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Wound Care: A Handbook for Community Nurses
JOY RAINEY
WHURR PUBLISHERS
Wound Care
A Handbook for Community Nurses
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Wound Care
A Handbook for Community Nurses
J
!
RAINE!
"S#$ BS#$ %PSN$ R&N$ %N
Tissue Viability Nurse, Wolverhampton Health Care
SERIES EDITOR "ARIL!N E%WAR%S$ BS#'Hons($ SRN$ )E*C Specialist ractitioner, !eneral ractice Nursin", #ilbroo$ %e&ical Centre, Sta''or&shire
WH(RR (#)ISHERS )ONDON *ND HI)*DE) HI*
+ ,--, Whurr ublishers )t& .irst publishe& ,--, by Whurr ublishers )t& /0b Compton Terrace )on&on N/ ,(N En"lan& an& 1,2 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
Content
Series re'ace re'ace

C+a0ter 1
.ii i/
1
Woun& healin"
C+a0ter 2 11
Woun& assessment
C+a0ter 3 23
.actors a''ectin" 5oun& healin"

C+a0ter 4 35
Woun& cleansin"
C+a0ter 6 33
Dressin"s
C+a0ter 7 46
Sur"ical 5oun&s
C+a0ter 8 65
#urns, scal&s an& minor in6uries

C+a0ter 9 67
)e" ulcers
v
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 Freeman !lossary Resources Re'erences In&e= 12: 133 137 143
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$s is not nee&e&4 This is achieve& throu"h the 8uestion an& ans5er 'ormat, 5ith cross? re'erencin" bet5een sections4 Where 'urther in'ormation may be re8uire&, the rea&er is re'erre& to speci'ic te=ts4 %any patients 5ant some control over their illnesses, an& use the internet to access in'or? mation4 The use'ul a&&ress sections inclu&e 5ebsite a&&resses to share 5ith both patients an& collea"ues4 It is hope& that these han&y re'erence boo$s 5ill ans5er most every&ay 8uestions4 I' there are areas 5hich you 'eel have been ne"lecte&, please let us $no5 'or 'uture e&itions4 "andy Ed;ards
vii
Prefa#
The &ay?to?&ay responsibility 'or 5oun& mana"ement is usually un&erta$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& $no5 ho5 to treat them4 Only 5ith a thorou"h un&erstan&in" o' these areas 5ill it be possible to ma$e a &etaile& assessment o' the patient an& the 5oun&, 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 in 5oun& 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 &ress? 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''ective4 This 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
i=
&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& relate& 'actors 'or both acute an& chronic 5oun&s that may be encountere& 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 are many &ressin" types available to community nurses, an& Chapter 2 "ui&es the rea&er throu"h the uses o' commonly use& pro&ucts4 The 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
Prefa#
/-
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 haveC
The s$in is the lar"est or"an o' the bo&y4 It covers appro=imately , m, an& 5ei"hs aroun& 1 $"4 The s$in has many 'unctions, 5hich inclu&e the 'ollo5in"< D %aintenance o' bo&y temperature 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$in is bro$enC
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/-4,A4 .lui& is lost 'rom the bo&y an& i' the area o' s$in lost is lar"e enou"h @as in a
ma6or burnA this can be li'e threatenin"4

/
/B/41

Ho5 is the s$in ma&e upC
The s$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
Epi&ermis Dermis
@bA
Subcutaneous tissue
)i-ure 1<1 The s$in4
Woun& healin"
B/4E Can I tell by loo$in" at a 5oun& 5hat layers are &ama"e&C
Super'icial 5oun&s &ama"e only the epi&ermis @.i"ure /4,A4 I' the &ermis is intact, normal s$in mar$in"s 5ill be present4 artial? thic$ness 5oun&s &ama"e the &ermis an& 5ill loo$ pale pin$ @.i"ure /41A4 .ull?thic$ness 5oun&s reach the subcutaneous 'atty tissue or "o &eeper to muscle an& bone @.i"ure /4EA4 These 5oun&s may reveal islan&s o' yello5 'at an& may e=pose muscle, ten&on or bone4
B/42 What is the &e'inition o' a 5oun&C
* 5oun& is an abnormal brea$ 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
)i-ure 1<4 * 'ull?thic$ness 5oun&4 B/43 Ho5 are 5oun&s &escribe& or cate"orise&C
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 care4
Primary intention or se#ondary
* 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" ulcers, pressure &ama"e, an& lacerations 5ith substantial tissue loss or &irty sur"ical or traumatic in6uries, 5hich may become in'ecte& i' the s$in e&"es are oppose& an& secure&4
*y0es tissue of
Woun&s can also be cate"orise& by the type o' tissue 5ithin the 5oun&<
D The 5oun& contains blac$ necrotic tissue @see B,4/-A D The 5oun& is yello5 an& slou"hy @see B,4//A
Woun& healin"
D The 5oun& is re& an& "ranulatin" @see B,4/,A D The 5oun& is startin" to &isplay si"ns o' the 'ormation o' ne5 pin$ epithelial tissue @see B,4/1A D The 5oun& is "reen an& in'ecte& @see B,4/EA4
%e0t+ ;ound of
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 @Stirlin" scaleG Rei& an& %orison /00EA @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 reache&4
*ab,e 1<1 The (: consensus classi'ication o' pressure sores Sta"e / Sta"e , Sta"e 1 Sta"e E Discoloration o' intact s$in @li"ht 'in"er pressure applie& to the intact s$in &oes not alter the &iscolorationA artial?thic$ness s$in loss or &ama"e involvin" epi&ermis an&Hor &ermis .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 .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 meanC
*s previously mentione&, 5oun&s can be &escribe& as healin" by primary or secon&ary intention @see B/43A4 Healin" by primary 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$in e&"es are hel& to"ether @see B/43A4 In 5oun&s healin" by secon&ary intention, the 5oun& e&"es are apart an& the &e'ect 5ill nee& to 'ill 5ith "ranulation tissue be'ore ne5 epi&ermis can cover the 5oun&4 These inclu&e le" ulcers, open incisions @e4"4 a'ter &rainin" abscesses 5hen closure may encoura"e in'ectionA an& 'ull?thic$ness burns4
Woun& healin"
Occasionally, 5oun&s may be &escribe& as healin" by tertiary 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' there appears to be little ris$ o' in'ection it is then close& in the normal 5ay @Dealey /00EA4
B/49 What are the phases o' 5oun& healin"C
Woun& healin" is usually &escribe& in 'our physiolo"ical phases< the in'lammatory, &estructive, proli'erative an& maturation sta"es @ ro'essional Development /00EA4 In reality it is a continuous process 5ith the sta"es mer"in" an& overlappin"4
The inflammatory stage! 0"# $ays %Fig&re '()
When tissue is in6ure& or &isrupte& the bo&y7s imme&iate response is to re?establish haemostasis4 Dama"e& cells an& bloo& vessels release histamine, causin" vaso&ilatation o' the surroun&in" capillaries, ta$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
%acropha"es Vaso&ilate& bloo& vessels
)i-ure 1<6 The in'lammatory sta"e< -I1 &ays4
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 prolon"e&4
*estr&+ti,e phase! '-) "- $ays %Fig&re
White cells line the 5alls o' bloo& vessels an& mi"rate throu"h the 5alls, 5hich become more porous, into surroun&in" tissue4 Here pha"ocytic cells brea$ &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 are 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< /I3 &ays4
.roliferati,e phase! #"2/ $ays %Fig&re '0)
The 'ibroblasts continue to multiply, 'ormin" colla"en 'ibrils, 5hich ma$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 stren"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 tissue )i-ure 1<8 The proli'erative sta"e< 1I,E &ays4
Woun& contraction be"ins
1at&ration phase! 2/ $ays to '2)
year %Fig&re
When the 5oun& has 'ille& 5ith "ranulation tissue, colla"en 'ibres pull in the 5oun&, causin" it to contract an& become smaller4 This spee&s up the healin" process as less colla"en 5ill be necessary to repair the &e'ect4 *s the 5oun& space &ecreases, vascularity also &ecreases, 'ibroblasts shrin$ an& the colla"en 'ibres chan"e the re& "ranulation tissue to 5hite avascular tissue as 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$e cells 'rom another area o' the 5oun&, sometimes 'ormin" islan&s in the 5oun& centre4 This process is slo5e& &o5n i' the 5oun& is &ry an& has a scab or eschar over it @see B,4/-A4 In this case they have to burro5 un&er the &ry scab @see B/40A4
%i"ratin" cells lose their ability to &ivi&e an& so
Scab &etaches
Epithelium no5 complete
*vascular scar tissue replaces "ranulation
Vascularity &ecreases )i-ure 1<9 The maturation sta"e< ,E &ays to / year4
epithelialisation &epen&s on the ability o' li$e cells to $eep meetin"4 When the sur'ace o' the 5oun& is covere& 5ith epithelial cells, the epithelium thins4 Hair 'ollicles are not replace&4 Woun& maturation usually ta$es bet5een ,E &ays an& / year4
B/40 What is meant by moist 5oun& healin"C
Tra&itionally, 5oun& care encoura"e& nurses to allo5 5oun&s to &ry out an& 'orm a scab4 This 5as thou"ht to provi&e a mechanical 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 @/03,A 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 &ry 5oun&s, epithelial cells 5ere han&icappe& 5hen mi"ratin" across the 5oun& sur'ace by the
colla"en 'ibres 6oinin" the scab to the
sur'ace o' the 5oun&4 Epithelial cells in the moist 5oun&s coul& mi"rate more 8uic$ly throu"h the 5oun& e=u&ate an& &i& not nee& to traverse a scabbe& area @see B,4/1A4 Dyson et al4 @/099A have sho5n that a moist 5oun& moves throu"h the in'lammatory sta"e o' healin" 'aster than a &ry 5oun& an& pro&uces "reater capillary "ro5th4 Initially it 5as thou"ht that the moist environment may encour? a"e "reater bacterial "ro5th an& lea& to a hi"her number o' 5oun& in'ections4 This vie5 has been &isprove&4 Stu&ies by Hutchinson an& )a5rence @/00/A sho5e& that the reverse 5as true an& occlu&e& 5oun&s sho5e& a lo5er rate o' in'ection4 Since the late /0F-s, manu'acturin" companies have been creat? in" &ressin"s that "ive a moist environment to spee& 5oun& healin"4 Some clinicians 5ho clin" to tra&itional pro&ucts, such as "auJe, use the hi"her cost o' mo&ern pro&ucts to support their choice4 Ho5ever, mo&ern pro&ucts encoura"e 5oun&s to heal 'aster an& "et in'ecte& less o'ten4 The unit cost becomes less relevant 5hen vie5e& in relation to patient &iscom'ort @see B,4FA, nursin" time an& "reater use o' other materials, such as sterile "loves, aprons, &ressin" pac$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 tertiary intention, 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
CHAP*ER 2
Wound assessment
Woun& assessment is a vital part o' 5oun& care i' the healin" process is to be optimise&4 This chapter &iscusses the in'ormation that nee&s to be sou"ht an& &ocumente& to complete a 5oun& assessment, an& e=plains 5hy &ocumentation is important both 'or reasons o' practi? calHclinical e''ectiveness an& as a le"al an& pro'essional re8uirement4
B,4/ Why is it important to assess a 5oun& thorou"hlyC
Woun& assessment is commonly a responsibility le't to the nurse4 .or the care "iven to be appropriate, it is important that this is &one thor? ou"hly to i&enti'y a "oal o' treatmentG 'or e=ample this may be to &eslou"h, to protect an& $eep moist, to choose the most appropriate treatment, an& to evaluate treatment to chec$ 'or pro"ress or &eteri? oration4 It is also important that this assessment an& subse8uent evaluations are clearly &ocumente&, 'or several reasons4 .irst, it allo5s evaluation to ta$e place4 I' "oo& recor&s are not $ept, the eval? uation is li$ely to be va"ue an& sub6ective 5ith reliance on comments such as >loo$in" better7 or >healin" 5ell7, 5hich say nothin" about the state o' the 5oun&4 This is perhaps even more important i' more than one person is responsible 'or the patient7s care4 Secon&, recor&s are o' e=treme importance in case o' complaint or liti"ation4 In le"al terms, i' it is not recor&e&, the care &i& not happen, so recor&s must be timely, accurate an& clear @see B,4,A4 *lthou"h assessment may seem a len"thy process, the time spent assessin" a 5oun& shoul& lea& to the selection o' appropriate treat? ment4 This shoul& optimise 5oun& healin" an& lea& to
/,
s5i'ter reso? lution o' care4
Woun& Care< * Han&boo$ 'or Community Nurses //
Thorou"h assessment o' the 5oun& 5ill ta$e time, but i' it lea&s to the correct treatment bein" chosen an& 5oun& healin" optimise& it is time 5ell spent4 In the lon"er term, the patient re8uires 'e5er episo&es o' care4 *ssessment &etails can be 5ritten in the patient notes or on a purpose?ma&e chart4 *n e=ample is sho5n in .i"ure ,4/4
atient name< *nn Kones Type o' 5oun&< )aceration Date Si3e of 4o&n$! %a=imum 5i&th %a=imum len"th Type of tiss&e 4ithin 4o&n$< e4"4 slou"h, necrosis, "ranulation E5&$ate! *mount, colour O$o&r! None, some, o''ensive .ain Where, 5hen, severity S&rro&n$ing skin! Erythema, 5etH&ry, ecJema Infe+tion! Suspecte&, s5ab ta$en, result Treatment s&mmary! Cleansin" lotion, i' use& Topical treatment to 5oun& an& surroun&in" s$in rimary &ressin" Secon&ary &ressin" .i=e& by *ssesse& by osition o' 5oun&< )e't shin Duration o' 5oun&< , 5ee$s /H3H-1 cm / cm !ranulation %inimal None Occasionally i' touche& Healthy Not clinically in&icate& None None Duo&erm None NH* %E
)i-ure 2<1 *n e=ample o' a 5oun& assessment chart4 B,4, The nurse only has about /- minutes to see each patient4 Woul&n7t a brie' note be su''icientC
Recor&s must be $ept in or&er to ai& clinical &ecision?ma$in" @Williams /00FA @see B,4/A4 The (:CC ro'essional Co&e o'
Woun& assessment
/1
Con&uct @(:CC /00,A states that one o' the purposes o' recor&s maintaine& by the re"istere& nurse is to >provi&e a base line recor& a"ainst 5hich improvement or &eterioration can be 6u&"e&74 The importance o' clear concise recor&s an& the 'ailure to maintain them can be seen as a ne"li"ent act an& a breach o' a nurse7s &uty to care @%oo&y /001A4 To illustrate this point consi&er the 'ollo5in" scenario4
S+enario for +ase st&$y
Nurse S ha& seen .re& on his 'irst visit to the sur"ery 5ith a le" ulcer4 She per'orme& a 'ull assessment, inclu&in" Doppler recor&in"s, an& &ia"nose& the ulcer to be the result o' arterial insu''iciency4 .re& &ran$ about 'our times the recommen&e& alcohol limit each 5ee$ an& a&mitte& to smo$in" about Eci"arettes a &ay4 He also ha& poorly controlle& type / &iabetes an& a history o' heart problems4 Nurse S clearly remembere& her &iscussion 5ith .re& an& stron"ly su""este& that he re&uce his alcohol an& ci"arette consump? tion an& mo&i'y his &iet4 She also verbally recommen&e& to the ! that a vascular opinion 5as re8uire&4 Ho5ever, a'ter per'ormin" the assessment, she 5as runnin" late an& the entry in her recor&s reporte& >Doppler sho5s arterial, a&vice "iven74 Over the ne=t 'e5 5ee$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 E 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 care 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 in amputation4 .rom her recor&s coul& you &e'en& her practiceC
B,41 What shoul& be inclu&e& in a 5oun& assessmentC
It is important that the cause o' the 5oun& is i&enti'ie& an&
/E
recor&e&4 ersonal observation su""ests that acute 5oun&s such as
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& B943AC Is it an arterial ulcer @see B94FIB940AC Di& the 5oun& start 'rom trauma or a biteC 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
.ositio n
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 B,4EA4

6istory
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 be relevant @see B941,A4
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$in, perhaps cause& by me&ication such as lon"?term steroi& use, it may be inappropriate to apply an a&hesive &ressin"4 )e" ulcers may be surroun&e& by varicose ecJema, 5hich may re8uire an emollient, or by contact &ermatitis 'rom previous treat? ments, 5hich may re8uire a short course o' a topical steroi& cream @see B24,-, B94/E an& B94,3A4
/3
Tiss&e
The state o' the tissue 5ithin the 5oun& shoul& be recor&e&4 This 5ill help to i&enti'y the "oal o' treatment an& in many 5ays i&enti'y an appropriate treatment4 There may be more than one type o' tissue 5ithin the 5oun& in 5hich case an estimate o' the percenta"e o' each type shoul& be ma&e, e4"4 1-L slou"h, F-L "ranulation @see B,4// an& B,4/,A4
.ai n
The patient7s level o' pain shoul& be assesse& an& treate& 5ith appropriate anal"esia4 Other 'actors to consi&er are< D Is the pain ischaemicC @see B949 an& B940A D Is the 5oun& in'ecte&C @see B/-4/A D Is the &ressin" causin" pain either by &ryin" out an& a&herin" to the 5oun& sur'ace, or by causin" an aller"ic reactionC @see B94,3 an& B94,FA D Is the 5oun& pain'ul at &ressin" chan"e because the &ressin" has &rie& out or is bein" remove& inappropriatelyC @see B,4FA *ny 5oun& o&our shoul& also be recor&e&4 This may be a si"n o' in'ection, or may be anaerobes in necrotic tissue @see B,43A4
B,4E Ho5 shoul& 5oun&s be measure&C
It is important to recor& 5oun& siJe so that healin" pro"ress or &ete? rioration can be observe&4 #oth the nurse an& patient can be moti? vate& i' healin" can be observe&4 This also encoura"es the patient7s compliance 5ith continuin" a treatment about 5hich they are not enthusiastic, such as compression therapy @see B94,0A4 The simplest 5ay to recor& 5oun& siJe is to ta$e the ma=imum &imensions 5ith a ruler @.i"ure ,4,A4 * 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$a"in" in 5hich many &ressin"s come4 The tracin" can be either store& in the patient7s notes or use& as a template to &ra5 aroun& an& a&& to notes4 Consi&er 5hether or not the plastic is sterile4 It is a&visable to hol& non?sterile materials sli"htly above the 5oun&
Woun& assessment
/F
sur'ace or to cleanse the sur'ace touchin" the 5oun& both be'ore an& a'ter5ar&s 5ith an *lco5ipe4
)i-ure 5oun&4
2<2
%easurin"
hoto"raphs are the most accurate 5ay to recor& siJe an& appearance o' lar"e 5oun&s @see B,42A4 Woun& &epth can be more &i''icult to measure, but use o' a sterile probe is probably the most accurate metho&4 These are sometimes available 'rom pharmaceuti? cal companies4
B,42 What sort o' issues must be consi&ere& 5hen purchasin" a cameraC
erhaps the most important issue is in'orme& patient consent4 I' the materials are to be use& 'or teachin" or publication this consent shoul& be 5ritten4 There are several other issues to consi&er be'ore embar$in" on 5oun& photo"raphy4 #ellamy @/002A su""ests the 'ollo5in"< D Choice o' e8uipment D Choice o' materials D Choice o' processin" D Control o' sub6ect D Control o' li"htin" D Control o' bac$"roun&4
/9
E8uipment in the main may be 5hat is a''or&able4 %any people choose a olaroi&?type camera because they "et instant results an& they &o not have to 5orry about 5here to "et material processe& or 'inishin" a 5hole 'ilm4 Results, ho5ever, may not be as "oo& as 5ith a 12?mm sin"le?lens re'le= camera4 With the choice o' materials, because the colour o' a 5oun& is an important in&icator o' con&ition, only colour 'ilm shoul& be use& @#ellamy /002A4 I' the pictures are to be store& in patients7 notes, prints are a&e8uate, but i' photo"raphs are to be use& 'or publication or teachin" purposes, sli&es may be more practical4 Thou"ht shoul& be "iven to processin"4 Hi"h?street >8uic$ process7 shops may have photo"raphs rotatin" behin& the counter4 )ocal labs may even have someone 5or$in" there 5ho reco"nises the patient4 The use o' a "eo"raphically &istant pro'essional laboratory that can provi&e con'irmation o' con'i&entiality is recommen&e& @#ellamy /0024A .ilms shoul& be han& trans'erre& @e4"4 by courierA or i' necessary sent by re"istere& post, but not by re"ular mail4 ut a ruler close to the 5oun& so that the siJe can be rou"hly ascertaine&4 This 5ill ai& reassessment an& sho5 pro"ress4 It is also use'ul to 5rite the &ate an& the patient7s initials on a piece o' a&hesive tape an& stic$ this close to the 5oun&G this helps to i&enti'y the patient an& also to place photo"raphs in chronolo"ical or&er4 )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, treat? 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 care4
B,43 What can be &one about 5oun& o&ourC
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 ersonal e=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$s,
Woun& assessment
/0
it is 5orth reassurin" the patient that the 5oun& has not become in'ecte&4 Charcoal &ressin"s may be use& to absorb o&our @see B24,1A4 Oral or topical metroni&aJole may re&uce 5oun& o&our @*sh'or& et al4 /09EG Ne5man et al4 /090A, or an aromatherapy oil o' the patient7s choosin" may be applie& to the outer &ressin"4
B,4F What points shoul& be consi&ere& in re"ar& to painC
ain is a sub6ective e=perience arisin" 5ithin the brain in response to &ama"e to bo&y tissues @#on& /09EA4 It is an issue that is o'ten over? loo$e& in 5oun& care4 ain perception is uni8ue to each in&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 re8uire& 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& /09EG 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 are applie& to li"htly e=u&in" 5oun&s @Thomas /00-A @see B240IB24/-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 /00EA, 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 &ress? in" chan"e4 Soa$in" the &ressin" o'' is time?consumin" an& &oes not al5ays result in pain?'ree removal
,-
@Thomas /00-A4
Woun& assessment
,/
In'ection is associate& 5ith pain, so chec$ the 5oun& 'or the si"ns o' in'ection @Cuttin" an& Har&in" /00EA @see B/-4/A an& treat 5ith systemic antibiotics i' in'ection is present4 ain also occurs as a result o' poor ban&a"e techni8ue, 5hich causes ban&a"e slippa"e, or has insu''icient pa&&in" or incorrect application @see B94,0A4 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 3EL 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&4 Deep 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
B,49 Ho5 shoul& pain be assesse&C
*ccurate pain assessment is the $ey to pain relie'4 Nurses o'ten 'ail to use even a simple assessment tool4 * visual analo"ue scale is a practical tool 'or assessin" a patient7s pain at &ressin" chan"es @Choiniere et al4 /00-A4 Type an& amount o' pain vary bet5een in&ivi&ualsG stu&ies have sho5n that nurses o'ten 'ail to believe patients7 reports o' pain @Sa=ey /093G Seers /09FA4 *n e=ample o' a pain assessment scale is sho5n in .i"ure ,414
B,40 Ho5 shoul& pain be mana"e&C
*ppropriate anal"esia shoul& be o''ere& 'ollo5in" liaison 5ith the ! , but other measures shoul& also be ta$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 removal4 Cleansin" shoul& be by "entle irri"ation 5ith 5arm physiolo"ical saline @see BE4,IBE4EA i' it is necessary to remove &ebris4 Woun&s shoul& not be rubbe& or scrubbe&G this 5ill not only
,,
cause unnecessary pain but 5ill also &ama"e the 5oun& be&4
Woun& assessment
,1
)i-ure 2<3 *n e=ample o' a pain assessment scale4 Repro&uce& by $in& permission o' Nursin" Times 5here this 'irst appeare&, 0 %ay /09E, Vol 9-, No /0, p4 294
Other therapies such as rela=ation techni8ues, heat an& col& therapies, an& &iversion therapy can all help re&uce perceive& pain @Em'lor"o /000A4
B,4/- What is necrotic tissue an& ho5 shoul& it be treate&C
* 5oun& may contain necrotic tissue, 5hich may be so't, spon"y an& blac$H"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$in" a sur"ical opinion on sharp &Mbri&ement 5hen tissue is sur"ically remove&4
B,4// What is slou"h an& ho5 shoul& it be treate&C
Nello5 or slou"hy tissue is 'orme& in many chronic 5oun&s4 It is not &ea& tissue but a mi=ture o' &ea& cells an& serous e=u&ate4 It nee&s to be remove& to optimise healin" an& is a similar process to &Mbri&e? ment @see B24/2 an& B24/3A4 It is important not to mista$e e=pose&
,E
ten&ons or epithelial islan&s 'or slou"h because they can have a simi? lar appearance4
B,4/, What is "ranulation tissue an& ho5 shoul& it be treate&C
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$en &urin" 5oun& cleansin" @see BE4/IBE4EA an& a &ressin" shoul& be selecte& that 5ill not a&here to the sur'ace o' the 5oun& an& cause trauma &urin" &ressin" chan"es4
B,4/1 What is epithelial tissue an& ho5 shoul& it be treate&C
in$ 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
B,4/E Ho5 &o I reco"nise an in'ecte& 5oun&C
The classic symptoms o' 5oun& in'ection inclu&e the 'ollo5in"< D D D D D D Erythema Oe&ema Increase& e=u&ate O''ensive o&our ain yre=ia4
See B/-4/IB/-4E, 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& care4 *llo5in" the patient to see pro"ress improves
Woun& assessment
motivation an&
,2
,3
complianceG 5oun& measurement is simple an& &oes not re8uire 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& re"ular reassessment is nee&e&4 *ssessment an& treatment o' pain are important parts o' 5oun& care4 Recor& $eepin" is a le"al an& pro'es? sional re8uirement an& accurate &ocumentation is essential4
CHAP*ER 3
)a#tors affe#tin;ound +ea,in-
It is not only the &ressin" that is chosen 5hich a''ects the 5ay 5oun&s heal4 This chapter e=amines other issues that may impact on 5oun& healin", an& e=plains 5hy it is important to loo$ 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 patientC
*s 5ell as assessin" the 5oun& itsel', it is important to loo$ at the 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$e place4 Some o' the 'actors a''ectin" healin" are liste& in Table 14/4 Not all can be treate& but, i' hi"hli"hte&, at least an un&erstan&in" o' 5hy healin" is slo5 can be reache&4
*ab,e 3<1 .actors a''ectin" healin" *"e Concurrent &isease Nutritional status Dru"s Smo$in" E=cessive alcohol consumption B14/%obility 5oun& See B14,, B04E See B141, B04E See B14EIB14F, B04E See B149, B04E See B140 See See B04E, B94/E
B14,
What e''ect &oes a"e have on 5oun& healin"C
*s people a"e the metabolic processes slo5 &o5n, 5hich prolon"s tissue repair4 Woun& in'ection may also be more common as
,E
Woun& Care< * Han&boo$ 'or Community Nurses ,1
immune competence becomes less speci'ic an& in'lammation less e''ective @Davi& /093A @see B/-4,A4 El&erly people are more li$ely to have chronic concurrent illness, 5hich may &elay healin" an& re8uire &ru" therapy4
B141 Which concurrent &iseases particularly inter'ere 5ith 5oun& healin"C
Diabetes has lon" been associate& 5ith poor 5oun& healin"4 It is important to control &iabetes i' 5oun& healin" is to be achieve&4 eople 5ith &iabetes are also more susceptible to 5oun& in'ection @see B94/9A4 D Car&iovascular an& pulmonary &isease may &elay 5oun& healin" because the transport o' o=y"en to the 5oun& site may be ina&e? 8uate, an& o=y"en is essential 'or 5oun& healin" @see B140A4 D (raemia increases the ris$ 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 rates4 D 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
B14E Ho5 &oes &iet a''ect 5oun& healin"C
#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$s bet5een nutrients an& healin" are sho5n in Table 14,4 It shoul& be remembere& that in6ury may also lea& to a patient7s ener"y &eman&s bein" hi"her than usual4 rotein is also lost in 5oun& e=u&ate4 I' a patient is unable to maintain a "oo& nutritional status, &ietary supplements may be necessary, in the 'orm o' tablets @e4"4 Jinc supplements, multivitaminsA, by in6ection @e4"4 Neocytamen, ironA, or as 'oo& supplements or meal replacements4 Obese patients have re&uce& o=y"en pressures in their tissues @*rmstron" /009A4 *&ipose tissue is poorly net5or$e& by bloo&

