Community nursing:

Wound care

Tissue Viability Service

Aims of this session
 Identify layers and functions of the skin
 Identify phases of normal wound healing
 Assess and describe a wound
 Have an understanding of wound bed preparation and the TIME principle.
 Have an understanding of debridement methods
 Identify skin tear classifications
 Make appropriate wound dressing choices
Anatomy of the skin
– Label the diagram

Sweat gland

Nerve Oil gland

E

Oil gland Epidermis

A

Follicle
SweatFgland
Dermis Dermis
B

Epidermis
Follicle
C FattyGtissue
Fatty tissue

Nerve
D
Make a list
Functions of the skin
Functions of the skin
Protection –
The skin maintains a homeostatic environment and
acts as a barrier
Temperature regulation –
Body temperature is controlled by two mechanisms:
sweating and blood circulation [1]
Vitamin D production –
Vitamin D is synthesized in the presence of daylight [2]
Sensation –
Receptors in the skin transmit impulses to the brain
when touch is detected [1]
Plus, excretion and storage of fat

[1]
Bale et al, 2006
[2]
Docherty & Hodgson, 2000
Phases of wound healing

Haemostasis

Inflammation

Proliferation

Maturation
What is a wound?

A wound by true definition is a

breakdown in the protective function of the skin;
the loss of continuity of epithelium,
with or without loss of underlying connective tissue

( i.e. muscle, bone, nerves)

(Leaper & Harding, 1998)

What local factors affect
wound healing?

Increased blood Increased skin

supply tension

Poor venous
Wound dehiscence
drainage

Presence of foreign Continued presence

body of micro-organisms

Excess local
Infection
mobility (e.g. over a joint)
What systemic factors
affect wound healing?
Advanced age and Obesity Smoking
general immobility

Malnutrition Smoking Vitamin deficiency

Systemic Shock (of any Chemotherapy and

malignancy and cause) radiotherapy
terminal illness

Immunosuppressant Diabetic foot

drugs, corticosteroids, (neuropathy and Infection
anticoagulants ischaemia)
Diabetic foot is the most common cause of
non-traumatic lower extremity amputations [3]

Diabetic foot problems require urgent attention.

Morbidity and mortality increases when there
is a delay in diagnosis and management [4]

[3]
Boulton et al, 2005
[4]
Reiber et al, 1999
Assessing the wound

Treat the whole patient;

not the hole in the patient

Physical Spiritual

Social Environmental
What we need to know about…

The wound The patient

Type (surgical/non-surgical; Allergies and skin

acute/chronic/acute on chronic)
Recent changes and age sensitivities

Smoking
Anatomical site and (nicotine and haemoglobin)
Size
position
Oxygen
Exudate Pain/discomfort
Blood glucose and WBC

Odour and appearance Stage of healing Nutrition

(protein and albumin)

Surrounding skin Clinical signs of infection Medication

Wound bed assessment and preparation

The TIME principle

T – Tissue

Is there dead or
devitalised tissue
present within the wound?

What effect will this have on the

healing process?
I – Infection or inflammation

Wound infection is the result of an

imbalance between the patient’s immune
system bacteria and the conditions in the
wound.
Infection occurs when there are ideal
conditions in the wound for an imbalance to
occur, and/or where the host (patient) has
low resistance.
M – Moisture imbalance
A moist wound environment is
Clear
needed to enhance the Often considered ‘normal’, but may be
Amber associated with infection
autolytic debridement and Serous
acts as a transport medium Cloudy May indicate the presence of fibrin strands
for essential growth factors Milky (fibrinous exudate– a response to
Creamy inflammation) or infection
during epithelisation.
Pink Due to the presence of red blood cells and
indicating capillary damage (sanguineous
Red or haemorrhagic exudate)

May be indicative of bacterial infection,

Green (e.g. Pseudomonas aeruginosa)

Yellow May be due to the presence of wound

Brown slough or material from an enteric fistula

Grey May be related to the use of silver-

Blue containing dressings
E – Edge of wound
(non-advancing or undermined)

What is the appearance

of the peri-wound skin?
 How quickly should
a wound heal?

