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 Wound Management Guidelines Page 2 of 12 Version 1.0 September 2016 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 Wound Management Guidelines Page 3 of 12 Version 1.0 September 2016 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. Wound Management Guidelines Page 4 of 12 Version 1.0 September 2016 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.