WOUND CARE

Wound care in the community:

infection, exudate and conformability
Tracey Morgan

Community nurses require a wide skill set to deal with the variety

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of clinical presentations they meet in any given day. This includes
wound care, which can present nurses with a range of management THE SCIENCE

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challenges, i.e. how to combat infection, which kind of dressings INFECTION AND EXUDATE
to use to control exudate volume and how to ensure that dressings Community nurses can

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provide patient comfort and do not further damage the wound or use wound exudate to glean
skin on removal. It is important, therefore, that community nurses important information on

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have access to a range of versatile products that can be used in a wounds condition. The
a variety of clinical situations and which are also cost-effective. properties of wound exudate
This article examines some of the common wound care issues that such as volume, colour, viscosity

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community nurses can face, as well as looking at how a versatile and odour all provide clues to
wound dressing (Durafiber Ag; Smith & Nephew) which has the state of the wound, such as
a variety of applications in primary care can help with some of its bacterial load and infection
these issues. status (WUWHS, 2007), for
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example, a wound infected
with bacteria may have a green
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KEYWORDS: colour or tinge.
Wound care Infection Wound coverage Exudate
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nlike in the hospital setting exudate; correct dressing choice, to primary care and can form a useful
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where nurses are often able to name but a few without immediate part of the community nurses wound
draw on a number of fellow recourse to wound care specialists. care toolkit (Table 1; Figure 1).
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expert professionals when presented This was backed up by research from

with a particular clinical problem, Drew et al (2007), which found that WOUND CARE IN
in the community, nurses are more over 70% of wound care was carried THE COMMUNITY
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isolated and may be forced to make out in the community.

clinical decisions alone and without Due to the wide range of wound
access to specialist opinion (Queens Similarly, while the inpatient nurse types seen in the community, it is
14

Nursing Institute [QNI), 2009). may have an in-depth knowledge of important that community nurses
a particular specialty, the community have a working knowledge of some
Nowhere is this truer than in nurse is required to have a wide of the more common symptoms
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the realm of wound care, where understanding of many subjects and/or problems that they are
treatment choice can have a serious including different wound types and likely to encounter. However, with
effect on healing and nurses often their treatments, ranging from burns, wound care being just one element
have to make on-the-spot decisions the compression therapy required in of the extensive knowledge base

(Hallett et al, 2000). Whereas the
inpatient nurse may have access to
onsite infection control teams, tissue
viability specialist nurses, link nurses
and various medical specialties such as
vascular, plastic surgery, surgical, etc,
the community practitioner may have
to act alone to identify and commence
treatment in a range of wound
complications infection; excess
Tracey Morgan, clinical nurse specialist, tissue
viability, Aneurin Bevan University Health
Board, Wales
leg ulcers, through to the intensive
techniques involved in managing
diabetic foot ulcers, for example
(Mahoney, 2014).
This article examines some of
the common wound issues that the
community nurse may have to assess
and diagnose such as excess exudate,
infection and patient concordance
(Mahoney, 2014). The author also
looks at a versatile wound dressing
(Durafiber Ag; Smith & Nephew),
which has a variety of applications in
required by community nurses, it
can be hard to keep abreast of the
latest developments and techniques
(Nash Greally and Wardick, 2013). It
is, therefore, crucial that community
nurses have access to clear and
concise wound care information,
which will not only improve their
knowledge of innovative equipment
and techniques (Dowsett, 2009),
but also make sure that patients
continue to receive evidence-based
care in order to prevent and
manage complications.

JCN 2014, Vol 28, No 5 43

 WOUND CARE

WOUND TYPES COMMONLY

FOUND IN THE COMMUNITY

Community nurses may be called

upon to deal with a range of wounds
in the community, including:
Leg ulcers
Pressure ulcers
Diabetic foot ulcers
Surgical wounds
Traumatic wounds
Donor sites
Partial thickness burns

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Fungating wounds.

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However, by far the most common
wounds seen by community nurses

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will be chronic wounds that are
struggling to heal, particularly,

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pressure ulcers, diabetic foot ulcers Figure 1.
and venous leg ulcers (Health Service Durafiber Ag is available in a range of sizes..
Executive, 2009). These wounds can

involve ongoing treatment, and, while
they all have their own particular
treatment requirements, for example,
leg ulcers require compression
bandaging, pressure ulcers require
regular repositioning etc, there are
some issues that are common to all
which community nurses need to
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contaminated with a certain number Wound pain
of organisms and most wounds go Swelling
on to heal despite this (Butcher, Feeling of warmth in the tissues
2013). However, understanding Purulent wound discharge
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when a wound is about to become Malodour
infected is not easy, as there is no Fever.
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set number of bacteria for a wound
to become infected. A diagnosis of There are a number of stages that
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identify and address, including: wound infection is usually based lead to a wound becoming infected,
Infection risk on the presence of classic signs which involve a delicate balance
Excess exudate production and symptoms (Butcher, 2013; between the amount of bacteria
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Ensuring that dressing choice is Cutting and Harding, 1994; World present and the ability of the patients
conformable and does not cause Union of Wound Healing Societies defenses to fight off infection (Butcher,
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trauma or pain at dressing change. [WUWHS], 2008): 2013):

