Exudate Management Patient-Centred Wound Care

Exudate Management Patient-centred wound care

In association with

Contents Foreword 3 1 Exudate management 4 2 Exploring the link between the clinical challenges of wound exudate and infection 8 3 Quality of life: patient safety and satisfaction 13

Flivasorb® case studies Case study 1: Treating a sinus 5 Case study 2: Leaking venous leg ulcer 7 Case study 3: Diabetic patient with sinus on left foot 9 Case study 4: Pressure ulcer to sacrum 11 Case study 5: Trauma injury to right lower limb 15 Case study 6: Management of a sacral sinus 17 Case study 7: When a foam is not enough in managing sacral pressure ulcers 18 Case series: Management of moderate to high exudate in chronic wounds 19

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P 2 exudate management M a r c h 2 0 1 3 Foreword: quality of life

Consultant Editor Janice Bianchi, Medical Education Specialist, Janice Bianchi Honorary Lecturer at University of Glasgow Authors Louise Gregory Sylvie Hampton ound healing is a sophisticated, and chronic wound exudate and how to June Jones continuous process where cells assess it. Deborah Kattell undergo a number of complicated In article 2, June Jones discusses Karen Ousey W biological changes to facilitate haemostasis, the link between infection and exudate. Brigitte Price Joy Tickle combat infection, migrate to the wound The different wound environments Debby Verrall space, deposit a matrix, form new blood seen in chronic wounds, such as wound Lynne Whitmore vessels and contract to close the defect contamination, colonisation, critical (Jones et al, 2008). Wound exudate is an colonisation, infection and biofilms, essential component of this normal wound are explained. She also describes the healing process. ideal environment for bacterial growth In chronic wounds, however, the exudate and how we can intervene to alter this, produced can be detrimental to the process. creating a healthier wound bed to allow Wound exudate, particularly from chronic healing to occur. Finally, June discusses wounds, contains a cocktail of elements how different types of dressing deal with (cellular debris and enzymes), which can be these challenges. highly corrosive, both to the wound bed and In article 3, Karen Ousey looks at the intact skin surrounding the wound (Coutts issues around quality of life in patients et al, 2001). with exuding wounds. She examines the For the health professional caring for government agenda, which takes patient patients with chronic wounds, controlling safety and effectiveness of care for granted, exudate can be one of the biggest with the focus now on the patient experience challenges. Managing wet wounds is costly and patient satisfaction with care. Karen in terms of dressing materials and nursing discusses how the government agenda time and in the current economic climate relates to wound care—and patients with within health care we are more than ever exuding wounds, in particular. aware of reducing costs. To bring a clinical focus to the Of perhaps greater importance, the supplement, we have included a series of 7 impact on the patient of living with a case studies and 1 case series on different chronic exudating wound should not be chronic wounds, where either Flivasorb® underestimated. As health professionals, or Flivasorb® Adhesive (Activa Healthcare) we must have an awareness of the were used to control high levels of exudate. emotional impact that having a wet and In addition to the positive effects of these possibly malodorous wound has on the dressings on the wounds, the case studies patient and his or her family and carers. provide insight into the impact of effective Detailed assessment will allow us to exudate control on the patient. References determine the cause of high levels of Due to many factors, including an ageing Coutts P, Queen D, Sibbald RG exudate and put into place a management population and diverse disease processes, (2001) Peri-wound Skin Protection: A comparison of a new skin barrier plan to reduce exudate levels and ultimately we are faced with multiple challenges vs. traditional therapies in wound improve the quality of life of the patient. relating to patients with chronic wounds. management. Poster presentation, CAWC, London This supplement explores the challenge Ultimately, if we assess and treat patients Jones V, Harding K, Stechmiller J, of wet wounds and aims to offer some with highly exuding wounds appropriately, Schultz G (2008) ‘Acute and chronic practical solutions. we can improve quality of life for the wound healing’. In: Baranoski S, Ayello EA (eds). Wound Care In article 1, Sylvie Hampton and Debby patient, reduce treatment costs and meet Essentials: Practice Principles. 2nd Verrall explain what causes exudate. the government agenda on the need for edn. Lippincott, Williams, Wilkins, Philadelphia PA They look at the difference between acute patient-centred care.

e x u d at e management M a r c h 2 0 1 3 P 3 1 Exudate management

Sylvie Hampton, Tissue Viability Consultant Nurse, and Debby Verrall, Tissue Viability Assistant Practitioner, Eastbourne Wound Healing Centre

Figure 1 Abstract Controlling wound exudate is a common problem that has traditionally been managed by changing dressings frequently—and using dressings that were not designed for highly exuding wounds. Wound exudate can have a significant impact on a patient’s quality of life and can delay wound healing (World Union of Wound Healing Societies (WUWHS), 2007). It is also challenging for clinicians and can be costly in terms of clinical time and dressing cost (Dowsett, 2011). Use of appropriate absorbent dressings for effective exudate management can reduce time to healing, Figure 1. Maceration caused by exudate and proteolytic enzyme damage reduce exudate-related problems such as periwound requiring less frequent changing (Tadej, 2009). Therefore, skin damage and infection, improve patients’ quality use of appropriate absorbent dressings for effective exudate of life, reduce dressing change frequency and clinician management can reduce time to healing, reduce exudate- input, and so, overall, improve healthcare efficiency related problems such as periwound skin damage and (Romanelli, et al, 2009). infection, improve patients’ quality of life, reduce dressing change frequency and clinician input, and so, overall, improve Key words healthcare efficiency (Romanelli et al, 2009). This is vital in Exudate • Superabsorbent dressings • today’s climate of calls for efficiency and cost-effective care Acute inflammatory phase• Chronic phase in the NHS. Successful wound management requires a flexible approach to the selection and use of products, based upon ince George Winter’s seminal paper on moist wound an understanding of the healing process and knowledge of healing (Winter, 1962), it has been recognised that the the properties of the various dressings available (Stephen- Scontrol of fluid is pivotal. However, although a moist Haynes, 2011). Assessment of the wound should be part wound environment is necessary for optimal wound healing of the holistic assessment of the patient (Figure 8), which (Okan et al, 2007), over- or under-production of exudate may should include the cause of the wound being identified. adversely affect healing (Romanelli et al, 2009) and fluid lost Appropriate treatment should then be considered, such as from chronic wounds can cause damage if it is not properly compression therapy for venous leg ulcers and removal of controlled (Hampton, 2011). Even with the knowledge that pressure where pressure ulcers have occurred. It must also exudate must be controlled, there are still situations in be accepted that such treatment may not be possible in all which nurses are having to change dressings a number of patients for a variety of reasons, which may include patient times in 24 hours to prevent maceration, soiling, and the concordance and appropriateness of the therapy for that potential for cross-infection (Benbow and Stevens, 2010). individual patient and their circumstances. Having identified Highly exuding wounds are common and cause great the cause of the wound and a suitable management plan, distress to patients. Efficient and cost-effective management the choice of dressing and associated products becomes of excessive wound exudate continues to present unique important with regard to an acceptable solution for the challenges to nurses (Benbow and Stevens, 2010). Clinicians patient and creating the right environment for the wound to who routinely handle the challenge of wound management heal, if indeed healing is the end goal. face the well-known problems of wound deterioration or delayed healing (White, 2003). Superabsorbent dressings Exudate have been designed to deal with this problem and have a We are now urged to create the optimum moist environment, greater fluid-handling capacity than traditional dressings, avoid maceration, and be cost-effective. However, the

P 4 exudate management M a r c h 2 0 1 3 Treating a sinus

Introduction Figure 2 Figure 3 Mr RC is an 85-year-old gentleman who developed a pressure injury while in hospital, with a sudden onset of chest infection. However, the pressure injury had never fully healed and had formed a sinus that was oozing considerably (Figure 2). The failure to heal could have been associated with blockage created by a ribbon dressing applied in the sinus to prevent it sealing over

before it could heal from the base. The thought was that C ase Study 1 Figure 4 Figure 5 the ribbon was creating a pressure at the lower end of the sinus, preventing it from granulating upward. The secondary dressing tended to slip (Figure 3). It was decided to allow it to drain freely, but assess the potential for the surface closing too soon.