30-40% in 3-4 weeks

(Flanagan, 2003)
Wound pain

Type of wound pain Receptive to…

Nociceptive Throbbing/stabbing NSAIDS

(tissue)

Anti-depressants,
Neuropathic Burning/tingling anti-convulsants,
(nerve)
tricyclics

Ischaemic
(associated with Excruciating Resolved blood flow
decreased blood flow)
Signs of infection

Localised erythema, pain

Cellulitus
and heat

Oedema Abnormal smell

Discharge Discolouration of tissues

(may be viscous in nature, discoloured
(both within and at the wound margins)
and purulent)

Unexpected pain and/or

Friable
tenderness

Wound breakdown Delayed healing

 Local Wound Infection
Decision making pathway for the use of antimicrobials

Document patient assessment in accordance with trust guidelines – (including wound assessment chart, pain assessment, Waterlow
assessment, MUST screening tool, leg ulcer assessment form where appropriate)

Is the wound infected?

No Refer to criteria for wound infection (on the reverse) noting that Yes
infection could be masked and signs and symptoms subtle and
slight, particularly in patients with diabetes.
Is the patient clinically unwell? OR
Are any of the following present?
* Exposed bone
* Dry necrosis that has turned wet
Standard Wound Protocol: No
* Use correct dressing where appropriate to provide a moist * Necrosis – new or spreading.
wound healing environment. Please refer to the guidance on Especially in arterial or diabetic
the formulary card. ulcers.
* Also use, where appropriate, pressure relieving equipment Does the wound have a cavity?
and/or compression therapy if indicated by full Doppler
assessment. Refer to Leg Ulcer Guidelines.
Yes
* Complete a re-assessment/evaluation at 2 weeks or sooner if No
wound deteriorates. Yes
Is the patient No Liaise with
diabetic? GP for
systemic
Has the wound reduced in
NB. If foot wound antibiotics
size by 30-40% by 3-4 weeks? Assess Exudate Levels
refer to Podiatry
(Flanagan 2003)

Yes Yes
No
Low Medium High
Suitable antimicrobial Suitable Suitable antimicrobial
2 weeks then review antimicrobial 2 Weeks
Gently pack with suitable 2 Weeks
antimicrobial and re-evaluate
after 2 weeks

NB- Use antimicrobial from the formulary. If none suitable contact TVN
Apply suitable antimicrobial
for 2 weeks, then review

Has infection
resolved? No Yes
Has infection resolved? See Standard
Wound Protocol
No information
Yes above
Low Med High

Apply suitable antimicrobial 2

weeks then review
NB- Use antimicrobial from the formulary. If none suitable contact TVN

NB – Use all dressings in accordance with manufacturers

NB- Use antimicrobial from the formulary. If none suitable contact TVN
instructions
Guidelines for practice

Effective debridement
in a changing NHS
A UK consensus

Wounds UK
Do we debride everything?
Debridement method
The debridement method must be based on the wound management plan and
the goals for each patient and wound.
Things to consider:
 Assessment of the patient
 The aim and goal for the wound
 Expected outcomes of debridement
Autolytic debridement

Alginate Hydrogel Hydrocolloid

Hydrofiber Gelling foam

Larvae

Mechanical
Surgical/sharp debridement

 Fastest method

 Expensive (surgeon, anaethetist,

theatre, bed, nursing, etc.)

 Sharp debridement is an enhanced

practice and shouldn’t be
undertaken if not trained
Our responsibility
 Conversation

 Skills/confidence

 Harm

 Environment

 Resources/equipment necessary
Areas of concern

Blood vessels,
High-risk areas Malignancy
nerves and tendons

Informed consent Palliative Assessment

Blood clotting Implants and/or Inflammatory

disorders dialysis fistulas conditions
Always remember:

 Check clinical guidelines/policies

 Seek advice from a specialist or colleagues in the
multidisciplinary team (as simple as making a call)
 Refer to another practitioner for debridement
 Select the most appropriate debridement method,
based on:
• The wound
• Patient need
• Speed with which it’s necessary
• Patient preference
Dressing
selection
Moist wound healing
Winter, 1962 –
Using young pigs, Winter demonstrated that an
occluded moist wound, provided better epithelialisation
than a dry environment.
 Make a list
Characteristics of an ideal
dressing
Characteristics of an ideal dressing
(Thomas, 2008)