Erythema (red skin colouration, Contamination: the presence in
INFECTION resulting from capillary congestion the wound of low numbers
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and often due of bacteria

It is normal for a wound to be to inflammation) Colonisation: the absence of
effective patient defenses, which
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Table 1: What is Durafiber Ag? means bacteria can multiply

Durafiber Ag is an absorbent, non-woven, silver-containing antimicrobial gelling dressing designed for use
Critical colonisation: where the
in a range of wounds, including chronic and acute, full thickness, partial thickness, or shallow granulating numbers of bacteria begin to
20

exuding wounds. For the community nurse who has to deal with a wide range of wounds, Durafiber Ags impact on wound healing.
versatility is an asset, particularly as it can be used on
the following: Many bacterial species can be
Leg ulcers involved in wound infection, with one

Pressure ulcers study of 676 post surgical patients

Diabetic ulcers who had clear signs and symptoms of
Surgical wounds wound infection identifying a number
Traumatic wounds of different bacterial strains, the most
Donor sites common being (Giacometti, 2000):
Partial thickness burns Staphylococcus aureus
Tunnelling and fistulae wounds (191 patients)
Wounds left to heal by secondary intention Pseudomonas aeruginosa
Wounds prone to bleeding, such as those that have been surgically or mechanically debrided (170 patients)
Fungating wounds. Escherichia coli (53 patients)
Staphylococcus epidermidis
While Durafiber Ag assists in the management of wounds prone to minor bleeding, it is not intended to be (48 patients)
used as a surgical sponge in heavily bleeding wounds. Enterococcus faecalis
(38 patients).

