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8/12/2019 Wound.care.a.handbook.for.Community.nurses.ebook EEn
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Wound Care:A Handbook for
Community Nurses
JOY RAINEY
WHURR PUBLISHERS
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Wound
CareA Handbook
for
CommunityNurses
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Wound
CareA Handbook
forCommunityNurses
J! R AINE! "S#$ BS#$ %PSN$ R&N$
%NTissue Viability Nurse, Wolverhampton Health
Car e
SERIES EDITOR
"ARIL!N E%WAR%S$ BS#'Hons($ SRN$)E*C
Specialist ractitioner, !eneral ractice Nursin", #ilbroo$
%e&ical
Centre, Sta' ' or&shir e
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WW H ( R R ( # ) I S H E R S
) O N D O N * N D H I ) * D E ) H I *
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+ -- Whurr ublishers )t&
.irst publishe& --
by Whurr ublishers )t&
/0b Compton Terrace
)on&on N/ (N En"lan& an&12 Chestnut Street, hila&elphia * /0/-3 (S*
*ll ri"hts reserve&4 No part o' this publication may be
repro&uce&, store& in a retrieval system, or transmitte& in
any 'orm or by any means, electronic, mechanical,
photocopyin", recor&in" or other5ise, 5ithout the prior
permission o' Whurr ublishers )imite&4
This publication is sol& sub6ect to the con&itions that it
shall not, by 5ay o' tra&e or other5ise, be lent, resol&,
hire& out, or other5ise circulate& 5ithout the publisher7s
prior consent in any 'orm o' bin&in" or cover other than
that in 5hich it is publishe& an& 5ithout a similar
con&ition inclu&in" this con&ition bein" impose& upon
any subse8uent purchaser4
Britis+ Library Cata,o-uin- in Pub,i#ation %ata
* catalo"ue recor& 'or this boo$
is available 'rom the #ritish )ibrary4
IS#N / 93/23 90 3
rinte& an& boun& in the (: by *thenaeum ress )t&,
!ateshea&, Tyne ; Wear4
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vi Woun& Care< * Han&boo$ 'or Community Nurses
C+a0ter : 91
ressure sores
C+a0ter 15 :6
Woun& in'ection
C+a0ter 11 156
%iscellaneous
C+a0ter 12 111
Clinical e''ectiveness, Sarah F r eeman
!lossar y 12:
R esour ces 133
R e'er ences 137
In&e= 143
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Series
This series o' han&boo$s has been &evise& to help community
nurses ans5er commonly as$e& 8uestions4 %any o' the 8uestions
are as$e& by patients, others by collea"ues4 The boo$s have been
5ritten by specialists, an& althou"h they are not inten&e& as 'ull
clinical te=ts, they are 'ully re'erence& 'rom current evi&ence
to vali&ate the content4 The purpose o' each han&boo$ is to
provi&e >'acts at the 'in"ertips7, so that tra5lin" throu"h
te=tboo$s is not nee&e&4 This is achieve& throu"h the 8uestionan& ans5er 'ormat, 5ith cr oss? re'erencin" bet5een sections4
Where 'urther in'ormation may be re8uire&, the rea&er is re'erre&
to speci'ic te=ts4 %any patients 5ant some control over their
illnesses, an& use the internet to access in' or? mation4 The use'ul
a&&ress sections inclu&e 5ebsite a&&resses to share 5ith both
patients an& collea"ues4
It is hope& that these han&y re'erence boo$s 5ill ans5er
most every&ay 8uestions4 I' there are areas 5hich you 'eel have been ne"lecte&, please let us $no5 'or 'uture e&itions4
"andy Ed;ards
vii
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Prefa#
The &ay?to?&ay responsibility 'or 5oun& mana"ement is usuallyun&erta$en by nurses4 It inclu&es assessin" the 5oun&, selectin"
an appropriate treatment an& evaluatin" the patient7s pro"ress4
To &o this e''ectively the nurse nee&s to un&erstan& the healin"
process, reco"nise 'actors that may &elay 5oun& healin",
un&erstan& ho5 5oun& healin" can be optimise&, $no5 ho5 to
reco"nise complica? tions i' they arise an& $no5 ho5 to treat them4
Only 5ith a thor ou"h un&erstan&in" o' these areas 5ill it be
possible to ma$e a &etaile& assessment o' the patient an& the5oun&, an& ma$e a clinical &eci? sion on treatment that 5ill be
clinically e' 'ective4
%uch o' the success o' 5oun& care is built up 'rom
$no5le&"e an& e=perience, but ine=perience o' complications
can leave the nurse unsure 5hat to e=pect4 This can be &i''icult to
cope 5ith, espe? cially i' the nurse 5or$s in an area 5here she has
little peer support4
In recent years there have been numerous &evelopments in5oun& mana"ement, an& research has provi&e& a better un&er?
stan&in" o' the healin" process an& ho5 this can be optimise&4
%any ne5 &ressin"s have been &evelope& an&, althou"h this
shoul& enhance 5oun& mana"ement, the ran"e available may
ma$e &r ess? in" selection a &auntin" tas$4 %any 'actors a''ect
&ressin" choice, inclu&in" research articles, past e=perience,
a&vice 'rom collea"ues an& manu'acturers7 mar$etin" strate"ies4
The pro&uct chosen nee&s to be both e''icacious an& cost?e' 'ective4This boo$ is 5ritten 'or community nurses, inclu&in"
practice nurses 5ho o'ten 5or$ as the only nurse in a practice,
5hich ma$es e=chan"e o' i&eas an& $no5le&"e &i''icult4 Some
practice nurses see many 5oun&s 5hereas others see 5oun&s only
rarely, so it is more &i''icult to buil& up a $no5le&"e base on
5hich to ma$e clinical
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= Woun& Care< * Han&boo$ 'or Community Nurses
i=
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Prefa#&ecisions4 Nursin" home nurses can also become isolate& an&
may have &i''iculty "ettin" release 'or stu&y &ays4
The boo$ aims to provi&e a picture o' 5oun& healin" an&
r elate& 'actors 'or both acute an& chronic 5oun&s that may beencounter e& in a community practice situation4 *n overvie5 o' the
'unction o' the s$in an& phases o' 5oun& healin" is "iven be'ore
loo$in" at the rela? tionship bet5een 5oun& healin" an& the
patient7s health an& li'estyle4 Woun& assessment is an essential
component 'or 5oun& mana"ement4 This is &iscusse& in &etail
in Chapter 4 There ar e many &ressin" types available to
community nurses, an& Chapter 2 "ui&es the rea&er throu"h the
uses o' commonly use& pr o&ucts4The 8uestion an& ans5er 'ormat inclu&es many o' the
8uestions 're8uently as$e& by nurses4 Case stu&ies are also use& to
"ive e=am? ples o' both "oo& an& ba& practice4
.inally, I 5oul& li$e to e=press my sincere "ratitu&e to
Sarah .reeman, #*@HonsA, Clinical !overnance Coor&inator,
Wolver? hampton rimary Care !roups, 'or her contribution o'
Chapter /4
Joy Rainey
September 200
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/- Woun& Care< * Han&boo$ 'or Community Nurses
CHAP*ER 1
Wound+ea,in-
This chapter is a basic e=amination o' the 'unctions o' the s$in,
ho5 5oun&s can be cate"orise&, the sta"es an& mechanisms o'
5oun& healin", an& ho5 a moist environment enhances 5oun&
healin"4 To un&erstan& these processes in "reater &epth, it 5oul&
be necessary to consult a &etaile& anatomy an& physiolo"y te=t4
B/4/ What 'unctions &oes the s$in have
The s$in is the lar"est or"an o' the bo&y4 It coversappr o=imately
m an& 5ei"hs aroun& 1 $"4 The s$in has many 'unctions,
5hich inclu&e the 'ollo5in"<
D %aintenance o' bo&y temperatur e
D rotection 'rom bacteria, &ehy&ration, ultraviolet ra&iation
an& physical abrasion
D resence o' nerve en&in"s that 5arn o' unpleasant stimuli such
as pain an& e=treme heat
D Helpin" the bo&y "ain vitamin D 'rom
sunli"ht4
B/4 What problems occur 5hen the s$in is bro$en
Once the s$in is bro$en the protective 'unctions o' the s$in are
lost4 The "reater the s$in loss the more serious these problems 5ill
be4
#acteria an& other micro?or"anisms can "ain entry into &eeper
tissues an& cause in'ection @see B/-4/ an& B/-4A4 .lui& is lost
'rom the bo&y an& i' the area o' s$in lost is lar"e enou"h @as in a
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ma6or burnA this can be li'e thr eatenin"4
/
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/- Woun& Care< * Han&boo$ 'or Community Nurses
B/41 Ho5 is the s$in ma&e up
The s$in is ma&e up 'rom t5o layers< the outer epi&ermis an& the
&ermis4 The &ermis contains hair 'ollicles, sebaceous "lan&s an&s5eat "lan&s4 #eneath the &ermis is subcutaneous 'atty
tissue containin" nerves, bloo& vessels an& lymphatics @.i"ure
/4/A4
@aA
@bA
Epi&ermis
Dermis
Subcutaneous
tissue
)i-ure 1<1 The s$in4
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Woun& healin" 1
B/4 Can I tell by loo$in" at a 5oun& 5hat layers are &ama"e&
Super'icial 5oun&s &ama"e only the epi&ermis @.i"ure /4A4 I'
the &ermis is intact, normal s$in mar$in"s 5ill be present4artial? thic$ness 5oun&s &ama"e the &ermis an& 5ill loo$ pale
pin$ @.i"ur e
/41A4 .ull?thic$ness 5oun&s reach the subcutaneous 'atty tissue or
"o &eeper to muscle an& bone @.i"ure /4A4 These 5oun&s may
r eveal islan&s o' yello5 'at an& may e=pose muscle, ten&on or
bone4
B/42 What is the &e'inition o' a 5oun&
* 5oun& is an abnormal brea$ in the s$in, as the result o' cell
&eath or &ama"e4
)i-ure 1<2 * super'icial 5oun&4
)i-ure 1<3 * partial?thic$ness 5oun&4
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Woun& Care< * Han&boo$ 'or Community Nurses
)i-ure 1<4 * 'ull?thic$ness 5oun&4
B/43 Ho5 are 5oun&s &escribe& or cate"orise&
Woun&s are o'ten put into &i''erent cate"ories or classi'ications4
This enables pro'essionals to share in'ormation an& e=periences
$no5in" that they are tal$in" about similar 5oun&s4 Woun&s can be
classi'ie& in several 5ays but each 5oun& is uni8ue an& &eserves
in&ivi&ual car e4
Primary or se#ondary
intention
* common 5ay o' classi'yin" 5oun&s is by &i''erentiatin"
bet5een those that heal by primary or secon&ary intention @see
B/4FA4
Those healin" by primary intention are those 5ith s$in e&"es
that have been brou"ht to"ether, usually by sutures, clips,a&hesive strips or sur"ical a&hesive4 These may be traumatic
lacerations or sur "ical 5oun&s4
Secon&ary intention &escribes 5oun& healin" 5hen the s$in
e&"es are not brou"ht to"ether, an& have to heal by contractin"
an& 'illin" up 5ith "ranulation tissue4 These 5oun&s inclu&e le"
ulcer s, pressure &ama"e, an& lacerations 5ith substantial tissue
loss or &irty sur"ical or traumatic in6uries, 5hich may become
in'ecte& i' the s$in e&"es are oppose& an& secure&4
*y0es of
tissue
Woun&s can also be cate"orise& by the type o' tissue 5ithin the
5oun&<
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Woun& healin" 2D The 5oun& contains blac$ necrotic tissue @see
B4/-A
D The 5oun& is yello5 an& slou"hy @see
B4//A
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3 Woun& Care< * Han&boo$ 'or Community Nurses
D The 5oun& is re& an& "ranulatin" @see B4/A
D The 5oun& is startin" to &isplay si"ns o' the 'ormation o'
ne5 pin$ epithelial tissue @see B4/1A
D The 5oun& is "reen an& in'ecte& @see B4/A4
%e0t+ of
;ound
Woun&s can also be classi'ie& by &epth4 This is a common 5ay
o' &escribin" pressure sores an& several scales e=ist4 *n e=ample
o' this is the (: consensus classi'ication o' pressure sore severity
@Stir lin" scaleG Rei& an& %orison /00A @Table /4/A4
*lthou"h it is not usual to see pressure sores in the "eneral practi? tioner7s sur"ery, this type o' classi'ication can be use& or
a&apte& to &escribe other 5oun&s4 *lso, althou"h these are the
most common 5ays o' cate"orisin" 5oun&s, other metho&s can be
use&, such as by the cause or by the sta"e o' the healin" process that
the 5oun& has r eache&4
*ab,e 1<1 The (: consensus classi'ication o' pressure sores
Sta"e / Discoloration o' intact s$in @li"ht 'in"er pressure applie& to the intact
s$in &oes not alter the &iscolorationA
Sta"e artial?thic$ness s$in loss or &ama"e involvin" epi&ermis an&or &ermis
Sta"e 1 .ull?thic$ness s$in loss involvin" &ama"e or necrosis o' subcutaneous
tissue but not e=ten&in" to un&erlyin" bone, ten&on or 6oint capsule
Sta"e .ull?thic$ness s$in loss 5ith e=tensive &estruction an& tissue
necrosis e=ten&in" to un&erlyin" bone, ten&on or 6oint capsules
B/4F What &o the terms >primary7 an& >secon&ary intention7 mean
*s previously mentione&, 5oun&s can be &escribe& as healin" by
primary or secon&ary intention @see B/43A4 Healin" by
primar y intention shoul& be achieve& 'or all incise& sur"ical
5oun&s an& primary close& lacerations4 Woun& healin" shoul& be
rapi& because there is no tissue loss an& the s$in e&"es are hel&to"ether @see B/43A4
In 5oun&s healin" by secon&ary intention, the 5oun& e&"es ar e
apart an& the &e'ect 5ill nee& to 'ill 5ith "ranulation tissue
be'ore ne5 epi&ermis can cover the 5oun&4 These inclu&e le"
ulcers, open incisions @e4"4 a'ter &rainin" abscesses 5hen closure
may encoura"e in'ectionA an& 'ull?thic$ness bur ns4
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Woun& healin" F
Occasionally, 5oun&s may be &escribe& as healin" by
tertiar y intention4 This is &esirable i' the 5oun&, such as a
laceration, has been contaminate&, e4"4 &irt 'ollo5in" an
acci&ent4 The 5oun& is initially cleane& an& le't open4 I' thereappears to be little ris$ o' in'ection it is then close& in the normal
5ay @Dealey /00A4
B/49 What are the phases o' 5oun& healin"
Woun& healin" is usually &escribe& in 'our physiolo"ical phases<
the in'lammatory, &estructive, proli'erative an& maturation
sta"es @ro'essional Development /00A4 In reality it is acontinuous process 5ith the sta"es mer"in" an& over lappin"4
The inflammatory stage! 0"# $ays %Fig&r e'()
When tissue is in6ure& or &isrupte& the bo&y7s imme&iate response
is to re?establish haemostasis4 Dama"e& cells an& bloo& vessels
release histamine, causin" vaso&ilatation o' the surroun&in"
capillaries, ta$in" serous e=u&ate an& 5hite cells to the area o'&ama"e4
It is this increase& bloo& 'lo5 an& serous e=u&ate that cause
local oe&ema, re&ness an& heat, "ivin" rise to an in'lame&
appearance4
#loo& clot
Re& bloo& cells
olymorphs
Vaso&ilate&
bloo&
vessels
%acropha"es
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9 Woun& Care< * Han&boo$ 'or Community Nurses
)i-ure 1<6 The in'lammatory sta"e< -1 &ays4
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The coa"ulation system an& platelets cause the bloo& to clot,
5hich prevents 'urther blee&in" or loss o' bo&y 'lui&s4 In6ure&
vessels thrombose an& re& cells become entan"le& in a 'ibrin
mesh, 5hich be"ins to &ry an& becomes a scab4 The scab is the bo&y7s natural &e'ence to $eep out micro?or"anisms4 ha"ocytic
5hite cells @poly? morphs an& macropha"esA are attracte& to
the area to &e'en& a"ainst bacteria, in"est &ebris an& be"in the
process o' repair4 In a clean acute 5oun& this sta"e lasts up to 1
&ays4 I' the 5oun& is in'ecte& or necrotic tissue is present this
sta"e is pr olon"e&4
*estr &+ti,e phase! "- $ays %Fig&r e'-)
White cells line the 5alls o' bloo& vessels an& mi"rate throu"h
the 5alls, 5hich become more porous, into surroun&in" tissue4
Here pha"ocytic cells brea$ &o5n &evitalise& necrotic tissue,
an& the macropha"es en"ul' an& in"est bacteria an& &ea& tissue4 In
a&&ition, the macropha"es stimulate the &evelopment o' ne5 bloo&
vessels an& the 'ormation an& multiplication o' 'ibroblasts, 5hich
in turn ar e responsible 'or the synthesis o' colla"en an& other
connective tissues4 This sta"e normally lasts 'rom / to 3 &ays, but
5hite cell activity can be compromise& in &ry e=pose& 5oun&s
@%orison /00/A4
)ocalise& oe&ema
Ne5 bloo&
capillaries "ro5in"
into 5oun& mar"in
.ibroblasts
)i-ure 1<7 The &estructive sta"e< /3 &ays4
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.r olif er ati,e phase! #"2/ $ays %Fig&r e')
The 'ibroblasts continue to multiply, 'ormin" colla"en 'ibrils,
5hich ma$e a 'ibrous net5or$4 This traps re& bloo& cells, 5hich
"o on to become ne5 capillary loops4 *t this sta"e the tissue is
very &elicate, havin" none o' the or"anisation o' normal tissue4
This "ranulation tissue is so calle& because o' its re& "ranular
appearance4 *s the colla"en matures, there is a rapi& increase in
the tensile str en"th4 Si"ns o' in'lammation subsi&e an& the process
o' contraction be"ins4 In an open 5oun&, this sta"e may be
prolon"e& because more colla? "en is nee&e& to repair the tissue
&e'ect4
Epithelial
cells bri&"e
5oun&
Colla"en 'ibres
!ranulation tissueWoun& contraction be"ins
)i-ure 1<8 The proli'erative sta"e< 1 &ays4
1at&ration phase! 2/ $ays to year %Fig&r e')
When the 5oun& has 'ille& 5ith "ranulation tissue, colla"en
'ibres pull in the 5oun&, causin" it to contract an& become
smaller4 This spee&s up the healin" process as less colla"en 5ill
be necessary to repair the &e'ect4 *s the 5oun& space &ecreases,
vascularity also &ecreases, 'ibroblasts shrin$ an& the colla"en
'ibres chan"e the re& "ranulation tissue to 5hite avascular tissueas epithelium mi"rates in5ar&s4 Epithelial cells 5ill mi"rate
'rom the 5oun& e&"e, s5eat "lan&s an& the remnants o' hair
'ollicles4 They mi"rate over the "ranulation tissue until they meet
5ith li$e cells 'rom another area o' the 5oun&, sometimes
'ormin" islan&s in the 5oun& centre4 This process is slo5e& &o5n
i' the 5oun& is &ry an& has a scab or eschar over it @see B4/-A4
In this case they have to burro5 un&er the &r y scab @see B/40A4
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%i"ratin" cells lose their ability to &ivi&e an& so
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Scab &etaches Epithelium no5
complete
*vascular scar
tissue replaces
"ranulation
Vascularity &ecreases
)i-ure 1<9 The maturation sta"e< &ays to / year4
epithelialisation &epen&s on the ability o' li$e cells to $eep
meetin"4 When the sur'ace o' the 5oun& is covere& 5ithepithelial cells, the epithelium thins4 Hair 'ollicles are not
replace&4 Woun& maturation usually ta$es bet5een &ays an& /
year 4
B/40 What is meant by moist 5oun& healin"
Tra&itionally, 5oun& care encoura"e& nurses to allo5 5oun&s to
&r y out an& 'orm a scab4 This 5as thou"ht to provi&e amechanical barrier to in'ection an& be the most appropriate
treatment4 E=ten? sive research has sho5n that this is not the case
@althou"h some clini? cians an& many patients still clin" to
tra&itional metho&sA4
Wor$ on moist 5oun& healin" starte& in the early /03-s4
The most 8uote& research in relation to this is Winter @/03A
5ho con&ucte& a clinical trial usin" super'icial 5oun&s on pi"s4
Hal' o' these 5oun&s 5ere allo5e& to &ry out an& 'orm scabs,5hereas the other hal' 5ere covere& 5ith polythene, thus creatin"
a moist envi? ronment4 The results sho5e& that those covere&
5ith polythene epithelialise& nearly t5ice as 'ast as those 5oun&s
allo5e& to &ry out4 *'ter e=aminin" the histolo"y, Winter
conclu&e& that, in the &r y 5oun&s, epithelial cells 5ere
han&icappe& 5hen mi"ratin" acr oss the 5oun& sur'ace by the
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colla"en 'ibres 6oinin" the scab to the
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sur'ace o' the 5oun&4 Epithelial cells in the moist 5oun&s coul&
mi"rate more 8uic$ly throu"h the 5oun& e=u&ate an& &i& not
nee& to traverse a scabbe& area @see B4/1A4
Dyson et al4 @/099A have sho5n that a moist 5oun&moves throu"h the in'lammatory sta"e o' healin" 'aster than a
&ry 5oun& an& pro&uces "reater capillary "r o5th4
Initially it 5as thou"ht that the moist environment may
encour? a"e "reater bacterial "ro5th an& lea& to a hi"her number
o' 5oun& in'ections4 This vie5 has been &isprove&4 Stu&ies by
Hutchinson an& )a5rence @/00/A sho5e& that the reverse 5as
true an& occlu&e& 5oun&s sho5e& a lo5er rate o' in'ection4
Since the late /0F-s, manu'acturin" companies have beencreat? in" &ressin"s that "ive a moist environment to spee& 5oun&
healin"4 Some clinicians 5ho clin" to tra&itional pro&ucts, such as
"auJe, use the hi"her cost o' mo&ern pro&ucts to support
their choice4 Ho5ever, mo&ern pro&ucts encoura"e 5oun&s to
heal 'aster an& "et in'ecte& less o'ten4 The unit cost becomes less
relevant 5hen vie5e& in relation to patient &iscom'ort @see B4FA,
nursin" time an& "r eater use o' other materials, such as sterile
"loves, aprons, &ressin" pac$s an& antibiotics4
Summar
y
The s$in is a lar"e or"an 5ith many 'unctions4 Woun&s can be
cate? "orise& in several 5ays, 5hich enables stan&ar&isation o'
classi'ica? tion throu"hout the nursin" pro'ession4
Woun&s can heal by primary, secon&ary or tertiaryintention, 5ith 5oun& healin" occurrin" in several phases4 In
reality this is a continuous process 5ith sta"es overlappin"4 It has
been 5ell estab? lishe& that 5oun&s "ranulate better 5hen $ept
moist4
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/ Woun& Care< * Han&boo$ 'or Community Nursess5i'ter r eso? lution o' car e4
//
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Thorou"h assessment o' the 5oun& 5ill ta$e time, but i' it lea&s
to the correct treatment bein" chosen an& 5oun& healin" optimise&
it is time 5ell spent4 In the lon"er term, the patient re8uires 'e5er
episo&es o' care4 *ssessment &etails can be 5ritten in the patientnotes or on a purpose?ma&e chart4 *n e=ample is sho5n in .i"ure
4/4
atient name< *nn Kones osition o' 5oun&< )e't shin
Type o' 5oun&< )aceration Duration o' 5oun&< 5ee$s
Date /H3H--
Si3e of 4o&n$!%a=imum 5i&th 1 cm
%a=imum len"th / cm
Type of tiss&e 4ithin 4o&n$ <
e4"4 slou"h, necrosis, "ranulation !ranulation
E5&$ate!
*mount, colour %inimal
O$o&r!
None, some, o''ensive None
.ain
Where, 5hen, severity Occasionally i' touche&
S&rro&n$ing skin!
Erythema, 5et&ry, ecJema Healthy
Infe+tion!
Suspecte&, s5ab ta$en, result Not clinically in&icate&
Treatment s&mmary!
Cleansin" lotion, i' use& None
Topical treatment to 5oun& an&
surroun&in" s$in None
rimary &ressin" Duo&erm
Secon&ary &ressin" None
.i=e& by N*
*ssesse& by %E
)i-ure 2<1 *n e=ample o' a 5oun& assessment chart4
B4 The nurse only has about /- minutes to see each patient4 Woul&n7t a
brie' note be su''icient
Recor&s must be $ept in or&er to ai& clinical &ecision?ma$in"
@Williams /00FA @see B4/A4 The (:CC ro'essional Co&e o'
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Woun& assessment /1
Con&uct @(:CC /00A states that one o' the purposes o' recor&s
maintaine& by the re"istere& nurse is to >provi&e a base line r ecor &
a"ainst 5hich improvement or &eterioration can be 6u&"e&74
The importance o' clear concise recor&s an& the 'ailure to maintainthem can be seen as a ne"li"ent act an& a breach o' a nurse7s &uty
to car e @%oo&y /001A4
To illustrate this point consi&er the 'ollo5in" scenario4
S+enario for +ase st&$y
Nurse S ha& seen .re& on his 'irst visit to the sur"ery 5ith a le"
ulcer 4 She per'orme& a 'ull assessment, inclu&in" Dopplerrecor&in"s, an& &ia"nose& the ulcer to be the result o' arterial
insu''iciency4 .r e& &ran$ about 'our times the recommen&e&
alcohol limit each 5ee$ an& a&mitte& to smo$in" about -
ci"arettes a &ay4 He also ha& poorly controlle& type / &iabetes
an& a history o' heart problems4
Nurse S clearly remembere& her &iscussion 5ith .re& an&
stron"ly su""este& that he re&uce his alcohol an& ci"arette
consump? tion an& mo&i'y his &iet4 She also verballyrecommen&e& to the ! that a vascular opinion 5as re8uire&4
Ho5ever, a'ter per'ormin" the assessment, she 5as runnin" late
an& the entry in her recor&s reporte& >Doppler sho5s arterial,
a&vice "iven74
Over the ne=t 'e5 5ee$s, the ulcer continue& to &eteriorate an&
.re&7s approach to li'e remaine& the same4 Nurse S remembere&
tal$in" to .re& repeate&ly about his li'estyle an& &iabetes4 Her
recor&s state& >)oo$s lar"er7, >Re&resse&7, >)ar"er, a&vice "iven74
.re& receive& his appointment 'or a vascular assessment but
5ee$s be'ore this he &evelope& a severe in'ection in his le"4 This
re8uire& imme&iate a&mission an& resulte& in belo5?$nee amputa?
tion4
His 'amily complaine& to the health authority about .re&7s
car e an& sai& the amputation 5as the result o' the care he receive&
by the practice nurse4 They state& that .re& 5as una5are that his
alcohol consumption, smo$in" an& &iabetes coul& result inamputation4
.rom her recor&s coul& you &e'en& her practice
B41 What shoul& be inclu&e& in a 5oun& assessment
It is important that the cause o' the 5oun& is i&enti'ie& an&
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/ Woun& Care< * Han&boo$ 'or Community Nursesrecor&e&4 ersonal observation su""ests that acute 5oun&s such
as
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Woun& assessment /2
lacerations, bites an& postoperative 5oun&s are usually clearly
i&en? ti'ie&, but chronic 5oun&s such as le" ulcers are
"eneralise&4 It is important that the e=act un&erlyin" cause is
i&enti'ie&4 Is it a venous ulcer @see B942 an& B943A Is it anarterial ulcer @see B94FB940A Di& the 5oun& start 'rom trauma
or a bite In this case there may be no un&erlyin" &isease4
The treatment 'or each 5oun& type is &i''erent an&, in the case
o' venous an& arterial ulcers the opposite, so 5ithout i&enti'ication
the chosen treatment may be incorrect4 )e" ulcers are &iscusse& in
more &etail in Chapter 94
. osition
The position o' the 5oun& shoul& be clearly &ocumente& an& may
be ai&e& by the use o' &ia"rams4
Si3e
The siJe o' the 5oun& shoul& be recor&e& @see
B4A4
6istor y
The history o' the 5oun& shoul& be ta$en4 *s$ the patient ho5
lon" it has been present, 5ho, up until no5, has been &ressin"
it an& 5hat treatments have been use&4 This 5ill "ive some
in&ica? tion o' any aller"ies or treatments that have previously
'aile&4 The 5oun& may be a recurrence o' a le" ulcer @particularly
venousA an& treatment o' previous episo&es o' ulceration may berelevant @see B941A4
Skin +on$ition
It is important to assess the surroun&in" s$in4 *ny re&ness or
erythema may in&icate in'ection4 I' the patient has 'ra"ile s$in,
perhaps cause& by me&ication such as lon"?term steroi& use, it
may be inappropriate to apply an a&hesive &ressin"4
)e" ulcers may be surroun&e& by varicose ecJema, 5hich mayre8uire an emollient, or by contact &ermatitis 'rom previous tr eat?
ments, 5hich may re8uire a short course o' a topical steroi&
cr eam @see B24-, B94/ an& B943A4
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/3 Woun& Care< * Han&boo$ 'or Community Nurses
Tiss&e
The state o' the tissue 5ithin the 5oun& shoul& be recor&e&4 This
5ill help to i&enti'y the "oal o' treatment an& in many 5ays
i&enti'y an appropriate treatment4 There may be more than one
type o' tissue 5ithin the 5oun& in 5hich case an estimate o' the
per centa"e o' each type shoul& be ma&e, e4"4 1-L slou"h, F-L
"ranulation @see B4// an& B4/A4
.ai
n
The patient7s level o' pain shoul& be assesse& an& treate& 5ithappropriate anal"esia4 Other 'actors to consi&er ar e<
D Is the pain ischaemic @see B949 an& B940A
D Is the 5oun& in'ecte& @see B/-4/A
D Is the &ressin" causin" pain either by &ryin" out an& a&herin"
to the 5oun& sur'ace, or by causin" an aller"ic reaction @see
B943 an& B94FA
D Is the 5oun& pain'ul at &ressin" chan"e because the &ressin"
has &rie& out or is bein" remove& inappropriately @see B4FA
*ny 5oun& o&our shoul& also be recor&e&4 This may be a si"n
o' in'ection, or may be anaerobes in necrotic tissue @see B43A4
B4 Ho5 shoul& 5oun&s be measure&
It is important to recor& 5oun& siJe so that healin" pro"ress or
&ete? rioration can be observe&4 #oth the nurse an& patient can bemoti? vate& i' healin" can be observe&4 This also encoura"es the
patient7s compliance 5ith continuin" a treatment about 5hich
they are not enthusiastic, such as compression therapy @see B940A4
The simplest 5ay to recor& 5oun& siJe is to ta$e the ma=imum
&imensions 5ith a ruler @.i"ure 4A4 * more accurate 5ay is to
trace the 5oun&, usin" a purpose?ma&e chart @available 'rom
several companies that manu'acture &ressin"sA, acetate sheets or
the clear pac$a"in" in 5hich many &ressin"s come4 The tracin"can be either store& in the patient7s notes or use& as a template to
&ra5 ar oun& an& a&& to notes4 Consi&er 5hether or not the plastic
is sterile4 It is a&visable to hol& non?sterile materials sli"htly
above the 5oun&
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Woun& assessment /F
sur'ace or to cleanse the sur'ace touchin" the 5oun& both be'ore
an& a'ter5ar&s 5ith an *lco5ipe4
)i-ure 2<2 %easurin" a
5oun&4
hoto"raphs are the most accurate 5ay to recor& siJe an&
appearance o' lar"e 5oun&s @see B42A4 Woun& &epth can be more
&i''icult to measure, but use o' a sterile probe is probably the most
accurate metho&4 These are sometimes available 'rom
phar maceuti? cal companies4
B42 What sort o' issues must be consi&ere& 5hen purchasin" a camera
erhaps the most important issue is in'orme& patient consent4 I'
the materials are to be use& 'or teachin" or publication this
consent shoul& be 5ritten4 There are several other issues to
consi&er be'ore embar$in" on 5oun& photo"raphy4 #ellamy
@/002A su""ests the 'ollo5in"<
D Choice o' e8uipment
D Choice o' materials
D Choice o' pr ocessin"
D Control o' sub6ect
D Control o'
li"htin"
D Control o' bac$"r oun&4
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/9 Woun& Care< * Han&boo$ 'or Community Nurses
E8uipment in the main may be 5hat is a''or&able4 %any
people choose a olaroi&?type camera because they "et instant
results an& they &o not have to 5orry about 5here to "et material
processe& or 'inishin" a 5hole 'ilm4 Results, ho5ever, may not beas "oo& as 5ith a 12?mm sin"le?lens re'le= camera4
With the choice o' materials, because the colour o' a 5oun& is
an important in&icator o' con&ition, only colour 'ilm shoul& be
use& @#ellamy /002A4 I' the pictures are to be store& in patients7
notes, prints are a&e8uate, but i' photo"raphs are to be use& 'or
publication or teachin" purposes, sli&es may be more practical4
Thou"ht shoul& be "iven to processin"4 Hi"h?street
>8uic$ process7 shops may have photo"raphs rotatin" behin& thecounter 4 )ocal labs may even have someone 5or$in" there 5ho
reco"nises the patient4 The use o' a "eo"raphically &istant
pro'essional laborator y that can provi&e con'irmation o'
con'i&entiality is recommen&e& @#ellamy /0024A .ilms shoul& be
han& trans'erre& @e4"4 by courierA or i' necessary sent by re"istere&
post, but not by re"ular mail4 ut a ruler close to the 5oun& so
that the siJe can be rou"hly ascertaine&4 This 5ill ai& reassessment
an& sho5 pro"ress4 It is also use'ul to 5rite the &ate an& the patient7s initials on a piece o' a&hesive tape an& stic$ this close to
the 5oun&G this helps to i&enti'y the patient an& also to place
photo"raphs in chronolo"ical or &er 4
)i"htin" may be &i''icult to control in a sur"ery or 5ithin the
patient7s home an& most nurses are not e=pert photo"raphers4 *
'lash or a camera 5ith an automatic 'lash 5ill be necessary in
most cases4 The bac$"roun& to any clinical photo"raph shoul& be
plain an& unobtrusive rather than the clutter o' a &ressin" trolley,tr eat? ment room, $itchen or 'ront room4
Once ta$en an& &evelope&, photo"raphs 'orm part o' a
patient7s clinical recor&s an& shoul& be store& 5ith the same car e4
B43 What can be &one about 5oun& o&our
O&our can be very &istressin" 'or the patient an& o'ten occurs in
heavily in'ecte& or 'un"atin" 5oun&s @see B//4/A4 ersonale=peri? ence sho5s that this may be the only reason a patient has
sou"ht treatment4 Some &ressin"s such as hy&rocolloi&s may
cause o&our 5hen they interact 5ith 5oun& e=u&ate @see
B24/3A4 I' this is e=pecte& to happen, either at &ressin" chan"e or
i' the &ressin" lea$s,
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Woun& assessment /0
it is 5orth reassurin" the patient that the 5oun& has not become
in'ecte&4
Charcoal &ressin"s may be use& to absorb o&our @see B241A4
Oral or topical metroni&aJole may re&uce 5oun& o&our @*sh'or& etal4 /09G Ne5man et al4 /090A, or an aromatherapy oil o' the
patient7s choosin" may be applie& to the outer &ressin"4
B4F What points shoul& be consi&ere& in re"ar& to pain
ain is a sub6ective e=perience arisin" 5ithin the brain in response
to &ama"e to bo&y tissues @#on& /09A4 It is an issue that is o'ten
over? loo$e& in 5oun& care4 ain perception is uni8ue to eachin&ivi&ual an& sub6ective @%cCa''ery /091A4 ain is 5hat the
patient says it is4 Nurses7 interpretation o' a patient7s pain 5ill
a''ect the care that is "iven @Hos$ins an& Welche5 /092A4
Di''erin" 5oun&s 5ill result in &i''erent types o' pain4 S$in
&ama"e results in pain that is o'ten &escribe& as >cuttin"7 or
>burnin"74 This usually respon&s 5ell to non?steroi&al anti?
