CHRONIC WOUNDSCHRONIC WOUNDS

Ann MoodyAnn Moody

TVN & Leg Ulcer Specialist TVN & Leg Ulcer Specialist NurseNurse

NHS CumbriaNHS Cumbria

What is a chronic wound?What is a chronic wound?

• Leg ulcerLeg ulcer• DFUDFU• Pressure ulcerPressure ulcer• ““persisting over a long time”persisting over a long time”

– A surgical wound “that won’t heal”A surgical wound “that won’t heal”– A burn that takes a long time to healA burn that takes a long time to heal– A trauma wound that takes a long time A trauma wound that takes a long time

to healto heal

What is a chronic wound?What is a chronic wound?

• Any breach to the integrity of the skin Any breach to the integrity of the skin which has failed to proceed through which has failed to proceed through an orderly and timely reparativean orderly and timely reparative process (haemostasis, inflammation, process (haemostasis, inflammation, proliferation, maturation)proliferation, maturation)

• Any wound which by nature of the Any wound which by nature of the underlying aetiology is not likely to underlying aetiology is not likely to heal (eg fungating wound)heal (eg fungating wound)

What problems does managing What problems does managing the chronic wound present us the chronic wound present us

withwith• ExudateExudate

• InfectionInfection

• OdourOdour

• PainPain

• De-vitalised tissueDe-vitalised tissue

• Peri-wound carePeri-wound care

• QOL and functionalityQOL and functionality

• Body imageBody image

The right approachThe right approach

• Holistic assessment (treat the whole Holistic assessment (treat the whole person)person)– Full medical historyFull medical history– Factors which may delay healing Factors which may delay healing

(intrinsic – patient related) and (extrinsic (intrinsic – patient related) and (extrinsic – wound related)– wound related)

– Accurate wound assessmentAccurate wound assessment

STAGES OF WOUND STAGES OF WOUND ASSESSMENTASSESSMENTT.I.M.E.T.I.M.E.

• Tissue – is the tissue non-viable or Tissue – is the tissue non-viable or deficientdeficient

• Infection – is this infection or inflammationInfection – is this infection or inflammation

• Moisture – how much – enough?/not Moisture – how much – enough?/not enough?/too much?enough?/too much?

• Edges – non-advancing (failing to close) or Edges – non-advancing (failing to close) or undermined?undermined?

Tissue non-viable or Tissue non-viable or deficientdeficient• DebridementDebridement• willwill• restorerestore• wound basewound base• andand• repairrepair• damaged tissuedamaged tissue• to achieveto achieve• a viable wound beda viable wound bed•

Infection or inflammationInfection or inflammation

• Removal of infected foci willRemoval of infected foci will

• reduce bacterial countsreduce bacterial counts

• reduce inflammatory cytokinesreduce inflammatory cytokines

• reduce protease activityreduce protease activity

• and promoteand promote

• and increase growth factor activityand increase growth factor activity

•

Moisture imbalanceMoisture imbalance

• Moderation of fluid balance willModeration of fluid balance will• reduce risks of macerationreduce risks of maceration• reduce exudate levelsreduce exudate levels• reduce oedemareduce oedema• reduce risks of macerationreduce risks of maceration• promote epithelial cell promote epithelial cell

migrationmigration• Achieve moisture balance for increased speed Achieve moisture balance for increased speed

of healing of healing • •

Edge of wound non-advancing Edge of wound non-advancing or underminedor undermined

• Reassess cause or consider corrective Reassess cause or consider corrective therapies – correct action willtherapies – correct action will

• promote migrating keratinocytes and promote migrating keratinocytes and responsive wound cellsresponsive wound cells

• restore appropriate protease restore appropriate protease profileprofile

• and will achieveand will achieve

• advancing edge of woundadvancing edge of wound

WOUND CARE OBJECTIVESWOUND CARE OBJECTIVES

– Will follow in order of priorityWill follow in order of priority– Will change over timeWill change over time– Must take account of each patient’s Must take account of each patient’s

particular and individual needsparticular and individual needs– Will come out of an holistic assessmentWill come out of an holistic assessment– Must respond to the stages of wound healingMust respond to the stages of wound healing– Must respond to the needs of the wound bed Must respond to the needs of the wound bed

and peri-wound areaand peri-wound area– Will therefore be different, patient to patientWill therefore be different, patient to patient

TERMS USED IN WOUND CARETERMS USED IN WOUND CARE

GranulationGranulation

SloughSlough

Necrotic infectedNecrotic infected

EpitheliumEpithelium

ShallowShallow

Deep - gradesDeep - grades

DiffuseDiffuse

PunchedPunched

ColourColour

OdourOdour

• IndurationInduration

• HyperkeratosisHyperkeratosis

• LypodermatosclerosisLypodermatosclerosis

• ErythemaErythema

• Blanching erythemaBlanching erythema

• ExudateExudate

• VenousVenous

• ArterialArterial

• MixedMixed

• Auto-immuneAuto-immune

TOOLS OF THE TRADETOOLS OF THE TRADE

• CameraCamera• SyringeSyringe• ProbeProbe• RulerRuler• Tape measureTape measure• Wound mapWound map• VisitracVisitrac• DopplerDoppler• (pulse oximeter)(pulse oximeter)

