspaper or a carrier bag. The primary container may then be placedinto a second bag (black plastic) before being placed in the dustbin fordisposal with the household waste.

Higher risk waste (dialysis, highly infectious waste or high volumes)

In the home care setting if the health care worker assesses the wasteas being of high risk (e.g. large volumes of blood, dialysis waste, orhighly infectious e.g. large volumes of diarrhoea from a patient withcryptosporidiosis) a clinical/medical waste collection must be arranged.This can be done by contacting South Gloucestershire Council, 01454 863594 ask for Kath James. A letter will also need to be sent statingin my professional opinion needs waste collecting.



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Appendix 1

Pressure Sore Grading Scale

Grade 1PressureSore

Grade 2Pressure Sore

Grade 3PressureSore

Grade 4APressureSore

Grade 4BPressure\sore

Discolourationof skin, witherythemaafter pressurereleased

Oedema,blistering,epidermal skinlossPain

Tissue islostthroughthedermis

Woundextends intothesubcutaneoustissueWound has a

sinus

Necrotictissue /escharpresentDepth ofdamage

unclear



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Appendix 2

Waterlow risk assessment

Build/weight forheight

Risk areasvisual skin type

Sex/Age Tissue Malnutrition

Average 0 Healthy 0 Male 1 e.g. Terminal Cachexia 8

Above average 1 Tissue paper 1 Female 2 Cardiac failure 5

Obese 2 Dry 1 14-49 1Peripheral vascularDisease

6

Below average 3 Oedematous 1 50-64 2 Anaemia 2

Continence Clammy 1 65-74 3 Smoking 1

Complete/Catheterised

0 Discoloured 2 75-80 4Neurological Deficit

Occasionalincontinence

1 Broken/spot 3 81+ 5e.g. Diabetes, CVA, M.S.,paraplegia, Motor/Sensory

4-8

Cath/incont offaeces

2 Mobility Appetite MajorSurgery/Trauma

Doublyincontinent

3 Fully 0 Average 0Orthopaedic-below waist/SpinalOn table > 2 hrs

5

5

Restless/Fidgety 1 Poor 1 Medication

Apathetic 2N.G tube/Fluids only

2Steroids, Cytotoxics,Anti-inflammatory

4

Restricted 3 NBM/Anorexic 3

Inert/Traction 4

Chairbound 5

10= at risk 15= high risk 20=very high risk

Sterling Pressure Sore Severity Scores

Stage 1 Discoloration of intact skin, light fingerpressure applied to site does not alterDiscoloration

Stage 2 Partial thickness skin loss or damageinvolving dermis or epidermis

Stage 3 Full thickness skin loss, involving damage or necrosisofSubcutaneous tissue, not extending to underlyingbone,tendon or joint capsule

Stage 4 Full thickness skin loss with extensive destruction andtissue necrosis, extending to underlying bone, tendonor joint



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References

BMA (2002) Nurse Prescribers Formulary 2002-2003 BMA & BPS London

Collier M (2002) A ten-point assessment plan for wound management Journalof Community Nursing Vol 16 No 6

Collier M (1996) The Principles of Optimum Wound Management NursingStandard Vol 10 No 43 pp47-52

Fairbairn K et al (2002) A sharp debridement procedure devised by specialistnurses Journal of Wound Care Vol 11 No 10

Fernadez R Griffeths R Ussia C (2002) Water for Wound Cleansing (CohraneReview) in The Cochrane Library. Issue 4 Oxford: Update Software

Hollingworth H (2002) Professional Concerns in wound care; a discussion ofquestionable practice recorded by nurses Wound Care September

Leaper D (2002) Sharp technique for wound debridement World WideWounds December

Pudner R (2002) Measuring Wounds Journal of Community Nursing Vol 16No 9

National Collaboration Centre for Nursing & Supportive Care (2003)

The use of pressure relieving devices (beds, mattresses and overlays) for theprevention of pressure ulcers in primary and secondary care. NCC London(Guidelines commissioned by the National Institute of Clinical ExcellenceOctober 2003)

NICE (2001) Guidelines on Pressure ulcer risk assessment and preventionNICE London

NICE (2001) Guidance on the use of debriding agents and specialist woundcare clinics for difficult to heal surgical wounds. NICE London

North Bristol NHS Trust (2002) Wound Care Policy unpublished

Royal Marsden Hospital (2001) Manual of Clinical Nursing ProceduresLondon Blackwell Sciences

Todorovic V (2002) Food and wounds: nutritional factors in wound formationand healing Wound Care September

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