Print Unit Code

Care plan

LTH2655

Wound Assessment & Management Care Plan (Longer version)

LTH3052 A

Wound Assessment & Management Care Plan (Short Stay Wards)

LTH3052 B

Wound Assessment & Management Care Plan continuation sheet

Action

Rationale

1

Wound cleansing is not always necessary and is only required to :

• Remove excess wound exudate from the wound bed and surrounding skin using moist gauze.
• Remove loose slough or debris from the wound bed
• Remove contamination (e.g. faeces, urine, dirt)
• For patient comfort (e.g. odour control)

Clean, granulating or epithlialising wounds should NOT be cleansed using cotton wool or dry gauze

There is no strong evidence that wound cleansing per se increases healing or reduces infection (1). Wound cleansing can interrupt the healing process by disrupting fragile tissue growth and damaging new capillaries, or reducing the temperature of the wound bed (2-4). Cleansing can be painful for the patient and therefore clear treatment objectives should be established prior to wound cleansing in order to ensure that an optimum environment for wound healing is maintained.
Cleansing the surrounding skin is required to remove excess exudate to protect skin from maceration and excoriation
Evidence level C

Fibres can be shed into the wound bed keeping the wound in the inflammatory stages of healing, and to reduce the potential trauma from dry gauze (4).

2

Chronic wounds such as leg ulcers and pressure ulcers can be cleansed using:

• Drinking quality tap water at body temperature* (NB in LTHT sterile solutions are first line for wound cleaning. Tap water should only be used for washing lower limbs/leg ulceration)
• Boiled water cooled to body temperature
• Distilled water
• Sterile solutions such as sodium chloride 0.9% or sterile water

*In hospital and clinic settings not all tap water is of drinking quality. Notices will be posted in the sink area.

The decision to use tap water in an acute setting should be as a result of a risk assessment based on the quality of the water, nature of the wounds and the general condition of the patient including co-morbidities and immune status.
The evidence suggests that there is no difference in infection or healing rates in acute and chronic wounds cleansed with either potable water or saline (1)
Evidence level A

3

Aseptic technique (see LTHT Asepsis guideline) and sterile solutions should be used for:

• Acute wounds (e.g. recent surgery, traumatic injury, laceration)
• Immuno-compromised patients
• Diabetics at high risk of infection
• Wounds where bone or tendon are visible to the wound bed
• Severe ischaemia or arterial impairment present

To reduce the risk of wound infection in vulnerable patient groups
Evidence level C

4

Additional considerations (Special Wound Groups):
Surgical wounds healing by primary intention (closed)
Only cleanse if exudate present
Surgical wounds healing by secondary intention (dehisced or temporarily left open)
Only cleanse if exudate present
only irrigate a wound if the base of the wound can be visualised/palpated.
Do not irrigate actively bleeding wounds

Topical antimicrobial agents Eusol, moist gauze or mercuric antiseptic solutions should not be used for these wounds (6)
Traumatic wounds
May need cleansing or irrigation to remove any debris or non-viable tissue. Irrigation can be administered using a saline filled syringe (5, 7). High pressure irrigation or scrubbing may be used in theatres or emergency departments to remove foreign bodies
Burns
May require the removal of non-viable tissue (referral to Tissue Viability and/or plastic surgery/burns outreach nurse should be considered)
Sinus/Cavity wounds
Do not routinely irrigate sinus or cavity wounds, unless under instruction of a specialist.


If cleansing/irrigation is essential, ensure that all irrigation solution is removed from the wound.