 Free of toxic or irritant extractables  Requires minimal disturbance or

 Does not release particles or non-
biodegradable fibres into the
wound
 Forms an effective bacterial barrier
 If self-adhesive, forms an effective
water-resistant seal to the peri-
wound skin, but is easily removed
without causing trauma or skin
stripping
 Maintains the wound and the
surrounding skin in an optimum
state of hydration
replacement
 Protects the peri-wound skin from
potentially irritant wound exudate
and excess moisture
 Produces minimal pain during
application or removal as a result
of adherence to the wound surface
 Maintains the wound at the
optimum temperature and pH
Cleansing a wound
 Warmed  Not saline if
 Irrigation, not rubbing pseudomonas present

Dressings
Wound type and objectives
– Black (hard necrotic eschar)
Treatment options

Primary Secondary

Covered with hard dry layer Low exudate Hydrocolloid

of dead tissue

Objectives:
Hydrogel or alginate or
Debridement and rehydration in order to Mod exudate Hydrocolloid or foam
hydrofibre
loosen dry necrotic tissue.
i. Reverse dehydration with hydrocolloid
ii. Debride/ rehydrate with hydrogel High exudate Alginate or hydrofibre Foam or absorbent pad
iii. Larvae therapy if moist enough
iv. Sharp debridement (by competent
practitioner) Hydrogel or alginate or
v. Refer for surgical intervention Cavity Foam or absorbent pad
hydrofibre
NB. Necrotic eschar on the diabetic foot
requires dry dressing and urgent referral Carbon sheet and film, or
Necrotic eschar on a leg ulcer may indicate Malodorous/
Hydrogel soft silicone foam if
ischaemia. fungating
fragile skin
Wound type and objectives
– Slough
Treatment options

Primary Secondary

Filled with soft yellow Low exudate Hydrogel or Hydrocolloid Hydrocolloid if required
glutinous

Objectives: Mod exudate

Hydrogel or alginate or
Hydrocolloid or foam
hydrofibre
i. Debride wound; allow wound to granulate
ii. Remove excess exudate
iii. Protect from infection
High exudate Alginate or hydrofibre Foam or absorbent pad
iv. Reduce colonisation
v. Consider larvae therapy

Hydrogel or alginate or
Cavity Foam or absorbent pad
hydrofibre

Carbon Sheet or Soft

Malodorous/
Hydrogel silicone foam if fragile
fungating
skin
Wound type and objectives
– Granulating
Treatment options

Primary Secondary

Open superficial or deep cavity wounds Low exudate Hydrocolloid

Significant loss of tissue, which has
granular/pebble like appearance.

Mod exudate Hydrocolloid or Foam

Objectives:
i. Optimise conditions for moist wound
healing.
Foam or
ii. Manage exudate High exudate Alginate or hydrofibre
absorbent pad
iii. Protect from infection. Reduce factors
which delay healing.
Hydrogel or alginate or hydrofibre.
Large cavities with high exudate Foam or
Cavity
may be suitable for topical negative absorbent pad
pressure systems, via TVN

Malodorous/ Carbon Sheet & film or Soft

fungating silicone foam if fragile skin.
 Wound type and objectives
– Clinical infection (could be at any stage of healing)
Treatment options

Primary Secondary
Inflammation and Cellulitis, heat at wound site,
Increased exudate/odour, Oedema, pain,
Fragile granulation tissue that bleeds easily Low exudate Antimicrobial Foam or Absorbent Pad
inflammation, Deterioration of wound.

Objectives:
i. Identify pathogens by wound swab. Mod exudate Antimicrobial Foam or Absorbent Pad
ii. Treat infection.
iii. Manage exudate and odour.
iv. Assess and manage pain. High exudate Antimicrobial Foam or Absorbent Pad
v. Refer to Wound infection management
summary
vi. Wound swab for culture & sensitivities.
Antimicrobial alginate or
vii.Refer for medical opinion, analgesia if Cavity Foam or Absorbent Pad
Hydrofibre
appropriate.
viii.Systemic antibiotics.
ix. Antimicrobial dressings. Malodorous/ Antimicrobial or Carbon Sheet & High
x. Larvae therapy if sloughy fungating Metronidazole Gel vapour Transfer Film
xi. Consider carbon sheet if malodorous
Antimicrobial dressings

 Infected Wounds

 MRSA

 Pseudomonas

 2 weeks
Honey
Diverse in appearance, due to weather, climatic conditions, flower
source and processing methods (Manuka, Bulgarian Mountain Flower)

Properties:
 Antimicrobial
 Deodorises (bacteria prefer sugar to
protein; metabolic product is lactic acid
(Stephen-Haynes, 2004))
 Promotes autolytic debridement
 Anti-inflammatory

Precautions:
• Increased exudate
• Pain
• Maceration to peri-wound
Iodine
In the past its use has been limited by the fact that
elemental iodine can be absorbed systemically.