*ab,e 3<2 Important nutrients in 5oun& healin" Nutrient rotein Carbohy&rate healin" Vitamin C Vitamin #/, Oinc Iron Copper Role in healin" Repair an& replacement o' tissue Ener"y, spares protein 'or 5oun& Colla"en synthesis, immunity rotein synthesis Tissue repair, protein synthesis Haemo"lobin pro&uction Increases the tensile stren"th o' colla"en
,2
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& thus heal? 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 in the pelvic area4 Re&ucin" obesity 5ill also 'acilitate increase& mobility an& re&uce venous stasis @see B94/E an& B94,9A4 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 2 st&$y
Nurse * 5as as$e& to visit %iss 4 *n assessment in&icate& that she ha& a venous ulcer4 %iss 5as E1 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 treat? 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"ht4 Over 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
,3
ha& almost
,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 virtually all 'oo& e=cept 'ruit an& ve"etables4 She e=plaine& that &inner that &ay ha& been a bo5l o' broccoli4 She $ne5 these 'oo&s 5ere "oo& 'or her I the nurse ha& sai& plenty o' 'ruit an& ve"etables I but she ha& no concept o' her bo&y7s nee& 'or protein an& some 'at an& carbohy? &rate4 Nurse * ha& assume& this level o' un&erstan&in"4 *'ter a &etaile& &iscussion a more healthy &iet 5ith a slo5er level o' 5ei"ht loss 5as establishe&4
7ase # st&$y
%rs R 5as an e=tremely obese 5oman o' 194 Her 5ei"ht 5as esti? mate& to be in e=cess o' E- 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 &o5nstairs 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$s later there appeare& to be no chan"e in her siJe an& she 5as "ettin" &espon&ent4 #oth she an& her husban& 5ere a&amant that she 5as stic$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$a"e& an& labelle& lo5 or lo5er 'at4 This inclu&e& cheese, cream, crisps an& chips4 #ut lo5er 'at than 5hatC *"ain &etaile& &iscussion about 'oo& shattere& the myths an& enable& %rs R to ma$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& patientC
Encoura"e a hi"h ener"y inta$e, such as san&5iches, ca$es, biscuits an& chocolate4
,9
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& temperature4 D Ta$e care 5ith 'oo&s that have lo5 ener"y &ensity such as 'ruit an& ve"etables4 They contain essential micronutrients but the patient may 'eel 'ull be'ore their ener"y nee&s are met @!uest an& earson /00FA4
B143 What shoul& be inclu&e& in a nutritional assessmentC
The patient7s history is important4 This shoul& inclu&e the 'ollo5in"< D What is the patient7s normal &ietC D Have there been any recent chan"es or unintentional 5ei"ht lossC Observe i' the patient7s clothes 'it4 D hysical measurements such as 5ei"ht an& hei"ht 5ill allo5 calculation o' the bo&y mass in&e=4 D Direct observation o' muscle bul$, 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' appropriate4 I' necessary, involve the community &ietitian4 The patient shoul& be re"ularly reassesse& by 5ei"hin" an& monitorin" inta$e4 This shoul& all be recor&e& on the care plan to allo5 evaluation4
B14F *re supplements o' vitamins an& Jinc use'ul to promote 5oun& healin"C
The recommen&e& inta$e o' vitamin C 'or a healthy a&ult is E- m"H&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 result 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"H&ay split into 'our &oses4
.actors a''ectin" 5oun& ,0 Hi"her healin" &oses shoul& be avoi&e& because o' a relatively lo5 renal
threshol& @Dic$erson /001A4
1-
Oinc &e'iciency may be prevalent in in&ivi&uals 5ith chronic malnutrition an& 5ill lea& to &i''iculties 5ith 5oun& healin", an& the liability o' 5oun& &ehiscence an& 5oun& in'ection @Dic$erson /001A4 Supplementation is usually 33- m"H&ay split into three &oses, but may carry the ris$ o' copper &epletion @)e5is /009A4 There is no point in supplements i' the patient is not &eplete&4 I' a 5oun& is 'ailin" to heal an& Jinc &e'iciency is suspecte&, a bloo& test may be ta$en4 .or 'urther in'ormation on nutrition, the rea&er is re'erre& to #uttriss, Wynne an& Stanner, N&trition! A 6an$8 book for 7omm&nity N&rses I in this series4
B149 What &ru" therapy a''ects 5oun& healin"C
Dru"s ta$en therapeutically 'or other con&itions may inhibit 5oun& healin" @see B34,A, inclu&in"< D D *nti?in'lammatory &ru"s, both steroi&al an& non?steroi&al, 5ill &elay 5oun& healin"4 These are commonly use& to treat arthritis, 5hich is o'ten a problem in el&erly people4 *spirin, commonly sel'?a&ministere& or "iven to treat circulatory &isease, 5ill also &elay healin"4 These &ru"s are &esi"ne& to suppress in'lammation, 5hich is essential 'or tissue repair @see B/49A4 Immunosuppressive &ru"s inhibit 5hite cell activity an& so &elay the clearance o' 5oun& &ebris4 atients on these &ru"s are at hi"h ris$ o' &evelopin" a 5oun& in'ection an& may re8uire prophylac? tic antimicrobial therapy an& care'ul monitorin"4 Thou"ht nee&s to be "iven to timin" appointments 'or these patients to re&uce the ris$s o' cross?in'ection, such as be'ore seein" any other patients 5ho may have an in'ecte& 5oun&4 Cytoto=ic &ru"s arrest cell &ivision an& also re&uce protein pro&uction4 This is true 'or both mali"nant cells an& those vital 'or tissue repair4
B140 Ho5 &oes smo$in" a''ect 5oun& healin"C
Smo$in" alters platelet 'unction 5ith a hi"her ris$ o' clots bloc$in" smaller vessels4 Smo$ers also have re&uce& haemo"lobin 'unction @Davi& /093A4 This means less haemo"lobin is available 'or o=y"en
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"C
atients 5ho are heavy &rin$ers may have liver &isease4 This may result in a re&uction in the number o' platelets an& in clottin" 'unc? tion4 They may also have a lo5er resistance to in'ection4 !astritis an& &iarrhoea may pre&ispose to malnourishment throu"h malab? sorption an& anaemia cause& by bloo& loss4
B14// Do social 'actors have a role in 5oun& healin"C
Research su""ests that there is a stron" lin$ bet5een a person7s social circumstances an& his or her health @%iller /000A4 The #lac$ Report @#lac$ /09,A 'oun& that people in the lo5er socioeconomic "roups 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 5hich 5ill 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& previous "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 appropriate4
CHAP*ER 4
Wound #,eansin-
The topic o' 5oun& cleansin" has o'ten been surroun&e& 5ith controversy4 To clean or not to cleanC This chapter &iscusses 5hat constitutes best practice 5hen cleansin" a 5oun&, 5hat solutions are 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 &epartments4
BE4/ Why shoul& cotton 5ool not be use& to clean 5oun&sC
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$s available on the &ru" tari'' all contain cotton?5ool ballsG these shoul& be &iscar&e&4 Vi"orous s5abbin" may also &ama"e healthy tissue4 !entle irri"ation is there'ore "ener? ally the pre'erre& metho&4
BE4, When shoul& 5oun&s be cleanse&C
Which 5oun&s 5ill bene'it 'rom cleansin"C Traumatic 5oun&s that contain particles o' &irt or other matter 5ill bene'it 'rom vi"orous irri"ation @)a5rence /00FA4 Woun&s may also bene'it 'rom cleansin" to remove "ross e=u&ate, remains o' previous topical applications or crustin" @%iller an& Dyson /003G )a5rence /00FA4 #acteria are not remove& but merely re&istribute& aroun& the 5oun& sur'ace4 It is pointless to cleanse 5oun&s routinelyG it is appropriate only to remove &ebris or ol& &ressin" material4
Woun& cleansin"
1-
1/
Reasons 'or not cleansin" shoul& be e=plaine& to the patient to avoi& any misun&erstan&in"s, because most patients thin$ that cleansin" is essential4
BE41 What 'lui&s are recommen&e& 'or cleansin" 5oun&s, as I7ve been tol& antiseptics are o' little valueC
The most 're8uently use& 'lui&s are tap 5ater, physiolo"ical @>normal7A saline or antiseptics4 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 be sterile 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= E4/4 re'erre& 5oun& cleansin" a"ents are &escribe& in #o= E4,4 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 BE4E Ho5 can physiolo"ical saline be 5arme& be'ore useC
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
BE42 What is an emollientC
Emollients are &esi"ne& either as creams or 'or a&&in" to bathsHbuc$ets o' 5ater to soothe an& rehy&rate &ry scale& areas o'
1,
Bo/ 4<2 re'erre& 5oun& cleansin" a"ents Chlorhe=i&ine solutions< this is a "oo& s$in an& har& sur'ace &isin'ectant an& sho5s lo5 to=icity to livin" tissue in animal mo&els @see B/-40A ovi&oneIio&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 B94,2A 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$in4 I' use& in 5ater it &oes not matter i' they touch the ulcer itsel' @see B94,2A4
Summar y
Woun&s shoul& be "ently irri"ate& an& not s5abbe&4 Clean 5oun&s only i' it is necessary to remove &ebris such as the remains o' &ress? in"s or e=u&ate4 Warm saline is the pre'erre& cleansin" lotion4
CHAP*ER 6
%ressins
%any types o' 5oun& &ressin"s are no5 available an& it can be &i''i? cult to choose the one most appropriate to the 5oun&4 This chapter attempts to place the &ressin"s into broa& cate"ories 5ith some su""estions 'or their appropriate use4 The &ressin"s mentione& are not the only ones available an& 'or 'urther in'ormation it 5oul& be appropriate to re'er to a te=t such as the Form&lary of 9o&n$ 1anage8 ment .ro$&+ts @%or"an /00EA4 Nour primary care "roup, or trust, may have a 5oun& care 'ormulary that recommen&s speci'ic pro&ucts4 .or in'ormation about metho&s o' application, time bet5een &ressin" chan"es, removal an& contrain&ications, see the manu'ac? turers7 instructions4 Only &ressin"s on the &ru" tari'' are &iscusse&4 It is important that the chosen &ressin" is appropriate to the 5oun&, that it has been prove& to be clinically e''ective an& that it is cost?e''ective4 This chapter loo$s at some o' the pro&ucts available an& in 5hat circumstances they may be bene'icial althou"h, as ne5 pro&ucts are becomin" available constantly, it is inevitable that some recent &evelopments are not covere&4 Dealin" 5ith aller"ic reactions is also &iscusse&4
B24/ I&eally a 5oun& shoul& have a moist healin" environment4 Ho5 is this achieve& in practiceC
* primary 'actor in optimisin" healin" is that the &ressin" shoul& provi&e a moist environment @see B/40A4 *ll mo&ern occlusive &ress? in"s shoul& provi&e this type o' environment4 No &ry &ressin"s shoul& be use& on open 5oun&s because these 5ill allo5 the area to &ry out an& thus impe&e healin" @see B242A4
1E
Woun& Care< * Han&boo$ 'or Community Nurses 11
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&C
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"C
Woun& healin" is optimise& 5hen 5oun&s are $ept at bo&y tempera? ture4 I' the temperature o' the 5oun& &rops, mitotic activity slo5s &o5n thus re&ucin" 5oun& healin"4 * &rop in 5oun& temperature also &isrupts leu$ocytic activity an& o=yhaemo"lobin &issociation @Thomas /00-G %iller an& Dyson /003A4 )oc$ @/09-A an& %yers @/09,A 'oun& that a'ter cleansin" it coul& ta$e a 5oun& up to E- minutes to re"ain bo&y temperature an& a 'urther 1 hours 'or mitotic activity to return to normal4 Thus it is a&visable to 5arm saline be'ore 5oun& cleansin" @see BE4EA, 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 $eep a 5oun& at aroun& ,FP C 5hereas a hy&rocolloi& or 'oam &ressin" 5ill increase the temperature to 12P C @Thomas /00-A4
B24E Can micro?or"anisms "et un&er &ressin"sC
The &ressin" shoul& be impermeable to micro?or"anisms4 This shoul& 5or$ both 5ays4 While micro?or"anisms shoul& be $ept a5ay 'rom 5oun&s, it is also un&esirable to have micro?or"anisms 'rom a 5oun& sprea&in" to the environment4
Dressin"s
12
*ny non?a&hesive &ressin" shoul& be tape& li$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&"es o' the &ressin"A occurs, a 5arm 5et passa"e is create& 'or micro? or"anisms4 Secon&ary pa&&in" shoul& be applie& or the 5oun& re&resse& @see B24,1A4 The patient shoul& be a&vise& that, i' lea$a"e occurs, he or she shoul& cover it 5ith a &ressin" pa& 5hile a5aitin" a &istrict nurse visit or sur"ery appointment4
B242 Can I use tra&itional "auJe as a primary &ressin"C
Dressin"s shoul& not she& particles on to a 5oun&4 %o&ern &ress? in"s are &esi"ne& to hi"h stan&ar&s an& 5ill not she& 'ibres on to the 5oun& sur'ace4 Ho5ever, tra&itional "auJe, lint or cotton 5ool all she& 'ibres 5hich can serve as a 'ocus 'or in'ection4 In a&&ition, the &ressin" shoul& not cause trauma to the 5oun&4 I' the chosen &ressin" a&heres to the 5oun&, trauma an& pain may occur 5hen the &ressin" is remove& @see B,4FA4 The i&eal healin" environment shoul& be 'ree 'rom materials that a&hereG this is provi&e& by all mo&ern &ressin"s4 .or both o' these reasons, tra&itional &ressin"s such as cotton "auJe an& para''in "auJe shoul& not be use& on open 5oun&s4 *&herence occurs as the 5oun& e=u&ate becomes incorporate& into the "auJe an& &ries out, a&herin" to the tissue belo54 Removal causes the top layer o' "ranulation tissue to be remove& 5ith the &ressin"4 ara''in "auJe leaves a criss?cross pattern 5here ne5 "ran? ulation tissue has "ro5n throu"h the mesh, illustratin" this 8uite "raphically4
B243 *re occlusive &ressin"s recommen&e&C
Occlusive &ressin"s stop any atmospheric o=y"en "ettin" to the 5oun&4 It has been note& that an"io"enesis @'ormation o' ne5 bloo& vesselsA in "ranulatin" 5oun&s ta$es place rapi&ly in the hypo=ic environment o' occlusive &ressin"s such as hy&rocolloi&s @Cherry 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
13
to an o=y"en?permeable &ressin" @e4"4 a 'oam &ressin"A to encoura"e epithelialisation @see B/49 an& B,4/1A4
B24F Some &ressin"s are not available on prescription4 Can they still be use&C
%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 interests 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"C
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 clinical trials D *cceptable to the patient D Cost?e''ectiveG &o not 6ust thin$ in terms o' unit cost D Capable o' stan&ar&isation an& evaluation D *llo5s monitorin" o' the 5oun& D rovi&es mechanical protection D Non?'lammable D Sterilisable D 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 treatment "oal an& select the most appropriate &ressin" 'rom those available4 I' 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/IB14FA4
B240 What is an al"inate &ressin"C
These &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
Dressin"s
1F
19
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&y temperature4 *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 are manu'acture& as ropes an& ribbons especially 'or pac$in"4 They also have haemostatic 8ualities an& so are e=cellent 'or mana"in" some minor sur"ical blee&s an& minor in6uries @see B343 an& BF4//A4 * secon&ary &ressin" is re8uire& @see B24,1A4 E=amples o' al"inates are :altostat @ConvatecA, SeaSorb @ColoplastA, Sorbsan an& Sorbsan lus @ harma? last, Te"a"en @1%A, *l"osteril @#iers&or'A, *l"isite lus @Smith ; Nephe5A an& %el"isorb @%onlyc$eA4
B24/- What are bea& &ressin"sC
These &ressin"s are ma&e up o' polysacchari&e bea&s4 They are in&i? cate& 'or 5et slou"hy 5oun&s an& shoul& not be use& on clean or &ry 5oun&s4 The bea&s are e=tremely hy&rophilic an& 5ill cause pain i' the 5oun& is too &ry @see B,4FA4 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 B24,1A4
B24// What is an enJyme &ressin"C
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 B,4/- an& B,4//A4 The po5&er can be reconstitute& 5ith sterile saline an& applie& to &ry scabs that have been cross?hatche& 5ith a scalpel as a soa$4 Some practitioners &o in6ect un&er scabs, but this must be &one 5ith care so that healthy tissue is not a''ecte& an& this metho& is not "enerally recommen&e&4 *n alternative is to reconstitute the po5&er 5ith 2 ml sterile 5ater an& mi= 5ith /2 ml intrasite "el4 Whichever metho& o' application is chosen, a secon&ary
Dressin"s
&ressin" is re8uire&4
10
E-
When mi=in" Vari&ase po5&er 5ith any solution, care must be ta$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'arctionC
*ll patients treate& 5ith Vari&ase sho5 an increase in antistrepto$i? nase titres4 %or"an @/00EA recommen&s that it 5oul& be sensible not to use it on patients at ris$ o' myocar&ial in'arction4 #u= et al4 @/00FA con&ucte& a stu&y to assess antistrepto$inase levels in patients treate& 5ith intravenous strepto$inase 'or acute myocar&ial in'arction, an& in patients treate& 5ith topical strepto$i? nase 'or cutaneous 5oun&s4 He 'oun& that topical application o' strepto$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$inase is "iven intravenously4 #u= et al4 conclu&e that, i' a patient has been treate& 5ith topical strepto$inase in the last 3 months, it 5oul& be pru&ent to avoi& intra? venous strepto$inase an& an alternative thrombolytic shoul& be use& in the treatment o' a myocar&ial in'arction4 *nother small stu&y by !reen @/001A measure& the antistrepto$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'arction4
B24/1 What are 'oam &ressin"sC
.oam &ressin"s @inclu&in" hy&ropolymer an& hy&rocellular &ress? in"sA are "enerally hi"hly absorbent an& create a moist environment '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 &ressin"s4 They can be use& on their o5n or as a secon&ary &ressin", e4"4 5ith hy&ro"els @see B24,1A4 Some non?a&hesive 'oams inclu&e *llevyn @Smith ; Nephe5A, )yo'oam an& )yo'oam E=tra @SetonA4 )yo'oam is use'ul 'or resolvin" over"ranulation4
Dressin"s
E/
*&hesive 'oams inclu&e *llevyn *&hesive @Smith ; Nephe5A, CombiDER% @ConvatecA an& Tielle @Kohnson ; KohnsonA4
B24/E What are hy&ro'ibre &ressin"sC
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&ition4 Hy&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 B24,1A4 *n e=ample o' a hy&ro'ibre &ressin" is *8uacel @ConvatecA4
B24/2 What are hy&ro"elsC
*morphous hy&ro"els have a hi"h 5ater content4 They are very 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 are &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 /00EA4 They re8uire a secon&ary &ressin" @see B24,1A4 E=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&sC
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 occurs4
E,
Hy&rocolloi&s can ai& &eslou"hin" @see B,4//A an& can be use& on 5oun&s 5ith li"ht?to?me&ium e=u&ate4 Their occlusive nature "ives a hypo=ic environment, 5hich stimulates an"io"enesis @see B243A, an& the moist environment "ives pain relie' by $eepin" nerve en&in"s moist @see B/40A4 E=amples o' hy&rocolloi&s are Com'eel @ColoplastA, !ranu'le= @ConvatecA an& Te"asorb @1%A4 E=tra thin versions are also available< Com'eel Transparent @ColoplastA an& Duo&erm @ConvatecA4 *ll hy&rocolloi&s can be use& alone or as a secon&ary &ressin" @chec$ manu'acturers7 recommen&ationsA @see B24,1A4
B24/F What is a hy&rocolloi& "el &ressin"C
!ranu"el @ConvatecA is a "el that contains hy&rocolloi& 'or &eslou"h? in" an& &Mbri&in" 5oun&s @see B,4/- an& B,4//A an& can also be applie& to clean 5oun&s4 It re8uires a secon&ary &ressin" such as !ranu'le= @see B24/3A4
B24/9 What are vapour?permeable 'ilm &ressin"sC
These 5ere the 'irst mo&ern &ressin"s to be pro&uce&4 Waterproo' a&hesive 'ilms create a moist environment but have no 'lui&? han&lin" capabilities4 They can be use& on super'icial 5oun&s 5ith minimal e=u&ate, prophylactically, e4"4 to re&uce shearin" 'orces, on 5oun&s healin" by primary intention or as a secon&ary &ressin" securin" other pro&ucts @see B24,1A4 They have the a&vanta"e o' allo5in" the 5oun& to be observe& 'or any a&verse happenin"s such as in'ection, e4"4 over a suture line @see B34/A4 E=amples o' 'ilm &ressin"s are #ioclusive @Kohnson ; KohnsonA, Opsite .le=i"ri& @Smith ; Nephe5A, Te"a&erm @1%A, Cuti'ilm @#iers&or'A an& %e'ilm @%onlyc$eA4
B24/0 Can pro'lavine cream be use& to pac$ 5oun&sC
ro'lavine cream is an antimicrobial preparation o' &oubt'ul e''i? cacy, 5hich 5as popular at one time 'or pac$in" a 5oun& such as piloni&al sinus @see B341A4 It is mil&ly bacteriostatic a"ainst some !ram?positive bacteria, but less e''ective a"ainst !ram?ne"ative or"anisms such as .rote&s an& .se&$omonas spp4 an& Es+heri+hia +oli4
Dressin"s
E1
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 cream contains 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&uctsC
Lano,i n
)anolin @5ool alcoholA is a $no5n sensitiser4 It can be 'oun& in many creams, ointments, bath a&&itives, baby pro&ucts an& barrier prepa? rations4 It is better not to use any pro&ucts containin" lanolin on the s$in aroun& le" ulcers4
Antibioti# s
Neomycin an& 'ramycetin are topical antibiotics that are commonly reporte& as s$in sensitisers4 When mana"in" le" ulcers, "entamicin an& bacitracin are also si"ni'icant sensitisers @Cameron /009A4 Topi? cal antibiotics are 'oun& in creams, ointments, tulle &ressin"s an& me&icate& po5&ers4 They are best avoi&e& because o' the problems o' both sensitisation an& resistant bacteria4
A,#o+o,
Cetyl alcohol, stearyl alcohol an& cetylstearyl alcohol are emulsi'iers4 These are &i''icult to avoi& because they are 'oun& in many popular le" ulcer preparations such as a8ueous creams, corticosteroi& creams, moisturisers, some paste ban&a"es an& emulsi'yin" oint? ments4
Rubbe r
Rubber may be 'oun& in elastic ban&a"es, some support hosiery, tubular elastic supports an& late= "loves4 I' the patient has a rubber aller"y, the nurse shoul& 5ear vinyl "loves4
Paraben s
EE
The parabens "roup o' preservatives possess antibacterial an& anti? 'un"al propertiesG they are 5i&ely use& preservatives in topical me&icaments, moisturisers an& some paste ban&a"es4
Dressin"s
E2
Ester resin
of
Colophony @an ester o' resinA is 'oun& in the a&hesive bac$in" o' some plasters, tapes an& &ressin"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&C
The 'ollo5in" measures can be ta$en to minimise the ris$ o' contact &ermatitis, particularly i' the patient is $no5n to be sensitive to a variety o' preparations< (se 5arm physiolo"ical saline @-40LA to irri"ate le" ulcers or 5ash the le" 5ith plain 5arm tap 5ater @see BE41, BE4E, B241 an& B94,2A4 D *voi& usin" topical antibiotics or antiseptics @see BE41A4 D Do not use a&hesive tape &irectly on to the s$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 preparations 'or sel'?treatment4 D Consi&er re'errin" the patient to a &ermatolo"ist 'or patch testin" i' the patient is $no5n to be sensitive to a ran"e o' pro&ucts4
B24,, Can 5oun& &ressin"s be combine&C
%any combinations are 're8uently seen, but 'ar less research
E3
about the clinical e''ectiveness o' such treatments is available4 %anu'actur? ers o' &ressin"s &o not normally ma$e statements about their &ress? 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$e e=amples o' both pro&uct types, they may 5ell be prepare& to
Dressin"s
EF
provi&e some assurances that their pro&ucts use& in combination are sa'e @Thomas an& Vo5&en /009A4 I' in &oubt about the sa'ety o' a combination, a company helpline or a pharmacist may be able to ans5er your 8uery4 *lso remember that, i' a s$in reaction occurs, you may not be able to tell 5hich o' the pro&ucts has cause& it, 5hich may limit 'uture mana"ement4
B24,1 What types o' &ressin"s can be use& as secon&ary &ressin"sC
)o5 a&herence &ressin"s such as N?* Dressin" or Tricote= can be use& over "els, creams, al"inates, etc4 These are simple &ressin"s 5ith 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 these are sleeve& to prevent loose 'ibres enterin" the 5oun& an& 'or this reason shoul& not be cut4 (nless stri$e?throu"h occurs they "ive a reason? able barrier to bacteria @Thomas /009A @see B24EA4 Orthopae&ic 5a&&in", 5hich 5as ori"inally &esi"ne& 'or use un&er plaster casts, is no5 're8uently use& un&er compression ban&a"in" both to protect bony prominences an& to absorb e=u&ate @see B94,0A4 Vapour?permeable 'ilm &ressin"s, &esi"ne& as a primary &ressin" 'or super'icial lo5 e=u&ate 5oun&s, can also be use& to prevent mois? ture loss 'rom hy&ro"els applie& to &ry 5oun&s or 5oun&s 5ith lo5 e=u&ate @see B24/9A4 They may also be use& over al"inates4 There is a "ro5in" tren& to use hy&rocolloi& &ressin"s over "els an& al"inates4 *lthou"h this may be acceptable in some instances, it shoul& be remembere& that some hy&rocolloi&s can absorb a consi&? erable amount o' 'lui& an& may there'ore re&uce a hy&ro"el7s ability to rehy&rate a 5oun&4 The clinical si"ni'icance o' this has not been &etermine& @Thomas /009A4 .oam &ressin"s are usually use& alone but, as 5ith hy&rocolloi&s, there is a tren& to use them in combination 5ith "els an& al"inates @see B24/1A4 There is no publishe& evi&ence to support this practice
E9
an& a"ain they may ta$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 * "elH'oam combination may then be a bene'it i' the 5oun& is pro&ucin" a hi"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& charcoal may be appropriate @see B,43A4 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" proper? 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 are responsible 'or the smell @Thomas /009A4
B24,E *re there any pro&ucts that shoul& be avoi&e& 5ith ve"etarian patientsC
%ost pro&ucts are suitable, althou"h some hy&rocolloi&s may contain "elatin, 5hich is an animal &erivative, 5hereas other &ress? 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'acturer4
Summar y
No one &ressin" 5ill meet all the criteria 'or the i&eal 5oun& &ress? 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 the combination is cost?e''ective4
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&C
Sur"ical 5oun&s are usually close& 5ith sutures or clips, 5hich are le't in place 'or 2IF &ays &epen&in" on the type o' sur"ery, an& the &epth o' the 5oun& they are closin" @see B/43A Stu&ies have sho5n that a'ter ,E 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$in e&"es have been brou"ht to"ether tra&itional &ress? in"s such as "auJe or %elolin are o'ten use&4 Ho5ever, these may not be com'ortable an& are not 5aterproo' @%iller /002A @see B242A4 It may be appropriate to consi&er a more mo&ern alternative such as a vapour?permeable 'ilm @see B24/9A, a polyurethane &ressin" @see B24/1A or a thin hy&rocolloi& @see B24/3A4 *&vanta"es o' these
E3
Woun& Care< * Han&boo$ 'or Community Nurses E2
&ressin"s inclu&e com'ort an& less bul$, they &o not re8uire ban&a"in" or tapin" into position, are 5aterproo' an& in most cases can be le't in position until the sutures or clips can be remove&4 @Thomas /00-A4 Once sutures or clips have been remove&, a &ressin" shoul& not be necessary unless the 5oun& continues to e=u&e 'rom any areas alon" the suture line4 *&vice "iven to the patient may inclu&e coverin" the 5oun& 'or ,E hours a'ter sur"ery4 I' the 5oun& then appears &ry, he or she may sho5er, but shoul& avoi& bathin" because this 5ill re&uce the natural barrier4 While a5aitin" the removal o' sutures or clips, the patient shoul& observe the 5oun& 'or any si"ns o' in'ection @see B/-4/A an& see$ me&ical ai& i' any o' these occur4
B34, What 'actors can a''ect the healin" o' sur"ical 5oun&sC
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 B14,IB14//A4 The len"th o' hospital stay be'ore sur"ery has been su""este& as a '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" susceptibility 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 alrea&y &ebilitate& 'rom a mali"nant &isease @#lan& et al4 /09EA4 Ra&iother? apy can also &ama"e s$in by &ecreasin" vascularity an& 'ibrosis @Cuttin" an& Har&in" /00EA, 5hich ma$es it more vulnerable to trauma 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
Sur"ical 5oun&s
EF
Woun& in'ection can also be a complication o' 5oun& healin" @see B/-4/ an& B/-4,A4 In'ection rates are hi"her in patients 5ho are ol&, obese, ta$in" steroi&s, malnourishe& or &iabetic, an& those 5ith lon"er preoperative stays @ artri&"e /009A4 atients 5ho are un&er"oin" sur"ery may also su''er stress an& an=iety4 *lthou"h the relationship to 5oun& healin" is not 'ully un&erstoo& this appears to impair the healin" process4 Stress an& an=iety may also re&uce motivation an& inter'ere 5ith rest an& sleep 5hich is important to optimise 5oun& healin"4
B341 What is a piloni&al sinusC
The most common site 'or a piloni&al sinus is bet5een the buttoc$s in the upper natal cle't4 It is "enerally accepte& that it is an ac8uire& abnormality @!oul& /00FG Ho&"$in /009A4 iloni&al &isease starts at the onset o' puberty 5hen the se= hormones be"in to a''ect sebaceous "lan&s in the natal cle't4 * hair 'ollicle becomes &isten&e& 5ith $eratin to 'orm an asymptomatic cyst4 !ra&ually a combination o' 'riction an& trauma provo$e an in'lammatory response @see B/49A4 atients may present 5ith a piloni&al abscess, 5ith a short history o' intense pain, s5ellin" an& re&ness aroun& the in'ecte& area4 *lter? natively, they may have mo&erate?to?mil& pain an& a history o' recurrent &ischar"e4 atients are usually bet5een the a"e o' puberty up to Eyears4 %en are t5ice as li$ely as 5omen to &evelop this &isease, presumably because they are more hirsute @!oul& /00FA4
B34E What is the recommen&e& treatment 'or piloni&al &iseaseC
I' an abscess has 'or me&, it is treate& as a sur"ical emer"ency an& 5ill re8uire incision an& &raina"e4 The 5oun& 5ill re8uire loose pac$in" until it heals4 Commonly use& &ressin"s are al"inates or in some circumstances hy&ro"els @!oul& /00FA @see B240 an& B24/2A4 Tra&itionally, ribbon "auJe soa$e& in a solution such as pro'lavine @see B24/0A 5as use&, but this is no lon"er recom? men&e&4 !auJe may &ry out an& cause trauma an& pain on removal an& may also she& 'ibres into the 5oun&, so it shoul& not be use& @see B242A4
E9
I' no abscess has 'orme& there are several options, althou"h treat? ment is controversial @Ho&"$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 treatments 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&C
*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 internal 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 /00,A4 The result? in" cavity is then pac$e& 5ith a &ressin" such as an al"inate or hy&ro'ibre &ressin" @B240 an& B24/EA, 5hich allo5s 'or 'uture &raina"e4 *ntibiotics penetrate poorly into an abscess but serve as an a&6unct to sur"ery4
B343 Is there a recommen&e& mana"ement 'ollo5in" removal o' in"ro5in" toenailsC
The proce&ure 'or removal o' part or all o' an in"ro5in" toenail varies 5ith the practitioner4 Some &octors treat the area 5ith phenol to prevent re"ro5th, others &o not4 Invariably the nail be& blee&s pro'usely4 (se o' a haemostatic &ressin", such as an al"inate @see B240A, covere& 5ith a 'oam &ressin" @see B24/1A re&uces a&hesion o' the &ressin" to the toe4 The 5oun& can be assesse& a'ter 1IE &ays, 5hen 'urther mana"ement can be planne&4 The use o' 'oam &ress? in"s on the 'eet appears to re&uce pressure 'rom 'oot5ear, 5hich patients 'in& com'ortable4 The use o' tulle &ressin"s is not recom? men&e&, because they a&here to the 5oun& an& cause &ama"e on removal @see B242A4
Sur"ical 5oun&s
E0
Summar y
%ost sur"ical 5oun&s are close& 5ith the s$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
CHAP*ER 8
Burns$ s#a,ds and 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$s at the treatment o' these con&itions, because they are rele? vant to all community nurses4 Recommen&ations are ma&e as to 5hich patients 5ill re8uire specialist a&vice4 The a'tercare o' &onor sites an& mana"ement o' scar tissue are also &iscusse&4 It is reco"? nise& that specialist centres may have their o5n re"imen 'or the care o' these 5oun&s, an& the rea&er is e=pecte& to 'ollo5 local protocols4
BF4/ atients 5ith burns an& scal&s 're8uently atten& the ! sur"ery4 Which shoul& be re'erre& to acci&ent an& emer"encyC
*s a "eneral rule, patients 'ittin" the 'ollo5in" criteria shoul& atten& the acci&ent an& emer"ency &epartment @!o5er an& )a5rence /002A< D *ny burn e=cee&in" 2L o' the bo&y sur'ace area4 D #urns o' 'unctionally important areas, such as the 'ace, han&s, 'eet, perineum, 6oints or 'le=or sur'aces4 D I' other in6ury is suspecte&, e4"4 inhalation o' smo$e or other 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
early "ra'tin" @see .i"ure /4EA4 in6uries *nyone sho5in" si"ns o' local in'ection or evi&ence o' septi? caemia @see Tables /-4/ an& /-4,A4
2-
#urns, scal&s an& minor
2/
#urns that create &oubt, such as non?acci&ental in6ury, or those o' un$no5n &epth, such as chemical or electrical burns4
BF4, Ho5 shoul& sunburn be treate&C
.re8uently sunburn is erythema 5hich 5ill subsi&e 5ithin E9 hours @)a5rence /003A, leavin" no tissue &ama"e4 Col& 5ater is e''ective 'or relievin" the pain, 5hile the usual treatment is reassurance an& calamine lotion4 I' the s$in has blistere&, this is a si"n o' actual tissue loss4 The burn shoul& then be assesse& to see 5hether it can be treate& in the sur"ery or 5hether it 5ill re8uire hospital treatment4 atients atten&in" 5ith sunburn shoul& be remin&e& o' the potential &an"ers o' sun &ama"e in the &evelopment o' s$in cancer an& a&vise& on 'uture protection4
BF41 What is the best treatment 'or minor burns an& scal&sC
I' a patient in a nursin" home su''ers a minor burn or scal&, or i' a patient comes to the sur"ery imme&iately, the recommen&e& 'irst ai& treatment 'or most burns is col& 5ater 'or a minimum o' /minutes or until the pain has &ecrease&4 This treatment is en&orse& by the #ritish #urns *ssociation @)a5rence /003A4 The purpose o' this is to 8uench resi&ual heat rapi&ly4 )ocal coolin" also has a mar$e& anal? "esic e''ect4 Ho5ever, most patients 5ill have su''ere& their burn or scal& 5ell in a&vance o' atten&in" the sur"ery4 Treatment 5ill &epen& on the siJe, site an& &epth o' the burn4 I' present, blisters shoul& not be &eroo'e& @!o5er an& )a5rence /002A4 The absence o' s$in may allo5 'or "reater possibility o' in'ec? tion4 I' the blister is 'ull o' 'lui& an& causin" acute &iscom'ort 'rom pressure, aspiration un&er sterile con&itions shoul& be consi&ere&4 Very minor burns are o'ten treate& 5ith simple tulle &ressin"s4 Those containin" antibiotics shoul& be avoi&e& @see B/-4EA4 Silver sulpha&iaJine cream @.lamaJineA is o'ten applie& un&er lo5 a&her? ent &ressin"s or simple tulle, but may be &i''icult to secure an& may cause maceration4 One su""este& treatment re"imen is< D Day /< .lamaJine an& tulle D Day ,< tulle D Day 2< tulle an& revie5 as
#urns, scal&s an& minor necessary4 in6uries
2/
2,
Other &ressin"s that may be suitable inclu&e 'ilm &ressin"s or hy&rocolloi& &ressin"s @see B24/3 an& B24/9A4 %ost minor burns 5ill heal 5ithin a 5ee$ to /- &aysG a'ter this they shoul& be &resse& as appropriate4 I' the burn has not heale& or almost heale& 5ithin 1 5ee$s o' in6ury, it may be 'ull thic$ness an& re8uire a s$in "ra't @!o5er an& )a5rence /002A @see .i"ure /4EA4 %inor burns to the 'ace 5here it is &i''icult to apply &ressin"s may be treate& 5ith /-L a8ueous povi&oneIio&ine4 This nee&s to be applie& three to 'our times a &ay 'or 2IF &ays4 This 5ill re&uce the possibility o' bacterial complications @see #o= E4,A4 Tetanus cover shoul& also be revie5e&4
BF4E *re there any instances 5hen treatment 'or burns 5ith col& 5ater is not appropriateC
Col& 5ater treatment is not appropriate i' the burns have been cause& by metallic so&ium, potassium or calcium4 These all react violently 5ith any a8ueous solution4 These burns are rare an& appropriate me&ical a&vice shoul& be sou"ht4
BF42 What a&vice shoul& the patient be "iven 5hen the burn has heale&C
The ne5 epithelium o' a recently heale& burn is &elicate an& sun sensitive4 Dry &ressin"s mi"ht initially be in&icate& 'or protection4 Total sun bloc$ shoul& be use& i' the area is e=pose& to sunli"ht an& the area 5ell moisturise& 5ith a simple non?per'ume& cream4 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$in resultin" in episo&es o' ulceration @!o5er an& )a5rence /002A4
BF43 What a&vice shoul& patients be "iven about carin" 'or heale& &onor sitesC
%ost &onor sites heal 5ell 5ith little scarrin"4 The patient shoul& be a&vise& to protect the area 'rom e=tremes o' temperature, trauma an& e=posure to the sun @.o5ler an& Dempsey /009A4 S$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

