Wound Care Giudeline NHS Bolton Hospital PDF

WOUND CARE GUIDELINES
March 2008
wound care dressings
BOLTON PRIMARY CARE NHS TRUST

&
BOLTON HOSPITALS NHS TRUST
WOUND CARE GUIDELINES
CONTENTS
A INTRODUCTION ................................................................................................................................................. 2
B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES ............................................ 5
B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES (CONTINUED) ....................... 6
B:2 PRESSURE ULCERS: DRESSING SELECTION ............................................................................................................. 7
C: 1 LEG ULCERS: THE FACTS (AETIOLOGY) ..................................................................................................... 8
C2 LEG ULCERS: DRESSING SELECTION....................................................................................................................... 9
D: DIABETIC FOOT ULCERS............................................................................................................................... 10
E: WOUND INFECTION .................................................................................................................................................. 11
F: WOUND BED PREPARATION & DRESSING SELECTION .............................................................................................. 12
G: MINOR WOUNDS DRESSING SELECTION .............................................................................................................. 13
H: CELLULITIS.......................................................................................................................................................... 14
I: WOUND COMPLICATIONS: ............................................................................................................................... 15
I:1 OVERGRANULATION ............................................................................................................................................ 15
I:2 - HYPERTROPHIC / KELOID SCARS .......................................................................................................................... 15
I: 3 - FUNGATING WOUNDS ........................................................................................................................................... 16
J: WOUND CLASSIFICATION................................................................................................................................ 17
K MECHANISMS OF WOUND HEALING ......................................................................................................... 18
L WOUND ASSESSMENT ................................................................................................................................... 18
Wound Bed..................................................................................................................................... ...19
Wound Measurement ............................................................................................................................19
Exudate .................................................................................................................................................19
Infection ................................................................................................................................................20
Pain.. ...............................................................................................................................20
Surrounding Skin ..................................................................................................................................21
M FACTORS DELAYING WOUND HEALING................................................................................................... 21
N NUTRITIONAL ASPECTS OF WOUND HEALING ....................................................................................... 23
O WOUND MANAGEMENT ................................................................................................................................ 26
i. Wound Cleansing...................................................................................................................................26
ii. Choice of Dressings..............................................................................................................................27
P: FORMULARY OF PRODUCT GROUPS WITH RECOMMENDATIONS FOR USE ............................................................ 29
REFERENCES.31
APPENDICES:............................................................................................................................................................ 35
1. Clinical Evidence Grading Criteria ......................................................................................................35
2. Wound Care Assessment Tool ...............................................................................................................35
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Review Date: March 2010
INTRODUCTION
The wound care guidelines have been developed by clinicians who are treating patients with wounds.
They reflect current research and evidence based expert opinion.
The guidelines are intended for use as a resource for wound management and should be available to all
medical,nursing and therapist caring for patients with wounds in Bolton Primary Care NHS Trust and
Bolton Hospitals NHS Trust,Bolton Hospice and The Beaumont Hospital. Evidence based
recommendations are included and a formulary of wound care products is included to promote rational
prescribing.
These guidelines have been produced for use by any member of the healthcare team.They are not
intended as a substitute for professional judgement but are in support of the practitioner making an
informed decision relating to the management of the patient,in accordance with individual professional
competence.
The guidelines have been developed incorporating available evidence of best practice. Where evidence
of best practice is not available, expert opinion has been sought and consensus agreement between the
multi-professional team has been reached.
Acknowledgement to the patients who are part of the leg ulcer service who gave valuable comments
and advice on leg ulcer management.
They will be reviewed annually and updated every two years. Comments from users of the guidelines
are welcomed.
Authors:
Jacqui Ashton Consultant Nurse Tissue Viability
Nicky Morton Tissue Viability Specialist Nurse
Susan Beswick Podiatrist Bolton Hospitals NHS Trust
Vivienne Barker Tissue Viability Podiatrist Bolton PCT
Freda Blackburn Sister Beaumont Hospital
Carolyn Wright Dietetics Manager Bolton Hospitals NHS Trust
Lisa Turner Pharmacist Bolton Hospitals NHS Trust
Kathryn Morton Dietitian Bolton PCT
Andrea Jennings District Nurse
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Reviewers:
Hannah Dobrowolska Assistant Chief Executive Bolton PCT
Mr. G Ferguson Consultant Vascular Surgeon
Mr. G Shepard Consultant Orthopaedic Surgeon
Mr. R Hopkins Consultant Obstetrician
Jackie Solomon Deputy Director of Nursing Bolton Hospitals NHS Trust
Peter Hilton Manager Podiatry Bolton PCT
Irene Pennington Podiatry Manager Bolton Hospitals NHS Trust
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Summary of Conclusions and Grading of Recommendations:

Recommendation
Grade of
Evidence
C
Holistic assessment of the patient is an essential part of the wound care process
All patients with wounds will have their wounds assessed by nursing staff within
24 hours of admission to an episode of care
Optimal nutrition facilitates wound healing, maintains immune competence and

decreases the risk of infection.
It is essential to consider the nutritional status of all patients with wounds.

Referral to the dietitian should then be made where appropriate
Wound cleansing(where necessary) should be carried out by irrigation with sterile

normal saline warmed to body temperature
For chronic wounds such as leg ulcers, ordinary tap water can be used
Antiseptics are toxic to human tissue and may delay wound healing
Topical antibiotics are frequent sensitisers and should be used with caution
Systemic antibiotics should be used to treat clinical wound infections
Wound dressings should:
maintain a moist environment at the wound/dressing interface.

(The only possible exceptions are peripheral necrosis secondary to arterial disease).
be able to control (remove) exudate. A moist wound environment is good, a wet
environment is not beneficial
not stick to the wound and cause trauma on removal
protect the wound from the outside environment
aid debridement if there is necrotic or sloughy tissue in the wound (caution with
ischaemic lesions)
keep the wound close to normal body temperature
be acceptable to the patient
be cost-effective
Diabetes choose a dressing that will allow frequent inspection
Please refer to Appendix 2 for Evidence Grading Criteria.

NB For wounds failing to respond to treatment according to the guidelines please refer to the
Tissue Viability Servic.
Tel No 01204 360005/2
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B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES

INDICATOR /
DESCRIPTOR
Grade 1
Must relieve pressure, regular skin inspection

Do not cover area easy visual inspection
Adhesive dressing could cause tissue damage
Re-position patient 2 4 hourly. Turning chart.
Appropriate pressure relieving equipment must still reposition
patient 2 4 hourly
Assess nutritional needs
Partial thickness skin loss

involving epidermis, dermis, or
both.
The ulcer is superficial and
presents clinically as an
abrasion or blister.
Relieve pressure, observe frequently, do not cover

Small blisters may resolve without intervention
If partial skin loss protect area with a thin foam dressing
Large blistered area
Drain blister large blisters will not resolve without aseptically

releasing the fluid with a sterile needle, until all the fluid is
dispersed
Non adherent foam dressing
Relieve the pressure, observe at least daily
Non-blanchable
erythema of intact skin.
Discolouration of the skin,
warmth, oedema, induration or
hardness may also be used as
indicators, particularly on
individuals with darker skin.
Grade 2
ACTION
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B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES (continued)

INDICATOR /
DESCRIPTOR
ACTION
Grade 3
Full thickness skin loss
involving damage to or necrosis
of subcutaneous tissue that may
extend down to, but not through
underlying fascia.

