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7/31/2019 Wounds Chronic
1/12
Assessing and Managing
Chronic Wounds
Developed by:
Helle Simonsen, RN, DK
Patricia Coutts, RN, CA
Sandra van den Bogert-Janssen, RN, Nurse Practioner, NL
Susan Knight, RN, UK
Wound Care Reerence Guide
For health care professionals
who want to increase their basic knowledge
on chronic wound management
7/31/2019 Wounds Chronic
2/122 WoundCareReerenceGuide
Bacteria Singlecellorganismsthatcandamagehealthycells/tissues.
Bacterial load Thetotalnumberobacteriainawound;theymayormaynotbe
causingahostresponse.
Colonisation Thepresenceoreplicatingbacteriathatadheretothewound
bedbutdonotcausecellulardamagetothehost.
Critical colonisation
/ Local inection
Anincreasingbacterialloadonawoundthatisbetweenthe
categoryocolonisationandinection.Thewounddoesnotheal
butmaynotdisplayclassicsignsoinection.
Emollients Emollients(moisturisers)preventtheskinrombecomingdry.Emollientscanbeappliedasotenasneeded.
Epithelialization Theprocessotheormationonewepithelialtissue
theupperlayerotheskin.
Granulation tissue Thepinktored,moist,ragilecapillarytissuethatllsinanopen
woundbedduringtheprolierative(celldivision)phaseohealing.
Inection Thehostresponsetobacterial,viralorsimilarinvasion.
Infammation Anon-specichostresponsetoinvasionooreignmaterial.Thegoalotheinfammatoryprocessistoremovedeadtissue
andbacteria.Thewoundcontainsyellow,sloughymaterialand
producesexudate.Chronicwoundsareotenstuckintheinfam-
matoryphase.
Maceration Theskinsurroundingawoundcanshowsignsomaceration
(thin,shiny,pale,whiteorgreytissue).Macerationisabarrierto
woundhealingduetothehighriskoskinbreakdown.Macera-
tionisotenduetoleakageoexudate.Thereorethechoiceo
dressingshouldrefecttheexudatelevelinthewound.
Necrotic tissue Dead,blackoryellowtissue.Thenecrotictissuecanbesotor
canormaneschar.
Persistent pain Painthatpersistswithactivityand/oratrest
Slough Depositsodeadwhitecells,deadbacteria,etc.inthewound
bed,yellowinappearance.
Temporary painProcedurallyrelatedpain,orexampleatdressingchanges,duringcleansingordebridement.
Wound Care Mini Glossary
7/31/2019 Wounds Chronic
3/12
REASSESS
ASSE
SS
TREATTREATIntroduction to Wound Management ................................4
Assess - Treat - Reassess .................................................4
1. Assess .............................................................................5
2. Treat .................................................................................7
3. Reassess .........................................................................9
The Wound Care Model ...................................................10
Coloplast Wound Care Solutions .....................................11
Pocket Guides provided by Coloplast ............................12
WoundCareReerenceGuide 3
Table of Contents
This pocket guide, on basic patient & wound assessment and
treatment, aims to help health care professionals to assess andmanage chronic wounds.
By facilitating knowledge of basic wound management it is our goal
to supportfaster wound healing whenever possible.
7/31/2019 Wounds Chronic
4/124 WoundCareReerenceGuide
Introduction to Wound Management
Themostimportantpartowoundmanagementistodiagnosetheaetiologyothewound
andtreatoroptimisetheunderlyingcause.Thiswillpromotehealingwiththeassistanceomodernwounddressings.
Woundshealbestinamoistenvironmentandmostwounddressingshavebeendesigned
toassistthisprocess.
Asthewoundhealingisdeterminedbythegeneralhealthothepatient,acomprehensive
assessmentothepatientiscriticaltoassistintheplanningandevaluationoanywound
treatment.
Assess Treat ReassessThecircularmodeloutlinedbelowcomprisestheimportantelementsinwoundmanage-
ment.Themodelisdescribedindetailsontheollowingpages.