in'lammatory &ru"s @Em'lor"o /000A4 I' bloo& vessels are in6ure&,
pain may be &escribe& as>throbbin"7 in nature4 I' lon"?term ischaemia is a li$ely
outcome, opiate anal"esia may be re8uire&G i' this is unli$ely it
may be r e8uir e& initially an& then re&uce& @Em'lor"o /000A4
Dama"e to nerves results in itchin", tin"lin", smartin" or stin"in"4
This may respon& to anti? epileptic &ru"s @#on& /09G War'iel&
/00FA4 Stu&ies also sho5 that a moist 5oun& healin" environment,
5hich bathes nerve en&in"s in 'lui&, prevents their stimulation an&
thus re&uces &iscom'ort @Thomas/00-A @see B/40A4 Occlusive &ressin"s that pro&uce an anaerobic
envi? ronment also re&uce 5oun& pain @ Kohnson /099A4 I' a 5oun&
&ries out or the &ressin" causes &ryin" at the sur'ace, localise& pain
results4 This can happen i' polysacchari&e bea& &ressin"s or
al"inate &ressin"s ar e applie& to li"htly e=u&in" 5oun&s @Thomas
/00-A @see B240B24/-A4
ain on &ressin" removal can occur i' the &ressin" becomes
incor? porate& into the 5oun&4 Ne5ly 'orme& capillaries may"ro5 into &ressin"s 5ith mesh sur'aces @Dealey /00A, or i'
the &ressin" becomes saturate& 5ith e=u&ate an& then &ries an&
a&heres to the 5oun& sur'ace @Value 'or %oney (nit /00FA @see
B242A4 In these situ? ations 5oun& pain occurs an& &ama"e occurs
to tissue at each &r ess? in" chan"e4 Soa$in" the &ressin" o'' is
time?consumin" an& &oes not al5ays result in pain?'ree removal
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- Woun& Care< * Han&boo$ 'or Community Nurses@Thomas /00-A4
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Woun& assessment /
In'ection is associate& 5ith pain, so chec$ the 5oun& 'or the
si"ns o' in'ection @Cuttin" an& Har&in" /00A @see B/-4/A an&
treat 5ith systemic antibiotics i' in'ection is present4 ain also
occurs as a r esult o' poor ban&a"e techni8ue, 5hich causes ban&a"e slippa"e, or has insu''icient pa&&in" or incorrect
application @see B940A4
Venous le" ulcers are o'ten sai& to be not pain'ul unless
accompa? nie& by oe&ema or in'ectionG ho5ever, Ho'man et al4
@/00FA reporte& that 3L o' patients e=perience& pain4 *rterial le"
ulcers o'ten cause severe an& persistent pain, 5hich may re8uire
treatment 5ith opiates @see B940A4
ain 'rom pressure ulcers &epen&s on the &epth o' the 5oun&4Deep ulcers o'ten result in less severe pain than shallo5 ones
because the nerve en&in"s in the s$in have been &estroye&
@Em'lor"o /000A4 Ho5ever, i' the area is s5ollen or in'ecte&, pain
is li$ely4 *s 5ith pres? sure ulcers, small &eep burns o'ten result in
a lo5er level o' pain than more super'icial ones, but the site o' the
burn is si"ni'icant4 Those to the han&s, 'ace or "enitalia are more
pain'ul4
B49 Ho5 shoul& pain be assesse&
*ccurate pain assessment is the $ey to pain relie'4 Nurses o'ten
'ail to use even a simple assessment tool4 * visual analo"ue scale
is a practical tool 'or assessin" a patient7s pain at &ressin"
chan"es @Choiniere et al4 /00-A4 Type an& amount o' pain vary
bet5een in&ivi&ualsG stu&ies have sho5n that nurses o'ten 'ail
to believe patients7 reports o' pain @Sa=ey /093G Seers /09FA4 *ne=ample o' a pain assessment scale is sho5n in .i"ure 414
B40 Ho5 shoul& pain be mana"e&
*ppropriate anal"esia shoul& be o''ere& 'ollo5in" liaison 5ith
the
!, but other measures shoul& also be
ta$en4* &ressin" shoul& be chosen that 5ill not stic$ to the 5oun&
an& cause trauma, an& that is ri"ht 'or the e=u&ate level,
$eeps the 5oun& moist an& allo5s pain?'ree r emoval4
Cleansin" shoul& be by "entle irri"ation 5ith 5arm
physiolo"ical saline @see B4B4A i' it is necessary to remove
&ebris4
Woun&s shoul& not be rubbe& or scrubbe&G this 5ill not only
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Woun& Care< * Han&boo$ 'or Community Nursescause unnecessary pain but 5ill also &ama"e the 5oun& be&4
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Woun& assessment 1
)i-ure 2<3 *n e=ample o' a pain assessment scale4 Repro&uce& by $in& permission o'
Nursin" Times 5here this 'irst appeare&, 0 %ay /09, Vol 9-, No /0, p4 294
Other therapies such as rela=ation techni8ues, heat an& col&
therapies, an& &iversion therapy can all help re&uce perceive& pain
@Em'lor"o /000A4
B4/- What is necrotic tissue an& ho5 shoul& it be treate&
* 5oun& may contain necrotic tissue, 5hich may be so't, spon"y
an& blac$"rey, or 'orm a har& blac$ eschar over the 5oun&
sur'ace4 It is the result o' tissue &eath secon&ary to ischaemia4
This 5ill al5ays &elay healin" an& increases the chance o'
5oun& in'ection4 The treatment aim 5ill be &Mbri&ement by use o'
an appropriate &ressin" @see B24// an& B24/2A, or i' necessary
see$in" a sur"ical opinion on sharp &Mbri&ement 5hen tissue is
sur"ically r emove&4
B4// What is slou"h an& ho5 shoul& it be treate&
ello5 or slou"hy tissue is 'orme& in many chronic 5oun&s4 It is
not &ea& tissue but a mi=ture o' &ea& cells an& serous e=u&ate4 It
nee&s to be remove& to optimise healin" an& is a similar process to
&Mbri&e? ment @see B24/2 an& B24/3A4 It is important not to mista$e
e=pose&
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Woun& Care< * Han&boo$ 'or Community Nurses
ten&ons or epithelial islan&s 'or slou"h because they can have a
simi? lar appearance4
B4/ What is "ranulation tissue an& ho5 shoul& it be treate&
Re& or "ranulatin" 5oun&s have 'ra"ile ne5 tissue 'ormin",
5hich is easily &ama"e&4 The aim o' treatment 5ill be to protect
the tissue an& provi&e a moist environment to optimise healin"
@see B/40A4 articular care shoul& be ta$en &urin" 5oun&
cleansin" @see B4/B4A an& a &ressin" shoul& be selecte& that
5ill not a&here to the sur'ace o' the 5oun& an& cause trauma
&urin" &ressin" chan"es4
B4/1 What is epithelial tissue an& ho5 shoul& it be treate&
in$ or epithelial tissue is the ne5 layer o' epi&ermis, 5hich
5ill cover the 5oun& 5hen it has 'ille& up 5ith "ranulation
tissue4 The epithelial cells mi"rate 'rom the 5oun& mar"ins4 They
sometimes meet to 'orm clusters or islan&s on the 5oun& sur'ace4
* moist envi? ronment ai&s movement o' these cells, so the chosen&ressin" shoul& a"ain provi&e this environment an& protect the
5oun& sur'ace @see B/40A4
B4/ Ho5 &o I reco"nise an in'ecte& 5oun&
The classic symptoms o' 5oun& in'ection inclu&e the
'ollo5in"<
D Er ythema
D Oe&ema
D Increase& e=u&ate
D O''ensive o&our
D ain
D yr e=ia4
See B/-4/B/-4, B/-4F an& B/-4/1 'or more &etails on reco"?
nisin" an& treatin" 5oun& in'ection4
Summar
y
Thorou"h assessment o' all 5oun&s is a prere8uisite 'or "oo&
car e4 *llo5in" the patient to see pro"ress improves
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3 Woun& Care< * Han&boo$ 'or Community Nurses
complianceG 5oun& measurement is simple an& &oes not r e8uir e
special s$ills4 The 5oun& shoul& be treate& in relation to the
tissue state 5ithin the 5oun&4 This 5ill chan"e over time an&
r e"ular reassessment is nee&e&4 *ssessment an& treatment o' pain ar e important parts o' 5oun& care4 Recor& $eepin" is a le"al
an& pr o'es? sional re8uirement an& accurate &ocumentation is
essential4
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CHAP*ER 3
)a#tors affe#tin-;ound +ea,in-
It is not only the &ressin" that is chosen 5hich a''ects the 5ay5oun&s heal4 This chapter e=amines other issues that may impact
on 5oun& healin", an& e=plains 5hy it is important to loo$ at
the patient7s li'estyle an& health status 5hen assessin" the patient
an& plannin" his or her 5oun& mana"ement4
B14/ What shoul& be inclu&e& in a "eneral assessment o' the patient
*s 5ell as assessin" the 5oun& itsel', it is important to loo$ atthe patient holistically4 %any 'actors in'luence 5oun& healin"4
I' these are not a&&resse&, healin" 5ill be &elaye& or may even
'ail to ta$e place4 Some o' the 'actors a''ectin" healin" are liste&
in Table 14/4 Not all can be treate& but, i' hi"hli"hte&, at least an
un&erstan&in" o' 5hy healin" is slo5 can be r eache&4
*ab,e 3<1 .actors a''ectin" 5oun&
healin"
*"e See B14, B04
Concurrent &isease See B141, B04
Nutritional status See B14B14F, B04
Dru"s See B149, B04
Smo$in" See B140
E=cessive alcohol consumption SeeB14/-
%obility See B04, B94/
B14 What e''ect &oes a"e have on 5oun& healin"
*s people a"e the metabolic processes slo5 &o5n, 5hich
pr olon"s tissue repair4 Woun& in'ection may also be more
common as
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Woun& Care< * Han&boo$ 'or Community Nurses1
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immune competence becomes less speci'ic an& in'lammation
less e''ective @Davi& /093A @see B/-4A4 El&erly people are more
li$ely to have chronic concurrent illness, 5hich may &elay
healin" an& re8uire &ru" therapy4
B141 Which concurrent &iseases particularly inter'ere 5ith 5oun& healin"
D Diabetes has lon" been associate& 5ith poor 5oun& healin"4 It
is important to control &iabetes i' 5oun& healin" is to be
achieve&4 eople 5ith &iabetes are also more susceptible to
5oun& in'ection @see B94/9A4
D Car&iovascular an& pulmonary &isease may &elay 5oun&healin" because the transport o' o=y"en to the 5oun& site may
be ina&e? 8uate, an& o=y"en is essential 'or 5oun& healin" @see
B140A4
D (raemia increases the ris$ o' 5oun& &ehiscence as a result o'
a re&uction in colla"en &eposition4 !ranulation may also
be &elaye& @see B/49A4
D Thyroi& or pituitary &e'iciency may &elay healin" as a result
o' slo5e& metabolic rates4D Cushin"7s syn&rome treate& 5ith steroi&s 5ill &elay healin"@see
B149A4
D Rheumatoi& arthritis o'ten necessitates hi"h &oses o'
cortico? steroi&s @see B94/3A4
B14 Ho5 &oes &iet a''ect 5oun& healin"
#oth obesity an& malnourishment inhibit 5oun& healin"4 *&vice
'rom a community &ietitian may be nee&e& in some cases4
oor nutrition an& malnourishment a&versely a''ect 5oun&
heal? in" in many 5ays4 The lin$s bet5een nutrients an&
healin" ar e sho5n in Table 144 It shoul& be remembere& that
in6ury may also lea& to a patient7s ener"y &eman&s bein" hi"her
than usual4 r otein is also lost in 5oun& e=u&ate4
I' a patient is unable to maintain a "oo& nutritional status,&ietar y supplements may be necessary, in the 'orm o' tablets
@e4"4 Jinc supplements, multivitaminsA, by in6ection @e4"4
Neocytamen, ironA, or as 'oo& supplements or meal r e placements4
Obese patients have re&uce& o=y"en pressures in their tissues
@*rmstron" /009A4 *&ipose tissue is poorly net5or$e& by
bloo&
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.actors a''ectin" 5oun& 2
*ab,e 3<2 Important nutrients in 5oun& healin"
Nutrient Role in healin"
rotein Repair an& replacement o' tissue
Carbohy&rate Ener"y, spares protein 'or 5oun&
healin" Vitamin C Colla"en synthesis, immunity
Vitamin #/ rotein synthesis
inc Tissue repair, protein synthesis
Iron Haemo"lobin pro&uction
Copper Increases the tensile stren"th o' colla"en
vessels so there are lar"e areas o' >&ea& space7 5hich re&uce the
o=y"en tension4 ro&uction o' colla"en is also re&uce& an& thusheal? in" &elaye& @see B/49A4 Obesity is also a ma6or ris$ 'actor in
postop? erative 5oun& in'ection an& the obese patient is more
li$ely to su''er haematoma 'ormation a'ter sur"ery, 5hich may
&elay healin" by 'urther re&ucin" tissue o=y"enation @*rmstron"
/009A4
.or the patient 5ith venous ulcers, the control o' obesity is an
important 'actor in ulcer healin", re&ucin" prolon"e& bac$
pressure in the venous system cause& by &eep vein obstruction inthe pelvic area4 Re&ucin" obesity 5ill also 'acilitate increase&
mobility an& re&uce venous stasis @see B94/ an& B949A4
When &iscussin" issues such as 5ei"ht control an& &iet, it
is important to be sure o' the patient7s level o' un&erstan&in"4
This is illustrate& in the 'ollo5in" t5o scenarios4
7ase st&$y2
Nurse * 5as as$e& to visit %iss 4 *n assessment in&icate& that
she ha& a venous ulcer4 %iss 5as 1 years ol&, mo&erately
over5ei"ht an& ha& sli"ht learnin" &i''iculties4 Her mobility 5as
impaire& by both her 5ei"ht an& s5ellin" in her le"s4 Nurse *
insti"ate& a tr eat? ment re"imen o' an al"inate &ressin" an&
sin"le?layer compression4 She also "ave a&vice about elevatin"
the le"s 5hen sittin", tryin" some mo&erate e=ercise an& losin"
5ei"ht4Over the ne=t 'e5 5ee$s, the ulcer &ecrease& in siJe an& the
oe&ema 5as settlin"G %iss ha& bou"ht a lar"e beanba" on 5hich
to elevate her le"s, an& ha& noticeably lost 5ei"ht as her
clothes appeare& looser4
Nurse * &i& not see %iss 'or several 5ee$s as other sta''
un&er? too$ her care4 When she 5ent to reassess %iss , the ulcer
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3 Woun& Care< * Han&boo$ 'or Community Nursesha& almost
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.actors a''ectin" 5oun& F
heale&, there 5as no oe&ema an& an improvement in mobility 5as
note&4 Her 5ei"ht appeare& to have re&uce& consi&erably over a
relatively short perio&4 When nurse * insti"ate& a &iscussion
about &iet, it became apparent that %iss ha& cut out virtuallyall 'oo& e=cept 'ruit an& ve"etables4 She e=plaine& that &inner that
&ay ha& been a bo5l o' broccoli4 She $ne5 these 'oo&s 5ere "oo&
'or her the nurse ha& sai& plenty o' 'ruit an& ve"etables but
she ha& no concept o' her bo&y7s nee& 'or protein an& some 'at
an& carbohy? &rate4 Nurse * ha& assume& this level o'
un&erstan&in"4 *'ter a &etaile& &iscussion a more healthy &iet
5ith a slo5er level o' 5ei"ht loss 5as establishe&4
7ase st&$y#
%rs R 5as an e=tremely obese 5oman o' 194 Her 5ei"ht 5as
esti? mate& to be in e=cess o' - stones but an accurate
measurement 5as &i''icult to obtain4 She ha& an e=tensively
ulcerate& le", 5hich 'aile& to respon& to treatment, an& 5as
&i''icult to &ress or ban&a"e because o' the shape o' the limb4 She
5as basically con'ine& to the &o5nstair s o' the house because o'her obesity4 She ha& been previously a&vise& to lose 5ei"ht an&
ha& been seen by a &ietitian to no e''ect4
On a 6oint visit bet5een the &istrict nurse an& !, %rs R 5as
tol& that i' her 5ei"ht &i& not re&uce she stoo& no chance o' her
5oun&s healin", an& she 5as en&an"erin" her li'e4 %rs R
a"ree& to try to stic$ to a lo5?'at &iet4
Several 5ee$s later there appeare& to be no chan"e in her siJe
an& she 5as "ettin" &espon&ent4 #oth she an& her husban& 5er ea&amant that she 5as stic$in" to a lo5?'at &iet4
The nurse &eci&e& to try to probe a bit &eeper into e=actly
5hat %rs R 5as eatin"4 It transpire& that most 'oo& 5as
prepac$a"e& an& labelle& lo5 or lo5er 'at4 This inclu&e& cheese,
cream, crisps an& chips4 #ut lo5er 'at than 5hat *"ain &etaile&
&iscussion about 'oo& shattere& the myths an& enable& %rs R to
ma$e a more success'ul attempt at 5ei"ht loss4
B142 What &ietary a&vice shoul& be "iven to help improve 5oun& healin"
in a poorly nourishe& patient
D Encoura"e a hi"h ener"y inta$e, such as san&5iches,
ca$es, biscuits an& chocolate4
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9 Woun& Care< * Han&boo$ 'or Community Nurses
D Encoura"e a hi"h protein inta$e, such as meat, 'ish, poultry,
e""s an& &airy 'oo&s4
D Encoura"e small but 're8uent snac$s4
D Ensure that any supplements prescribe& are palatable an& sip'ee&s are the ri"ht 'lavour an& temperatur e4
D Ta$e care 5ith 'oo&s that have lo5 ener"y &ensity such as
'ruit an& ve"etables4 They contain essential micronutrients
but the patient may 'eel 'ull be'ore their ener"y nee&s are met
@!uest an& earson /00FA4
B143 What shoul& be inclu&e& in a nutritional assessment
The patient7s history is important4 This shoul& inclu&e the
'ollo5in"<
D What is the patient7s normal &iet
D Have there been any recent chan"es or unintentional 5ei"ht
loss
Observe i' the patient7s clothes 'it4
D hysical measurements such as 5ei"ht an& hei"ht 5illallo5 calculation o' the bo&y mass in&e=4
D Direct observation o' muscle bul$, subcutaneous 'at,
&ehy&rate& s$in an& the patient7s "rip stren"th 5ill ai&
assessment4
D * nutritional assessment scale may be use'ul, alon" 5ith
'lui& balance an& 'oo& inta$e charts i' appr opriate4
I' necessary, involve the community &ietitian4 The patientshoul& be re"ularly reassesse& by 5ei"hin" an& monitorin"
inta$e4 This shoul& all be recor&e& on the care plan to allo5
evaluation4
B14F *re supplements o' vitamins an& Jinc use'ul to promote 5oun&healin"
The recommen&e& inta$e o' vitamin C 'or a healthy a&ult is
- m"&ay @Department o' Health /00/A4 The sic$ may re8uire
more, but ho5 much more is uncertain4 It is su""este& that
patients 5ith pressure ulcers shoul& al5ays be suspecte& o' bein"
&e'icient as a r esult o' 'actors such as chronic serious illness an&
institutionalise& &iets @Dic$erson /001A4 The best 5ay to reach the
re8uirement is by &ietary inta$e, but i' the patient is suspecte& to be
&e'icient it is usual to "ive up to /--- m"&ay split into 'our &oses4
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.actors a''ectin" 5oun& 0Hi"her &oses shoul& be avoi&e& because o' a relatively lo5 renal
threshol& @Dic$erson /001A4
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.actors a''ectin" 5oun& 1/
transport, thus a&versely a''ectin" 5oun& healin"4 The ris$ o'
arter? ial &isease is also increase& 5hich may cause ischaemia an&
necrosis @see B94/2A4
B14/- Ho5 &oes alcohol a''ect 5oun& healin"
atients 5ho are heavy &rin$ers may have liver &isease4 This
may result in a re&uction in the number o' platelets an& in clottin"
'unc? tion4 They may also have a lo5er resistance to in'ection4
!astritis an& &iarrhoea may pre&ispose to malnourishment
throu"h malab? sorption an& anaemia cause& by bloo& loss4
B14// Do social 'actors have a role in 5oun& healin"
Research su""ests that there is a stron" lin$ bet5een a person7s
social circumstances an& his or her health @%iller /000A4 The #lac$
R e port @#lac$ /09A 'oun& that people in the lo5er
socioeconomic "r oups e=perience& poorer health an& earlier &eath
than those in the hi"her "roups4 atients 'rom these "roups may be
more li$ely to eat a less nutritious &iet or to smo$e ci"arettes 5hich5ill impair 5oun& healin"4
sycholo"ical 'actors also play a part in 5oun& healin"4
E=peri? ence sho5s that, i' a patient &evelops venous le" ulcers,
an& pr evious "enerations in their 'amily ha& ha& ulcers that 'aile&
to heal, their e=pectations o' a positive outcome are lo5er an&
they may be less 5illin" to tolerate treatments, such as
compression ban&a"in", because they vie5 them as pointless4
Other patients are o'ten suspecte& o' tamperin" 5ith their&ressin"s an& scratchin" the a''ecte& area, causin" tissue
&ama"e4 This may be because they 'ail to un&erstan& the
importance o' this or because they li$e to see the nurse an& 5oul&
rather their 5oun& 'aile& to heal4
Summar
y
I' the chosen topical treatment is not havin" the &esire&
e' 'ect, consi&er the other 'actors that may be impe&in" 5oun&
healin"4 The patient7s a"e, concurrent &isease@sA an& "eneral
li'estyle 'actors are all pertinent 'or 5oun& healin"4 !ive the
patient clear li'estyle a&vice, chec$ that he or she un&erstan&s that
a&vice an& rein'orce it 5hen appr opriate4
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CHAP*ER 4
Wound#,eansin-
The topic o' 5oun& cleansin" has o'ten been surroun&e&
5ith controversy4 To clean or not to clean This chapter
&iscusses 5hat constitutes best practice 5hen cleansin" a 5oun&,
5hat solutions ar e appropriate an& 5hen 5oun& cleansin" is
necessary4 The 'ollo5in" in'ormation is pertinent 'or community
nurses, althou"h it may not be applicable to all hospital
&e partments4
B4/ Why shoul& cotton 5ool not be use& to clean 5oun&s
It is "enerally accepte& that cleansin" 5oun&s by s5abbin"
5ith cotton 5ool or "auJe results in the materials she&&in" 'ibres
into the 5oun&, 5hich may act as a 'ocus 'or in'ection
@Draper /092A4 Despite this, &ressin" pac$s available on the &ru"
tari'' all contain cotton?5ool ballsG these shoul& be &iscar&e&4
Vi"orous s5abbin" may also &ama"e healthy tissue4 !entle
irri"ation is there'ore "ener? ally the pre'erre& metho&4
B4 When shoul& 5oun&s be cleanse&
Which 5oun&s 5ill bene'it 'rom cleansin" Traumatic 5oun&s
that contain particles o' &irt or other matter 5ill bene'it 'rom
vi"or ous irri"ation @)a5rence /00FA4 Woun&s may also bene'it'rom cleansin" to remove "ross e=u&ate, remains o' previous
topical applications or crustin" @%iller an& Dyson /003G )a5rence
/00FA4 #acteria are not remove& but merely re&istribute& aroun&
the 5oun& sur'ace4 It is pointless to cleanse 5oun&s routinelyG
it is appropriate only to remove &ebris or ol& &ressin" material4
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Woun& cleansin" 1/1-
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Reasons 'or not cleansin" shoul& be e=plaine& to the patient to
avoi& any misun&erstan&in"s, because most patients thin$
that cleansin" is essential4
B41 What 'lui&s are recommen&e& 'or cleansin" 5oun&s, as I7ve been
tol& antiseptics are o' little value
The most 're8uently use& 'lui&s are tap 5ater,
physiolo"ical
@>normal7A saline or antise ptics4
There is little evi&ence to su""est that use o' antiseptics
re&uces the bacterial content o' 5oun&s4 Woun&s &o not nee& to besterile to heal4 Current thin$in" su""ests that the use o'
antiseptics is not a&vanta"eous in optimisin" 5oun& healin"4
Some o' the criticisms a"ainst antiseptics are liste& in #o= 4/4
re'erre& 5oun& cleansin" a"ents are &escribe& in #o= 44
The sa'er antiseptic options are su""este& by )a5rence @/00FA4
Bo/ 4<1 Disa&vanta"es o' antiseptics in 5oun& healin"
*ntiseptics &o not come into contact 5ith bacteria 'or lon" enou"h to $ill them
&urin" normal 5oun& cleansin"
#acteria may become resistant to antiseptics an& those antiseptics containin"
cetrimi&e or chlorhe=i&ine un&er certain con&itions
The 're8uent use o' antiseptics may contribute to5ar&s bacterial resistance to antibiotics
@no lin$ proven as
yetA
*ntiseptics a&versely a''ect bloo& 'lo5 in the healin" 5oun&
Or"anic matter such as pus an& 5oun& e=u&ate inactivates antiseptics
@%iller an& Dyson /003A
B4 Ho5 can physiolo"ical saline be 5arme& be'ore use
The simplest 5ay to 5arm saline be'ore 5oun& cleansin" is to
place the sachet, po& or canister in a suitable container such as a
6u", mu" or $i&ney &ish that has 5arm 5ater in it4 This 5ill raise
the tempera? ture 5ithout any ris$ o' contamination The solution
shoul& be at bo&y temperature 5hen use&4
B42 What is an emollient
Emollients are &esi"ne& either as creams or 'or a&&in" to
bathsbuc$ets o' 5ater to soothe an& rehy&rate &ry scale& areas
o'
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1 Woun& Care< * Han&boo$ 'or Community Nurses
Bo/ 4<2 re'erre& 5oun& cleansin" a"ents
Chlorhe=i&ine solutions< this is a "oo& s$in an& har& sur'ace &isin'ectant an&
sho5s lo5 to=icity to livin" tissue in animal mo&els @see B/-40A
ovi&oneio&ine< io&ine $ills bacteria rapi&ly, possibly 5ithin a 'e5 secon&s, but
can impair the microcirculation in animals
Tap 5ater< one stu&y con&ucte& 5ith tap 5ater 'oun& that there 5ere 'e5er
in'ections in 5oun&s cleanse& 5ith tap 5ater an& that no bacteria 5ere
trans'erre& to the 5oun& @*n"eras et al4 /00/A4 Ho5ever, some cell &ama"e may
occur as a result o' osmotic pressure an& this may cause pain @)a5rence /00FA4
)e" ulcers may be cleanse& in a buc$et o' 5arm 5ater @see B942A
Saline in a -40L @physiolo"icalA solution< has similar osmotic pressures to the tissue
in mammals4 This rein'orces the 'act that saline baths are inappropriate because
the concentrations vary 5i&ely4 Saline is currently 'avoure& as the treatment o'choice, minimisin" the ris$ o' tissue &ama"e an& pain4 This shoul& be use& as a
5arm solu? tion @see B241A
s$in4 I' use& in 5ater it &oes not matter i' they touch the ulcer
itsel'
@see B942A4
Summary
Woun&s shoul& be "ently irri"ate& an& not s5abbe&4 Clean
5oun&s only i' it is necessary to remove &ebris such as the
remains o' &r ess? in"s or e=u&ate4 Warm saline is the pre'erre&
cleansin" lotion4
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One notable e=ception to this is in the case o' peripheral
necrosis secon&ary to arterial &isease @e4"4 necrotic toes, peripheral
&iabetic ulcersA 5here moisture may increase the ris$ o' rapi&
in'ection @see B94-A4
B24 Ho5 can maceration 'rom e=u&ate be avoi&e&
The 5oun& shoul& be $ept 'ree 'rom e=cessive e=u&ate4 *lthou"h
the 5oun& nee&s to be $ept moist, it must not be 5et4 This 5ill
allo5 the s$in to become so""y an& macerate& an& may lea& to
'urther tissue brea$&o5n4 * &ressin" shoul& be selecte& that
provi&es the correct absorbency an& the 're8uency o' &ressin"
chan"es shoul& re'lect the anticipate& level o' e=u&ate4 *ll
&ressin"s are &esi"ne& 5ith particular types o' 5oun&s in min&,
e4"4 al"inates are &esi"ne& 'or hi"hly e=u&in" 5oun&s @see B240A
an& vapour?permeable 'ilms 'or 5oun&s 5ith very little e=u&ate
@see B24/9A4 This is an important criterion in &ressin" selection @see
also B//42A4
B241 Does temperature have an e''ect on 5oun& healin"
Woun& healin" is optimise& 5hen 5oun&s are $ept at bo&y
tempera? ture4 I' the temperature o' the 5oun& &rops, mitotic
activity slo5s &o5n thus re&ucin" 5oun& healin"4 * &rop in
5oun& temperatur e also &isrupts leu$ocytic activity an&
o=yhaemo"lobin &issociation @Thomas /00-G %iller an& Dyson
/003A4
)oc$ @/09-A an& %yers @/09A 'oun& that a'ter cleansin" it
coul& ta$e a 5oun& up to - minutes to re"ain bo&y temperaturean& a 'urther 1 hours 'or mitotic activity to return to normal4
Thus it is a&visable to 5arm saline be'ore 5oun& cleansin" @see
B4A, to $eep 5oun&s e=pose& 'or as short a time as possible, to
try not to &isturb 5oun&s unnecessarily an& to consi&er the type
o' material bein" use&, i4e4 cotton "auJe 5ill $eep a 5oun& at
aroun& FP C 5hereas a hy&rocolloi& or 'oam &ressin" 5ill
increase the temperature to 12P C @Thomas /00-A4
B24 Can micro?or"anisms "et un&er &ressin"s
The &ressin" shoul& be impermeable to micro?or"anisms4 This
shoul& 5or$ both 5ays4 While micro?or"anisms shoul& be $ept
a5ay 'rom 5oun&s, it is also un&esirable to have micro?or"anisms
'rom a 5oun& sprea&in" to the envir onment4
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Dressin"s 12
*ny non?a&hesive &ressin" shoul& be tape& li$e a >picture
'rame7 i' the surroun&in" s$in is in "oo& con&ition, or ban&a"e& to
cover the &ressin" completely4
I' >stri$e?throu"h7 @e=u&ate seeps throu"h or un&er the e&"eso' the &ressin"A occurs, a 5arm 5et passa"e is create& 'or
micr o? or"anisms4 Secon&ary pa&&in" shoul& be applie& or the
5oun& re&resse& @see B241A4 The patient shoul& be a&vise& that,
i' lea$a"e occurs, he or she shoul& cover it 5ith a &ressin" pa&
5hile a5aitin" a &istrict nurse visit or sur"ery appointment4
B242 Can I use tra&itional "auJe as a primary &ressin"
Dressin"s shoul& not she& particles on to a 5oun&4 %o&ern &r ess?
