Art & science tissue viability supplement Best practice in wound assessment

Benbow M (2016) Best practice in wound assessment. Nursing Standard. 30, 27, 40-47. Date of submission: August 8 2015; date of acceptance: October 11 2015.

Abstract increasing (Bennett et al 2004, Dowsett and Shorney 2010). Much of this expenditure comprises hidden Accurate and considered wound assessment is essential to fulfil costs. As Dowsett (2015) identified, the challenge for professional nursing requirements and ensure appropriate patient and healthcare providers is to balance demands for cost wound management. This article describes the main aspects of holistic efficiency with high quality outcomes for patients. assessment of the patient and the wound, including identifying patient Evaluating costs and successful management of risk factors and comorbidities, and factors affecting wound healing to wounds is not only about dressing choices, but also ensure optimal outcomes. the number of people with wounds, how long these have been present, any complications, the effect on Author the time spent by healthcare professionals and the Maureen Benbow Independent nursing consultant, Crewe, cost of hospital admission when management proves Cheshire, England. ineffective (Drew et al 2007). Correspondence to: [email protected] Keywords Patient assessment The best quality wound management is ineffective if acute wound, chronic wound, exudate, holistic assessment, the patient’s risk and other contributing factors are multidisciplinary working, pain, patient assessment, skin care, not considered during the assessment, along with wound assessment, wound care, wound management their involvement in and acceptance of treatment. Conditions such as diabetes, cardiovascular disease, Review respiratory disease, anaemia, immune disorders, All articles are subject to external double-blind peer review and renal failure and obesity, and concurrent systemic checked for plagiarism using automated software. influences such as ageing, smoking, mobility, nutrition and stress, are important in determining Online the development or occurrence of a wound and how, or whether, it heals. This is because optimal healing For related articles visit the archive and search using the keywords relies on the wound environment being clean, above. Guidelines on writing for publication are available at: not infected, adequately perfused, nourished and free journals.rcni.com/r/author-guidelines. of foreign or devitalised material. Assessment involves identifying, gathering and interpreting information about the patient to THE CODE: PROFESSIONAL Standards of ensure diagnosis is accurate, appropriate treatment Practice and Behaviour for Nurses and Midwives decisions can be made, the patient and the wound (Nursing and Midwifery Council 2015) states can be monitored, and complications can be avoided. that its values and principles are not ‘negotiable or It is also important to ensure cost-effective use of discretionary’, although they may be interpreted in resources and a positive experience for the patient. a range of different settings. This means that, where Assessment includes consideration of the patient’s possible, practice must be high quality, consistent age, the history of the presenting problem and the and designed to meet the standards that patients individual’s past and current medication, medical and members of the public expect. Our professional and family background, nutritional status, chronic responsibilities as healthcare professionals dictate medical conditions, lifestyle choices, psychological that appropriate dressing and/or therapy choices status and socioeconomic circumstances (Fletcher should follow holistic assessment of the patient 2010). The practitioner must be knowledgeable and and the wound, with consideration of the patient’s aware of the importance of the assessment as well as experiences and preferences and their acceptance of allowing sufficient time to conduct the assessment the proposed management. thoroughly and efficiently, making the appropriate It is estimated that up to 4% of the UK’s links and documenting the information accordingly. NHS budget is spent on wound care, which is Wounds should be prevented, where possible, approximately £1.4-2.1 billion annually and is to ease the burden of distress, anxiety, pain,