1. Assessyourpatientandthewound
2. Treatunderlyingpathologyandthewound
3. Reassessthewoundtoevaluatetheeectothetreatment.
Ithewoundishealingasexpected,continuethetreatment asplanned.Inot,adjusttreatmentaccordingtothe
reassessment.
REASSESS
ASSESS
TREAT
TREAT
7/31/2019 Wounds Chronic
5/12 WoundCareReerenceGuide 5
Assess
Assess the Patient Fullmedicalhistorye.g.diseasessuchas:
-Diabetes
-Vasculardiseases
-Immunecompromise
-Connectivetissuedisorders
-Allergies
Medication
Nutritionalstatus
Liestyle
-Tobacco/alcoholhabits,etc.
-Impairedmobility
Psychological/psychiatricproblems
QualityoLie
Planning the optimal treatment
requires assessment of both thepatient and the wound
REASSESS
ASSESS
TREATTREAT
7/31/2019 Wounds Chronic
6/126 WoundCareReerenceGuide
Ongoingassessmentisrequiredateachdressingchange,
careullyrecordingtheollowing:
Location o wound
Wound size(includingcavity,sinusandstula)
Characteristics o wound bed(necrosis,granulation,inection)
Exudate(none,low,moderate,high)
Odour(absent,present)
Clinical signs o critical colonisation / local inectionsuchasdelayed
healing,odour,absentorabnormalgranulationtissue,neworincreasedpain
atwoundsite,excessiveorincreasedexudate1
Condition o surrounding skin
(normal,oedematous,white,shiny,warm,red,dry,scaling,thin,etc.)
In case o chronic wound pain, determine the kind o pain2
-Location(woundbedorotherareas)
-Duration(persistent/temporary)
-Intensity(onascalerom0(nopain)to10(worstpain))
-Quality(aching,throbbing,burning,stinging,shooting,stabbing)
Barriersconsistingolocalandsystemicactorsmaydelayorimpedehealing.
Throughtheassessmentitisessentialtoidentiytheseactorsandcontrolthem
toacilitateasterwoundhealingwheneverpossible.
Assess the wound
Assessment of the wound is a
prerequisite for the selection of anappropriate dressing
REASSESS
ASSESS
TREATTREAT
1Reertothepocketguide:Clinical Wound Assessment orurtherinormationonbacteriainwoundsand
dressingswithsilver.2Reertothepocketguide:Assessing and Managing Painul Chronic Woundsorurtherinormationonwound
relatedpain.
7/31/2019 Wounds Chronic
7/12WoundCareReerenceGuide 7
Treat REASSESS
ASSESS
TREATTREAT
3Reertothepocketguide:Improved Patient outcomes or Diabetic Foot Ulcersorurtherinormationonbacte-
riainwoundsanddressingswithsilver.
Following the initial wound assessment
the specifi c points below should beconsidered when choosing the treatment
Leg ulceration
Ascertaintheunderlyingdisease,e.g.venous/arte-
rial.Avenouslegulcershouldbetreatedwithgraduated
compressiontherapy,whereasanarterialulcercannotbe
treatedwithcompression.Ithelegulcerisarterial,always
reertoaspecialist.
Diabetic oot ulcers
Alwaysreertoaspecialist3
Pressure ulceration
Relieveorremovepressuretopreventurtherinjury.
Patient
Discusswhatissuesconcernhimthemostaboutthe
wound.
7/31/2019 Wounds Chronic
8/128 WoundCareReerenceGuide
Extensive necrotic tissue
Considerareerraltoaspecialistorsharpdebridementormaggottherapybeore
applicationoanappropriatedressing.
Exudate
Istheamountoexudateincreasing/decreasing?Manageexudate.Donotletthe
woundbeddryout.
Critical colonisation or local inection
Checkorclinicalsignssuchasdelayedhealing,odour,absentorabnormalgranula-tiontissue,neworincreasedpainatwoundsite,excessiveorincreasedexudate4.