in"s are &esi"ne& to hi"h stan&ar&s an& 5ill not she& 'ibres on to
the 5oun& sur'ace4 Ho5ever, tra&itional "auJe, lint or cotton
5ool all she& 'ibres 5hich can serve as a 'ocus 'or in'ection4
In a&&ition, the &ressin" shoul& not cause trauma to the 5oun&4
I' the chosen &ressin" a&heres to the 5oun&, trauma an& pain
may occur 5hen the &ressin" is remove& @see B4FA4 The i&eal
healin" environment shoul& be 'ree 'rom materials thata&hereG this is provi&e& by all mo&ern &r essin"s4
.or both o' these reasons, tra&itional &ressin"s such as
cotton "auJe an& para''in "auJe shoul& not be use& on open
5oun&s4 *&herence occurs as the 5oun& e=u&ate becomes
incorporate& into the "auJe an& &ries out, a&herin" to the tissue
belo54 R emoval causes the top layer o' "ranulation tissue to be
remove& 5ith the &ressin"4 ara''in "auJe leaves a criss?cross
pattern 5here ne5 "ran? ulation tissue has "ro5n throu"h themesh, illustratin" this 8uite "raphically4
B243 *re occlusive &ressin"s recommen&e&
Occlusive &ressin"s stop any atmospheric o=y"en "ettin" to
the 5oun&4 It has been note& that an"io"enesis @'ormation o' ne5
bloo& vesselsA in "ranulatin" 5oun&s ta$es place rapi&ly in the
hypo=ic environment o' occlusive &ressin"s such as
hy&rocolloi&s @Cher r y an& Ryan /092A4 Ho5ever, 5hen a 5oun&
be"ins to sho5 si"ns o' ne5 epi&ermis 'ormin", it appears to
happen more rapi&ly in a more o=y"en?rich environment @Silver
/092A4 It may be appropriate to use an occlusive &ressin" 5hen a
5oun& nee&s to "ranulate, but to s5itch
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13 Woun& Care< * Han&boo$ 'or Community Nurses
to an o=y"en?permeable &ressin" @e4"4 a 'oam &ressin"A to
encoura"e epithelialisation @see B/49 an& B4/1A4
B24F Some &ressin"s are not available on prescription4 Can they still be use&
%any nurses have arran"ements 5here they or&er one item 'rom
a pharmacist an& e=chan"e it 'or another pro&uct o' the same
value4 This is ille"alQ Even thou"h it is &one 5ith the patient7s
best inter ests at heart, this action constitutes 'rau&4 I' prosecute&
the nurse coul& 'ace a 'ine, imprisonment an& &ismissal4
B249 What 'actors shoul& be consi&ere& 5hen choosin" a &ressin"
Here is a list o' areas to consi&er4 The &ressin" shoul& have
the 'ollo5in" 8ualities<
D Sa'e to use, i4e4 has been prove& sa'e an& e''ective by clinicaltrials
D *cceptable to the patient
D
Cost?e''ectiveG &o not 6ust thin$ in terms o' unitcost
D Capable o' stan&ar&isation an&
evaluation
D *llo5s monitorin" o' the
5oun&
D rovi&es mechanical protection
D Non?' lammable
DSterilisableD Com'ortable an& moul&able
D Re8uires in're8uent
chan"in"4
Currently, no one &ressin" meets all these criteria4 There'ore it
is important to assess the 5oun& thorou"hly, &eci&e on a
tr eatment "oal an& select the most appropriate &ressin" 'rom those
available4I' the 5oun& &oes not respon& to the chosen &ressin", it is
impor? tant to remember that the &ressin" plays only a part in the
healin" process an& any un&erlyin" causes must be treate& an&
'actors a' 'ect? in" healin" revie5e& @see B14/B14FA4
B240 What is an al"inate &ressin"
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Dressin"s 1FThese &ressin"s are ma&e 'rom sea5ee&, 5hich contains lar"e
8uan? tities o' al"inate4 They are hi"hly absorbent so they
shoul& not be
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19 Woun& Care< * Han&boo$ 'or Community Nurses
use& on 5oun&s 5ith very little e=u&ate, because they 5ill a&here
to the 5oun& sur'ace4 Some clinicians 5et the &ressin" 5ith
saline, but this seems pointless as the &ressin" is &esi"ne& to be
hi"hly absorbent an&, on a &ry 5oun&, 5ill &ry out at bo&ytemperature4 *ll al"inates are hi"hly absorbent an& 'orm a "el on
contact 5ith 5oun& e=u&ate, "ivin" a moist environment 5hile
absorbin" e=cess 'lui&4 They may be use& on 'lat 5oun&s an& also
to pac$ cavity 5oun&s4 Some ar e manu'acture& as ropes an&
ribbons especially 'or pac$in"4 They also have haemostatic
8ualities an& so are e=cellent 'or mana"in" some minor sur"ical
blee&s an& minor in6uries @see B343 an& BF4//A4 * secon&ary
&ressin" is re8uire& @see B241A4 E=amples o' al"inates ar e:altostat @ConvatecA, SeaSorb @ColoplastA, Sorbsan an&
Sorbsan lus @harma?last, Te"a"en @1%A, *l"osteril
@#iers&or'A, *l"isite lus @Smith ; Nephe5A an& %el"isorb
@%onlyc$eA4
B24/- What are bea& &ressin"s
These &ressin"s are ma&e up o' polysacchari&e bea&s4 They arein&i? cate& 'or 5et slou"hy 5oun&s an& shoul& not be use& on
clean or &r y 5oun&s4 The bea&s are e=tremely hy&rophilic an& 5ill
cause pain i' the 5oun& is too &ry @see B4FA4 The ones in most
common usa"e are Io&osorb an& Io&o'le= @Smith ; Nephe5A4
#oth contain io&ine an& have been use& 5ith some success on
5oun&s 5ith super'icial in'ection or super'icial 5oun&s
contaminate& 5ith methicillin? resistant Staphylo+o++&s a&re&s
@%RS*A @see B/-4F an& B/-4/1A4 *ll re8uire a secon&ary&ressin" @see B241A4
B24// What is an enJyme &ressin"
Vari&ase @Wyath )absA is a &ry po5&er containin" t5o
enJymes, strepto$inase an& strepto&ornase4 Vari&ase is &esi"ne&
to &Mbri&e necrotic or very slou"hy 5oun&s @see B4/- an&
B4//A4 The po5&er can be reconstitute& 5ith sterile saline an&applie& to &r y scabs that have been cross?hatche& 5ith a scalpel
as a soa$4 Some practitioners &o in6ect un&er scabs, but this must
be &one 5ith car e so that healthy tissue is not a''ecte& an& this
metho& is not "enerally recommen&e&4 *n alternative is to
reconstitute the po5&er 5ith
2 ml sterile 5ater an& mi= 5ith /2 ml intrasite "el4
Whichever metho& o' application is chosen, a secon&ary
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Dressin"s 10&ressin" is r e8uir e&4
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- Woun& Care< * Han&boo$ 'or Community Nurses
When mi=in" Vari&ase po5&er 5ith any solution, care must
be ta$en not to sha$e the vial vi"orously or the enJymes 5ill
become &enature& an& the treatment ine' 'ective4
B24/ Can the use o' topical strepto$inase a''ect the treatment o'
myocar&ial in'arction
*ll patients treate& 5ith Vari&ase sho5 an increase in
antistr e pto$i? nase titres4 %or"an @/00A recommen&s that it
5oul& be sensible not to use it on patients at ris$ o' myocar&ial
in'ar ction4
#u= et al4 @/00FA con&ucte& a stu&y to assessantistr e pto$inase levels in patients treate& 5ith intravenous
strepto$inase 'or acute myocar&ial in'arction, an& in patients
treate& 5ith topical str e pto$i? nase 'or cutaneous 5oun&s4 He
'oun& that topical application o' strepto$inase causes a
si"ni'icant humoral response 'or / month 5hich then &eclines
over a 3?month perio&4 This antibo&y response is si"ni'icantly
lo5er than 5hen strepto$inase is "iven intravenously4 #u= et al4
conclu&e that, i' a patient has been treate& 5ith topicalstrepto$inase in the last 3 months, it 5oul& be pru&ent to avoi&
intra? venous strepto$inase an& an alternative thrombolytic shoul&
be use& in the treatment o' a myocar&ial in'ar ction4
*nother small stu&y by !reen @/001A measure& the
antistr e pto$i? nase titres o' 'ive patients treate& 5ith topical
Vari&ase, 5ho all sho5e& an increase& titre4 He conclu&e& that
the use o' Vari&ase shoul& be restricte& to those not at ris$ o' a
myocar&ial in'ar ction4
B24/1 What are 'oam &ressin"s
.oam &ressin"s @inclu&in" hy&ropolymer an& hy&rocellular &r ess?
in"sA are "enerally hi"hly absorbent an& create a moist
envir onment 'or 5oun& healin"4 They can be use& on a 5i&e
variety o' 5oun&s althou"h, i' the 5oun& is very &ry, they may
stic$4
These &ressin"s are available 5ithout a&hesive, 5hich is use'ul
i' the surroun&in" s$in is 'ra"ile or &ama"e&, or as a&hesive
&r essin"s4 They can be use& on their o5n or as a secon&ary
&ressin", e4"4 5ith hy&ro"els @see B241A4
Some non?a&hesive 'oams inclu&e *llevyn @Smith ;
Nephe5A, )yo'oam an& )yo'oam E=tra @SetonA4 )yo'oam is use'ul
'or r esolvin" over "ranulation4
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Dressin"s /
*&hesive 'oams inclu&e *llevyn *&hesive @Smith ;
Nephe5A, CombiDER% @ConvatecA an& Tielle @Kohnson ;
KohnsonA4
B24/ What are hy&ro'ibre &ressin"s
Hy&ro'ibre &ressin"s are ma&e o' /--L so&ium
carbo=ymethylcel? lulose4 This is the main in"re&ient o'
hy&rocolloi& &ressin"s an& it is spun into 'ibres an& ma&e into
sheets or ribbon &ressin"s4 It absorbs 'lui& &irectly into its 'ibre
structure4 In the presence o' e=u&ate it converts into a so't "el
sheet 5hich maintains a 5arm, moist, local 5oun& con&ition4Hy&ro'ibre &ressin"s 5ill absorb mo&erate?to?lar"e 8uantities
o' e=u&ate, loc$in" it a5ay 'rom "oo& s$in an& preventin"
maceration4 They can be use& to treat a variety o' 5oun&s,
slou"hy or clean, ' lat or cavities @Williams /000A4 They are use&
'or 5oun&s similar to those &resse& by al"inates4 They al5ays
re8uire a secon&ary &ressin" @see B241A4
*n e=ample o' a hy&ro'ibre &ressin" is *8uacel @ConvatecA4
B24/2 What are hy&ro"els
*morphous hy&ro"els have a hi"h 5ater content4 They are ver y
use'ul 'or &Mbri&in" or &eslou"hin" 5oun&s by rehy&ratin" the
&ea& tissue, thus allo5in" the bo&y to she& this tissue by autolysis4
!els ar e &esi"ne& to be use& on 'lat 5oun&s an& to 'ill cavities4
They are also reporte& to re&uce pain at the 5oun& site @%or"an
/00A4 They re8uire a secon&ary &ressin" @see B241A4E=amples o' hy&ro"els are Intrasite !el @Smith ;
Nephe5A, Nu?!el @Kohnson ; KohnsonA, Steri"el @SetonA an&
urilon !el @Colo? plastA4
B24/3 What are hy&rocolloi&s
Hy&rocolloi& &ressin"s are ma&e 'rom combinations o' synthetic
polymers an& are one o' the ol&est o' the >mo&ern7 &ressin"sG they
are use& in many situations4 These &ressin"s are 5aterproo',
a&he? sive an& interactive, an& 'orm a "el on contact 5ith 5oun&
e=u&ate4 This may have a sli"ht o&our, 5hich is normal, an& it is
a&visable to 5arn the patient so that he or she &oes not "et upset
i' this occur s4
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Dressin"s 1
I' the cream is a 5ater?in?oil emulsion, the pro'lavine has very
little antibacterial activity because it is not release& 'rom the
emulsion base4
Hypersensitivity has been reporte& because the creamcontains lanolin, a $no5n sensitisin" a"ent @see B24-A4
B24- What common irritants an& aller"ens li$ely to cause contact
&ermatitis may be 'oun& in 5oun& care pro&ucts
Lano,i
n
)anolin @5ool alcoholA is a $no5n sensitiser4 It can be 'oun& inmany creams, ointments, bath a&&itives, baby pro&ucts an& barrier
pr e pa? rations4 It is better not to use any pro&ucts containin"
lanolin on the s$in aroun& le" ulcer s4
Antibioti#
s
Neomycin an& 'ramycetin are topical antibiotics that are
commonly reporte& as s$in sensitisers4 When mana"in" le"ulcers, "entamicin an& bacitracin are also si"ni'icant sensitisers
@Cameron /009A4 Topi? cal antibiotics are 'oun& in creams,
ointments, tulle &ressin"s an& me&icate& po5&ers4 They are best
avoi&e& because o' the problems o' both sensitisation an& resistant
bacteria4
A,#o+o,
Cetyl alcohol, stearyl alcohol an& cetylstearyl alcohol are
emulsi'iers4 These are &i''icult to avoi& because they are 'oun& in
many popular le" ulcer preparations such as a8ueous creams,
corticoster oi& creams, moisturisers, some paste ban&a"es an&
emulsi'yin" oint? ments4
Rubbe
r
Rubber may be 'oun& in elastic ban&a"es, some support hosier y,
tubular elastic supports an& late= "loves4 I' the patient has a
rub ber aller"y, the nurse shoul& 5ear vinyl "loves4
Paraben
s
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Woun& Care< * Han&boo$ 'or Community NursesThe parabens "roup o' preservatives possess antibacterial an&
anti? 'un"al propertiesG they are 5i&ely use& preservatives in
topical me&icaments, moisturisers an& some paste ban&a"es4
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Dressin"s 2
Ester of
resin
Colophony @an ester o' resinA is 'oun& in the a&hesive bac$in"
o' some plasters, tapes an& &r essin"s4
)ra-ran#es
.ra"rances use& in many over?the?counter pro&ucts such as
bath a&&itives an& moisturisers may cause sensitisation4
B24/ Ho5 can irritants an& aller"ens best be avoi&e&
The 'ollo5in" measures can be ta$en to minimise the ris$ o'
contact &ermatitis, particularly i' the patient is $no5n to be
sensitive to a variety o' pr e parations<
D (se 5arm physiolo"ical saline @-40LA to irri"ate le" ulcers
or 5ash the le" 5ith plain 5arm tap 5ater @see B41, B4,
B241 an& B942A4
D *voi& usin" topical antibiotics or antiseptics @see
B41A4
D Do not use a&hesive tape &irectly on to the
s$in4
D (se a simple emollient such as 2-L 5hite so't para''in,2-L
li8ui& para''inG this can be ma&e up by the pharmacist4
D Do not use any pro&uct containin" lanolin @see B24-A4
D *voi& creamsG use ointments
instea&4
D Do not apply elastic ban&a"es &irectly on to the
s$in4
D Wear vinyl not late=
"loves4
D Discoura"e the patient 'rom usin" over?the?counter
pr e parations 'or sel'?treatment4
D Consi&er re'errin" the patient to a &ermatolo"ist 'or patch
testin" i' the patient is $no5n to be sensitive to a ran"e o'
pr o&ucts4
B24 Can 5oun& &ressin"s be combine&
%any combinations are 're8uently seen, but 'ar less research
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3 Woun& Care< * Han&boo$ 'or Community Nursesabout the clinical e''ectiveness o' such treatments is available4
%anu'actur? ers o' &ressin"s &o not normally ma$e statements
about their &r ess? in"s in combination 5ith other pro&ucts
because the ran"e o' primary an& secon&ary &ressin"s is vast4 I'
manu'acturers happen to ma$e e=amples o' both pro&uct types,
they may 5ell be prepare& to
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Dressin"s F
provi&e some assurances that their pro&ucts use& in combination
ar e sa'e @Thomas an& Vo5&en /009A4 I' in &oubt about the sa'ety
o' a combination, a company helpline or a pharmacist may be
able to ans5er your 8uer y4*lso remember that, i' a s$in reaction occurs, you may not
be able to tell 5hich o' the pro&ucts has cause& it, 5hich may
limit 'uture mana"ement4
B241 What types o' &ressin"s can be use& as secon&ary &ressin"s
)o5 a&herence &ressin"s such as N?* Dressin" or Tricote= can be
use& over "els, creams, al"inates, etc4 These are simple &ressin"s5ith no absorbency an& may nee& more substantial pa&&in" over
them4
a&&in" such as !am"ee pro&ucts shoul& be use& only over a
suitable primary &ressin" that protects the 5oun& 'rom any loose
'ibres, 5hich may become incorporate& into the 5oun& causin"
a&herence4 lace& over a suitable &ressin", it &oes allo5 easy
passa"e o' ' lui&4
%ore mo&ern pa&s such as the Sur"ipa& are availableG thesear e sleeve& to prevent loose 'ibres enterin" the 5oun& an& 'or this
r eason shoul& not be cut4 (nless stri$e?throu"h occurs they "ive a
r eason? able barrier to bacteria @Thomas /009A @see B24A4
Orthopae&ic 5a&&in", 5hich 5as ori"inally &esi"ne& 'or
use un&er plaster casts, is no5 're8uently use& un&er
compression ban&a"in" both to protect bony prominences an& to
absorb e=u&ate @see B940A4
Vapour?permeable 'ilm &ressin"s, &esi"ne& as a primary&ressin" 'or super'icial lo5 e=u&ate 5oun&s, can also be use& to
prevent mois? ture loss 'rom hy&ro"els applie& to &ry 5oun&s or
5oun&s 5ith lo5 e=u&ate @see B24/9A4 They may also be use& over
al"inates4
There is a "ro5in" tren& to use hy&rocolloi& &ressin"s over
"els an& al"inates4 *lthou"h this may be acceptable in some
instances, it shoul& be remembere& that some hy&rocolloi&s can
absorb a consi&? erable amount o' 'lui& an& may there'ore re&uce a
hy&ro"el7s ability to rehy&rate a 5oun&4 The clinical si"ni'icance
o' this has not been &etermine& @Thomas /009A4
.oam &ressin"s are usually use& alone but, as 5ith
hy&rocolloi&s, there is a tren& to use them in combination 5ith
"els an& al"inates @see B24/1A4 There is no publishe& evi&ence to
support this practice
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9 Woun& Care< * Han&boo$ 'or Community Nurses
an& a"ain they may ta$e up moisture 'rom a "el, but this &oes
not seem to occur to any "reat e=tent an& sli"htly more "el
coul& be applie& to stop this e''ect @Stevens /009A4 * "el'oam
combination may then be a bene'it i' the 5oun& is pro&ucin" ahi"h level o' e=u&ate, but 'or &ry necrotic or slou"hy 5oun&s it
is &i''icult to 6usti'y the cost @Thomas /009A4
I' a 5oun& is malo&orous, &ressin"s containin" activate&
char coal may be appropriate @see B43A4 These 'it into t5o
cate"ories< those inten&e& as primary &ressin"s such as *ctisorb
lus, )yo'oam C an& Carbo'le=, an& those inten&e& as secon&ary
&ressin"s such as Clini? Sorb or Deni&or4 *lthou"h they have no
o&our?absorbin" pr oper? ties, occlusive pro&ucts such as 'ilm&ressin"s or hy&rocolloi&s may re&uce o&our by preventin" the
escape o' volatile molecules that ar e responsible 'or the smell
@Thomas /009A4
B24 *re there any pro&ucts that shoul& be avoi&e& 5ith ve"etarian patients
%ost pro&ucts are suitable, althou"h some hy&rocolloi&s
may contain "elatin, 5hich is an animal &erivative, 5hereas other&r ess? in"s may not4 .ibracol is a colla"en al"inate that contains
over 0-L bovine colla"en, so it is unsuitable 'or a ve"etarian
patient4
I' necessary chec$ 5ith the pro&uct manu'actur er 4
Summar
y
No one &ressin" 5ill meet all the criteria 'or the i&eal 5oun&
&r ess? in"4 Tra&itional &ressin"s such as "auJe shoul& not be
use& as a primary &ressin" on any open 5oun&s4 The chosen
&ressin" shoul& be the one most suite& to the sta"e o' healin",
e=u&ate level an& patient satis'action4 *voi& irritants an&
aller"ensG &ocument any $no5n aller"ies 'or 'uture re'erence4 I'
combinin" &ressin"s, consi&er 5hether they are li$ely to
counteract each other or react 5ith each other an& 5hether thecombination is cost?e' 'ective4
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CHAP*ER 7
Sur-i#a,;ounds
Community nurses are o'ten as$e& to mana"e postoperative
sur "ical 5oun&s 'ollo5in" early patient &ischar"e 'rom hospital4
%any !s un&erta$e minor sur"ery 5ithin the practiceG this is
e=pecte& to rise un&er the chan"in" health care initiatives4
This chapter e=amines mana"ement o' sur"ical 5oun&s, an&
consi&ers 'actors that may a''ect healin" 5hich are particular
to these 5oun&s4 iloni&al sinuses an& abscesses are also&iscusse& in the 'ollo5in" te=t as these are 're8uently
mana"e& 5ithin the community settin"4
B34/ Ho5 shoul& sur"ical 5oun&s be mana"e&
Sur"ical 5oun&s are usually close& 5ith sutures or clips, 5hich
ar e le't in place 'or 2F &ays &epen&in" on the type o' sur"ery,
an& the &epth o' the 5oun& they are closin" @see B/43AStu&ies have sho5n that a'ter hours the s$in 5ill have
'orme& a natural barrier at the suture or clip line 5hich means a
&ressin" may be unnecessary @ChrintJ /090A4 atients 5ill re8uire
&ressin"s i' there is any lea$a"e 'rom the suture line or to protect
the 5oun& 'rom rubbin" on clothin"4 Some areas, such as the
"roin a'ter vari? cose vein sur"ery, may be particularly prone to
'riction an& may re8uire a li"ht &ressin" to absorb any
perspiration an& to re&uce 'ric? tion4 *s the s$in e&"es have been brou"ht to"ether tra&itional &r ess? in"s such as "auJe or %elolin
are o'ten use&4 Ho5ever, these may not be com'ortable an& are
not 5aterproo' @%iller /002A @see B242A4 It may be appropriate to
consi&er a more mo&ern alternative such as a vapour?permeable
'ilm @see B24/9A, a polyurethane &ressin" @see B24/1A or a thin
hy&rocolloi& @see B24/3A4 *&vanta"es o' these
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3 Woun& Care< * Han&boo$ 'or Community Nurses2
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&ressin"s inclu&e com'ort an& less bul$, they &o not re8uire
ban&a"in" or tapin" into position, are 5aterproo' an& in most
cases can be le't in position until the sutures or clips can be
remove&4 @Thomas /00-A4 Once sutures or clips have beenremove&, a &ressin" shoul& not be necessary unless the 5oun&
continues to e=u&e 'rom any areas alon" the suture line4
*&vice "iven to the patient may inclu&e coverin" the 5oun& 'or
hours a'ter sur"ery4 I' the 5oun& then appears &ry, he or she
may sho5er, but shoul& avoi& bathin" because this 5ill re&uce the
natural barrier4 While a5aitin" the removal o' sutures or clips,
the patient shoul& observe the 5oun& 'or any si"ns o' in'ection
@see B/-4/A an& see$ me&ical ai& i' any o' these occur 4
B34 What 'actors can a''ect the healin" o' sur"ical 5oun&s
The patient7s physiolo"ical con&ition an& the sur"ical an& nursin"
environment 5ill have a pro'oun& e''ect on 5oun& healin"4 *s
5ith all 5oun&s 'actors such as a"ein", un&erlyin" &isease,
nutrition an& li'estyle 5ill a''ect healin" @see B14B14//A4
The len"th o' hospital stay be'ore sur"ery has been su""este& asa 'actor a''ectin" postoperative recovery @artri&"e /009A4
Trauma patients re8uirin" sur"ery or those 5ith a preoperative
illness appear to heal more slo5ly4
Other concurrent therapies may also &elay healin" @see
B140A4 Corticosteroi&s 5ill a''ect all sta"es o' healin"4
Immunosuppressive &ru"s &elay the in'lammatory response in
5oun& healin", 5hich results in a re&uce& 5hite bloo& cell count,
increasin" susce ptibility to in'ection @Davi& /093A4*nticoa"ulants are sometimes "iven prophylactically 5hen
patients have ma6or sur"ery4 These impair bloo& clottin" an&
may result in haematoma 'ormation4 Cytoto=ic &ru"s inter'ere
5ith cell replication by suppressin" the in' lamma? tory response
an& protein synthesis in patients 5ho are alr ea&y &ebilitate&
'rom a mali"nant &isease @#lan& et al4 /09A4 Ra&iother? apy can
also &ama"e s$in by &ecreasin" vascularity an& 'ibrosis
@Cuttin" an& Har&in" /00A, 5hich ma$es it more vulnerable totrauma as 5ell as re&ucin" the patient7s non?speci'ic cell?
me&iate& response to bacterial invasion4 enicillin inter'eres
5ith colla"en 'ormation an& 5ill &ecrease a 5oun&7s tensile
stren"th @Cooper
/00-A @see B/49A4
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9 Woun& Care< * Han&boo$ 'or Community Nurses
I' no abscess has 'orme& there are several options, althou"h
tr eat? ment is controversial @Ho&"$in /009A4 Hair can be
remove& 5ith 'orceps an& curette, i' the sinus is small an& not
in'ecte&4 The patient can have phenol in6ections as an outpatient,or sur"ical tr eatments inclu&e layin" the area open to permit
&raina"e an& allo5 healin" by secon&ary intention @see B/4FA4 On
occasion the area can be opene& an& hairs an& &ebris remove&,
'ollo5e& by primary closure4
B342 What is an abscess an& ho5 shoul& incision an& &raina"e be mana"e&
*n abscess is a localise& collection o' pus, comprisin" e=u&ate, bac? teria, &ea& 5hite cells an& the partial li8ue'action o' other
cells an& tissue4 The in'ection becomes 5alle& o'' by "ranulation
tissue an& a layer o' &ea& 5hite cells4 *s the abscess increases in
siJe, the inter nal pressure increases an& this pro&uces pain4
The usual treatment is sur"ical incision o' the abscess an&
&raina"e o' the contents @The Woun& ro"ramme /00A4 The
r esult? in" cavity is then pac$e& 5ith a &ressin" such as an
al"inate or hy&ro'ibre &ressin" @B240 an& B24/A, 5hichallo5s 'or 'utur e &raina"e4 *ntibiotics penetrate poorly into an
abscess but serve as an a&6unct to sur "er y4
B343 Is there a recommen&e& mana"ement 'ollo5in" removal o'
in"ro5in" toenails
The proce&ure 'or removal o' part or all o' an in"ro5in" toenail
varies 5ith the practitioner4 Some &octors treat the area 5ith
phenol to prevent re"ro5th, others &o not4 Invariably the nail
be& blee&s pro'usely4 (se o' a haemostatic &ressin", such as an
al"inate @see B240A, covere& 5ith a 'oam &ressin" @see B24/1A
re&uces a&hesion o' the &ressin" to the toe4 The 5oun& can be
assesse& a'ter 1 &ays, 5hen 'urther mana"ement can be
planne&4 The use o' 'oam &r ess? in"s on the 'eet appears to
re&uce pressure 'rom 'oot5ear, 5hich patients 'in& com'ortable4
The use o' tulle &ressin"s is not r ecom? men&e&, because they
a&here to the 5oun& an& cause &ama"e on removal @see B242A4
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Sur"ical 0
Summar
y
%ost sur"ical 5oun&s are close& 5ith the s$in e&"es appose& an&only a simple &ressin" is re8uire&4 Several 'actors 5ill a''ect the
heal? in" o' sur"ical 5oun&s, inclu&in" len"th o' hospital stay,
poor health be'ore sur"ery, concurrent therapies an& 5oun&
in'ection4 *s 5ith all 5oun&s, the choice o' &ressin" is &irecte&
by the in&ivi&ual 5oun& state4
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CHAP*ER 8
Burns$ s#a,dsand minor
in=uries
The practice nurse is o'ten consulte& 'or a&vice an& mana"ement
o' minor in6uries, burns an& scal&s &urin" the &aily sur"ery4 This
chap? ter loo$s at the treatment o' these con&itions, because they
are r ele? vant to all community nurses4 Recommen&ations are
ma&e as to 5hich patients 5ill re8uire specialist a&vice4 The
a'tercare o' &onor sites an& mana"ement o' scar tissue are also
&iscusse&4 It is reco"? nise& that specialist centres may have their
o5n re"imen 'or the car e o' these 5oun&s, an& the rea&er is
e=pecte& to 'ollo5 local protocols4
BF4/ atients 5ith burns an& scal&s 're8uently atten& the ! sur"ery4
Which shoul& be re'erre& to acci&ent an& emer"ency
*s a "eneral rule, patients 'ittin" the 'ollo5in" criteria shoul&
atten& the acci&ent an& emer"ency &epartment @!o5er an&)a5r ence
/002A<
D *ny burn e=cee&in" 2L o' the bo&y sur'ace
ar ea4
D #urns o' 'unctionally important areas, such as the 'ace,
han&s, 'eet, perineum, 6oints or 'le=or sur'aces4
D I' other in6ury is suspecte&, e4"4 inhalation o' smo$e orother no=ious "as or electric shoc$4
D atients 5ith &iseases such as epilepsy or
&iabetes4
D I' the burn 5ill limit a person7s ability to sel'?mana"e, e4"4 to
the han&s o' an el&erly person livin" alone4
D atients 5ith 'ull?thic$ness burns 5hich may bene'it 'rom
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#urns, scal&s an& minor 2/ear ly "ra'tin" @see .i"ure /4A4
D *nyone sho5in" si"ns o' local in'ection or evi&ence o'
se pti? caemia @see Tables /-4/ an& /-4A4
2-
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#urns, scal&s an& minor 2/necessar y4
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2 Woun& Care< * Han&boo$ 'or Community Nurses
Other &ressin"s that may be suitable inclu&e 'ilm &ressin"s or
hy&rocolloi& &ressin"s @see B24/3 an& B24/9A4 %ost minor bur ns
5ill heal 5ithin a 5ee$ to /- &aysG a'ter this they shoul& be &resse&
as appropriate4 I' the burn has not heale& or almost heale& 5ithin1 5ee$s o' in6ury, it may be 'ull thic$ness an& re8uire a s$in
"ra't @!o5er an& )a5rence /002A @see .i"ure /4A4
%inor burns to the 'ace 5here it is &i''icult to apply &ressin"s
may be treate& 5ith /-L a8ueous povi&oneio&ine4 This nee&s
to be applie& three to 'our times a &ay 'or 2F &ays4 This 5ill
re&uce the possibility o' bacterial complications @see #o= 4A4
Tetanus cover shoul& also be r evie5e&4
BF4 *re there any instances 5hen treatment 'or burns 5ith col& 5ater is
not appropriate
Col& 5ater treatment is not appropriate i' the burns have been
cause& by metallic so&ium, potassium or calcium4 These all r eact
violently 5ith any a8ueous solution4 These burns are rare an&
appropriate me&ical a&vice shoul& be sou"ht4
BF42 What a&vice shoul& the patient be "iven 5hen the burn has heale&
The ne5 epithelium o' a recently heale& burn is &elicate an& sun
sensitive4 Dry &ressin"s mi"ht initially be in&icate& 'or
protection4 Total sun bloc$ shoul& be use& i' the area is e=pose& to
sunli"ht an& the area 5ell moisturise& 5ith a simple non?per'ume&
cr eam4
I' the burn 5as to the lo5er limb o' an el&erly patient, support
ban&a"es may be re8uire& to re&uce the possibility o' $noc$s to
&eli? cate s$in resultin" in episo&es o' ulceration @!o5er an&
)a5r ence
/002A4
BF43 What a&vice shoul& patients be "iven about carin" 'or heale&
&onor sites
%ost &onor sites heal 5ell 5ith little scarrin"4 The patient shoul& be a&vise& to protect the area 'rom e=tremes o' temperature,
trauma an& e=posure to the sun @.o5ler an& Dempsey /009A4 S$in
shoul& be moisturise& 5ith a simple non?per'ume& cream to $eep it
supple an& so't4 I' it is li$ely to be e=pose& to &irect sunli"ht, a sun
bloc$ o' 'actor
2 or hi"her shoul& be use&4
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2 Woun& Care< * Han&boo$ 'or Community Nurses5oun&s 5here there is little 'orce nee&e& to $eep the 5oun&
e&"es
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#urns, scal&s an& minor 22
to"ether4 They cause less trauma than sutures on both
application an& r emoval4
The 'ollo5in" is the application pr oce&ur e<
D Ensure that the surroun&in" s$in is
&r y4
D Start by &ra5in" the s$in 'rom each si&e o' the 5oun& to"ether
at the centre, ensurin" that the strip a&heres ri"ht up to the
e&"e o' the cut4
D %ore closures are then use& to &ra5 the si&es o' the
5oun& to"ether an& "ra&ually any "aps 'ille& in to ma$e a neat
r e pair 4D * secon&ary &ressin" is place& over the close& 5oun&
@see
B241A4
Once close& a small 5oun& shoul& have heale& 5ithin 2F &ays
@&epen&in" on positionA an& the strips may be
r emove&4
BF4/- When is sur"ical "lue appropriate
Sur"ical "lue has been use& in secon&ary care 'or many years4 It
is also a use'ul primary care tool4 The use o' sur"ical "lue in
primar y care can re&uce the nee& 'or suturin" 5oun&s, thus
re&ucin" the pain an& an=iety in chil&ren4 Sur"ical "lue is
particularly use'ul 'or closin" small lacerations on the 'ace an&
hea&, ta$in" care to avoi& the eye area4 It is not recommen&e& 'or bo&y parts 5here tension occurs, e4"4 the chin or on 'in"er 6oints4
!lue can be use& in con6unc? tion 5ith a&hesive strips4
*&vanta"es o' sur"ical "lue inclu&e the 'ollo5in"<
D Nurse?only mana"ement
D Spee& o' application
D No local anaesthetic r e8uir e&
D No 'ollo5?up 'or suturer emoval
D Re&uce& pain an& an=iety, especially 'or
chil&r en
D Re&uce& atten&ance at hospital4
The 5oun& shoul& be $ept &ry 'or 2 &ays4 No 'ollo5?up
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23 Woun& Care< * Han&boo$ 'or Community Nursesis re8uire& unless the 5oun& reopens4 It can be re"lue& or suture&
i' appr opriate4
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#urns, scal&s an& minor 2F
BF4// Is there a simple metho& 'or mana"in" lacerations
Stanley $ni'e bla&es are a common cause o' lacerations, 5hich
o'ten blee& pro'usely4 *l"inate &ressin"s act as a haemostat, an& i'applie& on to a blee&in" 5oun& 5hich is then elevate& the
blee&in" 5ill re&uce 'airly 8uic$ly4 It is essential to ensure that
there is no ' or ei"n bo&y in the 5oun& be'ore applyin" pressureG
this is o' particular r ele? vance i' the 5oun& 5as cause& by bro$en
"lass4
Summar
yOnly minor burns an& scal&s shoul& be treate& in the sur"eryG
r e'er any o' concern 'or secon&ary care mana"ement4 In most
instances, col& 5ater is the most e''ective 'irst ai& measure4 I'
patients atten& 5ith sunburn, consi&er health promotion issuesG
promote sunscreen an& bo&y protection to prevent 'urther episo&es
o' sunburn4 Ne5ly heale& burns an& &onor sites shoul& be
protecte& 'rom sunli"htG hi"h?'actor sun lotionsun bloc$ is
recommen&e& 'or these sites4
*&hesive strips an& sur"ical "lue are alternatives to
suturin"4 Each has a&vanta"es an& &isa&vanta"es, an& these
shoul& be 5ei"he& a"ainst patient pre'erence, cost?e''ectiveness
an& e' 'icacy4
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CHAP*ER 9
Le-u,#ers
The mana"ement o' patients 5ith le" ulcers is a problem
commonly encountere& by community nurses4 Stu&ies have
sho5n that bet5een 32L an& 92L o' patients are mana"e&
e=clusively by the primary health care team @:en&ric$ et al4
/00A4 This care is costly4 In /00- Charin" Cross Hospital le"
ulcer service estimate& the annual cost o' treatin" a le" ulcer to
be bet5een F-- an& 2-- per patient4 This su""ests that the
treatment o' le" ulcers costs the National Health Service 1--
3-- million a year 'or the (: as a 5hole @%orison /00/A4
(n&erstan&in" the aetiolo"y an& mana"ement o' both venous
an& arterial ulcers can re&uce the morbi&ity o' these con&itions
an& improve the 8uality o' li'e 'or patients4
B94/ What is a le" ulcer
* le" ulcer can be &e'ine& as an area o' &iscontinuity o' the
e pi&er? mis an& &ermis on the lo5er le" persistin" 'or 5ee$s or
more, e=clu&in" ulcers con'ine& to the 'oot4
B94 What are the principal causes o' le" ulcers
)e" ulcers may be cause& by a number o' un&erlyin"
patholo"ies4 %inor trauma is o'ten the imme&iate cause o' theulcer but un&er ly? in" patholo"y lea&s to ulcer &evelopment4 The
most common o' these patholo"ies is venous &isease @see B94/A,
5hich accounts 'or about F-L o' ulcers4 *roun& /-/2L are the
result o' arterial &isease @see B94/2A4 *bout /-L o' patients 5ill
have both venous an& arterial &isease4 These ulcers are $no5n as
mi=e& aetiolo"y ulcer s4
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)e" ulcers 2F23
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29 Woun& Care< * Han&boo$ 'or Community Nurses
D hlebitis o' the a''ecte& le"
D Suspecte& &eep vein thrombosis, e4"4 s5ollen le" a'ter
sur "er y, pre"nancy or trauma
D Sur"ery on a''ecte& le"D Trauma to the a''ecte& le", e4"4 'ractur e
D History o' pulmonary embolism4
B943 What is the typical appearance o' a venous ulcer
The 'ollo5in" are typical o' a venous ulcer<
DSite< o'ten near the me&ial or lateral malleolus4
D Depth an& shape< usually shallo5 5ith a poorly &e'ine& e&"e4
D ain< the pain o' venous ulceration is o'ten associate&
5ith oe&ema, 'rom local in'ections or cellulitis @see B/-42A4
ain is usually relieve& by compression ban&a"in" an&
elevation @see B940A4
D Development< usually slo5 unless in'ecte& @see B/-4/A4
B94F What are the clinical si"ns an& symptoms o' arterial &isease
Si"ns o' arterial &isease may inclu&e the 'ollo5in"<
D Col& le"s an& 'eet in a 5arm envir onment
D ale or blue 'eet 5hen raise&
D .eet &us$y pin$ 5hen unsupporte&
D Shiny hairless le"
D !an"renous toes
D *bsent 'oot pulses
D Trophic chan"es to nails
D oor tissue per'usionG i' the nail be& has &irect pressure applie&
to it, it ta$es lon"er than 1 secon&s to return to normal colour4
B949 What is the typical me&ical history o' a patient 5ith arterial &isease
* me&ical history su""estive o' arterial involvement may inclu&e
the 'ollo5in"<
D Hypertension
D %yocar&ial in'ar ction
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)e" ulcers 20
D *n"ina
D Transient ischaemic attac$s
D *rterial sur "er y
D Cerebrovascular acci&ent @see B94/2AD Intermittent clau&ication @see B94/2A
D Rheumatoi& arthritis @see B94/3A
D Diabetes mellitus @see B94/9A
D eripheral vascular &isease @see
B94/9A4
B940 What is the typical appearance o' an arterial ulcer
The 'ollo5in" are typical o' arterial
ulcer s<
D Site< o'ten on the 'oot or lateral aspect o' the le" but may
occur any5here inclu&in" the malleolar ar eas4
D Depth an& shape< o'ten &eep 5ith a punche&?out appearance,
o'ten irre"ular shapes or multiple small ar eas4
D ain< invariably pain'ul, o'ten the pain is ma&e 5orse byelevation or e=ercise4 atient may report han"in" the le"s out
o' be& to relieve pain4
D Development< o'ten rapi&4
B94/- What shoul& be inclu&e& in the assessment o' a patient presentin"
5ith le" ulcers
Success'ul treatment o' le" ulcers re8uires thorou"h
assessment to allo5 the &ia"nosis o' the un&erlyin"
patholo"y4 *ssessment shoul& inclu&e assessment o' the
patient7s "eneral con&ition, ulcer ? relate& history, clinical
investi"ations an& e=amination o' the ulcer itsel'4
atient assessment an& 5oun& assessment have been &iscusse&
in some &etail in earlier 8uestions, but an overvie5 an& issues
speci'ic to le" ulcers are "iven in Table 944 @see B4/B4 an&
B4/A4
:l+er8relate$
histor y
The assessment o' a patient presentin" 5ith either a 'irst or a
r ecur? rent le" ulcer shoul& inclu&e a &etaile& history o' the onset
o' the problems4 B94B943 &escribe the clinical si"ns an&
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3- Woun& Care< * Han&boo$ 'or Community Nursessymptoms, appearance o' the ulcer an& relevant me&ical histor y4
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)e" ulcers 3/
*ab,e 9<2 *ssessment o' the patient7s "eneral con&ition
*ssessment shoul&
inclu&e< *"e
Se=.amily history< there may be a pre&isposin" 'actor in le" ulcer &evelopment
Occupational history< venous le" ulcers are o'ten associate& 5ith occupations
involvin" prolon"e& stan&in"
%obility< re&uce& mobility contributes to ulcer &evelopment an& poor healin" @see
B94/A
Diet< poor nutritional status may &elay healin" @see B14A
Obesity< may contribute to poor healin" an& ulcer &evelopment @see B14A
Smo$in" habits< may contribute to poor healin" an& circulatory &isease @see B140 an&
B94/2A
!eneral livin" con&itions
sycholo"ical status< this is important in &eterminin" a patient7s participation in
care an& his or her compliance 5ith treatment
The patient shoul& have a thorou"h e=amination o' both the
le"s, 5hether or not ulcerate&4 *ny history o' ulceration
shoul& be inclu&e&, 5ith &uration, treatments use& or $no5n
aller"ies to &r ess? in"s @see B24-A4 * history o' the currentepiso&e o' ulceration shoul& also be &ocumente&4
B94// What clinical investi"ations may be necessary
Some routine investi"ations can ai& the &ia"nosis o' the le" ulcer
or help in its mana"ement4 Other investi"ations 5ill be necessary
only in a 'e5 circumstances4 Investi"ations are summarise& in
Table 9414
*ab,e 9<3 Clinical investi"ations
Investi"ation Rationale
#loo& pressure measurement To &etect hypertension @see B949A
(rinalysis#% stic$ To &etect &iabetes @see B949A
#loo& tests .ull bloo& count an& haemo"lobin levels to
i&enti'y anaemia4 Test 'or rheumatoi& 'actor @see
B14 an& B949AWoun& s5ab I' si"ns o' in'ection are present, to &etermine
antibi? otic sensitivity @see B/-4/A
Tissue biopsy I' mali"nancy is suspecte& @see Table 94/A
Wei"ht I' the patient is obese, &ietary a&vice an&
5ei"ht re&uction can ai& healin" @see B14A
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3 Woun& Care< * Han&boo$ 'or Community Nurses
B94/ Ho5 can vascular status be assesse&
The simplest 'orm o' vascular assessment is to palpate the
'oot pulses, both the &orsalis pe&is an& the posterior tibial @.i"ure94/A4
Ho5ever, the presence o' oe&ema may ma$e these pulses
&i' 'icult to 'eel4 * more accurate 5ay to ascertain the con&ition o'
the arterial circulation is to measure the an$le brachial pressure
in&e= @*#IA usin" Doppler ultrasono"raphy4 This shoul& be &one
only by a nur se 5ho has receive& trainin" an& practise& un&er
supervision4 The brie' &escription "iven here is not su''icient to
enable anyone to start usin" this techni8ue4
)ateral
malleolus
*nterior
tibial
eroneal
Dorsalis
pe&is
%e&ial
malleolus
osterior
tibial
)i-ure 9<1 Dia"ram sho5in" the positions o' pe&al pulses4
1eas&ring the ankle bra+hial press&re in$e 5
This &etermines the ratio o' the an$le to the brachial systolic
pres? sure 5ith the ai& o' a battery?operate& han&?hel& Doppler
probe4
The patient shoul& be lyin" as 'lat as possible 'or at least
/- minutes @%orison an& %o''att /00A4 This is to overcome the
e''ects o' e=ercise on the bloo& pressure4 This time can be use& to
ta$e the patient7s histor y4
The brachial systolic shoul& be recor&e& 'or both arms an& the
hi"her 'i"ure use& 'or calculation @Vo5&en et al4 /003A4 *n
appropri?
