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Special Considerations in Wound Bed Preparation 2011: an Update

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Special Considerations in Wound Bed Preparation 2011: an Update CLINICAL PRACTICE Special Considerations in Wound Bed Preparation 20 11: An Update Part one of this article was published in the Spring 2012 issue of Wound Care Canada . Part two is published here. R. Gary Sibbald BSc Local Wound Care There are several new electronic technologies avail - MD MEd FRCPC(Med, Derm) MACP FAAD 5. Assess and monitor the wound history and physical able for wound assessment, but they may be costly MAPWCA, Professor, examination for clinicians and healthcare systems. Novel camera Public Health Sciences Documentation of a detailed patient and wound systems accurately calculate the length, width, depth and Medicine; Director, International assessment is a legal requirement from both an and surface of exposed wound areas. Limitations Interprofessional Wound organizational and professional standards perspective. include undermined areas or sinuses that are not Care Course and Masters of Science in Community Specific details about the wound history and physical measureable using this technology, requiring supple - Health; Dalla Lana appearance will facilitate communication within the mentation by visual clinical inspection and probing. School of Public Health, University of Toronto, patient’s circle of care. This includes the type of wound Wound assessment devices differ markedly from Toronto, Ontario, Canada and its history, the patient-centred plan of care and computer-based documentation systems that capture 57 Laurie Goodman BA targeted patient-specific goals. The details of the multiple data points and assessments about wound RN MHScN, Director, wound assessment should be communicated to parameters inputted by skilled clinicians. and Mississauga Halton Wound Care Initiative, other professionals when referrals are made. Whether Toronto Regional a wound is healable, nonhealable or maintenance, an 6. Gently cleanse wounds with low-toxicity solu - Wound Clinics, Toronto, individualized care plan is made to identify specific tions: saline, water and acetic acid (0.5–1.0%). Do Ontario, Canada interventions and outcomes that the patient and not irrigate wounds where you cannot see where Kevin Y. Woo PhD RN interprofessional team agree upon and modify based the solution is going or cannot retrieve (or aspirate) FAPWCA, Assistant Professor, Faculty of on a new holistic interprofessional assessment. the irrigating solution Health Sciences, School Using a framework allows consistent documentation The standard of care for wound cleansing is to use of Nursing, Queen’s University, Kingston; of a wound. When a framework is used to assess a solutions that are gentle and the least cytotoxic to the Wound Care Consultant, wound over time, clinicians can identify if a wound wound: saline, water and acetic acid (0.5–1.0%). West Park Health Centre, Toronto, Ontario, Canada is improving, stalled or deteriorating. One example of Research has shown that certain solutions can be such a framework is the mnemonic MEASURE 58 – the cytotoxic to healing cells, such as fibroblasts, in vitro. 59 Diane L. Krasner PhD RN CWCN CWS MAPW - wound location plus MEASURE is described: In an analysis of Cochrane Reviews prior to 2008, CA FAAN, Clinical Nurse • Measure size – the longest length and the widest the authors concluded: “There is not strong evidence Specialist/Wound, width at right angles. that cleansing wounds per se increases healing or Ostomy, Continence Nurse, Rest Haven–York; • Exudate amount (none, scant, moderate, heavy) reduces infection.” The Cochrane Collaboration Wound and Skin Care and characteristics (serous, sanguineous, pustular or updated evidence reviews on wound cleansing Consultant, York, Pennsylvania, USA combinations). for PUs in 2011 and concluded there is “no good • Appearance (base: necrotic [black], fibrin [firm yellow], evidence to support use of any particular wound Hiske Smart MA RN 60 PG Dip (UK) IIWCC slough [soft yellow] or granulation tissue [pink and cleansing solution or technique for PUs.” A specific (Canada), Clinical Nurse healthy vs. red and friable = easy bleeding, unhealthy]). type of solution for wound cleansing in adults was Specialist and IIWCC Course Coordinator – • Suffering (pain). the subject of an additional evidence review in 2010. South Africa, Division • Undermining (measure in centimetres and use The authors concluded that there was no evidence of Community Health, Department of hands of clock to document: 12 o’clock, 6 o’clock and to indicate that using tap water to cleanse an acute Interdisciplinary Health so on). wound increases infection rates. In addition, there Sciences, Stellenbosch University, Stellenbosch, • Re-evaluate. was no strong evidence demonstrating that cleansing South Africa • Edge (hyperkeratotic, macerated, normal). of wounds at all decreases healing infection or Wound Care Canada / Volume 10, Number 3 Soins des plaies Canada / Volume 10, numéro 3 25 Gulnaz Tariq RN promotes healing. 