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DisclaimerAny reference to specific products in the following text is by way of example only andis not to be taken as constituting any form of recommendation or endorsement on thepart of CREST
hese guidelines have been prepared by CREST
REST is a small committee of doctors established under the auspices of the Central Medicaldvisory Committee, to promote clinical efficiency in the health service in Northern Ireland whilensuring that the highest possible standard of clinical practice is maintained.
REST wishes to express its appreciation to Mrs Mary Waddell and the working group forroducing this guidance, to all the members of the sub-groups and to all those who contributed any way to the development of these guidelines.
pecial thanks are due to Mrs Heather Reid for the major contribution which she made to theroduction of these booklets.
urther copies may be obtained from:REST Secretariatoom 517undonald Housepper Newtownards RoadelfastT4 3SF
Tel: 02890 524391
CREST Websitewww.n-i.nhs.uk/CREST
GENERAL PRINCIPLES OF WOUND CARE
Table of Contents
Foreword Page1. Summary of Conclusions and Key Recommendations 3
2. Physiology of the Wound Healing Process 4
3. Holistic Assessment 5
4. The Role of Nutrition in Wound Management 6
5. Local Wound Assessment 10
6. Wound Bed Classification 13
7. Wound Cleansing 14
8. Treatment Objectives 15
9. Selecting a Dressing 19
10. Seven Principles for Selecting an Ideal Wound Dressing 20
Appendices
1. Wound Observation Chart 23
2. Dressings’ Formulary 26
3. Guideline Development Sub-Group 40
4. CREST Wound Management Group 41
Glossary 43
Useful Addresses 44
References: A full list of references and further reading may be obtained by contacting theCREST Secretariat
Foreword
These consensus guidelines have been drawn up following an in-depth investigation of relevantliterature and expert opinion. They are designed to help practitioners base their clinicaldecisions on the best information available and offer a structured approach to the assessmentand management of patients with wounds. Please refer to the guideline folder for furtherinformation on the development process.
These guidelines are not meant to be a definitive guide to the management of specific woundtypes, rather they contain information on the general principles of wound management -principles which can be applied to most situations.
Before any clinical decision is taken, practitioners should take into consideration their localcircumstances, including patient preferences and any further knowledge of more recentfindings.
The authors would like to acknowledge all the practitioners who have taken the time to reviewand comment on the guidelines.
3
1. SUMMARY OF CONCLUSIONS AND KEY RECOMMENDATIONS
A number of key recommendations highlighted throughout the report are listed below. Each recommendation isgraded so as to give the reader an indication of the type of evidence supporting it.
GRADE A Requires at least one randomised controlled trial as part of the body of literature which is of overallquality and consistency addressing the specific recommendation.
GRADE B Requires availability of well conducted clinical studies but no randomised clinical trials on the topicof recommendation.
GRADE C Requires evidence from expert committee reports or opinions and/or clinical experience ofrespected authorities. Indicates absence of directly applicable studies of good quality.
AssessmentGrade See Section
• A holistic patient assessment is an essential part of thewound care process.
C 3
• The systematic assessment of a wound is essential as itprovides baseline data on which to evaluate healing andthe efficacy of the treatment regime.
C 5
Management• Optimal nutrition facilitates wound healing, maintains
immune competence and decreases the risk of infection.B 4
• Nutritional assessment is essential to determine bothdeficiencies or excesses of macronutrients andmicronutrients involved in the wound healing process.
B 4.1
• Physiological Saline (0.9%) is the universal woundcleansing agent of choice.
C 7
• For chronic wounds such as leg ulcers ordinary tap watercan be used.
C 7
• If wound cleansing is indicated the wound should begently irrigated rather than swabbed.
C 7
• Saline and water used for cleansing should be warmedat least to room temperature.
B 7
• Antiseptics are toxic to human tissue and probably delaywound healing.
B 7
• Topical antibiotics are frequent sensitisers and should beused with caution.
B 7
• Systemic antibiotics should be used to treat clinicalinfection.
A 8
• Wound dressings should:• Provide a moist wound environment; B 10• Manage excess exudate;• Allow gaseous exchange;• Provide a constant wound interface temperature;• Protect the wound from pathogenic organisms;• Protect the wound from contamination with
particulate matter;• Protect the wound from trauma.
4
2. PHYSIOLOGY OF THE WOUND HEALING PROCESS
The word healing, used in a pathological context, refers to the body’s replacement of destroyedtissue by living tissue. Wound healing is an extremely complex process involving differentbiologic and immunologic systems. Injury triggers an organised cascade of cellular andbiochemical events which result in a healed wound.
For descriptive purposes, the wound healing response can be divided into distinct butoverlapping phases:
(i) Haemostasis;(ii) Inflammatory phase;(iii) Proliferative phase;(iv) Maturation or remodelling phase.
(i) Haemostasis
Haemostasis protects the body from excessive blood loss and increased exposure to bacterialcontamination through:
- Vasoconstriction;
- Migration of leukocytes and platelets;
- Formation of fibrin.
(ii) The inflammatory phase
This phase prepares the wound bed for healing by removing necrotic and foreign material. Thisnatural process is known as:
- Autolysis.
(iii) The proliferative phase
This phase fills and covers the wound bed as quickly as possible through:
- Granulation;- Contraction;- Epithelialisation.
(iv) The maturation or remodelling phase
During this phase the tensile strength of the healed wound is increased by the remodelling ofcollagen.
5
3. HOLISTIC ASSESSMENT
A true healing environment accepts the person for theirindividuality and holds their physical, mental, emotional,social and spiritual needs in high regard. It is therefore,achieved through a holistic health assessment and anevidence based treatment plan.
The success of wound healing is known to depend on many intrinsic and extrinsic factors, e.g.underlying disease, nutrition and psychological well-being. In order to create a healingenvironment, all factors which adversely affect the health of the patient must be identified and,where possible, rectified. Table 1 highlights some of the most common factors which can delayhealing.
Table 1 - Key Factors adversely affecting the healing process.
Intrinsic Factors Extrinsic FactorsAdvancing age
Disease processes, e.g. diabetes, cancer
Psychological factors
- stress and anxiety - sleep disturbances
Poor surgical technique
Poor wound care
Malnutrition
Dehydration
Smoking
Drug Therapy
Radiotherapy
It is important to remember that in some instances wound healing is not always possible. Inthese situations care must be directed towards physical and psychological comfort.
6
4. THE ROLE OF NUTRITION IN WOUND MANAGEMENT
Optimal nutrition facilitates wound healing, maintains immunecompetence and decreases the risk of infection. Most woundstend to heal rather than not; however malnutrition andclinically evident deficiencies are commonly associated with adelayed healing response and increased rate of complications.