40 march 2 :: vol 30 no 27 :: 2016 NURSING STANDARD embarrassment, inconvenience, morbidity, hospital and disciplinary and/or legal repercussions for admission and even death associated with wound the practitioner. complications and suboptimal treatment of underlying comorbidities. An accurate, holistic Type of wound assessment should identify potential barriers to Acute wounds progress through the normal healing and inform the wound care plan. However, stages of wound healing and usually heal without successful healing, where possible, is ultimately complication in a healthy person. Chronic wounds determined by the general health of the patient do not progress normally through the stages of (Box 1). It is acknowledged that the emphasis of healing, resulting in extended healing times palliative wound care is wound management because and/or non-healing. Healing of chronic wounds most of these wounds do not heal. In addition to the may occur between four weeks (Cullum et al 1997) patient’s medical history, the cause of the wound, and 12 weeks (Mustoe et al 2006). Lacerations, any medication or allergies, the patient’s lifestyle and contusions, skin tears and surgical wounds are environment, the availability of social support and generally categorised as acute wounds; however, it is any psychological problems should be considered. possible that acute wounds could become chronic Baranoski et al (2008) provided a useful framework in people with significant comorbidities and risk to guide the assessment process, the ‘Nine Cs of factors. These wounds require monitoring, since wound assessment’, comprising: they may deteriorate into chronic wounds. Pressure  Cause of the wound. ulcers, leg ulcers, diabetic foot ulcers and malignant  Clear picture of what the wound looks like. wounds are classified as chronic wounds, with the  Comprehensive picture of the patient. associated underlying risk factors of immobility  Contributing factors. and chronic venous hypertension, or the effects of  Communication to other healthcare practitioners. diabetes or cancer influencing their development.  Continuity of care. In these cases, the wound is effectively chronic from  Centralised location for wound care information. its development and should be treated as such.  Components of the wound care plan. The production of exudate is an essential part  Complications from the wound. of the moist wound healing process. However, Patient assessment involves a thorough physical the amount produced and the components of examination of all skin areas for: signs of exudate in acute and chronic wounds differ. Growth dermatological disorders; scarring, particularly factors, wound debris, electrolytes, enzymes, over pressure points; skin changes, such as those glucose, white blood cells, red blood cells, platelets, associated with venous stasis; the condition of fibrin and fibrinogen are found in normal wound the skin, hair and the nails of the extremities; exudate (Cutting 2003). In an acute wound, skin colour; temperature; pulse; capillary refill; and oedema. Failure to complete a holistic BOX 1 assessment of the patient may result in a Factors affecting wound healing multitude of problems and has the potential to misdirect treatment. General factors:  Underlying disease.  Vascularity. Wound assessment  Nutritional status.  Immune status. A simple definition of a wound is ‘an injury  Obesity. or damage, usually restricted to those caused  Disorders of sensation or movement. by physical means with disruption of normal  Psychological state. continuity of structures’ (Farlex Partner  Radiation therapies. Medical Dictionary 2012). Once the cause of the  Drugs – prescribed, recreational and/or alternative wound is confirmed, it is important to consider therapies. parameters such as whether the wound is acute  Allergies and/or sensitivities. or chronic, the stage of healing, how it is healing, Local factors: whether there are any obvious impediments to  Hydration. healing and the patient’s attitude to having a  Wound management. wound. However, two difficulties that arise are  Wound temperature. that assessment of these parameters is largely  Pressure, friction and shearing forces. subjective and accurate assessment relies on  Foreign bodies.  Wound infection. the knowledge, experience and skill of the  Pain levels. practitioner. Failure to assess a wound accurately (Carville 2005) can result in life-changing sequelae for patients

NURSING STANDARD march 2 :: vol 30 no 27 :: 2016 41 Art & science tissue viability supplement

the exudate is rich in endogenous proteases that bud around the base and sides of the wound to form contribute to the proliferation and growth of new granulation tissue to fill the defect. This occurs cells, thus facilitating wound closure and healing. during secondary intention healing in wounds in Wysocki et al (1993) compared levels of activated which there is a varying amount of tissue loss, often metalloproteinases (MMP) in acute (mastectomy) presenting as ulceration. If the tissue loss is extensive, wound fluid and chronic (leg ulcer) wound fluid. grafting may be required to preserve structure and The authors found elevated levels of MMP in function. Tertiary intention or delayed primary the chronic wound fluid, which they suggested closure may be required in heavily contaminated may result in slower tissue turnover and failed wounds and where the superficial layers are left wound closure. open and packed lightly with dressings followed Physiologically, the healing of chronic wounds by closure after four to five days. These may be bite may be affected by an extended inflammatory wounds or dehisced surgical wounds complicated by phase (Eming et al 2007), repeated infections infection (Waldrop and Doughty 2000). (Edwards and Harding 2004) and the formation of biofilms (Wolcott et al 2008). These factors increase the inconvenience, pain and stress to Assessment parameters patients, as well as increasing related healthcare Wound assessment should be carried out by a costs. An understanding of the healing process and practitioner who has been trained and is competent whether a wound is acute or chronic is necessary in to consider carefully the overall health of the patient the early stages of wound assessment to develop an in relation to what they observe about the wound. appropriate treatment plan. Recognising personal limitations, knowing when to ask for help and team working are vital to successful Type of healing wound management. The initial wound assessment Wounds heal in different ways according to the should be accurate and sufficiently detailed to mechanism of injury and the amount of tissue loss. provide a baseline for subsequent assessments to be In primary or first intention healing, tissue is restored compared and measured against. A standardised, directly in uncomplicated wounds, such as deliberate systematic approach to assessment facilitates incisional wounds with no or minimal tissue loss accurate ongoing evaluation of wound progress, where the wound edges are held in apposition to whether positive or negative. The World Union of each other (Dealey 2012), with no formation of Wound Healing Societies (2007) provides a sequence granulation tissue. Where the wound edges cannot of assessment to ensure best practice (Figure 1). be apposed, fibroblasts proliferate and capillaries Initial observation and measurement FIGURE 1 Observation of the condition of the wound and surrounding skin is essential to assess whether Wound assessment sequence the wound requires cleaning and/or removal of slough or necrotic tissue to improve visualisation of the wound. Removal of slough and/or necrotic 1. Assess the patient tissue may be achieved quickly using moistened debridement products, de-sloughing products or irrigation (Table 1). When the wound type has been identified, 7. Manage exudate 2. Assess the region and related problems of the wound the age of the wound and its location should be considered and should help to confirm the aetiology of the wound. For example, the sudden appearance of a wound on the foot of a patient with diabetes may indicate a diabetic foot ulcer. 6. Assess the 3. Assess the periwound skin current dressing However, there may be confusion about whether a wound on the heel of a patient with diabetes is a diabetic foot ulcer or a pressure ulcer, and this requires further exploration. Non-healing ulcers in unusual locations should prompt suspicion of 5. Assess the wound 4. Assess the base and edge exudate malignancy (Grey et al 2006). The anatomical location must be documented accurately using appropriate terminology and noting the correct side of the body. For example, an ischial tuberosity (World Union of Wound Healing Societies 2007) pressure ulcer is not the same as a sacral pressure