44 JCN 2014, Vol 28, No 5

 When a wound becomes infected,
this not only affects the patient
negatively, but also has a deleterious
effect on healthcare budgets, leading
to higher treatment costs and rising
numbers of inpatients (Cook and
Ousey, 2011).
Antimicrobial dressings
Butcher (2013) points to guidelines
on the management of wound
infection (European Wound
Management Association [EWMA],
2006; WUWHS, 2008), which
suggest that topical antimicrobial
dressings are useful in reducing
wound bioburden. These dressings
work in a variety of ways some
incorporate ingredients that
interrupt the ability of bacteria
to thrive; some are poisonous to
cells; others bind bacteria to the
dressing, which is then removed at
dressing change.
Studies have recommended
antimicrobial agents such
as iodine, silver, honey and
polyhexamethylene biguanide
(PHMB) and these are considered
to be the first line of treatment in
wound infection (Cooper, 2004),
particularly as they act against
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multiresistant organisms such as
meticillin-resistant Staphylococcus
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aureus (MRSA) (Sibbald et al, 2001)
and do not effect the healthy
bacteria in other parts of the body,
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such as the gut.
Silver
Studies have shown the positive
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effects of silver as an antimicrobial
in wound care (Gottrup et al, 2013).
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Essentially, silver destroys bacterial
cells by disrupting the cell wall and
causing cell leakage (Butcher, 2013).
It also eliminates a wide range
of bacteria, including antibiotic-
resistant species such as MRSA and
vancomycin-resistant Enterococci
(VRE) (Parsons et al, 2005).
The use of silver in the
manufacture of Durafiber Ag means
that it provides antimicrobial
action for up to seven days (in
vitro) against a broad spectrum of
common wound pathogens, helping
to reduce bacterial bioburden and
the risk of infection (Woodmansey,
2010; Vaughan et al, 2010).
EXUDATE
Wound exudate is the fluid that
oozes from the blood vessels in a
wound as a response to inflammation
(Wolcott, 2012). For something that
causes so many issues in wound
care, exudate is both a natural and
necessary part of healing, preventing
the wound bed from becoming too
dry and providing the much-needed
nutrients that enable healing to
progress, such as electrolytes,
proteins and growth factors, as
well as various cells including
neutrophils, platelets, leukocytes and
macrophages (White and Cutting,
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2006; World Union of Wound Healing
Societies [WUWHS], 2007).
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The use of silver in the
manufacture of Durafiber
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Ag means that it provides
antimicrobial action for up to
seven days (in vitro) against a
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broad spectrum of common
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wound pathogens
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However, if the wound
produces too much exudate it can
begin to cause problems, chiefly
maceration (softening and breaking
down of skin) around the wound
(Beldon, 2014). Exudate can be
a management problem for the
community nurse causing leaking
and heavy dressings as well considered by community nurses
as discomfort and malodour for
patients (Beldon, 2014).
Exudate also provides clues to
the condition of the wound. Factors
like the volume, colour, viscosity
and odour of the exudate indicate
potential problems such as bacterial
load and infection (WUWHS,
2007). Dressings that have just been
removed can also be examined
for their level of saturation, which
provides clues to how well the
chosen dressing is managing and
if healing is progressing for
example, an infected wound will
leave a purulent residue in the
dressing (WUWHS, 2007).
Community nurses should also
discuss the state of exudate with
patients, as they may be anxious about
the volume or smell (Beldon, 2014).
Many dressings are designed
specifically to deal with exudate, for
example, some form a gel on contact
with wound fluid that absorbs excess
fluid, locks exudate away from
the wound and provides a moist
environment to support autolytic
debridement.
Any dressing required to absorb
exudate requires some of the following
characteristics (Adderley, 2008;
Stephen-Haynes, 2011):
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High absorbency, thereby reducing
dressing frequency
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The ability to lock away exudate
within its structure
Ability to be used under
compression bandaging
Easy to remove, thereby
minimising trauma and pain at
dressing changes
Conformity to the wound site.
Durafiber Ag is specifically
designed to form a gel on contact
with wound fluid, absorbing excess
exudate, and locking it away from the
wound (Dowler, 2010). This provides
a moist environment to support
autolytic debridement (Myers, 2012)
and means that the dressing conforms
to the wound bed (Forlee et al, 2014).
ADDITIONAL DRESSING
CHARACTERISTICS
The following factors need to be
when choosing a dressing that
will protect the full extent of the
wound area.
Conformability
The conformability of a dressing or
how well it fits the wound site and
is able to deal with elements such
as pain on removal, leakage, patient
positioning and wear and tear is
crucial, particularly as no one wound
is the same. Wounds can be a range of
sizes, depths, in different anatomical
positions, as well as forming cavities or
skin flaps where exudate and bacteria
can collect, greatly increasing the risk
of infection (Bowler et al, 2010).
Coverage
Dressings also need to provide
adequate coverage of the wound
bed, both to promote a moist wound
healing environment, and prevent
JCN 2014, Vol 28, No 5 45
 WOUND CARE
CASE STUDY
Elaine Forster, community staff nurse,
5 Borough Partnership, Knowsley
This case study was undertaken to
demonstrate the efficacy of Durafiber
Ag on a clinically infected venous
leg ulcer.
Patient
Patient A was a 61-year-old woman
with a trauma wound to the gaiter
area of her left leg. She had a history
of underactive thyroid, previous
venous leg ulcers and reports of
multiple dressing allergies. She was
referred to the leg ulcer clinic and
an assessment confirmed venous
aetiology.
Wound history
With regards to her latest venous leg
ulcer, patient A had been self-caring
for four weeks until a district nurse
suspected wound infection. She was
then admitted to hospital for a 10-day
course of intravenous (IV) antibiotics.
On discharge, she attended the local
treatment room service and the
wound was managed with absorbent
dressings and crepe bandages.
After three weeks however, she was
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referred to the leg ulcer clinic.
Wound assessment
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At presentation at the leg ulcer
clinic, patient As venous leg ulcer
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exhibited 100% slough and was
difficult to measure, being described
as circumferential. She was also
experiencing a considerable amount
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of pain, which required regular
analgesia. The wound was infected
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and exhibited malodour with
moderate volumes of exudate and
erythematous surrounding tissue.
Wound progress
As mentioned above, in February and
early March of 2014, patient A was
at home and self-caring. Then on 10
March she was admitted to hospital
and given IV antibiotics for a wound
and leg infection. When she was sent
home on 4 April the plan was that the
district nurse would visit to continue
the care programme for the venous
leg ulcer.
Subsequently, on 11 April patient
A attended the clinic treatment
46 JCN 2014, Vol 28, No 5
Figure 4.
18 June, 2014: Durafiber Ag stopped
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and full compression therapy started.
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Figure 1. room and it was decided to use an
9 May, 2014: front of patient As left leg. absorbent dressing (UrgoTM Clean;
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Urgo Medical) and a crepe bandage
to manage the wound.
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On 9 May, patient A had an
appointment at the leg ulcer clinic for
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assessment. The venous leg ulcer now
had a circumferential length of 18cm
and exhibited 100% slough. It was
decided to use Durafiber and reduced
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compression. The dressing was to be
changed at the twice-weekly home
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visits by the district nurse.
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At a further visit to the clinic on
Figure 2. 16 May, the wound was described
9 May, 2014: lateral aspect of left leg. as clinically infected. Patient A
was experiencing increased pain,
exudate and malodour. The care
plan was, therefore, amended to
include Durafiber Ag and reduced
compression.
On 23 May,it was noted at the
leg ulcer clinic that the symptoms
were reducing. The team decided
to continue with Durafiber Ag and
reduced compression. Patient A was
informed that she now only needed
weekly attendances at the leg
ulcer clinic.
On 13 June, she once again visited
the leg ulcer clinic and it was noted
that her symptoms were resolving
further there was no pain or odour
and the ulcer had reduced, now
comprising two smaller ulcers with
80% granulation tissue. Finally, on
the last visit to the leg ulcer clinic, it
was decided that the use of Durafiber
Ag had resolved the symptoms to a
point where it could be discontinued.
This meant that patient A was able to
Figure 3. start full compression, with the aim of
18 June, 2014: lateral aspect of left leg. facilitating complete healing.
 WOUND CARE