Wound irrigation through the 3M KCI installation VAC can be considered, only under instruction of the surgeon and/or Tissue Viability Nurse Specialist

These wounds usually have intact skin and therefore cleansing is only required to removed exudate to protect the skin
Evidence level C

Gentle irrigation may facilitate in the removal of loose slough or debris (5)
Evidence level C
Irrigation may dislodge any clots forming and prevent haemostasis (5)
As per NICE NG125 (6)
Evidence level B

Deep wounds and cavities should not be routinely irrigated as they are at higher risk of infection due to devitalised tissue and exposed structures, and irrigation fluid could be retained in the cavity
Evidence level B

Excess fluid will tend to leak from the wound over time reducing the absorbency of the dressings used. A pocket of irrigation fluid which cannot drain out by gravity may become a focus for infection.
As per manufacturer/Trust guidance

5

Record on the wound care plan which method of cleansing and which solution is being used.

To ensure consistency of care and to direct treatment

Action

Rationale

1

Skin cleansing pre-operatively
Pre operatively patients may require decolonisation of skin if pre-operative skin swab is MRSA positive or the patient is identified as high risk.
(LTHT MRSA screening programme)

To reduce risk of post-operative wound infection

2

Peri-operative: skin preparation
An antiseptic preparation such as alcohol or aqueous based chlorhexadine or povidone iodine should be used to prepare the skin at the site of surgery immediately before incision.
Note: If diathermy is to be carried out:

• use evaporation to dry antiseptic skin preparations and
• avoid pooling of alcohol-based preparations.

Pre-operative patients may require decolonisation of skin if pre-operative swab of the skin is MRSA positive or the patient is identified as high risk (See LTHT MRSA Screening programme) 

To reduce bacterial load prior to incision. Overall, the evidence showed that chlorhexidine in alcohol was associated with the lowest incidence of surgical site infections, whereas aqueous povidone-iodine was associated with the highest incidence (6). Evidence level B due to quality of included trials
To reduce the risk of post-operative wound infection

3

Post operatively
Sterile saline can be used for up to 48 hours post operatively for wound cleansing.
NICE recommend 48 hours post operatively for safe showering (6), although evidence suggests it could be safe after 12 hours, but this is dependent on the water quality.  

No difference has been seen in wound infection rates for early bathing (12 hours post-operative) versus delayed (48 hours post-operative) (8,9)

4

Skin cleansing for patients with chronic wounds
An individual risk assessment for infection should be undertaken for patients with chronic wounds (e.g. leg ulcers) prior to showering or bathing

Considerations should include IPC for shared bathrooms, patient well-being and the impact upon the wound
Evidence level C

5

Management of the surrounding skin.
Maceration may occur due to poor exudate management. Skin protectors such as Cavilon, Mediderma S or MediHoney Barrier may be used until the exudate is under control (see Prevention and Management of Moisture Associated Skin Damage Guideline for further details).
Alternatively a thin hydrocolloid sheet may be cut to fit the wound margins e.g. Duoderm.

For patients who have fragile / papery thin skin which may tear with the use of adhesive dressings then consider the use of a bandage or tubular gauze. Where this is not possible, a silicone coated dressing may be appropriate e.g. Mepilex Border.
Dry wound margins may need an emollient applying at each dressing change. See guideline for the Compression Bandaging in Adults Cared for Outside of Specialist Areas within LTHT.

Uncontrolled exudate can exacerbate skin damage leading to enlargement of the wound.
Skin protectors can help adhesive dressings to adhere and form an effective seal.


This will act as a barrier to exudate and adhesive of dressings.

To maintain skin integrity.


To maintain skin integrity. However, this may affect adhesion of some dressings.

6

Exudate management.
Excessive exudate must be managed to prevent further damage to the skin. A number of products are available.
Additional products such as super-absorbent dressings with or without a fluid repellent backing may be considered.

 
These will absorb large amounts of exudate but will add bulk. This may affect the level of compression if applied under compression bandages.

Action

Rationale

1

Devitalised (necrotic) tissue supports the growth of bacteria and is therefore thought to increase the risk of infection and sepsis.
To reduce the risk of complications and direct the method of debridement, prior to commencing debridement and deciding whether active debridement is appropriate and the method, the following should be considered:-

• The nature/extent of necrotic tissue
• The risk of infection
• Any underlying disease process
• Any ischemia and the extent of this
• Location of the wound
• Client consent
• Pain control
• Possible complications such as structures and bleeding
• The skills of the clinician

Examples of debridement include: autolytic, enzymatic, sharp, biological (larvae).