Avoid packing if sacral wound as this will add
further pressure to the area
Assess patient for appropriate pressure relieving
equipment according to mobility, waterlow score
etc
If known peripheral vascular disease, do not
debride heel pressure ulcers refer to Tissue
Viability
Otherwise, refer to dressing selection (B:2) for
wound management
Grade 4
Full thickness
Extensive destruction, tissue
necrosis, or damage to muscle,
bone, or supporting structures
with or without full thickness skin
loss.
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Avoid packing if sacral wound as this will add
further pressure to the area
Assess patient for appropriate pressure relieving
equipment according to mobility, waterlow score
etc
If known peripheral vascular disease, do not
debride heel pressure ulcers refer to Tissue
Viability
Otherwise, refer to dressing selection (B:2) for
wound management
B:2
Pressure Ulcers: Dressing selection
The cost of treating pressure ulcers within the UK has been estimated as high as 750 million (Roberston, 1990), which is higher than the reported national cost of treating heart disease (Durham and
Grice, 1991). Much of this cost is due to the high levels of nursing time taken to manage extensive pressure ulcers, in addition to the costs associated with hospitalisation.
Tissue Type
Descriptor
Aims
Grade 1
Grade 2
Grade 3
Grade 4
Non-blanchable erythema of
intact skin.
warmth, oedema, induration
or hardness may also be used
as indicators, particularly on
individuals with darker skin.

involving epidermis, dermis,
or both.

involving damage to or
necrosis of subcutaneous
tissue that may extend down
to, but not through underlying
fascia.
Full thickness
Extensive destruction, tissue
necrosis, or damage to
muscle, bone, or supporting
structures with or without full
thickness skin loss.
Necrotic
Identified by
presence of
predominantly
black / brown
tissue
To rehydrate eschar
and reduce risk of
infection
Not applicable
Not applicable
Hydrogel + semi-permeable
film or adhesive foam
Sloughy
Identified by
formation of
viscous,
predominantly
yellow tissue
To remove all
debris and promote
autolysis
Not applicable
Not applicable
Low exudate:
Mod High Exudate:
Hydrofibre + adhesive foam
Low exudate:
Mod High Exudate:
Granulating
Wound has
granular
appearance, looks
red and bleeds
easily
To promote
angiogenesis and
aid wound healing
Not applicable
Protect new tissue with

thin foam dressing
Low exudate:
adhesive foam
Mod High Exudate:
Low exudate:
adhesive foam
Mod High Exudate:
Epithelialising
Wound is pink in
appearance,
tissue very fragile
and needs to be
kept moist
To protect new
tissue and allow
final stage of
healing
Not applicable
Protect new tissue with

thin foam dressing
semi-permeable film or
adhesive foam
semi-permeable film or
adhesive foam
Reddened
Skin which is likely

to break down as
a result of
friction/shear or
site of previous
injury
To prevent friction,
relieve pressure and
reduce risk of tissue
breakdown
No dressing - observe
Not applicable
Not applicable
Not applicable
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C: 1
LEG ULCERS: THE FACTS (AETIOLOGY)
Leg ulceration is a common condition with a point-prevalence between 1.5 and 3 per 1000 (EHCB, 1997). Bolton population is 280,000, therefore Bolton PCT might expect to have between 420 and
840 patients under treatment at any time. Annual treatment cost are estimated to be 1200 - 1500 per patient for treatment with usual care. This implies that Bolton PCT faces a total treatment cost
in the range of 0.5m to 1.3million per year.
TYPE
INDICATOR/DESCRIPTOR
Venous
Usually gaiter area.
Exuding wound, shallow with diffuse
edge.
Generalised oedema and staining of
skin will occur.
Some pain,
Doppler assessment greater than 0.8
Mixed
Of both venous and mixed aetiology
Involves both venous problems and
arterial insufficiency
Doppler assessment between 0.6 and
0.8
Arterial
Any part of the leg, commonly below
the ankle
Dry wound, deep with cliff edges
Localised oedema, no staining of the
skin.
Pain greater at night, Doppler
assessment<0.6
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MANAGEMENT AIMS
To rehydrate eschar
To reduce pressure in
superficial venous
system
Aid venous return by
increasing velocity of
flow in deep veins
Reduce pain and
oedema
Increase venous return

Reduce pain and
oedema
Prevent infection
TREATMENT OPTIONS
Multi-layer compression
system
4 layer or 2 layer
compression system or
Compression Hoisery
system
Each patient should be
individually assessed
according to there daily
activity requirements.
Skin care:
Hydrate with emollient
Reduced compression
system 3 layer
Or Compression Hoisery
Skincare:
Hydrate skin with emollient
If Doppler < 0.8 indicates
significant arterial
impairment
Prevent infection
Treat symptoms
No compression at all
Non-adherent dressing
Compression
bandages must
never be used on
arterial ulcers
Wool and crepe lightly

applied toe to knee
Diabetic may have normal
ABPI but high
compression bandaging is
not appropriate. Suspect
peripheral arterial disease
and refer to Tissue
Viability Service
Other considerations
Only practitioners who have
undertaken a leg ulcer
management course (Level
2 0r 3) can undertake a full
doppler assessment
Compression bandages
must only be applied by
practitioner who have
undertaken training at Lever
Chambers / Satellite clinics.
Doppler Assessment Must
be performed on any lesion
on the leg of more than six
weeks at the nearest leg
ulcer satalite clinic.
Nutrition: Assess Nutritional
Needs.
Pain Assessment Consider
the difference between
Arterial pain and Venous
pain
In the case of venous leg
ulcers, recurrence can be
substantially reduced by
continuous application of
compression hosiery after
healing.
Complex patients ie,not
responding to standard
treatment after four weeks
please refer to the Tissue
Viability Service.
C2
Leg Ulcers: Dressing Selection
Tissue Type
Indicator/
Descriptor
Management Partial thickness

aims
Full thickness
Necrotic
Identified by
presence of
predominantly
black / brown
tissue
To rehydrate
eschar and
reduce risk of
infection
Primary dressing:
Hydrogel
Primary dressing:
Hydrogel
Secondary Dressing:
Semi-permeable film dressing to
occlude the area
Secondary Dressing:
Semi-permeable film
dressing
Identified by
formation of
viscous,
predominantly
yellow tissue
To remove all
debris and
promote
autolysis
Primary dressing:
Hydrogel
Primary dressing:
Hydrogel
Secondary Dressing:
Non-adherent foam if heavy
exudates or Non adherent
contact dressing light/moderate
exudate
Secondary Dressing:
Non-adherent foam
If slough persists consider
cadexomer iodine
Granulating
Wound has
granular
appearance, looks
red and bleeds
easily
To promote
angiogenesis
and aid wound
healing
Non-adherent
wound contact layer
Non-adherent
wound contact layer
Epithelialising
Wound is pink in
appearance, tissue
very fragile and
needs to be kept
moist
To protect new
tissue and allow
final stage of
healing
Non-adherent
wound contact layer
Non-adherent
wound contact layer
Sloughy
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Other
considerations
It is important to check the

wound for signs of
infection, please refer to
infected wounds in section
D.
If unable to contain
exudate, seek advice from
Tissue Viability service at
Lever Chambers
If wound is failing to
respond to treatment after
following guidelines (or is
deteriorating) please refer
to Tissue viability Service.
D:
DIABETIC FOOT ULCERS
Foot complications in people with diabetes are common, accounting for almost half of all diabetes-related admissions in the UK. In community-based surveys, prevalence of foot ulceration has been
shown to be 3 4 %, whilst the overall incidence of foot complications in the diabetic population is 5-10%. Amputation affects 1.3% of all patients with diabetes and diabetic foot complications are
responsible for 50% of all non-traumatic amputations (Williams 1985)
Tissue Type
Indicator/
descriptor
Management
aims
Grade 1
Grade 2
Non-blanchable erythema
of intact skin.
warmth, oedema, induration
or hardness may also be
used as indicators,
particularly on individuals
with darker skin.

involving epidermis, dermis, or
both.
Grade 3

involving damage to or
necrosis of subcutaneous
tissue that may extend
down to, but not through
underlying fascia.
Grade 4
Full thickness
Extensive destruction,
tissue necrosis, or
damage to muscle, bone,
or supporting structures
with or without full
thickness skin loss.
Necrotic
Identified by
presence of
predominantly
black / brown
tissue
To reduce risk of
infection in
diabetic foot
Necrotic lesions in diabetic foot ulcers should be treated cautiously. Dry necrotic toes should be left dry and
allowed to separate naturally. Due to the increased risk of infection and amputation, necrotic lesions on feet
should be left dry until a full foot assessment has been performed by Podiatry. Referral to Tissue Viability for
multidisciplinary assessment is essential.
Sloughy
Identified by
formation of
viscous,
predominantly
yellow tissue
To remove all
debris and
promote autolysis
Not applicable
Low exudate;
Hydrogel + non adhesive
Foam
Mod High Exudate
Hydrogel + non adhesive foam
Low exudate:
Hydrogel + nonadhesive
foam
Mod High Exudate:
Hydrofibre + non adhesive
foam
Low exudate:
Hydrogel + non adhesive
foam
Mod High Exudate:
foam
Granulating
Wound has
granular
appearance,
looks red and
bleeds easily
To promote
angiogenesis and
aid wound healing
Not applicable
Thin foam dressing for

protection
Low exudate:
Non adhesive foam
Mod High Exudate:
foam
Low exudate:
Non adhesive foam
Mod High Exudate:
foam
Epithelialising
Wound is pink in
appearance,
tissue very
fragile and
needs to be kept
moist
To protect new
tissue and allow
final stage of
healing
Not applicable
Thin foam dressing for