BF4F What is a scar, an& 5hat a&vice can the patient be "iven 'or improvin" its appearanceC
21
* scar is the mar$ le't a'ter a 5oun& has heale&4 Dama"e to the epi&ermis is heale& by replacement o' the epi&ermis an& 5ill normally result only in sli"ht scarrin" 5hich 5ill 'a&e naturally4 I' &eeper tissue such as the &ermis is &ama"e&, the bo&y lays &o5n colla"en &urin" the healin" process @see B/49A, an& the resultin" scar 5ill be much more noticeable4 O'ten these &o not 'a&e an& 5ill remain re& or &ar$ an& raise&4 Scars can be &escribe& as hyper? trophic, i4e4 they remain in the ori"inal 5oun& site an& continue to "ro5 'or up to 3 months, or they can be $eloi& I such scars "ro5 lar"er than the ori"inal 5oun& an& "ro5 in&e'initely4 * recently &evelope& pro&uct, Circa?Care @Smith ; Nephe5A, is a sheet o' silicone in an a&hesive "el sheet4 This is place& over the scar 'or ,IE months an& has been sho5n to improve appearances in 0-L o' cases @&ata 'rom Smith ; Nephe5A4 This pro&uct can be bou"ht 'rom pharmacies, but is also available on . /-4
BF49 What is the pre'erre& treatment 'or pretibial lacerationsC
retibial lacerations o'ten leave a 'lap o' s$in on the shin4 Commonly the patient has e=tremely 'ra"ile s$in, so consi&eration is nee&e& to select a &ressin" that 5ill not cause trauma 'rom any a&hesive on removal4 I' the s$in 'lap remains, it can be secure& bac$ into place 5ith a&hesive strips @see BF40A, but o'ten the bloo& supply to the 'lap is poor an& the replace& 'lap 5ill not remain viable4 Complications o' pretibial lacerations inclu&e in'ection an&Hor the &eterioration o' the 5oun& into a chronic state @see B94/ an& B941,A4 I' there are un&erlyin" problems 5ith the venous circula? tion, a venous ulcer may result4 )i$e5ise, i' the arterial circulation is poor healin" 5ill be compromise& @see B140A4 I' the area o' the laceration continues to ooJe bloo&, an al"inate &ressin" such as :altostat may be use& as a haemostat @see B240A4
BF40 When are a&hesive 5oun& closure strips appropriateC
Woun& closure strips are appropriate 'or minor lacerations or minor
2E
5oun&s 5here there is little 'orce nee&e& to $eep the 5oun& e&"es
22
to"ether4 They cause less trauma than sutures on both application an& removal4 The 'ollo5in" is the application proce&ure< D Ensure that the surroun&in" s$in is &ry4 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 repair4 D * secon&ary &ressin" is place& over the close& 5oun& @see B24,1A4 Once close& a small 5oun& shoul& have heale& 5ithin 2IF &ays @&epen&in" on positionA an& the strips may be remove&4
BF4/- When is sur"ical "lue appropriateC
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 primary 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 re8uire& D No 'ollo5?up 'or suture removal D Re&uce& pain an& an=iety, especially 'or chil&ren D Re&uce& atten&ance at hospital4 The 5oun& shoul& be $ept &ry 'or 2 &ays4 No 'ollo5?up
23
is re8uire& unless the 5oun& reopens4 It can be re"lue& or suture& i' appropriate4

BF4// Is there a simple metho& 'or mana"in" lacerationsC
2F
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 'orei"n bo&y in the 5oun& be'ore applyin" pressureG this is o' particular rele? vance i' the 5oun& 5as cause& by bro$en "lass4
Summar y
Only minor burns an& scal&s shoul& be treate& in the sur"eryG re'er any o' concern 'or secon&ary care mana"ement4 In most instances, col& 5ater is the most e''ective 'irst ai& measure4 I' patients atten& 5ith sunburn, consi&er health promotion issuesG promote sunscreen an& bo&y protection to prevent 'urther episo&es o' sunburn4 Ne5ly heale& burns an& &onor sites shoul& be protecte& 'rom sunli"htG hi"h?'actor sun lotionHsun bloc$ 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
CHAP*ER 9
Leu,#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 /00EA4 This care is costly4 In /00- Charin" Cross Hospital le" ulcer service estimate& the annual cost o' treatin" a le" ulcer to be bet5een R,F-- an& R2,-- per patient4 This su""ests that the treatment o' le" ulcers costs the National Health Service R1--I 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" ulcerC
* le" ulcer can be &e'ine& as an area o' &iscontinuity o' the epi&er? mis an& &ermis on the lo5er le" persistin" 'or E 5ee$s or more, e=clu&in" ulcers con'ine& to the 'oot4
B94, What are the principal causes o' le" ulcersC
)e" ulcers may be cause& by a number o' un&erlyin" patholo"ies4 %inor trauma is o'ten the imme&iate cause o' the ulcer but un&erly? in" patholo"y lea&s to ulcer &evelopment4 The most common o' these patholo"ies is venous &isease @see B94/EA, 5hich accounts 'or about F-L o' ulcers4 *roun& /-I/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 ulcers4
)e" ulcers
23
2F
B941
*re there any other causes o' le" ulcers to consi&erC
*roun& ,I2L o' patients &evelop ulcers as a result o' other causes4 *lthou"h rare these shoul& be $ept in min&4 Some o' these are liste& in Table 94/4
*ab,e 9<1 %inority causes o' le" ulcers Neuropathy< o'ten associate& 5ith &iabetes mellitus @see B94/9A %ali"nancy< basal cell carcinoma, s8uamous cell carcinoma or melanoma @see B94,/ an& B//4/A In'ections< tuberculosis, &eep 'un"al in'ections, leprosy, syphilis4 These are rare in the (: but &o consi&er, particularly i' the patient has been travellin" or livin" in the tropics )ymphoe&ema< usually only associate& 5ith ulceration 'ollo5in" cellulitis @see B/-42A or i' venous &isease is also present @%orison /00/A #loo& &isor&ers< e4"4 sic$le?cell &isease, thalassaemia Sel'?in'licte& ulcers Iatro"enic< these can be cause& by ill?'ittin" plaster casts or ba&ly applie& ban&a"es bein" use& to treat e=istin" ulcers
B94E
What are the clinical si"ns an& symptoms o' chronic venous hypertensionC
Si"ns o' venous &isease inclu&e the 'ollo5in"< D Varicose veins D )ipo&ermatosclerosis< har&enin" o' the &ermis an& subcutaneous 'at @see .i"ure /4/A D Stasis ecJema D *n$le 'lare< the appearance o' many &ilate& intra&ermal venules over the me&ial aspect o' the an$le D Stainin" o' the s$in as a result o' brea$&o5n pro&ucts o' haemo? "lobin 'rom e=travasate& re& bloo& cells4 D *trophe blanche< areas o' 5hite s$in 5ith tiny spots that are &ilate& capillary loops @see B94/EA4
B942 What is a typical me&ical history o' a patient 5ith venous &iseaseC
* me&ical history o' patients 5ith venous &isease may inclu&e any o' the 'ollo5in"< D Varicose veins @either treate& or untreate&A @see B94/EA D Deep vein thrombosis
29
D D
hlebitis o' the a''ecte& le" Suspecte& &eep vein thrombosis, e4"4 s5ollen le" a'ter sur"ery, pre"nancy or trauma D Sur"ery on a''ecte& le" D Trauma to the a''ecte& le", e4"4 'racture D History o' pulmonary embolism4
B943 What is the typical appearance o' a venous ulcerC
The 'ollo5in" are typical o' a venous ulcer< D Site< o'ten near the me&ial or lateral malleolus4 D Depth an& shape< usually shallo5 5ith a poorly &e'ine& e&"e4 D ain< the pain o' venous ulceration is o'ten associate& 5ith oe&ema, 'rom local in'ections or cellulitis @see B/-42A4 ain is usually relieve& by compression ban&a"in" an& elevation @see B94,0A4 D Development< usually slo5 unless in'ecte& @see B/-4/A4
B94F What are the clinical si"ns an& symptoms o' arterial &iseaseC
Si"ns o' arterial &isease may inclu&e the 'ollo5in"< D D D D D D D D Col& le"s an& 'eet in a 5arm environment ale or blue 'eet 5hen raise& .eet &us$y pin$ 5hen unsupporte& Shiny hairless le" !an"renous toes *bsent 'oot pulses Trophic chan"es to nails oor tissue per'usionG i' the nail be& has &irect pressure applie& to it, it ta$es lon"er than 1 secon&s to return to normal colour4
B949 What is the typical me&ical history o' a patient 5ith arterial &iseaseC
* me&ical history su""estive o' arterial involvement may inclu&e the 'ollo5in"< D Hypertension D %yocar&ial in'arction
)e" ulcers
20
D *n"ina D Transient ischaemic attac$s D *rterial sur"ery D Cerebrovascular acci&ent @see B94/2A D 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 ulcerC
The 'ollo5in" are typical o' arterial ulcers< Site< o'ten on the 'oot or lateral aspect o' the le" but may occur any5here inclu&in" the malleolar areas4 D Depth an& shape< o'ten &eep 5ith a punche&?out appearance, o'ten irre"ular shapes or multiple small areas4 D ain< invariably pain'ul, o'ten the pain is ma&e 5orse by elevation 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" ulcersC
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 94,4 @see B,4/IB,4E an& B,4/EA4
:l+er8relate$ history
The assessment o' a patient presentin" 5ith either a 'irst or a recur? rent le" ulcer shoul& inclu&e a &etaile& history o' the onset o' the problems4 B94EIB943 &escribe the clinical si"ns an&
3-
symptoms, appearance o' the ulcer an& relevant me&ical history4
)e" ulcers
*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/EA Diet< poor nutritional status may &elay healin" @see B14EA Obesity< may contribute to poor healin" an& ulcer &evelopment @see B14EA 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
3/
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 $no5n aller"ies to &ress? in"s @see B24,-A4 * history o' the current episo&e o' ulceration shoul& also be &ocumente&4
B94// What clinical investi"ations may be necessaryC
Some routine investi"ations can ai& the &ia"nosis o' the le" ulcer or help in its mana"ement4 Other investi"ations 5ill be necessary only in a 'e5 circumstances4 Investi"ations are summarise& in Table 9414
*ab,e 9<3 Clinical investi"ations Investi"ation #loo& pressure measurement (rinalysisH#% stic$ #loo& tests Rationale To &etect hypertension @see B949A To &etect &iabetes @see B949A .ull bloo& count an& haemo"lobin levels to i&enti'y anaemia4 Test 'or rheumatoi& 'actor @see B14E an& B949A I' si"ns o' in'ection are present, to &etermine antibi? otic sensitivity @see B/-4/A I' mali"nancy is suspecte& @see Table 94/A I' the patient is obese, &ietary a&vice an& 5ei"ht re&uction can ai& healin" @see B14EA
Woun& s5ab Tissue biopsy Wei"ht
3,

