CHRONIC WOUNDS
Ann Moody
TVN & Leg Ulcer Specialist Nurse
NHS Cumbria
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
What is a chronic wound?
• Any breach to the integrity of the skin
which has failed to proceed through an
orderly and timely reparative process
(haemostasis, inflammation, proliferation,
maturation)
• Any wound which by nature of the
underlying aetiology is not likely to heal
(eg fungating wound)
What problems does managing the
chronic wound present us with
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Exudate
Infection
Odour
Pain
De-vitalised tissue
Peri-wound care
QOL and functionality
Body image
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
STAGES OF WOUND ASSESSMENT
T.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?
Tissue non-viable or deficient
• Debridement
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will
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restore
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wound base
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and
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repair
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damaged tissue
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to achieve
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a viable wound bed
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Infection or inflammation
• Removal of infected foci will
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reduce bacterial counts
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reduce inflammatory cytokines
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reduce protease activity
• and promote
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and increase growth factor activity
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Moisture imbalance
• Moderation of fluid balance will
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reduce risks of maceration
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reduce exudate levels
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reduce oedema
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reduce risks of maceration
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promote epithelial cell
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migration
Achieve moisture balance for increased speed of
healing
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
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
TERMS USED IN WOUND CARE
Granulation
Slough
Necrotic infected
Epithelium
Shallow
Deep - grades
Diffuse
Punched
Colour
Odour
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Induration
Hyperkeratosis
Lypodermatosclerosis
Erythema
Blanching erythema
Exudate
Venous
Arterial
Mixed
Auto-immune
TOOLS OF THE TRADE
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Camera
Syringe
Probe
Ruler
Tape measure
Wound map
Visitrac
Doppler
(pulse oximeter)
• DOCUMENTATION
FACTORS TO CONSIDER WHEN
CHOOSING A DRESSING
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How
When
Where
Size
Co-morbidities
Age
Medication
Nutritional status
Level of concordance
Exudate
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Sensitivities/allergies
Function of dressing
Wear time
Pain – at dressing
change
Pain – from dressing
action
Smell – of wound
Smell – of dressing
Ease of application
THE CHRONIC WOUND
leg ulcer
• Problems:
– Wound static or
deteriorating
– Macerated skin to periulcer
– Sloughy wound bed
– Ulcer secondary to
venous hypertension
THE CHRONIC WOUND
leg ulcer
• Care objectives:
– Reduce risks of further deterioration
– Promote skin integrity to peri-ulcer
– Debride of slough
– Reverse venous hypertension
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
THE CHRONIC WOUND
pressure ulcer
CHRONIC WOUND
pressure ulcer
• Problems:
– Grade 4 pressure ulcer to buttocks
– Blanching erythema to peri-ulcer
– Sloughy wound bed
– High levels of exudate
THE CHRONIC WOUND
pressure ulcer
• Objectives
– Remove cause deal with specific wound care
problems:
• Slough
• exudate
THE CHRONIC WOUND
fungating breast
• Problems:
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Painful
Smelly
Wet
Risks of secondary
infection
– Risks of haemorrhage
THE CHRONIC WOUND
fungating breast
• Objectives:
– Reduce pain
– Reduce odour
– Contain exudate
– Reduce risks of secondary infection
– contingency for possible haemorrhage
ACUTE OR CHRONIC?
• Problems:
– Static wound was
acute, now chronic
– Stuck in inflammatory
phase
STATIC WOUND
• Objectives
– Reduce risks of
deterioration
– Reduce risks of wound
infection
– Promote healing
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)
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
NOW ITS YOUR TURN
Any questions?