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

2. What is a chronic wound? Leg ulcer Leg ulcer DFU DFU Pressure ulcer Pressure ulcer “persisting over a long time” “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 reparative process (haemostasis, inflammation, proliferation, maturation) 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) 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 Exudate Infection Infection Odour Odour Pain Pain De-vitalised tissue De-vitalised tissue Peri-wound care Peri-wound care QOL and functionality QOL and functionality Body image Body image

5. The right approach Holistic assessment (treat the whole person) 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 ASSESSMENT T.I.M.E. Tissue – is the tissue non-viable or deficient Tissue – is the tissue non-viable or deficient Infection – is this infection or inflammation Infection – is this infection or inflammation Moisture – how much – enough?/not enough?/too much? Moisture – how much – enough?/not enough?/too much? Edges – non-advancing (failing to close) or undermined? Edges – non-advancing (failing to close) or undermined?

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

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

9. Moisture imbalance Moderation of fluid balance will Moderation of fluid balance will reduce risks of maceration reduce risks of maceration reduce exudate levels reduce exudate levels reduce oedema reduce oedema reduce risks of maceration reduce risks of maceration promote epithelial cell migration promote epithelial cell migration Achieve moisture balance for increased speed of healing 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 Reassess cause or consider corrective therapies – correct action will promote migrating keratinocytes and responsive wound cells promote migrating keratinocytes and responsive wound cells restore appropriate protease profile restore appropriate protease profile and will achieve and will achieve advancing edge of wound 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. TERMS USED IN WOUND CARE GranulationSlough Necrotic infected EpitheliumShallow Deep - grades DiffusePunchedColourOdour Induration Induration Hyperkeratosis Hyperkeratosis Lypodermatosclerosis Lypodermatosclerosis Erythema Erythema Blanching erythema Blanching erythema Exudate Exudate Venous Venous Arterial Arterial Mixed Mixed Auto-immune Auto-immune

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

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

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

16. THE CHRONIC WOUND leg ulcer Care objectives: 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: 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 WOUND pressure ulcer

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

20. THE CHRONIC WOUND pressure ulcer Objectives Objectives –Remove cause deal with specific wound care problems: Slough Slough exudate exudate

21. THE CHRONIC WOUND fungating breast Problems: Problems: –Painful –Smelly –Wet –Risks of secondary infection –Risks of haemorrhage

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

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

24. STATIC WOUND Objectives 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 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) 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 Understand what different dressings are designed to do Know what is available to you (formulary) Know what is available to you (formulary) Evaluate and re-evaluate Evaluate and re-evaluate Modify care plan as wound changes using good rationale Modify care plan as wound changes using good rationale

27. NOW ITS YOUR TURN Any questions?