B94/, Ho5 can vascular status be assesse&C
The simplest 'orm o' vascular assessment is to palpate the 'oot pulses, both the &orsalis pe&is an& the posterior tibial @.i"ure 94/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 nurse 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
%e&ial malleolus osterior tibial
)ateral malleolus *nterior tibial eroneal
Dorsalis pe&is
)i-ure 9<1 Dia"ram sho5in" the positions o' pe&al pulses4
1eas&ring the ankle bra+hial press&re in$e5
This &etermines the ratio o' the an$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 /00EA4 This is to overcome the e''ects o' e=ercise on the bloo& pressure4 This time can be use& to ta$e the patient7s history4 The brachial systolic shoul& be recor&e& 'or both arms an& the hi"her 'i"ure use& 'or calculation @Vo5&en et al4 /003A4 *n appropri?
ately siJe& sphy"momanometer cu'' is place& aroun& the arm an& ultrasoun& "el place& over the brachial pulse to ensure a "oo& seal bet5een the probe an& the s$in4 The Doppler probe is place& at a sli"ht an"le over the brachial pulse until a "oo& si"nal is hear&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$e the 'oot pulses, secure an appropriately siJe& sphy"mo? manometer cu'' 6ust above the me&ial malleolus4 *ny 5oun&s 5ill re8uire coverin" to prevent contamination either to or 'rom the cu''4 In turn, locate the &orsalis pe&is, posterior tibial an& anterior tibial pulses4 .or each pulse in'late the cu'' until the si"nal is lost, then slo5ly &e'late the cu'' until the si"nal returns4 .or ma=imum accu? racy each pulse shoul& be measure& t5ice4 It shoul& be note& that the &orsalis pe&is pulse is con"enitally absent in up to /,L o' people @#arnhorst an& #arner /039A4 In practice it is o'ten necessary to use only t5o o' the pe&al pulses 'or measurement @%o''att /009A4 I' there is any &oubt 5hatsoever about the patient7s arterial status, a&vice shoul& be sou"ht 'rom a specialist4 To calculate the *# I &ivi&e the hi"hest an$le pressure measure& by the hi"hest brachial pressure4
*n$le systolic pressureH#rachial systolic pressure S *n$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-I-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 /00EA4 * ratio o' -42-I-4F2 5ill o'ten mean that the patient su''ers intermittent clau&ication, an& belo5 this level ischaemic rest 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
ban&a"es shoul& not be applie& to people 5ith &iabetes e=cept un&er close me&ical supervision @%orison an& %o''att /00EA @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 nurse 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'essionalC
The vast ma6ority o' ulcers shoul& not re8uire specialist assessment4 In some instances, 'urther a&vice an& assessment may be re8uire&, e4"4< * si"ni'icantly re&uce& *# I4 Discuss 5ith the ! the nee& 'or vascular re'erral @see B94/,A4 D Rapi& &eterioration o' the ulcer4 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,-A4 D Cellulitus @see B/-42A4 D (lcers that 'ail to respon& to treatment a'ter a 1?month perio& @see B941,A4 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 re'erral4
B94/E Ho5 &oes venous &isease cause ulcerationC
The venous system in the le" comprises both &eep an& super'icial veins @.i"ure 94,A4 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
*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 'rom the 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 /00EA, 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
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 &ermis4 Capillary &ama"e allo5s lea$a"e o' re& bloo& cells an& protein molecules into the interstitial 'lui&G the re& bloo& cells are &estroye&, releasin" haemo"lobin 5hich brea$s &o5n an& causes s$in pi"mentation an& ecJema4 .ibrino"en, 5hich is release& 5ith the re& bloo& cells, turns into 'ibrin 5hich &eposits a cu'' aroun& the capillaries an& re&uces the &i''usion o' o=y"en an& other nutri? ents4 This in turn causes tissue ischaemia4 With the s$in bein" thin an& susceptible to trauma, minor &ama"e lea&s to le" ulceration @see BF49A4
B94/2 Ho5 are arterial ulcers cause&C
*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 are &iabetes an& smo$in" @see B949A4
B94/3 Why are patients 5ith rheumatoi& arthritis susceptible to ulcersC
*bout /-L o' patients 5ith rheumatoi& arthritis &evelop an ulcer @ un et al4 /00-A4 Everyone has poorly vascularise& s$in over the tibia, but in those 5ith rheumatoi& arthritis it is particularly suscepti? 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& arthritis an& 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
B94/F Ho5 shoul& ulcers associate& 5ith rheumatoi& arthritis be mana"e&C
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 is chronic venous hypertension, "ra&uate& compression shoul& be applie& but it is e=tremely important to e=clu&e arterial &isease @see B94/, an& B94,0A4 articular attention shoul& be "iven to the s$in to prevent 'urther &eterioration or trauma4 The s$in shoul& be $ept supple an& treate& 5ith emollients @see BE42A, an& i' a&hesive &ressin"s are use& "reat care must be ta$en in removin" them so as not to &ama"e the s$in 'urther4 %any o' these patients have a poor appetite @%orison an& %o''att /00EA an& may re8uire nutritional supplements @see B14EIB14FA4 Re"ular an$le an& 'oot e=ercises 5ill be o' bene'it but the patient may re8uire help 5ith these @see B94,0A4 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 ulcerationC
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 very 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 /099A4 Calci'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$in", hypertension an& hypercholes? terolaemia @%orison an& %o''att /00EA4
eople 5ith &iabetes may also have chan"es to small vessels as 5ell as the lar"er arteries4 This means that the toes may su''er ischaemic &ama"e4 This ris$ is much "reater in people 5ith poorly controlle& &iabetes4 Other &iabetic ulcers are the result o' neuropathy4 There are 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 corn removers4 %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$in becomes very &ry an& prone to &evelop crac$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 /00EA4 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 be re8uire& @see B,4/-, 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 careC
This a&vice is probably best "iven both verbally an& 5ith a lea'let that the patient can $eep 'or re'erence @#o= 94/A4
Bo/ 9<1 .oot care a&vice 'or people 5ith &iabetes Wash 'eet &aily, ma$in" sure they &ry them 5ell particularly bet5een the toes .eet shoul& be chec$e& &aily 'or any &ama"e, re&ness or blisterin"4 I' patients cannot see their o5n 'eet, they shoul& as$ 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 $eep the 'eet 5arm to avoi& chilblains 5hich may ulcerate atients shoul& be as$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 limbs They shoul& not smo$e
B94,- Shoul& &iabetic ulcers be mana"e& li$e other arterial ulcersC
*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 so that 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 /00EA4 )evin @/099A su""ests that the mana"ement o' &iabetic 'oot ulcers shoul& be a""ressive4 This involves rapi& local &Mbri&ement leavin" only healthy tissue, systemic antibiotic therapy, &iabetic control an& non?5ei"ht?bearin" 'or plantar ulcers4 *n appropriate local &ressin" shoul& be chosen but the ulcer 5ill
respon& only i' the above treatment is "iven4 Ho5ever, an inappro? priate &ressin" may ma$e the situation 5orse4 (lcerate& 'eetHtoes shoul& be $ept &ry to eliminate maceration bet5een the toes 5hich 5ill allo5 in'ections to enter @see B24/A4 atients shoul& be "iven a&vice about 'oot care @see #o= 94/A4 The person 5ith &iabetes shoul& be stron"ly a&vise& to stop smo$? 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$book for 7omm&nity N&rses I in this series4
B94 ,/ When shoul& I suspect that an ulcer is mali"nantC
%ali"nant ulcers are rare in the (: @more 're8uent in tropical coun? triesA, but i' ulcers 'ail to respon& to treatment this shoul& not be overloo$e& as a cause @*c$roy& an& Noun" /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 @*IDSAG they are usually small an& multiple an& may ulcerate @%orison an& %o''att /00EA4
B94,, What are the main aims o' le" ulcer treatmentC
The aim three'ol&<
o'
treatment
is
/4 To heal the ulcer ,4 To treat the un&erlyin" con&ition 14 To prevent reoccurrence4

B94,1 What primary &ressin"s shoul& be use& on le" ulcersC
Choice o' &ressin" 5ill &epen& on the 5oun& state @see Chapter 2A4 In most instances a simple &ressin" that is capable o' maintainin" a
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 B94,0A4
B94,E Ho5 o'ten shoul& the &ressin" be chan"e&C
(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 necessary4
B94,2 What is the best 5ay to cleanse an ulcerC
(lcers shoul& be cleanse& by irri"ation 5ith 5arm physiolo"ical saline i' necessary @see BE41 an& BE4EA4 I' there is no ol& &ressin" material or e=u&ate this may not be nee&e&4 )e"s may 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$in scales an& is also pleasant 'or the patient 5ho may other5ise be unable to 5ash the 'eet an& le"s 'or lon" perio&s4
B94,3 Some patients 5ith le" ulcers seem sensitive to the pro&ucts use&4 Ho5 can this be avoi&e& or treate&C
atients can become sensitise& to treatments at any time @see B24,- an& B24,/A4 atients 5ith reactions to un$no5n sensitisers shoul& be re'erre& to a &ermatolo"ist 'or patch testin"4 In cases o' sensitivity, remove the $no5n or potential aller"en, apply a simple non?a&herent &ressin", an& elevate an& rest the limb4 )iaise 5ith the ! to prescribe a steroi& ointment @cream may contain sensitisersA4 *pply the ointment 'or ,IE &ays4 Re&uce the amount o' ointment use& over the 'ollo5in" 1IE &ays an& replace the steroi& 5ith 5hite so't para'? 'in emollient4
B94,F Some le" ulcers are very pain'ul4 Is there anythin" practical that can be &one to helpC
I' the pain is at the 5oun& site, consi&er 5hether the &ressin" is caus? in" the &iscom'ort4 It may be stic$in" to the 5oun& an& causin" trauma 5hen the patient moves4 * less a&herent &ressin" 5oul& re&uce the pain4 Or, i' the &ressin" is very hy&rophilic an& causin" a stin"in" or &ra5in" sensation on the 5oun& be&, a"ain chan"in" to a pro&uct more suitable to the 5oun& 5ill help @see B,4FA4 Compression therapy, e=ercise an& elevation 5ill re&uce oe&ema an& pain in patients 5ith venous ulceration @see B94,0A4 *nal"esia must be tailore& to the in&ivi&ual patient7s re8uire? mentsG in cases such as arterial ulceration 5hen pain may be severe, opiate anal"esia may be re8uire& @see B,4FIB,40A4
B94,9 What shoul& patients be o''ere& in terms o' e&ucationC
*ll patients shoul& be o''ere& accessible an& appropriate in'orma? tion on their le" ulcer &isease4 This shoul& inclu&e the rationale 'or their treatment, sel'?help strate"ies, services available to them, &ietary a&vice an& li'estyle a&vice4 atients 5ith any type o' ulcer shoul& be encoura"e& to e=ercise because mobilisin" 5ill encoura"e venous return an& limit the e''ects o' immobility @%orison an& %o''att /00EA, but their capabilities 5ill vary @see B94,0A4 %any manu'acturin" companies pro&uce comprehensive patient boo$lets 5hich can be obtaine& 'rom representatives4 Consi&er usin" your o5n e&ucational an& health promotional s$ills4
B94,0 Ho5 shoul& venous ulcers be treate&C
The un&erlyin" venous &isease must be treate&4 This is the most important aspect o' treatment an& unless this is ma&e a priority the ulcer is unli$ely to respon& to local treatment4 I' arterial involvement has been e=clu&e& @see B94/,A, the un&er? lyin" venous &isor&er shoul& be treate& 5ith compression ban&a"? in", e=ercise an& elevation4
7ompression
!ra&uate& compression 5ill assist venous return an& improve muscle pump 'unction4 The su""este& level o' compression is
bet5een ,- an& E- mmH" at the an$le, to 2-L o' that value at the $nee @:en&ric$ et al4 /00EA4 * 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 $nee4 %anu'acturers7 instructions shoul& be 'ollo5e&4 #an&a"es that are incorrectly applie& are at best uncom'ortable an& useless an& at 5orst &an"erous4 It is important that anyone applyin" a compression ban&a"e has been tau"ht the correct metho& o' application, un&er? stan&s the rationale 'or the treatment an& is competent to carry out the treatment4 Compression can be applie& as a sin"le?layer, lon", stretch ban&a"e, e4"4 Sure ress or Tensopress4 Orthopae&ic pa&&in" may be re8uire& to protect the le", particularly over bony prominences4 Note that patients 5ith an an$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" stretch 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 I 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 no elasticity 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" circum'erence re&uces, other5ise any bene'its 5ill be lost4
E5er+is e
Wal$in" e=ercises the cal' muscle an& 5or$s the muscle pump, increasin" venous return4 %any patients 5ith venous ulcers are 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 Re"ular 'le=ion an& e=tension e=ercises are bene'icial in 5or$in" the cal' muscle pump 'or patients 5ith limite& mobility4
Ele,atio n
atients shoul& be encoura"e& to elevate their le"s above hip hei"ht 5hen sittin" to 'acilitate venous return4
B941- Ho5 shoul& mi=e& aetiolo"y or arterial ulcers be treate&C
I' the *# I is bet5een -49 an& -402, the limb can have compression therapy @see B94/,A4 #elo5 this level, unless a&vise& to the contrary, e4"4 by a vascular sur"eon, ulcers shoul& be treate& as arterial4
B941/ What is the recommen&e& mana"ement 'or arterial ulcerationC
Compression must not be use& on ulcers 5ith a substantial arterial component4 *ny ban&a"es use& shoul& be li"ht retention ban&a"es4 %il& e=ercise an& an$le e=ercises shoul& be encoura"e& especially i' the patient is immobile @see B94,0A4 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 B,4FIB,40 an& B24/1IB24/3A4 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 ulcerC
I' the patient has a history o' le" ulceration an& $no5n vascular problems, any minor in6ury to the le" shoul& be treate& as a recur? rence o' ulceration, an& appropriate treatment commence&
imme&i? ately @see B,41 an& B94/-A4
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/,A4 eople 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&C
In&ivi&ual healin" rates 5ill vary 5hatever the un&erlyin" con&ition4 *ny ulcer not respon&in" to treatment in EI9 5ee$s shoul& be reassesse&4 Treatment may nee& to be chan"e& or the patient may re8uire 'urther investi"ation or re'erral to a specialist nurse or consultant @see B94/1A4
B941E Ho5 can recurrence be prevente&C
*ppro=imately F2L o' patients su''er recurrence o' ulceration4 This can be re&uce& i' appropriate a&vice is "iven4 atients shoul& be a&vise& to report any ne5 &ama"e to le"s as soon as possible, so that treatment can be starte&4 atients 5ith venous &isease re8uire compression 'or li'e4 When healin" is complete, they shoul& be measure& 'or suitable hosiery @see B9412IB94E/A4 Encoura"e patients to continue 5ith e=ercise @see B94,0A4 Rein? 'orce a&vice on &iet, li'estyle an& smo$in" habits4 Encoura"e protec? 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 ulcerationC
*s the primary cause o' venous ulceration is the &evelopment o' patholo"ical venous hypertension, it is important that the un&erlyin" cause continues to be treate& @see B94/E an& B94,0A4 !ra&uate& compression hosiery applies e=ternal pressure to the s$in an& un&erlyin" tissues 5hich supports the super'icial veins, helpin" to counteract the raise& capillary pressure an& thus re&ucin"
oe&ema4 The re&uction o' oe&ema has been sho5n to be a crucial 'actor in relation to both ulcer healin" an& preventin" 'urther s$in brea$&o5n an& ulceration @%o''att an& O7Hare /002A4
B9413 Which are pre'erre& I above? or belo5?$nee stoc$in"sC
.or most patients either len"th is e8ually e''ective @%o''att an& O7Hare /002A4 Ho5ever, above?$nee stoc$in"s are more appropriate 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$in"s @compression ,2I12 mmH"A are &esirable, a patient 5ith &e=terity problems may be encoura"e& to comply by movin" &o5n to class , @compression /9I,E mmH"A4
B941F Shoul& stoc$in"s be open or close& toeC
This is a 8uestion o' patient pre'erence4 Some patients, especially those 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"sC
%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 mornin" be'ore any oe&ema has accumulate& or imme&iately a'ter the ulcer has heale& an& the compression ban&a"e has been remove&4 %ost patients 5ill 'it into the stan&ar& siJes available on prescrip? tion but those 5ith very lon" or &isproportionate le"s may re8uire ma&e?to?measure stoc$in"s4 I' both le"s re8uire a stoc$in" they shoul& be measure& separately4 The measurements re8uire& are sho5n in .i"ure 9414 %anu'acturers su""est that stoc$in"s shoul& be rene5e& every 3 months4 The limb shoul& be measure& on each occasion that a
@CA
@#A
@*A
@EA
@DA
)i-ure 9<3 %easurements to be ta$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 $eep the patient in compression ban&a"es 'or 1IE 5ee$s a'ter healin" to limit the possi? bility o' &ama"e to ne5ly 'orme& 'ra"ile s$in4
B9410 There are &i''erent classes o' compression hosiery4 What are their usesC
Compression hosiery 'alls into three classes4 D D D Class /< "ives /EI/F mmH" pressure at the an$le4 They are recommen&e& 'or varicose veins an& mil& oe&ema4 Class ,< "ives /9I,1 mmH" pressure at the an$le4 They are recommen&e& 'or mo&erate?to?severe varicose veins an& preven? tion o' ulcer reoccurrence4 Class 1< "ives ,2I12 mmH" pressure at the an$le4 They are recommen&e& 'or "ross varices, postphlebitic le"s, recurrent ulceration an& lymphoe&ema4
* class 1 stoc$in" is the best choice 'or patients 5ith repeate& episo&es o' ulceration an& consi&erable venous &isease but they are &i''icult to put on, particularly 'or el&erly patients4 !enerally a class , stoc$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$in"s may prove easier to put on @this 5ill "ive "reater pressure than a class , overallA4
B94E- *re there any tips 'or easier application o' hosieryC
Some ai&s are available to assist 5ith application such as the Valet @%e&iA but these are not available on prescription an& have to be purchase& 'rom a pharmacy4 atients may 'in& application easier i' they &ust their le" li"htly 5ith a simple non?per'ume& talcum po5&er be'ore application to ma$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$in" is in place4
B94E/ *re there any haJar&s associate& 5ith the use o' compression stoc$in"sC
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'ormity4 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$in" that has a cotton layer ne=t to the le"4
B94E, Ho5 can patients be prevente& 'rom inter'erin" 5ith their ulcers, thus &elayin" healin"C
%uch has been 5ritten about the >social ulcer7 but the actual number o' patients 5ho inter'ere 5ith their ulcer in an attempt to &elay healin" is un$no5n4 Some patients may inter'ere 5ith their ban&a"es 'or a "oo& reason, e4"4< D The compression ban&a"e may have been applie& unevenly up the le", causin" ri&"es in the s$in that are pain'ul4 D The ban&a"e may have been applie& too ti"htly, causin" pain4 D I' the ban&a"e has slippe&, it may 'eel uncom'ortable or 'orm a ti"ht ban&, causin" s5ellin" over the top4 D The patient may have problems "ettin" shoes an& soc$s on 5ith? out &isturbin" the ban&a"e4 D I' the le" is itchy, the patient may be usin" somethin" li$e a $nit? tin" nee&le to scratch the itch4 *ll o' these issues shoul& be consi&ere& be'ore suspectin" the patient o' inter'erin" to intentionally &elay healin"4 I' this is in 'act the problem, it nee&s to be &ealt 5ith "ently4 %any o' these patients are el&erly an& lonely, an& en6oy social contact 5ith the nurse4 One 5ay o' ensurin" contact is to hol& >5ell ulcer7 clinics @see B94E1A4
B94E1 What is a >5ell ulcer7 clinicC
These clinics have been sho5n to re&uce recurrence rates @%orison an& %o''at /00EA4 They can be use& to reiterate a&vice @see B94,9A4 Support stoc$in"s can be chec$e& an& rene5e& i' necessary @see B9419A4 The le"s can be chec$e& 'or s$in con&ition an& any $noc$s the patient may not have notice&4 *ppropriate treatment can be commence& imme&iately4 The 'ollo5in" three scenarios illustrate a 'e5 o' the aspects o' le" ulcer care4
7ase / st&$y
%rs # 5as an active 5oman in her mi&?E-s 5ho 5or$e& as a school &inner la&y, an& en6oye& activities such as line &ancin"4 T5elve months previously she ha& &evelope& a small le" ulcer an& atten&e& the ! 7s sur"ery4 He prescribe& tulle &ressin"s
an&
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 T E cm an& 5as covere& by appro=imately 2-L slou"h4 .our?layer compres? 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 revie5e&4 The ulcer ha& starte& to re&uce in siJe an& 5as no5 , T 142 cm 5ith about ,2L slou"h4 She also 'elt more com'ortable4 Within another 1 5ee$s the ulcer measure& / T /42 cm an& 5as clean4 .ortunately, , 5ee$s later @school holi&aysA sa5 the ulcer heale&4 She 5as amaJe& at the pro"ress an& happy to 5ear the prescribe& stoc$in"s4 She 5as less happy about the 5aste& year o' treatment4
7ase ( st&$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$e a bloo& sample 'rom %rs ), an& the results sho5e& pernicious anaemia4 *ppropriate treatment 5as commence& by the ! an& a'ter a 'e5 months the ulcer slo5ly starte& to improve4
7ase st&$y
%r . 5as an active 93?year?ol& man4 He live& alone 5ith no help an& each &ay cycle& to the shops or 5or$in" men7s club4 He en6oye& other people7s company an& 5as happy4 He ha& a /,?year history o' bilat? eral venous ulceration about 5hich he seeme& to be unperturbe&4
They appeare& to cause him no &iscom'ort an& althou"h e=tensive they 5ere static, not chan"in" in siJe 'rom month to month4 The ulcers 5ere &resse& three times a 5ee$ by the &istrict nurse4 *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?care 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 inappropriate4 What 5oul& you &oC 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
Summar y
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 three'ol&< to heal the ulcer, to treat the un&erlyin" con&ition an& to prevent reoccurrence4
9,
CHAP*ER :
Pressure sores
ressure ulcers are a common problem4 Inci&ence an& prevalence stu&ies "enerally &emonstrate that bet5een 1L an& /-L o' the population in both hospital an& community settin"s ac8uire a &e"ree o' pressure &ama"e 5hile un&er"oin" care @)an& /00EA, althou"h some estimates put the 'i"ure hi"her4 .inancial costs to the NHS have been estimate& as hi"h as RFF2 million a year @West an& riest? ley /00EA4 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 are 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' R/-- --- 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 @/00EA 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 circumstances4 *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 area care4
9/
9,
B04/