Method Flivasorb® Adhesive (Activa Healthcare) was applied over the sinus (Figure 4), allowing free drainage directly Figure 6 Figure 7 into the dressing. As the dressing locked the fluid away, it was unlikely to reflect fluid onto the skin and would, therefore, not cause maceration.

Results The wound responded extremely well and the wound and periwound area began to dry and to granulate from the base of the wound (Figures 5 and 6). Conclusion The only concern was selection of the most appropriate Discussion dressing and Flivasorb® Adhesive provided an ideal The dressing absorbed extremely well (Figure 7) and the environment for this wound and remained in situ between wound achieved full closure. Mr RC’s care was optimal, dressing changes (Figure 7) without slippage, ensuring with equipment and repositioning regimes in place. patient comfort and supporting wound closure.

means to reach these goals are not always obvious, nor the practitioner about bacterial contamination, infection easily achieved (White, 2003), particularly in wounds that and stage of healing (Hampton and Collins, 2003). are producing large amounts of fluid. Devising strategies Production of wound exudate is a complex phenomenon to minimise the impact on the patient’s physical and that occurs as a result of vasodilation during the early psychosocial wellbeing can be particularly demanding. inflammatory stage of healing under the influence of Over-production of exudate can cause devastating damage inflammatory mediators such as histamine and bradykinin to the skin (Figure 1) and must be effectively managed if the and has a vital role in wound healing. Exudate contains: optimal moist environment necessary for wound healing is • Water to be created, and the surrounding skin protected from the • Nutrients risks of maceration (White and Cutting, 2006). • Electrolytes The management of wound exudate requires the • Inflammatory mediators clinician to have an understanding of what it is, why it • White cells is present and how to monitor and assess it accurately • Protein-digesting enzymes (White and Cutting, 2006). Exudate can also be an • Growth factors. excellent indicator of what is happening within a wound, and therefore provides valuable information during patient Acute inflammatory phase of exudate assessment (Tadej, 2009). The volume, consistency, and Proteases are the enzymes present in wound exudate and particularly odour and colour of any exudate will inform in acute wounds. They maintain a balance between tissue

e x u d at e management M a r c h 2 0 1 3 P 5 synthesis and degradation by regulating gene expression • Preventing the wound from drying out and enzyme activation and inhibition. This will occur during • Aiding the migration of tissue-repairing cells the acute inflammatory phase and means that the wound • Providing the essential nutrients for cell metabolism requires little nursing care as, providing the underlying • Enabling the diffusion of immune and growth factors causes of the wound are addressed and the dressing is • Assisting the separation of dead or damaged tissue— appropriate, the exudate constituents will orchestrate the autolysis (World Union of Wound Healing Societies healing process. (WUWHS), 2007). However, once a wound becomes chronic, the MMPs Chronic phase of exudate also become chronic and this can then become a significant This clever and automatic healing environment changes factor in delaying wound healing (WUWHS, 2007). The when the wound becomes chronic through infection or chronic inflammation created within the wound can lead patient comorbidities, or because underlying causes such to unmanageably high levels of exudate, which in turn can as pressure or inefficient venous return remain a problem, cause periwound damage (Bishop et al, 2003) with the skin due to poor knowledge or lack of skill in addressing being eroded by the proteolytic enzymes in the exudate the underlying condition. At this point, there is chronic (Young, 2000; Fletcher, 2002). The WUWHS recommends inflammation and the exudate changes from orchestrating assessing the exudate levels and has produced a document, the healing process with assistance of proteases to a Wound exudate and the role of dressings, which provides a condition that will delay healing considerably, through useful tool in order to assess appropriately (see Figure 8). damaging proteolytic enzymes and over-hydration. There The WUWHS recommends reviewing the local will be increased proteolytic activity in chronic wound factors that may be influencing exudate production and exudate; this is implicated in perpetuating wounds, establishing whether the patient accepts and cooperates damaging the wound bed, degrading the extracellular with treatment. matrix, and causing periwound skin problems (Romanelli Once the assessment is completed, there is a et al, 2009), as seen in Figure 1. requirement—for the patient’s comfort and safety—to Wound exudate can be a challenge to the health choose an appropriate dressing that will absorb well and professional and to the patient who has to live with oozing retain the fluid without reflecting it back onto the skin. and discomfort associated with a leaking wound. Chronic Flivasorb® is an ideal dressing for this purpose because, wound exudate contains high levels of matrix metallo- as a superabsorbent dressing, it has a greater fluid- proteases (MMPs). These MMPs are essential when handling capacity than other absorbent dressings, such a wound is acute and actually orchestrate the wound as some foam-type dressings. Flivasorb® is excellent healing process by: as a primary dressing, but can be used as a secondary

Figure 8. Exudate assessment and management (WUWHS, 2007)

Management of exudate 1. Assess the patient and related problems • Comorbidities (wound and exudate aetiology) • Medication • Cooperation with therapy 6. Assess the periwound skin • Psychological issues • Nutritional status • Maceration/excoriation – reddening/loss of colour, spongy texture, loss of Exudate skin surface assessment 2. Assess the region of the wound • Local disease/other skin conditions • Wound position 5. Assess the wound base and edge • Wound history • Size 4. Assess the exudate 3. Assess the current dressing • Stage of healing • Colour • In situ and after removal • Infection/inflammation • Consistency • Use as an indication of amount • Fistula/sinus • Odour of exudate

P 6 exudate management M a r c h 2 0 1 3 Leaking venous leg ulcer Figure 9 Figure 10 Figure 11 Figure 12

Introduction Results C ase Study 2 SW is a 67-year-old man with a venous leg ulcer that Within 1 week of application of Flivasorb® as a primary was constantly leaking. The dressings were an alginate dressing, the wound had reduced by 20% and epithelial under a foam secondary dressing and the Actico® tissue had increased by the same amount (Figure 10). At cohesive inelastic compression bandage system (Activa 3 weeks, the wound had achieved 90% closure (Figure 11) Healthcare). The Actico® system is simple to apply, and a week later had achieved full closure (Figure 12). remains in place and allows the patient to wear normal shoes. It is consistently used with high success in Discussion Eastbourne Wound Healing Centre and was an excellent This wound progressed from a static state to full closure compression system to select in this case. The wound in less than 5 weeks and this change in the healing (Figure 9) was of 7 months’ duration and was extremely status occurred after the application of Flivasorb®. painful. A Doppler assessment showed an ankle brachial Non-adhesive dressings are always used under pressure index of 0.9. compression; adhesive is unnecessary as the dressing will remain safely in situ, held by the bandage. Method Additionally, adhesives can cause increased sensitivity The wound had some granulation and epithelial tissue so their use under compression is not advisable. (Figure 9), but had become static and had not shown signs of healing for 3 weeks. The exudate had increased Conclusion and the wound was painful to a level of 5 on a scale of 1 Once healed, the wound area was no longer painful. (no pain) to 10 (worst pain possible). The fluid was obviously no longer a problem as the Flivasorb® was selected as the dressing and the tissues were closed and SW could wear hosiery patient consented to be photographed for an evaluation instead of compression bandages. This resulted in an of the product. improvement in his quality of life.