61 Expert opinion recommends that Alternatively, autolytic debridement is most accepted to BSN PG Dip (Pak), caution should be considered in the use of tap water work by keeping a moist wound environment to enhance Wound Care Specialist, Sheikh Khalifa for immunocompromised individuals, especially the the activities of phagocytic cells and endogenous Medical City; IIWCC use of nonpotable water, which may be a problem in enzymes on nonviable tissues. Mechanical debridement Course Coordinator – Abu Dhabi, Abu Dhabi, developing countries. with saline wet-to-dry dressing contributes to local trauma United Arab Emirates Avoiding cytotoxic solutions, such as Dakin’s and povi - and pain. In the US, the Centers for Medicare and done-iodine, to cleanse healable wounds or using them Medicaid Services, in its Tag F314 guidance, cautions that Elizabeth A. Ayello PhD RN ACNS-BC for only limited periods is reasonably prudent practice. there should be limited use of wet-to-dry dressings. CWON MAPWCA FAAN, However, there is a place for these agents in the Emerging technology using ultrasonic devices has also Faculty, Excelsior College School of Nursing, management of maintenance or nonhealable wounds been demonstrated to aid wound bed preparation with - Albany; President, to potentially control bioburden and odour. In these out the incumbent painful and traumatic scraping and Ayello, Harris and Associates, Inc., cases, the reduction in bioburden and moisture reduc - cutting associated with sharp and mechanical debride - Copake, New York, USA tion outweighs the small potential for tissue toxicity. ment. When using enzymatic debridement, clinicians Wound irrigation has also been the subject of should ensure that the cleansing solutions and type of Robert E. Burrell PhD MSc, Professor and controversy and disagreement between health profes - dressing used to cover the wound do not interfere with Chair, Department of sionals. In general, the authors recommend that or cancel out the action of the enzyme. Biomedical Engineering, Faculties of Engineering clinicians should not irrigate wounds where they In summary, the different methods of debridement and Medicine and cannot see where the solution is being instilled into have distinct features in terms of pain potential, cost, Dentistry; Professor and Canada Research the dead space at the base of the wound, or if they healthcare professional time and skill level required, Chair, Nanostructured cannot retrieve the irrigating solution. More research resources used and wound characteristics. Select Biomaterials Chemical on wound cleansing is needed. the appropriate method of wound debridement and Materials Engineering, Faculty of considering the patient, the wound characteristics, Engineering, University 7. Debride: healable wounds – sharp or conservative and the skill and knowledge of the clinician, along of Alberta, Edmonton, Alberta, Canada surgical, autolytic, mechanical, enzymatic, biological with the available resources. (medical maggots); nonhealable and maintenance David H. Keast, MD MSc BSc(Hon) – conservative surgical or other methods of 8. Assess and treat the wound for superficial critical DipEd CCFP FCFP, removal of nonviable slough colonization/deep infection/abnormal persistent Centre Director, Aging, The wound bed is optimally prepared by aggressive inflammation (mnemonic NERDS), deep infection Rehabilitation and Geriatric Care Research and regular debridement of any firm eschar or soft (mnemonic STONEES) or persistent inflammation: Centre, Lawson Health slough if the wound is healable. A firm eschar serves any 3 NERDS – treat topically: Nonhealing, h Research Institute, London, Ontario, Canada as a pro-inflammatory stimulus inhibiting healing, Exudate, Red friable tissue, Debris, Smell; any 3 whereas the slough acts as a culture media for STONEES – treat systemically: h Size, h Temperature, Dieter Mayer MD bacterial proliferation and should be removed. 62 Os, New breakdown, Exudate, Erythema/ FEBVS FAPWCA, Head h h of Wound Care, Senior Debridement may also promote healing by removing edema (cellulitis), Smell; persistent inflammation Vascular Consultant, senescent cells that are deficient in cellular activities (non-infectious): topical and/or systemic anti- Clinic for Cardiovascular 63 Surgery, University and biofilms that contain the bacterial colonies. inflammatories. Hospital of Zurich, Sharp debridement is the most expeditious method Chronic wounds containing bacteria and/or the Zurich, Switzerland but may not always be feasible because of pain, presence of bacteria obtained from a surface swab Linda Norton BScOT bleeding potential,
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