Wound nutrition is essentially whole body nutrition and its goal is to maintain body mass, limitweight loss and provide adequate nutrients to promote healing. Nutritional intake should bevaried and balanced to provide all the essential nutrients.
A significant number of studies have investigated the potential value of specific nutrients inregulating wound healing as follows :
Kcalories (energy) Provision of adequate kcalories is the primary concern in facilitating woundhealing. Excess kcalories may lead to obesity, itself a complicating factor for woundhealing, whilst insufficient kcalories from fat and carbohydrate may result in protein beingused as an energy source.
Protein deficiency impairs wound healing by inhibiting fibroblast proliferation and collagensynthesis. An inadequate protein intake, often in conjunction with excessive losses ofprotein via heavily exudating wounds, will lead to a deficiency which can prolong theinflammatory response and result in oedema secondary to hypoalbuminaemia, therebyimpairing the healing process. The value of various amino acids has been investigated :-
Glutamine is essential for immune system function. Its requirement is increased duringinjury or disease and it appears to help decrease protein catabolism frequently seenwith injury.
Arginine enhances wound collagen deposition and protein synthesis. It also stimulatesinsulin and growth hormone secretion, two products known to be closely related towound healing.
Vitamin C (ascorbic acid) deficiency results in very little collagen deposition and markedlyretarded gain in tensile strength. It has been shown that the elderly tend to have lowplasma ascorbate concentrations as do smokers and patients with liver disease andcancer. The Vitamin C status of hospitalised patients deteriorates during hospital stay.This suggests that the combination of injury or sepsis with marginal Vitamin C status maydetermine alterations in wound healing of clinical relevance. Intake to prevent deficiency isclearly indicated.
7
Zinc The role of zinc in cellular proliferation and protein synthesis has been well established.The potential role of zinc supplementation in wound healing has been investigated; healingappears to be accelerated only in patients with low serum zinc levels. Hospitalisedpatients are potentially at risk of zinc deficiency due to decreased food intake andincreased losses due to diarrhoea, fistulae and malabsorption.
Vitamin A promotes re-epithelialisation and granulation of a wound and seems to counteractthe deleterious effects of glucocorticoids on wound healing. Patients with severe injuriesor those receiving steroids could benefit from supplementation.
Iron is vital in collagen metabolism and for oxygen transport. Deficiency due to poor intake andblood loss may result in iron deficiency anaemia which, unless corrected, will delay woundhealing.
Fluid intake should be given important consideration as dehydrated skin becomes inelastic,fragile and more susceptible to breakdown.
Other nutrients which have important functions in association with wound healing includevitamin E, vitamin K, vitamin B complex, copper, manganese, chromium and essential fattyacids.
Poor nutrition leading to nutrient deficiencies will interfere with wound healing, mostly bydelaying the healing response. Evaluation of a patient’s nutritional status through assessmentand the provision of a nutritionally appropriate diet is one of the first principles to healing.
4.1 NUTRITIONAL ASSESSMENT
Nutritional assessment is essential to determine bothdeficiencies or excesses of macronutrients (carbohydrate, fatand protein) and micronutrients (vitamins, minerals and traceelements) involved in the wound healing process. It alsoprovides an important base line of data on which to evaluatethe adequacy of nutritional intervention.
The need for a detailed nutritional assessment and dietetic intervention is usually determined bynursing and/or medical staff. This should involve screening patients to identify those who aremalnourished or at risk of developing malnutrition, which in itself acts as a predisposing factorfor delaying wound healing and increasing the risk of wound related complications.
8
The process of screening is referred to as nutritional risk assessment, and referral to a stateregistered dietitian is indicated by a combination of the following:
• more than 10% weight loss in less than 3 months;
• body mass index of less than 20 kg/m2 or greater than 30 kg/m2;
• inability to consume sufficient nutrients to meet requirements due to:
- poor appetite, that is consumption of less than 1/2 of meals;
- difficulties in chewing and/or swallowing necessitating altered texture meals;
- patient unable to take food/fluid by the normal oral route as it is deemed unsafe.
• malabsorption due to abnormal gut function, such as diarrhoea and/or vomiting;
• increased nutritional requirements due to disease or injury.
Many hospitals and community trusts now have access to nutrition risk assessment tools, whichshould be used whenever possible, in line with the British Association for Parenteral and EnteralNutrition (BAPEN) recommendations.
On referral to the dietitian a more detailed assessment should involve:
• assessment of present nutritional status;
• calculation of nutritional requirements;
• calculation of actual nutrient intake;
• biochemical analysis to identify specific micronutrient deficiencies with:
- tissue breakdown, for example, pressure sore formation or wound dehiscence;
- slow to heal wounds, that is wounds which show no signs of improvement within 5-6weeks;
- patients who have not been receiving their optimal nutritional requirements.
9
4.2 TREATMENT OBJECTIVES
(i) Prevent clinical nutrient deficiencies by ensuring that the patient is provided with optimalnutritional care through one or more of the following:
• a varied, balanced diet;
• nutritional supplements;
• multivitamin and mineral preparations;
• enteral tube feeding;
• parenteral nutrition.
(ii) Correct specific nutrient deficiencies as detected through biochemical investigations andclinical observation, with pharmacological doses of the nutrient concerned. Evidence ofclinical efficacy of such nutritional supplementation is limited, the consequence being alack of consensus as to whether to supplement and in what dose. The most abundantinformation exists regarding Vitamin C, iron and zinc. A range of doses forsupplementation suggested in the literature is provided below:
Vitamin C - 100-1000 mg per day (adjust with response) for example, 500mg ofascorbic acid once per day.
Zinc - 50 mg maximum per day (adjust with response), for example, 200mgSolvazinc® once per day.
Iron - 100-200 mg per day (adjust with response), for example, 200 mg offerrous sulphate (dried) three times per day.
Specific micronutrients if supplemented, without biochemical evidence of a deficiency stateand in too high a dose could interfere with the absorption of other important nutrients andresult in complications of toxicity.
Biochemical parameters should be reviewed and vitamin and/or mineral supplementationdiscontinued only when nutrient deficiency states are corrected and other sources providesufficient quantities of the concerned nutrients. This will prevent rebound deficiency statesparticularly notable with regard to Vitamin C.
(iii) Control total calorie intake in the obese patient to reduce weight and/or prevent furtherweight gain.
(iv) Ensure dietary intake is conducive to optimal glycaemic control in patients with diabetes.