Ho5 is a pressure sore &e'ine&C
The European ressure (lcer *&visory anel /00F @E (* A "ives a 5or$in" &e'inition as<
* pressure ulcer is an area o' localise& &ama"e to the s$in an& un&erlyin" tissue cause& by pressure, shear, 'riction an&Hor a combination o' these4 B04, What is meant by the prevalence an& inci&ence o' pressure ulcersC
It is important to $no5 the rates o' prevalence an& inci&ence as a baseline so that improvements can be monitore&4
.re,alen+ e
Dealey @/001A &e'ines prevalence as >the measurement o' the number o' persons 5ith a speci'ic &isease or con&ition 'rom 5ithin a "iven population, measure& at a particular point in time74 Thus these stu&ies "ive a >snapshot7 o' the situation an& can be use& to &emon? strate the e''ectiveness o' prevention strate"ies an& use& to i&enti'y any a&&itional resources that are re8uire&4 revalence stu&ies &o not &i''erentiate bet5een 5here sores are ac8uire&4
In+i$en+e
Inci&ence is< >the number o' persons &evelopin" a speci'ic &isease or con&ition as a proportion o' the local population, measure& over a perio& o' time7 @Dealey /001A4 Inci&ence stu&ies are more &etaile& an& inclu&e outcomes4 They are more time?consumin" to complete than prevalence stu&ies an& re8uire re"ular &ata collection, an& rely heavily on sta'' motivation4
B041 What are the causes o' pressure ulcersC
The causes o' pressure ulcers can be &ivi&e& into< D intrinsic 'actors @con&itions inherent in the patientA D e=trinsic 'actors @con&itions outsi&e the patientA4
B04E
What are the intrinsic 'actors that cause pressure ulcersC
Intrinsic 'actors that cause pressure ulcers inclu&e the 'ollo5in"<
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 /00EA4
=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 /00EA4
N&trition
%alnutrition is a primary contributin" 'actor an& re&uces the tissue7s ability to 5ithstan& pressure @%a$leburst an& Sie"reen /003A4 It also causes &elaye& healin" @%c)aren /00,G Dealey /00EA @see also B14EIB14FA4 Obese patients can also be malnourishe& @see B04FA4
1e$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 @Torrance /091G Dealey /00EA @see
9E
B04FA4 Some &ru"s such as aperients, &iuretics an& antibiotics may e=acerbate incontinence @Dealey /00EA4
: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 /00EG #an$s /00FA4
Skin +on$ition
Tissue paper s$in can be the result o' a"ein" or the use o' lon"? term hi"h?&ose steroi&s @see B149A4 Oe&ematous s$in can also result in a re&uce& o=y"en supply an& impaire& removal o' 5aste pro&ucts @Torrance /091G Dealey /00EA4
Infe+tion
Systemic in'ection can lea& to pyre=ia, e=cessive s5eatin" an& tissue brea$&o5n @#an$s /00FA @see B/-4/ an& B/-4,A
Smoking
See B1404 Smo$in" can also result in loss o' appetite4

Other fa+tors
These inclu&e pain, state o' consciousness, psycholo"ical 'actors, sociolo"ical 'actors an& 5ho is provi&in" home care @Dealey /00EA4
B042 What are the e=trinsic 'actors that cause pressure ulcersC
E=trinsic 'actors resultin" in patients e=periencin" pressure &ama"e inclu&e pressure, shear an& 'riction4
.ress&r
ressure sores
92
ressure &ama"e usually occurs over the bo&y7s bony prominences4 When pressure is applie& to the s$in 'rom the support sur'ace @i4e4
93
mattress, trolleyA it is transmitte& throu"h to the bones, an& all the tissues in bet5een are compresse& an& the capillary vessels occlu&e& @Collier /000aA4 There is no a"reement as to the len"th o' time local pressure can be e=erte& be'ore tissue &ama"e be"ins, or 5hat pressure is re8uire& to occlu&e the capillary vessels4 The amount o' pressure re8uire& may vary bet5een bo&y parts, &epen&in" on the local bone, muscle an& s$in structure @Collier /000bA4 Capillaries in the s$in run vertical to the sur'ace an& are coile& at their bases, limitin" the ris$ o' occlu? sion, but in subcutaneous tissue the vessels lie in the parallel planes o' the &eep 'ascia, 'ollo5in" the paths o' nerves an& li"aments @see .i"ure /4/A4 This causes them to be vulnerable to &istortion an& occlusion 'rom both e=ternal pressure an& pressure 'rom un&erlyin" bony prominences4 Capillary occlusion results in ischaemic chan"es an& tissue necro? sis at an& aroun& the point o' occlusion 5ithin the subcutaneous tissues4 The vessels in the subcutaneous tissues also "ive rise to the per'orators, 5hich supply the s$in, an& so &eep vessel obstruction is li$ely to result in ischaemia o' both cutaneous an& subcutaneous tissue i' pressure is sustaine& @Collier /000bA4 *s the &ama"e 'rom pressure is transmitte& throu"h to the &eeper tissues, e=ternal pressure ulcers may in&icate that un&erly? in" tissue necrosis is alrea&y establishe&4 This can be seen 5hen an apparently super'icial 5oun& is &Mbri&e& to reveal an un&erlyin" cavity or sinus4
Shearing for+es
These can be &e'ine& as >a mechanical stress that is parallel to a plane o' interest7 @#ennett an& )ee /093A4 I' a hi"h level o' shear is present, &ama"e can be cause& by only hal' the amount o' pressure normally nee&e& to &ama"e tissue4 Shear ulcers occur 5hen the patient7s s$in a&heres to the be& clothes, particularly 5hen in the sittin" position an& the patient be"ins to sli&e &o5n the be&4 The &eep 'ascia moves &o5n5ar&s 5ith the s$eletal structures as a result o' "ravitational 'orces, 5hereas the sacral 'ascia remains attache& to the sacral &ermis4 This stretches the &ermal microcirculation an& unless resolve& avulsion o' the local capillaries an& arterioles occurs, 5hich in turn increases the possibil? ity o' local tissue necrosis @Collier /000bA4
ressure sores
9F
Fri+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$in4 This can occur in a community settin" i' the patient7s carers are also el&erly or in'irm, an& they have &i''iculty li'tin" the patient, or i' care sta'' are ina&e8uately traine&4 .riction &ama"e can also occur as a result o' an ill?'ittin" plaster cast or limb prosthesis4
B043 Ho5 can patients at ris$ o' &evelopin" pressure &ama"e be i&enti'ie&C
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$e8m>moire to carers @.lana"an /001A D Help provi&e 8uanti'iable &ata 'or au&itin" purposes @.lana"an /001A D rovi&e evi&ence that preventiveHtreatment plans are base& on ob6ective criteria an& a speci'ic rationale @.lana"an /001A D *i& the rational allocation o' limite& resources @such as special mattressesA to those most li$ely to bene'it 'rom them @Effe+ti,e 6ealth 7are =&lletin /002A D *ct as case mi= a&6usters to help ma$e sensible comparisons o' pressure sores bet5een units over time @Effe+ti,e 6ealth 7are =&lletin /002A4 The 'irst ris$ assessment scale 5as the Norton ressure Sore Ris$ *ssessment Scale @Norton et al4 /03,A %any mo&i'ications have appeare& since4 Norton is probably one o' the best $no5n an& most 5i&ely use& @#arrett /09FG Davies /00EA but is 'elt by some to be too simplistic4 It is important to choose a scale that is suitable 'or your area o' 5or$4 *lthou"h all scales have a research?base& rationale, they 5ere &esi"ne& 'or &i''erent purposes an& settin"s4 Norton7s scale 5as &esi"ne& speci'ically 'or use 5ith the ol&er person4 Some &i''erences are
99
sho5n in Tables 04/ an& 04,4
ressure sores
*ab,e :<1 The Norton ScoreV hysical state !oo& .air oor Very ba& %obility .ull Sli"htly limite& Very limite& Immobile E 1 , / E 1 , / %ental state *lert *pathetic Con'use& Stuporous Incontinence None Occasional (sually urine Double E 1 , / E 1 , / *ctivity *mbulant Wal$s 5ith help Chairboun& #e&boun& E 1 , /
90
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' W/E in&icates vulnerability to pressure sores4 * score o' W/, is hi"h ris$4 *ab,e :<2 assessment Ris$ 'actor %obility *ctivity Nutritional status %ental status IncontinenceHmoisture !eneral physical con&ition S$in appearance %e&ication .rictionHshear Wei"ht *"e Speci'ic pre&isposin" &isease rolon"e& pressure Comparison o' ris$
Norton H H T H H H T T T T T T T
!osnall H H H H H T H H T T T T T
:noll H H H H H H T T T T T H T
Waterlo5 H T H T H H H H T H H H H
#ra&en H H H H H T T T H T T T T
* comparison o' pressure sore ris$ 'actors use& in various ris$ assessment scales @.lana"an /001A4
The Waterlo5 score, Table 041, is another popular assessment tool, &evelope& in the (: in /09E4 It is more comple= than the Norton score @#irchall /001A, covers a lar"er number o' ris$ 'actors an& "roups patients into three cate"ories o' ris$ status4 It also covers su""estions 'or care "ui&elines4
*ab,e :<3 The Waterlo5 ressure Sore reventionHTreatment olicy4 Repro&uce& 5ith $in& permission o' %rs Ku&y Waterlo5
99
Water,o; Pressure Sore Pre.ention>*reatment Po,i#y

RIN! SCORES IN T*#)E, *DD TOT*)4 SEVER*) SCORES ER C*TE!ORN C*N #E (SED
Bui,d>Wei-+t for Hei-+t *vera"e *bove *vera"e Obese #elo5 *vera"e
V / , 1
Skin *y0e Healthy Tissue aper Dry Oe&ematous Clammy @ TempX A Discoloure& #ro$enHSpot "obi,ity .ully RestlessH.i&"et y *pathetic Restricte& InertHTraction Chairboun& ,-Y Very Hi"h Ris$
V / / / / , 1 V / , 1 E 2
Se/>A-e %ale .emale /EIE0 2-I3E 32IFE F2I99/Y A00etite *vera"e oor N4!4 TubeH.lui&s only N#%H*nore=ic
V / , / , 1 E 2 V / , 1
S0e#ia, Risks *issue "a,nutrition e4"4 Terminal Cache=ia Car&iac .ailure eripheral Vascular Disease *naemia Smo$in" Neuro,o-i#a, %efi#it e4"4 Diabetes, %4S4, CV*, %otorHSensory araple"ia "a=or Sur-ery>*rauma Orthopae&ic #elo5 Waist, Spinal on Table , hours "edi#ation
V V 9 2 2 , / V EI3 V 2 2 V E
Continen#e CompleteHCatheterise& Occasionally Incontinent CathHIncontinent o' .aeces Doubly Incontinent
V / , 1
Score
/-Y * Ris$
/2Y Hi"h Ris$
Remember tissue &ama"e o'ten starts prior to a&mission, in casualty4 * seate& patient is also at ris$4
Cytoto=ics Hi"h Dose steroi&s *nti?In'lammatory
*ssessment< I' the patient 'alls into any o' the ris$ cate"ories then preventative nursin" is re8uire&4 * combination o' "oo& nursin" techni8ues an& preventative ai&s 5ill &e'initely be necessary4
REVENTION< REVENT*TIVE *IDS< Special %attressH#e&< /-Y overlays or specialist 'oam mattresses4 /2Y alternatin" pressure overlays, mattresses an& be& systems4 ,-Y #e& System< .lui&ise&, bea&, lo5 air loss an& alternatin" pressure mattresses4 Note< reventative ai&s cover a 5i&e spectrum o' 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 5ithout some 'orm o' cushionin"4 I' nothin" else is available Z use the patient7s o5n pillo54 /-YE[[ .oam cushion4 /2Y Specialist cell an&Hor 'oam cushion ,-Y Cushion capable o' a&6ustment to suit in&ivi&ual patient4 #e& Clothin"< *voi& plastic &ra5 sheets, inco pa&s an& ti"htly tuc$e& in sheetsHsheet covers, especially 5hen usin" Special? ist be& an& mattress overlay systems4 (se Duvet?plus vapour permeable cover4 N(RSIN! C*RE !eneral< ain Nutrition atient Han&lin"< I .re8uent chan"es o' position, lyin"Hsittin" (se o' pillo5s *ppropriate pain control Hi"h protein, vitamins, minerals Correct li'tin" techni8ue I Hoists I %on$ey ole
W UN% CLASSI)ICA*I N Stirlin" ressure Score severity scale @S SSSA Trans'er Devices atient Com'ort *i&s< Real sheeps$ins Z #e& Cra&le Operatin" Table \\ TheatreH*;E Trolley E cover plus a&e8uate protection4 S$in Care< !eneral Hy"iene, NO rubbin", cover 5ith an appro? priate &ressin" If treatment is re?uired$ first remo.e 0ressure
ressure sores 90
Sta-e 5 Z No clinical evi&ence o' pressure sore 5<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$in 1<1 Z Non?blanchable erythema 5ith increase& local heat 1<2 Z #lueHpurpleHblac$ &iscoloration Z the sore is at least Sta-e 1 @a or bA Sta-e 2 Z artial thic$ness s$in loss or &ama"e 2<1 Z #lister 2<2 Z *brasion 2<3 Z Shallo5 ulcer, no un&erminin" o' a&6acent tissue 2<4 Z *ny o' these 5ith un&erlyin" blueHpurpleHblac$ &iscoloration or in&uration4 The sore is at least Sta-e 2 @a, b or cY& 'or 2<3, Ye 'or 2<4A Sta-e 3 Z .ull?thic$ness s$in loss involvin" &ama"eHnecrosis o' subcuta? neous tissue, not e=ten&in" to un&erlyin" bone ten&on or 6oint capsule 3<1 Z Crater, 5ithout un&erminin" a&6acent tissue 3<2 Z Crater, 5ith un&erminin" o' a&6acent tissue 3<3 Z Sinus, the 'ull e=tent o' 5hich is uncertain 3<4 Z Necrotic tissue mas$in" 'ull e=tent o' &ama"e4 The sore is at least Sta-e 3 @b, YH?e, ', ", Yh 'or 3<4A Sta-e 4 Z .ull?thic$ness loss 5ith e=tensive &estruction an& tissue necrosis e=ten&in" to un&erlyin" bone ten&on or capsule 4<1 Z Visible e=posure o' bone ten&on or capsule 4<2 Z Sinus assesse& as e=ten&in" to same @bYH?e, ', ", h, iA !ui&e to types o' Dressin"sHTreatment a4 Semipermeable membrane '4 *l"inate ropeHribbon b4 Hy&rocolloi& "4 .oam cavity 'iller c4 .oam &ressin" h4 EnJymatic &ebri&ement &4 *l"inate i4 Sur"ical &ebri&ement e4 Hy&ro"el
0-
Ris$ assessment tools shoul& be use& as an a&&ition to clinical 6u&"ement4 The Effe+ti,e 6ealth 7are =&lletin @/002A su""ests that there is little evi&ence that usin" a pressure sore ris$ scale is better than clinical 6u&"ement or that it improves outcomes4 Ho5ever, 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& re"ularly an& 5henever there is a chan"e in his or her con&ition4
B04F Ho5 can pressure sores be prevente&C
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$&o5n4 @see B04E an& B042A *ssess the patient7s ris$ 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 /00,A4 %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 /09,A4 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 most commonly cite& 'actors in the &evelopment o' pressure &ama"e @Closs /001A @see B04EA4 I' the patient is 'ailin" to eat a balance& &iet an&Hor 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
ressure sores
0/
such as .resubin @.reseniusA or Ensure @*bbottA 'or consumption bet5een meals @see B14EIB14FA4 .lui& inta$e shoul& also be moni? tore&4 Inspect hi"h?ris$ areas re"ularly 'or any si"ns o' &ama"e an& &evelop a plan o' mobilityHturnin" 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$in" 'or &ama"e an& reportin" &ama"e strai"ht a5ay4 It may help to have carers7 in'ormation lea'lets available to rein'orce a&vice "iven @see B94,9A4
B049 What shoul& be ta$en into account 5hen selectin" an appropriate support sur'aceC
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$erations
The intrinsic an& e=trinsic ris$ 'actors @see B04E an& B042A nee& to be consi&ere&, an& also issues such as< What is the patient7s ris$ levelC7 an& >Is this e=pecte& to chan"eC Has &ama"e alrea&y occurre&C Does the patient have other re8uirements 'rom a mattress, such as nee&in" a 'irm e&"e to allo5 trans'er out o' be&C *re there any me&ical problems that ma$e certain types o' mattress unsuit? ableC @Clar$ an& .letcher /000A
.ra+ti+al +onsi$erations
Will the mattress 'it on the patient7s e=istin" be&C Consi&er both the 5i&th an& the chan"e in hei"ht4 Does the patient share a &ouble be& 5ith his or her partnerC D Ho5 easy is the support sur'ace to transport an& to set upC
0,
Will sta'' nee& to be traine& to use the e8uipment an& 5ill sta'' be re8uire& to supervise its useC This is particularly important i' it is to be use& in the patient7s home4 D Ho5 shoul& it be cleane& in bet5een patient use an& ho5 much stora"e space &oes it re8uireC Ho5 much maintenance is re8uire& an& 5ho 5ill per'orm thisC D Is the patient 5ithin the correct 5ei"htHhei"ht limit su""este& by the manu'acturerC D Is the mattress acceptable to the patientC @Clar$ an& .letcher /000A
Finan+ial +onsi$erations
.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"er nee& that level o' e8uipment, so that other more nee&y in&ivi&uals can "ain access to itC *re there any hi&&en costs, e4"4 maintenance costs or specialist cleanin"C What 5ill it cost the patient or relatives to run the e8uipment, an& is this acceptable to themC
B040 What type o' support sur'ace shoul& be selecte&C
D D
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 provi&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& mattresses, lo5 air?loss or air?'lui&ise& systems @:enney an& Rithalia /000A4 ressure 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 mattress4
ressure sores
01
Static overlays are the simplest 'orm o' pressure? re&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 area4 There are a number o' static mattresses 5ith pressure?re&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 are &esi"ne& to &istribute pressure evenly un&er the patient4 Consi&era? tion shoul& be "iven to ho5 o'ten the mattress nee&s turnin" to $eep it in "oo& con&ition, an& 5hat type o' 'abric the cover is ma&e o' @Collier /000aA4 Static cushions are available an& shoul& have the same 8ualities as the mattress chosen4 )o5 air?loss systems are available either as be& systems or mattresses an& provi&e pressure re&uction via in&ivi&ual air? 'ille& cells, o'ten "roupe& re"ionally to ma=imise the pressure? re&ucin" e''ect4 *lternatin" pressure sur'aces can be supplie& as overlays or replacement mattresses4 They consist o' a number o' seale& cells in a removable cover, 5hich in'late an& &e'late alternately, thus re&istrib? utin" the pressure over the so't tissues o' the bo&y an& allo5in" reper'usion o' previously supporte& areas @%c)eo& /00FA4 Natural sheeps$ins may re&uce 'riction or shear but &o not re&uce pressure @Collier /000bA4 Synthetic sheeps$ins have been sho5n to be ine''ective an&, i' poorly laun&ere&, to increase inter'ace pressure @)othian an& #arbenal /091A4 Rubber or Sorbo rin"s shoul& never be use& to re&uce pressure, because they actually concentrate pressure on a smaller sur'ace an& may cause ne5 ulcers @)othian an& #arbenal /091A4 Su""estions 'or types o' mattress are &i''icult4 I&eally, all health? care areas shoul& have a local policy that su""ests e8uipment base& on clinical e''ectiveness4 The Effe+ti,e 6ealth 7are =&lletin @/002A states that >most o' the e8uipment available 'or the prevention an& treat? ment o' pressure sores has not been reliably evaluate& an& no ]best buy^ can be recommen&e&74
0E
* "eneral "ui&e coul& be the 'ollo5in"< D !ra&e /H, sore< static overlayHcushion D !ra&e ,H1 sore< alternatin" air5ave overlayHcushion D !ra&e 1HE sore< alternatin" air5ave mattressHcushion4 Ho5ever, a patient 5ith no sore may in&icate a hi"h level o' ris$ 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, reliable 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
CHAP*ER 15
Wound infe#tion
This chapter &iscusses the care o' in'ecte& 5oun&s, ho5 to reco"nise 5oun& in'ection an& ho5 it shoul& be treate&4 The principles o' cross?in'ections an& asepsis are a&&resse& an& the precautions that are necessary to &eal 5ith patients 5ho have %RS*4 .or 'urther in'ormation about in'ection control the rea&er is re'erre& to Du""al, #eaumont an& Ken$inson, Infe+tion 7ontrol! A 6an$book for 7omm&nity N&rses I in this series4
B/-4/ Ho5 is 5oun& in'ection reco"nise&C
In'ecte& tissue 5ithin a 5oun& o'ten has a "reenish appearance4 Routine s5abbin" o' 5oun&s is inappropriate 'or &ia"nosis o' in'ec? tion an& an unnecessary cost @see B/-41A4 It is important to un&er? stan& that 5oun&s may have transient or"anisms present, 5hich s5ab results &etect in small numbers4 These or"anisms are o'ten the usual s$in 'lora an& are not usually re"ar&e& as patho"enic4 %any chronic 5oun&s become colonise& by a variety o' bacteria 5hich may be potentially patho"enic4 Colonisation means that the or"anisms have multiplie& an& are o'ten present in lar"e numbers, althou"h in'ection is not inevitable an& many colonise& 5oun&s heal 5ithout problem4 These micro?or"anisms can, ho5ever, be &isperse& &urin" &ressin" chan"es an& measures shoul& be ta$en to limit this4 Woun& in'ection occurs 5hen colonisin" bacteria reach su''icient numbers to cause &istinct clinical si"ns @Table /-4/A4 I' a 5oun& e=hibits one or more o' these si"ns, it is appropriate to ta$e a 5oun& s5ab4 atients 5ho are immunocompromise&
03
or &iabetic may 'ail to sho5 si"ns o' in'lammation an& si"ns o' clinical in'ection, an& may re8uire a s5ab to be ta$en i' the 5oun& is 'ailin"
02
*ab,e 15<1 Si"ns o' 5oun& in'ection Erythema Oe&ema Increase& e=u&ate O''ensive o&our ain yre=ia @Thompson an& Smith /00EA
to respon& to treatment, even i' the usual clinical si"ns are not present4 Occasionally, other patients may not e=hibit the classic immune response @ le5a /00-A4 I' 5oun&s are 'ailin" to respon& to treatment, it is 5orth consi&erin" the 'ollo5in" seven other criteria @Table /-4,A that may in&icate in'ection, su""este& by Cuttin" an& Har&in" @/00EA4
*ab,e 15<2 Other in&ications o' 5oun& in'ection Delaye& healin" Discoloration .riable "ranulation tissue 5hich blee&s easily (ne=pecte& ten&erness oc$etin" at the base o' the 5oun& #ri&"in" o' so't tissue an& epithelium Woun& brea$&o5n @Cuttin" an& Har&in" /00EA
B/-4, What 'actors increase the chances o' 5oun& in'ection occurrin"C
The chance o' 5oun& in'ection 5ill increase 5ith the len"th o' hospital stay, 5ith very youn" an& very el&erly patients bein" more prone to in'ection, plus patients 5ho are immunosuppresse&, have &iabetes @see B94/9A or are malnourishe& @see B14EA, an& 5here the patient inter'eres 5ith their 5oun&4 The 'ollo5in" t5o scenarios illustrate this4
7ase 0 st&$y
%rs K 5as an articulate an& 5ell?&resse& 5oman o' 3- 5ho ha& sel'? care& 'or her le" ulcer 'or several years be'ore she 5as re'erre& to the
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$4 Initially the ulcer respon&e& 5ell an& 5as re&ucin" in siJe4 *'ter a 'e5 5ee$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$4 The ulcer a"ain starte& to pro"ress an& 'inally 5ent on to heal4
7ase 2 st&$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& $ept "ettin" in'ecte&4 This situation 5as not helpe& by copious amounts o' 'armyar& manure4 His con&ition 5as startin" to limit his mobility an& his ability to ta$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 $ept &isturbin" the ban&a"es 5hich 5ere 'ilthy 5ith manure4 * 'our?layer ban&a"e ha& been consi&ere& but, 5ith the amount o' e=u&ate an& the necessity 'or the Wellin"ton boot, &ismisse&4 *'ter a 6oint consultation o' the vascular specialist, tissue viability nurse, &istrict nurse, %r H an& his sister, it 5as a"ree& that the prior? ities 5ere to re&uce the amount o' in'ection an& thereby the e=u&ate, an& to achieve a "oo& level o' compression4 .our?layer ban&a"in" 5as commence&, %r H7s sister purchase& a lar"er Wellin"ton boot
09
an& cut it &o5n to hal' le" len"th to ai& easier application an& removal, an& a pop soc$ 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$4 %r H7s le"s improve& &ramatically, the e=u&ate &ecrease&, the ban&a"es staye& in place an& the 'armyar& manure &i& not pene? trate the layers o' ban&a"e, an& so the in'ections subsi&e&4 His mobility returne&4 *'ter 3 months o' treatment, the le" 5as heale& an& %r H continue& to run his 'arm4
B/-41 Is there a recommen&e& metho& o' ta$in" a 5oun& s5abC
There is some controversy over the best metho& o' per'ormin" a 5oun& s5ab4 The metho& &escribe& by Cooper an& )a5rence @/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/-4E Ho5 shoul& in'ecte& 5oun&s be treate&C
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&C
Cellulitis is an acute, rapi&ly s5ellin" in'lammation o' the s$in an& so't tissues @!rey /009A4 It is characterise& by s5ellin", pain, erythema an& heat, an& sometimes 'ever4 These si"ns are usually con'ine& to the area aroun& the 5oun&, but in some severe cases it may be accompanie& by 'eatures o' systemic to=icity, inclu&in" septi? caemia4 It o'ten occurs a'ter minor brea$s in the s$in, lacerations, sur"ical 5oun&s an& ulcers4 The t5o main causative or"anisms are Staphylo+o++&s a&re&s an& Strepto+o++&s pyogenes @!rey /009A4 Streptococcal in'ection ten&s to be associate& 5ith small brea$s in the s$in an& staphylococcal in'ections 5ith lar"er 5oun&s such as ulcers4
Woun& in'ection
00
I&enti'ication o' the causative or"anism is o'ten &i''icult, 5ith tests such as 5oun& s5abs an& bloo& cultures "ivin" poor results4 Dia"nosis an& treatment ten& to be empirical an& base& on the bacteriolo"y o' the associate& 5oun&4 Ho5ever, culture o' any tissue 'lui& or pus shoul& be attempte&4 #loo& shoul& be ta$en i' there are 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 limb4 Treatment is normally a systemic antibiotic @%orison an& %o''att /00EAG in'ection present 5ithin the tissues cannot be reache& by applyin" topical a"ents @see B/-4EA4
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'ectionC
E''ective han& 5ashin" is the most important 'actor in re&ucin" cross? in'ection @ ar$er /000A4 *lthou"h this is routinely ac$no5le&"e&, a constant application o' this practice still &oes not e=ist4 %icro? 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 vary 'rom person to person4 They "enerally are not virulent an& rarely cause the person harm4 Ho5ever, i' trans'erre& to &eeper structures 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 5ill remove them4 Han&s shoul& be 5ashe& as 'ollo5s< /4 Rub palm to palm ,4 Rub bac$s o' both han&s
/-
14 Rub palms a"ain 5ith 'in"ers interlace& E4 Rub bac$s o' interlace& 'in"ers 24 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 /-I/2 secon&s 5ith either soap or an antisep? tic, 5hereas 'or minor sur"ery 5ashin" shoul& be ,I2 minutes4 Other points to consi&er are< /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&5ash a"ent4 E4 (se only non?ionic han&creamG &o not use communal 6ars4 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"ents4 F4 I' han&s sho5 si"ns o' irritation "et me&ical a&vice @ ar$er /000A4
B/-4F What is %RS*C
%RS* stan&s 'or methicillin @or multiA?resistant Staphylo+o++&s a&re&s4 Staphylo+o++&s a&re&s is a bacteria carrie& by ,-IE-L o' the population 5ith no ill e''ects @Weaver /003AG it colonises the s$in, nasal passa"es an& mouth4 Wi&esprea& use o' antibiotics has le& to an emer"ence o' resistant strains4 %RS* is resistant to penicillin, important anti? staphylococcal a"ents such as 'luclo=icillin, cephalosporins an& other relate& antibiotics4 I' a patient has a severe clinical in'ection o' %RS*, he or she
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
Woun& in'ection
/-/
/,