absorbent layer, for example, over a cavity or where an References Benbow M, Stevens J (2010) Exudate, infection and patient quality of life. Br J Nurs 19(20): antimicrobial dressing is used as the primary dressing. S30–6 The main role of dressings in exudate management is to Bishop SM, Walker M, Rogers AA, Chen WY (2003) Importance of moisture balance at the wound dressing interface. J Wound Care 12(4) 125–8 absorb the excess fluid (Menon, 2012). They must be able Dowsett C (2011) Moisture in wound healing: exudate management. Br J Community Nurs 16(6 suppl): 6–12 to lock the exudate into the dressing to protect the wound Fletcher J (2002) Exudate theory and clinical management of exuding wounds. Prof Nurse bed and surrounding skin from excess chronic fluid and 17(8): 475–8 Hampton S (2011) Understanding and managing wound exudate. Nursing & Residential harmful components such as the proteolytic enzymes Care 13(10): 480–2 Hampton S, Collins F (2003) Tissue Viability. Whurr Publications, London and bacteria. Menon J (2012) Managing exudate associated with venous leg ulceration. Br J Community In conclusion, before applying any dressing, there should Nurs 17(6)(supplement): S6–16 Okan D et al (2007). The role of moisture balance in wound healing. Adv Skin Wound Care be an holistic assessment of the patient and the individual 20(1): 39–53 Romanelli M, Vowden K, Weir D (2009) Exudate management made easy. Wounds wound, which would lead to appropriate dressing selection International. http://tinyurl.com/4zt3nqh (accessed 9 January 2013) Stephen-Haynes J (2011) Managing exudate and the key requirements of absorbent and provision of the optimum wound-healing environment. dressings. Br J Community Nurs 16(3 Suppl): S44–9 In order to support any wound that is highly exudating, Tadej M (2009) The use of Flivasorb® in highly exuding wounds. Br J Nurs 18(15): s38–s42 White R (2003) Exudate management in the 21st century. Introduction. Br J Community a superabsorbent dressing is the ideal solution. It will Nurs 8(9)(Exudate Suppl 1): 3–3 White R, Cutting KF (2006) Modern wound exudate management: a review of wound support the moist environment without being too wet or treatments. World Wide Wounds. http://tinyurl.com/6cfloz (accessed 9 January 2013) Winter G (1962) Formation of the scab and the rate of epithelisation of superficial wounds drying out and will provide the optimum healing conditions. in the skin of the young domestic pig. Nature 193: 293–4 If the dressing is appropriate and the wound is prepared, World Union of Wound Healing Societies (2007) Principles of best practice: Wound exudate and the role of dressings. A consensus document. MEP, London healing should occur. Young T (2000) Why wound pain should be accurately assessed. Community Nurse 6(10): 41–4

e x u d at e management M a r c h 2 0 1 3 P 7 2 Exploring the link between the clinical challenges of wound exudate and infection

June Jones, Independent Nurse Consultant and Associate Tutor, Edge Hill University

chronic wound exudate should be regarded as a wounding Abstract agent in its own right (Trengrove et al, 2008). Nonetheless, Exudate and infection are two of the key challenges facing exudate is a good and essential component of the normal clinicians in the management of wounds, especially wound healing process. The presence of exudate provides an chronic wounds. The associated increased use of environment that stimulates healing, as it contains growth healthcare resources and nursing time are also important factors, cytokines, matrix metallaproteinases (MMPs) consequences. What we cannot underestimate, however, and white cells (World Union of Wound Healing Societies is the challenge for patients and their carers of living (WUWHS), 2007a). Moisture also aids autolytic debridement with wounds that impact on the quality of their daily and is necessary in the process of epithelialisation to permit lives, causing misery and distress. This article focuses movement of the cells across the wound surface. Exudate on the importance of exudate as a marker of infection production reduces over time in a healing wound, while and the link between the two. It looks at infection and production tends to continue excessively in a non-healing the difficulties confronting clinicians in managing wound or chronic wound, and the constituents take on negative bioburden when sometimes the wound appears not changes generating clinical challenges. to give any clues, or at the least, very subtle ones that In some chronic and/or large surface area wounds, under could easily be missed. The pivotal role of ongoing patient certain systemic or regional circumstances, the exudate assessment and wound assessment is discussed; timely can increase to unacceptable levels (See Figure 13). This intervention is seen as the key to management. can be detrimental to healing, as it contains a corrosive cocktail of elements, which damage the wound bed as Key words well as the periwound skin (Bishop et al, 2003). Levels of Exudate • Biofilm• Dressing selection MMPs rise dramatically when a wound becomes infected and begin to degrade extracellular matrix protein, which is considered an additional factor in the regression of healing. xudate can be good, bad and downright ugly, since at As well as addressing these factors, dressing selection is its worst it can result in malodour, pain, maceration, an important consideration in management on the part of Einfection and unsightly, soiled dressings, which the clinician, together with the patient. If the exudate levels can have a negative impact on a patient’s quality of life, are poorly managed due to inadequate dressing selection, triggering feelings of self-loathing, disgust and low self- the wound bed becomes saturated and there is a strong esteem (Jones et al, 2008). It has been suggested that chance of strikethrough and leakage, increasing the risk of infection (Graham, 2004), with its concomitant malodour, maceration and poor patient experience. Figure 13. Factors influencing It is important to monitor any increase or changes exudate production in colour of the exudate, as this should alert the clinician • Infection that the wound and patient are at risk of increased • Oedema/lymphoedema problems and may also be indicative of the causative • Venous disease bacteria. For example, if the infection is due to the presence • Malignancy of Pseudomonas aeruginosa (P. aeruginosa), the exudate • Medication becomes thicker and greenish-blue in colour. Inspection of • Sustained inflammatory response the dressings on removal can provide valuable information on what may be happening to the wound. Wound exudate

P 8 exudate management M a r c h 2 0 1 3 Diabetic patient with sinus on left foot Joy Tickle, Tissue Viability Nurse Specialist, NHS Telford and Wrekin

Introduction Figure 14 Figure 15 Mrs M is a 90-year-old lady who presented with a history of diabetes and evidence of osteomyelitis within her left foot. The wound presented as a sinus that tracked from the inner malleoli area through to the sole of the heel (Figure 14). Mrs M was referred to the

tissue viability service by her nursing home, which was C ase Study 3 experiencing the following difficulties managing this complex wound: dressings were often disturbed and had to be 1. Management of extremely high levels of exudate replaced frequently. 2. Retention of a suitable dressing in a difficult location On assessment by a tissue viability specialist, the 3. Long-term management options. dressing regimen was changed to the use of the silver hydrofibre rope, followed by the use of a bordered Discussion superabsorbent dressing, Flivasorb® Adhesive. Previously, Mrs M was reviewed by a diabetologist, who decided invasive treatment or surgical intervention Results would not be advisable due to multiple comorbidities Following 6 weeks of treatment, the wound was almost and her underlying condition. He advised palliative healed, exudate levels minimal and the super-absorbent management of wound symptoms, as the wound was dressing replaced with a lower absorbent secondary unlikely to heal. dressing, due to low levels of exudate (Figure 15).