leakage of exudate from the wound
bed onto the surrounding skin (Davies
and Rippon, 2010). Coverage can be
an issue with some dressings, which
shrink or expand when they come into
contact with moisture such as wound
exudate (Aramwit et al, 2010).
contact, thereby reducing the amount
of trauma on removal (Greenwood
and Grothier, 2012). Community
nurses should consider any option
that will improve the quality of life and
reduce pain and trauma for
the patient.
treatment, Durafiber Ag can be left in
place for up to seven days (Dowler,
2012; Forlee at al, 2014).
See Table 2 for guidelines on how
to apply Durafiber Ag (Dowler, 2012;
Forlee at al, 2014).

Pain and trauma at Similarly, a dressing that is easy CONCLUSION

dressing change to apply and remove will involve
Application and removal of dressings less nursing time than one that is Community nurses require a wide
are also important considerations, more difficult to use (Davies and skill set in order to deal with the
both for ease of use for the nurse and Rippon, 2010). Ease of removal and variety of clinical presentations that

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to avoid unnecessary trauma to the application, therefore, can have they may encounter in any given day.

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wound bed and periwound skin. significant time and budgetary This includes wound care, which
benefits and these, factors that can present nurses with a range of
Pain and damage to the community nurses should also management challenges, including

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fragile periwound skin are both consider when choosing a dressing. how to combat infection, which kind
considerations for the community of dressings to use to manage exudate

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nurse at dressing change With regards to patient comfort, and how to ensure that any dressing
(Hollinworth, 2002). Exudate can the high integral wet strength of provides patient comfort and does not
soak into a dressing and then cause Durafiber Ag also means that it can further damage the wound or skin

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trauma when it dries out and binds be removed from moist wound beds on removal. It is important, therefore,
to the dressing, causing problems on and cavity wounds in one piece, that community nurses have access to
removal (Edwards, 2013). Dressings thereby reducing trauma and pain versatile products that can be used in
that have dried out while in place (Dowler, 2010). different clinical situations, while also
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are one of the most common causes being cost-effective.
of wound pain (Bell and McCarthy, USING DURAFIBER AG IN THE
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2010). Other researchers have agreed COMMUNITY SETTING Durafiber Ag has a range of
with this, citing the most widespread applications, including the ability
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causes of wound pain as dressings Like any other wound dressing, to manage excess exudate and a
that have adhered to the wound bed, Durafiber Ag should be changed composition that helps to ensure
skin stripping through the use of when clinically indicated, for conformability and patient comfort
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dressings with adhesive borders, and example, where there is leakage (Dowler, 2010). Durafiber Ag also
maceration of the periwound skin or excessive bleeding. Community provides the ability to manage
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through exudate leakage (Davies and nurses should exercise professional infection. It can also be left in place
Rippon, 2008). judgement in assessing this. for a significant amount of time,
crucial to the community nurse
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Dressings with a variety of wound Similarly, in the first stages of (Dowler, 2012). This means that for the
contact layers have been designed treatment, the dressing should be busy nurse with a range of patients
to reduce the amount of adherence frequently inspected. and clinical presentations, Durafiber
14

to a drying wound (Thomas, 2003). Ag represents a useful addition to the

These include soft silicones (Edwards, However, crucially for the time clinical armoury. JCN
2013) and gelling fibres, which retain management of community nurses
REFERENCES
20

moisture and lock in exudate on is the fact that once established as a

Table 2: How to apply Durafiber Ag Adderley, U (2008) Wound Exudate: What

it is and How to Manage it. Wounds

Cleanse the wound according to local clinical protocol
Essentials 3: 813
Select appropriate dressing size
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JCN 2014, Vol 28, No 5 47

 WOUND CARE
Five-minute test
Answer the following questions
about this article, either to test the
new knowledge you have gained
or to form part of your ongoing
practice development portfolio.
1 What types of wounds are
commonly found in the
community?
2 What constitutes an infected
wound?
3 What are some of the properties of
wound exudate?
4 Why is conformability important in
a wound dressing?
5 Can you explain why some
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