Managing Wounds Esther White Tissue Viability Nurse
First things first.. Assess, measure and photograph Know what you re dealing with, look at anatomical position and the bigger picture to look for extra clues!
Wound Assessment and Measurement Ideal Kit Opsite flexigrid is perfect, but a film dressing over grid could work 4 tiny squares = 1cm 2 PERMANENT fine marker pen
Measure wound Remember to use permanent marker! Arrowhead indicates patient head Line of arrow indicates spine Mark anything unusual (?bone etc) Initials of pt Wound site
Calculate wound bed Each tiny square is quarter of a cm 2 Mark along thicker lines (1cm 2 ) Calculate full squares Calculate part squares and total both
Updated measurement 6 weeks later Old surface area = 6.5cm 2 re-measure Assume new surface is 5cm 2 Take new area (5cm 2 ) last surface area (6.5cm 2 ) x 100 = 76.9% THIS IS NOT THE REDUCTION!! This is what s left Take 76.9 from 100 to get the percentage lost Reduction is 23.1% We don t do maths, we re nurses!
After re-measurement Aim for 40% minimum reduction in 6 weeks Anything less than this should be referred to Tissue Viability Please give as much info when referring, it will speed up the info. GP summary and photos can be emailed Tissue Viability, here to help, happy to help!
Measuring cavities Use sterile gloved finger first if possible, to feel ALL base of wound bed and ascertain what tissue it is Using the clock face, 12 o clock indicates the head Remember to get a centre depth measurement
Photograph! Good position of patient Not too close up, need to see the anatomical position Measurement guide next to wound Beware of flash back!
Managing wounds... but how do we know what dressing to use?
T.I.M.E... For wounds to heal T = Tissue type In order for a wound to heal, the wound bed must be healthy, so spend time preparing it. Devitalised tissue including slough, necrotic tissue and infected tissue will slow or even stop healing These unhealthy wound beds will need cleaning or debriding before healing can start BEWARE OF DEBRIDING HEELS only after Doppler assessment says it s safe!
Slough
Necrotic tissue (necrosis)
I = Infection Can be systemic patient can become septic, requires urgent treatment
Infection Can also present as a local wound bed infection, which could become systemic if not treated
Infection Causes pain in the wound and can make the patient systemically unwell Causes the wound to become more wet, leading to complications with managing exudate levels (especially when wanting to use honey which also makes wounds wet) Significantly delays healing Can be malodorous
M = Moisture Wounds need a moist bed in order to heal, this way all of the tiny cells can do what they need with regards to moving and multiplying A dry wound bed will delay or even stop healing A dry and deep scab can reveal an unhealed and deteriorating are beneath, so try to avoid deep scab formation
Moisture Use dressings to help manage and maintain moisture levels. A hydrocolloid adds moisture to a wound bed, when used on a wet wound it makes it soggy and more macerated and can lead to hypergranulation A super absorbent pad can dry up a wet wound quickly BUT can cause a wound to become too dry if it is not stopped in time
E = Edges/Epithelisation In order for a wound to close, the bed of the wound needs to be at the same height as the edges scabby edges or a raised bed (hypergranulation) will prevent this happening Epithelisation, is the sign that the edges are pulling across and starting to close, usually with white fine spiders web effect
Epithelisation not to be confused with maceration!
Management Challenges Primary problem Infection Infection Infection Exudate Pain Odour Oedema Slough Hypergranulation Cavity wound Compression Extra challenges Increased pain Increased exudate Potential increase in odour Too much/too little Nocioceptive/Neuropathic Cause Cause Cause To pack or not to pack?!
Treatment and dressing types all to help prepare the wound bed just as with medication, know why you are using a certain dressing, know its side effects and how long it should be used for
Infection AMBL tool Honey Iodine Treat for 2 weeks Systemic Infection, oral/iv antibiotics?
Honey Try to KEEP AWAY from healthy skin as it can cause maceration First line antimicrobial Alginate deeper wounds Impregnated gauze Honey Gel Reinforced alginate Due to osmotic affect of honey, expect increased exudate, so consider your absorbent pads. It can also can be uncomfortable for patient, though this usually subsides after 30 minutes or so
Cadexomer iodine Iodoflex, type of paste sandwiched in gauze Iodosorb tube Iodine is drawn into the wound to fight the bacteria, through exudate, therefore is ineffective in a dry wound! NOT TO BE CONFUSED WITH INADINE
Exudate management First line Zetuvit (ONPOS) (Xupad only for sterile (up to 5 days post op) - Sorbion Sachet Extra ONPOS
Exudate cont. Remember to step up and down as required clinical decision needed at each dressing change Using super absorbents when not required can lead to dry wound beds, which will not heal
Primary Dressings Atrauman ONPOS silicone gauze can granulate through the grid Tricotex ONPOS dry low adherent ADAPTIC TOUCH Urgotul prescription only
Pain Pain in wounds - especially in chronic wounds, is something that often seems to be overlooked! Nocioceptive or Neuropathic? What pain tool? Abbey Pain Tool for those unable to verbalise (good for dementia) How do you measure the outcome?
Odour Cause of odour? Address cause first, rather than try to mask it Infection can cause odour honey can treat infection and deal with odour Is it the wound or dressing? Fungating wounds can be malodorous Gangrene Last resort, try charcoal dressings
Oedema Fluid floods the interstitial tissues Makes it hard for wounds to heal if oedema is present Address oedema (compression, if appropriate), elevation etc Avoid tourniquets!
Slough, Necrosis, Eschar Is devitalised tissue Is perfect breeding ground for infection Usually removed via autolytic debridement (dressings that add moisture) Hydrocolloid ONPOS Actiform cool ONPOS Urgoclean ONPOS Urgotul Prescription Remember to check vascular status on lower limbs
Hypergranulation (Overgranulation) Granulation gone into overtime! Epithelial cells Epithelial cells can only grow horizontally
Hypergranulation Usually caused by Friction (supra-pubic catheter / trachy) Excess moisture rule out cause infection? Oedema? need to swap dressing hydrocolloid particularly and step up on super absorbent Infection AMBL tool and pathway SO FIND THE CAUSE AND TREAT IT!
Cavity wounds Regular cavity Cavity with undermining
Cavity cont. Fistula Sinus
Cavity wounds -Pack or not? Why not? Recent evidence indicates no difference in healing rates Painful Time consuming Extra resources Damage to granulation tissue = delay in healing YOU MUST KNOW WHERE THE ENTIRE WOUND BED IS Protect fragile granulation tissue and use a wick Measure what goes in and out
Compression Lower limbs need full lower limb assessment including Doppler assessment If a patient needs compression then they NEED it! Dressings will not replace the effect of compression Actico oedema, active patient K2 non active patient Ko-Flex reduced compression Leg Ulcer kits (Acti-lymph for oedema)
Any questions? Thank you!