Method Conclusion On initial assessment, the sinus was packed daily Mrs M and the nursing staff were highly satisfied with with a silver hydrofibre covered by a superabsorbent the improvement in the wound. Her quality of life has secondary dressing. Due to the location of the wound, greatly improved and she can now mobilise fully.

is produced at a higher rate than normal in the presence and naturally found on the surface of the skin; these are known of infection; this is partly due to the histamine response. as skin flora. The pathogens most commonly associated with Infection Figure 16. Recognising infection Wounds do not exist in isolation and it is important that Classic criteria Additional criteria the clinician can confidently distinguish between the signs and symptoms of the normal physiological inflammatory Pyrexia Delayed (or stalled) healing response in healing and those related to infection or Inflammation Bridging of skin across a wound underlying aetiologies, such as rheumatoid arthritis or Oedema Dark/discoloured granulation tissue vasculitis (Figure 16). Pain Increased friability (tissue that The mere presence or multiplication of microorganisms bleeds easily) on the wound surface does not necessarily equate to wound infection. Wound bacteria can be acquired from Increase in Painful/altered sensation to the wound exudate or pus site/surrounding skin the patient’s own endogenous flora or from exogenous microbial contamination (European Wound Management Abscess Altered odour/malodour Association (EWMA), 2005). The notion of a continuum in Cellulitis Wound breakdown the development of wound infection was described by Pocketing at the base of the wound Kingsley (2001), naming the increasingly severe forms of wound bioburden as contamination, colonisation, critical Increased watery/serous exudate, rather than pus colonisation and wound infection (Figure 17). Contamination is the presence of organisms on the wound Erythema extending from the surface in low numbers. Often these microbes are harmless wound edge

e x u d at e management M a r c h 2 0 1 3 P 9 Figure 17. The wound infection continuum proteases (matrix metalloproteinases (MMPs) and elastase) and reactive oxygen species (ROS). Phillips et al (2010) suggest that biofilms are a major contributing factor to persistent, Contamination Presence of bacteria on the surface without multiplication chronic inflammatory changes in the wound bed, particularly in chronic wounds. By inducing an ineffective inflammatory response, the biofilm protects the microorganisms it Presence of muliplying bacteria, which Colonisation does not result in an immune response contains and increases exudate production, providing a or trigger clinical signs and symptoms source of nutrition that perpetuates the biofilm. Biofilms need to be reduced or eliminated for a wound to heal. While The patient’s immune it is generally agreed that biofilms cannot be seen with the Critical colonisation response barrier is breached Covert infection and can no longer control naked eye, there may be a link between biofilms and slough the bacteria (which can be seen) (Cutting et al, 2010). Biofilms stimulate inflammation, which in turn increases vascular permeability The multiplying bacteria within the wound and production of wound exudate and the build-up of fibrinous Infection overwhelm the patient’s immune response, resulting in associated clinical signs slough (Wolcott et al, 2008), suggesting that slough may be and symptoms indicative of a biofilm in the wound. Wound healing is delayed Source: adapted from Kingsley, 2001 as the bioburden increases and healing is more likely to occur with regular debridement of devitalised tissue. wound infections in the UK are Staphylococcus aureus, P. aeruginosa, Streptococcus pyogenes, with anaerobes and Eliminating biofilms various coliforms occurring frequently in chronic wounds Cutting et al (2010) propose that slough is a thriving (Bowler et al, 2001; Cooper, 2005). Gray et al (2005) describe accumulation of bacteria that requires regular and frequent the stage of colonisation as one in which one particular debridement. Wolcott et al (2009) likewise recommend bacterial pathogen becomes dominant within the wound. debridement as the key to maintaining a healthy wound However, the signs of colonisation are not easy to detect, bed in most chronic wounds. In some wounds, quick, easy as there are no physical changes in the wound bed. Critical debridement can be achieved using Debrisoft® (Activa colonisation is considered to be the precursor or transitional Healthcare) by a generalist nurse. stage between colonisation and infection, with concern When a wound starts to progress towards healing, expressed that even at this stage, with high levels of bacteria, together with a concomitant reduction in exudate and there may well be an absence of traditional signs of infection slough, these are clinical indicators that the wound might (Edwards and Harding, 2004; Warriner and Burrell, 2005). be free from biofilms. Until that point, it is important Percival and Bowler (2004) have suggested that the presence that wounds and the patient are regularly and frequently of maturing bacterial biofilms can impact on the progression reassessed and treated with antibiofilm agents, namely from critical colonisation to infection. antimicrobials and/or topical antiseptics such as honey, PHMB, cadexomer iodine or silver (Phillips et al, 2010; Best Biofilms Practice Statement, 2011). These products help to reduce There is growing interest and concern about the role of the bioburden and therefore reduce the inflammatory biofilms in wound healing and infection, since they are response within the wound, so less exudate is produced. known to have a significant negative influence in chronic What then tips the balance and upsets the equilibrium, wounds (Phillips et al, 2010). Their eradication is a vital resulting in a wound that becomes infected, with a patient part of wound management and healing (Leaper et al, with increased morbidity and risk of mortality? Often it is 2012), as well as a huge challenge, as James et al (2008) the ability of the host to mount a robust immune response suggest that 60% of chronic wounds contain biofilms. A against an increasing bacterial virulence, as there is biofilm is a complex microbial community, consisting of increased competition between bacteria and the host’s cells bacteria embedded in a slimy glycocalyx, a protective matrix for vital nutrients and oxygen; there are many systemic and of sugars and proteins, which makes them more difficult local wound factors that put the patient at increased risk of to eradicate by the host’s own immune system, as well infection (Figure 20). The need for assessment and constant as by antimicrobials and environmental stresses such as reassessment of not only the wound but also the patient nutritional or oxygen limitation. cannot be over-emphasised, as often the signs and symptoms Biofilms release antigens (as do all bacteria), stimulating are as subtle as loss of appetite, a general lethargy, malaise the production of antibodies, which cause damage to and apathy, with the patient seemingly unwilling or unable the surrounding tissue. Biofilms are also inflammatory to undertake normal activities. Poor wound-related hygiene and constantly shed bacteria onto the wound, causing will also increase a vulnerable patient’s risk of developing a inflammation and tissue damage through the release of wound infection. Stephen-Hayes and Toner (2007) comment

P 1 0 exudate management M a r c h 2 0 1 3 Pressure ulcer to sacrum Joy Tickle, Tissue Viability Nurse Specialist, NHS Telford and Wrekin

Introduction Figure 18 Figure 19 Mr W is an 89-year-old patient who was referred to the tissue viability service with a Grade 4 pressure ulcer to his sacrum. On examination, the wound was found to be 11 cm in length, 8 cm in width and 8 cm in depth. The wound

tissue was 100% granulated; the periwound skin C ase Study 4 was showing signs of maceration and there was also evidence of skin stripping due to high exudate levels have the dressing changed twice daily’. He also reported (Figure 18). Before assessment, the wound was dressed that his skin did not ‘feel wet’, as it had before. From an daily with a hydrofibre rope and a secondary dressing economic perspective, the new regimen reduced the of a foam adhesive dressing. Dressings were being amount of nursing time and wound dressings used. performed daily and on many occasions the secondary dressing had to be replaced twice daily, due again to Discussion the high levels of exudate and the incapacity of the Some 4 weeks later, the wound was reducing in size. secondary dressing to absorb and retain the exudate. Periwound skin was healthy and intact and the wound edge healthy (Figure 19). The dressing regimen Method was changed to alternate days, as the exudate was Following the assessment by the tissue viability retained and managed within the Flivasorb® Adhesive specialist, the wound dressing regimen was changed secondary dressing. to a hydrofibre rope, as before. However, the selected secondary dressing was Flivasorb® Adhesive, in Conclusion order to manage the high exudate levels and address Overall, the benefits of the use of Flivasorb® periwound skin damage. Adhesive were: 1. Increased patient comfort and quality of life Results 2. Reduced number of dressing changes, thus reduced Following the initiation of the new dressing regimen, Figureamount 2 of nursing time and reduced need for dressing change was reduced to once daily. This dressing regimen resources dramatically improved quality of life for Mr W, who 3. Excellent exudate retention within reported that it was ‘more comfortable not having to Flivasorb® Adhesive. that even low levels of bacterial burden can impair wound handle the fluid is important and makes a huge difference healing in susceptible patients. It would seem the healthier to the progress of the wound and, importantly, the comfort the patient, the less at risk they are of wounds moving from and quality of life of the patient (Romanelli et al, 2010). contamination and colonisation to infection. Clinicians have a Patient comfort and acceptability are important factors pivotal role in preventing and managing wound infection and when determining success or otherwise of a treatment its sequelae, but this necessitates constant vigilance when regimen and in optimising their wellbeing (International observing the wound and the patient for early warning signs Consensus, 2012). and symptoms. WUWHS acknowledged that specific descriptions of levels of exudate were necessary in order to ensure Dressing selection optimal patient care. Simply describing a wound as The WUWHS (2007a) emphasises that dressing selection ‘highly exuding’ does not provide health professionals is important in helping to control the exudate and remove with enough information to select the most appropriate any excess along with any associated debris. This will approach to wound management. To ensure accurate ensure the wound bed is moist, not saturated, preventing information is passed between health professionals and damage and pain to the surrounding skin, and reducing appropriate dressings are selected, WUWHS defined the the risk of infection from strikethrough. An understanding key descriptors of exudate as dry, moist, wet, saturated of the way in which dressing materials function and and leaking (WUWHS, 2007b).