10
5. LOCAL WOUND ASSESSMENT
The systematic assessment of a wound is essential as itprovides baseline data on which to evaluate healing and theefficacy of the treatment regime.
Assessment and evaluation should be carried out at regularly stated intervals and the processshould be clearly documented. The following data should be recorded:
5.1 Site of Wound
It is important to record the site of the wound for the following reasons:
• accurate record keeping differentiates between wounds;• the position of a wound may suggest its pathology, for example, venous leg ulcers tend to
occur in the gaiter area, whilst ulcers on the foot are usually due to ischaemia or diabetes.
5.2 Wound Measurement
The accurate measurement of the physical size of a wound is vital for assessing the progress ofhealing.
Although there are many different ways of measuring wounds the most simple and accessiblemethods include:
(i) ruler based assessment, e.g. (maximum) width x depth x breadth;(ii) transparency tracings;(iii) photography/Grid Camera.
• In general cavity wounds should be gently probed to establish the extent of underminingand/or the depth of hidden extensions. Caution should be exercised where the woundoverlies sensitive structure e.g. bowel.
• Measurements should be recorded in millimetres or centimetres.• Weekly measurements are usually sufficient.
Note: In some instances a sinogram or x-ray will be required to establish the full extent ofthe wound.
11
5.3 Surrounding Skin
The condition of the skin surrounding the wound provides important information aboutunderlying disease and the effectiveness of current treatment regimes. For example, pinktissue on the wound margins may indicate epithelialisation; cool, shiny, hairless skin on thelower leg may indicate arterial disease; maceration may indicate an ineffective dressing regime.
In some instances a sinogram or x-ray will be required toestablish the full extent of the wound.
In general, the shape of the wound’s edge is an unreliable discriminant of a wound’s progress.However, a rolled (lipped) edge may indicate malignancy or another aetiology and may requirebiopsy.
5.4 Wound Bed
The appearance of the wound bed is said to indicate both the stage of healing and the health ofthe wound. The wound bed must be thoroughly assessed as tissue type often provides therationale behind the main treatment objective. For example a red granulating wound will requireprotection whilst a black necrotic or a yellow sloughy wound will probably require some form ofdebridement.One of the most effective ways to describe tissue type is by its colour. In general:• Eschar = Black tissue• Slough = Yellow tissue• Granulation = Red tissue• Epithelialisation = Pink tissue
Although the colour system is not perfect, for example, yellow tissue does not always indicateslough, it is easy to use and aids communication. The type of tissue on the wound bed can befurther quantified through percentages, e.g. 50% red/granulation tissue + 50% yellow/slough.
5.5 Exudate
A knowledge of the level and type of wound exudate is extremely important as it, in conjunctionwith the type of tissue on the wound bed, will influence dressing choice.The level and type of exudate tends to be described subjectively. In order to improvecommunication it may be helpful to standardise the meaning behind the subjective descriptions.For example, wound exudate may be described as:
Serous Clear fluid with apparent visual absence of blood, pus or other debris;Sanguinous Bloody, appearing to be composed entirely of blood;Serosanguinous Blood mixed with obvious quantities of clear fluid;Purulent Pus like in appearance, cloudy and viscous.
12
It is very difficult to devise an accurate method of describing the level/amount of woundexudate. However, the following terms may be useful:
Dry The wound does not produce exudate;Low The wound bed is moist, i.e. there is scant or small amounts of exudate;Moderate The surrounding skin is wet and there is exudate in the wound bed;High The surrounding skin is saturated (sometimes macerated) and the wound is bathed
in fluid.
Note: The dressing regime may add to or detract from the true level of wound exudate.
5.6 Wound Odour
Malodour may cause the patient to suffer social or psychological isolation. It can also causephysical symptoms such as nausea and vomiting and this can result in severe nutritionaldeficits.
Wound odour may be caused by infection, necrotic tissue or the use of certain dressingmaterials. The cause must be established and where possible rectified, e.g. treat infection,remove necrotic matter, change dressing regime.
Odour is very subjective and difficult to quantify. However, the following descriptive terms maybe useful:
• none;• smell only noticeable on dressing removal and disappears when the dressing is discarded;• smell fills the room.
5.7 Wound Pain
Although pain is subjective, its location, frequency and severity can be helpful in determining thepresence of underlying disease, the exposure of nerve endings, the efficacy of local wound careand psychological need. Visual or verbal rating scales can help patients to communicate thelevel of pain which they are experiencing. Local pain management policies should beimplemented.
Please refer to Appendix 1.
13
6. WOUND BED CLASSIFICATION
NECROTIC Necrotic – This is a necrotic heel. Note thehard, black, dry, leathery eschar.
SLOUGHY Sloughy – Note the soft yellow tissue on thewound bed.
GRANULATING Granulating – Note the healthy red tissue onthe wound bed.
OVERGRANULATION Overgranulation – Note the exuberant raisedred tissue.
EPITHELIALISING Epithelialising 1 – Note the pink tissue at thewound edges moving over the healthygranulating tissue.
EPTIHELIALISED Epithelialising 2 – Same wound fullyepithelialised 5 months later.
14
7. WOUND CLEANSING.
Considerable debate surrounds this area of wound care. There are, however, a number of keypoints that should be adhered to when cleansing wounds.
• Wounds that are healthy and free from debris do not requireritualistic cleansing. However if dead tissue or foreign debrisare present the wound should be cleaned as this matter maysupport the growth of pathogenic organisms. Inflammatoryexudate is produced by all healthy wounds. This exudatecontains important substances which are essential for woundhealing e.g. growth factors.
• If cleansing is indicated, the wound should be irrigated using,for example, a syringe rather than swabbed - swabbing canresult in the breakdown of fragile granulation/epithelialisingtissue.
• Physiological saline (sodium chloride 0.9%) is the only solutionwhich is recommended for all wound types - recent studiesindicate that physiological saline is compatible with humantissue and is unlikely to cause cellular damage. However,some experts recommend ordinary tap water for the cleansingof chronic wounds such as leg ulcers.
• Studies indicate that saline and water should be warmed tobody temperature (37 C) - cold solutions slow down cellularrepair. However, many practitioners will find it difficult toachieve this ideal in the practice setting. Therefore, it isrecommended that cleansing solutions are kept at a minimumof room temperature.
• There is at present debate about the use of topical antisepticsand antibacterials in wound care. Some argue that topicalantibiotics and antiseptics have an important role to play withinclearly defined areas in wound care, while others stress thatantiseptics may have toxic effects on tissues and may delaywound healing. Therefore, at present, the cautious use of suchchemicals in wound care is recommended.
Note! Instigate general infection control precautions when caring for all patients withwounds e.g. hand washing, plastic aprons and gloves.