42 march 2 :: vol 30 no 27 :: 2016 NURSING STANDARD

Art & science tissue viability supplement

ulcer; the cause, management and care plan for such as the European Pressure Ulcer Advisory both types of pressure ulcer are different. Panel and National Pressure Ulcer Advisory Panel One of the few objective parameters of wound (2009) categorisation of pressure ulcers, the STAR assessment is measurement of the size of the wound, classification for skin tears (Stephen-Haynes which provides an idea of the amount of tissue and Carville 2011) and the Texas diabetic foot loss. Simple linear measurements with a ruler classification system (Laveryet al 1996). However, should be taken at the greatest length and width the same caveat applies. Wound classification tools perpendicular to each other. Validated measurement are effective only if practitioners are confident in techniques such as transparency tracings and/or using the tools and understanding the findings to photographs (National Institute for Health ensure accurate diagnosis and appropriate treatment. and Care Excellence (NICE) 2014) are useful Without a universal approach and understanding, to compare change over time and establish an such tools may represent a barrier to effective important record. NICE (2014) also recommends multidisciplinary working and optimal patient estimating the depth of wounds but not the volume. outcomes (Watret 2005). The usefulness of measuring the depth of a wound has been questioned, since obtaining an accurate Clinical appearance measurement is quite difficult (Benbow 2005). The type of tissue in the wound bed may be necrotic, Wound photography is an adjunct to sloughy, infected, granulating or epithelialising, documentation of assessment and serves to or may present as a combination of some or all of support the written wound documentation only these. Appropriate identification determines the (Wound Ostomy and Continence Nurses Society wound status and directs treatment. (WOCN) 2012). The WOCN (2012) fact sheet Identification of the tissue types present in the provides essential guidance and advice on consent wound bed enables the practitioner to select the to photography, who should take the photographs, appropriate dressings and course of treatment. and practical issues such as photographs being taken As part of ongoing monitoring of healing progress, from the same vantage point and the same distance or lack of progress, the percentage of different tissue from the wound, use of a measuring guide and not types should be estimated and documented (Fletcher altering clinical photographs. Ongoing consistent 2010). A logical colour classification may be useful measurements, in centimetres and millimetres, for descriptive purposes: black for necrotic, yellow at reassessment are useful, and an awareness of the for sloughy, green for infected, red for granulation effect of treatment with de-sloughing products, and pink for epithelialising tissue. This concept for example, which cause the wound to enlarge has been further developed as a wound healing in the early stages, is necessary. Tracings and continuum to incorporate intermediate colour photographs should be appropriately annotated and combinations (Gray et al 2005), recognising that stored in the patient’s clinical record. not all wound appearances fit neatly into one of the Wounds may be classified according to depth five categories since there is often more than one – superficial, partial thickness and full thickness – tissue type in a wound at the same time. Treatment is but accuracy of assessment relies on the practitioner’s usually aimed at managing the dominant tissue type, knowledge of anatomy. Different wounds may but it also depends on exudate levels. be classified according to wound type-specific Necrotic and sloughy tissue or devitalised tissue is classification systems that reflect their depth, the end product of the death of cells that accumulate as a result of tissue damage in either a dry or moist TABLE 1 medium. The basic principles of management of necrotic and sloughy wounds are to remove Types of debridement the tissue so that healing can proceed in a moist Type Setting and/or mechanism environment (Parnham 2002) and also to reduce Sharp At the bedside, using a scalpel or curette. the risk of infection (Eagle 2009). Debridement Surgical In the operating theatre. or de-sloughing is achieved using gels to assist the natural process of autolysis or by mechanical Autolytic Facilitation of the body’s mechanism of debridement means such as moistened debriding pads or with a with appropriate dressings. scalpel by a practitioner who has been trained and Biological Larval therapy. is competent in the procedure. There are exceptions Enzymatic Not widely used; pawpaw (papaya) or banana skin is that require special consideration and referral to used in developing countries. specialist services, such as patients with diabetes or Mechanical Wet to dry dressings – not used in the UK. peripheral vascular disease, which should have been identified in the patient assessment. The presence (Grey et al 2006) of granulation or epithelialising tissue in the wound

