Download Wound Management Guidelines

Wound Management Guidelines
Rationale /Background
This guideline has been developed to support healthcare professionals to ensure
standardised quality evidence based practice is delivered across the Trust.
Purpose of the Guideline
The following wound management guideline has been developed to aid clinicians to
appropriately identify, assess and manage wounds.
Explanation of Terms used in this guideline
Term
Anti-microbial
Debridement
Diabetic foot
ulcer
Epithelisation
Exudate
Granulation
Leg ulcer
Pressure ulcer
Slough
Necrosis
Definition
A general term for drugs, chemicals, or other substances that either
kill or slow the growth of microbes. Among the antimicrobial agents
are antibacterial drugs, antiviral agents, antifungal agents, and
antiparisitic drugs
The process of cleaning an open wound by removal of foreign
material and dead tissue, so that healing may occur
A foot affected by ulceration that is associated with neuropathy
and/or peripheral arterial disease of the lower limb in a patient with
diabetes
Epithelialisation is characterised by the proliferation and migration
of epithelial cells across the wound surface
Fluid, such as pus or clear fluid, that leaks out of blood vessels into
nearby tissues. The fluid is made of cells, proteins, and solid
materials. Exudate may ooze from cuts or from areas of infection or
inflammation
Granulating tissue is composed of collagen and "ground
substance", and contains new capillary loops that give granulation
tissue its characteristic red colour
A loss of skin below the knee on the leg or foot which takes more
than 6 weeks to heal
A pressure ulcer is localized injury to the skin and/or underlying
tissue usually over a bony prominence, as a result of pressure, or
pressure in combination with shear
Slough refers to moist necrotic tissue. This type of devitalised tissue
is soft, moist and often stringy in consistency and is usually yellow,
white or grey in colour
A necrotic wound contains tissue that has become devitalised due
to damage to its blood supply, for example from pressure or
trauma. When this tissue becomes dehydrated it forms a hard,
black leathery layer over the wound, commonly called an eschar
Who does this Guideline apply to?
All clinicians who are competent in wound care assessment and management.
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When should the Guideline be applied?
This guideline must be followed at every assessment of a patient presenting with a
chronic/acute wound.
The Wound Healing Process
Phase
Inflammatory
Time scale
0-5 days
Proliferation
5-24 days
Maturation
24 days to 2 years
Characteristics
Clotting vasodilation
Phagocytosis
Fibroblast and endothelial cells increase
Collagen synthesis
Granulation tissue
Epithelial closure(wound shrinkage)
Scar formation
Progressive fibrosis
Primary Intention Healing
Surgical wounds or lacerations where the wound edges are brought together and
closed by either sutures, skin closure strips or wound adhesive. Normally blood loss
and exudate will be normal and within 48 hours will have formed a natural barrier
against invasion of pathogenic bacteria.
Surgical wounds can therefore be exposed after this time frame and wound cleansing
should not take place unless there are signs and symptoms of infection or wound
breakdown.
Secondary Intention Healing
Wounds involving tissue loss and contamination (including pressure ulcers and leg
ulcers), heal by a combination of granulation, contraction and epithelialisation. The
wound dressing selected must provide optimum conditions for these healing processes
to take place.
Tertiary Intention Healing
Wound closure is delayed to allow for reduction in exudate and swelling. Once exudate
and swelling reduced the wound edges are brought together.
Types of Wound
There are three main categories of wounds:
Mechanical injuries
Abrasions
An abrasion can be defined as a scraped area on the skin or on a mucous membrane,
resulting from injury or irritation. Abrasions are superficial injuries normally caused by
friction between the skin and a blunt object. These wounds can often be left to scab
over and they often heal without scarring
Cut
A ‘cut’ can be defined as a wound made by cutting. Cuts are usually straight wounds
with well-defined wound edges, caused by a sharp object. These wounds are often
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closed using sutures, topical skin adhesives or adhesive strips and usually heal without
complication.
Lacerations
A laceration can be defined as a torn, jagged wound. Lacerations are often caused by a
blunt instrument or force. There is also often bruising associated with the wound.
Penetrating Wounds
They can be defined as a forceful injury caused by a sharp, pointed object that
penetrates the skin. A puncture wound is usually narrower and deeper than a cut or
scrape. Puncture wounds have an increased risk for infection because they are difficult
to clean and provide a warm, moist place for bacteria to grow.
Bites
Bites can be caused by dogs, cats, spiders, snakes and humans. The expected tissue
trauma will be different depending on the type of bite. These wounds will require a very
thorough clean prior to closure. If the wound is heavily contaminated with debris it may
need to be left open for a few days whilst antibiotics are given to the patient. The