protection
Non adhesive foam
Non adhesive foam
Reddened
Skin which is
likely to break
down as a result
of friction/shear
or site of
previous injury
To prevent
friction, relieve
pressure and
reduce risk of
tissue breakdown
No dressing observe
No dressing observe
Not applicable
Not applicable
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E: Wound Infection
According to the most recent figures wound infection in the UK accounts for 10.7% of all hospital-acquired infections and 0.7% of community acquired
infection. Extra costs include in-patient stay, diagnostic procedures, cost of treatment, nursing time, pain, anxiety and quality of life. Wound infection rates can
be used as a key quality indicator but care should be taken to compare criteria for definition between centres.
TYPE
Indicator / Descriptor
Colonised
Multiplications of
organisms with, as
yet, no host reaction
Positive swab/biopsy
Sufficient organisms
present to interfere
with healing but not
invading surrounding
tissue, therefore no
inflammation
Critically Colonised
Management aims
Prevent infection
Reduce bacterial
numbers
Prevent bacterial
proliferation
Reduce bacterial
numbers
Prevent bacterial
infection
Remove barriers to
healing
Characteristics:
Treatment Options
Other
considerations
Exudate levels
In cases of clinical
infection, systemic
antibiotics must be
used
No Low
Mod - High
Primary
Dressing:
Hydrogel
Primary
Dressing:
Hydrogel
Secondary
Dressing
Thin Foam
Secondary
Dressing:
Foam Dressing
Primary
Dressing:
Hydrogel
Primary
Dressing:
Cadexomer Iodine
Secondary
Dressing
Thin Foam
Secondary
Dressing:
Foam Dressing
Primary
Dressing:
Hydrogel
Primary
Dressing:
Cadexomer Iodine
Secondary
Dressing:
Thin foam
Secondary
Dressing:
Foam Dressing
Measure may be
required to control
exudate, pain and
odour
Pain, excess exudate, Dull,

dark red granulation tissue,
wound is static and delayed
healing
Deposition and
multiplication of
bacteria with host
reaction
Clinically infected
Characteristics of
infection
Pain, Erythema,
Inflammation, Pyrexia, Pus,
Odour, Heavy exudate,
Non-healing
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Resolve deep
infection using
systemic antibiotics
Reduce bacterial
numbers
Treat symptoms
Prevent septicaemia
Remove Barriers to
healing
Infected wounds:
When assessing a
wound, check for
signs of a spreading
infection:
Pyrexia
Localised
heat and
swelling
around the
wound
margins
Pain
Friable wound
bed
Also pus, green
slough and offensive
odour may be present
F: Wound Bed Preparation & Dressing Selection

This is simply the removal of local barriers to healing. Modern wound dressings provide excellent healing rates but there are still a certain percentage of
chronic wounds that fail to heal. If the wound bed is properly prepared this may yield faster healing rates from existing products and hence a greater cost
effectiveness.
Type
Necrotic / Sloughy
High bacterial Count
Chronic Exudate
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Indicator/ Descriptor
Management Aims
Treatment Options
Identified by presence of
black non-viable / yellow
viscous tissue
To rehydrate eschar and

remove the physical
barriers to healing
Primary Dressing:
Hydrogel
Secondary Dressing:
Adhesive Foam Dressing
If after 7 days there is no

improvement in wound bed
consider Cadexomer
Iodine preparation
In a large cavity must
document in the care plan
the number of
alginate/hydrofibre ropes
placed in the wound.
Identified by a chronic
wound not healing, with or
without clinical signs of
infection
To reduce the bacterial

numbers
Prevent bacterial
proliferation
Remove barriers to healing
Primary Dressing:
Cadexomer Iodine
Copious amounts of wound

exudate
Maceration of surrounding
skin
Lack of wound healing and
cell proliferation
Control the wound exudate

whilst avoiding dessication
of wound bed
Keep surrounding skin dry
whilst maintaining a moist
wound environment
Primary Dressing:
Hydrofibre
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Secondary Dressing:
Secondary Dressing:
G: Minor Wounds Dressing Selection

The minor injuries market consists of: cuts, abrasions, minor burns/scalds, skin flaps, sprains and strains. Such wounds are classified as those where damage
to the epidermis or superficial damage has occurred. These wounds are characterised by redness, minor bleeding and skin abrasion and are wounds
commonly seen from day to day
Tissue Type
Indicator/
Descriptor
Management
aims
Necrotic
Identified by
presence of
predominantly
black / brown
tissue
To rehydrate
eschar and reduce
risk of infection
Identified by
formation of
viscous,
predominantly
yellow tissue
To remove all
debris and promote
autolysis
Wound has
granular
appearance,
looks red and
bleeds easily
To promote
angiogenesis and
aid wound healing
Wound is pink in
appearance,
tissue very fragile
and needs to be
kept moist
To protect new
tissue and allow
final stage of
healing
Sloughy
Granulating
Epithelialising
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Broken
Shallow
Other
considerations
Primary dressing:
Hydrogel
Primary dressing:
Hydrogel
Secondary Dressing:
Film or adhesive foam
Secondary Dressing:
Primary dressing:
Hydrogel
Primary dressing:
Hydrogel
Exceptions
Some pressure ulcers on
heels which are necrotic
and dry should beleft dry
to prevent potential
infection in patients with
Diabetes or Arterial
Disease see section D and
summary
recommendations
Secondary Dressing:
Secondary Dressing:
Non-adherent
wound contact layer
Non-adherent
wound contact layer
Non-adherent
wound contact layer
Non-adherent
wound contact layer
It is important to check the

wound for signs of infection,
please refer to infected
wounds in section D.
If wound is failing to respond

to treatment after following
guidelines (or is
deteriorating) please refer to
Tissue viability Service.
H: CELLULITIS
Cellulitis of the lower limb can usually be managed in the community with appropriate antibiotics if recognised at an early stage. Where cellulitis has progressed, IV
antibiotics may be required and can, in most cases be administered at home via the Rapid Response Team. Very occasionally cellulitis of the lower limb requires hospital
admission.
Antibiotics are the essential basis for therapy in these cases and they will rarely require a Tissue Viability Referral.
TYPE
Management aims
Treatment Options
The extent of the Erythema should

be marked as soon as it is identified
then monitored to determine
Cellulitis of the
Lower Limb
The patient will
complain of feeling
unwell with flu like
symptoms.
Characteristics:
Blistering
Pain,
Erythema,
Inflammation,
Pyrexia,
Pus,
Odour,
Heavy exudate,
Non-healing
Resolve deep infection

using systemic
antibiotics
whether the cellulitis is

increasing or resolving with
antibiotic therapy.
Exudate levels
Drain blister large blisters

will not resolve without
aseptically releasing the
fluid with a sterile needle,
until all the fluid is
dispersed
Reduce bacterial numbers

Treat symptoms
Prevent septicaemia
Remove Barriers to healing
No Low
Mod - High
Primary
Dressing:
Non Adherent
dressing
Primary Dressing:
Absorbent pads
Secondary
Dressing
Wool and crepe
toe to knee
Secondary Dressing
Wool and crepe toe to
knee
In cases of clinical
infection, systemic
antibiotics must be
used
Measures may be
required to control
exudate, pain and odour
Tissue Viability Referral
NOT usually required
Change regularly
according to exudate
As the blisters and wounds

dry out, rehydrate dry legs
by washing the legs in
warm water with Aqueous
cream
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I: WOUND COMPLICATIONS:
I:1 Overgranulation
Type
Management aims
Treatment Options
Other Considerations
Overgranulation occurs at
the proliferative stage of
wound healing. It presents
clinically as granulation
tissue raised above the
level of the surrounding
skin
To reduce further
development of granulation
tissue
To promote
epithelialisation over the
surface of the wound
To effectively manage
wound exudate
To provide a dressing that
is comfortable and
acceptable to the patient
Foam dressing must be

non adhesive
Silver nitrate: caustic and a

potential cause of
metabolic disturbances with
prolonged use or possible
malignancy
Short term Hydrocortisone

1% to be applied to a layer
of 3mm daily
Seek advice from tissue
viability service if no
improvement within two
weeks
I:2 - Hypertrophic / Keloid scars

Type
Hypertrophic
Management aims
Treatment Options
Other Considerations
Red/dark raised scar within the

boundary of the original wound
and can be very itchy or
painful.
To flatten and fade scar and to

improve function and mobility
over a joint
Silicone gel sheet
Not to be used on open

wounds
Application time should be
increased gradually
Typical causes: Following any

injury. Result of an imbalance
in production of collagen in a
healing wound.
More common in the young.
Keloid
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As above.
Keloid scars are most common
in dark skinned people
15
Refer to Tissue Viability