15
8. TREATMENT OBJECTIVES
Treatment objectives for wounds by their wound bed classification.
8.1 Necrotic Wounds
Description:
Necrosis is a term used to describe dead (ischaemic) tissue, e.g. eschar and slough.However, within the field of wound care the term tends to be used to describe dead tissuewhich is black/brown in colour.
Note: Hard, black, dehydrated, leathery necrosis is known as ESCHARAim of Treatment:
• debridement and management of exudateManagement Techniques:
• debridement with a scalpel (see footnote);• dressings* which promote autolysis, e.g. hydrogels, hydrocolloids;• enzymes (efficacy of some enzymes has been questioned);• larvae (if necrosis is soft/wet);
* The choice of dressing will depend on the depth of the wound and the amount of exudate.
Necrotic tissue prolongs healing and in most situations should be removed (debrided). Thetrue size of the wound may not be apparent until this necrotic tissue is removed. However, incertain situations debridement may not be appropriate. This decision is usually made when alimb or digit is ischaemic and amputation is not possible. This wound cannot be healed. Inorder to prevent malodour and infection the necrotic tissue should be kept as dry as possible.Patients usually like the limb covered for cosmetic reasons.
There is evidence to suggest that for some wounds, removing eschar is not necessary e.g.small areas of eschar on heels and toes. If the eschar is hard and dry and the surroundingskin is not inflamed then the eschar may be left intact. It should be inspected daily for anysigns of deterioration.
Note! Debridement with a scalpel should be undertaken with caution and health careprofessionals should only do so if appropriate training and experience has beengained.
16
8.2 Sloughy Wounds
Description:
Slough is a term used to describe the accumulation of dead cellular debris on the woundsurface. It tends to be yellow in colour due to large amounts of leucocytes present.Its presence will delay healing.
Warning! - Yellow tissue is not always indicative of slough. You may be looking atsubcutaneous tissue, tendon or bone.Aim of treatment:
• debridement and management of exudate
Management Techniques:
• sharp debridement with a scalpel [see note on debridement in section 8.1];• *dressings which promote autolysis, e.g. hydrogels, hydrocolloids, alginates, larvae;• enzymes (efficacy of some enzymes has been questioned);• larvae.
* The choice of dressing will depend on the depth of the wound and the amount ofexudate.
17
8.3 Granulating WoundsDescription:
Granulation is the process by which the wound is filled with highly vascular connective tissue.Granulation tissue is usually red and moist and has an uneven granular appearance.
Unhealthy infected granulation tissue often looks dark and bleeds very easily.
Aim of Treatment:
• keep wound warm and moist;• manage exudate;• PROTECTION.
Management Techniques:
• All dressings* which maintain a warm moist environment, e.g. hydrogels, hydrofibre,hydrocolloids, alginates, foam dressings.
* The choice of dressing will depend on the depth of the wound and the amount of exudate.
8.4 Epithelialising WoundsDescription:
Epithelialisation is the process by which the wound is covered with epithelial cells. Thisprocess can be recognised by the presence of pink tissue which migrates from the woundedges and / or the remnants of hair follicles in the wound bed.
Epithelial cells will only migrate over living granulation tissue. Epithelialisation occurs 2 - 3times quicker in a warm moist environment.Aim of Treatment:
• keep wound warm and moist;• manage exudate;• PROTECTION.Management Techniques:
• all dressings* which maintain a warm moist environment, e.g. low - adherent dressings,vapour-permeable films, hydrogels, hydrocolloids, alginates, foams.
* Dressing choice will depend on the level of exudate.
18
8.5 Infected WoundsDescription:
Infection occurs when organisms deposited in the wound evoke a reaction from the host, i.e. antigen-antibody response.Signs of infection may include:
• delayed healing / dehiscence;
• increased wound pain;
• malodour (an acrid or putrid smell is highly indicative of an anaerobic infection);
• abscess / sinus formation;
• localised swelling, redness or heat;
• increased level of exudate / purulent discharge;
• pyrexia, rigours or tachycardia.
Aim of Treatment:
• patient will be free from pain, discomfort and infection;
• to promote wound healing.
Management Techniques:
• general infection control precautions, e.g. hand washing, plastic aprons and gloves;
• swab for ‘Organisms and Sensitivities’;
• SYSTEMIC ANTIBIOTICS;
• unless advised otherwise, treat the wound according to the type of tissue on the wound bed;
• it may be prudent to avoid all occlusive dressings if anaerobic infection is suspected or cultured
(occlusive dressings are thought to promote an anaerobic environment);
• daily dressings.
The presence of bacteria in a wound does not mean that it is infected - remember that allchronic wounds are colonised by micro organisms. Do not diagnose a wound infection on thewound swab result alone, look for local and systemic signs of infection. Patients with aninfected wound require a systemic antibiotic.
Examples of Aerobic and Anaerobic Bacteria Cultured from Wounds
Aerobic BacteriaBeta-haemolytic StreptococciEscherichia coliKlebsiellaProteusPseudomonasStaphylococcus Aureus & MRSAStaphylococcus Epidermis
Anaerobic BacteriaBacteroidesClostridium tetaniClostridium welchii (gas gangrene)
19
9. SELECTING A DRESSING
When selecting a dressing consider:
• stage of healing
• aetiology;
• tissue involved;
• the patient’s general health and environment.
Before applying the dressing consider:
• the treatment objective;
• the site of the wound;
• the size of the wound;
• the frequency of the dressing change;
• comfort and cosmetic appearance;
• where and by whom the dressing will be changed;
• if the dressing is available on the drug tariff.
Note: Where all other considerations are equal, choose the cheapest dressing.
Never apply a dressing or lotion in ignorance. Be aware of the manufacturer’s recommendations,contraindications, precautions and warnings.
Note: A formulary of wound dressings may be found in Appendix 2
Remember that you are accountable for the decisions you make!
20
10. SEVEN PRINCIPLES FOR SELECTING AN IDEAL WOUNDDRESSING.The ideal dressing will:
• provide a moist environment;
• manage excess exudate;
• allow gaseous exchange;
• provide a constant wound interface temperature;
• protect the wound from pathogenic organisms;
• protect the wound from contamination with particulate matter;
• protect the wound from trauma.
Principle 1: Provide a Moist Wound Environment
Arising from the seminal work of George Winter in 1962, the phrase ‘moist wound healing’ hasbeen coined to describe an optimum environment for wound healing. It was observed thatwounds covered with an occlusive dressing healed twice as fast as those left to dry out.