e x u d at e management M a r c h 2 0 1 3 P 1 1 There are many different types of absorbent dressing It is important that a dressing can retain the exudate, available, which can be used as either primary or secondary even when external pressure is applied (for whatever dressings, such as foams, alginates, hydrofibre dressings reason), to prevent the wound and periwound from coming and absorbent pads. Many of these have traditionally been into contact with the potentially corrosive components of used to manage high exudate levels. However, in some the exudate such as MMPs. cases, the fluid-handling capacity is less than optimum, causing problems for the patient of strikethrough, plus Conclusion feelings of anxiety and unwillingness to socialise (Jones et This paper has highlighted the complexities of managing al, 2008). Negative pressure wound therapy (NPWT) devices potentially highly exuding wounds and the need for constant are also available, which necessitate additional knowledge vigilance and reassessment of a patient and their wound and skills on the part of the clinician, together with the for subtle signs and symptoms. The need for clinicians cost element. Superabsorbent dressings indicated for the to consider multiple factors when determining the most management of moderately to heavily exuding wounds are suitable dressing for the wound and the patient with whom also now available, which have the ability to trap unwanted they are faced is paramount for a good outcome. components of the exudate, such as bacteria, proteases and inflammatory mediators, within the dressing (Wiegand References Best Practice Statement (2011) The Use of Topical Antimicrobial Agents in Wound et al, 2011). Wiegand et al (2012) found that superabsorbent Management. Wounds UK, London dressings aid treatment of wound infections by entrapping Bishop SM, Walker M, Rogers AA, Chen WY (2003) Importance of moisture balance at the the microorganisms in the forming gel during uptake of wound-dressing interface. J Wound Care 12(4): 125–8 Bowler PG, Duerden BI, Armstrong DG (2001) Wound microbiology and associated wound exudate and inhibiting microbial growth. Their in approaches to wound management. Clin Microbiol Rev 14(2): 244–69 vitro study showed that superabsorbent dressings achieved Cooper R (2005) ‘Understanding wound infection.’ In: Cutting K, Gilchrist B, Gottrup F et al (eds) Identifying Criteria for Wound Infection. European Wound Management a strong reduction of P. aeruginosa, Klebsiella pneumoniae, Association Position Document. MEP, London and Escherichia coli. The dressings also significantly Cutting KF, Wolcott R, Dowd SE, Percival SL (2010) ‘Biofilms and significance in wound healing.’ In: Percival S (ed) Microbiology of Wounds. CRC Press, London inhibited the growth of S. aureus and Candida albicans. Edwards R, Harding KG (2004) Bacteria and wound healing. Curr Opin Infect Dis 17(2): 91–6 European Wound Management Association (EWMA) (2005) Position Document. Figure 20. Risk factors for infection Identifying Criteria for Wound Infection. MEP, London Graham C (2004) Best management of exudate and maceration. Nursing in Practice 14: 1–7 Systemic factors Gray D, White R, Cooper P, Kingsley A (2005) Understanding applied wound • Inadequate blood supply or hypoxia/ management. Wounds UK 1(1): 60–2 International consensus (2012) Optimising wellbeing in people living with a wound. An poor tissue perfusion expert working group review. http://tinyurl.com/aaevtxd (accessed 7 January 2013) James GA, Swogger E, Wolcott R et al (2008) Biofilms in chronic wounds.Wound Rep • Metabolic disorders, such as diabetes Regen 16(1): 37–44 Jones JE, Barr W, Robinson J (2008) Impact of exudate and odour from chronic venous • Medication: corticosteroids, cytotoxic agents, leg ulceration. Nurs Stand 22(45): 53–61 immunosuppressants Kingsley A (2001) A proactive approach to wound infection. Nurs Stand 15(30): 50–8 Leaper DJ, Schultz G, Carville K et al (2012) Extending the TIME concept: what have we • Alcohol abuse/smoking learned in the past 10 years? Int Wound J 9(Suppl 2): 1–19 • Poor nutritional status Percival S, Bowler P (2004) Biofilms and their potential role in wound healing.Wounds 16(7): 234–40 • Uncontrolled oedema Phillips PL, Wolcott RD, Fletcher J, Shultz GS (2010) Biofilms made easy.Wounds International 1(3): 1–6 • Malignancy Romanelli M, Vowden K, Weir D (2010) Exudate management made easy. Wounds International 1(2) http://tinyurl.com/at2c2yj (accessed 22 January 2013) • Rheumatoid arthritis Stephen-Hayes J, Toner L (2007) Assessment and management of wound infection: the 12 • Renal impairment role of silver. Br J Community Nurs (3 Suppl): S6–S12 Trengrove NJ, Bielefeldt-Ohmann H, Stacey MC (2008) Mitogenic activity and cytokine • Poor standards of wound-related hygiene levels in non-healing and healing chronic leg ulcers. Wound Repair Regen 8(1): 13–25 Warriner R, Burrell R (2005) Infection and the chronic wound: a focus on silver. Adv Skin Wound characteristics Wound Care 18(Suppl 1): 2–12 Wiegand C, Abel M, Ruth P, Hipler UC (2011) Superabsorbent polymer-containing • High exudate levels wound dressings have a beneficial effect on wound healing by reducing PMN elastase concentration and inhibiting microbial growth. J Mater Sci Mater Med 22(11): 2583–90 • Large in size and/or deep Wiegand C, Abel M, Ruth P, Hipler U-C (2012) Comparison of the antimicrobial effect of two superabsorbent polymer-containing wound dressings in vitro. Wounds UK 2012 • Prolonged duration Wound Care Conference, Harrogate 12-14 November 2012 Wolcott RD, Kennedy JP, Dowd SE (2009) Regular debridement is the main tool for • Anatomical position, e.g. anal area, that raises maintaining a healthy wound bed in most chronic wounds. J Wound Care 18: 54–6 potential contamination risk Wolcott RD, Rhoads DD, Dowd SE (2008) Biofilms and chronic wound inflammation.J Wound Care 17(8): 333–41 • Necrotic tissue World Union of Wound Healing Societies (2007a) Principles of Best Practice: Wound Infection in Clinical Practice. An International Consensus. MEP, London • Foreign bodies World Union of Wound Healing Societies (2007b) Wound exudate and the role of dressings • Concurrent infections e.g. osteomyelitis A consensus document. MEP, London

P 1 2 exudate management M a r c h 2 0 1 3 3 Quality of life: patient safety and satisfaction