Properties:
 Active against a number of pathogens

Precautions:
• Shouldn’t be used with patients that have
thyroid conditions, and patients that are
pregnant
Silver
Silvers have been used for over a century.

Properties:
 Interferes with the bacterial electron
transport system and inhibits the
multiplication of the bacteria

Products that can sustain the interaction of

silver with micro-organisms in the exuding
wound are likely to be more effective in
preventing/controlling local infection as
potentially more silver ions will be available to
enter bacterial cells
Antibiotic treatments

The routine use of topical antibiotics is not justified

for colonised or infected wounds.

There may be some value in the prophylactic use

of topical antimicrobials for the initial management
of acute cellulitis.
Make a list

Other wound healing treatments

Negative pressure wound therapy

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??

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Documentation

Importance Paper trail

• Audit • Standardise
• Complaints (verbal/written) • Facts, not opinion
• Litigation • Wound assessment chart for each
wound
• Death
• Photo/ tracing
• Care Plan
• Evaluation
• Nutritional assessment
Skin tears

Skin tears are traumatic injuries* which can result in

partial or full separation of the outer layers of the
skin (1-3).

These tears may occur due to shearing and friction

forces or a blunt trauma, causing the epidermis to
separate from the dermis (partial thickness wound) or
both the epidermis and the dermis to separate from
the underlying structures (full thickness wound).
* First defined by Payne and Martin in 1993 and more recently by an
international consensus group
What are the risk factors
for skin tears?
History of previous
Age and gender Dry, fragile skin
skin tears

Medications that thin Impaired mobility or

the skin, such as Echymoses*
steroids vision

Comorbidities that
Poor nutrition and Cognitive or
compromise
hydration sensory impairment vascularity and skin

Status, including Dependence on others

Cerebral vascular
chronic heart disease (for showering, dressing
and renal failure
accident or transferring)

* Bruising/discolouration of the skin caused by leakage of blood into the subcutaneous tissue as a
result of trauma to the underlying blood vessels
Why do skin tears occur?
Intrinsic factors
• Skin ages, pathological skin sweat gland activity causes the skin
changes occur to dry out.
• Thinning and flattening of the • Arteriosclerotic changes in the small
epidermis and large vessels causes thinning
of vessel walls and a reduction in
• Loss of collagen and elastin, and
the blood supply to the extremities
atrophy and contraction of the
dermis
• Decreased sebaceous gland and
Extrinsic factors
The need for assisted transfers, showering or other activities of daily living
increases the risk of skin tears among dependent individuals.
Carers and patients can reduce these risks by keeping fingernails trimmed, not
wearing jewellery, padding bed rails and wheelchairs, and taking care when
transporting patients. In addition, a good skin care regimen is important to
maintain skin integrity.
 How should skin
tears be assessed?

The same as any wound

STAR classification system
– Category 1
Category 1a
A skin tear where the edges can
be realigned to the normal
anatomical position (without
undue stretching) and the skin or
flap colour is not pale, dusky or
darkened.
Category 1b
A skin tear where the edges can
be realigned to the normal
anatomical position (without
undue stretching) and the skin or
flap colour is pale, dusky or
darkened.
STAR classification system
– Category 2
Category 2a
A skin tear where the edges
cannot be realigned to the
normal anatomical position
(without undue stretching) and
the skin or flap colour is not
pale, dusky or darkened.
Category 2b
A skin tear where the edges
cannot be realigned to the
normal anatomical position
(without undue stretching) and
the skin or flap colour is pale,
dusky or darkened.
STAR classification system
– Category 3

A skin tear where the skin

flap is completely absent
Management of skin tears

The main aims of management:

• Preserve the skin flap and protect the surrounding tissue
• Re-approximate the edges of the wound without undue stretching
• Reduce the risk of infection and further injury

Special considerations:
• Oedema
• Pain
Referral – to who and when

• Tissue Viability • Not responding to treatment

• Equipment Specialist Nurse • Deterioration
• Podiatry • Leg ulcer unhealed after 12 weeks
• Plastics • Sharp debridement
• Dermatology • Alternative dressings advice
• Vascular • Current formulary unsuitable