Under dry conditions the bed of an open wound rapidly dries out and forms a scab made up ofdead and dying cells. New epidermal cells have to burrow beneath the scab to find a moist layerto allow movement across the wound. In a moist environment epidermal cells are able to slideacross the surface of the wound because the dressing maintains humidity on the woundsurface.
Wounds which are healed in a moist environment heal faster, are less inflamed and less painful.There is more collagen production and better contraction which results in less scarring.
Principle 2: Manage Excess Exudate
Although the effective management of exudate is probably the most common problemencountered by practitioners involved in wound care, the composition and function of woundfluid is generally not well understood.
From the physiology of wound healing, the presence of serous fluid in an open wound plays avital part in the healing process:
• it provides essential nutrients as an energy source for actively metabolising cells;
• it contains growth factors which actively promote healing;
• it serves as a transport medium for white cells;
• it helps to ensure that the wound surface does not become excessively dry.
Although the wound surface should remain moist, excessive moisture causes maceration andexcoriation of the surrounding skin which may in turn lead to infection. The precise balance that needs tobe maintained by the dressing between moisture and absorbency is still not certain.
21
Principle 3: Allow Gaseous Exchange
Successful wound healing is dependent upon good oxygen resources.
In the early stages of wound healing tissue oxygen is extremely low (<10mm Hg) indicating theabsence of a working microcirculation. A low oxygen tension is thought to stimulate fibroblastreplication and angiogenesis, and hence the production of granulation tissue thus helping toimprove the circulation and raise the tissue oxygen.
Once tissue oxygen improves (>10mm Hg collagen can be synthesised) the wound healingprocess can continue.
The presence of exudate or debris on the wound surface may inhibit gaseous exchange throughthe dressing. It would be fair to say that the wound does not rely on atmospheric oxygen for itsoxygen.
Principle 4: Provide A Constant Wound Interface Temperature
A constant temperature of 37 C promotes both macrophage and mitotic activity duringgranulation and epithelialisation.
Cells and enzymes function at normal body temperature. Reduced interface temperaturesinhibit the activity of phagocytic cells and significantly affect cell mitosis.
Principle 5: Protect the Wound from Pathogenic Organisms.
One of the major functions of intact healthy skin is to protect underlying structures from invasionby micro-organisms. A wound disrupts the integrity of the skin and provides a potential pathwayfor pathogenic organisms to enter the body. Wound infection can cause delayed healing and ifinfection is not controlled it may lead to cellulitis, bacteraemia and septicaemia.
Many modern dressings are bacteria-proof. This not only prevents airborne bacteria entering awound but also prevents contaminated exudate being released into the environment andcausing cross-infection. Moistened or leaking dressings can provide a pathway for bacteria totravel in both directions. It has been shown in vitro that motile bacteria such as Pseudomonascan pass through a moist dressing in a few hours. This has been termed “strike-through” andrequires immediate dressing change.
22
Principle 6: Protect the Wound from Contamination with Particulate Matter
It is well documented that the presence of debris in the wound may delay wound healing andact as a focus for infection. Foreign matter introduced into the skin causes an inflammatoryresponse and can lead to the formation of fibrous tissue, scarring and hypertrophy. It isundoubtedly true that fibres from certain dressings used in wound care can becomeincorporated into wounds, however some feel there is a need for more research into thedetrimental effects of this particularly to ensure that any residual chemicals left after complexmanufacturing processes do not inversely affect wound healing.
Principle 7: Protect the Wound from Trauma.
One of the priorities of wound management is to protect the wound from any further trauma. Ithas been reported that removal of adherent dressings can cause trauma to wounds. It is welldocumented that traditional dressings such as gauze have a tendency to adhere to the surfaceof wounds causing damage to newly formed epithelium. Adherence occurs either because (a)the wound exudate becomes incorporated into the dressing and dries or (b) granulation tissuegrows between the structure of the dressing.
Manufacturers of wound dressings have tried to overcome this problem by applying facinglayers to dressings which attempt to prevent adherence to the wound.
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Appendix 1Wound Observation Chart - sample
Note: The following chart has been devised to show how local wound care information can berecorded using a common language. It is not a holistic wound assessment chart and it isnot meant to be definite or all inclusive.
Professionals may use the chart as it stands or adapt it to meet the needs of their patients andTrust.
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Open Wound Observation Chart
Name: …………………………………
Unit No: …………. Ward…………..
Referrals (where appropriate):Dietitian: Date: …../…../…..Other: ……………. Date: …../…../…..Other: ……………. Date: …../…../…..
Consultant/ GP: Allergies:Type of wound: Wound site:
Date …………………. ………………... …………………...Maximum size(in centimetres ormillimetres)
Length
Depth
Width
Wound traced Yes/NoPhotograph Yes/No
Length
Depth
Width
Wound traced Yes/ NoPhotograph Yes/ No
Length
Depth
Width
Wound traced Yes/ NoPhotograph Yes/ No
Wound Bed(state approx %)NB. Other may includetendon, muscle, bone.
(Black) Necrosis(Yellow) Slough(Red) Granulation(Pink) EpithelialisingOther ……………….
NecrosisSloughGranulationEpithelialisingOther ……………….
NecrosisSloughGranulationEpithelialisingOther ……………….
Surrounding skin
Healthy/ Blistered/Dry/ Scaly/Wet or Dry Eczema/Macerated/ Red & HotExudate (colour)
Serous/ Sanguinous/Serosanguinous/PurulentExudate (amount)
Dry/ Low/ Moderate/HighOdour
None/ Only presentwhen dressing isremoved/ Fills theroomWound Pain(frequency)
None/ Only atdressing change/Intermittent/ContinuousWound Pain (Patient'sPerception)
Use Pain ScaleSignature
25
DateInfection (only completethis section ifappropriate)
Suspected/ Present
Swab taken (date)
Result/ Organism(s)isolated
Action taken
Signature
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……/……/…..
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……../……../……
………………………….…………………………..
…………………………………………………..
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……../……../….
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Date RecommendedDressings/ Bandages
Rationale Maximum Wear time Sign
Additional NotesSign.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please evaluate progress in the Nursing Care Plan.
26
Appendix 2FORMULARY OF WOUND DRESSINGS
Primary wound dressings are dressings applied directly onto a wound and these can be dividedinto a number of different generic classes.
• Non or low-adherent dressings
• Semi-permeable films
• Hydrogels
• Hydrocolloids
• Hydrofibre
• Alginate dressings
• Foams
• Odour absorbing dressings
• Paraffin Tulle
• Polysaccharide bead dressings
• Antibacterial agents
In the following formulary, products within each class are described and information is given onindications and contraindications.