wound can then be closed. The patient may require a tetanus booster (Benbow 2005)
Skin Tears
A skin tear is simply defined as a traumatic wound resulting from separation of the
epidermis from the dermis (Malone et al 1991). Skin tears are a specific type of
laceration that mostly affect older people with fragile skin as a result of the ageing
process, medications or dermatological conditions. The skin tear occurs due to the
force of shear or friction occurring that separates the layers of skin. There tends to be
change in the deposition of subcutaneous tissue in specific areas such as the face,
dorsal aspect of the hand and shins (Benbow 2009).
Skin tears are common in the elderly because of thinning skin, flattened ridges, loss of
natural skin lubrication and increased capillary fragility (Benbow 2009).
Classification of Skin Tears
Skin tears can be classified by the degree of severity and loss of epidermal tissue using
the Payne-Martin Classification for skin tears (Payne & Martin 1993) which ranges the
damage from category I – III.
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A linear Category I skin tear is an incision like lesion with separation between the
epidermis and dermis, the flap type category I has an epidermal flap skin tear
almost covers the dermis
Category II skin tear has partial loss of the overlying tissue. The sub types of
category II are scant loss (<25%) of the epidermal flap and moderate to large
tissue loss (>25%) of the epidermal skin flap
Category III is the most severe, the skin tear has complete loss of overlying
tissues, with no epidermal flap remaining
Burns and Chemical Injuries
Thermal, chemical electrical and those caused by radiation. Burns and scalds may be
classified to three types depending on the degree of tissue damage. They are most
commonly described as:
 Superficial (first degree) burns, involving the epidermis and superficial layers of
the dermis
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
Deep dermal (second degree) burns, in which most of the surface layers of the
epithelium is destroyed, together with much of the layer beneath
Full thickness (third degree) burns, in which all the elements of the skin are
destroyed
Chronic Wounds
A chronic wound is a wound that does not heal in an orderly set of stages. Wounds
that do not heal within 3 months are considered chronic. For example chronic wounds
often remain in the inflammatory phase. These wounds cause patients severe
emotional and physical stress as well as creating a significant financial burden on
patient and the whole of the health care system. Examples of chronic wounds may be
pressure ulcers, diabetic wounds and leg ulcers
Wound Assessment
It is essential to carry out a holistic wound assessment as a wound occurs or within 4
hours of the patient’s admission to hospital of an existing wound. The wound
assessment chart can be found in Appendix 1. The assessment must include factors
that may have an effect on the wound healing process and wound management
including:
Age
Allergies
Co-morbidity
Medication
Infection
Mobility
Continence
Neuropathy
Nutritional status
Pain
Psychological state
Sleep
Smoking
Social circumstances
Local wound assessment must include:
Type of wound (Dealey 2005)
Location of wound (Dealey 2005)
Stage of healing - using recognised scales (Dealey 2005)
Wound assessment will be guided by utilising the TIME framework. The key
components of TIME are recognised as follows (Watret 2005)
T
Tissue - Nature of the wound bed - healthy/unhealthy granulation tissue,
epithelialisation tissue, sloughy or necrotic tissue or eschar. This should be
recorded as a percentage of the wound bed.
I
Infection/ Inflammation - Colonisation/Infection - suspected, confirmed (specify
organisms) Odour - offensive, some/none. Pain - specify site, frequency,
continuously/intermittent, only at dressing change and severity.
M
Moisture - Exudates - colour, type, approximate amount/extent of strikethrough
onto primary and/or secondary dressings or bandages.
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E
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Edge - Wound dimensions - length, width, depth, sinus formation and undermining
of surrounding skin. Wound margins - oedema, colour, erythema (measure
extent), and maceration. General condition of surrounding skin - dry, eczema,
fragile, macerated, inflamed.
All wounds will be evaluated at each dressing change and any changes actioned
and documented within the nursing notes.
Chronic wounds must be reassessed after a minimum of 4 weeks.
Wound Healing Process
The process of wound healing commences immediately post injury. It includes three
recognised phases.
Effective wound management depends upon accurate wound assessment to enable
care plans to be individualised and appropriate. The wound care plan can be found in
Appendix 2.
Wound Measurement
When assessing a wound baseline measurement must always be undertaken in the
same way (length, width and depth in mm/cm), to increase reliability.
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
Wounds must be measured from the largest, widest and deepest aspect as
detailed on the wound assessment form
Accurate measurement will enable the clinician to evaluate the wound healing
process
Wound measurement should be carried out using:

Disposable tape measures

Disposable wound probes

Photography (with consent) in liaison with physical health matron
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Wound Classification
The four main types of tissue found during wound healing, which are often referred to
by their colour.
Example
Information
Necrotic – Black This is devitalised, dead tissue.
It often appears black, but may also appear brown or grey when
hydrated. Necrotic tissue can initially be soft, the dead tissue can
lose moisture rapidly and become dehydrated with the surface
becoming hard and dry.
Necrotic tissue needs to be removed so that wound healing can
begin. Removing this tissue will also allow for accurate
assessment of the wound bed as the necrotic eschar can mask
the true size of the wound.
Wound healing is delayed by the presence of devitalised tissue
(NICE 2001). Necrotic tissue also acts as a culture, providing an
ideal breeding ground for bacteria.
Infected – Green Wound infection is without doubt the most
troubling of all wound complications (Cutting 1998).
Avoiding infection is vital in good wound management. Therefore
it is good practice to recognise the contributing factors that
precede a diagnosis of infection.
Chronic wounds such as pressure ulcers, leg and diabetic foot
ulcers are likely to be colonized with bacteria due to the nature of
the open wound and the tissue types within the wound (Reilly et
al. 2006).
Sloughy –Yellow Wound tissue that is fibrous and yellow
adheres to the wound bed and cannot be removed on irrigation
indicates the presence of slough (Tong 1999).
Slough may predispose to wound infection and delay healing;
however the presence of slough is not necessarily indicative of
clinical infection. Exposed tendons should not be mistaken for
slough. Slough consists of dead cells and wound debris which
should be removed to enable healing to take place. This is often
referred to as ‘de-sloughing’. Slough can be found as patches
across the wound bed.
Granulating – Red Granulation tissue fills the wound as it is
healing. The tops of the capillary loops make the wound appear
red and granular. It is firm to the touch, painless and does not
bleed easily. Bright red granulation tissue, which bleeds easily,
may indicate infection (Bale and Jones 1997).
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Example
Information
Epithelising –Pink Epithelial tissue is formed in the final stages
of healing. This tissue forms the new epidermis.
Epithelial tissue is superficial pink/white tissue that migrates
across the wound from the wound margin, hair follicles or sweat
glands. It will cover the granulating tissue. In shallow wounds
with a large surface area islets of epithelialisation may be seen.
Managing the wound
Following the holistic wound assessment the management of a wound is to

Identify and refer for treatment any underlying causes i.e. infection

Assess and select the correct product for the stage of wound healing

Continuation of existing management plan as developed by health care
colleagues external to the Trust

Evaluate and reassess at every dressing change

Document findings and intervention

Discuss care plan with patient and relatives/carers to ensure concordance and
demonstrates patient /carer involvement
Where do I go for further advice or information?
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Tissue Viability Leads
Physical Health Matron
Tissue Viability Link Nurses
District Nurses
What overarching policies the guideline links to?
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Pressure Ulcer policy
Tissue Viability policy
Infection Control policy
Medicines management policy
NMP policy
Royal Marsden Manual of Clinical Nursing Procedures
References
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
Best Practice Statement Optimising Wound Care. Aberdeen. 2008
Wound Care Handbook 2013 – 2014 MA Healthcare Ltd
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Appendix 1 - Wound Assessment Tool
Please indicate on the diagram below the type and location of the wound by using the
appropriate letter from the table. Give each wound a number to correspond with the care
plan i.e. 1D
A. Pressure
Sore
B. Surgical
C. Trauma
D. Burn
E. Leg Ulcer
F. Foot
Ulcer
R
R
Date Wound
Occurred
L
R
Wound
Type
Wound & Plan
Number
Factors that could delay healing
*Delete as appropriate
Diabetes
Known Anaemia
Peripheral Vascular Disease
Smoking
Mobility Deficit
Incontinence
Poor Nutritional State
Known Allergy (list details)
MRSA Status
Positive
G. Other
Signature
Signature
Indicate Y/N
Metabolic Disorder
Neurological Disease
Rheumatoid Arthritis
Age Related
*steroids/NSAID’s/Chemo/Radiotherapy/Warfarin/
Benzodiazepines/Neuroleptics
Non-Concordance
Negative
Unknown
Specialist Referral
Vascular Dermatology Diabetic Foot
Clinic/Podiatry/Orthotics
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Carrier
Dietician
Tissue
Viability
Other
(please
state)
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Appendix 2 - Wound Assessment Chart
DATE OF ASSESSMENT
WOUND DIMENSIONS(CM)
Length
Depth
Breadth
PRESSURE ULCER
GRADE 1-4
M-Mapped
P- Photographed
NATURE OF WOUND BED
%covered
N- Necrosis
S- Slough
G- Granulation
E-Epithelialisation
H- Hypergranualtion
*MALODOUR Y/N
SURROUNDING SKIN
Enter a letter for all that
apply
B-Blister
C-Cellulitis
D-Dry
E-Eczema
F-Fragile
H-Healthy
M-Maceration O-Oedema
R-Redness/erythema
*PAIN Y/N
(If Y complete pain chart)
*EXUDATE DRAINAGE
AMOUNT
H-High
M-Medium
L-Low
EXUDATE COLOUR
S-Serous (clear)
HS-Haemoserous (Pink)
B- Blood (Red)
HP – Haemopurulent (Dark
blood stained
P – Pus (yellow/green)
WOUND INFECTION
Y/N**
KNOWN CONTAMINATION*
SWAB TAKEN Y/N
CHANGE IN TREATMENT
PLAN Y/N
SIGNATURE
**Wound type and plan number. Any increase in values marked with * along with friable, easily
bleeding granulation tissue; pocketing at base of wound; bridging of tissues, wound breakdown,
could indicate critical colonisation or wound infection
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Appendix 3
WOUND TREATMENT CARE PLAN NUMBER _______
SITE OF WOUND: _________________________________________________
Plan implementation date:
CLEANSING REGIME REQUIRED :
Completed by:
YES
NO
Product:
Method
DEBRIDEMENT PROCEDURE REQUIRED :
YES
NO
Product:
PRIMARY WOUND DRESSING
Size Required:
Quantity Used:
SECONDARY DRESSING
Product:
Application Details:
DRESSING CHANGE FREQUENCY
OBSERVE FOR AND REPORT ANY SIGNS OF INFECTION e.g.: heat, redness, swelling, odour,
increased pain, increased exudate
OTHER ACTIONS REQUIRED
e.g.: pressure sore prevention aids, consider behaviour needs,
Nurse Signature
Print name
Date
Discussion of care plan with patient occurred on (insert date)
Patient Signature:
If patient lacks capacity please discuss with family or carer and tick here
Discussion of care plan with family or carer occurred on (insert date)
Family or carer Signature: (print name and relationship
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Appendix 4 - Leg Ulcer Treatment Algorithm
Patient with a wound on the lower limb
Holistic patient assessment including:

Past medical history

Limb assessment

Ulcer history
Signs of venous
disease/oedema, e.g.
varicosities, skin changes, skin
staining oedema, eczema
Yes
ABPI <0.5
Urgent referral to
vascular centre, no
compression
Re-assess
weekly
ABPI -0.5-0.8
Mixed disease, refer
to vascular
centre/tissue
viability team,
reduced
compression
following specialist
advice
If oedema
present,
apply
inelastic
compression
bandage
system
If no oedema
present,
apply elastic
or inelastic
compression
bandage
system
Once leg ulceration is healed refer
to recommendations in the Best
Practice Statement:
nd
Compression Hosiery (2 edition)
Wounds UK, 2015). Consider
referral to vascular services to
assess need for venous intervention
to reduce the risk of recurrence, as
per NICE guidelines CG168 (2013)
Consider other
causes and refer
to appropriate
specialist:
 Dermatology
 Malignancy
 Pressure
 Autoimmune
 Arterial
 Diabetes
No
ABPI >1.3
Consider classification, assess
foot pulses, Doppler waveflow.
Consider referral to vascular
centre and/or tissue viability
Perform ABPI
ABPI 0.8-1.3
No evidence of significant
arterial disease safe to
compress
*Consider why exudate is
not controlled with topical
dressings, is there any
evidence of infection or
increased bacterial load, is
the dressing size/choice
appropriate for exudate
amount?
Is the exudate
controlled within
topical dressing?
No*
Yes
Is there a large amount
of reducible
oedema/limb distortion?
Yes
Apply inelastic
compression system
No
After 4 weeks of treatment, if
there is no reduction in ulcer
size refer to vascular/tissue
viability service for review.
If the wound does not heal in
12 weeks refer to
vascular/tissue viability
service for review
When oedema and limb
distortion controlled, change to
European classification hosiery
40mHg kit
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Compression
hosiery kit
40mmHg
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Training
Staff may receive training in relation to this guideline, where it is identified in their
appraisal as part of the specific development needs for their role and responsibilities.
Please refer to the Trust’s Mandatory & Risk Management Training Needs Analysis for
further details on training requirements, target audiences and update frequencies.
Monitoring / Review of this Procedure
In the event of new evidence or a planned change in the process(es) described within
this document or an incident involving the described process(es) within the review
cycle, this guideline will be reviewed and revised as necessary to maintain its accuracy
and effectiveness.
Guideline Details
Unique Identifier for this Guideline is
BCPFT-CLIN-GUI-02
State if Guideline is New or Revised
New
Policy Category
Clinical
Executive Director
whose portfolio this guideline comes under
Guideline Lead/Author
Job titles only
Committee/Group Responsible for
Approval of this Guideline
Executive Director of Nursing, AHPs and
Governance
Physical Health Matron
Medicines Management Committee
Month/year consultation process
completed
Month/year Guideline was approved
July 2016
Next review due
September 2019
Disclosure Status
‘B’ can be disclosed to patients and the
public
Review and Amendment History
Version Date
Description of Change
1.0
Sep
2016
New guidelines for BCPFT
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