B/-49 What s5abs shoul& be ta$en to screen 'or %RS*C
S5abs shoul& be pre?moistene& 5ith sterile saline in or&er to collect more bacteria4 The 'ollo5in" sites are recommen&e&< D E=ternal nares @nostrilsA D *=illa an& "roin D *ny 5oun&s D Sputum @i' the patient has a pro&uctive cou"hA D The 5oun& itsel' D I' the patient has a catheter, a urine specimen4 * patient is clear 5hen three sets o' s5abs at 5ee$ly intervals are ne"ative a'ter any treatment is terminate&4
B/-40 Ho5 shoul& a patient 5ho is a carrier o' %RS* be treate&C
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$in 5ith a 5ash cloth an& rinse o''4 I' the a=illa an& "roin are colonise&, he=a? chlorophene po5&er shoul& be applie&4 Hair shoul& be 5ashe& &aily an& on the 'irst an& thir& &ay o' treatment 5ashe& 5ith an antiseptic &eter"ent4 *'ter bathin" the patient shoul& put on clean clothes4 #e& linen shoul& be chan"e& as 're8uently as possible4 )aun&ry can "o on a normal 5ash pre'erably at 3-PC4 I' the e=ternal nares are colonise&, mupirocin ointment is applie& three times a &ay 'or F &ays4 The patient poses no ris$ 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$e the patient 'eel isolate&4 It is recommen&e& that antiseptic han& 5ashin" is bene'i? cial only i' there is prolon"e& contact or &irty materials such as &ress? in"s have been han&le&4 This is not the case 'or visitin" nurses or home helps 5ho may be in contact 5ith other at?ris$ in&ivi&uals a'ter5ar&s @see B/-4/-A4 The patient can continue 5ith normal social activities4 There are no restrictions on usin" public transport4 I' the patient nee&s to "o to outpatients, ambulance control shoul& be in'orme&, as
Woun& in'ection
shoul& the
/-1
/E
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 $eep the environment as clean as possible, especially &ust control4 *ny home carersHhome helps shoul& be e&ucate& in "oo& han&? 5ashin" techni8ues an& have &isposable "loves an& aprons available4 I' the patient has e8uipment on loan such as mattresses or commo&es, the loan centre shoul& be in'orme& be'ore the return o' any e8uipment4
B/-4/- What precautions shoul& the &istrict nurse ta$eC
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 /003A4 atients 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 areas4
B/-4// What precautions shoul& be ta$en in the ! sur"ery 'or a patient 5ith %RS* in'ectionC
atients 5ho are %RS* positive or a5aitin" s5ab results shoul& have their &ressin"s atten&e& to at the en& o' the &ay7s sur"ery4 The 5oun& shoul& be cleane& 5ith a chlorhe=i&ine?base& solution4 I' the patient has 'la$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$5orth /00-A4
Woun& in'ection
/-2
Han&s shoul& be 5ashe& 5ith an antiseptic chlorhe=i&ine a"ent or 5ith an alcohol rub, an& &rie& on &isposable paper to5els4 *ny open cuts shoul& be covere& 5ith a 5aterproo' plaster4 *ll soile& &ressin"s shoul& be ba""e& an& seale& in in'ecte& 5aste ba"s an& sent 'or incineration, in line 5ith your local in'ection control policyG contact your local in'ection control nurse 'or a&vice4
B/-4/, *re there any speci'ic "ui&elines 'or nursin"Hresi&ential homesC
atients shoul& be care& 'or in a sin"le room an& a5ay 'rom other patients 5ith open 5oun&s or brea$s in the s$in @Wolverhampton Health Care Control o' In'ection Committee /002A4 Ensuite han&? 5ashin" 'acilities shoul& be available i' possible an& an antiseptic han& 5ash available4 The patient7s personal clothin" an& be& linen shoul& be care& 'or as in'ecte& in accor&ance 5ith the home7s policy4 Contact your local in'ection control &epartment to see i' there is a speci'ic >Nursin" Home7 policy4 !eneral cleanin" 5ith a "eneral purpose &eter"ent is satis'actory4 Damp &ustin" is recommen&e&4
B/-4/1 What is the recommen&e& mana"ement 'or 5oun&s colonise& 5ith %RS*C
Topical antibiotics are o'ten a&vocate& 'or the treatment o' %RS*4 There is, ho5ever, concern about the e''icacy i' they are applie& in're8uently or over a lar"e area @Weaver /003A @see B/-4EA4 T5o antibiotics are recommen&e& an& treatment shoul& be no lon"er than FI/E &ays4 %upirocin can be applie& to shallo5 5oun&s no lar"er than 1 cm in &iameter4 .usi&ic aci& is a "oo& anti? staphylococcal a"ent but, i' use& alone or over a lar"e area, resis? tance may occur4 It may be use'ul in combination 5ith oral trimethoprim 'or /- &ays4 *'ter the antibiotics have stoppe&, the 5oun& shoul& be treate& accor&in" to its clinical appearance, e4"4 slou"hy, necrotic, etc4 T5o &ays a'ter antibiotic therapy has stoppe&, repeat 5oun& s5abs shoul& be ta$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
/3

B/-4/E Do sta'' nee& to be screene& 'or %RS*C
%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$, nor are their 'amilies4 #ecomin" a carrier o' %RS* is no re'lection on an in&ivi&? ual7s personal hy"iene4 I' in'ection control precautions are ta$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 carriers @Wolverhampton Health Care Control o' In'ection Committee /002A4 I' sta'' &o become carriers they can easily be treate& 5ith anti? 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$4
Summar y
Routine s5abbin" is ine''ective an& an unnecessary 5aste o' money4 It important to reco"nise si"ns o' in'ection4 Woun& in'ection shoul& be treate& systemically4 #e a5are o' the principles o' cross?in'ection an& asepsis4 *lso be a5are o' necessary precautions i' the patient has %RS*4
CHAP*ER 11
"is#e,,aneou s
This chapter &eals 5ith other 're8uently as$e& 8uestions that &o not 'it into any o' the other chapters in the boo$4 These inclu&e care o' 'un"atin" 5oun&s, &ressin" &i''icult areas, maceration an& the use o' ma""ots @larval therapyA4
B//4/ What is a 'un"atin" 5oun&C
.un"atin" &escribes a con&ition o' ulceration an& proli'eration that arises 5hen mali"nant tumour cells in'iltrate an& ero&e throu"h the s$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 'ormation4 .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, $i&ney, ovary, colon an& bla&&er may also in'iltrate in this 5ay @%ortimer /001A4 Tissue hypo=ia in a 'un"atin" 5oun& is a si"ni'icant problem lea&in" to a loss o' tissue viability4 *naerobic an& aerobic bacteria thrive in these con&itions an& are the cause o' the associate& malo&our an& pro'use e=u&ate @!roscott /002A4 In a&&ition, the capillaries o' tumours are 'ra"ile an& pre&ispose the tissue to blee&? in"4 Tumour "ro5th results in 5oun&s that are continually enlar"in", irre"ular in shape, necrotic an& e=u&in"4 Woun& mana"ement is comple= an& involves mana"in" o&our @see B,43A, e=u&ate @see B24,A, blee&in" @see B//4,A an& pain control @see B,4FIB,40A4
/-3
Woun& Care< * Han&boo$ 'or Community Nurses /-2
B//4, Ho5 can blee&in" in 'ra"ile 'un"atin" 5oun&s be controlle&C
Capillary blee&in" can occur 'or a number o' reasons4 *s tumours enlar"e the bloo& vessels become ero&e& an& bloo& loss can cause anaemia @Dealey /00EA4 Inappropriate removal o' a &ressin" causes clots to loosen4 *l"inates have haemostatic properties that are valu? able in the control o' blee&in" @see B240A4 The concentration o' calcium ions in the al"inate 'acilitates the e=chan"e 5ith so&ium ions in the 5oun& e=u&ate, activatin" the clottin" mechanism an& 'orm? in" a viscous "el4 *l"inate &ressin"s can be remove& 5ith "entle irri? "ation, 'urther re&ucin" capillary trauma4 To control pro'use blee&in", occasionally cautery or oral anti? 'ibrinolytic a"ents are use& @Thomas an& Vo5&en /009A4 Topical a&renaline shoul& only ever be use& 5ith caution an& un&er me&ical supervision @Dealey /00EA4 Em'lor"o @/009A a&vocates mi=in" sucral? 'ate 5ith a 5ater?soluble "el an& applyin" this as a primary &ressin" covere& by a lo5 a&herent &ressin"4
B//41 Can aromatherapy oils be use& in the treatment o' chronic 5oun&sC
In recent years interest in complementary therapies has been increasin" in both the "eneral public an& health?care 5or$ers4 Oils speci'ically mentione& in relation to topical application to assist 5oun& healin" are tea tree oil an& laven&er oil4 Ho5ever, it is an area that nee&s 'urther research, because most currently available evi&ence is anec&otal @*s8uith /000A4 It shoul& be remembere& that, althou"h the practice o' aromatherapy has many bene'its, essential oils are po5er'ul chemi? cals 5ith ris$s attache& to their use, an& they shoul& be use& only by a 8uali'ie& aromatherapist @*s8uith /000A4 I' they are to be use& as a >topical me&ication7, they shoul& really be pharmacolo"ically teste& as any other topical me&ication 5oul& be4
B//4E Some 5oun&s such as those on 'in"ers or elbo5s can be &i''icult to &ress4 *ny tips 'or applicationC
*reas that commonly cause &i''iculties inclu&e areas over 6oints 5here there is a problem retainin" mobility 5ithout loss o' inte"rity o' the &ressin", especially &i"its 5here it can be &i''icult to apply an& retain a &ressin" 5hile allo5in" normal 'unctionin",
/-3
an& heels 5here
%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 to secure 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 $nee can restrict mobility because the &ressin" &oes not stretch or it is bul$y4 Cuttin" a thin hy&rocolloi& or 'ilm an& applyin" it in sli"htly overlappin" 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$y pa&&in" is re8uire&4
B//42 What causes s$in macerationC
%aceration is cause& by prolon"e& e=posure to 'lui& that remains in contact 5ith the s$in4 This may be 5oun& e=u&ate, urine or s5eat4 It may cause &eterioration in the 5oun& an& also lea& to s$in brea$? &o5n4 The bo&y7s normal 5oun&?healin" response o' in'lammation causes local oe&ema, 5hich seeps 'rom the 5oun& sur'ace @see B/49A4 The e=u&ate 'rom acute an& chronic 5oun&s has &i''erent constituents @Cuttin" /000A4 The e=u&ate 'rom chronic 5oun&s contains proteases, 5hich brea$ &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 /03,A @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 B24,A4 Occlusive &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
/-9
&ressin"s are very absorbent an& can be covere& 5ith absorbent pa&s @see B240 an& B24/EA4 E=u&ate 'rom venous ulcers can be controlle& 5ith compression therapy an& elevation 5hen clinically in&icate& @Cuttin" /000A @see B94,0A4 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 Oinc 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/-4,A4
B//43 What is meant by over"ranulation an& ho5 shoul& I treat itC
Over"ranulation, or hyper"ranulation as it is sometimes calle&, is "ranulation tissue that rises above the e&"es o' the 5oun&4 E=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 -4,2L compress or as a silver nitrate stic$ is also sometimes use& @%or"an /00FA4
*+e use t+era0y of ma--ots: ,ar.a,
B//4F *re ma""ots available only 'or treatin" 5oun&s in hospitalC
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 larvaeC
%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 B,4/- an& B,4// an& Tables /-4/ an& /-4,A4
%iscellaneous
B//40 Ho5 are the ma""ots applie& to the 5oun&C
/-0
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 /- larvaeHcm, @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 &ampene& 5ith physiolo"ical saline is place& over this to $eep the ma""ots hy&rate&4 *ny pa&&in" can then be applie& to contain e=u&ate an& li8ue'ie& necrotic tissue4 The ma""ots shoul& be chan"e& every 1IE &ays4
B//4/- Ho5 shoul& ma""ots be remove& an& &ispose& o'C
When the soile& &ressin"s are remove& the larvae either 'all o'' or can be 'lushe& o'' the 5oun& sur'ace 5ith saline4 Dressin"s shoul& be place& in a yello5 ba", seale& securely an& sent 'or incineration4
B//4// Is there any ris$ o' ma""ots turnin" into 'liesC
* ne5ly hatche& larvae ta$es FI/E &ays to complete its li'e cycle an& turn into a 'ly4 *s &ressin"s are chan"e& every 1IE &ays they 5ill be remove& 'rom the 5oun& 5ell be'ore they pupate an& turn into a 'ly4
B//4/, Can the patient 'eel the ma""ots movin" on the 5oun& or eatin" the &ea& tissueC
%ost patients cannot 'eel the ma""ots on the 5oun&4 I' they are on intact s$in they may tic$le but surroun&in" the 5oun& 5ith hy&ro? colloi& eliminates this4 The ma6ority o' patients receivin" larval therapy report a re&uc? tion in 5oun&?relate& pain @Thomas et al4 /003A, althou"h a 'e5 report an increase in pain @see B,4FIB,40A4 The sterile larvae supplie& &o not burro5 into healthy tissue4
Informatio n
B//4/1 *re there any sources o' in'ormation about 5oun& care on the internetC
There are many sources o' in'ormation about 5oun& care on the
//-
internet4 !eneral search en"ines can be use& as 5ell as tools to assist
%iscellaneous
///
in locatin" me&ical in'ormation an& &irect access uni'orm resource locators @(R)sA to appropriate sites4 This is becomin" an increasin"ly popular 5ay o' searchin" the literature4 In'ormation is accessible 5orl&5i&e at any time an& to anyone 5ith the appropriate technolo"y4 It is a rich e&ucational source 5hich can assist e&ucational &evelopmentG it also "ives an e? mail lin$ 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 /1EI24
Summar y
.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
//,
CHAP*ER 12
C,ini#a, effe#ti.eness
Clinical e''ectiveness is about ensurin" that 5e provi&e the best possible care, in the ri"ht environment, at the optimum time, an& in a sensitive an& e''ective manner4 It brin"s to"ether patients7 5ants an& nee&s, 5ith the nurses7 e=pertise 'rom trainin" an& e=perience, an& the best available research evi&ence to provi&e the hi"hest 8ual? ity patient care4 This chapter e=plores both 5hat clinical e''ectiveness is, an& the s$ills an& processes involve&4 Sources o' evi&ence an& in'ormation, an& their use in every&ay practice, are &iscusse&4 *pproaches are &ra5n not only 'rom research evi&ence, but also 'rom patients7 vie5s an& e=periences at both in&ivi&ual an& "roup levels4 * variety o' tools is &iscusse&, inclu&in" clinical au&it, patient intervie5s, 'ocus "roups, re'lective practice an& critical inci&ents or si"ni'icant event analysis4 These tools can help the nurse be con'i&ent o' provi&in" the best possible service, an& can "ive the satis'action o' continuously maintainin" an& &evelopin" her or his s$ills4
B/,4/ Ho5 can the nurse ensure that the best possible care is provi&e& 'or the patientC
There is a variety o' techni8ues that can be use&G these are e=amine& in a little more &epth4 Tools an& resources that you can access inclu&e clinical au&it an& e''ectiveness, comments an& complaints, investi"atin" patient e=periences, critical inci&ence analysis an& re'lective practice4 This chapter e=plores these tools, an& ho5 they can be use& to provi&e clinically e''ective an& patient?'rien&ly care4
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B/,4, What is clinical e''ectivenessC
Clinical e''ectiveness or evi&ence?base& health care is an approach to practice that helps you to consi&er 5hether you are provi&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 Nou may 'eel that you currently &o not possess all o' the s$ills that are involve& in the process, an& i' this is the case &o not 5orry, 5e all have a lot to learn4 There are lots o' people 5ho can len& their s$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 $ey people are to contact 'or help in &evelopin" your e=pertise in this area4 Nou mi"ht 'in& it help'ul to raise any trainin" nee&s that you i&enti'y at your ne=t per'ormance revie5 meetin"4
In'ormation nee&
Evaluate *ns5erable per'ormance 8uestion *TIENT Select an& implement chosen option evaluate evi&ence I vali&ity, use'ulness )i-ure 12<1 The clinical e''ectiveness process4 B/,41 What in'ormation is nee&e&C HE*)TH C*RE TE*% Search 'or evi&ence *ppraise an&
This 8uestion is really as$in" about 5here the "aps in the mana"e? ment o' your patients are4 Each patient is uni8ue an& may come 5ith
Clinical e''ectiveness
//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 this 5oun&C D Ho5 lon" 5ill it ta$e to healC D Woul& physiotherapy helpC D Ho5 can I stop another ulcer &evelopin"C Once you start thin$in" about issues re"ar&in" all your &i''erent 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' care4
B/,4E What &oes it mean to as$ an ans5erable 8uestionC
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 the 8ues? 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 that intervention4 D In&ications o' the outcomes o' interest4 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
//E
Nou 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
//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 Nour 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 Nou have recently &evelope& several concerns about this4 Nou have rea& that "enerally people only remember /-L o' 5hat they have been tol& &urin" consultations an& are particularly 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 Nou have there'ore &eci&e& to revie5 the 5ay you provi&e in'ormation to your patients4
The ?&estion
Element atient or problem Intervention or test material ossible alternatives Outcome@sA o' interest E=ample eople 5ith 5oun&s 5ho &o not spea$ En"lish as their 'irst lan"ua"e Simple verbal e=planation supporte& by 5ritten @possibly in relevant lan"ua"esA Cassettes an& vi&eo tapes in relevant lan"ua"es, accessin" interpretation services (n&erstan&in" an& retention o' in'ormation, compliance 5ith recommen&ations, increase& healin" rates 'or 5oun&s
Nour 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 healC
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B/,42 Ho5 &o I search 'or evi&enceC
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"itimate action 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$s can become rapi&ly out o' &ate, an& in some areas o' me&icine it is estimate& that the te=t? boo$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 practice in the "iven area4 This is $no5n as a systematic revie5 or meta? analysis4 These can be use& to pro&uce "ui&elines on best practice4 *n e=ample o' this is the Effe+ti,e 6ealth 7are =&lletins pro&uce& by the Centre 'or Revie5s an& Dissemi? nation at Nor$ (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 are %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"
//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'ormation is via the internet4 One o' the issues raise& by the case stu&y on provi&? 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&enceC
Clinical appraisal is a techni8ue to assist you in revie5in" research to ensure that the results are vali&, believable, impressive an& applica? ble4 Chec$lists have been pro&uce& 'or &i''erent types o' research such as 8ualitative trials comparin" &i''erent interventions @ran&omise& controlle& trials or RCTsA, trials loo$in" at the pattern 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$ills ro"rammeA4 The clini? cal "overnance lea& o' your primary care "roup or trust shoul& be able to arran"e 'or you to have some trainin" on this either throu"h local trainin" initiatives or CD RO%?base& learnin" pac$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 $no5 5hether or not it has ha& the &esire& e''ectC
This is 5here the ne=t sta"e o' the clinical e''ectiveness process comes in as you can start to thin$ about evaluatin" your per'ormance, re'lectin" on 5hat has 5or$e& 5ell an& 5hat nee&s to be chan"e& to be even more e''ective4 Tools that can be use'ul in this process inclu&e clinical au&it, patient participation an&
//9
re'lective practice4
B/,49 What is clinical au&itC
//0
Clinical au&it is a tool to help you re'lect on your clinical practice an& to evaluate the e''ectiveness o' the care that you provi&e @.i"ure /,4,A4 *s in the clinical e''ectiveness process you nee& to i&enti'y the area or issue o' concern an& see$ to i&enti'y 5hat current best prac? tice is in this area4 Nou use this to set stan&ar&s 'or the care process4 .or 5oun& care these coul& inclu&e< *ll patients presentin" 5ith le" ulcers have a thorou"h assessment 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 care 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 be throu"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 an& repeatin" cycle stan&ar&s
*"ree criteria
*"ree an& collection implement chan"e rules
Set &ata
Re'lect on results
Collect &ata
/,-
)i-ure 12<2 The clinical au&it cycle4
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in'ormation over a limite& time scale4 Nour 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 Nou 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 result 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$es4 Nou coul& also learn 5hether your han&?5ritin" is li$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 6obs4 I' 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=ceptionally poor or "oo&, but you 5oul& not $no5 5hether the results 'or that patient 5ere abnormal 'or some reason4 #oo$s on statistics provi&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 letters in the alphabet4 This approach is also help'ul 5hen you are $een to revie5 your practice but have only very limite& time to &evote to it4 In such circumstances, provi&in" you are prepare& to ta$e on boar& the results 5hether they are "oo& or ba&, you can le"itimately revie5 smaller numbers o' notes4
/,,
Once you have collecte& your &ata, you nee& to thin$ about compilin" the results an& &evelopin" an action plan4 Nou 5ill proba? bly 'in& that there are some areas 5here you have per'orme& to a very hi"h stan&ar& an& others 5here there is room 'or improvement4 Nou 5ill then nee& to &evelop an action plan to i&enti'y 5hat you are "oin" to &o about the areas o' concern that have been hi"hli"hte&4 This mi"ht inclu&e thin"s that you can &o imme&iately such as ensurin" that you ta$e an& recor& a Doppler rea&in" on a re"ular basis @see B94/,A an& outcomes that 5oul& ta$e lon"er to achieve, such as obtainin" or pro&ucin" appropriate literature on &i''erent sorts o' 5oun&s to provi&e to patients4 I' tas$s cannot be &one imme? &iately, set yoursel' a &ea&line 'or achievin" each area an& put these in your &iary, as 5ell as in your action plan to help ensure that they 5ill happen4 Nou may 'in& thin"s that are out o' your control, such as a nee& 'or &ressin"s that are not available in the primary care "roup @ C!A 'ormulary4 Nou coul& share the results o' the au&it 5ith the practice team to help in'orm the &ebate about resource allocation, to provi&e the best possible care 'or your patient population 5ithin the available resources4 Even 5hen there are no resource implications, it is a "oo& i&ea to share 5hat you have &one 5ith your peers an& collea"ues4 Nou &eserve reco"nition both 'or un&erta$in" the au&it an& 'or the "oo& practice you have i&enti'ie&, an& in reportin" your propose& improvements you are committin" yoursel' to ma$in" chan"e 5here there is room 'or improvement4 The last thin" that you nee& to put on your action plan is your reau&it &ate4 When you have "one throu"h the process an& ma&e some chan"es, you nee& to revie5 your practice a"ain to ensure that the chan"es have ha& the &esire& results an& that the improvements in patient care have been sustaine&4 This may be &one by repeatin" the 5hole au&it, by loo$in" at a smaller number o' cases or by concentratin" on areas 5here problems 5ere i&enti'ie& &urin" the ori"inal survey4 Case note revie5s an& revie5 o' practice?hel& &ata are 6ust a couple o' the 5ays o' re'lectin" on the 8uality o' the care that you provi&e4 Nour stan&ar&s may inclu&e some more intan"ible areas o' care such as patients 'eelin" that they have been treate& 5ith &i"nity an& respect, provision o' in'ormation an& the maintenance o' con'i? &entiality, 5hich you cannot measure 'rom 5ritten notes or other
/,1
&ocumentation4 Nou may 'in& you nee& to revie5 the 5aitin" room to see 5hether posters provi&e appropriate an& up?to?&ate in'orma? 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$en ha& more than &ouble& an& in'ection rates ha& increase& but not so &ramatically4 Nurse T realise& that &urin" this time perio& the only real chan"e 5ithin the sur"ery 5as that a ne5 practice nurse ha& starte&4 Re?e=aminin" the 'i"ures in more &etail sho5e& that she 5as s5abbin" all 5oun&s routinely an& that many o' the patients 5ho ha& &evelope& in'ections ha& been treate& more or less e=clusively by this ne5 nurse4 This i&enti'ie& several trainin" nee&s that nurse T 5as able to 'acilitate4 B/,40 What is meant by investi"atin" patient e=periencesC
.or many years patients have been seen as passive recipients o' heath care, but increasin"ly the move is to5ar&s partnership in care, 5here patients have an active role an& responsibility in &ecision?ma$in" an& care mana"ement4 When you are revie5in" the 8uality o' the care you provi&e, one o' the $ey aspects o' this is to re'lect on the patient7s e=periences4 Some in'ormation 5oul& be available 'rom patient complaints an& comments as &iscusse& previously, but i' you
/,E
5ere loo$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 or other surveys, 'ace?to?'ace or phone semi?structure& intervie5s or 'ocus "roups4 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 resultsC
Nou 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$in" a lar"e?scale survey o' everyone 5ho lives in your clinical area 5oul& be very e=pensive in terms o' both time an& resources4 Even be'ore you ha& any results bac$, 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 Nou 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$e the intervie5s, an& ho5 you are "oin" to collate an& use the results4 Other issues that you nee& to consi&er are ethical ones4 There is no point as$in" patients i' they 5oul& pre'er to be treate& in the bac$ room o' the local pub i' you $no5 the lan&lor& is terri'ie& by mention o' all thin"s me&ical an& 'aints at the si"ht o' a stethoscope4 %ore seriously you 5oul& nee& to consi&er the implications o' unmet nee&s or &esires4 Nou may 'eel that "ettin" patients to tal$ 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'ore embar$in" on a patient consultation or participation e=ercise, you nee& to thin$ throu"h 5hat support an& resources you have to compile, &isseminate an& action the results o' your 5or$4 This may inclu&e "ainin" access to computers an& s$ills in mana"in" in'ormation, sprea&sheets an& &atabases4 Nou 5ill re8uire commitment 'rom all the practice sta'' to &iscuss an&
/,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 Nour local Community Health Council @CHCA, an in&epen? &ent or"anisation appointe& to support patient empo5erment 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&C
#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 $no54 Nou mi"ht 5ant to collect statistics on the prevalence o' si&e e''ects, 5hether speci'ic in'ormation 5as provi&e& or on 5hat other health services 5ere accesse& by the patient4 These can be establishe& by as$in" 5hat are re'erre& to as >close& 8uestions7, i4e4 a 8uestion 5ith yesHno or a limite& number o' possible responses4 E=amples inclu&e< D Ho5 o'ten is the &ressin" chan"e& on your 5oun&C D Have you ha& one or more episo&es o' 5oun& in'ectionC D Do you see a hospital consultant about your 5oun&C In research terms these 8uestions provi&e in'ormation that is 8uantitative in natureG it ans5ers the >ho57 8uestions, loo$in" at issues such as >ho5 manyC7, >ho5 o'tenC7 an& >ho5 muchC7 The other sorts o' in'ormation that you are li$ely to 5ant to collect relate to 8ualitative research4 Bualitative research a&&resses the >5hyC7 an& >5hatC7 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 D D What &o you 'eel has been "oo& about the care that you have receive&C What coul& have been &one &i''erently to provi&e better stan? &ar&s o' careC In 5hat 5ays have you ha& to chan"e your li'estyle because o' your le" ulcerC These 8uestions can o'ten be use& to e=plore the statistical &ata
/,3
in a little more &epth, e4"4 you mi"ht 5ish to e=plore 5hat people 'eel
/,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 Nou 5ill proba? bly 'in& that you 5ant a variety o' 8ualitative an& 8uantitative in'or? mation4 In as$in" patients about their e=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" care4
B/,4/, What are the a&vanta"es an& &isa&vanta"es o' un&erta$in" a patient surveyC
atient surveys are "enerally han&e& out to patients or sent to them at home 5ith a 'reepost envelope 'or them to return their responses4 They can be 8uite use'ul 'or 'in&in" out ho5 many people have opinions an& 'eelin"s about particular issues an& are most e''ective 5hen consistin" o' mostly yesHno an& multiple choice ans5ers4 Response rates are improve& i' the 8uestionnaires are relatively short @a ma=imum o' 'our si&es o' *E paper, pre'er? ably t5o si&esA an& are relevant to the people ans5erin" them, e4"4 you are li$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 Nou may nee& to "et the 8uestions an& responses translate& or a&opt alternative approaches to "ainin" patient vie5s4
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B/,4/1Have you any thou"hts about intervie5s an& 'ocus "roupsC
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' ans5ers 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& can help 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 venue o' 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$e tellin" someone that they 5ere not happy 5ith 5hat they &i& an& may 'eel that their 'uture care coul& be pre6u&ice&4 Nou may 'eel that it 5oul& be better to "et someone 5ho is less involve& 5ith &irect patient care to un&erta$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 Nou may choose to put up posters in the 5aitin" 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 Nou may tar"et a particular "roup o' patients an& 5rite invitin" them to participate, e=plainin"
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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 Nou 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$in" 5ithout 'eelin" that they have to reveal too much too soon4 This can inclu&e 8ues? tions such as<
Ho5 lon" have you ha& your le" ulcer an& 5here have you receive& care 'or itC
This then lea&s to more personal 8uestions about 5hat people have 'oun& help'ul about their care an& 5hat coul& have been &one &i''erently4 With a 'ocus "roup the i&ea is to allo5 participants to tal$ amon" themselves, althou"h not to the e=tent that they 'orm splinter "roups, an& 'or them to share their e=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& treatment4 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 Nou shoul& tell people 5hat you are "oin" to &o 5ith their comments an& the results o' the pro6ect, an& ho5 you are "oin" to let them an& other patients $no5 5hat you have &one4 This may inclu&e sen&in" them copies o' any reports an& action plans, plus puttin" up posters in the practice an& invitin" them to the openin" o' any ne5 services that 5ere in part the results o' their comments4
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B/,4/E What else can be &one to ensure that patient vie5s are ta$en on boar&C
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 5e can start to a&&ress policies an& proce? &ures to help ensure that similar &i''iculties &o not arise in the 'uture4 %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$le the issues that are 'ace& at the coal 'ront, a uni8ue set o' circumstances an& con&itions e=perience& at local level4 Rather than thin$ 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 you have &one about them4 Nou may 'in& that the number o' complaints receive& by the practice actually re&uce as patients can share their concerns be'ore they reach 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$s4
B/,4/2 What is re'lective practice an& critical inci&ent analysisC
Re'lective practice an& critical inci&ent analysis are techni8ues that can help the in&ivi&ual re'lect on the care receive& by in&ivi&ual
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patients4 Critical inci&ence analysis o'ten ta$es place 5ithin multi&is? ciplinary "roups o' sta'' 5hen particular patients 5ho ha& e=cep? 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$in" 5hat happene& to an in&ivi&ual patient, you may be able to i&enti'y &elays in treatment, problems 5ith communication an& possible trainin" nee&s4 The aim o' such "roups is not to be 6u&"emental but to encoura"e on"oin" learnin" in all members o' the team on a permanent basis4 It is also use'ul to un&erta$e re'lective practice as an in&ivi&ual practitioner by thin$in" about 5hat has happene& to a particular patient4 Nou shoul& be able to i&enti'y 5hat 5or$e& 5ell an& 5here 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 patientC D What 5as your role in the patient7s careC D What happene& that you e=pecte& to happenC D What happene& that you &i& not pre&ictC D Ho5 &o you 'eel about 5hat happene&C D Ho5 &o you 'eel about your role in 5hat happene&C D What &o you thin$ coul& have been &one &i''erentlyC D What have you learnt 'rom 5hat happene&C D What mi"ht you &o i' a similar situation arose a"ainC D What are the pros an& cons o' &i''erent optionsC D What outcomes 5oul& you loo$ 'orC 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$in"
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'ee&bac$ 'rom collea"ues about their perceptions o' the same inci&ents an& to inte? "rate on? an& o''?site learnin" an& trainin" nee&s4
B/,4/3 There seems to be so much to &o in evaluatin" the care provi&e& to the patients4 Where &o I startC
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Don7t 'eel that you have to &o everythin" all o' the time4 It is proba? bly a "oo& i&ea to 'ocus on a particular area o' care such as the mana"ement o' le" ulcers4 Then "et hol& o' the Effe+ti,e 6ealth 7are =&lletin an& any other evi&ence you can 'in& an& au&it a 'e5 sets o' case notes to see ho5 you are &oin"4 Deci&e on ho5 you are "oin" to approach a 'e5 patients to see ho5 they 'eel about the care you provi&e4 Kust as you re'lect on the care you have provi&e& to in&ivi&? ual patients, re'lect on 5hat 5or$s an& 5hat &oesn7t in evaluatin" care4 Nou may 'in& that no one respon&s to a comments bo= or that people &on7t li$e comin" out at ni"ht to atten& a 'ocus "roup4 In that case you may nee& to try alternative approaches, such as intervie5s at home or securin" a tape?recor&er in the 5aitin" room so that people can leave their vie5s as soun& bites4 Remember this process is not meant to be threatenin"G &on7t 6ust 'ocus on the ne"ative4 Ta$e time to en6oy an& re'lect on the positive comments an& compliments that you have receive&4 These tools can help you to &o an even better 6ob an& to "ive you the satis'action o' on"oin" &evelopment an& re'inement o' your o5n s$ills an& ability4
Summar y
#y &evelopin" your s$ills in evi&ence?base& health care you can help to ensure that you are provi&in" up?to?&ate an& e''ective care 'or your patients4 Clinical au&it is a tool to help you revie5 care system? atically an& ensure that you have implemente& stan&ar&s 'or best practice4 atients are $ey in'ormants an& participants in care an& there are a variety o' approaches that can be use& to re'lect on their opinions on the care that they have receive&4 Complaints shoul& be vie5e& as valuable opportunities to learn 'rom patient e=periences an& improve the care provi&e& by the practice4 #y re'lectin" on in&i? vi&ual patient cases, you can i&enti'y areas o' "oo& practice, trainin" an& learnin" nee&s, an& ma$e chan"es to practice processes that can a''ect the care o' the 5hole practice population4
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&,ossary
Abs#ess< a localise& collection o' necrotic tissue, bacteria an&
5hite cells, $no5n as pus containe& in a capsule, the 5all o' 5hich is 'orme& 'rom pha"ocytes an& stran&s o' 'ibrin @see B342A4 A,bumin< a soluble protein 5hich is a ma6or component o' serum proteins @see B14EA4 Anaerobe< bacteria that &o not tolerate 'ree o=y"en 'rom the air, an& "ro5 5here there is either no air or there are lo5 levels o' o=y"en @see B,4FA4 Anaerobi#< con&itions 5ith a lac$ 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$le an& heel @see B94EA4 At+eros#,erosis< a &isease o' the arterial 5all in 5hich the inner layer thic$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
multiplication o' micro?or"anisms 5ithout provo$in" a correspon&in" host reaction @see B/-4/A4 Commensa,s< non?patho"enic micro?or"anisms that &o not react 5ith their host an& become part o' the normal bo&y 'lora @see B/-4/A4 Contamination< presence o' micro?or"anisms @such as commensalsA 5ithout multiplication @see B/-4/A4 Contra#tion< 5oun&s that have "ranulate& start to contract, &ra5? in" the e&"es to5ar&s each other an& re&ucin" the sur'ace o' the ra5 area @see B/49A4 %@bridement< the removal o' 'orei"n material an& &evitalise& tissue 'rom a 5oun& until surroun&in" healthy tissue is e=pose& @see B,4/-A4 %e+is#en#e< the brea$&o5n o' a close& 5oun& resultin" in an open 5oun&4 %e.ita,ise< to &eprive o' vitality or li'e4 %o00,er u,trasono-ra0+y< use& to recor& the an$le brachial pres? sure in&e= by &etectin" the bloo& 'lo5 in the peripheral arteries @see B94/,A4 E0it+e,ia,isation< the 'inal sta"e o' the proli'erative sta"e o' healin" 5hen the 5oun& sur'ace becomes covere& 5ith epithelium @see B/49A4 E0it+e,ium>e0it+e,ia, tissue< the tissue coverin" the sur'ace o' the bo&y, linin" bo&y cavities an& 'ormin" "lan&s @see B/49A4 Eryt+ema< re&ness o' the s$in pro&uce& by con"estion o' the capil? laries @see B/49A4 Es#+ar< a scab consistin" o' &rie& serum an& &evitalise& &ermal cells, 5hich covers &ama"e cause& by a burn, abrasion, ulcers or other s$in &isease, &e'ect or in'ection @see B,4/-A4 E/#oriation< &ama"e to the sur'ace o' the s$in cause& by physical abrasion such as scratchin" or &ra""in" the patients over sheets @see B042A4 E/trinsi#< operatin" 'rom the outsi&e, not ori"inatin" in the bo&y part in 8uestion @see B041A4 E/udate< the 'lui& 'orme& at the sur'ace o' a 5oun& as a result o' small vessels lea$in" into the 5oun&4 Contains protein an& cells @see B/49 an& B//42A4 )ibrin< an insoluble elastic protein &erive& 'rom 'ibrino"en4 Involve& in the clottin" mechanism @see B/49A4
Co,onisation<
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&ranu,ation < the 'ormation o' ne5 tissue 5hich 'ills the
5oun& &urin" the proli'erative sta"e o' healin" @see B/49 an& B,4/,A4 Haematoma< a collection o' bloo& in the tissues4 Haemostasis< process lea&in" to the re&uction o' bloo& loss 'rom the bo&y @see B/49A4 Hea,in- by 0rimary 'first( intention< close& 5oun&s 5ith a minor &e'ect @see B/4FA4 Hea,in- by se#ondary intention< open 5oun&s allo5e& to heal by "ranulation @see B/4FA4 Hea,in- by tertiary intention< 5oun& initially le't open to &rain an& sur"ically close& at a later &ate @see B/4FA4 Infe#tion< multiplication o' micro?or"anisms pro&ucin" a host reac? tion @see Chapter /-A4 Inf,ammation< initial response o' the bo&y a'ter in6ury @see B/49A4 Is#+aemia < localise& &e'iciency o' bloo& an& there'ore o=y"en, cause& by obstruction o' the bloo& vessels @see B,4/- an& B94/2A4 Ae,oid< a protuberance o' pro"ressively enlar"in" scar tissue, cause& by e=cessive colla"en, 5hich may e=ten& into normal tissue @see BF4FA4 Li0odermatos#,erosis< bro5n stainin" o' the lo5er le" occurrin" as a result o' haemo"lobin brea$&o5n, closely associate& 5ith venous hypertension an& ulceration @see B94EA4 "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 B,4/-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 B243A4 edema< 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, 'orei"n cells an& &ebris by macropha"es or neutrophils @see
!lossary
B/49A4
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/1,
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& macropha"es an& bacteria @see B342A4 S#ab< see Eschar4 Se0ti#aemia < systemic &isease4 atho"enic micro?or"anisms or other to=ins are present an& persist in the bloo&stream @see B/-4EA4 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 B,4//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 Bas#u,itis < in'lammation o' small arteries or veins 5ith resultin" 'ibrosis an& thrombus 'ormation4 O'ten associate& 5ith rheuma? toi& &isease @see B94/3A4 Benous +y0ertension < abnormally hi"h pressure in the venous system @see B94EA4
Resour#es
Con.ate# ';ound #are +e,0,ine(
Tel< -9-- ,90F19