Service for advice
To flatten and fade scar and

to improve function and
mobility over a joint
Silicone gel sheet
I: 3 - Fungating wounds
Fungating wounds are caused by a local tumour infiltrating the skin, or by metastatic spread from the primary tumour. Both ulceration and proliferative
malignant growth may be present and consequently may require a number of planned interventions to control the exudate and odour, minimise the pain and
prevent maceration of the surrounding skin. Although the separate indicators are listed below and described more fully in the sub-sections, management of
fungating wounds (as with other complex wounds) is often by a combination of therapies.
Type
Indicator /
Descriptor
Management aims
Treatment Options Other

Considerations
Wound exudate
Manage excess
exudates
Control slough/necrotic
debris
Keep moist
Control odour
Check for infection
Alginate moderate
Hydrofibre Heavy
exudate
Odour
Maceration
Difficult sizes and sites

Pain
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Keep skin as dry as

possible to protect from
breakdown
Dress with appropriate
product
Use an appropriate
primary dressing that
can be left in place for
up to 7 days
Multidisciplinary
management
Symptom control
Irrigate with
metronidazole solution
Topical application of
Metrotop gel
Charcoal dressing,
protective barrier cream
for surrounding skin
Foam dressing
Silicone dressing
Psychological support
Pain control
Potential Haemorrhage
Body image
Refer to Tissue Viability
Service for advice if
necessary
J: WOUND CLASSIFICATION
A wound may be defined as a defect or break in the skin that results from physical, mechanical or
thermal damage, or that develops as a result of the presence of an underlying medical or
physiological disorder (Thomas, 1990)
Abrasions (grazes) are superficial wounds, generally caused by friction as a result of glancing or
tangential contact between the skin and a harder or rougher surface. Abrasions are generally
confined to the outer layers of the skin.
Lacerations (tears) are more severe than abrasions and involve both the skin and the underlying
tissues.
Penetrating wounds may be caused by knives, bullets, or may result from accidental injuries
caused by any sharp or pointed object. Internal damage can be considerable depending upon the
size and depth of penetration, and/or the velocity of the bullet or missile.
Bites caused by animals or humans may become infected by a range of pathogenic organisms
including spirochetes, staphylococci, streptococci, and various gram positive bacilli. If untreated,
these infections may have very serious sequelae, involving fascia, tendon and bone.
Burns and chemical injuries
There are several different types of burns: thermal, chemical, electrical, and radiation. Thermal
injuries are the most common. Burns and scalds (thermal) may be classified into three types
depending upon the degree of tissue damage.
Superficial (first degree) burns involve only the epidermis and superficial layers of the dermis and
usually result from exposure to prolonged low intensity heat.
Deep dermal (second degree) burns, in which most of the surface epithelium is destroyed together
with much of the dermal layer beneath. Only some isolated epidermal elements in the deeper layer
remain visible such as those within hair follicles and sweat glands.
Full thickness (third degree) burns, in which all the elements of the skin are destroyed.
Chronic Ulcerative Wounds
Ulcers can be divided into different types depending upon their underlying cause.
Pressure ulcers are usually caused by the sustained application of surface pressure over a bony
prominence, which inhibits capillary blood flow to the skin and underlying tissue. If the
pressure is not relieved it will ultimately result in cell death followed by tissue necrosis and
breakdown.
Leg or foot ulcers, which may be venous, ischaemic, mixed venous and ischaemic or traumatic
in origin.
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Diabetic foot ulcers

Ulcers associated with certain systemic infections.
Ulcers resulting from radiotherapy.
Ulcers resulting from malignant disease.
MECHANISMS OF WOUND HEALING
Irrespective of the nature or type of wound, the same basic biochemical and cellular procedures are
required to bring about healing.
The following types of wound healing are generally recognised.
PRIMARY CLOSURE.
Most clean surgical wounds and recent traumatic injuries are managed by primary closure. The
surgeon approximates the edges of the wound and individually sutures the different layers of tissue
together.
OPEN GRANULATION.
In wounds that have sustained a significant degree of tissue loss as a result of surgery, trauma or
chronic ulceration, it may be undesirable or impossible to bring the edges of the wound together.
The wound is left to heal by secondary intention.
DELAYED PRIMARY CLOSURE.
Delayed primary closure is carried out when, in the opinion of the surgeon, primary closure may be
unsuccessful (due to the presence of infections, a poor blood supply to the area, or the need for the
application of excessive tension during closure). In these circumstances, the wound is left open for
about three to four days before closure is affected.
GRAFTING AND FLAP FORMATION.
A skin graft is a portion of skin (composed of dermis and epidermis) that is removed from one
anatomical site and placed onto a wound elsewhere on the body. If successful, grafting will ensure
that the wound will heal rapidly, thus reducing the chance of infection. The disadvantage of this
technique is that the patients finishes up with two wounds instead of one, and the donor site can be
more painful than the original injury.
L
WOUND ASSESSMENT
Guideline Statement
Holistic assessment of the patient is an essential part of the wound care process.
All patients with wounds will have their wounds assessed by nursing staff within 24
hours of admission to an episode of care (hospital or community).
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To link in with the wound assessment tool, classification by wound bed tissue type is used in
addition to the following factors:
Wound measurement, exudate, presence of infection, pain and condition of surrounding skin.
Wound Bed
Necrotic
Wound containing dead tissue. It may appear hard, dry and black. Dead connective tissue may
appear grey. Eschars with time may soften by autolysis and bacterial liquefacation. The presence of
dead tissue in wounds delays healing.
Sloughy
Slough is formed by an accumulation of dead cells in the wound exudate. It is light yellow in
colour and must not be confused with infected tissue and pus.
Granulating
Healthy red tissue, which occurs during the proliferative phase of healing. Firbroblasts migrate to
the wound to produce collagen fibres. The tissue is well vascularised and bleeds easily.
Epithelializing
Process by which the wound surface is covered by new epithelium, this begins when the wound has
filled with granulation tissue. The tissue is pink, almost white, and only occurs on top of healthy
granulation tissue.
Wound Measurement
Wound measurement is a vital aid to examining the healing process within a wound. Chronic
wounds should be measured 4 weekly (diabetic foot ulcers weekly).
The wound should be measured at its greatest length and breadth: The two measurements are then
multiplied to give an approximate wound area in CM2. This method can be unreliable where
different professionals are assessing the same wound and also where the shape of the wound is
quite irregular.
Exudate
Exudate is produced by all acute and chronic wounds (to a greater or lesser extent) as part of the
natural healing process but may become more viscous and malodorous in infected wounds. It plays
an essential part in the healing process in that it:
Contains nutrients, energy and growth factors for metabolising cells
Contains high quantities of white blood cells
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Maintains a moist environment for wound healing

Uncomplicated exudate should ideally be left undisturbed on the wound surface, however the
surrounding skin may require some cleansing in order to reduce odour and prevent maceration.
With leg ulcers, excessive exudate may be produced as a result of venous hypertension and in this
case the patient should be referred to the appropriate leg ulcer clinic for holistic assessment and
doppler studies to determine suitability for compression.
Infection
Wound infection may be defined as the presence of bacteria or other organisms, which lead to a
host reaction. A host reaction can present as any one or combination of the following signs:
(Adapted from: Cutting & Harding, 1994)
Redness (erythema) around the wound
The production of large amounts of exudate or pus
A change in exudate colour
Malodour
A raised systemic temperature
Localised pain
Localised heat
Lymphangitis
Delayed or abnormal wound healing
Wound breakdown
The appearance of fragile tissues which may bleed easily when touched or at the time of a
dressing change.
Guideline Statement
Pain
The pain associated with chronic wounds is often underestimated. In over 50% of cases, nurses
recording of patients pain differed from self-reporting. In most of these cases, the nurses had
underestimated the patients pain. Pain assessment tools have many advantages:
Patient has a more active role in dealing with their pain
The patient may feel that their pain is being taken seriously
The tool often prompts more effective pain relieving measures, as documented evidence exists.
In wound care, accurate assessment of pain is essential with regard to choice of the most
appropriate dressing. Assessment of pain before, during and after the dressing change may
provide the nurse with vital information for future wound management.
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Exceptions: Patients with peripheral neuropathy (often diabetic patients) who may have lost
sensation in the foot and therefore are unable to feel pain in the foot.
In general, pain experienced by patients with chronic wounds, (although extremely subjective and
variable from patient to patient) falls into the following categories:
A deep, dull constant pain
A superficial, burning-type pain
A neuralgic type pain
An ischaemic type pain
The pain resulting from cellulitis
Whatever the cause of the pain, the patients perception of their pain should be acknowledged, and
appropriate action taken to alleviate suffering.
Surrounding Skin
Surrounding tissues may present as:
healthy
macerated
dry/flaky
eczematous
blue/black discolouration
oedema
erythema
cellulitis
The surrounding skin should be examined carefully as part of the process of assessment and
appropriate action taken.
M
FACTORS DELAYING WOUND HEALING
A number of local and systemic factors are well recognised causes of delayed or impaired wound
healing. Foreign bodies introduced deep into a wound at the time of injury can, if not removed,
cause a chronic inflammatory response and delay healing or lead to the formation of a granuloma
or abscess. Long standing wounds that heal by epithelialisation, such as burns and leg ulcers, may
develop Marjolins ulcer, an uncommon slow-growing squamous cell carcinoma.
Other major factors that have an important effect upon the rate of healing include the age and the
nutritional status of the patient; underlying metabolic disorders such as diabetes or anaemia; the
administration of drugs that suppress the inflammatory process; radiotherapy; arterial disease
which may be aggravated by smoking; and the presence of slough and necrotic tissue. (Thomas,
1990)
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Factors that may affect the healing process:

Increasing age
Nutrition
Dehydration
Blood Supply
Infection
Disease
Stress
Lack of Sleep
Adverse conditions at the wound site
Inappropriate wound management
Iatrogenic causes
Patient compliance/motivation
Unrelieved pressure
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NUTRITIONAL ASPECTS OF WOUND HEALING
Nutritional status plays a critical role in the wound healing process. Neglecting the nutritional
health of the individual may totally compromise all wound management to be carried out.
(Wallace, 1994)
Optimal Nutrition Helps To Maintain Immune Competence.
THE ESSENTIAL NUTRIENTS FOR WOUND HEALING
Protein, Vitamin C, B Complex and A, Zinc, Iron and Copper are essential for wound healing.
In addition to these nutrients, it is essential that adequate energy/calories are obtained from fats and
carbohydrates to prevent tissue protein being used as a source of energy.
PROTEIN
Requirements: 1.2 2.0g protein/kg/24h
Protein is required for healing tissues. Without adequate protein normal protein synthesis and
wound healing are inhibited. The immune response is diminished and there is a delay in matrix
formation.
Protein Sources:-
Meat, fish, eggs, milk, cheese, yoghurt, pulses and nuts.

Nutritional sip feeds will provide important sources of protein and
other nutrients if dietary intake is inadequate.
ENERGY
Requirements: 30-40 Kcal/kg/24h
An adequate energy/calorie intake is essential in order to prevent dietary and tissue protein being
used as a source of energy rather than for wound healing.
An excessive intake of energy, leading to obesity, also gives rise to problems with wound healing
decreased mobility, increased weight bearing and vascular insufficiency may precipitate wound
complications and increase the risk of pressure sores (Wells, 1994).
For obese patients during recovery from major surgical or trauma wounds, a strict weight-reducing
diet during this time is inappropriate, good quality nutrition is vitally important.
It is important to remember that overweight does not necessarily mean well nourished.
Malnutrition is a widespread problem (Edington, et al., 1996) which affects obese and underweight
patients.
Energy Sources:-
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All foods provide energy and preserve tissue protein.

Carbohydrate sources bread, potatoes, breakfast cereal, rice and pasta, oils,
23
spreads, butter, margarine, fried foods.

Fat sources oils and fats, butter, margarine, fried foods.
VITAMINS
Vitamin C
Requirements: A minimum of 60mg vitamin C. Vitamin supplements from 200 mg 1g per day are
sometimes recommended [Taylor, 1974], however excessive doses may cause renal stones
[Morton, 1995].
Vitamin C is required for collagen synthesis and aids iron absorption.
Vitamin C is not stored in the body with patients rapidly becoming deficient. Supplements may be
necessary.
Vitamin C Sources:- Citrus fruits and juices, blackcurrant juice drinks and fruit squashes fortified
with vitamin C tomato juice, all fruit and vegetables.
Vitamin A
Promotes epithelialization and granulation of healing wounds.
Vitamin A Sources:- Liver, dairy products, oily fish, carrots, dried fruits.
Vitamin B Complex
Co-factor for enzyme systems in protein, fat and carbohydrate metabolism.
Vitamin B Complex Sources: Liver, kidney, meat, poultry, fortified breakfast cereals, wholemeal
bread, yeast extract, eggs, and green vegetables.
Vitamin E
Controversial role. Some research states that it is beneficial, while others consider it detrimental
(Mazzotta, 1994).
Vitamin K
Indirect role in wound healing, needed for normal blood coagulation.
Vitamin K sources Green vegetables, potatoes, tomatoes, liver, soya beans.
MINERALS
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Zinc
Deficiency is associated with poor wound healing.
Zinc is required for collagen synthesis, epithelialization and cell proliferation.
Zinc supplements have been found to improve the healing of leg ulcers where zinc deficiency is
identified.
However, where there is no deficiency excess zinc can impair healing (Wells, 1994).
Zinc sources:- Liver, meat, fish, eggs, pulses including baked beans, wholegrain cereals.
Iron
Blood losses during injury or inadequate dietary intake, anaemia will result in decreased transport
of oxygen to damaged tissue and may delay wound healing.
Iron is required for collagen formation.
Iron Sources:- Liver, meat, poultry, oily fish, egg yolk, pulses, dried fruits.
Copper
Required for collagen formation and essential for red blood cells formation.
Copper Sources:- Meat, fish, cereals and pulses, green vegetables.
FLUIDS
Requirements:-
30-65 ml/kg/24h
Adequate fluids are required to prevent skin dehydration and essential with high protein diets.
Fortification of foods with energy/calories and/or protein supplements can enhance the quality of
the diet.
Supplementary drinks such as Build-up, Complan or Vitafood provide an important source of all
nutrients if dietary intake is inadequate.
Nutritional assessment.
Identification of high risk individuals allows prompt employment of nutritional support and
optimal use of resources to improve wound healing and reduce complications. [Ward et al., 1998
].
Guideline Statement
Optimal nutrition facilitates wound healing, maintains immune competence and decreases
the risk of infection.
It is essential to consider the nutritional status of all patients with wounds. Referral to the
dietitian should then be made where appropriate.
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WOUND MANAGEMENT
i.
Wound Cleansing
Most of the research on wound cleansing examines the efficacy of wound cleansing on removal of
bacteria from the wound. It is widely accepted that chronic wounds are heavily colonized with
bacterial skin flora and that attempts to remove these bacteria from a chronic wound are futile.
(Thomlinson, 1997)
Wound cleansing should not be undertaken to remove normal wound exudate. There is extensive
evidence to support the fact that exudate is beneficial to the wound, containing growth factors and
nutrients, which actually support the healing process (Leaper, 1986)
Excessive wound exudate may require removal and may also cause local maceration of the skin.
Some cleansing may be required in this case, however if the exudate is clear, enabling accurate
wound assessment the surrounding skin may be cleansed leaving the wound untouched.
The following criteria for wound cleansing are recommended in accordance with recent research:
Criteria for wound Cleansing
1.
2.
3.
To remove visible debris after a wound has initially occurred and to aid assessment
To remove excess slough and exudate in order to aid patient comfort
To remove remaining dressing material
(Miller & Gilchrist, 1998)
In cases where wound cleansing is necessary, warm normal saline should be used. Cell mitosis is
inhibited by cooling the wound and may actually delay healing (Lock, 1980).
Irrigation is the method of choice for cleansing wounds. This may be carried out utilising a
syringe in order to produce gentle pressure in order to loosen dressing debris etc., but to prevent
splashback of irrigation fluid.
Gauze swabs, cotton wool etc. should not be used for cleansing the wound surface, but may be used
to wipe away excess saline/exudate from the surrounding skin following irrigation. Mechanical
damage to new tissue and the shedding of fibres from gauze swabs/cotton wool delays healing
(Wood, 1976)
Guideline Statement
Wound cleansing (where necessary) should be carried out by irrigation with sterile normal
saline warmed to body temperature.
For chronic wounds such as leg ulcers, ordinary tap water can be used
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Other Solutions Used for Wound Cleansing:

The following solutions should not be routinely used in the cleansing of wounds. They should
only be used where the risk of infection outweighs the reported detrimental effects of the solution
and should only be used further to Consultant, Microbiological or Pharmacological advice:
Povidone Iodine only licensed as a skin antiseptic and not for use on open wounds
Chlorhexidine 0.5% shown to inhibit epithelialization and granulation of tissue (Neider &
Scoph, 1986). If used on traumatic wounds with a high risk of infection, then 0.05% in
aqueous form should be used.
Potassium Permanganate: No research traced relating to benefits, toxicity or allergies. BNF
states that it may be irritant to mucous membranes. Sometimes used under instructions of
dermatologist, vascular surgeon or General Practitioner for weeping eczema.
Hydrogen Peroxide: Not recommended for wound cleaning except in exceptional
circumstances. There have been unsubstantiated reports of air emboli resulting from its use in
cavity wounds. (Sleigh & Winter, 1985)
Guideline Statement
ii.
Choice of Dressings
It should be recognised that a wound will require treating differently at various stages of its
healing. No dressing is suitable for all wounds.
Following careful selection of the appropriate management plan for the patient, the wound
assessment tool should be used to monitor the progress of the wound through to its healing stage.
Guideline statement
Criteria for Choosing a Dressing In Order of Importance (Miller & Collier, 1997)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Choose a dressing that maintains a moist environment at the wound/dressing interface. (The only possible
exceptions are peripheral necrosis secondary to arterial disease.
Choose a dressing that is able to control (remove) exudate. A moist wound environment is good, a wet
environment is not beneficial
Choose a dressing that does not stick to the wound and cause trauma on removal
Choose a dressing that protects the wound from the outside environment
Choose a dressing that will aid debridement if there is necrotic or sloughy tissue in the wound (caution with
ischaemic lesions)
Choose a dressing that will keep the wound close to normal body temperature
Choose a dressing that is acceptable to the patient
Choose a dressing that is cost-effective
Diabetes choose a dressing that will allow frequent inspection
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Dressings Supplies
Methods for wound management should be re-assessed at each dressing change. However, the
following list is issued as guidance to minimise wastage of prescribed dressings as the wound
changes.
Wound Type / Suggested Duration of Supply *
Black/Necrotic
Sloughy
Low or no exudate
Medium to high exudate
Granulating
Epithelialising
7 days
7 - 10 days
>10 days
2 - 4 weeks
2 - 4 weeks
2 - 4 weeks
* The amount supplied depends on the frequency of dressing changes.

Manufacturers instructions are provided with all products and these must be read and followed at
all times.
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P:
Formulary of Product Groups With Recommendations for Use
Alginates
NB.
Formulary choice:
Kaltostat (Convatec)
Sorbsan Plus (Unomedical)
Indicated in the management of moderately to heavily exuding wounds

Calcium alginate with sodium alginate
Active haemostatic dressing
Fibres convert to a hydrophillic gel (biodegradable) when in contact with exudates
Use Sorbsan Plus for very heavy exudate only
Use placed on the surface of the wound. Alginate rope can be used in cavity wounds or sinuses but
do not pack tightly
Cover with film dressing or adhesive foam dressing

Change every 1 - 7 days depending on amount of exudate
Removal:
Kaltostat - remove with forceps once moistened with saline.
At dressing changes the fibre in contact with the surface should have formed a gel. If dressing
moist but not gelled, increase interval between dressing changes. If dressing has gelled and dried
out, use of a more occlusive dressing may be appropriate.
Antiseptics
Formulary Choice:
Cadexomer Iodine: Iodosorb &Iodoflex (Smith & Nephew)
Inadine (Johnson and Johnson)
Cadexomer Iodine is the product of choice within Bolton PCT as it releases Iodine slowly into the
wound at a controlled rate.
Inadine contains 10% povidone iodine with 1% available iodine, which imparts pronounced
(though short-term) antibacterial activity to the dressing (Thomas, 1990). Inadine adheres to the
wound bed and is deactivated by wound exudate (in some cases in only a few hours). Absorption
of iodine occurs and therefore it is contraindicated in patients on Lithium or thyroxine therapy. It
should NOT be used on children as it often causes trauma on removal.
The debate on the use of iodine continues at National and European levels (Gilchrist, 1997) and
therefore the use of these (and other iodine) dressings should remain restricted until clear guidance
is available.
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Foam Dressings
Use
Indicated for medium exuding wounds

Exudate absorbed horizontally across the hydrophillic surface
Place on wound surface
Secure with adhesive tape (if non-adhesive)
Change every 1 - 7 days depending on volume of exudate
Low adherence
Hydrocolloids
Formulary Choice:
Allevyn thin, adhesive and non-adhesive (Smith & Nephew)
Formulary Choice:
Hydrocoll basic, Hydrocoll border, Hydrocoll thin film
(Hartmann)
Indicated for light / medium exuding wounds

Interactive with the wound exudate, slowly absorbing fluid leading to a change in the physical
state of the dressing.
The dressing provides an environment for rapid debridement and an initial increase in the size
or depth of the wound therefore often occurs.
Use
Dressing should extend at least 2 cm beyond the edge of the wound
Dressings should be changed every 3 - 7 days depending on the amount of exudate
Hydrofibre
Formulary Choice:
Aquacel
(Convatec)
Indicated for medium/heavy exuding wounds
Interactive with the wound exudate, slowly absorbing fluid leading to a change in the physical
state of the dressing.
The dressing provides an environment for rapid debridement and an initial increase in the size
or depth of the wound therefore often occurs.
Use
There is minimal lateral wicking therefore it can overlap healthy skin slightly
When packing a wound with the ribbon, it must be very lightly packed to avoid further trauma
Hydrogel
Formulary Choice
Purilon (Coloplast)
Suitable for wound debridement and for light to medium exuding wounds
Dressing allows either the release of water to rehydrate surrounding tissues or the absorbtion
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of exudate from the wound

Use
Apply to the wound
Requires a secondary dressing which will encourage occlusion (eg film or adhesive foam
dressing)
Film Dressings
Formulary Choice:
Mefilm (Molynlycke)
Suitable for flat/shallow low exudate wounds

Sterile, thin, waterproof, self adhesive film
Can be used as a retention dressing aid alone
Some patients may be allergic to the adhesive
Odour Absorbing
Dressings
Formulary Choice:
Actisorb Plus (Johnson &Johnson)
Carboflex (Convatec)
Actisorb Plus is a primary dressing and is designed to be placed directly onto a wound and covered
with a secondary dressing. It contains 0.15% Silver, which provides antimicrobial properties, and
therefore this product, should only be used for malodorous and infected wounds.
Carboflex has an alginate wound contact layer and carbon layer for odour absorption. It is a
particularly useful dressing for fungating malignant wounds.
Polysaccharide Pastes Not Available in Bolton Formulary

(eg. Sugar Paste)
Unfortunately most of the evidence supporting use of sugar paste is anecdotal (Thomas, 1990),
however its use for rapid debridement of slough/eschar and reduction in bacterial contamination
are frequently reported. Wounds treated with sugar paste should be redressed daily, and may cause
severe pain therefore use of sugar paste is not advocated in Bolton.
Tulle Dressings
Formulary Choice
Jelonet
Although this is cited as a non-adherent dressing, this dressing often adheres to the wound bed.
There has also been evidence of granulation tissue protruding through the dressing, thus increasing
adherence. The dressing should therefore be changed frequently to avoid this and a double layer of
the product should be used to reduce adherence.
Antibiotic
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Not advised in Bolton Formulary

31
Impregnated
Dressings
(eg Sofra-tulle, Fucidin-Intertulle)
Due to increasing numbers of resistant strains of micro-organisms and also sensitivity reactions, the
use of antibiotic dressings is not recommended. Wherever possible antibiotics should be
administered orally, NOT by dressings applied to the wound.
Topical Negative Pressure