• DOCUMENTATIONDOCUMENTATION

FACTORS TO CONSIDER WHEN FACTORS TO CONSIDER WHEN CHOOSING A DRESSINGCHOOSING A DRESSING

• HowHow• WhenWhen• WhereWhere• SizeSize• Co-morbiditiesCo-morbidities• AgeAge• MedicationMedication• Nutritional statusNutritional status• Level of concordanceLevel of concordance• ExudateExudate

• Sensitivities/allergiesSensitivities/allergies• Function of dressingFunction of dressing• Wear timeWear time• Pain – at dressing Pain – at dressing

changechange• Pain – from dressing Pain – from dressing

actionaction• Smell – of woundSmell – of wound• Smell – of dressingSmell – of dressing• Ease of applicationEase of application

THE CHRONIC WOUNDTHE CHRONIC WOUNDleg ulcerleg ulcer• Problems:Problems:

– Wound static or Wound static or deterioratingdeteriorating

– Macerated skin to Macerated skin to peri-ulcerperi-ulcer

– Sloughy wound bedSloughy wound bed– Ulcer secondary to Ulcer secondary to

venous venous hypertensionhypertension

THE CHRONIC WOUNDTHE CHRONIC WOUNDleg ulcerleg ulcer• Care objectives:Care objectives:

– Reduce risks of further deteriorationReduce risks of further deterioration– Promote skin integrity to peri-ulcerPromote skin integrity to peri-ulcer– Debride of sloughDebride of slough– Reverse venous hypertensionReverse venous hypertension

THE CHRONIC WOUND- leg THE CHRONIC WOUND- leg ulcer (to give an example of ulcer (to give an example of how chronic differs from acute)how chronic differs from acute)• Problems may stay the Problems may stay the

same, even though same, even though wound is improving:wound is improving:– Reduce risks of further Reduce risks of further

deteriorationdeterioration– Promote skin integrity to Promote skin integrity to

peri-ulcerperi-ulcer– Promote granulation Promote granulation

tissue and tissue and epithelialisationepithelialisation

– Reverse venous Reverse venous hypertensionhypertension

THE CHRONIC WOUNDTHE CHRONIC WOUNDpressure ulcerpressure ulcer

CHRONIC WOUNDCHRONIC WOUNDpressure ulcerpressure ulcer• Problems:Problems:

– Grade 4 pressure ulcer to buttocksGrade 4 pressure ulcer to buttocks– Blanching erythema to peri-ulcerBlanching erythema to peri-ulcer– Sloughy wound bed Sloughy wound bed – High levels of exudate High levels of exudate

THE CHRONIC WOUNDTHE CHRONIC WOUNDpressure ulcerpressure ulcer

• ObjectivesObjectives– Remove cause deal with specific wound Remove cause deal with specific wound

care problems:care problems:•SloughSlough

•exudateexudate

THE CHRONIC WOUNDTHE CHRONIC WOUNDfungating breastfungating breast• Problems:Problems:

– PainfulPainful– SmellySmelly– WetWet– Risks of secondary Risks of secondary

infectioninfection– Risks of Risks of

haemorrhagehaemorrhage

THE CHRONIC WOUNDTHE CHRONIC WOUNDfungating breastfungating breast

• Objectives:Objectives:– Reduce painReduce pain– Reduce odourReduce odour– Contain exudateContain exudate– Reduce risks of secondary infectionReduce risks of secondary infection– contingency for possible haemorrhagecontingency for possible haemorrhage

ACUTE OR CHRONIC?ACUTE OR CHRONIC?

• Problems:Problems:– Static wound was Static wound was

acute, now chronicacute, now chronic– Stuck in Stuck in

inflammatory phaseinflammatory phase

STATIC WOUNDSTATIC WOUND

• ObjectivesObjectives– Reduce risks of Reduce risks of

deteriorationdeterioration– Reduce risks of Reduce risks of

wound infectionwound infection– Promote healingPromote healing

Making the right choiceMaking the right choice

• Cost effectiveness does not always Cost effectiveness does not always mean the “cheap option”, it is about mean the “cheap option”, it is about being clinically effectivebeing clinically effective

• Clinical effectiveness is about “doing Clinical effectiveness is about “doing the right thing in the right way for the right thing in the right way for the right patient at the right time” the right patient at the right time” (RCN, 1997)(RCN, 1997)

Making the right choiceMaking the right choice

• Understand what different dressings Understand what different dressings are designed to doare designed to do

• Know what is available to you Know what is available to you (formulary)(formulary)

• Evaluate and re-evaluateEvaluate and re-evaluate

• Modify care plan as wound changes Modify care plan as wound changes using good rationale using good rationale

NOW ITS YOUR TURNNOW ITS YOUR TURN

Any questions?Any questions?