Creden+i,, Limited
/- Cossall In&ustrial Estate Il$eston Derbyshire DEF 2(! Tel< -//2 01, -/EE .a=< -//2 0EE -E1F Email< sales_cre&enhill4co4u$ %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' Dermatolo"y Churchill Hospital Ol& Roa& Hea&in"ton, O='or& O`1 F)K Tel< -/932 ,,9,30 .a=< -/932 ,,9,11 Email< European ressure(lcer*&vis anel_compuserve4com
SCAR information ser.i#e
O #o= ,--1 Hull H(1 EDK Tel< -9E2 /,- -- ,, Website< 5554carin'o4or" In'ormation on scarrin" treatments an& support or"anisations4
/11
/1E
Smit+ C Ne0+e; ';ound #are +e,0,ine(
Tel< -9-- 20-/F1

*issue Biabi,ity So#iety !lanville
Centre Salisbury Wiltshire S , 9#K Tel< -/F,, E,0-2F .a=< -/F,, E,2,31 Email< tvs_&ial,pipe=4com Website< 5554tvs4or"4u$
*+e Water,o; Pressure Sore Pre.ention>*reatment Po,i#y
Ku&y Waterlo5 Ne5tons Curlan& Taunton T*1 2S! In'ormation on the use o' Waterlo5 an& other pressure sore prevention techni8ues4
*+e Wound Care So#iety
%rs HaJel %orley O #o= /FHuntin"&on E/9 F ) Tel< -/E9- E1EE-/ Email< 5oun&4care4society_tal$,/4com Website< 55545oun&caresociety4or" In'ormation about all aspects o' 5oun& mana"ement4
Websites %ermato,o-i#a, issues
5554s$insite4com
Wound #are ;it+ edu#ationa, basis
5554me&icale&u4com
Resources
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Abstra#ts$ arti#,es$ 0rodu#t ,inks and industry ne;s
55545oun&carenet4com
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Conne#tion to a,, of t+ese sites #an be made at:
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Referen#es
*c$roy& KS, Noun" *E @/091A )e" ulcers that &o not heal4 =ritish 1e$i+al Jo&rnal 297< ,-FI,-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< 1EFI12-4 *rmstron" % @/009A Obesity as an intrinsic 'actor a''ectin" 5oun& healin"4 Jo&rnal of 9o&n$ 7are 8@2A< ,,-I,,/4 *sh'or& R., lant !T, %aher K @/09EA Double blin& trial o' metroni&aJole in malo&or? ous ulceratin" tumours4 )ancet i< /,1,I/,114 *s8uith S @/000A The use o' aromatherapy in 5oun& care4 Jo&rnal of 9o&n$ 7are 9@3A< 1/9I1,-4 #an$s V @/00FA ressure sore e&ucation4 Jo&rnal of 9o&n$ 7are 7@/-A< 2-3I2-F4 #arnhorst D*, #arner H# @/039A revalence o' con"enitally absent 'oot pulses4 Ne4 Englan$ Jo&rnal of 1e$i+ine 289< ,3EI,324 #arrett E @/09FA uttin" ris$ calculators in their place4 N&rsing Times 93@FA< 32IF-4 #ellamy : @/002A hoto"raphy in 5oun& assessment4 Jo&rnal of 9o&n$ 7are 4 @FA< 1/1I1/34 #ennett ), )ee #N @/093A ressure versus shear in pressure sore 'ormation4 In< )ee #N, e&4 7hroni+ :l+ers of the Skin4 Ne5 Nor$< %c!ra5?Hill, pp4 10I224 #irchall ) @/001A %a$in" sense o' pressure sore pre&iction calculators4 N&rsing Times 9:@/9A< 1EI1F4 #lac$ D @/09,A Ine?&alities in 6ealth %=la+k Report)' Harmon&s5orth< en"uin4 #lan& :I, lain WE, von .raunho'er K* @/09EA E=perimental an& clinical observations o' the e''ects o' cytoto=ic chemotherapeutic &ru"s on 5oun& healin"4 Annals of S&rgery 1::< F9,IF0-4 #on& %R @/09EA .ain! Its nat&re@ analysis an$ treatment4 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-IF14 Cameron K @/009A S$in care 'or patients 5ith chronic le" ulcers4 Jo&rnal of 9o&n$ 7are 8@0A< E20IE3,4 Charles H @/000A Short stretch ban&a"es in the treatment o' venous le" ulcers4 Jo&rnal of 9o&n$ 7are 9@3A< 1-1I1-E4 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
Resources
/13
/1F
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 < /E1I/2,4 ChrintJ H @/090A Nee& 'or sur"ical 5oun& &ressin"s4 =ritish Jo&rnal of S&rgery 87 < ,-EI,-24 Clar$ %, .letcher K @/000A ro&uct selection4 Resource 'ile4 %attresses an& be&s4 Jo&rnal of 9o&n$ 7are @suppl EA< /I94 Closs KS @/001A %alnutrition4 The $ey to pressure soresC N&rsing Stan$ar$ 9@EA< 1,I 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$s4 Cooper D% @/00-A Optimisin" 5oun& healin"4 N&rsing 7lini+s of North Ameri+a 26@/A< /324 Cooper R, )a5rence KC @/003A The isolation an& i&enti'ication o' bacteria 'rom 5oun&s4 Jo&rnal of 9o&n$ 7are 6@FA< 112I1E-4 Cuttin" :. @/000A .actors in'luencin" 5oun& healin"4 N&rsing Stan$ar$ 9@2-A< 11I134 Cuttin" :., Har&in" :! @/00EA Criteria 'or i&enti'yin" 5oun& in'ection4 Jo&rnal of 9o&n$ 7are 3@EA< /09I,-/4 Davi& K @/093A 9o&n$ 1anagement' A +omprehensi,e g&i$e to $ressing an$ healing4 )on&on< %artin DunitJ4 Davies : @/00EA ressure sores< aetiolo"y, ris$ 'actors an& assessment scales4 =ritish Jo&rnal of N&rsing 3@3A< ,23I,3-4 Dealey C @/001A %easurin" the prevalence an& inci&ence o' pressure sores4 =ritish Jo&rnal of N&rsing 2@,-A< 009I/--34 Dealey C @/00EA The 7are of 9o&n$s! A g&i$e for n&rses 4 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< /-1I/-24 Department o' Health @/00/A *ietary Referen+e Aal&es for Foo$@ Energy an$ N&trients for the :B4 @Report on Health an& Social Sub6ects no4 E/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-I1214 Draper K @/092A %a$in" the &ressin" 'it the 5oun&4 N&rsing Times 91@EA< 1,I124 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/I1FF4 Dyson %, Noun" S, en&le C @/099A Comparison o' the e''ects o' moist an& &ry con&i? tions on &ermal repair4 Jo&rnal of In,estigati,e *ermatology :1@2A< E12IEE04 Effe+ti,e 6ealth 7are =&lletin @/002A Nu''iel& Institute 'or Health4 (niversity o' )ee&s4 NHS Centre 'or Revie5s an& Dissemination4 (niversity o' Nor$4 E$ *C, #oman ! @/09,A * &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/I2F4 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< 19EI 1924 European ressure (lcer *&visory anel @E (* A @/00FA .ress&re :l+er
/19
Treatment <&i$elines4 O='or&< E (* 4 .lana"an % @/001A re&ictin" pressure sore ris$4 Jo&rnal of 9o&n$ 7are 2@EA< ,/2I,/94 .letcher * @/00,A The epi&emiolo"y o' t5o common a"e relate& 5oun&s4 Jo&rnal of 9o&n$ 7are 1@EA< 10IE14
Re'erences
/10
.letcher K @/000A * practical approach to &ressin" 5oun&s in &i''icult positions4 =ritish Jo&rnal of N&rsing 9@/,A< FF0IF934 .o5ler *, Dempsey * @/009A Split thic$ness s$in &onor sites4 Jo&rnal of 9o&n$ 7are 8@9A< 100IE-,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 32I3F4 !oul& D @/00FA iloni&al sinus4 N&rsing Times :3@supplA< 1,4 !o5er K , )a5rence KC @/002A The inci&ence, causes an& treatment o' minor burns4 Jo&rnal of 9o&n$ 7are 4@,A< F/IFE4 !reen C @/001A *ntistrepto$inase titres a'ter topical strepto$inase4 ;an+et 341 < /3-,I/3-14 !rey KE @/009A Cellulitis associate& 5ith 5oun&s4 Jo&rnal of 9o&n$ 7are 8@FA< 119I1E-4 !roscott @/002A The palliative mana"ement o' 'un"atin" mali"nant 5oun&s4 Jo&rnal of 9o&n$ 7are 4@2A< ,E-I,E,4 !uest !, earson S @/00FA Recovery on a plate4 N&rsing Times :3@E3A< 9EI934 Ho&"$in W @/009A iloni&al sinus &isease4 Jo&rnal of 9o&n$ 7are 8@0A< E9/I E914 Ho'man D, Ryan T, *rnol& . @/00FA ain in venous le" ulcers4 Jo&rnal of 9o&n$ 7are 7@2A< ,,,I,,E4 Hos$ins K, Welche5 % @/092A .ost8operati,e .ain' :n$erstan$ing its nat&re an$ ho4 to treat it4 )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< 91I9E4 Kohnson * @/099A Woun& mana"ement4 *re you "ettin" it ri"htC .rofessional N&rse 3@9A< 1-3I1-04 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< E3FIE9/4 :en&ric$ %, )uc$er :, Cullun N, Roe # @/00EA 7lini+al Information .a+k4 Number /4 The management of leg &l+ers in the +omm&nity4 (niversity o' )iverpool4 :enney ), Rithalia S @/000A Technical aspects o' support sur'aces4 %attresses an& be&s4 Resource 'ile4 Jo&rnal of 9o&n$ 7are @suppl part 1A< /I94 )an& ) @/00EA 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< 1/0I1,,4 )a5rence KC @/00FA Woun& irri"ation4 Jo&rnal of 9o&n$ 7are 7@/A< ,1I,34 )evin %E @/099A The &iabetic 'oot< pathophysiolo"y, evaluation an& treatment4 In )evin %E, O7Neal )W, e&s4 The *iabeti+ Foot, Eth e&n4 St )ouis< CV %osby, pp4 /I/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/I124 )oa&er S, Delue %, Ho''man D @/00EA * constancy service that pays &ivi&en&s, settin" up a pressure service relie' "roup4 .rofessional N&rse 15< ,20I,334 )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
/E-