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ately siJe& sphy"momanometer cu'' is place& aroun& the arm an&
ultrasoun& "el place& over the brachial pulse to ensure a "oo&
seal bet5een the probe an& the s$in4 The Doppler probe is place&
at a sli"ht an"le over the brachial pulse until a "oo& si"nal ishear&4 The cu'' is in'late& until the si"nal &isappears an& then
"ra&ually &e' late& until the si"nal returns4 This is the brachial
systolic pressure4
To ta$e the 'oot pulses, secure an appropriately siJe&
sphy"mo? manometer cu'' 6ust above the me&ial malleolus4 *ny
5oun&s 5ill re8uire coverin" to prevent contamination either to or
'rom the cu' ' 4 In turn, locate the &orsalis pe&is, posterior tibial an&
anterior tibial pulses4 .or each pulse in'late the cu'' until thesi"nal is lost, then slo5ly &e'late the cu'' until the si"nal returns4
.or ma=imum accu? racy each pulse shoul& be measure& t5ice4 It
shoul& be note& that the &orsalis pe&is pulse is con"enitally absent
in up to /L o' people @#arnhorst an& #arner /039A4
In practice it is o'ten necessary to use only t5o o' the pe&al
pulses 'or measurement @%o''att /009A4 I' there is any &oubt
5hatsoever about the patient7s arterial status, a&vice shoul& be
sou"ht 'rom a specialist4To calculate the *#I &ivi&e the hi"hest an$le pressure
measur e& by the hi"hest brachial pressure4
*n$le systolic pressure#rachial systolic pressure S *n$le brachial
pressure in&e=
The value obtaine& 'or the *#I shoul& normally be "reater than
/4-4 I' the rea&in" obtaine& is belo5 /4- some &e"ree o' arterial&isease is in&icate&4 *n *#I o' -49--402 5oul& in&icate
minor levels o' arterial &isease4 *n *#I belo5 -49 in&icates
si"ni'icant arterial &isease an& compression ban&a"in" is
contrain&icate&4 Re'erral 'or 'urther vascular assessment is
re8uire& @%orison an& %o''att /00A4 * ratio o' -42--4F2 5ill
o'ten mean that the patient su''ers intermittent clau&ication, an&
belo5 this level ischaemic r est pain 5hich 5ill re8uire rapi&
re'erral to a vascular sur"eon @see B94/1A4*n *#I o' over /4 may be patholo"ical, e4"4 patients
5ith &iabetes may sho5 a 'alsely hi"h *#I as a result o'
me&icinal calci? nosis, 5ith vessels bein" &i''icult to
compress4 Compression
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ban&a"es shoul& not be applie& to people 5ith &iabetes e=cept
un&er close me&ical supervision @%orison an& %o''att /00A @see
B94/9A4
I' there is any &oubt about the si"ni'icance o' an *#I, a&octor shoul& be consulte& 'or a&vice4 No one 5ho has not been
traine& to &o Doppler rea&in"s shoul& attempt this proce&ure4
Contact the local tissue viability nurse, 5oun& care nurse or
&istrict nur se mana"er 'or a&vice4
Doppler rea&in"s shoul& be carrie& out 5hen the patient 'irst
presents 5ith an episo&e o' ulceration, i' the ulcer is &eterioratin"
or i' the ulcer &oes not respon& to treatment a'ter 1 months an&
at re"ular intervals &urin" treatment, e4"4 3 monthly4
B94/1 When shoul& the patient be re'erre& to another pro'essional
The vast ma6ority o' ulcers shoul& not re8uire specialist
assessment4 In some instances, 'urther a&vice an& assessment may
be r e8uir e&, e4"4<
D * si"ni'icantly re&uce& *#I4 Discuss 5ith the ! the nee&'or vascular re'erral @see B94/A4
D Rapi& &eterioration o' the ulcer 4
D Suspecte& mali"nancy @see
B94/A4
D Ne5ly &ia"nose& &iabetes mellitus @see B141 an&B94/9A4
D Si"ns o' contact &ermatitis @see
B24-A4D Cellulitus @see B/-42A4
D (lcers that 'ail to respon& to treatment a'ter a 1?month perio&
@see B941A4
Some areas may have specialist nurses 5ho may be able to
"ive a&vice in these instancesG other areas 5ill be &epen&ent on
consul? tant r e'er ral4
B94/ Ho5 &oes venous &isease cause ulceration
The venous system in the le" comprises both &eep an& super'icial
veins @.i"ure 94A4 The &eep veins are the popliteal an& 'emoral
veins4 The super'icial veins are the lon" an& short saphenous veins
5hich lie outsi&e the &eep 'ascia4
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*eep fas+ia
Femoral ,ein
%t4o ,al,es)
.opliteal ,ein
%t4o to three
,al,es)
Short sapheno&s ,ein
%&p to 2 ,al,es)
Saphenofemoral ,al,e
.erforating ,ein
%4ith ,al,es)
;ong sapheno&s ,ein
%&p to 20 ,al,es)
Ankle perforators
)i-ure 9<2 Dia"rammatic illustration o' the venous supply to the le"4
The super'icial veins are &esi"ne& to carry bloo& at lo5
pressureG they &rain into the &eep vein system via per'oratin"
veins4 The &eep veins return the bloo& bac$ to the heart at a much
"reater pressure4
When a person 5al$s, the cal' muscles act as a pump an&
'orce &eep venous bloo& bac$ up the le"4 When healthy an& intact,
valves in the per'oratin" system stop bloo& 'lo5in" bac$ into the
super'icial system4 When the muscle is restin", bloo& 'lo5s 'romthe super'icial veins 'illin" the &eep veins, 5hich have a temporary
lo5er pressure4
I' the valves in the per'orators become incompetent, bloo&
'lo5s bac$ into the super'icial veins at hi"h pressure 5hen the
cal' pump 5or$s an& &ama"es the valves in these4 This eventually
lea&s to vari? cose veins4
Dama"e to valves in the &eep an& per'oratin" veins lea&s to
chronic venous hypertension in the lo5er limb, the hi"h bac$ pres?sure causin" venous stasis an& oe&ema4 Venous return is 'urther
ai&e& by the an$le movement involve& in 5al$in" @%orison an&
%o''att /00A, 5ith the *chilles7 ten&on stretchin" an& rela=in"
the cal' muscle in&epen&ently o' cal' muscle contraction4 Wal$in"
also empties the 'oot veins an& ai&s venous return 'rom the 'oot as
the heel stri$es the "roun& @!ar&ner an& .o= /093A4
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In people 5ho have limite& mobility, the cal' muscle pump or
'oot pump is not bein" use& properly i' at all, an& venous return
is impaire&4 The increase& pressure in the super'icial system lea&s
to oe&ema, capillary &ama"e an& thinnin" o' the &ermis4Capillary &ama"e allo5s lea$a"e o' re& bloo& cells an&
protein molecules into the interstitial 'lui&G the re& bloo&
cells ar e &estroye&, releasin" haemo"lobin 5hich brea$s &o5n
an& causes s$in pi"mentation an& ecJema4 .ibrino"en, 5hich is
release& 5ith the re& bloo& cells, turns into 'ibrin 5hich
&eposits a cu'' ar oun& the capillaries an& re&uces the &i''usion o'
o=y"en an& other nutri? ents4 This in turn causes tissue
ischaemia4 With the s$in bein" thin an& susceptible to trauma,minor &ama"e lea&s to le" ulceration @see BF49A4
B94/2 Ho5 are arterial ulcers cause&
*rterial ulcers are cause& by an insu''icient arterial bloo& 'lo5 to
the lo5er le", 5hich results in tissue ischaemia an& necrosis4
The most common cause o' this is atherosclerosis4 .atty
materials are &eposite& on the 5alls o' arteries an& "ra&ually buil&up to 'orm pla8ues4 These "ra&ually increase 5ith a"e4 The
process is spee&e& up i' the patient has hypertension,
hyperlipi&aemia, &iabetes mellitus or smo$es4 The t5o 'actors
most stron"ly lin$e& to ischaemia ar e &iabetes an& smo$in" @see
B949A4
B94/3 Why are patients 5ith rheumatoi& arthritis susceptible to ulcers
*bout /-L o' patients 5ith rheumatoi& arthritis &evelop an ulcer
@un et al4 /00-A4 Everyone has poorly vascularise& s$in over
the tibia, but in those 5ith rheumatoi& arthritis it is particularly
susce pti? ble to trauma an& &elaye& healin" i' they are ta$in"
hi"h &oses o' corticosteroi&s @see B140A4
Other ulcers may be attribute& to arteritis4 These ten& to appear
su&&enly, &evelop 8uic$ly an& heal slo5ly4
Vasculitic ulcers are also associate& 5ith rheumatoi& arthritisan& other connective tissue &isor&ers4 They are o'ten present as
multiple small an& very pain'ul ulcers on limbs 5ith no si"n o'
chronic venous hypertension4 Healin" is slo5 an& 5ill be a''ecte&
by the cause o' the un&erlyin" &isease4
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B94/F Ho5 shoul& ulcers associate& 5ith rheumatoi& arthritis be mana"e&
This &epen&s on the un&erlyin" cause o' the ulcer @see B94 an&
B941A, an& the treatment shoul& be base& on this4 I' the cause ischronic venous hypertension, "ra&uate& compression shoul& be
applie& but it is e=tremely important to e=clu&e arterial &isease
@see B94/ an& B940A4
articular attention shoul& be "iven to the s$in to prevent
'urther &eterioration or trauma4 The s$in shoul& be $ept supple an&
tr eate& 5ith emollients @see B42A, an& i' a&hesive &ressin"s are
use& "r eat care must be ta$en in removin" them so as not to
&ama"e the s$in 'urther 4%any o' these patients have a poor appetite @%orison an&
%o''att /00A an& may re8uire nutritional supplements @see
B14B14FA4
Re"ular an$le an& 'oot e=ercises 5ill be o' bene'it but the
patient may re8uire help 5ith these @see B940A4
Oe&ema may be a problem 'or patients 5ho cannot raise their
le"s as a result o' arthritic chan"es or coe=istin" peripheral
vascular &isease4
B94/9 Why are patients 5ith &iabetes mellitus prone to ulceration
atients 5ith &iabetes may &evelop ulcers as a result o' one or a
combination o' un&erlyin" patholo"ies, so care'ul assessment o'
the patient is vital4
(lceration o' the lo5er limb, particularly the 'oot, is
ver y common in patients 5ith &iabetes mellitus4 They have&elaye& heal? in" an& an increase& ris$ o' in'ection @Koseph an&
*=ler /00-A4 !an"rene may &evelop lea&in" to lo5er limb
amputation4
Diabetic 'oot ulcers may result 'rom peripheral neuropathy,
peripheral vascular insu''iciency an& in'ection, either sin"ly or as
a combination4
eripheral vascular &isease is common in people 5ith &iabetes,
an& ten&s to occur more rapi&ly an& at a youn"er a"e @)evin /099A4Calci'i? cation o' the bloo& vessels is also si"ni'icant in people 5ith
&iabetes4
Ris$ 'actors increasin" the ris$ o' vascular &isease are
increasin" a"e, &uration o' &iabetes, smo$in", hypertension an&
hypercholes? terolaemia @%orison an& %o''att /00A4
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eople 5ith &iabetes may also have chan"es to small vessels
as 5ell as the lar"er arteries4 This means that the toes may
su''er ischaemic &ama"e4 This ris$ is much "reater in people
5ith poor ly controlle& &iabetes4Other &iabetic ulcers are the result o' neuropathy4 There ar e
three types o' neuropathy< sensory, motor an& autonomic4 eople
5ith &iabetes an& sensory neuropathy have re&uce& or absent
pain sensations in their 'eet, 5hich can lea& to unnotice& &ama"e4
This can be mechanical, e4"4 stan&in" on a sharp ob6ect or
shoes rubbin", thermal, e4"4 scal&in" 'rom stan&in" in 5ater
that is too hot, or chemical, e4"4 'rom sel'?treatment 5ith
chemical cor n r emover s4%otor neuropathy results in 'oot &e'ormity 5ith cla5in" o'
the toes an& metatarsal hea&s4 This chan"es the patient7s "ait
an& pro&uces unnatural pressure, 5hich may result in a buil&?up o'
callus an& ulceration on the sole o' the 'oot, especially over areas
such as the 'irst metatarsal hea&, enlar"e& bunions an& bony
prominences on the toes4
*utonomic neuropathy results in the absence o' s5eatin"
5hich means that the s$in becomes very &ry an& prone to &evelopcrac$s an& 'issures that allo5 the entry o' 'un"i an& bacteria4
(nli$e most ulcers o' the s$in, these ulcers &evelop initially 'rom
&eep 5ithin the tissues4 .lui& collects un&er callus 'ormation an&
becomes in'ecte&, lea&in" to abscess 'ormation an& ulceration
@%orison an& %o''att /00A4 The openin" o' the ulcer may be
small an& the e=tent o' the tissue &ama"e not imme&iately obvious4
This can lea& to 'urther in'ection e=ten&in" &o5n to the ten&on
an& bone4 I' treatment is not rapi&, ra&ical &Mbri&ement may bere8uire& @see B4/-, B24// an& B24/2A
*lthou"h people 5ith &iabetes are prone to the types o' ulcer
&escribe& here, they may also present 5ith venous ulceration or
some o' the more rare types o' ulcer4 *s a "roup, it is
especially important that patients 5ith &iabetes have the
un&erlyin" cause o' their ulcer &etermine& as soon as possible
@see B94/AG they have a particular nee& 'or specialist vascular
assessment4
B94/0 What a&vice shoul& patients 5ith &iabetes be "iven about 'oot care
This a&vice is probably best "iven both verbally an& 5ith a
lea'let that the patient can $eep 'or re'erence @#o= 94/A4
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Bo/ 9<1 .oot care a&vice 'or people 5ith &iabetes
Wash 'eet &aily, ma$in" sure they &ry them 5ell particularly bet5een the toes
.eet shoul& be chec$e& &aily 'or any &ama"e, re&ness or blisterin"4 I' patientscannot see their o5n 'eet, they shoul& as$ a carer or 'rien& to &o this4 *ny minor
in6uries shoul& be reporte& to the ! imme&iately
Soc$s an& stoc$in"s shoul& be clean an& chan"e& &aily
.oot5ear shoul& be chec$e& 'or 'orei"n bo&ies such as stones an& 'elt 'or any
6a""e& e&"es, be'ore 5ear
Ne5 shoes shoul& be 'itte& by a traine& 'itter
Care o' toenails, callus an& corns shoul& be per'orme& by a po&iatrist, 5ho shoul&
be in'orme& that the patient has &iabetes
atients shoul& be a5are o' e=treme temperatures an& chec$ the temperature o' the
bath be'ore puttin" their 'eet in4 They shoul& also try to $eep the 'eet 5armto avoi& chilblains 5hich may ulcerate
atients shoul& be as$e& not to 5ear soc$s or stoc$in"s 5ith bul$y seams or &arns
that may &i" in, an& not to 5ear shoes 5ithout soc$s or stoc$in"s
atients shoul& not 5al$ bare 'oot
atients shoul& not per'orm their o5n po&iatry or use chemicals to remove corns
or callus
atients shoul& not to put their 'eet too close to the 'ire, put their 'eet on hot
5ater bottles or soa$ their 'eet 'or a lon" time
atients shoul& avoi& ti"ht corsets an& "arters 5hich 5ill restrict bloo& 'lo5 to
the lo5er limbsThey shoul& not smo$e
B94- Shoul& &iabetic ulcers be mana"e& li$e other arterial ulcers
*lthou"h many ulcers on patients 5ith &iabetes are the result o'
arte? rial problems, their special nee&s shoul& be borne in min&4
They shoul& have a spee&y re'erral 'or specialist treatment sothat the ulcer &oes not &eteriorate rapi&ly an& lea& to lo5er limb
ampu? tation @see B94/1A4
The care is most e''ective 5hen it is multi&isciplinary,
involvin" the physician, specialist &iabetic nurse, po&iatrist,
orthotist an&, in some cases, the vascular an& orthopae&ic
sur"eon @%orison an& %o''att /00A4
)evin @/099A su""ests that the mana"ement o' &iabetic 'oot
ulcers shoul& be a""ressive4 This involves rapi& local &Mbri&ementleavin" only healthy tissue, systemic antibiotic therapy, &iabetic
control an& non?5ei"ht?bearin" 'or plantar ulcer s4
*n appropriate local &ressin" shoul& be chosen but the ulcer 5ill
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respon& only i' the above treatment is "iven4 Ho5ever, an
inappr o? priate &ressin" may ma$e the situation 5or se4
(lcerate& 'eettoes shoul& be $ept &ry to eliminate maceration
bet5een the toes 5hich 5ill allo5 in'ections to enter @seeB24/A4 atients shoul& be "iven a&vice about 'oot care @see #o=
94/A4
The person 5ith &iabetes shoul& be stron"ly a&vise& to stop
smo$? in" an& to 'ollo5 &ietary a&vice to re&uce lon"?term
complications4
.or 'urther in'ormation about mana"ement o' &iabetes, the
rea&er is re'erre& to Turner an& Crosby, *iabetes! A 6an$book f or
7omm&nity N&rses in this series4
B94 / When shoul& I suspect that an ulcer is mali"nant
%ali"nant ulcers are rare in the (: @more 're8uent in tropical
coun? triesA, but i' ulcers 'ail to respon& to treatment this shoul&
not be overloo$e& as a cause @*c$roy& an& oun" /091A4
S8uamous cell carcinoma may &evelop in a chronic venous
ulcer @it then becomes $no5n as a %ar6olin7s ulcerA4 *lthou"h
uncommon, it may be suspecte& i' the ulcer has an unusual
appearance 5ith over"ro5th o' tissue at the base o' the 5oun&
or 5oun& mar "ins4 Con'irmation is by biopsy an& histolo"ical
e=amination4
%elanomas are more common but unli$ely to be mista$en 'or
venous ulceration4
:aposi7s sarcomas are a"ain rare, but becomin" more common
5ith the sprea& o' ac8uire& immune &e'iciency syn&rome @*IDSAGthey are usually small an& multiple an& may ulcerate @%orison
an& %o''att /00A4
B94 What are the main aims o' le" ulcer treatment
The aim o' treatment is
thr ee' ol&<
/4 To heal the ulcer 4 To treat the un&erlyin"
con&ition
14 To prevent r eoccur r ence4
B941 What primary &ressin"s shoul& be use& on le" ulcers
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moist, 5arm environment con&ucive to 5oun& healin" shoul& be
chosen @see B249A4 E=cessive e=u&ate shoul& be absorbe&4
Dressin"s shoul& be non?to=ic, non?a&herent, non?aller"enic an&
non?sensitisin" @%or"an /09FA4 (n&er 'our?layer compression ban&a"es, o'ten all that is necessary is a simple non?a&herent
&ressin" @see B940A4
B94 Ho5 o'ten shoul& the &ressin" be chan"e&
(nless there is e=cessive e=u&ate, &iscom'ort or ban&a"e
slippa"e, the &ressin" shoul& be chan"e& once a 5ee$ @NHS
E=ecutive /002A4 Ho5ever, the treatment re"imen shoul& be&etermine& in con6unc? tion 5ith the patient an& there 5ill be
instances 5here more 're8uent chan"es are necessar y4
B942 What is the best 5ay to cleanse an ulcer
(lcers shoul& be cleanse& by irri"ation 5ith 5arm
physiolo"ical saline i' necessary @see B41 an& B4A4 I' there is
no ol& &ressin" material or e=u&ate this may not be nee&e&4 )e"smay be 5ashe& 5ith 5arm tap 5ater containin" an emollient i'
&esire&4 I' usin" a communal buc$et, it shoul& be line& 5ith
plastic @ne5 'or each patientA an& cleanse& bet5een use by local
in'ection control meth? o&s, to prevent any cross?in'ection4
Washin" helps to $eep the s$in in "oo& con&ition by removin"
loose s$in scales an& is also pleasant 'or the patient 5ho may
other5ise be unable to 5ash the 'eet an& le"s 'or lon" perio&s4
B943 Some patients 5ith le" ulcers seem sensitive to the pro&ucts use&4
Ho5 can this be avoi&e& or treate&
atients can become sensitise& to treatments at any time @see
B24- an& B24/A4 atients 5ith reactions to un$no5n sensitisers
shoul& be re'erre& to a &ermatolo"ist 'or patch testin"4 In cases o'
sensitivity, remove the $no5n or potential aller"en, apply a simple
non?a&her ent &ressin", an& elevate an& rest the limb4 )iaise
5ith the ! to prescribe a steroi& ointment @cream may contain
sensitisersA4 * pply the ointment 'or &ays4 Re&uce the amount
o' ointment use& over the 'ollo5in" 1 &ays an& replace the
steroi& 5ith 5hite so't para'? 'in emollient4
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bet5een - an& - mmH" at the an$le, to 2-L o' that value at
the $nee @:en&ric$ et al4 /00A4 * compression ban&a"e
shoul& be anchore& at the base o' the toes, e=ert ma=imum
compression at the an$le an& 'inish at the $nee4%anu'acturers7 instructions shoul& be 'ollo5e&4 #an&a"es
that are incorrectly applie& are at best uncom'ortable an& useless
an& at 5orst &an"erous4 It is important that anyone applyin" a
compression ban&a"e has been tau"ht the correct metho& o'
application, un&er? stan&s the rationale 'or the treatment an& is
competent to carry out the tr eatment4
Compression can be applie& as a sin"le?layer, lon",
str etch ban&a"e, e4"4 Sureress or Tensopress4 Orthopae&ic pa&&in" may be re8uire& to protect the le", particularly over bony
prominences4 Note that patients 5ith an an$le circum'erence o'
less than /9 cm @see .i"ure 941, p4 F3A are not suitable 'or
compression unless su' 'icient pa&&in" is applie& to buil& up the
an$le siJe4
%ultilayer compression systems @a"ain usin" lon" str etch
ban&a"esA provi&e a&e8uate pa&&in" an& a&e8uate sustaine&
compression 'or at least a 5ee$4 In most instances, a 5ee$ly&ressin" chan"e is recommen&e&4 Only accepte& systems shoul&
be use&4 These may come in $it 'orm, e4"4 ro'ore or (ltra .our or
ban&a"es can be purchase& separately4 *ll patients shoul& have
their an$le circum'erence measure& to ensure that the
appropriate ban&a"e re"imen is selecte&4 %anu'acturers7
instructions 'or application shoul& be a&here& to an& the
practitioner appropriately traine& in the application o' multilayer
ban&a"in"4*lternatively, short stretch ban&a"es can be use&, e4"4
Comprilan, Rosi&al :4 These have been use& e''ectively in
Europe since the early /03-s4 They are /--L cotton @use'ul i' the
patient is aller"ic to elastic 'ibres see B24-A4 They are applie&
at 'ull stretch so that &urin" e=ercise to the cal' muscle the
ban&a"e &oes not e=pan& in the 5ay a lon" stretch ban&a"e
5oul&4 The 5or$in" 'orce o' the cal' muscle is there'ore re'lecte&
bac$ into the le" @Charles /000A4 When 5ashe& they have noelasticity to lose an& can be reuse& 5ith the same e''ect as 5hen
ne54 a&&in" shoul& be use& over areas prone to pressure &ama"e
such as the *chilles7 ten&on, bunion area, tibia, malleoli an& the
&orsum o' the 'oot4 Initially, 5hen use& oe&ema re&uces so the
ban&a"e 5ill nee& reapplyin" as the le" cir cum'er ence re&uces,
other5ise any bene'its 5ill be lost4
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E5er +is
e
Wal$in" e=ercises the cal' muscle an& 5or$s the muscle pump,
increasin" venous return4 %any patients 5ith venous ulcers ar e
capable o' a mile or moreG this shoul& be encoura"e&4 Ho5ever, i'
they are el&erly or have other &isabilities, this 5ill not be
achievableG a&vice shoul& be tailore& to suit the patient7s
capabilities4 R e"ular 'le=ion an& e=tension e=ercises are
bene'icial in 5or$in" the cal' muscle pump 'or patients 5ith
limite& mobility4
Ele,ation
atients shoul& be encoura"e& to elevate their le"s above hip
hei"ht 5hen sittin" to 'acilitate venous r etur n4
B941- Ho5 shoul& mi=e& aetiolo"y or arterial ulcers be treate&
I' the *#I is bet5een -49 an& -402, the limb can have
compression therapy @see B94/A4 #elo5 this level, unless a&vise&
to the contrar y, e4"4 by a vascular sur"eon, ulcers shoul& be treate&
as arterial4
B941/ What is the recommen&e& mana"ement 'or arterial ulceration
Compression must not be use& on ulcers 5ith a substantial
arterial component4 *ny ban&a"es use& shoul& be li"ht retention
ban&a"es4 %il& e=ercise an& an$le e=ercises shoul& be encoura"e&especially i' the patient is immobile @see B940A4 Severe arterial
&isease may restrict mobility to less than /-- yar &s4
ain control may be achieve& by rest, anal"esia an& a suitable
&ressin", e4"4 'oam, hy&ro"el or hy&rocolloi& @see B4FB40
an& B24/1B24/3A4
atients 5ith arterial &isease, particularly those 5ith an
*#I belo5 -4F2, shoul& be consi&ere& 'or a sur"ical
opinion @see B94/A4
B941 When &oes a trauma to the le" become an ulcer
I' the patient has a history o' le" ulceration an& $no5n vascular
problems, any minor in6ury to the le" shoul& be treate& as a r ecur?