There is a lack of evidence to support one method of debridement over another (10).
(Evidence level C)
Expert opinion suggests the speed of debridement may depend upon the depth of the necrotic tissue, blood supply and removal / reduction of any contributing factors e.g. pressure.
Large cavities can develop beneath the surface of black eschar, which are filled with dead or partially liquefied tissues.

Necrotic tissue.
Debridement of necrotic tissue/black eschar can be debrided by a number of methods:-

• Rehydrating the necrotic tissue using Hydrocolloids and Hydrogels

• Sharp or surgical debridement

Larvae therapy may be considered for moist necrotic wounds. Refer to the Tissue Viability Service for advice and assessment.  
NB. Diabetic / ischaemic foot ulcers with black eschar / necrotic tissue.
It is generally recommended for the above ulcers with hard dry eschar and no clinical signs of infection that they should not be actively debrided. Depending upon the patient’s vascular supply these wounds will epithelise from underneath the eschar.
When the eschar is moist and may be critically colonised / infected, the risks and benefits of debridement versus drying the wound need to be assessed.

Hydrocolloids will maintain moisture whilst Hydrogels will add moisture to the eschar and thus promote autolysis.
Sharp debridement should only be carried out by a trained and competent practitioner. Training should be a recognised accredited course for non- medical staff. Care must be taken when sharp debriding a wound to ensure no viable structures are damaged e.g. tendons. Referral to a Plastic or other surgeon may be required.
Larvae therapy will rapidly debride moist necrotic tissue. Contraindications include the use of anticoagulants.

 These types of foot ulcers are at a higher risk of developing infection if the devitalised tissue becomes moist / wet. These patients should be referred to vascular/Diabetic limb salvage as per Trust Guidance
 
It may be more beneficial to dry the wound with a foam dressing and use an antimicrobial to treat / reduce the risk of infection and consider oral antibiotic cover.

Sloughy tissue.
Debridement of slough from the wound bed.
Loose slough may be sharp debrided (only by a trained specialist). 

A number of products are available to facilitate the debridement of slough. The selection of a product is dependent upon the level of wound exudate and the need to rehydrate the slough (Appendix 1).
Products include Hydrogels, Hydrocolloids, Hydrofibres, Foams.
NB Sloughy wounds which are producing moderate to high exudate will usually debride naturally and therefore rarely require the use of a Hydrogel to facilitate debridement.
Larvae therapy (bio surgical debridement) may be used to debride moist, sloughy wounds. Refer to the Tissue Viability Service for advice.

 
The presence of devitalised tissue is a potential medium for infection.
Care must be taken to ensure what appears to be slough, is slough and not a structure such as a tendon. Referral to the Tissue Viability Service / Plastics / General Surgeons may be required.
These products will either add moisture, thus rehydrating the wound or absorb exudate to create an optimum wound environment for autolysis to occur.


Adding extra moisture/gels to a moderate to high exuding wound may cause maceration and problems of exudate containment/management.
Larvae secrete a proteolytic enzyme which liquefies the slough and ingest it.

Action

Rationale

1

Dressing selection must aim to provide the optimum wound environment for each individual wound (11)
Before choosing a product, consideration must be given to:
• The primary treatment objectives
• The clinical and cost effectiveness of the product
• The availability of the product
• The function of the dressing
• The ease of application and removal of the dressing
• Variety of the size / shape of the dressing and alternatives available
• Length of time it will be used
• How to secure it

To facilitate wound healing the environment must be warm and moist. See Appendix 1 for further information and Appendix 2 for a list of dressings available within LTHT.
To promote clinical and cost effective treatment

2

Explain and discuss with the patient (if appropriate) products chosen to dress their wound, including any past use or adverse reactions to the product(s) selected

To gain informed consent for the use of wound care products and improve concordance. To reduce the risk of adverse reactions.