%c)aren S%! @/00,A Nutrition an& 5oun& healin"4 Jo&rnal of 9o&n$ 7are 1 @1A< E2I224 %c)eo& * @/00FA rinciples o' alternatin" pressure sur'aces4 A$,an+es in 9o&n$ 7are 15< 1-I134 %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< ,1I,34 %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< E30IEF14 %o''att C, O7Hare ) @/002A !ra&uate& compression hosiery 'or venous ulceration4 Jo&rnal of 9o&n$ 7are 4@/-A< E20IE3,4 %oo&y % @/001A *ccountability in 5oun& care< a practical approach4 9o&n$ 1anagement 3@/A< 3IF4 %or"an D @/09FA Form&lary of 9o&n$ 1anagement .ro$&+ts4 Car&i''< Whitchurch Hospital4 %or"an D @/00EA Form&lary of 9o&n$ 1anagement .ro$&+ts, 3th e&n4 Haselmere< Eurome& Communications4 %or"an D @/00FA Form&lary of 9o&n$ 1anagement .ro$&+ts, Fth e&n4 Haselmere< Eurome& Communications4 %orison % @/090A ressure sores< removin" the cause o' the 5oun&4 .rofessional N&rse 6< 0FI/-E4 %orison % @/00/A A 7olo&r <&i$e to the Assessment an$ 1anagement of ;eg :l+ers4 )on&on< Wol'e ublishin" )t&4 %orison %, %o''att C @/00EA 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$i+ine4 O='or&< O='or& %e&ical ublications4 %osely K! @/099A .alliation in 1alignant *isease4 E&inbur"h< Churchill )ivin"stone4 %yers K* @/09,A Woun& healin" an& the use o' a mo&ern sur"ical &ressin"4 The .harma+e&ti+al Jo&rnal 22:@3/93A< /-1I/-E4 Ne5man V, *ll5oo& %, Oa$es R @/090A The use o' metroni&aJole "el to control the smell o' malo&orous lesions4 .alliati,e 1e$i+ine 3@EA< 1-1I1-24 NHS E=ecutive @/002A 7onsens&s Strategy For 1anagement of ;eg :l+ers 4 )ee&s< NHS E=ecutive4 North Thames Research *ppraisal !roup @/009A The 7lini+al Effe+ti,eness .ro+ess 4 )on&on< NTR*!4 Norton D, %c)aren R, E=ton Smith *N @/03,A In,estigations of <eriatri+ N&rsing .roblems in 6ospital4 E&inbur"h< Churchill )ivin"stone4 Ny8uist R, Ha5thorne K @/09FA The prevalence o' pressure sores in a Health *uthority4 Jo&rnal of A$,an+e$ N&rsing 12< /91I/9F4 ar$er )K @/000A Importance o' han& 5ashin" in re&ucin" cross in'ection4 =ritish Jo&rnal of N&rsing 9< F/3IF,-4
Re'erences
artri&"e C @/009A In'luential 'actors in sur"ical 5oun& healin"4 Jo&rnal of 9o&n$ 7are 8@FA< 12-I1214
/E/
/E,
itcher % @/009A Internet sources on le" ulcer mana"ement4 Jo&rnal of 9o&n$ 7are 8@3A< 1/1I1/34 le5a % @/00-A *ltere& host response an& special in'ections in the el&erly4 Emergen+y 1e$i+ine 7lini+s in North Ameri+a 9@,A< 01I,-34 riest C, Clar$e % @/001A (p&ate< pressure sore ris$ 'actors4 Jo&rnal of 9o&n$ 7are 2@EA< ,/3I,/F4 ro'essional Development @/00EA Woun& care4 :no5le&"e 'or practice4 N&rsing Times :5< E04 un N)W, #arraclou"h DRE, %uir&en :D @/00-A )e" ulcers in rheumatoi& arthritis4 1e$i+al Jo&rnal of A&stralia 163@/-A< 292I29F4 Rei& K, %orison % @/00EA To5ar&s a consensus classi'ication o' pressure sores4 Jo&rnal of 9o&n$ 7are 3@1A< ,01I,0E4 Sa=ey S @/093A The nurses response to postoperative pain4 N&rsing 3@/-A< 1FFI 19/4 Seers : @/09FA erceptions o' pain4 N&rsing Times 93@E9A< 1FI194 Silver I* @/092A O=y"en an& tissue repair In< Ryan TK, e&4 An En,ironment for 6ealing' The role of o++l&sion 4 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 I a multi'acete& approach to prevention an& treatment4 Rehabilitation me&icine4 9estern Jo&rnal of 1e$i+ine 164< 210I2EE4 Stevens K @/009A )etters4 Jo&rnal of 9o&n$ 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 of 9o&n$ 7are 8@EA< /90I/0,4 Thomas S, Kones %, Shutter S, *n&re5s * @/003A Rea&er 8uestions4 Jo&rnal of 9o&n$ 7are N&rsing :2< E34 Thomas S, Vo5&en : @/009A Rea&ers7 8uestions4 Jo&rnal of 9o&n$ 7are 8@1A< /2E4 Thompson D, Smith DK @/00EA What is in'ectionC Ameri+an Jo&rnal of S&rgery 78a@supplA< F2I//24 Torrance C @/091A .ress&re Sores! Aetiology@ treatment an$ pre,ention4 )on&on< Croom Helm4 Turner TD @/092A Which &ressin" an& 5hyC In< Wesby S, e&4 9o&n$ 7are4 )on&on< William Heinemann %e&ical #oo$s4 (nite& :in"&om Central Council @/00,A 7o$e of .rofessional 7on$&+t4 )on&on< (:CC4 Value 'or %oney (nit @/00FA A .res+ribersC <&i$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< /,2I/,94 War'iel& C* @/00FA E5pert .ain 1anagement4 Sprin"house, *< Sprin"house Corporation4 Waterlo5 K @/092A * ris$ assessment car&4 N&rsing Times 91@E9A< E0I224 Weaver * @/003A %RS* an& its mana"ement in the community4 7omm&nity N&rse 2@0A< 13I194 West , riestley K @/00EA %oney un&er the mattress4 6ealth Ser,i+e Jo&rnal 14< ,-I,,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< 3F3I39-4 Williams E @/00FA *ssessin" the 'uture4 N&rsing Times :3@supplA< ,14 Winter ! @/03,A .ormation o' the scab an& the rate o' epithelialiJation o' super'icial 5oun&s in the s$in o' the youn" &omestic pi"4 Nat&re 1:3< ,01I,0E4
Re'erences
/E1
Wolverhampton Health Care Control o' In'ection Committee @WHC CICA @/002A 1ethi+illin Resistant Staphylococcus aureus .oli+y4 Wolverhampton< WHC CIC4 The Woun& ro"ramme @/00,A Centre 'or %e&ical E&ucation, (niversity o' Dun&ee, Scotlan&4
Inde/
a"e re'erences in bo,d ty0e re'er to &e'initions o' terms in the !lossary abscess E9, 12: piloni&al EF action plan //0 *ctisorb lus EE a&hesive strips E, 21 a&ipose tissue ,EI2 a"e, e''ect on healin" ,1IE, EF, 91 air5ay overlay 01 alcohol, in ulcer preparations E/ alcohol consumption, e''ect on 5oun& healin" /1, ,1, ,0 al"inate &ressin"s /9, 12, 13IF, E1, /-3, /-FI9 as cavity &ressin" EF, E9 as haemostat 21 aller"ens E/ *llevyn 19 *llevyn *&hesive 10 alternatin" pressure mattress 0, anaerobe 12: anal"esia /0, F/ an"ina 20 an"io"enesis 12, E-, 12: an$le brachial pressure in&e= @*# IA 3/I1, 12: an$le 'lare 2F, 12: antibiotics /0 systemic 09, 00 topical E/, /-1 anticoa"ulants E3
anti?in'lammatory &ru"s e''ects on 5oun& healin" ,9 an& pressure sore healin" 91 antimicrobial therapy ,9, E- antiseptics 1/ antistrepto$inase titre 19 an=iety EF *8uacel 10 aromatherapy /-3 arterial &isease 29I 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$ers, e''ect on pressure sore healin" 91 bacitracin E/ bacterial colonisation /, 02 #ioclusive E#lac$ Report ,0 blisterin" 2/ bovine colla"en EE #ritish #urns *ssociation 2/ burns 2, 2&ressin"s 'or 2/I, 'ull?thic$ness 2-, 2, minor 2/ pain associate& 5ith /0
/EE
Woun& Care< * Han&boo$ 'or Community Nurses /E1
camera, choice o' /3I /F capillary &ama"e 32 capillary occlusion 92 Carbo'le= EE car&iovascular &isease ,E case note revie5 //0 cavity 5oun&s 1F, 10, E9 cellulitis 29, 31, 09, 00, 12: cerebrovascular acci&ent 20 charcoal &ressin"s /9, EE chlorhe=i&ine 1, CIN*H) //2 Circa?Care 21 clinical appraisal //3 clinical au&it //F, /,- clinical &ecision?ma$in" /, clinical e''ectiveness ///'' CliniSorb EE Cochrane )ibrary //2 col& 5ater therapy as anal"esia 2/ contrain&ications 2, treatment 'or minor burns 2/ colla"en 'ormation F, 9, ,E, ,2, 12: e''ect o' penicillin on E3 colophony E, CombiDER% 10 Com'eel Ecommunity &ietitian ,F complementary therapy /-3 compression ban&a"in" /2, E1, F/I ,, /-9 +ase st&$ies F0I9-, 0FI9 contrain&icate& 'or arterial ulcer F1 contrain&icate& 'or &iabetic patient 3,I1 'or venous ulcer 29 compression hosiery FEI F Comprilan F, concurrent &isease, e''ect on 5oun& healin" ,1, ,E connective tissue F &isor&ers o' 32 contact &ermatitis /E, E/, E,, 31 corticosteroi&s ,E, E3, 32 cotton 5ool 1-, 12
critical inci&ent analysis /,3IF cross?in'ection 02, 00
Cushin"7s syn&rome ,E Cuti'ilm Ecytoto=ic &ru"s e''ect on pressure sores 91 an& 5oun& healin" ,9, E3 Database o' Revie5s o' E''ectiveness an& #est Evi&ence //2 &Mbri&ement ,-, 1F, 135 &eep vein thrombosis 2F, 29 &ehiscence ,E, ,9, 135 Deni&or EE &ermis ,, 1 thinnin" o' 32, 9E &eslou"hin" E&iabetes an& *# I 3, e''ect on 5oun& healin" /1, ,E, EF, 20, 3,I1, 33IF 'oot care 3FI9 'oot ulcers 33I9, 00 an& ischaemia 32 &ietary a&vice, +ase st&$ies ,2IF &ietary supplements ,E, ,2 &i"its, &ressin"s 'or /-3, /-F &iversion therapy, 'or pain control ,- &ocumentation // &onor sites 2, Doppler ultrasono"raphy /1, 3/I1, 135 &ressin"s choice o' 13 combinations E,I1 're8uency o' chan"in" F- lea$a"e /FI/9 pac$s 1prescription an& non?prescription 13 removal, trauma /9, /0, 12 secon&ary 1F, E1 ulcer 30IFsee 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
In&e=
polysacchari&e bea& &ressin"sG vapour?permeable &ressin"s Duo&erm E&uty to care /1 ecJema 32 Effe+ti,e 6ealth 7are =&lletins //2 emollients /E, 1/I,, 33 enJyme &ressin"s 1F eosin /-9 epi&ermis ,, 1 epithelial cells an& tissue 2, 9, 135 islan& ,/ mi"ration 0I/epithelialisation 0, 13, 135 erythema 2/, 135 eschar 9, ,-, 135 Es+heri+hia +oli E- ester o' resin E, European ressure (lcer *&visory anel 9, evaluation // evi&ence appraisal //3 evi&ence?base& health care //, e=ercise 33, F/, F1 e=u&ate 3, /0, ,/, 1-, 1E, 12, 10, /-2, /-F, /-9, 135 an& al"inate &ressin"s 13I F an& protein loss ,E .ibracol EE 'ibrin 135 'ibroblasts F, 9 .lamaJine 2/, /-1 'lui& loss / 'oam &ressin"s 19I0, E1, E9 'ocus "roups /,E, /,2 'ra"rances, as irritants E, 'ramycetin E/ 'riction E2, 93 an& incontinence 91 'un"atin" 5oun& /-2 'usi&ic aci& /-1 !am"ee E1 "auJe 12, E2 "elH'oam combination &ressin" EE "entamicin E/
/E2
!ranu'le= E!ranu"el E"ranulation tissue E, 9, ,/, 12, 131 haemostasis 3, 131 haematoma 'ormation ,2, E3, 131 han& 5ashin" 00I/--, /-,I1 heat an& col& therapy, 'or pain relie' ,heel, &ressin"s 'or /-3IF hy&rocellular &ressin"s 19 hy&rocolloi& &ressin"s 12, 10IE-, E1, E2 o&our 'rom /FI/9 hy&rocolloi& "el &ressin"s Ehy&ro'ibre &ressin"s 10, /-FI 9 hy&ro"els 10, Ehy&ropolymer &ressin"s 19 hypercholesterolaemia 33 hyper"ranulation /-9 hypertension 29, 33 hypertrophic scar 21 immunosuppressive &ru"s, e''ect on 5oun& healin" ,9, E3 Ina&ine /-1 incontinence, 'aecal an& urinary 91, 0- in'ection /, E, /0, ,/, EF, 131 e''ect o' a"e on ,1IE in'lammation 3, /-F, 131 in"ro5in" toenail E9 intermittent clau&ication 20 internet /-0I/-, //3 Intrasite !el 10 io&ine 1F Io&o'le= 1F Io&osorb 1F irritants E/ 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 $eloi& scar 21, 131
laceration pretibial 21 traumatic E, 22 lanolin E/ larval therapy /-9I0 le" elevation 29, F1, /-9 le" ulcer E, 23'' assessment 20I31 +ase st&$y /1 causes o' 23I F clinical investi"ations 3- costs o' treatin" 23 &ressin"s 30IFi&enti'ication /E in'ection, +ase st&$y 03IF recurrent /E, FE lipo&ermatosclerosis 2F, 131 literature search //2 lo5 a&herence &ressin"s E1 )yo'oam 19 )yo'oam C EE maceration 1E, 10, 0-, /-F, /-9, 131 an& incontinence 91 macropha"e F, 131 ma""ots see larval therapy malnourishmentG malnutrition ,E, ,3, EF, 0-I/ e''ect on pressure sore healin" 91 %ar6olin7s ulcer 30 mattresses see support sur'aces %e&line //2 %e'ilm Emelanomas 30 %elolin E2 methicillin?resistant Staphylo+o++&s a&re&s @%RS*A 1F, /--I E metroni&aJole /9 micro?or"anisms colonisation, /, 02, 135 resi&ent 00 transient 00 an& 5oun& &ressin"s 1E mobility ,1, ,2, 32 moist 5oun& healin" 0I/-, /9, ,/, 11, E-, /-F mupirocin /-1 myocar&ial in'arction 29 >mystery patient7 /,-
N?* Dressin" E1 necrosis, necrotic tissue E, ,-, 92, 131 e''ect o' smo$in" ,0 peripheral 1E neomycin E/ ne"li"ence /1 nerve &ama"e, pain associate& 5ith /9 neuropathy 3F Norton ressure Sore Ris$ *ssessment Scale 93IF 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" ,EI2, EF, 91 +ase st&$y ,2I3 occlu&e& 5oun&, in'ection /occlusive &ressin"s /9, 11, 12, /-F, 131 oe&ema ,/, 29, 3/, 32, 33, F2, 03, 131 opiate anal"esia /9 Opsite .le=i"ri& Eover"ranulation /-9, 131 o=y"en atmospheric 12 o=y"en?permeable &ressin"s 13 re&uce&, an& oe&ema 9E tension an& obesity ,EI2 pa&&in", as secon&ary &ressin" 12, E1, F, pain /2, /9, 9E abscess E9 assessment /0 assessment scale ,- control F1 ischaemic /9 le" ulcers /0, F/ venous ulcer 29 arabens E/ para''in "auJe 12 patients a&vice "iven to //E assessment o' ,1 complaints /,-
compliance /2, F9G +ase st&$ies F0I 9-, 03IF con'i&entiality /F, /,2 consent /3 e&ucation F/, //E recor&s //9 surveys //1, /,/I 1 vie5s o' /,/I, pe&al pulse 29, 3/, 3, penicillin, e''ect o' on colla"en 'ormation E3 peripheral vascular &isease 20, 33 pha"ocytic 5hite cells F, 131 phenol, E9 phlebitis 29 photo"raphic recor&s /3 piloni&al abscess EF, E9 piloni&al sinus E-, EFI9 pituitary &e'iciency ,E polymorphs F polysacchari&e bea& &ressin"s /9, 1F polyurethane &ressin" E2 postoperative recovery E3 5oun& in'ection ,2 potassium perman"anate /-9 povi&oneIio&ine 1,, 2, pressure sores, ulcers 2, /0, 9/'' causes o' 9,I3 costs o' treatin" 9/ &e'inition 9, inci&ence 9/, 9, mortality associate& 5ith 9/ prevalence 9/, 9, prevention 0ris$ assessment 93I 0- an& 5omen 91 pressure?re&ucin" mattress 01 see also support sur'aces ro'lavine E-I/, EF ro'ore F, protease /-F protein loss ,E .rote&s E.se&$omonas spp4 Epsycholo"ical 'actors, e''ect on 5oun& healin" ,0 pulmonary &isease ,E
pulmonary embolism 29 urilon !el 10 pyre=ia ,/, 9E, 03 ra&iotherapy E3 ran&omise& controlle& trials //3 recor& $eepin" //, /, +ase st&$y /1 revie5 //9 re'lective practice /,3IF rela=ation techni8ue ,rheumatoi& arthritis, 32 33 ris$ assessment 9FI0Rosi&al : F, rubber aller"y E/ saline, physiolo"ical 1/, 1, temperature o' 1E scab 'ormation F, 9, 0 scal&s 2/ scars 2,, 21 secon&ary &ressin"s 1F, E1 septicaemia 09, 132 shear ulcers 92 shearin" E-, 92I3 sheeps$in 01 silver nitrate /-9 silver sulpha&iaJine 2/ s$in con&ition /E 'unction o' / "ra't 2, stainin", an& vascular &isease 2F, 32 structure o' , slou"h E, ,-I/, 132 smo$in" e''ect on 5oun& healin" /1, ,1, ,9I0, 9E an& ischaemia 32 social 'actors, e''ect on 5oun& healin" ,0 >social7 ulcer F9 s8uamous cell carcinomas 30 staphylococcal in'ections 09 see also methicillin? resistant Staphylo+o++&s a&re&s stasis ecJema 2F
static mattress 01
Steri"el 10 steroi&s e''ect on pressure sores 91 e''ect on 5oun& healin" ,E an& s$in thinnin" /E topical /E see also corticosteroi&s strepto&ornase 1F strepto$inase 1F, 19 stress EF stri$e?throu"h 12, E1 subcutaneous 'at ,, 1 sunburn 2/ support sur'aces 0-, 0/ Sure ress F, sur"ical "lue E, 2E sur"ical clips E2I3 sur"ical 5oun& E, E2'' postoperative recovery E3 Sur"ipa& E1 sutures E, E2I3 systematic revie5 //2 systemic in'ection 9E systemic to=icity 00 Te"a&erm ETe"asorb ETensopress F, thyroi& &e'iciency ,E tissue brea$&o5n 9E, 0hypo=ia /-2 o=y"enation ,2 types /2 tissue paper s$in 9E total sun bloc$ 2, trauma 5oun&s 1an& ulcer F1IE treatment "oals // Tricote= E1 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 /,I/1 ulcers 132 cleansin" Fcosts o' treatin" 23 mali"nant 30 recurrence FE types o' /E see also 'oot ulcersG le" ulcersG pressure ulcersG vasculitic ulcers (ltra .our F, un&erlyin" &isease, e''ect on 5oun& healin" 9E uraemia ,E vapour?permeable 'ilm &ressin"s 1E, E-, E1, E2 varicose ecJema /E varicose veins 2F, 3E Vari&ase 1FI9 vascular status, assessment o' 3/ vasculitic ulcers 32 ve"etarians, &ressin"s suitable 'or EE venous &isease 23, 2F, 31I2, 132 venous le" ulcer /0, 21, 29, F/ +ase st&$ies ,2 F9I0 vitamin C supplements ,F see also malnourishmentG nutritionG nutritional supplements Waterlo5 ris$ score 9FI 0 5ell ulcer clinic F9 5hite cell activity F 5oun& acute /1 a&herence /9 assessment, //'' assessment chart /, cate"orisation E chronic /E cleansin" /0, 1cleansin" a"ents 1/, 1, closure strips 21IE &ebris clearance ,9 &epth 2, /3 &ressin"s /FI /9 &ry 9 'ull thic$ness 1
'un"atin" /F, /-2 healin"< by primary an& secon&ary intention E, 2, 131G by tertiary intention 3, 131G nutrient re8uirements 'or ,2G phases o' 3I0 in'ection EF, 02'' irri"ation 1maturation 0 measurement /2I/3
o&our /2, /F, ,/, EE, 03, /-2 partial thic$ness 1 recor&in" /E super'icial 1 s5ab 02, 09, /-/ temperature 1E tracin" /2I /3 Jinc &e'iciency ,9 Jinc o=i&e paste an& ban&a"es /-9

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Wound Care: A Handbook for Community Nurses

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"S#$ BS#$ %PSN$ R&N$ %N

Tissue Viability Nurse, Wolverhampton Health Care

WH(RR (#)ISHERS )ONDON *ND HI)*DE) HI*

Series re'ace re'ace

.actors a''ectin" 5oun& healin"

#urns, scal&s an& minor in6uries

Woun& Care< * Han&boo$ 'or Community Nurses

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Woun& Care< * Han&boo$ 'or Community Nurses

Woun& Care< * Han&boo$ 'or Community Nurses

ma6or burnA this can be li'e threatenin"4

Woun& Care< * Han&boo$ 'or Community Nurses

)i-ure 1<1 The s$in4

)i-ure 1<2 * super'icial 5oun&4

)i-ure 1<3 * partial?thic$ness 5oun&4

Woun& Care< * Han&boo$ 'or Community Nurses

Woun& Care< * Han&boo$ 'or Community Nurses

What &o the terms >primary7 an& >secon&ary intention7 meanC

%acropha"es Vaso&ilate& bloo& vessels

Woun& Care< * Han&boo$ 'or Community Nurses

)i-ure 1<6 The in'lammatory sta"e< -I1 &ays4

Ne5 bloo& capillaries "ro5in" into 5oun& mar"in

.ibroblasts )i-ure 1<7 The &estructive sta"e< /I3 &ays4

.roliferati,e phase! #"2/ $ays %Fig&re '0)

!ranulation tissue )i-ure 1<8 The proli'erative sta"e< 1I,E &ays4

Woun& contraction be"ins

1at&ration phase! 2/ $ays to '2)

%i"ratin" cells lose their ability to &ivi&e an& so

Epithelium no5 complete

*vascular scar tissue replaces "ranulation

Vascularity &ecreases )i-ure 1<9 The maturation sta"e< ,E &ays to / year4

colla"en 'ibres 6oinin" the scab to the

s5i'ter reso? lution o' care4

Woun& Care< * Han&boo$ 'or Community Nurses //

It is important that the cause o' the 5oun& is i&enti'ie& an&

recor&e&4 ersonal observation su""ests that acute 5oun&s such as

Woun& Care< * Han&boo$ 'or Community Nurses

The siJe o' the 5oun& shoul& be recor&e& @see B,4EA4

Woun& Care< * Han&boo$ 'or Community Nurses

Woun& Care< * Han&boo$ 'or Community Nurses

Woun& Care< * Han&boo$ 'or Community Nurses

Woun& Care< * Han&boo$ 'or Community Nurses

Woun& Care< * Han&boo$ 'or Community Nurses

Woun& Care< * Han&boo$ 'or Community Nurses

)a#tors affe#tin;ound +ea,in-

What e''ect &oes a"e have on 5oun& healin"C

Woun& Care< * Han&boo$ 'or Community Nurses ,1

.actors a''ectin" 5oun& healin"

Woun& Care< * Han&boo$ 'or Community Nurses

.actors a''ectin" 5oun& healin"

Woun& Care< * Han&boo$ 'or Community Nurses

threshol& @Dic$erson /001A4

Woun& Care< * Han&boo$ 'or Community Nurses

.actors a''ectin" 5oun& healin"

Woun& Care< * Han&boo$ 'or Community Nurses

Woun& Care< * Han&boo$ 'or Community Nurses 11

Woun& Care< * Han&boo$ 'or Community Nurses

Woun& Care< * Han&boo$ 'or Community Nurses

Woun& Care< * Han&boo$ 'or Community Nurses

Woun& Care< * Han&boo$ 'or Community Nurses

Woun& Care< * Han&boo$ 'or Community Nurses

WH(RR (#)ISHERS )ONDON ND HI)DE) HI*

Bui,d>Wei-+t for Hei-+t vera"e bove vera"e Obese #elo5 vera"e