rence o' ulceration, an& appropriate treatment commence&
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imme&i? ately @see B41 an& B94/-A4
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In other patients, i' the 5oun& &oes not respon& as you 5oul&
e=pect other minor 5oun&s to, a vascular assessment shoul& be
carrie& out an& i' either venous or arterial &isease is &iscovere&
the 5oun& shoul& be treate& as an ulcer @see B94/A4eople 5ithout vascular problems may still have problems
5ith more ma6or $noc$sG even in healthy people the s$in over the
tibia is poorly vascularise& an& pretibial lacerations can ta$e
some time to heal @see BF49A4
B9411 When shoul& the treatment be chan"e&
In&ivi&ual healin" rates 5ill vary 5hatever the un&erlyin"con&ition4 *ny ulcer not respon&in" to treatment in 9 5ee$s
shoul& be reassesse&4 Treatment may nee& to be chan"e& or the
patient may re8uire 'urther investi"ation or re'erral to a
specialist nurse or consultant @see B94/1A4
B941 Ho5 can recurrence be prevente&
*ppro=imately F2L o' patients su''er recurrence o' ulceration4This can be re&uce& i' appropriate a&vice is "iven4
atients shoul& be a&vise& to report any ne5 &ama"e to le"s as
soon as possible, so that treatment can be starte&4 atients 5ith
venous &isease re8uire compression 'or li'e4 When healin"
is complete, they shoul& be measure& 'or suitable hosiery @see
B9412B94/A4
Encoura"e patients to continue 5ith e=ercise @see B940A4
R ein? 'orce a&vice on &iet, li'estyle an& smo$in" habits4Encoura"e pr otec? tion o' the le"s 'rom trauma &ama"e an&
continue to monitor the un&erlyin" &isease4
B9412 What is the role o' compression hosiery in preventin" recurrence
o' venous ulceration
*s the primary cause o' venous ulceration is the &evelopment o'
patholo"ical venous hypertension, it is important that the
un&er lyin" cause continues to be treate& @see B94/ an& B940A4
!ra&uate& compression hosiery applies e=ternal pressure to the
s$in an& un&erlyin" tissues 5hich supports the super'icial
veins, helpin" to counteract the raise& capillary pressure an& thus
r e&ucin"
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oe&ema4 The re&uction o' oe&ema has been sho5n to be a crucial
'actor in relation to both ulcer healin" an& preventin" 'urther s$in
brea$&o5n an& ulceration @%o''att an& O7Hare /002A4
B9413 Which are pre'erre& above? or belo5?$nee stoc$in"s
.or most patients either len"th is e8ually e''ective @%o''att an&
O7Hare /002A4 Ho5ever, above?$nee stoc$in"s are more
appr opriate i' oe&ema collects aroun& the $nee, or i' the patient
has arthritic chan"es to the $nee that cause belo5?$nee stoc$in"s
to be uncom? ' ortable4
In other patients, compliance may be more li$ely 5ith belo5?$nee stoc$in"s 5hich are relatively easy to put on4 *lthou"h class
1 stoc$in"s @compression 212 mmH"A are &esirable, a patient
5ith &e=terity problems may be encoura"e& to comply by movin"
&o5n to class @compression /9 mmH"A4
B941F Shoul& stoc$in"s be open or close& toe
This is a 8uestion o' patient pre'erence4 Some patients, especiallythose 5ith &e'ormities o' the toe such as hammer toes, 'in& close&
stoc$in"s uncom'ortable an& restrictive, 5hereas others 'in& open
toes &i" in 5here the stoc$in" en&s4
B9419 What measurements shoul& be ta$en be'ore or&erin" stoc$in"s
%easurin" the limb accurately is important so that the stoc$in"
is 'itte& properly an& to ensure com'ort4 Ill?'ittin",
uncom'ortable stoc$in"s re&uce patient compliance in re"ular
5earin" o' the stoc$? in"4
%easurements shoul& be ta$en either 'irst thin" in the mor nin"
be'ore any oe&ema has accumulate& or imme&iately a'ter the
ulcer has heale& an& the compression ban&a"e has been r emove&4
%ost patients 5ill 'it into the stan&ar& siJes available on
prescrip? tion but those 5ith very lon" or &isproportionate le"s
may r e8uir e ma&e?to?measure stoc$in"s4 I' both le"s re8uire a
stoc$in" they shoul& be measure& separately4 The
measurements re8uire& ar e sho5n in .i"ure 9414
%anu'acturers su""est that stoc$in"s shoul& be rene5e& every
3 months4 The limb shoul& be measure& on each occasion that
a
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@CA
@#A
@*A @EA
@DA
)i-ure 9<3 %easurements to be ta$en 5hen 'ittin" compression stoc$in"s4 @*A
The an$le at its narro5est pointG @#A the cal' at its 5i&est pointG @CA above $nee only<the thi"h at its 5i&est pointG @DA the len"th o' the 'ootG @EA len"th o' le", heel to
belo5 $nee4 The patient shoul& be bare le""e& an& stan&in" to ensure accurate
measurement4
stoc$in" is re8uire&4 It may be pre'erable to $eep the patient in
compression ban&a"es 'or 1 5ee$s a'ter healin" to limit the
possi? bility o' &ama"e to ne5ly 'orme& 'ra"ile s$in4
B9410 There are &i''erent classes o' compression hosiery4 What are their uses
Compression hosiery 'alls into three
classes4
D Class /< "ives //F mmH" pressure at the an$le4 They
ar e recommen&e& 'or varicose veins an& mil& oe&ema4
D Class < "ives /91 mmH" pressure at the an$le4 Theyar e recommen&e& 'or mo&erate?to?severe varicose veins an&
pr even? tion o' ulcer r eoccur r ence4
D Class 1< "ives 212 mmH" pressure at the an$le4 They
ar e recommen&e& 'or "ross varices, postphlebitic le"s,
r ecur r ent ulceration an& lymphoe&ema4
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* class 1 stoc$in" is the best choice 'or patients 5ith r e peate&
episo&es o' ulceration an& consi&erable venous &isease but they
ar e &i''icult to put on, particularly 'or el&erly patients4 !enerally a
class stoc$in" is reco"nise& as su''icient to prevent recurrence i'
venous &isease is not severe, althou"h there is little available
research in this area @%o''att an& O7Hare /002A4
I' a patient has very limite& &e=terity t5o class / stoc$in"s
may prove easier to put on @this 5ill "ive "reater pressure than a
class overallA4
B94- *re there any tips 'or easier application o' hosiery
Some ai&s are available to assist 5ith application such as the
Valet @%e&iA but these are not available on prescription an&
have to be purchase& 'rom a pharmacy4
atients may 'in& application easier i' they &ust their le"
li"htly 5ith a simple non?per'ume& talcum po5&er be'ore
application to ma$e the stoc$in" slip on more easily4 Wearin"
rubber "loves may help to "rip the stoc$in"4 .or open?toe&stoc$in"s, placin" a Chinese slipper or plastic ba" over the 'oot
may ai& pullin" the stoc$in" over the 'oot4 The ba" or slipper
shoul& be pulle& out once the stoc$in" is in place4
B94/ *re there any haJar&s associate& 5ith the use o' compression stoc$in"s
The bi""est haJar& is i' the patient has a si"ni'icant amount o'
arter? ial &isease @see B94/A4 Care'ul patient assessment,
pre'erably 5ith a Doppler probe, shoul& eliminate this problem4
.or the patient 5ith arterial &isease, the &evelopment o' pressure
necrosis is a potential haJar &4
Ill?'ittin" stoc$in"s may also cause pressure or 'riction
&ama"e, particularly over the tibial crest, the &orsum o' the 'oot,
the bunion area, overcro5&e& or &e'orme& toes or any an$le
&e' or mity4
Stoc$in"s shoul& be chec$e& 'or correct 'it aroun& arthritic
&e'orme& $nees 5here they may 'orm constrictin" cu''s, "ivin"
a tourni8uet e''ect4 Some patients may su''er 'rom s$in aller"ies
or irritation @see B24-A an& 5ill re8uire a stoc$in" that has a
cotton layer ne=t to the le"4
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an&
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Tubi"rip an& as$e& her to &o her o5n &ressin"s4 Durin" this year,
the le" ha& 'aile& to respon& to the treatment an& the ulcer ha&
sli"htly increase& in siJe4 She 5as also 'eelin" miserable, because
the pain 'rom her ulcer 5as stoppin" her en6oyin" line &ancin",an& she 'elt unattractive4
.inally she &eci&e& to see$ a secon& opinion4 *t assessment,
her ulcer 5as sho5n to be venous4 It measure& appro=imately 1
cm an& 5as covere& by appro=imately 2-L slou"h4 .our?layer
compr es? sion 5as commence& an& she a"ree& to ta$e / month o''
5or$ to stop the necessity 'or prolon"e& stan&in"4 *'ter / 5ee$ she
5as r evie5e&4 The ulcer ha& starte& to re&uce in siJe an& 5as no5
142 cm 5ith about 2L slou"h4 She also 'elt morecom'ortable4 Within another 1 5ee$s the ulcer measure& / /42 cm an& 5as clean4
.ortunately,
5ee$s later @school holi&aysA sa5 the ulcer
heale&4
She 5as amaJe& at the pro"ress an& happy to 5ear the
pr escribe& stoc$in"s4 She 5as less happy about the 5aste& year o'
tr eatment4
7ase st&$y(
%rs ) ha& ha& a venous ulcer 'or years4 Despite compression
ther? apy an& appropriate &ressin"s, it remaine& static an& the
nursin" team, 5hile 'rustrate& at the lac$ o' pro"ress, 5ere
resi"ne& to t5ice? 5ee$ly &ressin" chan"es4
One team member starte& a &evelopmental course an& be"an to
8uestion 5hat 5as best practice4 She &eci&e& to loo$ at a 'e5
patients 5ho 'aile& to respon& to treatment an& see 5hether, by
rea&in" more about their con&itions, she coul& solve any o' the
problems4 *s part o' this, she starte& to rea& about 5oun& healin"
an& realise& that, althou"h the compression therapy an& &ressin"s
5ere 'ine, there coul& be some other un&erlyin" patholo"y
preventin" ulcer healin"4 She persua&e& the team lea&er to ta$e a
bloo& sample 'rom %rs ), an& the results sho5e& pernicious
anaemia4 *ppropriate treatment 5as commence& by the ! an& a'ter
a 'e5 months the ulcer slo5ly starte& to impr ove4
7ase st&$y-
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%r . 5as an active 93?year?ol& man4 He live& alone 5ith no help
an& each &ay cycle& to the shops or 5or$in" men7s club4 He
en6oye& other people7s company an& 5as happy4 He ha& a /?year
history o' bilat? eral venous ulceration about 5hich he seeme& to
be unperturbe&4
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They appeare& to cause him no &iscom'ort an& althou"h e=tensive
they 5ere static, not chan"in" in siJe 'rom month to month4 The
ulcers 5ere &resse& three times a 5ee$ by the &istrict nur se4
*s the nurses "aine& a better un&erstan&in" o' the bene'its o'compression therapy, they &eci&e& to start %r . on compression
ban&a"in"4 *n improvement in con&ition coul& be seen very
8uic$ly4 Ho5ever, %r . became pro"ressively more irritable an&
miserable4 It transpire& that he 'elt the ban&a"es 5ere impe&in" his
cyclin"4 He 5as relyin" on nei"hbours &oin" his shoppin" an&
erran&s, an& he ha& been unable to "o on his re"ular visits to the
club4 %r . 5as persua&e& to "et his bicycle out an& &emonstrate
the problem4 It 5as apparent that, 5hether or not it 5as a practical or psycholo"ical problem, he 5as unable to cycle4 He
persevere& 'or a 'urther 5ee$s "ettin" visibly lo5er in moo&4
The nurse met 5ith the health?car e team to &iscuss the problem4
The team 5ere &ivi&e&4 Hal' 'elt that the ne5 re"imen 5as
re&ucin" the 're8uency o' visits an& thus costs an&, as there 5as
an improvement, compression shoul& continue4 Hal' 'elt that his
rapi& &ecline in his "eneral con&ition an& moo& o''set any
bene'its an& that isolatin" him 5as inappropriate4What 5oul& you &o
4S4 Calle& in to a&6u&icate I &eci&e& that "iven his a"e an&
that the siJe o' the ulcers 5oul& preclu&e 'ast healin", to ma$e an
ol& man happy, 5e shoul& let him live 5ith his ulcers an& ri&e his
bi$e4
Summary
There are several causes o' le" ulceration an& it is important to
&etermine ulcer type at the onset o' treatment4 Thorou"h
assessment o' the patient7s "eneral con&ition, the a''ecte& limb,
ulcer site an& a vascular assessment are essential4 The aim o'
treatment is thr ee' ol&< to heal the ulcer, to treat the un&erlyin"
con&ition an& to pr event r eoccur r ence4
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9 Woun& Care< * Han&boo$ 'or Community Nurses
CHAP*ER :
Pressuresores
ressure ulcers are a common problem4 Inci&ence an& pr evalence
stu&ies "enerally &emonstrate that bet5een 1L an& /-L o' the
population in both hospital an& community settin"s ac8uire a
&e"r ee o' pressure &ama"e 5hile un&er"oin" care @)an& /00A,
althou"h some estimates put the 'i"ure hi"her4 .inancial costs
to the NHS have been estimate& as hi"h as FF2 million a year
@West an& riest? ley /00A4 This inclu&es sta'' time, &ru"s,
&ressin"s an& hospital over? hea&s, but e=clu&es costs to the patient
such as pain, su''erin", loss o' in&epen&ence an& in some
circumstances li'e4 These costs ar e impossible to calculate4 It
has been estimate& that 3- --- &eaths a year result 'rom
complications o' pressure &ama"e, althou"h &eath certi'icates
rarely re'lect this @Staas an& Cioschi /00/A4
atients are becomin" increasin"ly concerne& about pressure
sores bein" an unnecessary complication o' me&ical treatment
an& are be"innin" to see$ recompense throu"h the courts4 In
/09F &ama"es o' /-- --- 5ere a5ar&e& to a success'ul
claimant @Silver
/09FA4
It is obvious that the prevention o' pressure ulcers shoul& be o'
paramount importance to the nurse4 Ho5ever, it is apparent that
not all pressure sore &evelopment is preventable4 )oa&er et al4
@/00A estimate that, althou"h 02L o' pressure &ama"e can be
avoi&e&, the remainin" 2L is inevitable, resultin" 'rom 'actors
such as &ama"e bein" present be'ore the care episo&e, &ebilitatin"
un&erlyin" con&i? tions an& e=traor&inary cir cumstances4
*lthou"h nurses &o not 5or$ in isolation, nursin" care must be
re"ar&e& as a ma6or in'luence on outcomes relate& to pressure
ar ea car e4
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9/
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B04 What are the intrinsic 'actors that cause pressure ulcers
Intrinsic 'actors that cause pressure ulcers inclu&e the
'ollo5in"<
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ressure sores 91
<en$er
The Waterlo5 @/092A ris$ assessment tool ta$es "en&er into
account an& sho5s 5omen to be at "reater ris$ o' pressure &ama"e
than men4 Ho5ever, the reasons are poorly un&erstoo&4
Age
ressure &ama"e can occur at any a"e but is more common in
el&erly people because s$in has lost elasticity an& they are more
li$ely to have concurrent &iseases @Ny8uist an& Ha5thorne /09FA4
Immobility* re&uction in mobility 'or any reason increases the ris$ o'
&evelop? in" pressure &ama"e @Dealey /00A4
=o$y
4eight
)o5 bo&y 5ei"ht "ives less protection 'rom pressure over
bony prominences4 Obese patients may s5eat, increasin" the ris$
o' shear or 'riction @Dealey /00A4
N&trition
%alnutrition is a primary contributin" 'actor an& re&uces the
tissue7s ability to 5ithstan& pressure @%a$leburst an&
Sie"r een
/003A4 It also causes &elaye& healin" @%c)aren /00G Dealey
/00A @see also B14B14FA4 Obese patients can also bemalnourishe& @see B04FA4
1e$i+ation
Steroi&s, anti?in'lammatory &ru"s, stron" anal"esics, se&atives,
U? bloc$ers an& cytoto=ic &ru"s can increase the ris$ o'
pressure &ama"e by re&ucin" mobility, sensation, s$in inte"rity
an& appetite @#an$s /00FA4
In+ontinen+e
Incontinence o' either 'aeces or urine can result in s$in
maceration or e=coriation4 This lea&s to increase& ris$ o' 'riction
&ama"e an& increases the ris$ o' in'ection @Tor rance /091G
Dealey /00A @see
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9 Woun& Care< * Han&boo$ 'or Community Nurses
B04FA4 Some &ru"s such as aperients, &iuretics an& antibiotics may
e=acerbate incontinence @Dealey /00A4
:n$erlying$isease
%any un&erlyin" &iseases contribute to the &evelopment o'
pressure &ama"e4 Neurolo"ical problems can cause loss o'
mobility an& sensation4 )o5 bloo& pressure results in a lo5er
e=ternal pressure bein" re8uire& to occlu&e the capillary vessels4
Circulatory problems can re&uce bloo& supply to the tissues an&
impair the removal o' 5aste pro&ucts4 Other con&itions
increasin" the ris$ o' pressure &ama"e inclu&e *lJheimer7s&isease, carcinoma, &iabetes, arthritis, "astrointestinal, liver an&
renal problems @Dealey /00G #an$s /00FA4
Skin +on$ition
Tissue paper s$in can be the result o' a"ein" or the use o' lon"?
ter m hi"h?&ose steroi&s @see B149A4 Oe&ematous s$in can also
result in a re&uce& o=y"en supply an& impaire& removal o'5aste pr o&ucts @Tor rance /091G Dealey /00A4
Inf e+tion
Systemic in'ection can lea& to pyre=ia, e=cessive s5eatin" an&
tissue brea$&o5n @#an$s /00FA @see B/-4/ an& B/-4A
Smoking
See B1404 Smo$in" can also result in loss o'
appetite4
Other
f a+tor s
These inclu&e pain, state o' consciousness, psycholo"ical
'actor s, sociolo"ical 'actors an& 5ho is provi&in" home care
@Dealey /00A4B042 What are the e=trinsic 'actors that cause pressure ulcers
E=trinsic 'actors resultin" in patients e=periencin" pressure
&ama"e inclu&e pressure, shear an& 'riction4
.r ess&r
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ressure sores 92e
ressure &ama"e usually occurs over the bo&y7s bony
prominences4 When pressure is applie& to the s$in 'rom the
support sur'ace @i4e4
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ressure sores 9F
F ri+tio
n
This is the 'orce relate& to t5o sur'aces movin" across one another4
I' a patient is not move& usin" recommen&e& movin" an&han&lin" techni8ues, but is &ra""e& or pulle& across sur'aces,
'riction can &isrupt the epi&ermis an& cause an initial brea$ in the
s$in4 This can occur in a community settin" i' the patient7s carers
are also el&erly or in'irm, an& they have &i''iculty li'tin" the
patient, or i' care sta'' ar e ina&e8uately traine&4
.riction &ama"e can also occur as a result o' an ill?'ittin"
plaster cast or limb prosthesis4
B043 Ho5 can patients at ris$ o' &evelopin" pressure &ama"e be i&enti'ie&
When initiatin" a preventive strate"y it is necessary to i&enti'y
those patients at ris$ o' &evelopin" pressure sores4 This can be
achieve& by usin" ris$ assessment tools, 5hich<
D *ct as an ai$e8m>moire to carers @.lana"an
/001AD Help provi&e 8uanti'iable &ata 'or au&itin" [email protected]"an
/001A
D rovi&e evi&ence that preventivetreatment plans are base&
on ob6ective criteria an& a speci'ic rationale @.lana"an /001A
D *i& the rational allocation o' limite& resources @such as
special mattressesA to those most li$ely to bene'it 'rom them
@ Ef f e+ti,e 6ealth 7ar e =&lletin /002AD *ct as case mi= a&6usters to help ma$e sensible comparisons
o' pressure sores bet5een units over time @ Ef f e+ti,e 6ealth 7ar e
=&lletin/002A4
The 'irst ris$ assessment scale 5as the Norton ressure Sor e
Ris$ *ssessment Scale @Norton et al4 /03A %any
mo&i'ications have appeare& since4 Norton is probably one o'the best $no5n an& most 5i&ely use& @#arrett /09FG Davies
/00A but is 'elt by some to be too simplistic4 It is important to
choose a scale that is suitable 'or your area o' 5or$4 *lthou"h
all scales have a research?base& rationale, they 5ere &esi"ne&
'or &i''er ent purposes an& settin"s4 Norton7s scale 5as &esi"ne&
speci'ically 'or use 5ith the ol&er person4 Some &i''erences are
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99 Woun& Care< * Han&boo$ 'or Community Nursessho5n in Tables
04/ an& 044
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ressure sores 90
*ab,e <1 The Norton Score
hysical state %ental state *ctivity
!oo& *lert *mbulant .air 1 *pathetic 1 Wal$s 5ith help 1
oor Con'use& Chairboun&
Very ba& / Stuporous / #e&boun& /
%obility Incontinence
.ull None
Sli"htly limite& 1 Occasional 1
Very limite& (sually urine
Immobile / Double /
VThe Norton Score can be use& to assess the &e"ree o' ris$ o' &evelopin" pressure
sores4 It 5as &evelope& 'or use 5ith el&erly patients4 * score o' / in&icates
vulnerability to pressure sores4 * score o' / is hi"h ris$4
*ab,e <2 Comparison o' ris$assessment
Ris$ 'actor Norton !osnall :noll Waterlo5 #ra&en
%obility H H H H H
*ctivity H H H H
Nutritional status H H H H
%ental status H H H H
Incontinencemoisture H H H H H
!eneral physical con&ition H H H
S$in appearance H H
%e&ication H H
.rictionshear H
Wei"ht H
*"e H
Speci'ic pre&isposin" H H
rolon"e& pressure H
* comparison o' pressure sore ris$ 'actors use& in various ris$ assessment scales
@.lana"an /001A4
The Waterlo5 score, Table 041, is another popular assessmenttool, &evelope& in the (: in /094 It is more comple= than the
Norton score @#irchall /001A, covers a lar"er number o' ris$
'actor s an& "roups patients into three cate"ories o' ris$ status4 It
also cover s su""estions 'or care "ui&elines4
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Bui,d>Wei-+t for Hei-+t V Skin *y0e V Se/>A-e V S0e#ia, Risks
*vera"e*bove *vera"eObese
#elo5 *vera"e
-/
1
HealthyTissue aperDry
Oe&ematousClammy @ TempX
A Discoloure&#ro$enSpot
-/
/
//
1
%ale.emale/0
2-332FF29-9/Y
/
/
1
2
*issue "a,nutrition V
e4"4 Terminal Cache=ia
Car&iac .ailureeripheral VascularDisease
*naemiaSmo$in"
9
22
/
Continen#e V "obi,ity V A00etite V Neuro,o-i#a, %efi#it
CompleteCatheterise&Occasionally IncontinentCathIncontinent o' .aecesDoubly Incontinent
-/
1
.ullyRestless.i&"ety *patheticRestricte&InertTractionChairboun&
-/
1
2
*vera"eoor
N4!4 Tube.lui&s only N#%*nore=ic
-/
1
e4"4 Diabetes, %4S4, CV*,%otorSensory araple"ia 3
"a=or
Orthopae&ic#elo5 Waist, Spinalon Table hours
22
"edi#ation
Cytoto=icsHi"h Dose steroi&s*nti?In'lammatory
9 9
Woun&Care<*Han&boo$'orCommun
ityNurses
*ab,e <3 The Waterlo5 ressure Sore reventionTreatment olicy4 Repro&uce& 5ith $in& permission o' %rs Ku&y Waterlo5
Water,o; Pressure Sore Pre.ention>*reatmentPo,i#y
RIN! SCORES IN T*#)E, *DD TOT*)4 SEVER*) SCORES ER C*TE!OR C*N #E (SED
Score /-Y * Ris$ /2Y Hi"h Ris$ -Y Very Hi"h Ris$
Remember tissue &ama"e o'ten starts prior to a&mission, in casualty4 * seate& patient is also at ris$4
*ssessment< I' the patient 'alls into any o' the ris$ cate"ories then preventative nursin" is re8uire&4 * combination o' "oo& nursin" techni8ues an&
preventative ai&s 5ill &e'initely be necessary4
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ressuresores
9 0
REVENTION< WUN% CLASSI)ICA*INREVENT*TIVE *IDS< Stirlin" ressure Score severity scale @SSSSA
Special %attress#e&< /-Y overlays or specialist 'oam mattresses4/2Y alternatin" pressure overlays, mattresses an&
be&systems4-Y #e& System< .lui&ise&, bea&, lo5 air lossan&alternatin" pressure mattresses4
Note < reventative ai&s cove r a 5i&e spectrumo' specialist 'eatures4 E''icacy shoul& be 6u&"e&, i'
possi? ble, on the basis o' in&epen&ent evi&ence4
Cushions< No patient shoul& sit in a 5heelchair 5ithoutsome
'orm o' cushionin"4 I' nothin" else is available Zusethe patient7s o5n pillo54/-Y[[ .oam cushion4/2Y Specialist cell an&or 'oam cushion-Y Cushion capable o' a&6ustment to suitin&ivi&ual
patient4#e& Clothin"< *voi& plastic &ra5 sheets, inco pa&s an& ti"htlytuc$e&
in sheetssheet covers, especially 5hen usin"Special?ist be& an& mattress overlay systems4(se Duvet?plus vapour permeable cover4
N(RSIN! C*RE !eneral< .re8uent chan"es o' position, lyin"sittin"
(se o' pillo5sain *ppropriate pain control
Nutrition Hi"h protein, vitamins, mineralsatient Han&lin"< Correct li'tin" techni8ue Hoists %on$ey ole
Trans'er Devicesatient Com'ort *i&s< Real sheeps$ins Z #e& Cra&leOperatin" Table
\\Theatre*;E Trolley cover plus a&e8uate protection4
S$in Care< !eneral Hy"iene, NO rubbin", cover 5ith an appro? priate &ressin"
If treatment is re?uired$ first remo.e 0ressure
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Sta-e 5 Z No clinical evi&ence o' pressure sore5<1 Z Heale& 5ith scarrin"5<2 Z Tissue &ama"e not assesse& as a pressure sore @aA belo5
Sta-e 1 Z Discoloration o' intact s$in1<1 Z Non?blanchable erythema 5ith increase& local heat1<2 Z #luepurpleblac$ &iscoloration Z the sore is at least Sta-e 1 @aor bA
Sta-e 2 Z artial thic$ness s$in loss or &ama"e2<1 Z #lister 2<2 Z *brasion2<3 Z Shallo5 ulcer, no un&erminin" o' a&6acent tissue
2<4 Z
*ny o' these 5ith un&erlyin" bluepurpleblac$ &iscoloration or in&uration4 The sore is at least Sta-e 2 @a, b or cY& 'or 2<3, Ye 'or2<4A
Sta-e 3 Z .ull?thic$ness s$in loss involvin" &ama"enecrosis o'subcuta? neous tissue, not e=ten&in" to un&erlyin" bone ten&on or 6ointcapsule
3<1 Z Crater, 5ithout un&erminin" a&6acent tissue3<2 Z Crater, 5ith un&erminin" o' a&6acent tissue3<3 Z Sinus, the 'ull e=tent o' 5hich is uncertain3<4 Z Necrotic tissue mas$in" 'ull e=tent o' &ama"e4The sore is at least Sta-e 3 @b, YH?e, ', ", Yh 'or 3<4A
Sta-e 4 Z .ull?thic$ness loss 5ith e=tensive &estruction an& tissuenecrosis e=ten&in" to un&erlyin" bone ten&on or capsule
4<1 Z Visible e=posure o' bone ten&on or capsule4<2 Z Sinus assesse& as e=ten&in" to same @bYH?e, ', ", h, iA
!ui&e to types o' Dressin"sTreatment a4 Semipermeable membrane '4 *l"inate roperibbon
b4 Hy&rocolloi& "4 .oam cavity 'iller c4 .oam &ressin" h4 EnJymatic &ebri&ement&4 *l"inate i4 Sur"ical &ebri&emente4 Hy&ro"el
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0- Woun& Care< * Han&boo$ 'or Community Nurses
Ris$ assessment tools shoul& be use& as an a&&ition to clinical
6u&"ement4 The Ef f e+ti,e 6ealth 7ar e =&lletin @/002A su""ests that
ther e is little evi&ence that usin" a pressure sore ris$ scale is
better than clinical 6u&"ement or that it improves outcomes4Ho5ever, any tool that can help to assist in i&enti'yin" at?ris$
vulnerable patients is valuable 5hen plannin" care, but any tool
is o' bene'it only i' it is use& correctly an& the patient7s at?ris$
status is reassesse& r e"ular ly an& 5henever there is a chan"e in his
or her con&ition4
B04F Ho5 can pressure sores be prevente&
Choice o' an appropriate support sur'ace is important @see B049A
to remove the e=trinsic 'actors si"ni'icant in the &evelopment
an& &elaye& healin" o' pressure ulcers @%orison /090A, as is
alleviatin" the e''ects o' the intrinsic 'actors contributin" to tissue
brea$&o5n4 @see B04 an& B042A
*ssess the patient7s ris$ o' &evelopin" pressure &ama"e 5hen
they 'irst come into your care, an& reassess re"ularly or 5henever
there is a chan"e in the patient7s con&ition, usin" a reliable an&vali& assess? ment tool @see B043A4
Incontinence is o'ten associate& 5ith pressure sores @.letcher
/00A4 %oisture is $no5n to be a 'actor in increasin" pressure
&ama"e ris$, an& 5oun& e=u&ate an& perspiration as 5ell as
urine may lea& to s$in maceration @riest an& Clar$e /001A4 It
has also been su""este& that 'aecal incontinence is a more
important 'actor in pressure &ama"e than urinary incontinence
@riest an& Clar $e/001A4 The patient shoul& be cleanse& as soon as possible a'ter
bein" incontinent, e=cessive soap shoul& not be use&, avoi& the
rubbin" o' &elicate s$in, an& i' possible correct the cause o' the
incontinence @E$ an& #oman /09A4 Dealey @/002A su""ests
that the use o' a mil& cleanser in a spray 'ormat, such as the
Triple Care System @Smith ; Nephe5A, may re&uce pressure
sore inci? &ence4
%alnutrition has also been &escribe& as one o' the mostcommonly cite& 'actors in the &evelopment o' pressure &ama"e
@Closs /001A @see B04A4 I' the patient is 'ailin" to eat a balance&
&iet an&or is losin" 5ei"ht, chec$ on the reason 5hy, an& arran"e
prac? tical help such as meals on 5heels i' necessary an& 'oo&
supplements
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ressure sores 0/
such as .resubin @.reseniusA or Ensure @*bbottA 'or
consumption bet5een meals @see B14B14FA4 .lui& inta$e shoul&
also be moni? tor e&4
Inspect hi"h?ris$ areas re"ularly 'or any si"ns o' &ama"ean&
&evelop a plan o' mobilityturnin" appropriate to the patient7s
ris$, 5hich $eeps him or her o'' any &ama"e& s$in or hi"h?ris$
sites as much as possible, bearin" in min& the patient7s nee& 'or
com' ort, sleep, meals an& li'estyle4 I' much o' the care is bein"
carrie& out by relatives or other carers, it is important to involve
them in movin" the patient, loo$in" 'or &ama"e an& reportin"
&ama"e strai"ht a5ay4 It may help to have carers7 in'ormationlea'lets available to rein'orce a&vice "iven @see B949A4
B049 What shoul& be ta$en into account 5hen selectin" an appropriate
support sur'ace
When selectin" a suitable support sur'ace, 5hether 'or an
in&ivi&ual patient or 'or a "roup o' patients @such as in a nursin"
homeA, the 'ollo5in" 'actors nee& to be consi&ere&<
D Clinical
D ractical
D .inancial @Clar$ an& .letcher/000A4
7lini+al+onsi$er ations
The intrinsic an& e=trinsic ris$ 'actors @see B04 an& B042A nee&
to be consi&ere&, an& also issues such as< What is the patient7s
ris$ level7 an& >Is this e=pecte& to chan"e Has &ama"e
alr ea&y occurre& Does the patient have other re8uirements 'rom a
mattress, such as nee&in" a 'irm e&"e to allo5 trans'er out o'
be& *re ther e any me&ical problems that ma$e certain types o'
mattress unsuit? able @Clar$ an& .letcher /000A
.ra+ti+al+onsi$er ations
D Will the mattress 'it on the patient7s e=istin" be& Consi&er
both the 5i&th an& the chan"e in hei"ht4 Does the patient
share a &ouble be& 5ith his or her partner
D Ho5 easy is the support sur'ace to transport an& to set
up
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0 Woun& Care< * Han&boo$ 'or Community Nurses
D Will sta'' nee& to be traine& to use the e8uipment an& 5ill sta''
be re8uire& to supervise its use This is particularly important i'
it is to be use& in the patient7s home4
D Ho5 shoul& it be cleane& in bet5een patient use an& ho5much stora"e space &oes it re8uire Ho5 much
maintenance is re8uire& an& 5ho 5ill per'orm this
D Is the patient 5ithin the correct 5ei"hthei"ht limit su""este&
by the manu'actur er
D Is the mattress acceptable to the patient @Clar$ an& .letcher
/000A
Finan+ial+onsi$er ations
.inancial 'actors o'ten a''ect the availability o' support sur'aces
to patients4 The 'ollo5in" points nee& to be consi&ere& to avoi&
incur? rin" unnecessary costs an& to allo5 e8uity o' access to
e8uipment4
D Is there a clear proce&ure 'or >steppin" up an& &o5n7 to
ensure that e8uipment is remove& 'rom patients 5ho no lon"ernee& that level o' e8uipment, so that other more nee&y
in&ivi&uals can "ain access to it
D *re there any hi&&en costs, e4"4 maintenance costs or
specialist cleanin"
D What 5ill it cost the patient or relatives to run the
e8uipment, an& is this acceptable to them
B040 What type o' support sur'ace shoul& be selecte&
There is a lar"e selection o' support sur'aces available4 They can
be &ivi&e& into those provi&in" pressure re&uction an& those
pr ovi&in" pressure relie'4 ressure re&uction is the constant relie' o'
pressure that is bein" e=erte& on the patient7s bo&y4 This is
pro&uce& by e8uipment such as layere& or 'orme& 'oam?, "el?,
'ibre? or air?'ille& mattr esses, lo5 air?loss or air?'lui&ise& systems
@:enney an& Rithalia /000A4ressure relie' is intermittent lo5erin" o' the e=ternal pressure
on the patient7s bo&y by in'lation an& &e'lation o' the cells o'
the mattress or by li'tin" the bo&y clear o' the sur'ace4 This can
be achieve& by manual turns, or by the use o' an alternatin"
pressure mattr ess4
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ressure sores 01
Static overlays are the simplest 'orm o' pr essur e?
r e&ucin" mattresses @Collier /000aA4 They can be ma&e o' 'oam,
'ibre or "el, 5hich con'orms to the patient7s bo&y shape an&
re&istributes 5ei"ht over a lar"er sur'ace ar ea4There are a number o' static mattresses 5ith pr essur e?r e&ucin"
properties available4 These are ma&e o' 'oam4 Consi&eration
shoul& be "iven to the &ensity an& the har&ness o' the 'oam, hi"her
&ensity 'oam usually lastin" lon"er than lo5?&ensity 'oam
@:enney an& Rithalia /000A4 The mattress may be &esi"ne& 5ith
'oam slits or be pre'orme& to 'it the patient7s contours4 *ll these
mattresses ar e &esi"ne& to &istribute pressure evenly un&er the
patient4 Consi&era? tion shoul& be "iven to ho5 o'ten the mattressnee&s turnin" to $eep it in "oo& con&ition, an& 5hat type o'
'abric the cover is ma&e o' @Collier /000aA4 Static cushions are
available an& shoul& have the same 8ualities as the mattress
chosen4
)o5 air?loss systems are available either as be& systems
or mattresses an& provi&e pressure re&uction via in&ivi&ual air ?
