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    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

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    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

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    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.

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    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

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    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

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    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.

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    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.

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    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.

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    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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    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

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    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.

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    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.