Also known as Vacum-assissted closure (VAC KCI Medical Ltd). This is a treatment that subatmospheric pressure to a wound via a computerised therapy unit (Mendez Eastman 2001). This
device removes excess exudates, which is collected in a canister, reduces oedema, improves the
micro-circulation, decreases bacterial load and stimulates both new tissue formation and wound
contracture (Ballard and Baxter 2002). It has been shown to be effective in a variety of wounds,
particularly surgical dehiscence, pressure ulcers, leg ulcers, diabetic foot ulcers and skin grafts
(Baxandall 1997:Collier 1997:Ballard and Baxter 2002).
The Tissue Viabiltiy Team MUST be involved in the initial assessment for Vac therapy. Vac
therapy does have a cost implication. The funding has to be agreed by a department prior to
an order being placed. The Tissue Viability service does not have a budget for this treatment.
Important Note:
A single product is unlikely to be suitable for a particular wound throughout the wound healing
process. Regular re-assessment of the wound is essential together with documentation to support
rationale for change of dressing.
Communication between the acute/community setting and joint visits with other disciplines aid
holistic assessment and promote multidisciplinary team approach to wound care.
Guideline Statement
Wounds which are being managed in accordance with wound care guidelines but are
deteriorating should be referred to Tissue Viability Team.
Wounds failing to respond to treatment within a four to six week period can be referred to the
Tissue Viability Team for review.
Please also refer to specific referral and wound management criteria for leg ulcers & diabetic
foot ulcers within specific guidelines.
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Bibliography
Ballard K,Baxter H (2002) Developments in wound care for difficult to manage wounds In:White
R Ed Trends in Wound Care.Mark Allen Publishing:Salisbury,Wiltshire UK.
Baxandall T (1997) Healing cavity wounds with negative pressure.Elderly care 9 (1):20-2.
Burton A and Burton M., (1981) The Management and prevention of Pressure Sores
London, Faber and Faber,
Collier M (1997) Know How:Vacuum-assisted closure (VAC).Nursing Times 93(5):32-3.
Cutting K. F., Harding, K. G. (1994) Criteria for identifying wound infection. Journal of Wound
Care 3: 4, 198-201
Dealey C (1994) The Care of Wounds. Blackwell Scientific Publications, Oxford.
Duckworth, C Ed. (1996) Guide to the Research Base to Support a Wound Care Policy
Edington J., Kon P, Martyn CN. Prevalence of Malnutrition in Patients in General Practice.
Clinical Nutrition, Vol 15, 1996, Pp 60-63.
Feller N. and Lurie A., The early care of wounds caused by human and animal bites,
Fam Physn, 1977, 7, 29-30.
Gilchrist B.(1996) Wound infection: sampling bacterial flora: a review of the literature.
Gilchrist B (1997) Should iodine be reconsidered in Wound Management? Journal of Wound Care
6: 3, 148-150
Harding K. and Jones V. (1996)
Lock, P.M. The effects of temperature on mitotic activity at the edge of experimental wounds. In:
Sundell, B. (ed) Symposia on wound healing; plastic surgical and dermatological aspects. Molndal;
Switzerland: Lindgren, A. & Soner, A. B., 1980
Mazzotta M. Nutrition and Wound Healing. Journal American Podiatr. Medical Association, Vol
84 (9), 1994, pp 456-462.
Mendez-Eastman S (2001) Guidelines for using negative pressure wound therapy. Adv Skin
Wound Care 14 (6):314-325
Miller & Collier, (1997)Understanding Wounds. Professional Nurse Supplement
Miller & Gilchrist, (1998) Understanding Wound Cleansing and Infection. Professional Nurse
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Supplement
Moffatt C.J. et al, (1992) Community Clinics for Leg Ulcers and Impact on healing.
BMJ 1992 305`3989-1392.
Morrison MJ, (1992) A Colour Guide to the Assessment and Management of Leg Ulcers,
2nd Edition Mosby, London.
Morton, K. Nutrition and wound care. (1995) 5th European Conference on advances in wound
management proceedings. 21-24 November 1995, pp 31 34
Owen-Smith M., Wounds caused by weapons of the war, in Wound Care, Westaby S. (ed), London
Heinemann Medical, 1985, 110-120.
RCN (1998) Clinical Practice Guidelines.The Management of Patients With Venous Leg Ulcers.
SIGN (1998) The Care of Patients With Chronic Leg Ulcer.A National Clinical Guideline.Scottish
Intercollegiate Guidelines Newtwork.
Sims R and Fitzgerald V (1985) Community Nursing Management of Patients with
Ulceration/Fungating Malignant Breast Diseases. Oncology Nursing Society London.
Taylor A. D., Taylor R. and Marcuson RW, (1998) Prospective comparison of healing rates and
therapy costs for conventional and four-layer high-compression bandaging treatments of venous leg
ulcers. Phlebology 13:20-24
Thomas S. (1990) Wound Management and Dressings. The Pharmaceutical Press.
Thomas B. (Ed). Dietetic management of acute trauma.
In Manual of Dietetic Practice, Blackwell Scientific Publications, Oxford, 1994, p 637.
Thomlinson, D. (1997) To Clean or Not To Clean? Nursing Times; 83: 9, 71-75
Wallace E. Feeding the Wound: nutrition and wound care. British Journal of Nursing Vol 3(13),
1994, pp 662-667.
Ward, J. et al., Development of a screening tool for assessing risk of undernutrition in patients in
the community. Journal of Human Nutrition and Dietetics, Vol.11, No 4, 1998, pp 323 -330.
Wells L. The Importance of Nutrition in Wound Management. Professional Nurse, Vol 9, 1994, pp
525-530.
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APPENDICES:
1. Wound Care Assessment Tool
(a) Hospital
(b) Community
2. Clinical Evidence Grading Criteria

3. Summary of Recommendations and supporting graded evidence
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35
Bolton Hospitals NHS Trust
WOUND ASSESSMENT CHART

Date of Initial
Assessment
..
Name:
Address
GP
Consultant
Known Patient Allergies
SIZE OF WOUNDS
Width
Length
TYPE OF WOUNDS
Surgical
Pressure Ulcer / Grade
Diabetic foot ulcer
Leg Ulcer
Other (eg. Fungating)
WOUND WOUND WOUND

1
2
3
WOUND WOUND WOUND

1
2
3
POSSIBLE DELAYED HEALING DUE TO:

TICK ONE OR MORE IF APPLICABLE
Age 75+
Anorexia
Dehydration
Bedbound
Chairbound
Cachexia
Anaemia
Diabetes
Vasc Disease
Oedema
Incontinence
Steroids
Infection
Other please state:

If 4 or more factors consider impact on healing and try to correct
factors if possible
Date..
Refer on to appropriate teams below ONLY if significant complication or deterioration in wound:

Infection Control (if complications)
Tissue Viability Nurse (if wound deteriorating)

Dietitian (if required following nutritional assessment)
Pain Nurse (eg Uncontrolled pain at dressing)
Podiatrist (for complex foot ulcers , footwear etc)
Other (Please state)
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Date .. Sign .
Date .. Sign .
Date .. Sign .
Date .. Sign .
Date .. Sign .
Date .. Sign .
WOUND PROGRESS AND TREATMENT RECORD

This record should be used in conjunction with the patients care plan
Ongoing Wound Assessment:

Date
Wound Number
DESCRIPTION
Necrotic (Black)
%age
Sloughy (Yellow / Green) %age

Granulating (Red) %age
Epithelialising (Pink) %age
Condition of surrounding skin
Eg fragile, dry etc
EXUDATE
Exudate present
(Yes or No)
Odour
None
Slight
Offensive
Colour
clear
Straw
Blood
Purulent
Amount
(Mild/ Mod/ excessive)
PAIN
None/mild/moderate/ severe
INFECTION
Spreading Erythema
Excessive Inflammation
Green Slough / Exudate
Pyrexia
Pus (take a sample for C & S)
If clinical signs of infection obtain a
wound swab (Date)
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37
Bolton Primary Care NHS Trust
WOUND ASSESSMENT CHART

Date of Initial
Assessment
..
Name:
Address
GP
Consultant
SIZE OF WOUNDS
Width
Length
TYPE OF WOUNDS
Surgical
Pressure Ulcer / Grade
Diabetic foot ulcer
Leg Ulcer
Other (eg. Fungating)
WOUND WOUND WOUND

1
2
3
WOUND WOUND WOUND

1
2
3
If skin tear or laceration in a residential / nursing home, please ensure that you have seen
documented evidence that the home has completed an accident / incident report prior to accepting
patient on caseload
Evidence of completed Accident / Incident Report seen
Signature Date
Known Patient Allergies
POSSIBLE DELAYED HEALING DUE TO:

TICK ONE OR MORE IF APPLICABLE
Age 75+
Anorexia
Dehydration
Bedbound
Chairbound
Cachexia
Anaemia
Diabetes
Vasc Disease
Oedema
Incontinence
Steroids
Infection
Other please state:

If 4 or more factors consider impact on healing and try to correct factors
if possible
Date..
Refer on to appropriate teams below ONLY if significant complication or deterioration in wound:

Infection Control (if complications)
Tissue Viability Nurse (if wound deteriorating)

Dietitian (if required following nutritional assessment)
Pain Nurse (eg Uncontrolled pain at dressing)
Podiatrist (for complex foot ulcers , footwear etc)
Other (Please state)
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Date .. Sign .
Date .. Sign .
Date .. Sign .
Date .. Sign .
Date .. Sign .
Date .. Sign .
WOUND PROGRESS AND TREATMENT RECORD

This record should be used in conjunction with the patients care plan
Ongoing Wound Assessment:

Date
Wound Number
DESCRIPTION
Necrotic (Black)
%age
Sloughy (Yellow / Green) %age