44 march 2 :: vol 30 no 27 :: 2016 NURSING STANDARD bed indicates that the wound is healing and requires For example, vascular ulcers usually are well a more gentle approach because of its fragility. demarcated with steep sides, whereas the wound Normal granulation tissue has a beefy, red, shiny edges in venous stasis leg ulcers slope and are and textured appearance, and bleeds readily not always clearly demarcated (Grey et al 2006) (Figures 2 and 3). Necrotic tissue is usually hard, (Table 2). Undermining may be present where dark in colour and leathery (Figure 4), while slough wound edges are unattached (Worley 2004). may present from light yellow-white to dark brown Observation of wound edges may reveal malignant or grey and is usually soft but can be thick and changes over long periods of time. The colour, stuck-down to the wound surface making it difficult texture and temperature of wound margins should to remove. Over-granulation or hypergranulation be assessed and documented, in addition to any tissue is red with a soft texture and looks different observation of oedema, erythema and/or bruising. from normal granulation tissue. Non-adherent Ineffective management of exudate may silicone, foam or gel products may be used to lead to maceration and/or excoriation or maintain a moist wound environment, taking care irritant dermatitis of the skin surrounding that they do not adhere to the surface in granulating the wound, causing extension of the wound and epithelialising wounds. Wounds may become infected at any stage, FIGURE 2 so they must be monitored for early signs of Small wound with granulation tissue infection at each dressing change. Traditionally, wounds are examined for the classic signs of redness, heat, pain, swelling and loss of function, but these may not be obvious in older patients, people with depressed immune function or those with diabetes. Therefore, additional criteria have been identified that include delayed healing, discoloration, friable granulation tissue that bleeds easily, unexpected pain or tenderness, increased exudate, abnormal smell, bridging, pocketing or otherwise unexplained wound breakdown (Cutting ALAMY and Harding 1994). All wounds contain bacteria, but not all wounds succumb to infection, owing to FIGURE 3 the constant balance in wounds between bacteria Large wound with granulation tissue and the disruption threshold of the host’s immune system (Heinzelmann et al 2002); hence the need to assess the patient’s immune system status.

Exudate Assessment of exudate is possibly one of the most important aspects of wound assessment in terms of identifying underlying health problems and infection, patient satisfaction with care and dressing and/or therapy selection. The type, nature, amount, odour and consistency of exudate should be assessed in addition to why it is excessive in the case of heavily ALAMY exuding wounds. Recording exudate as ‘+’ or ‘+++’ is not particularly helpful, but measuring exudate is FIGURE 4 difficult unless a therapy such as negative pressure Leg wound with necrotic tissue wound therapy or a wound drainage bag is in use. Therefore, documentation of the assessed amount of exudate varies between practitioners depending on their background and experience. For patients, excess exudate can be the most distressing and inconvenient aspect of their wound management.

