CHRONIC WOUNDS

1. CHRONIC WOUNDS Ann Moody TVN & Leg Ulcer Specialist Nurse NHS Cumbria

2. What is a chronic wound? • Leg ulcer • DFU • Pressure ulcer • “persisting over a long time” • A surgical wound “that won’t heal” • A burn that takes a long time to heal • A trauma wound that takes a long time to heal

3. What is a chronic wound? • Any breach to the integrity of the skin which has failed to proceed through an orderly and timely reparativeprocess (haemostasis, inflammation, proliferation, maturation) • Any wound which by nature of the underlying aetiology is not likely to heal (eg fungating wound)

4. What problems does managing the chronic wound present us with • Exudate • Infection • Odour • Pain • De-vitalised tissue • Peri-wound care • QOL and functionality • Body image

5. The right approach • Holistic assessment (treat the whole person) • Full medical history • Factors which may delay healing (intrinsic – patient related) and (extrinsic – wound related) • Accurate wound assessment

6. STAGES OF WOUND ASSESSMENTT.I.M.E. • Tissue – is the tissue non-viable or deficient • Infection – is this infection or inflammation • Moisture – how much – enough?/not enough?/too much? • Edges – non-advancing (failing to close) or undermined?

7. Tissue non-viable or deficient • Debridement • will • restore • wound base • and • repair • damaged tissue • to achieve • a viable wound bed

8. Infection or inflammation • Removal of infected foci will • reduce bacterial counts • reduce inflammatory cytokines • reduce protease activity • and promote • and increase growth factor activity

9. Moisture imbalance • Moderation of fluid balance will • reduce risks of maceration • reduce exudate levels • reduce oedema • reduce risks of maceration • promote epithelial cell migration • Achieve moisture balance for increased speed of healing

10. Edge of wound non-advancing or undermined • Reassess cause or consider corrective therapies – correct action will • promote migrating keratinocytes and responsive wound cells • restore appropriate protease profile • and will achieve • advancing edge of wound

11. WOUND CARE OBJECTIVES • Will follow in order of priority • Will change over time • Must take account of each patient’s particular and individual needs • Will come out of an holistic assessment • Must respond to the stages of wound healing • Must respond to the needs of the wound bed and peri-wound area • Will therefore be different, patient to patient

12. Granulation Slough Necrotic infected Epithelium Shallow Deep - grades Diffuse Punched Colour Odour Induration Hyperkeratosis Lypodermatosclerosis Erythema Blanching erythema Exudate Venous Arterial Mixed Auto-immune TERMS USED IN WOUND CARE

13. Camera Syringe Probe Ruler Tape measure Wound map Visitrac Doppler (pulse oximeter) DOCUMENTATION TOOLS OF THE TRADE

14. How When Where Size Co-morbidities Age Medication Nutritional status Level of concordance Exudate Sensitivities/allergies Function of dressing Wear time Pain – at dressing change Pain – from dressing action Smell – of wound Smell – of dressing Ease of application FACTORS TO CONSIDER WHEN CHOOSING A DRESSING

15. THE CHRONIC WOUNDleg ulcer • Problems: • Wound static or deteriorating • Macerated skin to peri-ulcer • Sloughy wound bed • Ulcer secondary to venous hypertension

16. THE CHRONIC WOUNDleg ulcer • Care objectives: • Reduce risks of further deterioration • Promote skin integrity to peri-ulcer • Debride of slough • Reverse venous hypertension

17. THE CHRONIC WOUND- leg ulcer (to give an example of how chronic differs from acute) • Problems may stay the same, even though wound is improving: • Reduce risks of further deterioration • Promote skin integrity to peri-ulcer • Promote granulation tissue and epithelialisation • Reverse venous hypertension

18. THE CHRONIC WOUNDpressure ulcer

19. CHRONIC WOUNDpressure ulcer • Problems: • Grade 4 pressure ulcer to buttocks • Blanching erythema to peri-ulcer • Sloughy wound bed • High levels of exudate

20. THE CHRONIC WOUNDpressure ulcer • Objectives • Remove cause deal with specific wound care problems: • Slough • exudate

21. THE CHRONIC WOUNDfungating breast • Problems: • Painful • Smelly • Wet • Risks of secondary infection • Risks of haemorrhage

22. THE CHRONIC WOUNDfungating breast • Objectives: • Reduce pain • Reduce odour • Contain exudate • Reduce risks of secondary infection • contingency for possible haemorrhage

23. ACUTE OR CHRONIC? • Problems: • Static wound was acute, now chronic • Stuck in inflammatory phase

24. STATIC WOUND • Objectives • Reduce risks of deterioration • Reduce risks of wound infection • Promote healing

25. Making the right choice • Cost effectiveness does not always mean the “cheap option”, it is about being clinically effective • Clinical effectiveness is about “doing the right thing in the right way for the right patient at the right time” (RCN, 1997)

26. Making the right choice • Understand what different dressings are designed to do • Know what is available to you (formulary) • Evaluate and re-evaluate • Modify care plan as wound changes using good rationale

27. NOW ITS YOUR TURNAny questions?