Karen Ousey, Reader, School of Human and Health Sciences, Centre for Health and Social Care Research, University of Huddersfield

he Government’s quality agenda is by no means new, either to practitioners or to patients. Indeed, Abstract T since 2008, a range of Department of Health (DH) The UK has an ageing population with the fastest publications (2008a; 2008b; 2009a; 2009b; 2009c) has population increase being in those individuals aged 85 presented the challenges and opportunities to meet this years and over; by 2035, it is projected that the number agenda. Furthermore, tissue viability practitioners and of people aged 85 years and over will reach 3.5 million. academics have written about, debated and embraced With the increasing population, we can assume that the the changes to ensure they make a positive impact on number of acute, chronic and infected wounds will also patient care and the patient journey. The publication of increase. The Department of Health has been clear Quality, Innovation, Productivity and Prevention (QIPP) that patients should be kept at the heart of everything (DH, 2012a) saw the Government set out the challenge to we do and as such, should be actively involved in the make £20 billion of efficiency savings by 2014–15, while decision-making process relating to their care plans. improving the quality of care the NHS delivers. The DH It is vital that all practitioners are aware of the quality (2011) reported that 10% of patients were harmed during agenda and how to successfully engage patients in the hospital care, which could cost the NHS as much as decision-making process that will ultimately improve £1 billion per year. patient wellbeing. In order to measure the amount of harm-free care, the DH set up work streams, one of which was the ‘safe care Key words work stream’. This established a quality improvement Quality • QIPP • Wellbeing • Wound care programme, ‘Safety Express’, to help the NHS develop safer systems in hospitals and community settings thereby working to the shared aim of dramatically pressure ulcer incidence and to have pressure ulcers as a reducing harm. One of the areas it concentrated on was ‘never event’ is a step toward this. hospital- and community-acquired pressure ulcers, and this led to the development of the safety thermometer, The UK’s ageing population a local improvement tool for measuring, monitoring and The percentage of people aged 65 and over increased to analysing patient harm and to promote ‘harm-free’ care 17% in 2010 from 15% in 1985, and by 2035, it is projected (DH, 2012b). In order to make certain the patient’s voice that those aged 65 years and over will account for 23% was heard in relation to quality of care received during of the total population. However, the fastest population a hospital stay, Patient Reported Outcome Measures increases have been in those people aged 85 years and (PROMs) were used to collect and analyse feedback over; this number has doubled from nearly 0.7 million from patients about their experiences of health care. to reach over 1.4 million by 2010. By 2035, it is projected Initially the requirement to collect PROMs data applied that the number of people aged 85 years and over will be to four surgical procedures: hernia repair, hip and knee almost two and a half times higher than in 2010, reaching replacement and varicose veins. However, there are now 3.5 million and accounting for 5% of the total UK population discussions to extend the collection of PROMs data to a (Office for National Statistics (ONS), 2012). range of chronic conditions, including diabetes, asthma, With the ever-increasing older population, we can stroke, chronic obstructive pulmonary disease (COPD) safely assume that there will also be an increase in and others (Devlin and Appleby, 2010). There is no people presenting with wounds that may be acute, reason why this cannot be extended to measuring wound chronic, infected, painful or exudating, who will need infections, pressure ulceration and leg ulceration. Indeed, treating with the most effective evidence-based products the necessity for health professionals to record and report that are not only cost-effective but also maintain

e x u d at e management M a r c h 2 0 1 3 P 1 3 quality of life. In order to meet the needs of this What is quality? population group, practitioners must understand issues The World Health Organization (WHO) (1997:1) defined surrounding quality of life, evaluate and measure the quality of life as being: effect interventions have had on the patient’s quality of life, ensure effective communication between the patient ‘A broad-ranging concept affected in a complex way by and practitioner, and promote effective multidisciplinary the person’s physical health, psychological state, level of team (MDT) working practices. Importantly, the patient independence, social relationships, personal beliefs and must be involved in the decision-making process when their relationship to salient features of their environment’. choosing the correct wound dressing. The DH (2010), in its publication, Equity and Excellence: Liberating the NHS, WHO explored the importance of doctors highlighted the need to maintain and promote shared understanding how a disease affects a patient’s quality decision-making between practitioners and patients— of life, stating that a clear understanding would improve with the underpinning mantra being ‘no decision about the interaction between patient and doctor, allowing for me without me’. a more comprehensive healthcare plan to be provided. It is therefore important that all practitioners If a practitioner understands the healing process understand the meaning of wellbeing and quality. of a wound and the effect that issues including, pain, odour, excessive exudate and altered body image can What is wellbeing? have on mental wellbeing, and the significance of The international consensus document (Wounds choosing the most appropriate dressing for the wound— International, 2012) on optimising wellbeing in people while communicating the decision-making process to living with a wound highlighted that many people living the patient—then these too will improve interactions with a wound may focus on different priorities to healing, and promote quality of care. An association between such as reducing pain or odour, or covering up unsightly depression and wound-related pain, odour and delayed strikethrough. Or they may have concerns about wearing healing has been reported (Fletcher, 2008; Jones et al, bulky dressings that prevent them from wearing items of 2008; Vileikyte, 2007). clothing or shoes, or performing daily activities. Indeed, the consensus document offers a clear definition of Understanding the exudating wound maintaining wellbeing in relation to wound care: It is well accepted that a wound will heal in a moist environment. However, there are times when a wound ‘Wellbeing is a dynamic matrix of factors, including physical, can produce too much moisture or exudate and this social, psychological and spiritual. The concept of wellbeing needs to be effectively managed to encourage healing, is inherently individual, will vary over time, is influenced prevent damage to the wound bed and degradation to the by culture and context, and is independent of wound type, extracellular matrix and prevent periwound maceration duration or care setting. Within wound healing, optimising (Chen and Rogers, 2007; Gibson, 2009). Managing exudate an individual’s wellbeing will be the result of collaboration is a necessity of good wound bed preparation that will and interactions between clinicians, patients, their families prepare the wound for the healing process. and carers, the healthcare system and industry. The ultimate It must be remembered that wound exudate will assist goals are to optimise wellbeing, improve or heal the wound, the wound healing process. As the World Union of Wound alleviate/manage symptoms and ensure all parties are fully Healing Societies (WUWHS) (2007:4), explained, exudate will: engaged in this process.’ (Wounds International, 2012:1) • Prevent the wound bed from drying out • Aid the migration of tissue-repairing cells Practitioners must undertake a holistic assessment • Provide essential nutrients for cell metabolism during each visit to the patient that incorporates not • Enable the diffusion of immune and growth factors only a wound bed assessment but also a mental health • Assist separation of dead or damaged tissue (autolysis). assessment. Heavily exuding wounds have the potential However, it is vital that practitioners are able to to negatively impact on a patient’s wellbeing, causing a assess and evaluate wound exudate in the context of the reluctance to engage in activities with others outside of wound tissue type being treated. Romanelli et al (2010) the home environment. This is caused by the need for suggest that exudate produced by a necrotic wound as frequent wound dressings to manage fluid, malodour a result of autolytic or enzymatic debridement would and often pain. This can lead to social exclusion and a characteristically be opaque and tan, grey or green; and if possibility of both isolation and depression. Effective the wound contains certain bacteria, it may be malodorous. exudate management through correct dressing choice can High levels of, or an increase in, exudate production may assist in reducing these issues and will promote wellbeing be indicative of underlying disease processes, such as for the patient and their carers. infection (WUWHS, 2007).