Wound edges and periwound skin A wound’s edges can provide important information about its aetiology and status. ALAMY

NURSING STANDARD march 2 :: vol 30 no 27 :: 2016 45 Art & science tissue viability supplement

and distress and discomfort for the patient. Odour Regular reassessment indicates whether an The assessment of odour is subjective; however, underlying reason exists for the excess exudate the characteristic musty odour of Pseudomonas and whether dressings are managing the aeruginosa and acrid odour of Staphylococcus exudate adequately. If the skin is dry and scaly, aureus can be identified and raise suspicion of it should be hydrated with an emulsifying cream infection. Necrotic tissue may give rise to wound or ointment and the dead skin removed for odour and should be removed (Grey et al 2006). comfort (Eagle 2009). Pain TABLE 2 The International Association for the Study of Pain (2014) sets out the following minimum standards Wound edge characteristics for practitioners: they should have knowledge Type of wound edge Type of ulcer of pain theories and mechanisms, types of pain Sloping Venous ulcer and what influences patients’ perception of pain Punched-out Arterial or vasculitic ulcer and, in practice, have the ability to assess pain and the methods for relieving pain. Various pain Rolled Basal cell carcinoma assessment tools have been developed. Pain may be Everted Squamous cell carcinoma associated with the underlying pathology, be related Undermining Tuberculosis, syphilis to the dressing or therapy, or arise in anticipation of a painful procedure. The type, time of onset, Purple Vasculitic, such as pyoderma gangrenosum frequency and severity of pain as well as how patients cope with pain should be assessed and (Grey et al 2006) documented. The realisation that practitioners TABLE 3 Laboratory investigations Investigation Rationale Haemoglobin Anaemia may delay healing. White cell count May indicate presence of infection. Platelet count May indicate thrombocytopenia. Erythrocyte sedimentation rate and/or C-reactive These non-specific markers of infection and protein inflammation are useful in diagnosis and monitoring treatment of infections or inflammatory ulceration. Urea and creatinine High urea levels impair wound healing; renal function is important when using antibiotics. Albumin Protein loss delays healing. Glucose, glycated haemoglobin (HbA1c) For patients with diabetes. Markers of autoimmune disease, such as rheumatoid May indicate rheumatic disease, systemic lupus factor, antinuclear antibodies, anticardiolipin erythematosus and other connective tissue disorders. antibodies, lupus anticoagulant Cryoglobulins, cryofibrinogens, prothrombin time, May indicate haematological disease. partial thromboplastin time Deficiency or defect of antithrombin III, protein C, May indicate vascular thrombosis. protein S, factor V Leiden Haemoglobinopathy screen Screens for sickle cell anaemia, thalassaemia. Human immunodeficiency virus status May indicate Kaposi’s sarcoma. Serum protein electrophoresis; Bence-Jones proteins May indicate myeloma. Urine analysis Useful in connective tissue disease. Wound swab Not routine since all ulcers are colonised, which is not the same as infected; swab only when the wound is displaying clinical signs of infection. (Grey et al 2006)

46 march 2 :: vol 30 no 27 :: 2016 NURSING STANDARD and patients required more guidance on pain Conclusion assessment and management led to the development Holistic assessment involves identifying, of two consensus documents (European Wound gathering and interpreting information Management Association 2002, World Union of about the patient and wound to ensure Wound Healing Societies 2004). accurate diagnosis, appropriate treatment, ongoing monitoring and prevention of complications. For successful management Investigations of patients and wounds, practitioners require As part of the patient and wound assessment and appropriate knowledge of the healing to identify underlying and contributing factors, process. The use of a standardised, the laboratory investigations listed in Table 3 systematic approach to assessment assists should be considered. A multidisciplinary approach the practitioner in the accurate evaluation to managing patients with wounds is necessary of the wound, with the overall aim because of the variety of investigations that may be of ensuring optimal wound as well as carried out in different healthcare specialties. patient outcomes NS

