Assessment & Management of Wounds in primary practice.

Assessment & Management of Wounds in primary practice.

Nutrition Successful wound management depends on appropriate nutritional support. Poor nutrition is recognised as one of the major causes of poor wound healing. Proteins, carbohydrates, vitamins and minerals are all involved in the healing process and a higher than average daily intake of these components is needed for optimal wound healing (Zagoren, 2001).

Nutrition Poor nutritional intake or lack of individual nutrients significantly alters many aspects of wound healing. Careful assessment of nutritional status. Weight/ BMI Albumin Ferritin Food Chart. Total Protein

Exuding wounds can lose up to 100g protein a day. What would a patient need to replace this???????

Nutrition 6 oz red meat 2 eggs 8 slices of bread 1 pint of milk 1 yoghurt Purely to replace protein lost

Wound bed/stage of healing Tissue type identification is necessary to decide management therapy and dressing selection Wound site Position of wound will influence dressing choice Wound size Measure depth, length, width. Sinus, cavity Undermining. Regular measurement: trace, photograph, tape measure Wound healing is demonstrated by reduction in wound size

Amount of exudate Check moisture levels: wet or dry. Exudate quantities: low, medium, or high Consistency: frank pus, serous or blood-stained. Green Odour None, present or offensive Pain Cause (inflammation, infection), site, frequency, severity, all the time, at dressing change Surrounding skin Macerated, scaly, dry

Dressing selection Do not ask a dressing to do what it is not designed to do. Do not use dressing inappropriately Mechanical stress/shear Supply appropriate equipment Wound temperature Do not allow wound to get cold during dressing changes Maceration Has the appropriate dressing been selected? Malignancy. If a wound does not make sense. Think malignancy

Address causal factors Identify wound type and treat appropriately Pressure ulcers remove and redistribute pressure Venous leg ulcers compression therapy Arterial leg ulcers refer for vascular opinion Wound care/management Ensure it is appropriate for the needs of the wound

Wound classification Necrotic Sloughy Granulating Epithelisation

Necrotic Tissue Description Devitalised Ischaemic Tissue Black / Brown leathery Eschar Aim of Treatment Debride and Remove *NB Ischaemic wound Rationale Host for Infection Impairs Healing

Slough Description Mixture of Fibrin, Protein, Serous Exudate, Leucocytes and Bacteria Yellow/grey Aim of Treatment Remove Slough and Provide Clean Base for Granulation Rationale. Impairs healing Host for infection

Granulation Description Composed of Capillary Loops, Collagen, Proteins and Polysaccharides. Red, Granular Appearance. Delicate Aim of Treatment Protect and Promote Granulation Rationale Base for Epithelialisation Fills Wound Bed

Epithelialisation Description Epithelial Cells Migrate Across Wound bed to complete the Repair Process Pink Colour Aim of Treatment Protect and Promote Epithelial Tissue Rationale Complete Repair Process and Promote Maturation

INFECTION Description Inflammation, Exudate,Pain Aim of Treatment Isolate and Identify Pathogen Commence Appropriate Antimicrobial therapy Apply Dressing to Promote Healing Rationale Impairs Healing. Wound Extension, Breakdown

The 'Ideal Wound Dressing' should: Maintain a moist environment at wound interface Remove excess exudate without allowing 'strike through to surface of dressing Provide thermal insulation and mechanical protection Act as a barrier to micro-organisms

Ideal Wound Dressing Allow gaseous exchange Be no adherent and easily removed without trauma Leave non foreign particles in wound Be non-toxic, non-allergenic and non-sensitising No single dressing is appropriate for all wound types and all stages of healing

Varicose Eczema Incompetence in the deep perforating veins increasing hydrostatic pressure in the dermal capillaries. Treatment: Washing, (Oilatium, Aveeno, Silcocks base, Epaderm) Emollients, (Aveeno, Lipikar, Epaderm, Steroid creams when wet Change to ointments when weeping resolves. Paste bandages

Wound swabbing The Essen Rotary is an efficient, economic and uncomplicated modification of a conventional bacteriological swab technique, which is able to detect almost the whole spectrum of aerobic bacteria of the wound surface in patients having a chronic leg ulcer compared to the Levine technique. Therefore, the Essen Rotary may represent a new gold standard in routinely taken bacteriological swabs, especially for MRSA screenings in patients with chronic leg ulcers.

Older Persons Skin There is also an estimated 20% reduction in the thickness of the dermis, which results in the paper-thin appearance, commonly associated with the elderly (Haroun, 2003). This thinning of the dermis sees a reduction in the blood vessels, nerve endings and collagen, leading to a decrease in sensation, temperature control, rigidity and moisture retention (Baranoski and Ayello, 2004).

STAR Classification System (Carville et al, 2007). Silver Chain Nursing Association and School of Nursing and Midwifery, Curtin University of Technology. Revised 4/2/2010. Available at: http://www.silverchain.org.au/assets/group/research/star-skin-tear-tool- 04022010.pdf

Skin Flap Dressings: An appropriate dressing should be used to maintain moist wound healing. If an opaque dressing is used, an arrow should be placed on the dressing to indicate the preferred direction of removal and recorded in the notes. It is recommended that adhesive strips should be avoided and sutures or staples should only be used if the wound is considered to be a full thickness laceration. Dressings should remain in situ for several days to avoid trauma to the flap and secured with bandages or stocking-like products

Management principles should be: Control bleeding (Kaltastat) and clean the wound according. (Warm Saline) Realign (if possible) any skin or flap(use gloved finger or cotton bud) Assess degree of tissue loss and skin or flap colour using an appropriate classification system (e.g. STAR) Assess the surrounding skin condition for fragility, welling, discolouration or bruising Assess the person, the wound and the healing environment as per local protocol If skin flap is pale and dusky/darkened, reassess within 24-48 hours (Carville et al, 2012)

1. Skin health is essential to the wellbeing of the older person. 2. Skin problems are common in older people (Cowdell, 2011). 3. Pruritus is common in the older person.. 4.It is often associated with systemic disease, investigations are often necessary. 4. Emollients, applied at least twice daily, are the first line of treatment and will help to rehydrate and maintain skin integrity. 6. Ensure that nails are suitably trimmed to minimise/avoid skin trauma during scratching.

Thank you. Any Questions