For information regarding the legal category of the products included e.g. ‘prescription onlymedicine’, refer to BNF.
27
1. Non or Low-Adherent DressingsThree main types are available:
(A) Knitted Viscose Dressings
• consist of a knitted open structure which allows a free passage of exudate, e.g. NADressing®, Tricotex®.
A knitted viscose dressing coated with silicone is also available e.g. N.A. Ultra®.
(B) Perforated Film Absorbent Dressings
• consist of a film bonded onto an absorbent layer. The film is perforated allowing passage ofexudate into the absorbent pad, e.g. Release®, Melolin®.
(C) Non-adherent Silicone Dressings
• is a highly conformable silicone covered mesh, e.g. Mepitel®.
Indications:
• These are low-adherent sterile dressings which can be used for lightly exuding superficialwounds.
Contra-indications:
Type B should not be used on wounds which produce copious exudate as the exudatemay become trapped under the dressing leading to maceration and inflammation of thesurrounding skin;
• should not be used on necrotic or sloughy wounds.Other Points:
• sometimes adherence can be a problem. Always moisten the dressing with saline beforeremoval.
28
2. Semi-permeable Adhesive Film Dressings:• consist of a thin transparent sheet of polyurethane coated with a layer of acrylic adhesive;
• permeable to water vapour and oxygen but impermeable to micro-organisms.
• examples include Bioclusive®, Opsite®, Tegaderm®.
Indications:
• can be used on shallow wounds - in the treatment of superficial pressure sores, donor
sites, post-operative wounds and a variety of minor/superficial injuries;
• can be used as a protective dressing to prevent skin breakdown due to friction or
continuous exposure to moisture;
• frequently used as a secondary dressing for other products.
Contra-indications:
• not for use on deep wounds, infected or heavily exuding wounds.
Other Points:
• handling this dressing may be difficult. Removal can be traumatic to surrounding skin andshould be carried out carefully - follow manufacturers’ instructions. Watch out formaceration of surrounding skin.
29
3. Hydrogel Dressings:• consist of insoluble polymers which are hydrophilic and which contain large amounts of
water;
• can donate liquid to produce a moist environment at the surface of the wound. Can
absorb excess exudate;
• examples include Comfeel Purilon Gel®, Granugel®, Intrasite Gel®, Nu-gel®, Sterigel®.
Indications:
• cleansing sloughy and necrotic wounds by rehydrating dead tissue and encouraging
autolytic debridement. Can be used in many different types of wounds including pressure
sores, leg ulcers and surgical wounds;
• treatment of inflamed painful wounds, e.g. radiotherapy burns;
• treatment of extravasation injuries.
Contra-indications:
• not recommended for heavily exuding wounds.Other Points:
• a secondary dressing is needed;
• some hydrogels contain preservatives which can cause allergic reactions in sensitive
individuals;
• may be used on clinically infected wounds but must be changed daily.
30
4. Hydrocolloid Dressings• consist of gel-forming agents such as carboxymethylcellulose, applied to a flexible foam or
film sheet. The dressings are self-adhesive and absorb liquid in the presence of wound
exudate to form a gel;
• different hydrocolloid dressings vary in their composition and physical characteristics;
• examples include Comfeel Plus®, Duoderm extra thin®, Granuflex®, Tegasorb®.
Indications:
• management of light to moderately exuding wounds including pressure sores, leg ulcers,
minor burns and donor sites;
• cleansing of sloughy and necrotic wounds by rehydrating dead tissue and encouraging
autolysis.
Contra-indications:
• not recommended for very heavily exuding wounds;
• not recommended for wounds which are infected with anaerobic organisms.
Other points:
• over granulation may occur and may necessitate changing to a more permeable dressing;
• hydrocolloid dressings are self adhesive and waterproof;
• dressings can be left in place for up to seven days depending on the amount of wound
exudate;
• hydrocolloids which contain gelatin may be contraindicated in strict vegans.
31
5. Hydrofibre Dressing:• composed of sodium carboxymethycellulose spun into a fibre;
• these highly absorbent fibres absorb and retain significant amounts of exudate;
• as they absorb exudate the dry fibres convert into a gel sheet;
• hydrofibre is a new class of dressing. At the moment only one Hydrofibre, i.e. Aquacel®
exists.
Indications:
• management of all types of moderate to highly exudating wounds.
Contraindications:
• dry dressing will be of limited value in a dry wound.
Other Points:
• may be used on an infected wound so long as it is changed daily;
• flat dressing should overlap the surrounding skin by at least 1 cm as the dressing shrinks
slightly as it absorbs exudate;
• dressing can be left in place for up to seven days depending on level of exudate.
32
6. Alginate Dressings:• consist of sodium and calcium salts of alginic acid in a sterile absorbent fibrous dressing;
NB. Alginic acid is a polymer containing mannuronic and guluronic acid residues.
• alginates rich in mannuronic acid e.g. Sorbsan® form soft flexible gels whereas those
which are rich in guluronic acid e.g. Kaltostat® form firmer less mobile gels;
• when in contact with exudate alginates absorb moisture and produce a moist hydrogel;
• some alginates are licensed haemostats e.g. Kaltostat® and Algosteril®.
Indications:
• management of highly exudating wounds;
• filling cavities;
• bleeding wounds.
Contra-indications:
• alginate dressings are not suitable for dry wounds.
Other Points:
• may be used on infected wounds but the dressing must be changed daily;
• alginates are easily removed from the wound bed by irrigation with saline;
• narrow sinuses and diabetic foot ulcers must be lightly packed as the dressings may
prevent free drainage;
• some alginates require a secondary dressing, others do not e.g. Kaltoclude® and SorbsanSA® have a secondary adhesive film membrane.
33
7. Polyurethane Foam Dressings• many different types of ‘foam’ dressings are available. Each has special characteristics
which alter the absorbency of the product - see manufacturers’ instructions;
• all contain a hydrophilic, absorbent polyurethane foam. Some contain an outer waterproof,
bacteria-proof backing e.g. Tielle®;
• common examples include Lyofoam® range, Allevyn® range, Tielle® and Spyrosorb®.
Indications:
• low to moderately exudating wounds.
Contra-indications:
• not suitable for very dry wounds;
• Spyrosorb® should not be used on clinically infected wounds.
Other Points:
• dressing may be left in situ for up to seven days;
• most foam dressings can be used on clinically infected wounds (refer to manufacturersspecific instructions).
