Wound Update

Target 2018

Learning Outcomes

• Factors affecting wound healing

• Wound assessment

• Choosing correct dressing

• Management of over-granulation

• Managing infection/sepsis

• Wound Types

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The Stages of Wound Healing

There are four stages of wound healing:

• Vascular response

• Inflammation

• Proliferation

• Maturation (Flanagan M, 1997)

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Factors affecting wound

healing

INTRINSIC • Presence of systemic

disease

• Nutritional status

• Smoking

• Medication

• Adequate skin perfusion

• Age of individual and

wound

• PH of wound surface

• Dehydration (local and

systemic)

• Presence of infection

• Wound temperature

• Psychological factors

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Factors affecting wound

healing

EXTRINSIC • Poor wound care

• Dressings

• Hygiene

• Social problems

• Radiotherapy

• Ability to elevate the limb

• Wound location

• Mechanical stress

(pressure, friction and

shear)

• Presence of foreign

bodies

• Extent of tissue loss and

type of tissue involved

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Wound Assessment

When

•Baseline

•Deterioration

•At least monthly

How

•Wound assessment

template

•Map/measure

•Photograph

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The Ideal Wound Environment

• Moist environment at the

wound/dressing interface

• Gaseous exchange able

to take place

• Impermeable to micro-

organisms

• Absorption of excess

exudate

• Absorption of toxins

• Insulation from low

temperature

• Free from other particles

and other contaminants

• Protection from trauma

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Epithelialising wound

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Epithelialising Wounds

Treatment aim - to protect new fragile tissue

• Hydrocolloids

• Films

• Low absorbent foams

• NA Dressings

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Granulating Wounds

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Granulating Wounds Treatment aim: to maintain a healthy wound bed

for epithelialisation

Low Exudate

• Hydrocolloids

• NA dressings

• Low absorbent foams

High Exudate

• Hydrofibres

• Alginates

• Foams

• High absorbent pads

Sloughy Wound

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Sloughy Wound

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Sloughy Wounds Treatment aim: to remove slough and provide

clean base for granulation tissue

Low Exudate

• Hydrogels – with caution

contact TVN

• Hydrocolloids

• Low absorbent foams

High Exudate

• Hydrofibres

• Alginates

• Foams

• High absorbent pads

Necrotic Wound

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Necrotic Wounds Most necrotic/sloughy wounds auto-debride

naturally.

NB: Diabetic/ischaemic foot wounds – keep dry to

minimise risk of infection and consider referral to

WPMS Nurse or vascular

Dressing choices:

• N/A Dressing

• Hydrocolloids

• Absorbent dressings

• Films

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Cavities

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• Cavities should not routinely be packed in order

to allow free drainage of exudate

• Given the lack of high quality evidence,

decisions to pack may be based on local

practices or patient preferences.

Guideline for the Treatment of Wounds Healing

by Secondary Intention including Sinuses

and Cavities. Leeds Health Pathways (2017)

• http://nww.lhp.leedsth.nhs.uk/common/guidelines

/detail.aspx?ID=5239

Cavity Wounds

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Overgranulating Wounds

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Overgranulation

• Occurs at the proliferation stage of wound

healing

• Granulation tissue continues to be laid down

and stands proud of the rest of the skin

• Possibly related to wound infection/inflammation,

or friction from tubing or excess exudate

• It prevents epithelial cells from spreading across

the wound surface delaying the final stage of

wound healing

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Overgranulation – Management

and Prevention • Foam dressings – with a topical antiseptic

underneath, e.g. povidone or cadexomer iodines

• Corticosteroid cream- Haelan Cream/Tape

(Liciensed) 1% Hydrocortisone cream – not

licensed for this purpose

• Silver Nitrate pencil 95% - as last resort can

cause trauma to healthy tissue (Nelson A, 1999)

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Infection

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Signs of Local Infections

• Abscess/pus

• Cellulitis/excessive inflammation

• Erythema

• Oedema

• Heat

• Unexpected pain/tenderness

• Malodour

• Dehiscence

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Infected Wounds

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Anti-microbial dressings

• Four main categories:

• Silver – should only be used when symptoms or signs

of clinical infection are present. There is some evidence

to suggest they delay wound healing

(BNF 2015)

• Honey – osmosis promotes autolytic debridement,

should not be used on patients with allergies

to bee products, diabetic patient should be

monitored (BNF 2015)

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• Iodine – cadexomer-iodine releases free

iodine when exposed to wound

exudate

- povidone-iodine knitted viscose

dressing facilitates diffusion of the iodine

but is rapidly deactivated by wound

exudate

• PHMB Dressings – impregnated with

polyhexamethylene biguanide

• DACC dressing (dialkycarbamoyl chloride)

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Signs of Systemic Infection

• Pyrexia/fever

• Flu-like symptoms

• Sweats and chills

• Unexplained confusion

• Blood results = > CRP / > WCC

• Unstable blood sugar in diabetics

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Sepsis Screening

• Acute confusion, disorientation, reduced

conscious level

• Blood glucose non diabetic >7.7

• Temperature >38.3 or <36

• Respiratory rate > 20 per min >25 per min

• Heart rate >90 per min >130 per min

• Systolic B.P. <90mmHg,

• Oxygen sats <91%

• Purpuric rash

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When to Swab

• Enlarging of the wound

• Abnormal bleeding

• Increased pain

• Increasing Odour or exudate

• Cellulitis

• Pyrexia

• To check effectiveness of current antibiotic therapy

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Types of wounds

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Leg Ulcers

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Venous leg ulcer

The Evidence

Compression vs no compression

More patients heal with compression than without (Cullum et al 2001)

Results of VenUs 4

Compared 4 layer compression bandaging system with 40mmHg treatment hosiery kits

Treatment hosiery had similar healing rates to those randomised to compression bandages.

Quality of life improved for patients wearing hosiery

Promotes self care and independence

Venous Leg Ulcer Myth Busters

Best Practice Statement: Management of Venous

Leg Ulcers 2017

Lower Leg Injury

• Complete doppler within two weeks of initial assessment if no signs of improvement

• 0.8 – 1.3 Suitable for full compression

• >1.3 ? calcification – refer to WPMS or vascular

• 0.6 - 0.8 = Mixed aetiology – refer to WPMS

• <0.6 Refer to vascular team

• < 0.4 Urgent referral to vascular team

Frequency of Doppler

3 Monthly ABPI below < 0.8 and > 1.3 in hosiery/bandages

Active foot/leg ulceration

Change in medical condition

History of unstable dopplers over 12 months

6 Monthly No ulcer ABPI within range 0.8-1.3

History of recurrent lower limb ulceration/lymphoedema

Multiple co-morbidities with an established regime

Diagnosed with new condition which affects circulation

12 Monthly No Ulcer ABPI within range 0.8 – 1.3

Stable lymphoedema/ oedema

Healed ulcer and no recurrence in 12 months

Limited or well controlled co-morbidities

(Stephen-Hayes, 2015)

adopted by LCHT for leg ulcer guidelines 2016

Compression

Hosiery

Contact your local company reps to arrange

a training session.

BSN Medical (Jobst)

Jo Whittaker-Cox: 07850 659 658

Activa

Rose Richardson: 07973 862 780

Medi UK

Adam Hopkinson: 07469 858 357

In Summary

• Doppler lower leg wounds as

soon as possible

• Start compression if safe.

• Refer to Wound service if no

improvement

Further Info:

Wounds UK Best Practice

Statements:

Venous Leg Ulcers

Compression Hosiery

• Local Leg Ulcer Guidelines on

Leeds Health Pathways

Pressure Ulcers

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Pressure Ulcers

Pressure Ulcer Risk Factors

• Immobility • Existing pressure ulcer • Previous pressure damage • Perfusion • Diabetes • Nutrition • Sensory perception • Moisture

Pain!

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Foot Ulcers

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Non Diabetic Foot

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Diabetic Foot

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How to access referrals on LHP

Click: -Leeds Health Pathways

-Referral Pathways

-Referral Pathways and Forms

“Non Diabetic feet –

screening and referral

pathway”

“Diabetic Limb salvage

Service – Urgent”

“Community Diabetes

Team: Foot Protection

Service”