'ille& cells, o'ten "roupe& re"ionally to ma=imise the pr essur e?
r e&ucin" e''ect4*lternatin" pressure sur'aces can be supplie& as overlays or
replacement mattresses4 They consist o' a number o' seale& cells in
a removable cover, 5hich in'late an& &e'late alternately, thus
r e&istrib? utin" the pressure over the so't tissues o' the bo&y an&
allo5in" reper'usion o' previously supporte& areas @%c)eo&
/00FA4
Natural sheeps$ins may re&uce 'riction or shear but &o not
re&uce pressure @Collier /000bA4 Synthetic sheeps$ins have been sho5n to be ine''ective an&, i' poorly laun&ere&, to increase
inter'ace pressure @)othian an& #arbenal /091A4
Rubber or Sorbo rin"s shoul& never be use& to re&uce pressure,
because they actually concentrate pressure on a smaller sur'ace
an& may cause ne5 ulcers @)othian an& #arbenal /091A4
Su""estions 'or types o' mattress are &i''icult4 I&eally, all
health? care areas shoul& have a local policy that su""ests
e8uipment base& on clinical e''ectiveness4 The Ef f e+ti,e 6ealth 7ar e =&lletin @/002A states that >most o' the e8uipment available 'or the
prevention an& tr eat? ment o' pressure sores has not been reliably
evaluate& an& no ]best buy^ can be recommen&e&74
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0 Woun& Care< * Han&boo$ 'or Community Nurses
* "eneral "ui&e coul& be the 'ollo5in"<
D !ra&e / sore< static
over laycushionD !ra&e 1 sore< alternatin" air5aveover laycushion
D !ra&e 1 sore< alternatin" air5ave
mattr esscushion4
Ho5ever, a patient 5ith no sore may in&icate a hi"h level o'
ris$ an& re8uire an appropriate support sur'ace4 Immobile patients
5ho cannot turn 5ill nee& re"ular position chan"es to $eep them'ree o' sores4
Summar
y
ressure sores are cause& by e=trinsic an& intrinsic 'actors4 The
ris$ o' &ama"e &evelopin" shoul& be pre&icte& usin" a suitable,
r eliable an& vali& tool4 ressure &ama"e shoul& be prevente& by both select? in" an appropriate support sur'ace an& alleviatin" the
e''ects o' the intrinsic 'actors that contribute to pressure &ama"e4
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03 Woun& Care< * Han&boo$ 'or Community Nursesor &iabetic may 'ail to sho5 si"ns o' in'lammation an& si"ns o'
clinical in'ection, an& may re8uire a s5ab to be ta$en i' the 5oun&
is 'ailin"
02
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Woun& in'ection 0F
practice nurse4 * 'ull assessment, inclu&in" Doppler stu&ies,
in&i? cate& that the ulcer 5as o' venous ori"in4 Treatment 5as
commence& 5ith a 'oam &ressin" an& sin"le?layer compression,
an& the treatment 5as to be chan"e& once a 5ee$4Initially the ulcer respon&e& 5ell an& 5as re&ucin" in siJe4 *'ter
a 'e5 5ee$s it became in'ecte& an& nee&e& treatment 5ith
antibiotics4 The in'ection resolve&4 *'ter another couple o' 5ee$s
the ulcer a"ain became in'ecte& an& antibiotics 5ere re8uire&4
This became a pattern over the ne=t couple o' months an& no
pro"ress to5ar &s healin" 5as bein" ma&e4 Eventually, a'ter
"entle 8uestionin", it 5as reveale& that %rs K 5ante& her le"
&resse& more 're8uently than once a 5ee$ as she ha& al5ays&one it once or t5ice a &ay 5hen loo$in" a'ter it hersel'4 To
achieve this she 5as ta$in" o'' the ban&a"e, 5ashin" an&
&ryin" the 'oam &ressin" an& care'ully reban? &a"in" the limb4
The nurse e=plaine& to her that this 5as the cause o' the 're8uent
in'ections an& that it 5as pre'erable that the &ressin" be le't in
place to optimise 5oun& healin"4
To achieve a better level o' compliance, a compromise 5as
reache& 5hereby she atten&e& the sur"ery t5ice a 5ee$4 Theulcer a"ain starte& to pro"ress an& 'inally 5ent on to heal4
7ase st&$y
%r H 5as a F3?year?ol& 'armer4 He ha& al5ays been active an&
still mana"e& a small mi=e& 'arm inclu&in" co5s, &uc$s, sheep
an& hens4 He ha& recently &evelope& a venous le" ulcer 5hich ha&
&evelope& rapi&ly an& $ept "ettin" in'ecte&4 This situation 5asnot helpe& by copious amounts o' 'armyar& manure4 His con&ition
5as startin" to limit his mobility an& his ability to ta$e care o'
the 'arm4 This 5as ma$in" him e=tremely an=ious4 T5o?layer
compression ban&a"in" ha& been attempte&, but constant pullin"
o'' o' Wellin"ton boots $ept &isturbin" the ban&a"es 5hich 5ere
'ilthy 5ith manur e4
* 'our?layer ban&a"e ha& been consi&ere& but, 5ith the
amount o' e=u&ate an& the necessity 'or the Wellin"ton boot,&ismisse&4 *'ter a 6oint consultation o' the vascular specialist,
tissue viability nurse, &istrict nurse, %r H an& his sister, it 5as
a"ree& that the prior? ities 5ere to re&uce the amount o' in'ection
an& thereby the e=u&ate, an& to achieve a "oo& level o'
compression4 .our?layer ban&a"in" 5as commence&, %r H7s
sister purchase& a lar"er Wellin"ton boot
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09 Woun& Care< * Han&boo$ 'or Community Nurses
an& cut it &o5n to hal' le" len"th to ai& easier application an&
removal, an& a pop soc$ over the ban&a"e ma&e it less stic$y,
5hich also helpe&4 Initially the ban&a"e 5as chan"e& t5ice a
5ee$4%r H7s le"s improve& &ramatically, the e=u&ate &ecrease&,
the ban&a"es staye& in place an& the 'armyar& manure &i& not
pene? trate the layers o' ban&a"e, an& so the in'ections
subsi&e&4 His mobility returne&4 *'ter 3 months o' treatment, the
le" 5as heale& an& %r H continue& to run his 'ar m4
B/-41 Is there a recommen&e& metho& o' ta$in" a 5oun& s5ab
There is some controversy over the best metho& o' per'ormin" a
5oun& s5ab4 The metho& &escribe& by Cooper an& )a5r ence
@/003A is "ently to irri"ate the 5oun& 5ith physiolo"ical saline, to
use the s5ab in a Ji"?Ja" motion over the entire 5oun& sur'ace
5hile slo5ly rotatin" it4
B/-4 Ho5 shoul& in'ecte& 5oun&s be treate&
Treatment o' in'ection shoul& be 5ith systemic antibiotics,
because the use o' topical treatments 5ith antibacterial creams
can lea& to the "ro5th o' resistant or"anisms, an& shoul& be
avoi&e& @%or "an
/09FA4
(ntreate& 5oun& in'ection can lea& to septicaemia an& &eath
@see B/-4/1A4
B/-42 What is cellulitis an& ho5 shoul& it be treate&
Cellulitis is an acute, rapi&ly s5ellin" in'lammation o' the s$in
an& so't tissues @!rey /009A4 It is characterise& by s5ellin",
pain, erythema an& heat, an& sometimes 'ever4 These si"ns are
usually con'ine& to the area aroun& the 5oun&, but in some
severe cases it may be accompanie& by 'eatures o' systemic
to=icity, inclu&in" se pti? caemia4 It o'ten occurs a'ter minor
brea$s in the s$in, lacerations, sur"ical 5oun&s an& ulcer s4
The t5o main causative or"anisms are Staphylo+o++&s a&re&s an&
Strepto+o++&s pyogenes @!rey /009A4 Streptococcal in'ection ten&s to
be associate& 5ith small brea$s in the s$in an& staphylococcal
in'ections 5ith lar"er 5oun&s such as ulcer s4
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Woun& in'ection 00
I&enti'ication o' the causative or"anism is o'ten &i''icult,
5ith tests such as 5oun& s5abs an& bloo& cultures "ivin" poor
r esults4 Dia"nosis an& treatment ten& to be empirical an& base&
on the bacteriolo"y o' the associate& 5oun&4 Ho5ever, culture o'any tissue 'lui& or pus shoul& be attempte&4 #loo& shoul& be ta$en
i' there ar e clinical si"ns o' in'ection, but these tests are not al5ays
positive even i' there are si"ns o' systemic in'ection @!rey /009A4
Severe cases 5ill re8uire hospital a&mission4
atients 5ith &iabetic or ischaemic 'oot ulcers @see B94/9A,
5ho &evelop associate& cellulitis, are at hi"h ris$ o' &evelopin"
systemic to=icity @!rey /009A, an& i' un&ertreate& this can have
"rave conse? 8uences such as the loss o' a limb4Treatment is normally a systemic antibiotic @%orison an&
%o' 'att
/00AG in'ection present 5ithin the tissues cannot be reache& by
applyin" topical a"ents @see B/-4A4
B/-43 What is the sin"le most important thin" that can be &one in
clinical practice to re&uce the ris$ o' cross?in'ection
E''ective han& 5ashin" is the most important 'actor in re&ucin"
cr oss? in'ection @ar$er /000A4 *lthou"h this is routinely
ac$no5le&"e&, a constant application o' this practice still &oes
not e=ist4 %icr o? or"anisms 'oun& on the s$in are terme& >resi&ent7
an& >transient7 ' lora4
>Resi&ent7 or"anisms live an& multiply on the s$in an& 5ill
var y 'rom person to person4 They "enerally are not virulent an&
rar ely cause the person harm4 Ho5ever, i' trans'erre& to &eeperstructures they coul& be harm'ul, e4"4 &urin" invasive proce&ures
such as minor sur"ery4 HaJar& can be minimise& by usin" an
antiseptic han& 5ash @ar$er /0004A
>Transient7 or"anisms are ac8uire& 'rom contact 5ith another
person or ob6ect, such as 'rom contaminate& sur'aces4 Durin"
>&irty7 proce&ures, e4"4 chan"in" the &ressin" on an in'ecte&
5oun&, they can be pic$e& up even 5hen "loves are 5orn4 They
ten& to be loosely attache&, so 5ashin" 5ith soap an& 5ater 5illremove them4
Han&s shoul& be 5ashe& as 'ollo5s<
/4 Rub palm to palm
4 Rub bac$s o' both
han&s
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/- Woun& Care< * Han&boo$ 'or Community Nurses
14 Rub palms a"ain 5ith 'in"ers
inter lace&
4 Rub bac$s o' interlace&
'in"er s24 Remember to 5ash both thumbs
34 Rub both palms 5ith 'in"er
tips4
Washin" shoul& be un&er runnin" 5ater 5ith chosen cleanser
an& han&s shoul& be thorou"hly &rie& on a paper to5el4 Routine
social han& 5ashin" shoul& be /-/2 secon&s 5ith either soap or an
antise p? tic, 5hereas 'or minor sur"ery 5ashin" shoul& be 2minutes4
Other points to consi&er ar e<
/4 *voi& 5earin" 6e5ellery especially rin"s @5e&&in" rin"s
shoul& be manipulate& &urin" han& 5ashin" to remove micro?
or "anismsA4
4 :eep nails short4
14 Wet han&s be'ore applyin" han&5asha"ent4
4 (se only non?ionic han&creamG &o not use communal 6ar s4
24 *l5ays cover any cuts 5ith a 5aterproo'
&ressin"4
34 Han&5ash a"ents can become contaminate&G bar soap shoul&
be allo5e& to &rain &ry @no slimy soap &ishesAG &o not top up
li8ui& soap or antiseptic a"ents4F4 I' han&s sho5 si"ns o' irritation "et me&ical a&vice @ar$er
/000A4
B/-4F What is %RS*
%RS* stan&s 'or methicillin @or multiA?resistant Staphylo+o++&s
a&re&s4 Staphylo+o++&s a&re&s is a bacteria carrie& by --L o' the
population 5ith no ill e''ects @Weaver /003AG it colonises the s$in,nasal passa"es an& mouth4
Wi&esprea& use o' antibiotics has le& to an emer"ence o'
r esistant strains4 %RS* is resistant to penicillin, important anti?
staphylococcal a"ents such as 'luclo=icillin, cephalosporins
an& other r elate& antibiotics4
I' a patient has a severe clinical in'ection o' %RS*, he or she
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Woun& in'ection /-/5ill nee& hospitalisation an& treatment 5ith intravenous
vancomycin, but most patients are colonise& rather than in'ecte&4
I' the patient is a heavy carrier an& &isperser, althou"h not at
ris$ to him? or hersel' other patients 5ho are sic$ or have 5oun&s
may be at ris$ 'rom cross?in'ection @Wolverhampton Health Care
Control o' In'ection Committee /002A4
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/- Woun& Care< * Han&boo$ 'or Community Nurses
B/-49 What s5abs shoul& be ta$en to screen 'or %RS*
S5abs shoul& be pre?moistene& 5ith sterile saline in or&er to
collect more bacteria4 The 'ollo5in" sites are recommen&e&<
D E=ternal nares
@nostrilsA
D *=illa an& "r oin
D *ny 5oun&s
D Sputum @i' the patient has a pro&uctive
cou"hA
D The 5oun& itsel' D I' the patient has a catheter, a urinespecimen4
* patient is clear 5hen three sets o' s5abs at 5ee$ly intervals
ar e ne"ative a'ter any treatment is terminate&4
B/-40 Ho5 shoul& a patient 5ho is a carrier o' %RS* be treate&
The patient shoul& be a&vise& to have a &aily bath or strip 5ash4
He or she shoul& apply an antiseptic &eter"ent &irectly to the s$in
5ith a 5ash cloth an& rinse o''4 I' the a=illa an& "roin are
colonise&, he=a? chlorophene po5&er shoul& be applie&4
Hair shoul& be 5ashe& &aily an& on the 'irst an& thir& &ay o'
treatment 5ashe& 5ith an antiseptic &eter"ent4 *'ter bathin"
the patient shoul& put on clean clothes4 #e& linen shoul& be
chan"e& as 're8uently as possible4 )aun&ry can "o on a normal5ash pre'erably at 3-PC4 I' the e=ternal nares are colonise&,
mupirocin ointment is applie& three times a &ay 'or F &ays4
The patient poses no ris$ to anyone in his or her o5n home
unless they have a 5oun&, catheter or other invasive line
@Weaver /003A4 Visitors shoul& be a&vise& that they are at no
special ris$ an& that e=cessive han& 5ashin" 5ith antiseptics may
ma$e the patient 'eel isolate&4 It is recommen&e& that antiseptic
han& 5ashin" is bene'i? cial only i' there is prolon"e& contact or&irty materials such as &r ess? in"s have been han&le&4 This is not
the case 'or visitin" nurses or home helps 5ho may be in contact
5ith other at?ris$ in&ivi&uals a'ter5ar&s @see B/-4/-A4
The patient can continue 5ith normal social activities4 There
ar e no restrictions on usin" public transport4 I' the patient nee&s to
"o to outpatients, ambulance control shoul& be in'orme&, as
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/- Woun& Care< * Han&boo$ 'or Community Nurses
outpatients &epartment4 I' the patient re8uires hospital a&mission
the receivin" &octor shoul& be in'orme&4
!eneral &omestic cleanin" is a&e8uate, althou"h it is
important to $eep the environment as clean as possible, especially&ust contr ol4 *ny home carershome helps shoul& be e&ucate& in
"oo& han&? 5ashin" techni8ues an& have &isposable "loves an&
aprons available4 I' the patient has e8uipment on loan such as
mattresses or commo&es, the loan centre shoul& be in'orme&
be'ore the return o' any e8uipment4
B/-4/- What precautions shoul& the &istrict nurse ta$e
District nurses shoul& use &isposable "loves an& aprons, 5hich
can then be &ispose& o' in the patient7s normal househol& 5aste
@Wolver? hampton Health Care Control o' In'ection
Committee /002A4 Han&s shoul& be 5ashe& thorou"hly 5ith
antiseptic han&5ash such as Hibiscub4 aper to5els shoul& be le't
in the house 'or use rather than usin" househol& to5els4 *ny
cuts or abrasions shoul& be covere& 5ith a 5aterproo' plaster
@Weaver /003A4atients in'ecte& or colonise& 5ith %RS* shoul& have their
&ressin"s chan"e& at the en& o' the &ay4 Rubbish shoul& be
&ispose& o' in line 5ith the local in'ection control policy4
When the patient no lon"er re8uires &ressin"s no le't?over
stoc$s shoul& be ta$en out o' the house 'or use in other ar eas4
B/-4// What precautions shoul& be ta$en in the ! sur"ery 'or a patient 5ith
%RS* in'ection
atients 5ho are %RS* positive or a5aitin" s5ab results shoul&
have their &ressin"s atten&e& to at the en& o' the &ay7s sur"ery4
The 5oun& shoul& be cleane& 5ith a chlorhe=i&ine?base& solution4
I' the patient has 'la$y s$in, such as those 5ith venous ecJema,
care shoul& be ta$en to catch all s$in 'la$es4
Sta'' members are at no personal ris$ because the %RS*
&oes not pose a ris$ to healthy in&ivi&uals @Weaver /003A4
!oo& han&?5ashin" techni8ue is the best metho& o'
controllin" sprea& o' %RS* an& the use o' "loves @in line 5ith
your local in'ec? tion control policyA an& aprons is recommen&e&
@Duc$5orth /00-A4
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Woun& in'ection /-2
Han&s shoul& be 5ashe& 5ith an antiseptic chlorhe=i&ine a"ent or
5ith an alcohol rub, an& &rie& on &isposable paper to5els4 *ny
open cuts shoul& be covere& 5ith a 5aterproo' plaster 4
*ll soile& &ressin"s shoul& be ba""e& an& seale& in in'ecte&5aste ba"s an& sent 'or incineration, in line 5ith your local
in'ection control policyG contact your local in'ection control nurse
'or a&vice4
B/-4/ *re there any speci'ic "ui&elines 'or nursin"resi&ential homes
atients shoul& be care& 'or in a sin"le room an& a5ay 'rom other
patients 5ith open 5oun&s or brea$s in the s$in @WolverhamptonHealth Care Control o' In'ection Committee /002A4 Ensuite han&?
5ashin" 'acilities shoul& be available i' possible an& an
antise ptic han& 5ash available4 The patient7s personal clothin"
an& be& linen shoul& be care& 'or as in'ecte& in accor&ance 5ith
the home7s policy4 Contact your local in'ection control
&epartment to see i' there is a speci'ic >Nursin" Home7 policy4
!eneral cleanin" 5ith a "eneral purpose &eter"ent is satis'actory4
Damp &ustin" is recommen&e&4
B/-4/1 What is the recommen&e& mana"ement 'or 5oun&s colonise& 5ith
%RS*
Topical antibiotics are o'ten a&vocate& 'or the treatment o'
%RS*4 There is, ho5ever, concern about the e''icacy i' they are
applie& in're8uently or over a lar"e area @Weaver /003A @see
B/-4A4T5o antibiotics are recommen&e& an& treatment shoul& be
no lon"er than F/ &ays4 %upirocin can be applie& to shallo5
5oun&s no lar"er than 1 cm in &iameter4 .usi&ic aci& is a "oo&
anti? staphylococcal a"ent but, i' use& alone or over a lar"e area,
r esis? tance may occur4 It may be use'ul in combination
5ith oral trimethoprim 'or /- &ays4
*'ter the antibiotics have stoppe&, the 5oun& shoul& be tr eate&
accor&in" to its clinical appearance, e4"4 slou"hy, necrotic, etc4T5o &ays a'ter antibiotic therapy has stoppe&, repeat 5oun&
s5abs shoul& be ta$en4 I' the 5oun& is colonise& or not severely
in'ecte&, it may respon& to antiseptics alone4 Dressin"s such as
.lamaJine an& Ina&ine have been 'oun& to be e''ective a"ainst
some strains o' %RS*4
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/- Woun& Care< * Han&boo$ 'or Community Nurses
B/-4/ Do sta'' nee& to be screene& 'or %RS*
%RS* &oes not pose a threat to sta''4 There'ore a sta'' member
carin" 'or a patient 5ith %RS* is at no personal ris$, nor aretheir 'amilies4 #ecomin" a carrier o' %RS* is no re'lection on an
in&ivi&? ual7s personal hy"iene4
I' in'ection control precautions are ta$en the ris$ o' becomin"
a carrier is minimal4 Ho5ever, in an institution 5here several
patients are %RS* positive, it is possible that sta'' may
become car rier s @Wolverhampton Health Care Control o'
In'ection Committee
/002A4 I' sta'' &o become carriers they can easily be treate& 5ithanti? septic preparations4 Sta'' can be screene& 5ith a"reement
5ith the local in'ection control team an& they or the occupational
health &epartment 5ill a&vise on treatment an& 5hen to return to
5or $4
Summar
y
Routine s5abbin" is ine''ective an& an unnecessary 5aste o'
money4 It important to reco"nise si"ns o' in'ection4 Woun&
in'ection shoul& be treate& systemically4 #e a5are o' the
principles o' cr oss?in'ection an& asepsis4 *lso be a5are o'
necessary precautions i' the patient has %RS*4
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CHAP*ER 11
"is#e,,aneous
This chapter &eals 5ith other 're8uently as$e& 8uestions that &o
not 'it into any o' the other chapters in the boo$4 These inclu&e
care o' 'un"atin" 5oun&s, &ressin" &i''icult areas, maceration an&
the use o' ma""ots @larval therapyA4
B//4/ What is a 'un"atin" 5oun&
.un"atin" &escribes a con&ition o' ulceration an& proli'eration
that arises 5hen mali"nant tumour cells in'iltrate an& ero&e
throu"h the s$in @%ortimer /001A, or mali"nant cells sprea& alon"
path5ays o' least resistance, e4"4 bet5een tissue planes an&
lymph capillaries @%osely /099A4 .un"atin" tumours may be
complicate& by sinus or 'istula ' or mation4
.un"atin" tumours &evelop in a number o' sites4 %ost common
is the breast but melanoma, lymphoma, an& cancers o' the lun",
stom? ach, hea&, nec$, uterus, $i&ney, ovary, colon an& bla&&er
may also in'iltrate in this 5ay @%ortimer /001A4
Tissue hypo=ia in a 'un"atin" 5oun& is a si"ni'icant
problem lea&in" to a loss o' tissue viability4 *naerobic an&
aerobic bacteria thrive in these con&itions an& are the cause
o' the associate& malo&our an& pro'use e=u&ate @!roscott
/002A4 In a&&ition, the capillaries o' tumours are 'ra"ile an&
pre&ispose the tissue to blee&? in"4 Tumour "ro5th results in
5oun&s that are continually enlar "in", irre"ular in shape, necrotic
an& e=u&in"4
Woun& mana"ement is comple= an& involves mana"in"
o&our @see B43A, e=u&ate @see B24A, blee&in" @see B//4A an& pain
contr ol @see B4FB40A4
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/-3 Woun& Care< * Han&boo$ 'or Community Nursesan& heels 5her e
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%iscellaneous /-F
the &ressin" has to be shape& @.letcher /000A4 To &ress heels, a
' lat &ressin" such as a hy&rocolloi& or 'oam can be cut an& then
shape& aroun& the heel4
To &ress &i"its, many people use a cotton net an& applicator tosecure the primary &ressin"4 Other solutions inclu&e cuttin" a ' lat
pro&uct to allo5 it to be shape& aroun& the &i"it 5ithout too much
bul$4 I' the &ressin" re8uires securin" 5ith tape, ensure that the
tape &oes not completely 5rap aroun& the 'in"er4 I' oe&ema
occurs it coul& cause constriction4
Dressin"s over 6oints such as elbo5s or the $nee can r estrict
mobility because the &ressin" &oes not stretch or it is bul$y4
Cuttin" a thin hy&rocolloi& or 'ilm an& applyin" it in sli"htlyoverlappin" strips 5ill allo5 some 'le=ibility @.letcher /000A4 This
can be use& either as a primary &ressin" or a retention &ressin"4
(sually no other bul$y pa&&in" is r e8uir e&4
B//42 What causes s$in maceration
%aceration is cause& by prolon"e& e=posure to 'lui& that remains
in contact 5ith the s$in4 This may be 5oun& e=u&ate, urine ors5eat4 It may cause &eterioration in the 5oun& an& also lea& to
s$in brea$? &o5n4
The bo&y7s normal 5oun&?healin" response o' in' lammation
causes local oe&ema, 5hich seeps 'rom the 5oun& sur'ace @see
B/49A4 The e=u&ate 'rom acute an& chronic 5oun&s has &i''er ent
constituents @Cuttin" /000A4 The e=u&ate 'rom chronic 5oun&s
contains proteases, 5hich brea$ &o5n protein an& 5ill actually
&ama"e 5hat may be other5ise healthy tissue @Ho'man et al4/00FA4 E=u&ate pro&uction o'ten increases i' the 5oun&
&eteriorates4
%oist 5oun& healin" has been sho5n to spee& up 5oun&
healin" @Winter /03A @see B/40A an& many &ressin"s such as
'ilms, ' oams, hy&rocolloi&s, al"inates an& hy&ro'ibres promote
healin" usin" the theory o' moist 5oun& healin" @see B24A4Occlusive &ressin"s @see B243A are o'ten blame& 'or maceration
@Cuttin" /000A but it 5ill only occur i' the &ressin" re"imen is bein" use& inappropriately4 Wear time shoul& not e=cee& the time
beyon& 5hich the &ressin" can a&e8uately cope 5ith the
pro&uction o' e=u&ate4 The choice o' &ressin" nee&s to re'lect
e=u&ate levels as 5ell as the site an& con&ition o' the 5oun&4
Hy&ro'ibre an& al"inate
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/-9 Woun& Care< * Han&boo$ 'or Community Nurses
&ressin"s are very absorbent an& can be covere& 5ith absorbent
pa&s @see B240 an& B24/A4E=u&ate 'rom venous ulcers can be controlle& 5ith compression
therapy an& elevation 5hen clinically in&icate& @Cuttin" /000A@see
B940A4
I' s$in becomes macerate&, some people use eosin as an astrin?
"ent to &ry it @&o not use on the actual 5oun&A @%or"an
/00FA4 Others soa$ the le", inclu&in" the 5oun&, in a solution o'
potassium perman"anate4 Neither o' these t5o approaches has
been evaluate& in comparative clinical trials @Cuttin" /000A4
inc o=i&e paste or ban&a"es may be use& to provi&e protection by actin" as a barrier4 It is 5orth patch testin" be'ore
'ull application to avoi& sensitivity4 I' hi"h levels o' e=u&ate
persist, the possibility o' in'ection shoul& be consi&ere&4 @see B/-4/
an& B/-4A4
B//43 What is meant by over"ranulation an& ho5 shoul& I treat it
Over"ranulation, or hyper"ranulation as it is sometimes calle&,
is "ranulation tissue that rises above the e&"es o' the 5oun&4E=peri? ence has sho5n that removin" an interactive &ressin"
such as a hy&rocolloi& an& usin" a simple &ressin" such as a lo5
a&herent &ressin" or 'oam allo5s the 5oun& to settle &o5n on its
o5n4 Silver nitrate use& either as a -42L compress or as a silver
nitrate stic$ is also sometimes use& @%or"an /00FA4
*+e use of ma--ots: ,ar.a,
t+era0y
B//4F *re ma""ots available only 'or treatin" 5oun&s in hospital
There is no reason 5hy ma""ots or larvae cannot be use&
'or patients 5ithin their o5n homes or a nursin" home, provi&in"
that the patient an& their 'amily are in a"reement4 Ho5ever,
larvae are not on prescription at present an& so 'un&in" 5oul&
have to be provi&e& by the primary care "roup or trust4
B//49 What types o' 5oun& are suitable 'or treatment 5ith larvae
%a""ots remove both &ea& tissue an& bacteria, leavin" in most
cases a healthy "ranulatin" 5oun& @Thomas et al4 /003A4 Their
main use 5oul& be on a necrotic, slou"hy or in'ecte& 5oun& @see
B4/- an& B4// an& Tables /-4/ an& /-4A4
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%iscellaneous /-0
B//40 Ho5 are the ma""ots applie& to the 5oun&
The most common metho& o' application is to surroun& the 5oun&
5ith a bor&er o' hy&rocolloi&4 This is applie& to the intact s$in li$e
a picture 'rame4 The ma""ots are 'lushe& out o' their carria"e
contain? ers 5ith saline an& applie& to the 5oun& sur'ace,
appro=imately /- larvaecm @Thomas et al4 /0034A %a""ots are
appro=imately mm in len"th4 * piece o' sterile, 'ine nylon mesh
covers the ma""ots an& 5oun&, an& is hel& in position by stic$in"
it to the hy&rocolloi& 5ith a&hesive tape4 !auJe &ene& 5ith
physiolo"ical saline is place& over this to $eep the ma""ots
hy&rate&4 *ny pa&&in" can then be applie& to contain e=u&ate
an& li8ue'ie& necrotic tissue4 The ma""ots shoul& be chan"e&
every 1 &ays4
B//4/- Ho5 shoul& ma""ots be remove& an& &ispose& o'
When the soile& &ressin"s are remove& the larvae either 'all o''
or can be 'lushe& o'' the 5oun& sur'ace 5ith saline4 Dressin"s
shoul& be place& in a yello5 ba", seale& securely an& sent 'or
incineration4B//4// Is there any ris$ o' ma""ots turnin" into 'lies
* ne5ly hatche& larvae ta$es F/ &ays to complete its li'e cycle
an& turn into a 'ly4 *s &ressin"s are chan"e& every 1 &ays they
5ill be remove& 'rom the 5oun& 5ell be'ore they pupate an& turn
into a ' ly4
B//4/ Can the patient 'eel the ma""ots movin" on the 5oun& or eatin"
the &ea& tissue
%ost patients cannot 'eel the ma""ots on the 5oun&4 I' they are
on intact s$in they may tic$le but surroun&in" the 5oun& 5ith
hy&r o? colloi& eliminates this4
The ma6ority o' patients receivin" larval therapy report a
r e&uc? tion in 5oun&?relate& pain @Thomas et al4 /003A,
althou"h a 'e5 report an increase in pain @see B4FB40A4
The sterile larvae supplie& &o not burro5 into healthy tissue4
Information
B//4/1 *re there any sources o' in'ormation about 5oun& care on the internet
There are many sources o' in'ormation about 5oun& care on the
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//- Woun& Care< * Han&boo$ 'or Community Nursesinternet4 !eneral search en"ines can be use& as 5ell as tools to
assist
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%iscellaneous ///
in locatin" me&ical in'ormation an& &irect access uni'orm resource
locators @(R)sA to appropriate sites4
This is becomin" an increasin"ly popular 5ay o' searchin"
the literature4 In'ormation is accessible 5orl&5i&e at any timean& to anyone 5ith the appropriate technolo"y4 It is a rich
e&ucational source 5hich can assist e&ucational &evelopmentG it
also "ives an e? mail lin$ 5ith research 'oun&ations an& other
contributors an& thus ai&s the easy &iscussion o' 'in&in"s @itcher
/009A4
Some use'ul 5eb sites are liste& un&er Resources, pp4 /124
Summary
.un"atin" 5oun&s can be comple= to treat, an& specialist a&vice
may be nee&e&4 The nee& 'or sensitive care 5hen &ealin" 5ith
malo&orous 5oun&s cannot be overstresse&4 %a""ots can be a
use'ul an& e''ective therapy, 5hich is currently "ainin" in
popularity4 atient e&ucation an& support are essential 'or
compliance 5ith this therapy4
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///
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chosen option *ppraise an&
evaluate
evi&ence
vali&ity,
use'ulness
// Woun& Care< * Han&boo$ 'or Community Nurses
B/4 What is clinical e''ectiveness
Clinical e''ectiveness or evi&ence?base& health care is an
appr oach to practice that helps you to consi&er 5hether you are pr ovi&in" optimum care 'or your patients throu"h i&enti'yin"
e=istin" evi&ence on best practice4 The chart sho5n in .i"ure
/4/ 5as pro&uce& by the North Thames Research *ppraisal
!roup @/009A to help "ui&e people in ensurin" that they are
ma$in" the best possible use o' research in their clinical practice4
There are several steps to &evelopin" the process an& s$ills
involve& in ensurin" that the care you provi&e is evi&ence base&4
ou may 'eel that you currently &o not possess all o' the s$illsthat ar e involve& in the process, an& i' this is the case &o not
5orry, 5e all have a lot to learn4 There are lots o' people 5ho can
len& their s$ills an& e=pertise to help you alon" the 5ay4
*&&ressin" the sta"es o' the process in a little more &epth 5ill
i&enti'y 5ho the $ey people are to contact 'or help in &evelopin"
your e=pertise in this area4 ou mi"ht 'in& it help'ul to raise any
trainin" nee&s that you i&enti'y at your ne=t per'ormance revie5
meetin"4
In'ormation
nee&
Evaluate
*ns5erable per'ormance
8uestion
HE*)TH
*TIENT C*RE
TE*%
Select an& Search 'or
implement evi&ence
)i-ure 12<1 The clinical e''ectiveness process4
B/41 What in'ormation is nee&e&
This 8uestion is really as$in" about 5here the "aps in the
mana"e? ment o' your patients are4 Each patient is uni8ue an& may
come 5ith
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Clinical //1
one hun&re& an& one &i''erent 8uestions, so you 5ill almost
al5ays 'in& that there is somethin" 'or you to &iscover4 Buestions
can be about all aspects o' patient care4 In 5oun& care they may
inclu&e thin"s such as<
D What is the best sort o' &ressin" 'or this5oun&
D Ho5 lon" 5ill it ta$e to
heal
D Woul& physiotherapy help
D Ho5 can I stop another ulcer &evelopin"
Once you start thin$in" about issues re"ar&in" all your
&i''er ent patients, you 5ill probably 'in& that you have 'ar more
potential 8uestions than you coul& possibly 'in& the time to ans5er
so you 5ill nee& to &eci&e 5hat the $ey problems are an& ho5 to
prioritise4 Topics that are li$ely to come to the top o' the priority
list inclu&e problems common to a number o' patients, unusually
severe or seri? ous presentations o' con&itions, concerns about the
8uality o' the service raise& by sta'', patients or relatives, an&areas 5here there is perceive& to be real potential to improve the
8uality o' car e4
B/4 What &oes it mean to as$ an ans5erable 8uestion
Once you have thou"ht about the issues an& concerns that are o'
interest to you, it is 5orth 'ormulatin" them into a clear 8uestion4
This 5ill help you to tar"et your search 'or the ans5er to the8ues? tion4 These 8uestions ten& to inclu&e 'our elements<
D The $ey 'eatures o' the patient or problem4
D Details o' the intervention or test that you are
consi&erin"4
D ossible alternatives to thatintervention4
D In&ications o' the outcomes o'
inter est4
When i&enti'yin" the $ey 'eatures o' the patient or problem
you shoul& thin$ about ho5 you 5oul& &escribe a similar "roup
o' patients4 This may inclu&e aspects such as con&ition, a"e, se=
an& ethnicity4 The intervention or test an& possible alternatives
re'er to 5hat you thin$ your options are in treatin" your patients4
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// Woun& Care< * Han&boo$ 'or Community Nursesou may have to &eci&e bet5een t5o &i''erent types o' ban&a"es
or &ressin", or ans5er more "eneral 8uestions about 5hat is the
best 'orm o' 'oot5ear 'or someone 5ho has 'oot ulceration 5hen
you are not yet
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Clinical //2
a5are o' the possible options4 Outcomes can come 'rom a variety
o' perspectives, 5hether that o' the patient, carers, &octors or
nursin" sta'', an& on occasion can con'lict 5ith each other4 our
main aim may be the complete healin" o' a 5oun&, 5hereas the patient may be &esperate to maintain mobility an& in&epen&ence,
an& so may be prepare& to accept continuin" ulceration in return
'or that 'ree&om4
To help put this into some sort o' conte=t, a short scenario can
sho5 ho5 that can be use& to &evise an ans5erable 8uestion4
The s+enario
When people come to see you about 5oun& care, you currently
"ive them verbal a&vice about treatin" the 5oun&, &iet,
e=ercise an& li'estyle4 ou have recently &evelope& several
concerns about this4 ou have rea& that "enerally people only
remember /-L o' 5hat they have been tol& &urin"
consultations an& are particular ly concerne& that a substantial
number o' the local population belon" to ethnic minority "roups
an& &o not spea$ En"lish as their 'irst lan"ua"e4 ou have
there'ore &eci&e& to revie5 the 5ay you pr ovi&e in'ormation to
your patients4
The ?&estion
Element E=ample
atient or problem eople 5ith 5oun&s 5ho &o not spea$ En"lish as their
'irst lan"ua"e
Intervention or test Simple verbal e=planation supporte& by 5ritten
material
@possibly in relevantlan"ua"esA
ossible alternatives Cassettes an& vi&eo tapes in relevant lan"ua"es,
accessin" interpretation services
Outcome@sA o' interest (n&erstan&in" an& retention o' in'ormation,
compliance 5ith recommen&ations, increase& healin"
rates 'or 5oun&s
our 8uestion is there'ore li$ely to be somethin" li$e<
Is it more e''ective to provi&e oral, 5ritten, cassette or vi&eo
a&vice 'or people 5ith 5oun& care nee&s 5ho &o not spea$
En"lish as their 'irst lan"ua"e in or&er to ensure that they
un&erstan& an& remember the a&vice, comply 5ith treatment an&
have 5oun&s that heal
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//3 Woun& Care< * Han&boo$ 'or Community Nurses
B/42 Ho5 &o I search 'or evi&ence
The 'irst port o' call 'or most o' us 5hen 5e have a clinical
8uestion is to consult a collea"ue4 This is an entirely le"itimateaction an& the pro'essional $no5le&"e that you an& your
collea"ues share is a $ey 'actor in patient care4 Ho5ever, you also
nee& to be a5are that it is impossible 'or anyone to stay
abreast o' current practice an& research in all areas o' care4
Rea&in" all the 6ournal articles that come out each month about
community nursin" 5oul& in itsel' be more than a 'ull?time 6ob,
an& you are still e=pecte& to $eep seein" the patientsQ )i$e your
collea"ues, te=tboo$s can become rapi&ly out o' &ate, an& in someareas o' me&icine it is estimate& that the te=t? boo$s 5ill be out
o' &ate be'ore they even hit the shelves, so you 5ill nee& to turn to
other sources o' evi&ence an& ma$e 'rien&s 5ith your local
librarian 5ho can assist you in this4
The best evi&ence that you can 'in& comes 5hen
comprehensive literature searches have been &one to ans5er
8uestions about speci'ic areas o' care, the results consi&ere& 'or
their 8uality an& then combine& to in&icate best possible practicein the "iven area4 This is $no5n as a systematic revie5 or meta?
analysis4 These can be use& to pro&uce "ui&elines on best practice4
*n e=ample o' this is the Ef f e+ti,e 6ealth 7ar e =&lletins pro&uce& by
the Centre 'or Revie5s an& Dissemi? nation at or$ (niversity4
Topics covere& inclu&e prevention an& treatment o' pressure
sores an& mana"ement o' venous ulcers, an& copies o' these
shoul& be available throu"h your practice, clinic or your local
librarian or local au&it a&viser4 Other sources are&atabases
o'systemic revie5s inclu&in" the Cochrane )ibrary, Database o'
Revie5s o' E''ectiveness an& #est Evi&ence, an& your local
librarian shoul& be able to put you in touch 5ith these4 It is also
5orth contact? in" the Royal Colle"e o' Nursin" an& other
pro'essional bo&ies to see 5hether they have pro&uce& evi&ence?
base& "ui&elines4
I' you cannot 'in& the ans5er to your 8uestion in a systematic
revie5 or throu"h your pro'essional bo&y, you 5ill nee& to
un&erta$e your o5n literature search4 There are various &atabases
that you can search4 The main ones that you are li$ely to
come across ar e %e&line, 5hich inclu&es abstracts an& &etails o'
articles pro&uce& in over /--- &i''erent me&ical an& relate&
6ournals 5orl&5i&e, an& CIN*H) @Cumulative In&e= o' Nursin"
an& *llie& Health )itera? tureA 5hich a"ain contains abstracts an&
&etails o' articles in nursin"
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Clinical //F
an& pro'essional clinical service 6ournals4 *"ain your
librarian shoul& be able to a&vise you ho5 to be able to tap into
these resources e' 'ectively4
One o' the main sources you can use to search 'or in'ormationis via the internet4 One o' the issues raise& by the case stu&y on
pr ovi&? in" in'ormation relates to a possible nee& 'or 5ritten
in'ormation 'or patients4 I' your literature search in&icate& that
this 5oul& be e' 'ec? tive then you coul& also search 'or user
&isease?base& "roups 5ho may alrea&y be provi&in" in'ormation,
5hich you coul& inte"rate 5ith the resources that you provi&e 'or
your patients4 %any o' these "roups no5 have 5ebsites on the
internet @see B//4/1A4
B/43 Ho5 can I learn to appraise evi&ence
Clinical appraisal is a techni8ue to assist you in revie5in" research
to ensure that the results are vali&, believable, impressive an&
applica? ble4 Chec$lists have been pro&uce& 'or &i''erent types o'
r esear ch such as 8ualitative trials comparin" &i''erent
interventions @ran&omise& controlle& trials or RCTsA, trials
loo$in" at the patter n o' an illness or &isease over time
@lon"itu&inal stu&iesA, etc4 by or "an? isations such as NTR*!