3

Before prescribing any product, any allergies or reactions to wound care products must be checked with the patient, their nursing/medical records.
Any allergies/sensitivities to wound care products must be recorded in the patients nursing notes and medical records.

Also consider completing a Datix and a “Yellowcard” particularly for products which are new to the market. (https://yellowcard.mhra.gov.uk/)

To promote safety and reduce the risk of reoccurrence.

To ensure patients receive safe care from all professionals involved. In concordance with the national prescribing centre and BNF recommendations.

4

Dressings are medical devices. Before prescribing and using any wound care product for the first time nurses must be trained and competent in its use e.g. application and removal, contraindications, precautions.      

To ensure the product is used and removed safely and appropriately.
This is particularly applicable to the removal of film and adhesive dressings to prevent skin trauma.

Action

Rationale

3

Surgical wounds - Intra-operative
All patients who have a surgical procedure who require a dressing to the incision should have an interactive dressing (dressings which have a waterproof backing e.g. any film or hydrocolloid dressing). Opsite Post-op is the dressing of choice in LTHT.
Dry dressings such as Gauze, Mepore, Primapore are not interactive dressings.

Interactive dressings are defined as ‘those which are designed to promote the wound healing process and minimise infection through the creation and maintenance of a local warm, moist environment underneath the chosen dressing, when left in place for a period indicated through a continuous assessment process’ (6).

4

Post-operative: dressing change
The dressing will remain in place post-operatively for a period of 5-7 days.         

If there is a small amount of exudate under the dressing – leave dressing in situ.              

If fluid is seen ‘pooling’ or leaking out from under the dressing – a new interactive dressing should be applied.               
If exudate is excessive or the wound has ‘dehisced’ – the dressing should be removed and a more absorbent interactive dressing applied.
Advice from Tissue Viability may be sought.       

To allow for complete re-epithelialisation of the wound.

To maintain bacteria proof seal.

To prevent the exudate causing excoriation to the surrounding skin.

To appropriately manage the exudate and promote optimal wound healing.

Malodorous wounds.
The wound must be assessed for the cause of the malodour. This may be due to the presence of devitalised tissue and/or infection. The presence of malodour does not necessarily mean infection but should be ruled out. The aetiology of the wound must be determined in order to inform treatment. 
The aim of treatment is:
Dependent on the aetiology of the wound, consider debridement of devitalised tissue, but this should only be done following expert review.
To reduce the levels of bacterial colonisation / treat infection.

Fungating wounds are usually very vascular and thus will have a tendency to bleed. Debridement may reveal or damage underlying structures and thus is not recommended. Refer to Tissue Viability Service for further advice on dressing management

Products to manage malodour include:

• Charcoal dressings and activated charcoal dressings.
• Topical metronidazole gel is indicated for the treatment of anaerobic infections.

• Charcoal will help to deodorise the toxins. Activated charcoal dressings contain silver which is an antimicrobial.
• Requires prescribing and should only be used under direction of specialist only.

PLEASE SEE DRESSING SELECTION GUIDELINE (Appendix 1)

Epithelialising wounds.
Epithelialisation occurs once the wound has filled with granulation tissue.
Products include:

• Vapour-permeable films
• Thin hydrocolloids
• Hydrogels
• Foams
• Low adherent dressings

To maintain a moist environment and prevent trauma to the newly formed tissue allowing it to mature.
Pressure ulcers that have been categorised as a category 4 may take up to several years for the new tissue and underlying structures to mature. Therefore a dressing may be required protect new epithelium.

Bleeding wounds.
Haemostatic dressing – e.g. Kaltostat

The dressing contains calcium ions which assists haemostasis (not currently licensed for this purpose).

Over granulation wounds.
The aim is to reduce the over granulation to level of the wound surface.