P 1 4 exudate management M a r c h 2 0 1 3 Trauma injury to right lower limb

Joy Tickle, Tissue Viability Nurse Specialist, NHS Telford and Wrekin

Introduction Figure 21 Figure 22 Mrs J was an 63-year-old lady referred to the tissue viability service following a trauma injury to her right lower limb. On first assessment, there was a large wound to the gaiter region, which was 23 cm in length and 10 cm in width. The majority of the tissue C ase Study 5 was necrotic and sloughy with a small amount of granulation tissue (Figure 21). The wound bed required debridement. Mrs J was experiencing significant limb Results and wound pain. Exudate levels were high and both Some 8 weeks after the initial assessment, the wound the outer wound dressing and Mrs J’s clothes were bed was superficial, presented with 100% granulation wet and stained. tissue and had reduced in size to 17 cm in length by Due to levels of exudate, the wound dressing 5 cm in width (Figure 22). Periwound skin was clean was being replaced daily and often the secondary and healthy and exudate extremely well managed and dressing had to be reapplied twice daily. This not only retained within the Flivasorb® Adhesive. This continued exacerbated Mrs J’s pain but also impacted on the until final wound healing some 3 weeks later. community nurse’s time and dressing resources. Discussion Method Mrs J reported she was more confident to socialise and Following the clinical examination and assessment, was no longer anxious about the dressing slipping or the tissue viability specialist recommended the falling off, which frequently occurred with the use of limb be soaked and cleansed in order to assist previous non-adhesive absorbent dressings. with the debriding and cleansing of the wound and surrounding skin. The use of a hydrofibre sheet Conclusion in order to assist with autolysis of the wound bed Flivasorb® Adhesive retains exudate within itself, was recommended, with Flivasorb® Adhesive as preventing maceration and excoriation to periwound a secondary dressing. Mrs J was not suitable for skin. In this case study, the dressing stayed in place, compression therapy, due to reduced ankle brachial allowing Mrs J to carry out her normal daily activities, pressure index. The dressing regimen continued with minimal impact. There was a reduction in nursing daily for 3 weeks, alternate days for 2 weeks and time and dressing resources needed to heal this large then twice weekly. traumatic wound.

Romanelli et al (2010:6) advocate that effective How can quality be maintained? containment and treatment of exudate will improve an The provision, maintenance and development of a quality individual’s quality of life, but if exudate is not correctly service to all who access healthcare and maintaining managed then there will be: wellbeing are fundamental responsibilities of every health • Deterioration of a patient’s quality of life professional. To ensure this is achieved, practitioners • The periwound skin will be unhealthy and/or the must be aware of, and familiar with, local, national and wound will extend European guidance that can impact on delivery of services. • The wound bed will show signs of increasing Staff education must be ongoing, be this through study bacterial load days, academic courses, reading appropriate literature • There will be soiling outside the dressing or reflecting on practice, to guarantee that research and • The patient will need to make adjustments to dressing evidence-based practice is implemented. Patients must arrangements to accommodate the exudate be at the centre of, and involved in, decision-making when • Dressing changes will be frequent assessing and planning programmes of treatment, so that • Wound odour will be uncontrolled their quality of life and wellbeing is maintained. Importantly, • Wound pain will be present. patients must be encouraged to communicate any fears or

e x u d at e management M a r c h 2 0 1 3 P 1 5 Department of Health (2008a) Guidance on the Routine Collection Of Patient- worries they may be experiencing, to allow practitioners to Related Outcome Measures (PROMS).http://tinyurl.com/bz8kymr (accessed 8 discuss help that can be accessed or to change treatment January 2013) Department of Health (2008b) High Quality Care For All: NHS Next Stage regimens to prevent a reduction in quality of life. Review Final Report (CM78432). http://tinyurl.com/4t6uf8 (accessed 8 January All patients should have clear and achievable care plans 2013) Department of Health (2009a) NHS 2010–2015: From Good To developed that focus on optimising outcomes and contain Great. Preventative, People-Centred, Productive. http://tinyurl. com/6a434fm(accessed 8 January 2013) regular evaluation dates. Fletcher (2008) identified that Department of Health (2009b) Prime Minister’s Commission on the Future of every patient with a wound should be on a pathway that Nursing and Midwifery. http://tinyurl.com/amtu88x (accessed 8 January 2013) leads to effective management, whether that be healing, Department of Health (2009c) Chief Nursing Officer Bulletin. www.dh.gov.uk/ cnobulletin (accessed 8 January 2013) symptom management or an alternative goal. Significantly, Department of Health (2010 Equity and Excellence: Liberating the NHS. http:// all care that is administered must be appropriately tinyurl.com/agx7snn (accessed 8 January 2013) Department of Health (2011) QIPP Workstreams: Safe Care. http://tinyurl. documented and practitioners must make certain that com/8gorc4q (accessed 21 January 2013) any intervention can be measured so that, if necessary, Department of Health (2012a) Delivering the NHS Safety Thermometer CQUIN 2012/13. A Preliminary Guide to Measuring ‘Harm-Free’ Care. http://tinyurl. changes can be made to enhance future care interventions. com/amkvr2r(accessed 8 January 2013) Department of Health (2012b) Quality, Innovation, Productivity and Prevention (QIPP).http://tinyurl.com/au7krfu (accessed 8 January 2013) Summary Devlin NJ, Appleby J (2010) Getting the most out of PROMS. Putting health The effective management of wounds and ensuring quality outcomes at the heart of NHS decision-making. http://tinyurl.com/b7247by (accessed 8 January 2013) of life is maintained for all individuals with a wound, are Edwards H, Courtney M, Finlayson K et al (2005) Chronic venous leg ulcers: core skills that all health professionals require. The effect of a community nursing intervention on pain and healing. Nurs Stand 19(52): 47–54 continuing rise in the ageing population suggests there Fletcher J (2008) Optimising Wound Care in the UK and Ireland: a best practice will be more people with wounds who will require not only statement. Wounds UK 4(4): 73–81 Gibson D, Cullen B, Legerstee R et al (2009) MMPs Made Easy.http://tinyurl. wound management but also promotion of wellbeing. com/bxcozzo (accessed 8 January 2013) Empowerment of the patient is essential to encourage Jones JE, Robinson J, Barr W, Carlisle C (2008) Impact of exudate and odour from chronic venous leg ulceration. Nurs Stand 22(45): 53–4, 56, 58 development of a partnership when planning treatment Office for National Statistics (2012) Population Ageing in the United Kingdom, options or listening to concerns (Edwards et al, 2005). The its Constituent Countries and the European Union. http://tinyurl.com/9w74jl9 (accessed 8 January 2013) international consensus document (Wounds International, Romanelli M, Vowden K, Weir D. (2010) Exudate Management Made Easy. 2012) highlights that practitioners must listen to individuals http://tinyurl.com/at2c2yj (accessed 8 January 2013) World Health Organization (1997) Measuring Quality of Life: http://tinyurl.com/ to gain their confidence and trust, and explain to them what QOLInstruments (accessed 8 January 2013) they are doing and to do so with empathy. World Union of Wound Healing Societies (2007) Principles Of Best Practice: Wound Exudate And The Role Of Dressings. A Consensus Document. http:// tinyurl.com/b82jeab References Wounds International (2012) International consensus. Optimising wellbeing in Chen WY, Rogers AA (2007) Recent insights into the causes of chronic leg people living with a wound. An expert working group review. http://tinyurl.com/ ulceration in venous diseases and implications on other types of chronic amd2vef (accessed 8 January 2013) wounds. Wound Repair Regen 15(4): 434–49 Vileikyte L (2007) Stress and wound healing. Clinical Dermatology 25(1): 49–55

P 1 6 exudate management M a r c h 2 0 1 3 The management of a sacral sinus Brigitte Price, Tissue Viability Nurse, Betsi Cadwaladr University Health Board, Wrexham Maelor Hospital

Figure 23 Figure 24 Figure 25 C ase Study 6

The adhesive superabsorbent wound dressing was easy to handle, conformable in an awkward area and comfortable for the patient.