@North Thames Research * ppraisal !roupA an& C*S @Critical
*ppraisal S$ills ro"rammeA4 The clini? cal "overnance lea& o'
your primary care "roup or trust shoul& be able to arran"e 'or you
to have some trainin" on this either thr ou"h local trainin"
initiatives or CD RO%?base& learnin" pac$s 5hich may be
available 5ithin the or "anisation4
In or&er to &evelop your s$ills in this area, it 5oul& be
5orth consi&erin" 6oinin" a 6ournal club4 Kournal clubs consist
o' small "roups o' sta'' 5ho meet re"ularly to &iscuss research
papers an& their application to practice4 I' you &on7t 'eel li$e
6oinin" one 5ith !s you coul& thin$ about settin" one up 5ith
other practice sta''4
B/4F So i' I "o throu"h all this process, i&enti'y my problem, 'in& some
evi&ence that helps ans5er it an& intro&uce some chan"es to my prac? tice, ho5 &o I $no5 5hether or not it has ha& the &esire& e''ect
This is 5here the ne=t sta"e o' the clinical e''ectiveness process
comes in as you can start to thin$ about evaluatin" your
per' or mance, re'lectin" on 5hat has 5or$e& 5ell an& 5hat nee&s
to be chan"e& to be even more e''ective4 Tools that can be use'ul in
this process inclu&e clinical au&it, patient participation an&
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//9 Woun& Care< * Han&boo$ 'or Community Nursesre'lective practice4
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Clinical //0
B/49 What is clinical au&it
Clinical au&it is a tool to help you re'lect on your clinical
practice an& to evaluate the e''ectiveness o' the care that you provi&e @.i"ur e
/4A4
*s in the clinical e''ectiveness process you nee& to i&enti'y
the area or issue o' concern an& see$ to i&enti'y 5hat current best
prac? tice is in this area4 ou use this to set stan&ar&s 'or the care
process4 .or 5oun& care these coul& inclu&e<
D *ll patients presentin" 5ith le" ulcers have a thorou"hassessment inclu&in" Doppler stu&ies4
D *ll patients 5ith venous ulcers receive compression therapy4
D *ll patients are provi&e& 5ith 5ritten in'ormation about the
car e an& mana"ement o' venous ulcers an& relate& health an&
li'estyle a&vice4
Havin" set your stan&ar&s, you then nee& to &eci&e the best
5ay o' i&enti'yin" 5hether they have been achieve&4 This can bethr ou"h a variety o' techni8ues inclu&in" revie5in" patient notes,
&o5nloa&? in" in'ormation 'rom the practice computer an&
collectin" speci'ic
Select topic
%onitor by *"ree criteria
an& repeatin" cycle
stan&ar&s
*"ree an& Set &ata
collection implement chan"e
rules
Re'lect on results Collect &ata
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/- Woun& Care< * Han&boo$ 'or Community Nurses)i-ure 12<2 The clinical au&it cycle4
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Clinical //
in'ormation over a limite& time scale4 our practice, clinic,
or primary care "roup or trust may be luc$y enou"h to have an
in' or? mation technolo"y @ITA or computer specialist 5ho coul&
a&vise you on retrievin" in'ormation 'rom in'ormation systems4.or the stan&ar&s liste& above, you may &eci&e to create a
chec$? list 5hich you coul& use 5hile "oin" throu"h the notes to
tic$ o'' 5hether or not each stan&ar& has been achieve&4 ou may
5ish to a&& a comments column in 5hich you can recor& such
thin"s as "aps in the patient history or len"th o' time since the
last Doppler r esult 5as recor&e& i' it 5as not in the previous 1
months4
It is very har& to loo$ ob6ectively at our o5n notes an& practice, so you mi"ht 'in& it help'ul to 6oin up 5ith some other
practice nurses or community sta'' an& a"ree to loo$ at each
other7s notes4 Comin" to a set o' notes 5ith 'resh eyes, you o'ten
notice thin"s that you 5oul& overloo$ in your o5n notes, an& you
can learn 'rom other people7s "oo& practice an& their mista$es4
ou coul& also lear n 5hether your han&?5ritin" is li$ely to be
le"ible 'or someone cover? in" you 5hen you are on holi&ay or
'or someone ta$in" over i' you shoul& choose to chan"e 6obs4I' you are revie5in" patient recor&s, you 5ill nee& to &eci&e
ho5 many notes to select to provi&e a representative sample4 I'
you pull only one set o' notes you mi"ht 'in& that the results are
e=ce ptionally poor or "oo&, but you 5oul& not $no5 5hether the
results 'or that patient 5ere abnormal 'or some reason4 #oo$s on
statistics pr ovi&e samplin" tables that you coul& use to &eci&e
ho5 many notes you 5oul& nee& to revie5 to be con'i&ent that
the results 5ere not the result o' chance4 These are base& on the population siJe, i4e4 the number o' people 5ith the particular
con&ition that you are loo$in" at, not the population o' the entire
practice4 Ho5ever, you may 'eel that, rather than pursue a ri"i&
statistical approach, you 5oul& be happy to "et a 'eel o' 5hat is
happenin" in your practice4 In this case you may choose to select
the last /- sets o' notes o' people you sa5 5ith the chosen
problem or select one set 'or each o' the 'irst letter s in the
alphabet4 This approach is also help'ul 5hen you are $een torevie5 your practice but have only very limite& time to &evote to
it4 In such circumstances, provi&in" you are prepare& to ta$e on
boar & the results 5hether they are "oo& or ba&, you can
le"itimately r evie5 smaller numbers o' notes4
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Clinical /1
&ocumentation4 ou may 'in& you nee& to revie5 the 5aitin"
room to see 5hether posters provi&e appropriate an& up?to?&ate
in' or ma? tion an& are o' a "oo& con&ition4 Stran"ely, si"ns an&
posters o'ten &isappear on a re"ular basis at reception an&else5here in the clinic4 *lternatively, you may 'eel the nee& to
a&opt a >mystery patient7 approach4 This involves arran"in" 'or
someone to atten& the prac? tice an& provi&e con'i&ential 'ee&bac$
on 5hat it 5as li$e 'rom their perspective4 I' this 5as &one by
someone 5ith a &isability they coul& in'orm you not only about
5hether their con'i&entiality 5as main? taine& an& 5hether they
5ere treate& 5ith &i"nity an& respect, but also about 5i&er issues
such as physical access an& the provision o' in'ormation4 This is 6ust one o' the many approaches that you can ta$e in investi"atin"
patient e=periences4
The 'ollo5in" scenario &emonstrates ho5 clinical au&it can
bene? 'it practice4
*s senior practice nurse, nurse T ha& an interest in improvin" practice an&
ensurin" that it 5as evi&ence base&4 She ha& insti"ate& an au&it to e=amine
the amount o' 5oun& s5abs ta$en an& the levels o' 5oun& in'ection4
The practice ha& clear >best practice statements7 that 5oun&s shoul& be
s5abbe& only i' si"ns o' in'ection 5ere present an& also 'or the treatment o'
5oun&s an& on the principles o' cross?in'ection4
Over the previous / months both the number o' 5oun& s5abs ta$en an&
in'ection levels ha& &roppe&4 These 'i"ures 5ere collecte& 1 monthly4 *t the
'ollo5in" reau&it it appeare& that the number o' s5abs ta$en ha& more than
&ouble& an& in'ection rates ha& increase& but not so &ramatically4
Nurse T realise& that &urin" this time perio& the only real chan"e
5ithin the sur"ery 5as that a ne5 practice nurse ha& starte&4 Re?e=aminin"
the 'i"ures in more &etail sho5e& that she 5as s5abbin" all 5oun&sroutinely an& that many o' the patients 5ho ha& &evelope& in'ections ha&
been treate& more or less e=clusively by this ne5 nurse4
This i&enti'ie& several trainin" nee&s that nurse T 5as able to
'acilitate4 B/40 What is meant by investi"atin" patient e=periences
.or many years patients have been seen as passive recipients o'
heath care, but increasin"ly the move is to5ar&s partnership in
care, 5her e patients have an active role an& responsibility in
&ecision?ma$in" an& care mana"ement4 When you are revie5in"
the 8uality o' the care you provi&e, one o' the $ey aspects o' this
is to re'lect on the patient7s e=periences4 Some in'ormation
5oul& be available 'rom patient complaints an& comments as
&iscusse& previously, but i' you
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/ Woun& Care< * Han&boo$ 'or Community Nurses
5ere loo$in" 'or speci'ic in'ormation about mana"ement o'
5oun& care you 5oul& probably have to consi&er ta$in" a more
positive approach to 'in&in" out 5hat people thin$ about the care
that you are o''erin"4 The main approaches to this are postal orother surveys, 'ace?to?'ace or phone semi?structure& intervie5s
or 'ocus "r oups4 There are various stren"ths an& 5ea$nesses
attache& to all o' these, 5hich you nee& to consi&er be'ore
&eci&in" on the best 5ay ' or5ar &4
The 'irst 8uestion that you nee& to consi&er be'ore embar$in"
on any o' these techni8ues is B/4/-4
B/4/- What am I "oin" to &o 5ith the results
ou nee& to be clear in your o5n min& 5hat 8uestions you 'eel
nee& ans5erin" an& 5hat you 5ill &o 5ith the ans5ers, 'rom both
techni? cal an& service &elivery points o' vie54 (n&erta$in" a
lar "e?scale survey o' everyone 5ho lives in your clinical area
5oul& be ver y e=pensive in terms o' both time an& resources4
Even be'ore you ha& any results bac$, you 5oul& nee& to &evelop
an& pilot 8uestion? naires, "et them printe& an& &istribute&, an&then you 5oul& have to thin$ about 5hat you 5oul& &o 5ith the
results, inclu&in" &ata input an& analysis4 ou mi"ht thin$ that it
5oul& be easier to hol& a 'ocus "roup or intervie5 some
patients, but a"ain you nee& to thin$ throu"h all the
implications such as preparin" intervie5 sche&ules, time to
arran"e an& un&erta$e the intervie5s, an& ho5 you ar e "oin"
to collate an& use the results4 Other issues that you nee& to
consi&er are ethical ones4 There is no point as$in" patients i' they5oul& pre'er to be treate& in the bac$ room o' the local pub i' you
$no5 the lan&lor& is terri'ie& by mention o' all thin"s me&ical
an& 'aints at the si"ht o' a stethoscope4 %ore seriously you 5oul&
nee& to consi&er the implications o' unmet nee&s or &esires4 ou
may 'eel that "ettin" patients to tal$ about 5antin" treatments
that are not 'un&e& by your health authority raises unrealistic
e=pectationsG alter? natively startin" to 8uanti'y an& e=plore
such &eman&s may help in'orm o' such &ecisions4 #e'oreembar$in" on a patient consultation or participation e=ercise, you
nee& to thin$ throu"h 5hat support an& resources you have to
compile, &isseminate an& action the results o' your 5or$4 This
may inclu&e "ainin" access to computer s an& s$ills in mana"in"
in'ormation, sprea&sheets an& &atabases4 ou 5ill re8uire
commitment 'rom all the practice sta'' to &iscuss an&
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Clinical /2
consi&er any issues raise& seriously an& you 5ill nee& to &eci&e
ho5 'ee&bac$ an& chan"es coul& best be provi&e& 'or the patients
them? selves4 our local Community Health Council @CHCA, an
in&e pen? &ent or"anisation appointe& to support patientempo5er ment 5ithin the NHS, may be able to a&vise an&
support you in see$in" the vie5s o' your patients4
B/4// What sort o' 8uestions shoul& be as$e&
#e'ore &eci&in" on the best approach to use in 'in&in" out
patient vie5s, it is 5orth5hile thin$in" about 5hat it is you 5ant
to $no54 ou mi"ht 5ant to collect statistics on the prevalence o'
si&e e''ects, 5hether speci'ic in'ormation 5as provi&e& or on 5hat
other health services 5ere accesse& by the patient4 These can be
establishe& by as$in" 5hat are re'erre& to as >close& 8uestions7,
i4e4 a 8uestion 5ith yesno or a limite& number o' possible
responses4 E=amples inclu&e<
D Ho5 o'ten is the &ressin" chan"e& on your5oun&
D Have you ha& one or more episo&es o' 5oun&
in'ection
D Do you see a hospital consultant about your
5oun&
In research terms these 8uestions provi&e in'ormation that is
8uantitative in natureG it ans5ers the >ho57 8uestions, loo$in" at
issues such as >ho5 many7, >ho5 o'ten7 an& >ho5 much7 The
other sorts o' in'ormation that you are li$ely to 5ant to collect
relate to 8ualitative research4 Bualitative research a&&resses the
>5hy7 an&
>5hat7 8uestions, the so'ter in'ormation that e=plains 5hy people
&o the thin"s that cannot be counte& in 'i"ures4 E=amples o' these
sorts o' 8uestions can inclu&e<
D What &o you 'eel has been "oo& about the care that you have
receive&
D What coul& have been &one &i''erently to provi&e better
stan? &ar&s o' care
D In 5hat 5ays have you ha& to chan"e your li'estyle because
o' your le" ulcer
These 8uestions can o'ten be use& to e=plore the statistical &ata
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/3 Woun& Care< * Han&boo$ 'or Community Nursesin a little more &epth, e4"4 you mi"ht 5ish to e=plore 5hat people
'eel
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Clinical /F
are the a&vanta"es an& &isa&vanta"es o' comin" to the practice
'or treatment rather than bein" seen in their o5n home4 ou 5ill
pr oba? bly 'in& that you 5ant a variety o' 8ualitative an&
8uantitative in' or? mation4 In as$in" patients about theire=perience o' 5oun& care, you mi"ht 5ant to $no5 both
8uantitative in'ormation, about ho5 lon" they have ha& their
5oun& an& ho5 many &ays it has cause& them to miss 5or$, as
5ell as 8ualitative in'ormation inclu&in" ho5 they 5oul&
&escribe the pain they ha& e=perience& an& 5hat their e=peri?
ences 5ere o' accessin" car e4
B/4/ What are the a&vanta"es an& &isa&vanta"es o' un&erta$in" a patient survey
atient surveys are "enerally han&e& out to patients or sent
to them at home 5ith a 'reepost envelope 'or them to return
their responses4 They can be 8uite use'ul 'or 'in&in" out ho5
many people have opinions an& 'eelin"s about particular issues
an& ar e most e''ective 5hen consistin" o' mostly yesno an&
multiple choice ans5ers4 Response rates are improve& i' the8uestionnair es are relatively short @a ma=imum o' 'our si&es o'
* paper, pr e'er? ably t5o si&esA an& are relevant to the people
ans5erin" them, e4"4 you are li$ely to "et a lo5er response to
about ho5 people 'eel about the practice than you are to a
more speci'ic survey about ho5 people 'eel about the
mana"ement o' their le" ulcer or post? sur"ical 5oun&4
Response rates 'or "eneral surveys are notoriously lo5 an& o'ten
less than 1-L are returne&4 It is better to avoi& open?en&e&8uestions as 'ar as possible because people &o not li$e spen&in"
time provi&in" len"thy 5ritten responses an& the results o' these
are &i''icult to collate4 Surveys li$e this can be most use'ul 5hen
you have i&enti'ie& a particular issue or concern, perhaps as a
result o' a 'ocus "roup or throu"h patient complaints or sta' '
concerns, an& you are an=ious to see ho5 5i&esprea& the
'eelin"s are amon" the practice population4 One issue you 5oul&
nee& to consi&er 5oul& be 5hether your tar"et population coul&rea& an& 5rite En"lish to a speci'ically hi"h stan&ar& to be able
to partici? pate in the survey4 ou may nee& to "et the
8uestions an& responses translate& or a&opt alternative
approaches to "ainin" patient vie5s4
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/9 Woun& Care< * Han&boo$ 'or Community Nurses
B/4/1Have you any thou"hts about intervie5s an& 'ocus "roups
The use'ulness o' intervie5s an& 'ocus "roups principally lies in
the opportunity to e=plore 'eelin"s about an& e=periences o'service &elivery in more &epth than that allo5e& by a 5ritten
survey4 Rather than havin" a series o' set 8uestions 5ith a small
ran"e o' ans5er s you 5oul& use a semi?structure& 8uestionnaire
that 'ocuses on more open?en&e& responses an& allo5s
participants to e=pan& on the issues that they 'oun& o' particular
concern4 .ocus "roups "enerally consist o' 'our to ten people
5ho have e=perience& a particular service, an& throu"h sharin"
their e=periences they o'ten spar$ i&eas o'' each other an& canhelp to i&enti'y particular themes4 This can be particularly help'ul
i' you are loo$in" 'or su""estions about 5ays o' improvin" or
chan"in" service &elivery4 These "roups can be hel& either in the
sur"ery or at a >neutral7 venue4
Intervie5s are "enerally hel& on a one?to?one basis,
occasionally 5ith the participant bein" accompanie& by a 'rien&
or relative an& the intervie5er bein" accompanie& by someone
5ho ta$es notes on the &iscussion4 They can be hel& in any venueo' the intervie5ee7s choosin" an& so can be particularly "oo& 'or
&iscoverin" the vie5s about mobility problems or 'rom those
5hose con&itions are such that they &o not 'eel li$e &iscussin"
them in 'ront o' a lar"e "roup o' people4 One issue to bear in min&
is that people o'ten 'eel uncom? 'ortable 5hen tal$in" about the
care they have receive& 5ith the person 5ho actually provi&e&
that care4 eople &o not "enerally li$e tellin" someone that they
5ere not happy 5ith 5hat they &i& an& may 'eel that their 'uturecare coul& be pre6u&ice&4 ou may 'eel that it 5oul& be better to
"et someone 5ho is less involve& 5ith &irect patient care to
un&erta$e the intervie5 or 'ocus "roup, maybe a practice
mana"er or someone su""este& by your local clinical
"overnance lea& or a practice nurse 'rom another practice, or
community nurse mana"er or collea"ue4
There are various approaches to enlistin" participants 'or
these intervie5s4 ou may choose to put up posters in the5aitin" room an& then 5ait to see 5ho atten&s, althou"h this
can be a soul? &estroyin" e=ercise as you may 'in& yoursel' alone
in the room4 *lter? natively, you coul& use the meetin" o' an
e=istin" user "roup or patient council to elicit their vie5s4
ou may tar"et a particular "roup o' patients an& 5rite invitin"
them to participate, e=plainin"
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Clinical /0
5hat the meetin" is li$ely to inclu&e an& ho5 lon" it is li$ely to
ta$e an& provi&in" them 5ith a tear?o'' slip 'or them to in&icate
5hether they 5ish to participate4 The response may also in&icate
nee&s 'or interpreters or &isable& access4 In settin" up the "roup,you 5oul& also nee& to consi&er issues o' lan"ua"e nee&s,
transportation, re'reshments an& chil&care 'acilities4
The "eneral pattern to such intervie5s or "roups is to start by
e=plainin" the purpose o' the meetin" an& to clari'y that the
partic? ipants un&erstan& an& consent to this4 This is o'ten the
time that permission is "aine& to tape?recor& the intervie54 I' you
&eci&e not to recor& the intervie5s or "roups, you 5oul& nee& to
arran"e 'or a collea"ue to ta$e e=tensive notes on the procee&in"s because it is virtually impossible to 'acilitate the conversation
an& recor& it simultaneously4 ou 5ill nee& to reassure the
participants that, althou"h their comments are recor&e&, they
5ill be treate& 5ith con'i&entiality an& that they 5ill not be
personally i&enti'ie& in any subse8uent reports4 The 'irst
8uestions "enerally aim to be non? controversial to allo5 people
to "et use& to tal$in" 5ithout 'eelin" that they have to reveal too
much too soon4 This can inclu&e 8ues? tions such as<
Ho5 lon" have you ha& your le" ulcer an& 5here have you receive& care 'or it
This then lea&s to more personal 8uestions about 5hat people
have 'oun& help'ul about their care an& 5hat coul& have been
&one &i''erently4 With a 'ocus "roup the i&ea is to allo5
participants to tal$ amon" themselves, althou"h not to the e=tent
that they 'orm splinter "roups, an& 'or them to share theire=periences 5ith each other as 5ell as 5ith you4 Even i' your
concerns are 'ocuse& on a particular issue such as 5aitin" times,
you shoul& allo5 time 'or participants to e=press their vie5s on
other aspects o' their care an& tr eatment4
When closin" the intervie5 or 'ocus "roup, you nee& to than$
the members 'or their time an& participation an& e=plain 5hat
5ill happen ne=t4 ou shoul& tell people 5hat you are "oin" to
&o 5ith their comments an& the results o' the pro6ect, an& ho5 youare "oin" to let them an& other patients $no5 5hat you have
&one4 This may inclu&e sen&in" them copies o' any reports an&
action plans, plus puttin" up posters in the practice an& invitin"
them to the openin" o' any ne5 services that 5ere in part the
results o' their comments4
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/1- Woun& Care< * Han&boo$ 'or Community Nurses
B/4/ What else can be &one to ensure that patient vie5s are ta$en on boar&
Sta'' 5or$in" in primary care o'ten have the closest lin$s to
the health nee&s an& e=periences o' the local community4 This 5as part o' the &rivin" 'orce o' the establishment o' C!s an& the
chan"es in the NHS, an& puts the community nurse in a $ey
position to help ensure that service &elivery is sensitive to
local nee&s4 atient comments an& complaints can be $ey in
assistin" in this process4 *lthou"h a patient complaint is o'ten
e=perience& as a ne"ative e=perience or as a brea$&o5n in
communication, it can also o''er a real opportunity to the primary
care team4 #y re'lectin" on 5hat has "one 5ron" in the past 5ecan start to a&&ress policies an& proce? &ures to help ensure that
similar &i''iculties &o not arise in the 'utur e4 %any complaints
arise 'rom lac$ o' communication an& may help stimulate you to
thin$ about ho5 you can best relate to your local population,
5hether throu"h conversation, &emonstration o' tech? ni8ues,
lea'lets, boo$ lists, or even cassettes an& vi&eos in a variety o'
lan"ua"es4 #y startin" to tap into local concerns you can start
to tac$le the issues that are 'ace& at the coal 'ront, a uni8ue seto' circumstances an& con&itions e=perience& at local level4
Rather than thin$ about complaints as a ne"ative thin" to
be avoi&e& an& &iverte& at all costs, you coul& start to thin$
more creatively about ho5 patients can share their e=periences,
comments, compliments an& concerns 5ith you an& your team4
One o' the simplest 5ays o' &oin" this is by settin" up a comments
bo= 5ithin the sur"ery or clinic, perhaps accompanie& by a 5ipe
boar& on 5hich you coul& hi"hli"ht issues raise& an& 5hat youhave &one about them4 ou may 'in& that the number o' complaints
receive& by the practice actually re&uce as patients can share their
concerns be'ore they r each that level o' severity4 One o' the other
e''ects that you are li$ely to e=perience is the encoura"ement
&erive& 'rom positive comments an& e=periences4 %any patients
5elcome the opportunity to say than$ you an& to comment on
5hat they have 'oun& help'ul, an& you can 'urther &evelop your
stren"ths by re'lectin" on these remar$s4
B/4/2 What is re'lective practice an& critical inci&ent analysis
Re'lective practice an& critical inci&ent analysis are techni8ues
that can help the in&ivi&ual re'lect on the care receive& by
in&ivi&ual
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Clinical /1/
patients4 Critical inci&ence analysis o'ten ta$es place 5ithin
multi&is? ciplinary "roups o' sta'' 5hen particular patients 5ho
ha& e=ce p? tional outcomes, 5hether "oo& or ill, are &iscusse&4
These may inclu&e une=pecte& &eaths, avoi&able amputation,violence a"ainst sta'' or other patients, areas 5here care is
suspecte& to be less than optimum an& patients 5ith
e=ceptionally "oo& outcomes4 *ll members o' sta'' coul& be
encoura"e& to i&enti'y such cases 'rom 5hich lessons coul& be
learne& by the team as a 5hole4 In trac$in" 5hat happene& to an
in&ivi&ual patient, you may be able to i&enti'y &elays in
treatment, problems 5ith communication an& possible trainin"
nee&s4 The aim o' such "roups is not to be 6u&"emental but toencoura"e on"oin" learnin" in all members o' the team on a
permanent basis4
It is also use'ul to un&erta$e re'lective practice as an in&ivi&ual
practitioner by thin$in" about 5hat has happene& to a particular
patient4 ou shoul& be able to i&enti'y 5hat 5or$e& 5ell an&
5her e thin"s coul& be improve& to help in'orm the 'uture care o'
similar patients4 %any sta'' $eep a re'lective practice &iary as
part o' their on"oin" &evelopment port'olio an& use it to thin$throu"h issues in relation to in&ivi&ual patients such as<
D What 5ere you e=pectin" to happen 5ith this patient
D What 5as your role in the patient7s
care
D What happene& that you e=pecte& to happen
D What happene& that you &i& not pre&ict
D Ho5 &o you 'eel about 5hat happene&
D Ho5 &o you 'eel about your role in 5hat
happene&
D What &o you thin$ coul& have been &one
&i''erently
D What have you learnt 'rom 5hat happene&
D What mi"ht you &o i' a similar situation arosea"ain
D What are the pros an& cons o' &i''erent options
D What outcomes 5oul& you loo$ 'or
Such recor&s can help you to recor& your successes, personal
&evelopment an& learnin", 'eelin"s an& moo&s, insi"hts an&
8ues? tions4 They can also be as a basis 'or see$in"
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/1 Woun& Care< * Han&boo$ 'or Community Nurses'ee&bac$ 'rom collea"ues about their perceptions o' the same
inci&ents an& to inte? "rate on? an& o''?site learnin" an& trainin"
nee&s4
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/1- Woun& Care< * Han&boo$ 'or Community Nurses
&,ossary
Abs#ess< a localise& collection o' necrotic tissue, bacteria an&
5hite cells, $no5n as pus containe& in a capsule, the 5all o'
5hich is 'orme& 'rom pha"ocytes an& stran&s o' 'ibrin @see
B342A4
A,bumin< a soluble protein 5hich is a ma6or component o'
serum proteins @see B14A4
Anaerobe< bacteria that &o not tolerate 'ree o=y"en 'rom the air,
an& "ro5 5here there is either no air or there are lo5 levels o'
o=y"en @see B4FA4
Anaerobi#< con&itions 5ith a lac$ o' o=y"en @see B 243A4
An-io-enesis< the 'ormation o' ne5 bloo& vessels at the base o'
a 5oun&G this occurs &urin" the proli'erative phase o' healin"
@see B/49A4
Ank,e bra#+ia, 0ressure inde/ 'ABPI(< the result o' a Doppler
ultra? sono"raphy test use& to &etermine the presence an& level
o' arte? rial &isease in patients 5ith le" ulcers @see B94/A4
Ank,e f,are< associate& 5ith venous &isease o' the le"4 Small
vessels &isten& an& appear aroun& the an$le an& heel @see B94A4
At+eros#,erosis< a &isease o' the arterial 5all in 5hich the
inner layer thic$ens causin" a narro5in" an& har&enin" o' the
vessels @see B94/2A4
Auto,ysis< the brea$&o5n o' &evitalise& tissue by leu$ocytes@see
B/49A4
Ce,,u,itis< a sprea&in" in'ection o' the so't tissue, 5hich is
charac? terise& by re&ness, heat, oe&ema an& pain @see B/-42A4
Co,,a-en< a protein substance, 5hich provi&es 'ibres that ma$e
up the supportive net5or$ o' connective tissue4 ro&uce& &urin"
the proli'erative sta"e o' 5oun& healin" an& remo&elle&
&urin" the maturation phase @see B/49A4
/0
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/1 Woun& Care< * Han&boo$ 'or Community Nurses
&ranu,ation< the 'ormation o' ne5 tissue 5hich 'ills the
5oun& &urin" the proli'erative sta"e o' healin" @see B/49 an&
B4/A4
Haematoma< a collection o' bloo& in the tissues4Haemostasis< process lea&in" to the re&uction o' bloo& loss
'rom the bo&y @see B/49A4
Hea,in- by 0rimary 'first( intention< close& 5oun&s 5ith a
minor &e'ect @see B/4FA4
Hea,in- by se#ondary intention< open 5oun&s allo5e& to heal
by "ranulation @see B/4FA4
Hea,in- by tertiary intention< 5oun& initially le't open to
&rain an& sur"ically close& at a later &ate @see B/4FA4Infe#tion< multiplication o' micro?or"anisms pro&ucin" a host
reac? tion @see Chapter /-A4
Inf,ammation< initial response o' the bo&y a'ter in6ury @see B/49A4
Is#+aemia< localise& &e'iciency o' bloo& an& there'ore
o=y"en, cause& by obstruction o' the bloo& vessels @see B4/- an&
B94/2A4 e,oid< a protuberance o' pro"ressively enlar"in" scar
tissue, cause& by e=cessive colla"en, 5hich may e=ten& into
normal tissue @see
BF4FA4
Li0odermatos#,erosis< bro5n stainin" o' the lo5er le"
occurrin" as a result o' haemo"lobin brea$&o5n, closely
associate& 5ith venous hypertension an& ulceration @see B94A4
"a#eration< so'tenin" or so""iness o' the tissues resultin" 'rom
the retention o' e=cessive moisture @see B//42A4
"a#ro0+a-e< pha"ocytic cell 5hich plays a vital role in
in' lamma? tion an& initiates an"io"enesis @see B/49A4
"aturation sta-e< the 'inal sta"e o' 5oun& healin" @see B/49A4
Ne#rosis< localise& tissue &eath4 (sually blac$ or bro5n in
colour
@see B4/-4 an& B94/2A4
Neutro0+i,< a 5hite bloo& cell 5hich in"ests bacteria @see B/49A4
##,usi.e dressin-< a &ressin" that totally covers a 5oun&,
sealin" it o'' 'rom the environment @see B243A4edema< e=cess tissue 'lui& @see B/494 an& B943A4
steomye,itis< in'ection o' bone4
.er-ranu,ation '+y0er-ranu,ation(< "ranulation tissue
5hich is raise& above the level o' the 5oun& @see B//43A4
P+a-o#ytosis< the process o' en"ul'in" micro?or"anisms,
' or ei"n cells an& &ebris by macropha"es or neutrophils @see
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!lossary /1/B/49A4
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/1 Woun& Care< * Han&boo$ 'or Community Nurses
P,ate,et< component o' bloo&4 Involve& in the in'lammatory sta"e
o' healin" @see B/49A4
Pus< 'lui& consistin" o' e=u&ate, &ea& an& e=hauste&
macr opha"es an& bacteria @see B342A4S#ab< see Eschar 4
Se0ti#aemia< systemic &isease4 atho"enic micro?or"anisms
or other to=ins are present an& persist in the bloo&stream @see
B/-4A4
Skin -raft< s$in is remove& 'rom its normal location an& use&
to cover another open area @see BF43A4
S,ou-+< &evitalise& tissue 5hich is yello5, cream or "rey in
colour @see B4//A4
*o/in< substance havin" a &etrimental @to=icA e''ect on livin" cells4
U,#er< a persistent area o' &iscontinuity o' the epi&ermis an& &ermis
@see B94/A4
as#u,itis< in'lammation o' small arteries or veins 5ith
r esultin" 'ibrosis an& thrombus 'ormation4 O'ten associate&
5ith rheuma? toi& &isease @see B94/3A4
enous +y0ertension< abnormally hi"h pressure in thevenous system @see B94A4
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R esour#es
Con.ate# ';ound #are +e,0,ine(
Tel< -9-- 90F19
Creden+i,, Limited
/- Cossall In&ustrial Estate
Il$eston
Derbyshire DEF 2(!
Tel< -//2 01 -/
.a=< -//2 0 -1F
Email< sales_c re&enhill4c o 4u$
%a&e?to?measure compression hosiery on NHS prescription4
Euro0ean Pressure U,#er Ad.isory Pane,
E(* #usiness O''ice
Woun& healin" unit
Department o' Der matolo"y
Churchill Hospital
Ol& R oa&
Hea&in"ton, O='or& O`1 F)KTel< -/932 930
.a=< -/932 911
Email< Eu ropean r essu r e(lcer*&vis anel_compuser v e 4com
SCAR information ser.i#e
O #o= --1
Hull H(1 DK
Tel< -92 /- -- Website< 55 54carin ' o 4o r
" In'ormation on scarrin" treatments an& support or "anisations4
/11
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/1 Woun& Care< * Han&boo$ 'or Community Nurses
Smit+ Ne0+e; ';ound #are +e,0,ine(
Tel< -9-- 20-/F1
*issue iabi,itySo#iety !lanville
Centr e Salisbur yWiltshire S 9#K
Tel< -/F 0-2F
.a=< -/F 231
Email< tvs_&ial,pip e=4com
Website< 55 54tv s 4o r " 4u$
*+e Water,o; Pressure Sore Pre.ention>*reatment Po,i#y
Ku&y
Water lo5
Ne5tons
Cur lan&
Taunton T*1 2S!