Reertoaspecialistordecisiononneedoadressingwithsilverand/orsystemic
treatment.
Systemic inection(i.e.aninectionthathasspreadbeyondthewound)
Checkorclinicalsignssuchasredness,heatand/orpaininsurroundingtissue,
oedema,purulentexudate,everinadditionstothesignsolocalinection.Always
reertoaspecialistordecisiononneedosystemictreatment.
Condition o the surrounding skin
Macerated,shiny,red,dry,scaling,thin,etc.Useskinprotectantstominimisethe
eectsoexudate.Useemollientsordryandeczematousskin.
Wound pain
Treatthepossiblecauseothepainandconsiderlocalnon-pharmacologicaltreat-
ment.Forpersistentwoundpainconsidersystemicmedicationand/orlocalpharma-
cologicaltreatment,orexampleibuproenincorporatedintoawounddressing5.
Ongoing assessment is required
at each dressing change.
4Reertothepocketguide:Clinical Wound Assessment
orurtherinormationonbacteriainwoundsanddressingswithsilver.5Reertothepocketguide:Assessing and Managing Painul Chronic Wounds
orurtherinormationonwoundrelatedpain.
Treat REASSESS
ASSESS
TREATTREAT
Treatmentdecisionsandobjectivesshouldbebased
ontheunderlyingwoundproblemidentiedintheassessment.
Asthewoundchanges,consideradjustingthetreatmentaccordingtoreassessment.
ForchoiceodressingreertotheWound Care Model onpage10.
7/31/2019 Wounds Chronic
9/12 WoundCareReerenceGuide 9
Reassess REASSESS
ASSESS
TREATTREAT
During treatment the wound
should be frequently reassessedto evaluate the effect of the treatment.
Ithetreatmentobjectiveshavenotbeenmet,
consideradjustingthetreatment.
Somewoundsailtoheal.Thesewoundsrequirespecialistsupportorurtherassess-
mentounderlyingconditionsandtoimproveclinicaloutcomes.Examplesareungating
wounds,inoperablearterialwounds,patientswithendstagerenalailure,osteomyelitis,
nutritionaldisorders(e.g.anorexia),andconnectivetissuedisorders.
Many patients with chronic wounds experience persistent wound pain
that affects their general well-being and influences the wound healing
potential.
The pocket guide Assessing and Managing Painful Chronic
Woundsprovides guidance on treating painful wounds.
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7/31/2019 Wounds Chronic
10/1210 WoundCareReerenceGuide
TheWo
undCareMo
del
TheWoundCare
Modelshowstheappropriatedressingchoices.The
longerintervalsbetweend
ressingchanges,
themorebenefcialorthewoundhealingandcost-eectivenessortheorganization.
*Incombination
withasecondarydressing
**Incaseowoundpain
Whenchoosingaspecifcdressing,always
remembertoconsulttheInstructionsorUseortheproduct.
