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

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

14. FACTORS TO CONSIDER WHEN CHOOSING A DRESSING 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

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?