In'ormation on the use o' Waterlo5 an& other pressure sore
pr evention techni8ues4
*+e Wound Care So#iety
%rs HaJel %or ley
O #o= /F-
Huntin"&on E/9 F)
Tel< -/9- 1-/
Email< 5oun&4car e4society_tal$/4com
Website< 55 545 oun&ca r esociet y 4o r "
In'ormation about all aspects o' 5oun& mana"ement4
Websites
%ermato,o-i#a, issues
55 54s$insit e 4com
Wound #are ;it+ edu#ationa, basis
55 54me&icale&u4com
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Resources /12
Abstra#ts$ arti#,es$ 0rodu#t ,inks and industry ne;s
55 545 oun&ca r enet4com
)ree re-istration D in#,udes mi#robio,o-y$ #ase studies$
tria,s and ,ar.a, t+era0y
55 54me&scap e 4com
Wound #are usin- aromat+era0y
55 54alte r n a ti v eme&icin e 4com
&enera, ;ound #are forum
55 545 oun&4net
Conne#tion to a,, of t+ese sites #an be made at:
55 54maslt&4c o 4u$
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R eferen#es
*c$roy& KS, oun" *E @/091A )e" ulcers that &o not heal4 =ritish 1e$i+al Jo&rnal 297<
-F-94*n"eras %H, #ran&enber" *, .al$ *, Seeman T @/00/A Comparison bet5een
sterile saline an& tap 5ater 'or the cleansin" o' acute traumatic so't tissue
5oun&s4 E&ropean Jo&rnal of S&rgery 169@11A< 1F12-4
*rmstron" % @/009A Obesity as an intrinsic 'actor a''ectin" 5oun& healin"4 Jo&rnal of
9o&n$ 7are 8@2A< -/4
*sh'or& R., lant !T, %aher K @/09A Double blin& trial o' metroni&aJole in
malo&or? ous ulceratin" tumours4 )ancet i< /1/114
*s8uith S @/000A The use o' aromatherapy in 5oun& care4 Jo&rnal of 9o&n$ 7are 9@3A<
1/91-4
#an$s V @/00FA ressure sore e&ucation4 Jo&rnal of 9o&n$ 7are 7@/-A< 2-32-F4
#arnhorst D*, #arner H# @/039A revalence o' con"enitally absent 'oot pulses4 Ne4
Englan$ Jo&rnal of 1e$i+ine 289< 3324
#arrett E @/09FA uttin" ris$ calculators in their place4 N&rsing Times 93@FA< 32F-4
#ellamy : @/002A hoto"raphy in 5oun& assessment4 Jo&rnal of 9o&n$ 7are 4@FA<
1/11/34
#ennett ), )ee # @/093A ressure versus shear in pressure sore 'ormation4 In< )ee
#, e&4 7hroni+ :l+ers of the Skin4 Ne5 or$< %c!ra5?Hill, pp4 10224
#irchall ) @/001A %a$in" sense o' pressure sore pre&iction calculators4 N&rsing Times
9:@/9A< 11F4
#lac$ D @/09A Ine?&alities in 6ealth %=la+k Report)' Harmon&s5orth< en"uin4
#lan& :I, lain WE, von .raunho'er K* @/09A E=perimental an& clinical
observations o' the e''ects o' cytoto=ic chemotherapeutic &ru"s on 5oun& healin"4
Annals of S&rgery
1< F9F0-4
#on& %R @/09A .ain! Its nat&re@ analysis an$ treatment 4 E&inbur"h< Churchill
)ivin"stone4 #u= %, #ai" %:, Ro&ri"ues E, *rmstron" D, #ro5n * @/00FA
*ntibo&y response to
topical strepto$inase4 Jo&rnal of 9o&n$ 7are 7@A< F-F14
Cameron K @/009A S$in care 'or patients 5ith chronic le" ulcers4 Jo&rnal of 9o&n$ 7are8@0A< 2034
Charles H @/000A Short stretch ban&a"es in the treatment o' venous le" ulcers4 Jo&rnal of
9o&n$ 7are 9@3A< 1-11-4
Cherry !W, Ryan TK @/092A Enhance& 5oun& an"io"enesis 5ith a ne5
hy&rocolloi& &ressin"4 In< Ryan TK, e&4 An En,ironment for 6ealing' The role of o++l&sion4
International Con"ress an& Symposium4 Series no4 994 )on&on< Royal Society o'
%e&icine4
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Resources /1F/13
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Re'erences /1F
Choiniere %, %elJac$ R, !iran& N @/00-A Comparisons bet5een patient an&
nurses assessment o' pain an& me&ication e''icacy in severe burn in6uries4
.ain 45<
/1/24
ChrintJ H @/090A Nee& 'or sur"ical 5oun& &ressin"s4 =ritish Jo&rnal of S&rgery 87<--24
Clar$ %, .letcher K @/000A ro&uct selection4 Resource 'ile4 %attresses an& be&s4
Jo&rnal of 9o&n$ 7are @suppl A< /94
Closs KS @/001A %alnutrition4 The $ey to pressure soresC N&rsing Stan$ar$ 9@EA< 1
134 Collier % @/000aA %attresses an& be&s4 art /4 Jo&rnal of 9o&n$ 7are @suppl 9A<
F4
Collier % @/000bA ressure ulcer &evelopment an& principles 'or prevention4 In<
%iller %, !lover D, e&s4 9o&n$ 1anagement Theory an$ .ra+ti+e4 )on&on< Nursin"
Times #oo$s4
Cooper D% @/00-A Optimisin" 5oun& healin"4 N&rsing 7lini+s of North Ameri+a26@/A<
/324 Cooper R, )a5rence KC @/003A The isolation an& i&enti'ication o' bacteria
'rom
5oun&s4 Jo&rnal of 9o&n$ 7are 6@FA< 1121-4
Cuttin" :. @/000A .actors in'luencin" 5oun& healin"4 N&rsing Stan$ar$ 9@2-A< 11134
Cuttin" :., Har&in" :! @/00A Criteria 'or i&enti'yin" 5oun& in'ection4 Jo&rnal
of
9o&n$ 7are 3@EA< /09-/4
Davi& K @/093A 9o&n$ 1anagement' A +omprehensi,e g&i$e to $ressing an$ healing 4 )on&on<
%artin DunitJ4Davies : @/00A ressure sores< aetiolo"y, ris$ 'actors an& assessment scales4
=ritish
Jo&rnal of N&rsing 3@3A< 233-4
Dealey C @/001A %easurin" the prevalence an& inci&ence o' pressure sores4
=ritish
Jo&rnal of N&rsing 2@-A< 009/--34
Dealey C @/00A The 7are of 9o&n$s! A g&i$e for n&rses4 O='or&< #lac$5ell Scienti'ic
ublications4
Dealey C @/002A ressure sores an& incontinence< a stu&y evaluatin" the use o'
topical a"ents in s$in care4 Jo&rnal of 9o&n$ 1anagement 4@1A< /-1/-24Department o' Health @/00/A *ietary Referen+e Aal&es for Foo$@ Energy an$ N&trients for the
:B 4 @Report on Health an& Social Sub6ects no4 /A )on&on< H%SO4
Dic$erson KWT @/001A *scorbic aci&, Jinc an& 5oun& healin"4 Jo&rnal of 9o&n$ 7are
2@3A<
12-1214
Draper K @/092A %a$in" the &ressin" 'it the 5oun&4 N&rsing Times 91@EA< 1124
Duc$5orth !K @/00-A Revise& "ui&elines 'or the control o' epi&emic methicillin
resistant
Staphylo+o++&s a&re&s4 Jo&rnal of 6ospital Infe+tion 17< 12/1FF4
Dyson %, oun" S, en&le C @/099A Comparison o' the e''ects o' moist an& &rycon&i? tions on &ermal repair4 Jo&rnal of In,estigati,e *ermatology :1@2A< 1204
Effe+ti,e 6ealth 7are =&lletin @/002A Nu''iel& Institute 'or Health4 (niversity o' )ee&s4
NHS Centre 'or Revie5s an& Dissemination4 (niversity o' or$4
E$ *C, #oman ! @/09A * &escriptive stu&y o' pressure sores< the prevalence o'
pressure sores an& characteristics o' patients4 Jo&rnal of A$,an+e$ N&rsing 8< 2/2F4
Em'lor"o C* @/009A )etters4 Jo&rnal of 9o&n$ 7are 8@2A< 124
Em'lor"o C* @/000A The assessment o' 5oun& pain4 Jo&rnal of 9o&n$ 7are 9@9A< 19
1924 European ressure (lcer *&visory anel @E(*A @/00FA .ress&re :l+er
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/19 Woun& Care< * Han&boo$ 'or Community NursesTreatment
<&i$elines4 O='or&< E(*4
.lana"an % @/001A re&ictin" pressure sore ris$4 Jo&rnal of 9o&n$ 7are 2@EA< /2/94
.letcher * @/00A The epi&emiolo"y o' t5o common a"e relate& 5oun&s4 Jo&rnal
of
9o&n$ 7are 1@EA< 1014
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Re'erences /10
.letcher K @/000A * practical approach to &ressin" 5oun&s in &i''icult positions4
=ritish
Jo&rnal of N&rsing 9@/A< FF0F934
.o5ler *, Dempsey * @/009A Split thic$ness s$in &onor sites4 Jo&rnal of 9o&n$ 7are 8@9A<
100-4!ar&ner *%N, .o= RH @/093A The return o' bloo& to the heart a"ainst the 'orce
o' "ravity4 In< Ne"us D, Kantet !, e&s4 .hlebology4 )on&on< )ibby, pp4 323F4
!oul& D @/00FA iloni&al sinus4 N&rsing Times :3@supplA< 14
!o5er K, )a5rence KC @/002A The inci&ence, causes an& treatment o' minor burns4
Jo&rnal of 9o&n$ 7are 4@A< F/F4
!reen C @/001A *ntistrepto$inase titres a'ter topical strepto$inase4 ;an+et 341<
/3-/3-14
!rey KE @/009A Cellulitis associate& 5ith 5oun&s4 Jo&rnal of 9o&n$ 7are 8@FA< 1191-4
!roscott @/002A The palliative mana"ement o' 'un"atin" mali"nant 5oun&s4 Jo&rnal
of
9o&n$ 7are 4@2A< -4
!uest !, earson S @/00FA Recovery on a plate4 N&rsing Times :3@3A< 9934
Ho&"$in W @/009A iloni&al sinus &isease4 Jo&rnal of 9o&n$ 7are 8@0A< 9/
914
Ho'man D, Ryan T, *rnol& . @/00FA ain in venous le" ulcers4 Jo&rnal of 9o&n$ 7are 7@2A<
4
Hos$ins K, Welche5 % @/092A .ost8operati,e .ain' :n$erstan$ing its nat&re an$ ho4 to treat it 4
)on&on< .aber ; .aber4
Hutchinson KK, )a5rence KC @/00/A Woun& in'ection un&er occlusive &ressin"s4 Jo&rnal of 6ospital Infe+tion 18< 9194
Kohnson * @/099A Woun& mana"ement4 *re you "ettin" it ri"ht .rofessional N&rse 3@9A<
1-31-04
Koseph WS, *=ler D* @/00-A %icrobiolo"y an& antimicrobial therapy o' &iabetic
'oot in'ections4 7lini+s in .o$iatri+ 1e$i+ine an$ S&rgery 8@1A< 3F9/4
:en&ric$ %, )uc$er :, Cullun N, Roe # @/00A 7lini+al Information .a+k 4 Number /4
The management of leg &l+ers in the +omm&nity4 (niversity o' )iverpool4
:enney ), Rithalia S @/000A Technical aspects o' support sur'aces4 %attresses an& be&s4
Resource 'ile4 Jo&rnal of 9o&n$ 7are @suppl part 1A< /94
)an& ) @/00A A Re,ie4 of .ress&re *amage .re,ention Strategies4 * report initiate& by West%i&lan&s Re"ional Health *uthority4
)a5rence KC @/003A .irst ai& measures 'or the treatment o' burns an& scal&s4 Jo&rnal of
9o&n$ 7are 6@FA< 1/014
)a5rence KC @/00FA Woun& irri"ation4 Jo&rnal of 9o&n$ 7are 7@/A< 134
)evin %E @/099A The &iabetic 'oot< pathophysiolo"y, evaluation an& treatment4 In
)evin %E, O7Neal )W, e&s4 The *iabeti+ Foot , th e&n4 St )ouis< CV %osby, pp4
//24
)e5is #: @/009A Nutritional inta$e an& the ris$ o' pressure sore &evelopment in
the ol&er patient4 Jo&rnal of 9o&n$ 7are 8@/A< 1/124
)oa&er S, Delue %, Ho''man D @/00A * constancy service that pays &ivi&en&s,settin" up a pressure service relie' "roup4 .rofessional N&rse 15< 20334
)oc$ % @/09-A The e''ect o' temperature on mitotic activity at the e&"e o'
e=perimen? tal 5oun&s4 In< )un&"ren *, Soner *#, e&s4 Symposia on 9o&n$ 6ealing!
.lasti+@ s&rgi+al an$ $ermatologi+al aspe+ts4 S5e&en< %oln&al4
)othian , #arbenal K, e&s @/091A N&rsing Aspe+ts of .ress&re Sore *e,elopment in .ress&re Sores4
)on&on< %acmillan4
%cCa''ery % @/091A N&rsing the .atient in .ain4 )on&on< Harper ; Ro54
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/- Woun& Care< * Han&boo$ 'or Community Nurses
%c)aren S%! @/00A Nutrition an& 5oun& healin"4 Jo&rnal of 9o&n$ 7are 1@1A<
2224
%c)eo& * @/00FA rinciples o' alternatin" pressure sur'aces4 A$,an+es in 9o&n$ 7are
15<
1-134%a$leburst K, Sie"reen % @/003A .ress&re :l+ers' <&i$elines for pre,ention an$ n&rsing
manage8 ment , n& e&n4 Sprin"house, *< Sprin"house Corporation4
%iller % @/002A Woun& care 'or minor in6uries4 .rimary 6ealth 7are 6@/-A< 134
%iller % @/000A Woun& assessment4 In< %iller %, !lover D, e&s4 9o&n$ 1anagement@
Theory an$ .ra+ti+e4 )on&on< Nursin" Times #oo$s4
%iller %, Dyson % @/003A The .rin+iples of 9o&n$ 7are4 )on&on< %acmillan %a"aJines
)t&4
%o''att C @/009A Issues in the assessment o' le" ulceration4 Jo&rnal of 9o&n$ 7are
8@0A<
30F14
%o''att C, O7Hare ) @/002A !ra&uate& compression hosiery 'or venous ulceration4
Jo&rnal of 9o&n$ 7are 4@/-A< 2034
%oo&y % @/001A *ccountability in 5oun& care< a practical approach4 9o&n$
1anagement
3@/A< 3F4
%or"an D @/09FA Form&lary of 9o&n$ 1anagement .ro$&+ts4 Car&i''< Whitchurch Hospital4
%or"an D @/00A Form&lary of 9o&n$ 1anagement .ro$&+ts, 3th e&n4 Haselmere<
Eurome&
Communications4
%or"an D @/00FA Form&lary of 9o&n$ 1anagement .ro$&+ts, Fth e&n4 Haselmere< Eurome&
Communications4
%orison % @/090A ressure sores< removin" the cause o' the 5oun&4 .rofessional N&rse 6<
0F/-4
%orison % @/00/A A 7olo&r <&i$e to the Assessment an$ 1anagement of ;eg :l+ers4 )on&on<
Wol'e ublishin" )t&4
%orison %, %o''att C @/00A A 7olo&r <&i$e to the Assessment an$ 1anagement of ;eg
:l+ers,
n& e&n4 )on&on< %osby, Times %irror International ublishers )t&4
%ortimer @/001A S$in problems in palliative care< me&ical aspects4 In< Doyle D,Han$s !, %ac&onal& N, e&s4 O5for$ Te5tbook of .alliati,e 1e$i+ine4 O='or&< O='or&
%e&ical ublications4
%osely K! @/099A .alliation in 1alignant *isease4 E&inbur"h< Churchill )ivin"stone4
%yers K* @/09A Woun& healin" an& the use o' a mo&ern sur"ical &ressin"4 The
.harma+e&ti+al Jo&rnal 22:@3/93A< /-1/-4
Ne5man V, *ll5oo& %, Oa$es R @/090A The use o' metroni&aJole "el to control
the smell o' malo&orous lesions4 .alliati,e 1e$i+ine 3@EA< 1-11-24
NHS E=ecutive @/002A 7onsens&s Strategy For 1anagement of ;eg :l+ers4 )ee&s<
NHS E=ecutive4
North Thames Research *ppraisal !roup @/009A The 7lini+al Effe+ti,eness .ro+ess4)on&on< NTR*!4
Norton D, %c)aren R, E=ton Smith *N @/03A In,estigations of <eriatri+ N&rsing .roblems
in
6ospital 4 E&inbur"h< Churchill )ivin"stone4
Ny8uis t R, Ha5thorn e K @/09FA The prevalence o' pressure sores in a Health
*uthority4 Jo&rnal of A$,an+e$ N&rsing 12< /91/9F4
ar$er )K @/000A Importance o' han& 5ashin" in re&ucin" cross in'ection4 =ritish
Jo&rnal of N&rsing 9< F/3F-4
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Re'erences //artri&"e C @/009A In'luential 'actors in sur"ical 5oun& healin"4 Jo&rnal of 9o&n$
7are
8@FA< 12-1214
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/ Woun& Care< * Han&boo$ 'or Community Nurses
itcher % @/009A Internet sources on le" ulcer mana"ement4 Jo&rnal of 9o&n$ 7are 8@3A<
1/11/34
le5a % @/00-A *ltere& host response an& special in'ections in the el&erly4 Emergen+y
1e$i+ine 7lini+s in North Ameri+a 9@A< 01-34
riest C, Clar$e % @/001A (p&ate< pressure sore ris$ 'actors4 Jo&rnal of 9o&n$ 7are 2@A</3/F4
ro'essional Development @/00A Woun& care4 :no5le&"e 'or practice4 N&rsing Times
5< 04
un )W, #arraclou"h DRE, %uir&en :D @/00-A )e" ulcers in rheumatoi& arthritis4
1e$i+al Jo&rnal of A&stralia 163@/-A< 29229F4
Rei& K, %orison % @/00A To5ar&s a consensus classi'ication o' pressure sores4 Jo&rnal of
9o&n$ 7are 3@1A< 0104
Sa=ey S @/093A The nurses response to postoperative pain4 N&rsing 3@/-A< 1FF
19/4 Seers : @/09FA erceptions o' pain4 N&rsing Times 93@9A< 1F194
Silver I* @/092A O=y"en an& tissue repair In< Ryan TK, e&4 An En,ironment for 6ealing'
The role of o++l&sion4 International Con"ress an& Symposium4 Series no4 994
)on&on< Royal Society o' %e&icine4
Silver K @/09FA )etter4 7are S+ien+e an$ .ra+ti+e 6< 1-4
Staas WE, Cioschi H% @/00/A ressure sores a multi'acete& approach to
prevention an& treatment4 Rehabilitation me&icine4 9estern Jo&rnal of 1e$i+ine 164<
21024
Stevens K @/009A )etters4 Jo&rnal of 9o&n$ 7are 8@2A< 124
Thomas S @/00-A 9o&n$ 1anagement an$ *ressings4 )on&on< The harmaceutical ress4
Thomas S @/009A The importance o' secon&ary &ressin"s in 5oun& care4 Jo&rnal of9o&n$
7are 8@EA< /90/04
Thomas S, Kones %, Shutter S, *n&re5s * @/003A Rea&er 8uestions4 Jo&rnal of 9o&n$
7are N&rsing 2< 34
Thomas S, Vo5&en : @/009A Rea&ers7 8uestions4 Jo&rnal of 9o&n$ 7are 8@1A< /24
Thompson D, Smith DK @/00A What is in'ection Ameri+an Jo&rnal of S&rgery
78a@supplA<
F2//24
Torrance C @/091A .ress&re Sores! Aetiology@ treatment an$ pre,ention4 )on&on< Croom Helm4
Turner TD @/092A Which &ressin" an& 5hy In< Wesby S, e&4 9o&n$ 7are4 )on&on<William Heinemann %e&ical #oo$s4
(nite& :in"&om Central Council @/00A 7o$e of .rofessional 7on$&+t 4 )on&on< (:CC4
Value 'or %oney (nit @/00FA A .res+ribersC <&i$e to *ressings an$ 9o&n$ 1anagement
1aterials4 Report pro&uce& 5ith Jo&rnal of 9o&n$ 7are4
Vo5&en :R, !oul&in" V, Vo5&en @/003A Han& hel& Doppler assessment 'or
periph? eral arterial &isease4 Jo&rnal of 9o&n$ 7are 6@1A< /2/94
War'iel& C* @/00FA E5pert .ain 1anagement 4 Sprin"house, *< Sprin"house
Corporation4 Waterlo5 K @/092A * ris$ assessment car&4 N&rsing Times 91@9A< 0224
Weaver * @/003A %RS* an& its mana"ement in the community4 7omm&nity N&rse 2@0A<
13194West , riestley K @/00A %oney un&er the mattress4 6ealth Ser,i+e Jo&rnal 14< -4
Williams C @/000A *n investi"ation into the bene'its o' *8uacel Hy&ro'ibre
5oun& &ressin"4 =ritish Jo&rnal of N&rsing 9@/-A< 3F339-4
Williams E @/00FA *ssessin" the 'uture4 N&rsing Times :3@supplA< 14
Winter ! @/03A .ormation o' the scab an& the rate o' epithelialiJation o'
super'icial 5oun&s in the s$in o' the youn" &omestic pi"4 Nat&re 13< 0104
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Inde/
a"e re'erences in bo,d ty0e re'er
to &e'initions o' terms in the
!lossary
abscess 9,
12: piloni&al
F action plan
//0
*ctisorb lus
a&hesive strips ,21 a&ipose tissue
2
a"e, e''ect on healin" 1, F,
91 air5ay overlay 01
alcohol, in ulcer preparations /
alcohol consumption, e''ect on
5oun&
healin" /1, 1, 0
al"inate &ressin"s /9, 12, 13F, 1,
/-3, /-F9
as cavity &ressin" F,
9 as haemostat 21
aller"ens /
*llevyn 19
*llevyn *&hesive 10
alternatin" pressure mattress
0 anaerobe 12:
anal"esia /0,
F/ an"ina 20an"io"enesis 12, -, 12:
an$le brachial pressure in&e= @*#IA
3/1, 12:
an$le 'lare 2F,
12: antibiotics /0
systemic 09,
00 topical /, /-1
anticoa"ulants 3
anti?in'lammatory &ru"s
e''ects on 5oun& healin" 9
an& pressure sore healin"
91
antimicrobial therapy 9,
- antiseptics 1/
antistrepto$inase titre 19
an=iety F
*8uacel 10
aromatherapy /-3
arterial &isease 29
0
arterial ulceration 20, 32,
F1 pain associate& 5ith
/0
arteritis 32 aspirin 9
athersclerosis 32,
12: atrophe blanche
2F autolysis 10, 12:
U?bloc$ers, e''ect on pressure
sore healin" 91
bacitracin /
bacterial colonisation /, 02
#ioclusive -
#lac$ Report 0
blisterin" 2/
bovine colla"en
#ritish #urns *ssociation2/ burns 2, 2-
&ressin"s 'or 2/
'ull?thic$ness 2-,
2 minor 2/
pain associate& 5ith /0
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/ Woun& Care< * Han&boo$ 'or Community Nurses
/1
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Cushin"7s syn&rome
Cuti'ilm -
cytoto=ic
&ru"s
e''ect on pressure sores
91 an& 5oun& healin"
9, 3
Database o' Revie5s o'
E''ectiveness an& #est
Evi&ence //2
&Mbri&ement -, 1F, 135
&eep vein thrombosis 2F,
29 &ehiscence , 9,
135
Deni&or
&ermis ,
1
thinnin" o' 32,
9 &eslou"hin" -
&iabetes
an& *#I 3
e''ect on 5oun& healin" /1, , F,
20, 31,
33F 'oot care3F9
'oot ulcers 339,
00 an& ischaemia
32
&ietary a&vice, +ase st&$ies
2F &ietary supplements
, 2 &i"its, &ressin"s 'or
/-3, /-F
&iversion therapy, 'or pain control
- &ocumentation //&onor sites 2
Doppler ultrasono"raphy /1, 3/1,
135
&ressin"s
choice o' 13
combinations 1
're8uency o' chan"in"
F- lea$a"e /F/9
pac$s 1-
prescription an& non?prescription
13
removal, trauma /9, /0,
12 secon&ary 1F, 1
ulcer 30F-
see also al"inate &ressin"sG
charcoal &ressin"sG enJyme
&ressin"sG 'oam &ressin"s<
occlusive &ressin"sG
hy&rocellular
&ressin"sG hy&rocolloi&
&ressin"sG hy&ro'ibre &ressin"sG
lo5? a&hesive &ressin"sG
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In&e= /2
polysacchari&e bea& &ressin"sG
vapour?permeable &ressin"s
Duo&erm -
&uty to care /1
ecJema 32
Effe+ti,e 6ealth 7are =&lletins //2
emollients /, 1/, 33
enJyme &ressin"s
1F eosin /-9
epi&ermis , 1
epithelial cells an& tissue 2, 9, 135
islan& /
mi"ration 0/-
epithelialisation 0, 13, 135
erythema 2/, 135
eschar 9, -, 135
Es+heri+hia +oli
- ester o' resin
European ressure (lcer *&visory
anel 9
evaluation //
evi&ence appraisal //3evi&ence?base& health care //
e=ercise 33, F/, F1
e=u&ate 3, /0, /, 1-, 1, 12, 10, /-2,
/-F, /-9, 135
an& al"inate &ressin"s 13
F an& protein loss
.ibracol
'ibrin 135
'ibroblasts F,9
.lamaJine 2/, /-1
'lui& loss /
'oam &ressin"s 190, 1,
9 'ocus "roups /, /2
'ra"rances, as irritants
'ramycetin /
'riction 2, 93
an& incontinence 91
'un"atin" 5oun& /-2'usi&ic aci& /-1
!am"ee 1
"auJe 12, 2
"el'oam combination &ressin"
"entamicin /
!ranu'le= -
!ranu"el -
"ranulation tissue , 9, /, 12, 131
haemostasis 3, 131
haematoma 'ormation 2, 3, 131
han& 5ashin" 00/--, /-1
heat an& col& therapy, 'or pain relie'
-
heel, &ressin"s 'or /-3F
hy&rocellular &ressin"s 19
hy&rocolloi& &ressin"s 12, 10-,
1,
2o&our 'rom /F/9
hy&rocolloi& "el &ressin"s -
hy&ro'ibre &ressin"s 10, /-F
9 hy&ro"els 10, -
hy&ropolymer &ressin"s
19 hypercholesterolaemia
33 hyper"ranulation /-9
hypertension 29, 33
hypertrophic scar 21
immunosuppressive &ru"s, e''ect
on 5oun& healin" 9, 3
Ina&ine /-1
incontinence, 'aecal an& urinary 91,
0- in'ection /, , /0, /, F, 131
e''ect o' a"e on 1
in'lammation 3, /-F, 131
in"ro5in" toenail 9
intermittent clau&ication
20 internet /-0/-, //3Intrasite !el 10
io&ine 1F
Io&o'le= 1F
Io&osorb 1F
irritants /
ischaemia /9, -, 32, 92,
131 e''ect o' smo$in" 0
ischaemic 'oot ulcer 00
6oint &ressin"s
/-F 6ournal clubs
//3
:altostat 21
:aposi7s sarcoma
30 $eloi& scar 21,
131
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laceration
pretibial 21
traumatic , 22
lanolin /
larval therapy /-90
le" elevation 29, F1,/-9 le" ulcer , 23''
assessment 2031
+ase st&$y /1
causes o' 23
F
clinical investi"ations3- costs o' treatin" 23
&ressin"s 30F-
i&enti'ication /in'ection, +ase st&$y 03F
recurrent /, Flipo&ermatosclerosis 2F, 131
literature search //2
lo5 a&herence &ressin"s 1
)yo'oam 19
)yo'oam C
maceration 1, 10, 0-, /-F, /-9, 131
an& incontinence 91macropha"e F, 131
ma""ots see larvaltherapymalnourishmentG malnutrition , 3,
F, 0-/
e''ect on pressure sore healin" 91
%ar6olin7s ulcer 30
mattresses see support sur'aces%e&line //2
%e'ilm -melanomas 30%elolin 2
methicillin?resistant Staphylo+o++&s
a&re&s
@%RS*A 1F, /--
metroni&aJole /9
micro?or"anismscolonisation, /, 02,135 resi&ent 00
transient 00an& 5oun& &ressin"s
1 mobility 1, 2, 32moist 5oun& healin" 0/-, /9, /,11,
-, /-F mupirocin
/-1 myocar&ial in'arction 29
>mystery patient7 /-
N?* Dressin" 1
necrosis, necrotic tissue , -, 92, 131
e''ect o' smo$in"
0 peripheral 1neomycin /
ne"li"ence
/1
nerve &ama"e, pain associate& 5ith
/9 neuropathy 3F
Norton ressure Sore Ris$ *ssessment
Scale 93F
NS*IDs /9
Nu?!el 10
nutrition, nutritional status 1,91 assessment F
an& rheumatoi& arthritis 33
nutritional supplements 33
obesity, e''ect on 5oun& healin" 2,
F, 91
+ase st&$y 23
occlu&e& 5oun&, in'ection /-
occlusive &ressin"s /9, 11, 12, /-F,
131 oe&ema /, 29, 3/, 32, 33, F2, 03,131 opiate anal"esia /9
Opsite .le=i"ri& -
over"ranulation /-9,
131 o=y"en
atmospheric 12
o=y"en?permeable &ressin"s
13 re&uce&, an& oe&ema 9
tension an& obesity 2
pa&&in", as secon&ary &ressin" 12, 1,
F
pain /2, /9, 9
abscess 9
assessment /0
assessment scale
- control F1
ischaemic /9
le" ulcers /0,
F/ venous ulcer29
arabens /
para''in "auJe
12 patients
a&vice "iven to
// assessment o'
1 complaints /-
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compliance /2, F9G +ase st&$ies F0
9-,
03F
con'i&entiality /F,
/2 consent /3
e&ucation F/, //
recor&s //9
surveys //1, //
1 vie5s o' //
pe&al pulse 29, 3/, 3
penicillin, e''ect o' on
colla"en
'ormation 3
peripheral vascular &isease 20,33 pha"ocytic 5hite cells F, 131
phenol, 9
phlebitis 29
photo"raphic recor&s /3
piloni&al abscess F, 9
piloni&al sinus -, F9
pituitary &e'iciency
polymorphs F
polysacchari&e bea& &ressin"s /9,
1F polyurethane &ressin" 2 postoperative
recovery 3
5oun& in'ection 2
potassium perman"anate /-9
povi&oneio&ine 1, 2
pressure sores, ulcers 2, /0,
9/''
causes o' 93
costs o' treatin"
9/ &e'inition 9inci&ence 9/, 9
mortality associate& 5ith
9/ prevalence 9/, 9
prevention 0-
ris$ assessment 93
0- an& 5omen 91
pressure?re&ucin" mattress 01
see also support sur'aces
ro'lavine -/, F
ro'ore F
protease /-F
protein loss
.rote&s -
.se&$omonas spp4 -
psycholo"ical 'actors, e''ect on
5oun& healin" 0
pulmonary &isease
pulmonary embolism 29
urilon !el 10
pyre=ia /, 9,
03
ra&iotherapy 3
ran&omise& controlle& trials //3
recor& $eepin" //, /
+ase st&$y /1
revie5 //9
re'lective practice /3F
rela=ation techni8ue -
rheumatoi& arthritis, 32 33
ris$ assessment 9F0-Rosi&al : F
rubber aller"y /
saline, physiolo"ical 1/,
1 temperature o' 1
scab 'ormation F, 9, 0
scal&s 2/
scars 2, 21
secon&ary &ressin"s 1F,
1 septicaemia 09, 132shear ulcers 92
shearin" -, 923
sheeps$in 01
silver nitrate /-9
silver sulpha&iaJine
2/ s$in
con&ition /
'unction o' /
"ra't 2
stainin", an& vascular &isease 2F,
32 structure o'
slou"h , -/, 132
smo$in"
e''ect on 5oun& healin" /1,
1,
90, 9
an& ischaemia 32
social 'actors, e''ect on 5oun& healin"
0>social7 ulcer F9
s8uamous cell carcinomas
30 staphylococcal in'ections
09
see also methicillin?
resistant
Staphylo+o++&s a&re&s
stasis ecJema 2F
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Steri"el 10
steroi&s
e''ect on pressure sores 91
e''ect on 5oun& healin"
an& s$in thinnin" /
topical /
see also
corticosteroi&s
strepto&ornase 1F
strepto$inase 1F, 19
stress F
stri$e?throu"h 12,
1 subcutaneous 'at
, 1 sunburn 2/support sur'aces 0-, 0/
Sureress F sur"ical
"lue , 2 sur"ical
clips 23 sur"ical
5oun& , 2''
postoperative recovery 3
Sur"ipa& 1 sutures
, 23 systematic
revie5 //2 systemic
in'ection 9 systemicto=icity 00
Te"a&erm -
Te"asorb -
Tensopress F
thyroi& &e'iciency
tissue
brea$&o5n 9, 0-
hypo=ia /-2
o=y"enation 2types /2
tissue paper s$in
9 total sun bloc$
2 trauma 5oun&s
1-
an& ulcer F1
treatment "oals //
Tricote= 1
trimethoprim /-1
tulle 2/
tumour
blee&in" 'rom /-3
'un"atin" /-2
(: consensus classi'ication o'
pressure sores 2
(:CC ro'essional Co&e o' Con&uct
//1
ulcers 132
cleansin" F-costs o' treatin"
23 mali"nant 30
recurrence F
types o' /
see also 'oot ulcersG le" ulcersG
pressure ulcersG vasculitic ulcers
(ltra .our F
un&erlyin" &isease, e''ect on
5oun& healin" 9
uraemia
vapour?permeable 'ilm &ressin"s 1,
-, 1, 2
varicose ecJema /
varicose veins 2F,
3
Vari&ase 1F9
vascular status, assessment o'
3/ vasculitic ulcers 32
ve"etarians, &ressin"s suitable 'or venous &isease 23, 2F, 312,
132 venous le" ulcer /0, 21, 29, F/
+ase st&$ies 2 F90
vitamin C supplements
F
see also malnourishmentG nutritionG
nutritional supplements
Waterlo5 ris$ score 9F
0 5ell ulcer clinic F9
5hite cell activity
F 5oun&
acute /1 a&herence
/9 assessment, //''
assessment chart
/ cate"orisation
chronic /
cleansin" /0, 1-
cleansin" a"ents 1/,1 closure strips 21
&ebris clearance 9
&epth 2, /3
&ressin"s /F
/9 &ry 9
'ull thic$ness 1
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'un"atin" /F, /-2
healin"< by primary an&
secon&ary intention , 2, 131G
by tertiary intention 3, 131G
nutrient re8uirements 'or 2G
phases o'
30
in'ection F, 02''
irri"ation 1-
maturation 0
measurement /2/3
o&our /2, /F, /, , 03, /-2
partial thic$ness 1
recor&in" /
super'icial 1s5ab 02, 09,
/-/ temperature
1 tracin" /2
/3
Jinc &e'iciency 9
Jinc o=i&e paste an& ban&a"es /-9