34
8. Odour Absorbing Dressings:Two main types :(A) Charcoal Dressings
• contain activated charcoal which is able to filter and absorb malodorous chemicals which
are liberated from wounds;
• examples include CliniSorb®, Carbonet®.Indications:
all malodorous woundsContra-indications:
see manufacturers’ instructionsOther Points:
• the odour absorbing property of activated charcoal is reduced once the charcoal becomes
wet with exudate;
• some charcoal dressings are primary dressings, others are secondary dressings - read
manufacturers instructions;
• be aware that some of these ‘primary’ dressings will adhere to the wound bed if the wound
is allowed to dry out;
• may be used on infected wounds but should be changed on a daily basis.
• once malodour is noted the dressing should be changed.(B) Metronidazole Gel
• contains the antibiotic metronidazole;
• metronidazole is particularly effective against anaerobic bacteria (anaerobic bacteria are
usually responsible for the production of malodour);
• examples include Metrotop® 0.8% and Anabact® 0.75%Indications:
• malodorous fungating tumours;
For other indications, refer to manufacturer’s instructions.Contra-indications:
• patients who are hypersensitive to metronidazole;• pregnant or lactating mothers.Other Points:
• indiscriminate use of metronidazole may lead to the development of resistant micro-organisms;
• dressing should be changed 1 - 2 times per day.
35
9. Paraffin Tulle Dressings:• consist of yellow or soft white paraffin impregnated into an open weave cotton , or cotton
and viscose fabric;
• a ‘low loading’ paraffin tulle, e.g. Paratulle® contains 90 - 130 g of paraffin per square
metre of cloth;
• ‘traditional’ paraffin tulle, e.g. Jelonet® contains not less than 175g of paraffin per square
metre of cloth.
Indications:
• clean superficial wounds.
Contra-indications:
• heavily exudating wounds.
Other Points:
• newly formed capillary loops may grow through the open weave of the paraffin tulle fabric.If this happens the newly formed tissue will be traumatised as the dressing is removed;irrigating the dressing is of little benefit as paraffin is hydrophobic.
36
10. Polysaccharide Bead Dressings:• consist of highly absorbent hydrophilic beads;
• some bead dressings contain cadexomer iodine;
• examples include the Debrisan® range and Iodoflex®.
Indications:
• sloughy, exudating wounds;
• iodine bead dressings are recommended for infected, exuding wounds.
Cautions/Contra-indications:
• debrisan beads can be very difficult to remove, it may be better to avoid same in
narrow/sinus type wounds;
• iodine based products should not be prescribed for patients:
• with a known sensitivity to iodine;
• with a history of thyroid disorders;
• who are pregnant/breast feeding;
• on lithium or sulphonylureas.
• no more than 150g of Iodoflex® should be used per week and treatment duration shouldnot exceed three months.
Other Points:
• when iodine is used up , the colour of the dressing changes from brown to white;
• frequency of dressing change will depend on the level of exudate.
37
11. Antimicrobial Agents:For ease of reference these products have been divided into three groups: antibiotics,antibacterials and antiseptics.
(A) Topical Antibiotics:
Topical antibiotics are not recommended due to:
- development of resistance;
- high incidence of sensitivity reactions which delay healing;
- open weave dressing into which products are impregnated.
Common topical antibiotics used in wound care include neomycin sulphate (Cicatrin®), fusidicacid (Fucidin Intertulle®) and framycetin (Sofra-Tulle®). These products should be removedfrom general use.
(B) Antibacterials:
Examples include metronidazole gel (see section 8) and silver sulphadiazine cream.
Silver Sulphadiazine:
• a hydrophilic cream containing silver sulphadiazine 1%w/w;
• silver ions kill bacteria by causing structural changes to the bacterial cell surface;
• sodium sulphadiazine inhibits folic acid synthesis;
• inhibits the growth of most pathogenic bacteria in vitro.
Indications:
• treatment of choice for prevention of Gram-negative sepsis in patients with burns;
• most Pseudomonas and Staphyloccus Aureus infections.
Contraindications:
• sensitisation;
• use with caution in patients who have renal or hepatic problems;
• should not be used at or near term in pregnancy or on premature or newborn infants as
sulphonamides can cause kernicterus;
• leucopenia may occur.
Other Points:
• argyria has been reported with excessive use;
• do not apply cream to healthy/intact skin as maceration will occur
38
(C) Antiseptics: thought to harm healthy tissues. They should not be used for routine woundcleansing.
Traditional antiseptic cleansers include cetrimide, chlorhexidine, potassium permanganate,povidone-iodine, proflavine, antiseptic creams are also available e.g. sudocrem®.
Product Benefit ProblemsCetrimide useful in A&E as its
emulsifying and detergentproperties help lift dirt andgrit out of wounds
• toxic to fibroblasts even at lowconcentrations
• causes skin irritation• pseudomonas may thrive in stored
solutionsChlorhexidine solution is said to be
effective against a widerange of Gram positive andnegative organisms, someviruses and fungi but notspores.
• alcoholic solution will causepermanent damage to new tissue
• sensitivity may occur• must not come into contact with
mucous membranes and meninges• efficacy of chlorhexidine
impregnated dressing has beenquestioned
• acquired resistance with Proteusmirabilis and PS aeruginosa hasbeen reported
PotassiumPermanganate
used as an astringent inconcentrations of 1 in8,000 to 1 in 10,000 tocleanse and deodoriseeczematous type reactions
• irritant to mucous membranes• stains the skin and clothing brown• may be detrimental to wound
healing• lack of evidence on clinical
effectivenessPovidone – Iodine
Solutions:
Betadine®, Videne®
Dressings:
Inadine
• low toxicity
• active against gram
positive and gram
negative organisms
• active against spores
and fungi
• alcoholic solutions must not be usedon broken skin
• sensitivity to iodine based products• not recommended for prophylaxis or
routine use in chronic wounds• antibacterial effect is reduced by
contact with pus and exudate• not recommended for pregnant or
lactating mothers because of risk ofelevated serum iodine levels
• no more than 4 Inadine® dressingsshould be applied at any one timedue to absorption of iodine
39
Product Benefit ProblemsProflavine mildly bacteriostatic
against gram positivebacteria but lesseffective against gramnegative bacteria
• hypersensitivity reactions reportedoccasionally
• a water in oil emulsion of proflavinecream has little or no antibacterialactivity
• studies show that calcium alginatedressings are superior to proflavine inthe treatment of acute surgicalwounds and abcesses in terms ofdressing comfort and bacterialclearance.
Antiseptic Creamse.g. Sudocrem®
• some ingredients are irritant to theskin and mucous membranes
• hypersensitivity reactions haveoccurred
• not recommended as less complexproducts are available.