Necrotic/
sloughytissue
Localinfection/
criticalco
lonisa-
tion
Granulation
Epithelia
lization
Woundbed
Objectiv
eof
treatment
Removalonec
rotictis-
sue(reertospe
cialisti
indoubt,e.g.in
caseo
necrosisontoe
orheal)
Cleanupandreduce
bacterialburde
n
Supportgranu
lationand
tissuegrowth
Protectiono
newly
ormedtissue
Treatmentsu
ggestions
Exuda
te
Alginate*orsim
ilar
HydrocapillaryF
oamwith
ibuproen**
Silveroam
Silveralginate*
orsimilar
Hydrogel+FoamAlgi-
nate*orsimilar
Hydrocapillary
Silveroam
Silveralginate*
orsimilar
Foam
Alginate*orsimilarFoam
withibuproen
**
Hydrocolloid
Hydrogel+FoamorFilm
Silverhydrocolloid
Silverwoundcontact
layer*
Iodine*
HydrocolloidW
ound
contactlayer*
Foam
Foamwithibuproen**
Thinhydrocolloid
Woundcontactlayer
*Film
7/31/2019 Wounds Chronic
11/12 WoundCareReerenceGuide 11
Dressing type Coloplast solution
Moist wound healing dressings
Alginate SeaSorbSotNon-adhesiveAlginateDressing
Alginateller SeaSorbSotFiller
Foam BiatainAdhesiveFoamDressing
BiatainNon-adhesiveFoamDressingBiatainSot-HoldFoamDressing
Film Stabilon
Hydrocolloidthin ComeelPlusTransparentAdhesiveHydrocolloidDressing
Hydrocolloid ComeelPlusAdhesiveHydrocolloidDressing
Hydrocapillary AlioneAdhesiveHydrocapillaryDressing
AlioneNon-adhesiveHydrocapillaryDressing
Hydrogel PurilonGel
Woundcontactlayer PhysiotulleNon-adhesiveWoundContactLayer
Dressings with silver or inected wounds
Silveralginate SeaSorb - AgNon-adhesiveAlginateDressing
Silveroam Contreet / Biatain - Ag AdhesiveFoamDressing
withsilver
Contreet / Biatain - Ag Non-adhesiveFoamDressing
withsilver
Silverhydrocolloid Contreet/ComeelAdhesiveHydrocolloidwithsilver
Silverwoundcontactlayer Physiotulle - AgNon-adhesiveWoundContactLayer
withsilver
Dressings with ibuproen or painul wounds
Foamwithibuproen Biatain - IbuNon-adhesiveFoamDressingwithibuproen
Biatain - IbuSot-HoldFoamDressingwithibuproen
Notalltheabovesolutionsmaybeavailableinyourcountry.
Formoreinormationvisitwww.woundcare.coloplast.com .
Coloplast Wound Care Solutions
Anumberointernationalsuppliersprovidewoundcaredressings.
PleasendbelowanoverviewothesolutionsromColoplast.
7/31/2019 Wounds Chronic
12/12
ColoplastA/S
Holtedam13050HumlebkDenmark
www.coloplast.com,Alione, Biatain, Comeel, Contreet, Physiotulle, Purilon, SeaSorb and Stabilon
are registered trademarks of Coloplast A/S. 2007-03/dkcht. All rights reserved.
Pocket guides Readers ContentWound Care Reer-
ence Guide
Forproessionalswho
needabasicknowl-
edgeonmanagemento
chronicwounds
Providesageneralguidelineorbasic
woundtreatment,appropriatechoices
owounddressingsandwhentoreer
toaspecialist
Clinical Wound
Assessment
Forspecialiststreating
chronicwounds
Providesageneralguidelineoras-
sessmentandtreatmentowounds
withdelayedhealing.Focuson
evidence-basedwoundmanagementandcriticallycolonisedwounds
Improved Patient
Outcomes or Dia-
betic Foot Ulcers
Forspecialiststreating
diabeticwounds
Providesageneralguidelineorwhich
aspectstocoverwhentreatingdia-
beticootulcers
Assessing and
Managing Painul
Chronic Wounds
Forproessionalswho
needabasicknowl-
edgeonassessingand
managingpainulchronic
wound
Providesanoverviewohowtomeas-
urepainandhowtomanagepainin
chronicwounds
Persistent Wound
Pain Management
Guide
Forproessionalswho
needaquickABCD
overviewopainassess-
ment
Assessthepain.Beawareothe
cause.Consider
local.Doweneedsystemic?
Application and
Cutting Guide
Forproessionalswho
dealwithdicult-to-
dresswounds
Providesinspirationoncuttingo
dressingsinspecialshapes
CheckyoulocalColoplastoceoravailabilityothedierentguidesinyourlocal
languageordownloadanEnglishversionromwww.woundcare.coloplast.com
Pocket Guides provided by Coloplast
AnumberoWoundCareGuideshavebeendevelopedbycliniciansorclinicianstohelp
reducethebarrierstohealing.Thecontentotheguidesisbasedonclinicalexperience
andthebestavailableevidence.