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 Definition Anti-microbial 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 Debridement The process of cleaning an open wound by removal of foreign material and dead tissue, so that healing may occur Diabetic foot A foot affected by ulceration that is associated with neuropathy ulcer and/or peripheral arterial disease of the lower limb in a patient with diabetes Epithelisation Epithelialisation is characterised by the proliferation and migration of epithelial cells across the wound surface Exudate 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 Granulation Granulating tissue is composed of collagen and "ground substance", and contains new capillary loops that give granulation tissue its characteristic red colour Leg ulcer A loss of skin below the knee on the leg or foot which takes more than 6 weeks to heal Pressure ulcer 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 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 Necrosis 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. Wound Management Guidelines Page 1 of 12 Version 1.0 September 2016

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 Time scale Characteristics Inflammatory 0-5 days Clotting vasodilation Phagocytosis Proliferation 5-24 days Fibroblast and endothelial cells increase Collagen synthesis Granulation tissue Epithelial closure(wound shrinkage) Maturation 24 days to 2 years 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.

 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 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.

. 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?

 Tissue Viability Leads  Physical Health Matron  Tissue Viability Link Nurses  District Nurses

What overarching policies the guideline links to?

 Pressure Ulcer policy  Tissue Viability policy  Infection Control policy  Medicines management policy  NMP policy  Royal Marsden Manual of Clinical Nursing Procedures

References

 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 B. Surgical C. Trauma D. Burn E. Leg Ulcer F. Foot G. Other Sore Ulcer

R L

R R

Date Wound Wound Wound & Plan Signature Date Resolved Signature Occurred Type Number

Factors that could delay healing Indicate Y/N *Delete as appropriate Diabetes Metabolic Disorder Known Anaemia Neurological Disease Peripheral Vascular Disease Rheumatoid Arthritis Smoking Age Related Mobility Deficit *steroids/NSAID’s/Chemo/Radiotherapy/Warfarin/ Benzodiazepines/Neuroleptics Incontinence Poor Nutritional State Non-Concordance Known Allergy (list details)

MRSA Status Positive Negative Unknown Carrier

Specialist Referral Vascular Dermatology Diabetic Foot Dietician Tissue Other Clinic/Podiatry/Orthotics Viability (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 Wound Management Guidelines Page 9 of 12 Version 1.0 September 2016

Appendix 3

WOUND TREATMENT CARE PLAN NUMBER ______

SITE OF WOUND: ______

Plan implementation date: Completed by: CLEANSING REGIME REQUIRED : 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 Consider other  Ulcer history causes and refer to appropriate specialist:  Dermatology  Malignancy Signs of venous  Pressure disease/oedema, e.g. No  Autoimmune varicosities, skin changes, skin staining oedema, eczema  Arterial  Diabetes

Yes ABPI <0.5 ABPI >1.3 Urgent referral to Consider classification, assess vascular centre, no Perform ABPI foot pulses, Doppler waveflow. compression Consider referral to vascular centre and/or tissue viability

ABPI -0.5-0.8 Mixed disease, refer ABPI 0.8-1.3 to vascular No evidence of significant centre/tissue arterial disease safe to viability team, compress reduced compression *Consider why exudate is following specialist not controlled with topical advice dressings, is there any If oedema evidence of infection or present, Is the exudate increased bacterial load, is Re-assess apply weekly No* controlled within the dressing size/choice inelastic topical dressing? appropriate for exudate compression amount? bandage system If no oedema present, Yes apply elastic or inelastic compression bandage system Is there a large amount Compression of reducible No hosiery kit oedema/limb distortion? 40mmHg

Once leg ulceration is healed refer to recommendations in the Best Practice Statement: nd After 4 weeks of treatment, if Compression Hosiery (2 edition) Yes there is no reduction in ulcer Wounds UK, 2015). Consider size refer to vascular/tissue referral to vascular services to viability service for review. assess need for venous intervention Apply inelastic If the wound does not heal in to reduce the risk of recurrence, as compression system per NICE guidelines CG168 (2013) 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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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 Executive Director of Nursing, AHPs and whose portfolio this guideline comes under Governance Guideline Lead/Author Physical Health Matron Job titles only Committee/Group Responsible for Medicines Management Committee Approval of this Guideline Month/year consultation process

completed Month/year Guideline was approved July 2016

Next review due September 2019 ‘B’ can be disclosed to patients and the Disclosure Status public

Review and Amendment History Version Date Description of Change Sep 1.0 New guidelines for BCPFT 2016

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