Over granulation can occur in any wound including surgical wounds, leg ulcers, pressure ulcers supra-pubic catheter sites and peg sites. For over granulated peg site wounds please refer to the Enteral Feeding Service for further information.

 Occurs within the reconstruction or proliferation stage of wound healing and prevents epithelial cells spreading across the wound surface thus delaying healing.
The exact cause is unknown but it is thought to be related to prolonged inflammation and/or high levels of bacteria.

Wounds which present with over granulation must be carefully assessed to ensure accurate diagnosis as malignant wounds can present with over granulation tissue. 

Wounds of unknown / uncertain aetiology or not responding to the treatment recommendations below must be referred to a specialist such as the Tissue Viability Service or Dermatology.

Management is based upon expert opinion and includes the following steps:-

1. Apply a polyurethane foam dressing.
2. For over granulated wounds that are critically colonised or not responding to foam dressing alone apply polyurethane dressing with a topical antimicrobial underneath such as silver or iodine.
3. If the above treatments do not start to show a reduction in the wound after a couple of weeks, a topical corticosteroid cream such as 1% Hydrocortisone cream can be applied.
4. Silver nitrate pencil can be used for wounds not responding to the above treatment or that are small with excessive over granulation tissue. (NB. Not licensed for this purpose). Surrounding healthy skin should be protected with petroleum jelly.

To flatten the loops of granulation tissue.
A topical antimicrobial will assist to control the bacterial load and thus reduce inflammation.

To reduce inflammation.

Not recommended as first line treatment as it burns healthy tissue and can damage the wound margins. Should only be used under expert advice and supervision.

Bacterial colonisation / infected wounds.

Topical antimicrobials may be used to treat critically colonised/infected wounds.
These include silver based dressings, iodine dressings, PHMB and honey.
Contraindications of these products must be checked particularly in respect of children, pregnancy, kidney failure and Diabetes.  

Wound healing may be delayed in colonised wounds.
The importance of the presence of bacteria in a wound will depend on the type of wound, the type and number of bacteria and the patient’s immune system.
To promote safety.

Cavity wounds.
A cavity wound normally extends beyond the epidermis and dermis into the subcutaneous tissue, and can extend as far as fascia, muscle or bone.  A sinus or fistula is a cavity wound where the track is not easily identified (12).

Cavity wounds should be managed with a suitably absorbent dressing to cover the wound entrance and not packed.  Where exudate management is an issue a flat absorbent dressing (such as an alginate or super-absorbent) as opposed to a rope should be laid gently within the wound.  Flat dressing types are less likely to occlude the cavity entrance or act as a pressure point within the wound bed. 
Cavity wounds can be managed with Negative Pressure Wound Therapy following assessment and initiation by a surgeons/Tissue Viability

 Sinuses and cavities can develop for a number of different reasons e.g. pressure damage, the presence of infection, an infected hair follicle, a dehisced surgical wound or a surgical wound that has been purposely left open to heal by tertiary intention.  Identifying the cause of the wound and treating the underlying cause will facilitate wound healing but cannot always be determined.
Currently very little research exists to support the practice of wound packing and therefore the recommendations made are largely based upon level C evidence (13).

Please refer to the NPWT guidelines for further information

Painful wounds.
Patients must be assessed for wound pain. Some antimicrobial dressings and cleansing/irrigation fluids may increase pain whilst others can cause pain on application and or removal.

To ensure appropriate analgesia is provided and to guide dressing product selection.

Pilonidal sinuses/abscesses
Due to the high incidence of infection present in these types of wounds, free drainage of exudate is thought to reduce sinus and/or abscess recurrence.

Due to the highly sensitive nature of the site of many of these wounds, packing can cause increased pain for the patient, therefore pain must be assessed and addressed prior to wound packing.

Wound packing has not been found to improve healing, wound pain, reduce recurrence rates or affect the development of fistulae (12, 13).  Further clinical research is needed to assess the effects and patient experience of packing.
Pain has been documented in association with the packing of cavity wounds with ribbon gauze (13).