Granulating (Red) %age
Epithelialising (Pink) %age
Condition of surrounding skin
Eg fragile, dry etc
EXUDATE
Exudate present
(Yes or No)
Odour
None
Slight
Offensive
Colour
clear
Straw
Blood
Purulent
Amount
(Mild/ Mod/ excessive)
PAIN
None/mild/moderate/ severe
INFECTION
Spreading Erythema
Excessive Inflammation
Green Slough / Exudate
Pyrexia
Pus (take a sample for C & S)
If clinical signs of infection obtain a
wound swab (Date)
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39
Appendix 1
Levels of Evidence
This hierarchy is for use by Guideline and Pathway authors when preparing their work. It
should be used to help analyse individual items of evidence used.
Any staff using the Guidelines and Pathways should be able to see easily what type of
evidence is informing the document they refer to. Guideline and Pathway authors should
make this clear in their document. Good examples of this type of presentation are NICE
Guidelines (www.nice.org.uk)
1++
1+
12++
2+
23
4
High quality meta analyses, systematic reviews of RCTs, or RCTs with a very low risk
of bias
Well conducted meta analyses, systematic reviews of RCTs, or RCTs with a very low
risk of bias
Meta analyses, systematic reviews of RCTs, or RCTs with a high risk of bias
High quality systematic reviews of case control or cohort or studies High quality casecontrol or cohort studies with a very low risk of confounding, bias, or chance and a
high probability that the relationship is causal
Well conducted case control or cohort studies with a low risk of confounding, bias, or
chance and a moderate probability that the relationship is causal
Case control or cohort studies with a high risk of confounding, bias, or chance and a
significant risk that the relationship is not causal
Non-analytic studies, e.g. case reports, case series
Expert opinion
Grading
Grading is done by Guideline and Pathway authors when preparing their work for submission to the Clinical
Effectiveness Group. An overall single grading for the Guideline/Pathway should be stated on the document proforma
submitted for ratification.
A
At least one meta analysis, systematic review, or RCT rated as 1++, and directly
applicable to the target population; or
A systematic review of RCTs or a body of evidence consisting principally of studies
rated as 1+, directly applicable to the target population, and demonstrating overall
consistency of results
A body of evidence including studies rated as 2++, directly applicable to the target
population, and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
A body of evidence including studies rated as 2+, directly applicable to the target
population and demonstrating overall consistency of results; or
Extrapolated evidence from studies rated as 2++
Evidence level 3 or 4; or
extrapolated evidence from studies rated as 2
level of evidence and grading, August 2003
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Appendix 3
Evidence Ratings Used Within Guidelines

Recommendation
Holistic assessment of
the patient is an
essential part of the
wound care process
Grade of
Evidence
C
Evidence to support recommendation

1. Van Rijswijk L (1996) Wound assessment and
documentation. Chronic Wound Previews 8 (2)
57-68
2++
All patients with

wounds will have
their wounds assessed
by nursing staff within
24 hours of admission
to an episode of care
Optimal nutrition
facilitates wound
healing, maintains
immune competence
and decreases the risk
of infection.
21. Albina JE (1994) Nutrition and wound healing.

Journal of Parenteral and Enteral Nutrition 16:
367-376
2. Martin MTM, (1998) In: Leaper D (ed)
2++
th
Proceedings of the 7 European Conference on:
Advances in Wound Management. London:
EMAP Healthcare Ltd 129-133
2++
3. Sitton-Kent L, Gilchrist B (1993) The intake of
nutrients by hospitalized pensioners with chronic
wounds. Journal of Advanced Nursing 18: 12,
1962-1967
It is essential to
consider the
nutritional status of all
patients with wounds.
Referral to the
dietitian should then
be made where
appropriate
21. Albina JE (1994) Nutrition and wound healing.

Journal of Parenteral and Enteral Nutrition 16:
367-376
2. Martin MTM, (1998) In: Leaper D (ed)
2++
th
Proceedings of the 7 European Conference on:
Advances in Wound Management. London:
EMAP Healthcare Ltd 129-133
2++
3. Sitton-Kent L, Gilchrist B (1993) The intake of
nutrients by hospitalized pensioners with chronic
wounds. Journal of Advanced Nursing 18: 12,
1962-1967
Wound
cleansing(where
necessary) should be
carried out by
2++
1. Lock PM The effect of temperature on mitotic
activity at the edge of experimental
wounds.(1980) IN: Lundgren A , Soner AB (eds)
Symposia on Wound Healing: Plasitc surgical
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41
and dermatologic aspects. Sweden: Molndal
irrigation with sterile

normal saline warmed
to body temperature
For chronic wounds

such as leg ulcers,
ordinary tap water can
be used
Antiseptics are toxic

to human tissue and
may delay wound
healing
1. Angeras MH, Brandberg A, Falk A, Seeman T.

Comparison between sterile saline and tap water
for the cleaning of acute traumatic soft tissue
wounds. (1992) European Journal of Surgery
158: 33, 347-350
1. OMeara S M, Cullum NA, Majid M, Sheldon
TA (2001) Systematic review of antimicrobial
agents used for chronic wounds. British Journal
of Surgery 88, 4-21
2. Brennan SS and Leaper D J (1985) The effect of
antiseptics on the healing wound: a study using
the rabbit ear chamber
3. Tatnall FM, Leigh IM, Gibson JR (1990)
Comparative study of antiseptic toxicity on basal
keratinocytes, transformed human keratinocytes
and fibroblasts. Skin pharmacology 3, 3, 157163
of Surgery 88, 4-21
1+
1++
2++
2+
1++
Topical antibiotics are

frequent sensitisers
and should be used
with caution
Systemic antibiotics
should be used to treat
clinical wound
infections

of Surgery 88, 4-21
Wound dressings
should:
1. Winter GD (1962) Formation of the scab and the 2+

rate of epithelialisation of supervicial wounds in
the skin of the young domestic pig Nature 193:
293-294
2++
2. Hinman, CD, Maibach H (1963) Effect of air
exposure and occlusion on experimental skin
wounds. Nature 200: 377-378
2++
3. Dyson M, Young S, Pendle CL, Webster DF,
Lang SM (1988) Comparison of the effects of
moist and dry conditions on dermal repair.
Journal of Inversitgative Dermatology 91; 5,
435-439
4. Lock PM The effect of temperature on mitotic
activity at the edge of experimental
wounds.(1980) IN: Lundgren A , Soner AB (eds)
maintain
a
moist
environment
at
the
wound/dressing interface.
(The
only
possible
exceptions are peripheral
necrosis secondary to
arterial disease).
be able to control (remove)
exudate. A moist wound
environment is good, a wet
environment
is
not
beneficial
not stick to the wound and
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1++
cause trauma on removal
Symposia on Wound Healing: Plasitc surgical

and dermatologic aspects. Sweden: Molndal
protect the wound from the

outside environment
aid debridement if there is
necrotic or sloughy tissue
in the wound (caution with
ischaemic lesions)
keep the wound close to
normal body temperature
be acceptable to the patient
be cost-effective
Diabetes choose a
dressing that will allow
frequent inspection
Nurswc001
43

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WOUND CARE GUIDELINES

wound care dressings

BOLTON PRIMARY CARE NHS TRUST

Review Date: March 2010

wound care dressings

Review Date: March 2010

wound care dressings

Review Date: March 2010

Summary of Conclusions and Grading of Recommendations:

Optimal nutrition facilitates wound healing, maintains immune competence and

It is essential to consider the nutritional status of all patients with wounds.

Wound cleansing(where necessary) should be carried out by irrigation with sterile

Systemic antibiotics should be used to treat clinical wound infections

Wound dressings should:

maintain a moist environment at the wound/dressing interface.

Please refer to Appendix 2 for Evidence Grading Criteria.

Review Date: March 2010

B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES

Must relieve pressure, regular skin inspection

Partial thickness skin loss

Relieve pressure, observe frequently, do not cover

Large blistered area

Drain blister large blisters will not resolve without aseptically

Review Date: March 2010

B:1 PRESSURE ULCER CLASSIFICATION AND MANAGEMENT GUIDELINES (continued)

Must relieve pressure, regular skin inspection

Must relieve pressure, regular skin inspection

Review Date: March 2010

Pressure Ulcers: Dressing selection

Partial thickness skin loss

Full thickness skin loss

Protect new tissue with

Protect new tissue with

Skin which is likely

Review Date: March 2010

LEG ULCERS: THE FACTS (AETIOLOGY)

Increase venous return

Wool and crepe lightly

Review Date: March 2010

Leg Ulcers: Dressing Selection

Management Partial thickness

It is important to check the

Review Date: March 2010

DIABETIC FOOT ULCERS

Partial thickness skin loss

Full thickness skin loss

Thin foam dressing for

Thin foam dressing for

Non adhesive foam

Non adhesive foam

Review Date: March 2010

Pain, excess exudate, Dull,

Review Date: March 2010

F: Wound Bed Preparation & Dressing Selection

High bacterial Count

To rehydrate eschar and

If after 7 days there is no

To reduce the bacterial

Copious amounts of wound

Control the wound exudate

Review Date: March 2010

G: Minor Wounds Dressing Selection

It is important to check the