40
Appendix 3 - Guideline Development Sub-Group
Mrs Jeanette Collins Sister, Dermatology Unit,Craigavon Area Hospital Group Trust
Mrs Dawn Connolly Research Project NurseCraigavon Area Hospital Group Trust
Mrs Jeannie Donnelly[Chairman]
Tissue Viability Nurse,Royal Hospitals
Mrs Kay Kane Nurse Manager,South & East Belfast Community Trust
Mrs Elizabeth Moore Senior Dietitian,Royal Hospitals
Dr Jane Whiteman Senior Pharmacist,Greenpark Health Care Trust
Miss Ruth Woodmartin Chief Dietitian,Greenpark Health Care Trust
41
Appendix 4 - CREST WOUND MANAGEMENT GROUP
Mrs Mary Waddell[Chairman]
Director of NursingEastern Health & Social Services Board
Dr John Andrews Consultant PhysicianUnited Hospitals Trust
Mrs Lilian Bradley Leg Ulcer AdvisorUlster Community & Hospitals Trust
Miss Jackie Campbell Senior PodiatristNewry & Mourne Trust
Dr Vanessa Chambers PharmacistDHSS
Mrs Janette Collins Dermatology Ward SisterCraigavon Area Hospital Group Trust
Mrs Dawn Connolly Research Project NurseCraigavon Area Hospital Group Trust
Miss Jill Cundell Chief PodiatristHomefirst Community Trust
Mrs Jeannie Donnelly Tissue Viability NurseRoyal Hospitals
Dr Brid Farrell Consultant in Public HealthSouthern Health & Social Services Board
Dr Colin Fitzpatrick Medical AdvisorEastern Health & Social Services Board
Dr PJ Fox General PractitionerBallymena Health Centre
Mr Paul Gawley Orthotist, Bullen Health CareMusgrave Park Hospital
Mrs Dianne Gill Pharmacy Services ManagerUnited Hospitals Trust
Mr Stephen Guy PharmacistRoyal Hospitals
Professor Randal Hayes Consultant PhysicianBelfast City Hospital Trust
Mrs Marilyn Higgin Specialist Health VisitorBelfast City Hospital Trust/South & East Belfast Community Trust
Dr Carmel Hughes Lecturer, School of PharmacyQueens University, Belfast
Dr Hilary Jenkinson Consultant DermatologistUnited Hospitals Trust
Mrs Kay Kane Nurse Manager, Community NursingSouth & East Belfast Community Trust
42
Dr James Kelly Consultant PhysicianSperrin Lakeland Trust
Mr Bernard Lee Consultant Vascular SurgeonBelfast City Hospital Trust
Dr Jill Mairs Regional Procurement PharmacistEastern Health & Social Services Board
Dr Carolyn Mason Assistant Director of NursingEastern Health & Social Services Board
Dr Barry Mitchell General PractitionerLodge Health, Coleraine
Ms Andrée McCollum Director of Pharmaceutical ServicesEastern Health & Social Services Board
Miss Alyson Moore Chief DietitianRoyal Hospitals
Mrs Elizabeth Moore Senior DietitianRoyal Hospitals
Dr Kenneth Moles Consultant PhysicianAltnagelvin Hospital Trust
Mrs Bronagh Monaghan Chief PodiatristBelfast City Hospital Trust
Mrs Mary O’Hare Research PharmacistRoyal Hospitals
Mrs Heather Reid Project ManagerEastern Health & Social Services Board
Dr Keith Steele General PractitionerDunluce Health Centre, Belfast
Ms Kathryn Turner Pharmaceutical AdvisorEastern Health & Social Services Board
Dr Jane Whiteman Senior PharmacistGreenpark Health Care Trust
Mrs Anne Witherow Tissue Viability NurseAltnagelvin Hospital Trust
Miss Ruth Woodmartin Chief DietitianGreenpark Health Care Trust
CREST REPRESENTATIONDr Philip McClements
Deputy Chief Medical Officer, DHSSConvenor of CREST
CREST SECRETARIATMiss Angela LowryMrs Isobel ScottMr Gary Hannan
43
Glossary of TermsAbscess a collection of pus which has localised and is confined within tissues or an organ.
Aerobes organisms which need oxygen to survive.
Anaerobes organisms which do not need oxygen to survive.
Angiogenesis the process by which new blood vessels are formed.
Autolysis the natural breakdown of devitalised tissue.
Cellulitis a spreading non-suppurative infection of soft tissue.
Colonisation the presence and multiplication of micro-organisms at a particular site withoutdetrimental effect.
Contamination the presence of micro-organisms (no multiplication).
Contraction the drawing together of a wound edge when a wound is healing by secondaryintention.
Cytotoxic deadly to cells.
Debridement the removal of devitalised tissue and foreign matter from a wound.
Dehiscence the breakdown of a surgically closed wound.
Exudate a fluid produced in wounds, made up of serum, leucocytes and wound debris.
Fibroblast an immature collagen producing cell.
Gangrene the death of tissue because of anoxia.
Haemostasis arrest of haemorrhage.
Infection damage to body tissues by micro-organisms or by poisonous substances releasedby the organism.
Lysis the action of breaking down.
Maceration a softening or sogginess of the tissue surrounding a wound edge.
Necrosis the death of previously viable tissue.
Pus a fluid produced in infections, made up of exudate, bacteria and phagocytes whichhave completed their work.
Synthesis building up.
44
Useful Addresses
European Tissue Repair SocietySecretariat: G Gabbiani, Department of Pathology, University of Geneva,1 Rue Michel Servet, 1211 Geneva 4, Switzerland. Tel: 41 22 229 377
European Wound Management AssociationPO Box 864, London SE1 8TTTel: 0171 872 3496
The Leg Ulcer ForumCentre for Research and Implementation of Clinical PracticeWolfson Institute of Health SciencesThames Valley University32-38 Uxbridge Road, London W5 2BSTel: 01753 534585
The Tissue Viability SocietyGlanville Centre, Salisbury District Hospital, Salisbury Wilts SP2 8BJTel: 01722 336262 Ext. 4057
The Venous ForumRoyal Society of Medicine, 1 Wimpole Street, London W1M 8AETel: 0171 290 2900
The Wound Care SocietyPO Box 170, Huntingdon PE18 7PLTel: 01480 434401
The Wound Management Association of Ireland11 Beech Park AvenueCastleknockDublin 15
UK Wound Care Journals
Journal of Tissue Viability (Tissue Viability Society) – subscription
Journal of Wound Care (Macmillan Magazines) – subscription
Nursing Journal of the Tissue Viability Society - supplement in Nursing Standard
Wound Care, in Association with the Wound Care Society - supplement in Nursing Times