Introduction Results Mrs J was an 81-year-old lady who developed a sacral The dressing was very easy to handle, even with pressure ulcer in 2010, after which it became long- gloved hands (Figure 24). It fitted into place and standing and static. The cavity wound had not been filled conformed very well (Figure 25). Mrs J was an elderly sufficiently with a cavity dressing and the pressure ulcer lady, but her skin was in an excellent condition and became a non-healing, highly exuding sinus (Figure 23). assessed as being suitable for an adhesive dressing. Mrs J had a past medical history including heart The dressing stayed in place for 2–3 days and was failure and reduced mobility due to osteoarthritis of comfortable when in situ. This was important as she her knees and was being nursed in a care home. The sat in a chair most of the day, with regular changes nursing staff had abandoned wound dressings and in position. The dressing caused no pain or damage had opted to irrigate with a PHMB solution, and used on removal and there was no mark on the skin once it incontinent pads to absorb wound exudate. Mrs J had been removed. was not incontinent of faeces, but was occasionally incontinent of urine, due to poor mobility. Discussion Investigations had taken place to assess the depth Mrs J continued with the evaluation for 2 weeks but then, of the sinus, as it was thought at one stage that it might due to a mix-up in communication, the sample dressings have been a fistula. It was confirmed, however, that it ran out. The nurses decided to continue with an adhesive was in fact a blind-ended sinus. foam dressing until some further samples arrived at the care home. It was interesting to note that these adhesive Method foam dressings only stayed in place for a day, when the Mrs J agreed to take part in an evaluation of Flivasorb® dressing became full of exudate and had to be changed. Adhesive, a new bordered version of a superabsorbent Unfortunately, Mrs J died suddenly of an unrelated cause dressing (Flivasorb®) and a full explanation was given before complete healing could be achieved. to ensure she had made an informed choice. The wound was fairly close to the anal margin and it was Conclusion decided that the best way to position the dressing was Flivasorb® Adhesive, the new bordered superabsorbent in a diamond shape and to cut the corner off the border dressing, was shown to be: of the dressing, next to the anal margin. This was done • Easy to apply and remove with a sterile pair of scissors and care was taken not • Comfortable for the patient to cut into the dressing pad and to leave sufficient • Very absorbent, lasting 2-3 times longer than an adhesive border to provide a good seal. adhesive foam dressing.

e x u d at e management M a r c h 2 0 1 3 P 1 7 When a foam is not enough in managing sacral pressure ulcers

Deborah Kattell and Lynne Whitmore, Tissue Viability Specialist Nurses, Staffordshire and Stoke on Trent Partnership NHS Trust

Figure 26 Figure 27 Method Various daily wound dressing regimes were tried.

C ase Study 7 Exudate levels were high and periwound skin care was vital. The levels of exudate had begun to damage the surrounding skin. He was taking Oromorph to control the pain. The decision was made to change the secondary dressing from an adhesive foam to 3 August 8 August Flivasorb® Adhesive. It was hoped that the new secondary dressing would allow for less frequent dressing change, to promote an improvement in Figure 28 Figure 29 periwound skin condition and allow the primary antimicrobial wound dressing became more effective as it stayed in situ for longer.

Result Within a short time, Flivasorb® Adhesive reduced the dressing change frequency to alternate days and 15 August 28 August occasionally to every 3 days. Pain was reduced and appetite and nutritional intake improved. The wounds Introduction began to heal and the wound beds became cleaner and This is a case study describing a 75-year-old man began to reduce in size (see Figures 26–29). with a pressure ulcer and its management with a new bordered superabsorbent wound dressing (Flivasorb® Discussion Adhesive). Following a full holistic assessment, this This case study demonstrates that the application of a patient was noted to have a past medical history wound dressing to the sacral area should be undertaken including chronic obstructive pulmonary disease with care. It was noted that the district nurses had twice (COPD) and an above-knee amputation, following applied the dressing covering the anus completely, peripheral vascular disease (PVD). He was a smoker preventing complete evacuation of the bowel and also and he had a poor nutritional intake and was therefore lifting the dressing away from the wound. taking nutritional supplements. The new dressing was found to easily conform to the The man was able to move independently around wound and the surrounding skin in this ‘difficult-to- the bed by dragging his bottom and using his left leg. dress’ area and it fitted well around the anal margin. Because of this, he had developed grade 4 pressure damage to his right ischial tuberosity. He had previously Conclusion developed a pressure ulcer close to the anal margin It was important in this case that the periwound skin when he was an in-patient in a community hospital for was prepared correctly, i.e. washed and patted dry and 5 months with an exacerbation of his COPD. He was a barrier film applied into crevices/natal cleft. Careful discharged home in July 2012 under the care of the selection and application of an appropriate wound district nurses. dressing resulted in excellent absorption and retention His Waterlow pressure ulcer risk assessment of exudate, reduced number of dressing changes, score was 20 and, as he was at high risk of further improved comfort and reduced malodour by preventing pressure ulcer deterioration and further pressure leakage of exudate. It was felt that if the patient did not ulcer development, he was given a full replacement drag himself around the bed, this new dressing would alternating pressure relieving mattress. have stayed in place even longer.

P 1 8 exudate management M a r c h 2 0 1 3 The management of moderate to high exudate in chronic wounds Joy Tickle, Tissue Viability Specialist Nurse and Louise Gregory, Tissue Viability Nursing Assistant, Shropshire Community Health NHS Trust

Figure 30 Figure 31 C ase Series

New adhesive superabsorbent wound dressing on the top of the New adhesive superabsorbent wound dressing on a shoulder wound foot demonstrating conformability of the dressing. demonstrating the appearance of the dressing as it absorbs exudate. Introduction • Three patients also used compression hosiery; in the Wound exudate is known to assist healing. However, it other 9 patients, compression was not applicable can become a problem for patients and carers when the • In all 12 patients, the new adhesive superabsorbent levels are high, are not managed effectively and when wound dressing had reduced the number of dressing the composition delays or prevents wound healing changes required, sometimes from daily to twice a week (WUWHS, 2007). • In the section evaluating dressing performance, there As part of a county-wide (Shropshire) evaluation of were 9 questions, giving 108 possible evaluations for Flivasorb® Adhesive, a new bordered version of an existing the 12 patients (Figure 32) superabsorbent wound dressing (Flivasorb®), 12 patients Figure 32 were examined to see if this extension to the range would be useful. 60

Method 40 Data on the 12 patients was entered on to the same data 20 collection form to ensure consistency. This evaluation was divided into three sections: Number of responses of Number 0 • Patient details—including age, sex, wound type, Very good Good Fair Poor exudate level, previous treatment used and the Evaluation of dressing performance frequency of previous dressing changes • Dressing performance—including ability to hold The ‘poor’ and ‘fair’ responses related to a patient exudate, ease of application and removal, skin with sensitive skin, who may not have been suitable condition and adhesive border for an adhesive dressing. • Comments—including whether the new dressing reduced the frequency of dressing changes. Conclusions Many comments were made at the end of the evaluation Results form, including: • Wound types included sinus, leg ulcers, diabetic foot • ‘Patient preferred it to the previous absorbent pad’ ulcers and traumatic ulcers • ‘Staff state the dressing is excellent’ • Exudate levels varied from 1-10 (10 was the highest); • ‘Holds a lot of exudate.’ 10 patients scored 6-10 and 2 scored 4-5 It is important that any adhesive dressing is assessed • Previous treatment included an adhesive foam as being suitable for the skin type of the patient. dressing (7 patients), hydrofibre (1 patient) and another absorbent dressing (4 patients) Reference • Five patients had their wound redressed daily, 4 every World Union of Wound Healing Societies (2007) Principles of Best Practice: Wound other day and 3 every 2 to 3 days Exudate and the Role of Dressings. A Consensus Document. MEP, London

e x u d at e management M a r c h 2 0 1 3 P 1 9 Flivasorb adhesive advert (BJN Supp M1078 V1.1 February 2013).qxd:Flivasorb adhesive advert (BJN Supp).qxd 15/2/13 12:21 Page 1

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