References Baranoski S, Ayello EA, Langemo DK Drew P, Posnett J, Rusling L; Team Grey JE, Enoch S, Harding KE (2006) Waldrop J, Doughty D (2000) (2008) Wound assessment. In Wound Care Audit (2007) The cost Wound assessment. BMJ. 332, Wound healing-physiology. In Baranoski S, Ayello EA (Eds) Wound of wound care for a local population 7536, 285-288. Bryant R (2000) Acute and Chronic Care Essentials: Practice Principles. in England. International Wound Wounds: Nursing Management. Second edition. Lippincott, Williams Journal. 4, 2, 149-155. Heinzelmann M, Scott M, Lam T Second edition. Mosby, and Wilkins, Ambler PA, 77-92. (2002) Factors predisposing to London, 17-39. Eagle M (2009) Wound assessment: bacterial invasion and infection. Benbow M (2005) Evidence-Based the patient and the wound. Wound American Journal of Surgery. Watret L (2005) Wound bed Wound Management. Whurr, London. Essentials. 4, 14-24. 183, 2, 179-190. preparation and the diabetic foot. Diabetic Foot Journal. 8, 1, 18-26. Bennett G, Dealey C, Posnett J Edwards R, Harding KG (2004) International Association for (2004) The cost of pressure Bacteria and wound healing. Current the Study of Pain (2014) Pain Wolcott RD, Rhoads DD, Dowd SE ulcers in the UK. Age and Ageing. Opinion in Infectious Diseases. Treatment Services. www. (2008) Biofilms and chronic wound 33, 3, 230-235. 17, 2, 91-96. iasp-pain.org/Education/Content. inflammation.Journal of Wound aspx?ItemNumber=1381 (Last Care. 17, 8, 333-341. Carville K (2005) Wound Care Eming SA, Krieg T, Davidson JM accessed: January 26 2016.) Manual. Fifth edition. Silver Chain, (2007) Inflammation in wound World Union of Wound Healing Perth, repair: molecular and cellular Lavery LA, Armstrong DG, Societies (2004) Principles of mechanisms. Journal of Harkless LB (1996) Classification of Best Practice: Minimising Pain Cullum N, Fletcher A, Semlyen A, Investigative Dermatology. diabetic foot wounds. Journal of Foot at Wound Dressing-Related Sheldon TA (1997) Compression 127, 3, 514-525. and Ankle Surgery. 35, 6, 528-531. Procedures. A Consensus Document. therapy for venous leg ulcers. Quality MEP Ltd, London. in Health Care. 6, 4, 226-231. European Pressure Ulcer Advisory Mustoe TA, O’Shaughnessy K, Panel, National Pressure Ulcer Kloeters O (2006) Chronic wound World Union of Wound Healing Cutting K (2003) Wound exudate: Advisory Panel (2009) Pressure pathogenesis and current treatment Societies (2007) Principles of Best composition and functions. Ulcer Treatment: Quick Reference strategies: a unifying hypothesis. Practice: Wound Exudate and the British Journal of Community Guide. National Pressure Ulcer Plastic and Reconstructive Surgery. Role of Dressings. A Consensus Nursing. 8, 9, S4-S9. Advisory Panel, Washington DC. 117, 7, 35S-41S. Document. MEP Ltd, London.

Cutting KF, Harding KG (1994) European Wound Management National Institute for Health Worley CA (2004) Assessment Criteria for identifying wound Association (2002) Position and Care Excellence (2014) and terminology: critical issues in infection. Journal of Wound Care. Document: Pain at Wound Dressing Pressure Ulcers: Prevention and wound care. Dermatology Nursing. 3, 4, 198-201. Changes. MEP Ltd, London. Management. NICE, London. 16, 5, 451-452, 457.

Dealey C (2012) The Care of Wounds. Farlex Partner Medical Dictionary Nursing and Midwifery Council Wound Ostomy and Continence A Guide for Nurses. (2012) The Free Dictionary. http:// (2015) The Code: Professional Nurses Society (2012) Photography Fourth edition. Blackwell medical-dictionary.thefreedictionary. Standards of Practice and in Wound Documentation: Fact Science, Oxford. com/wound (Last accessed: Behaviour for Nurses and Sheet. www.wocn.org/resource/ January 26 2016.) Midwives. NMC, London. resmgr/Publications/Photography_ Dowsett C (2015) Breaking the in_Wound_Documen.pdf (Last cycle of hard-to-heal wounds: Fletcher J (2010) Development of Parnham A (2002) Moist wound accessed: January 26 2016.) balancing cost and care. Wounds a new wound assessment form. healing: does the theory apply to International. 6, 2, 17-21. Wounds UK. 6, 1, 92-99. chronic wounds? Journal of Wound Wysocki AB, Staiano-Coico L, Care. 11, 4, 143-146. Grinnell F (1993) Wound fluid from Dowsett C, Shorney R (2010) Gray D, White R, Cooper P, Kingsley A chronic leg ulcers contains elevated QIPP. High impact for less (2005) Understanding applied Stephen-Haynes J, Carville K (2011) levels of metalloproteinases MMP-2 pressure. Health Service Journal. wound management. Wounds UK. Skin tears made easy. Wounds. and MMP-9. Journal of Investigative 120, 6235, 24. 1, 1, 62-68. International. 2, 4, 1-6. Dermatology. 101, 1, 64-68.

NURSING STANDARD march 2 :: vol 30 no 27 :: 2016 47