Download problem surrounding skin and pain

PROBLEM
SOLVING
Judy Harker, BN (Hons), Pg Dip, DN Cert, RGN, Nurse Consultant, Tissue Viability,
Pennine Acute Hospitals NHS Trust, Oldham
The majority of wounds heal without complication. However, a significant number
do not, causing considerable distress, misery and delayed healing. For the
clinician they can prove time-consuming, frustrating and reduce job satisfaction.
It is therefore important that clinicians are skilled in both detecting wound healing
problems and solving them effectively. Common local wound problems include
management of hypergranulation, skin maceration, pain, exudate and odour.
Hypergranulation (over-granulation) tissue
An abundance of granulation tissue that becomes proud or protrudes from the
wound is commonly known as hyper- or over-granulation tissue (also termed
‘proud flesh’). In many cases the presence of this tissue is not detrimental to
wound healing and can be left untreated. Problems arise when the
hypergranulation tissue delays healing by preventing re-epithelialisation.
Sometimes the presence of such tissue can increase exudate levels and cause
wound discomfort. In addition, hypergranulation tissue bleeds easily.
Causes of hypergranulation
The exact mechanisms for hypergranulation are unclear, but it has been suggested
that it occurs when the wound fails to progress from the proliferative phase of
wound healing. The presence of hypergranulation tissue can sometimes indicate
malignancy within a wound. In this instance patients should be referred for tissue
biopsy to exclude such diseases.
Management options
There is currently a lack of agreement about the correct management of nonmalignant hypergranulation tissue. Some practitioners advocate no intervention,
whilst others suggest a more aggressive approach including topical corticosteroids or silver nitrate. Although the mechanisms of action are not clear, the use
of foam dressings can often help the problem.
SURROUNDING SKIN AND PAIN MANAGEMENT
Assessment of the surrounding skin is now considered to be as important as
assessment of the wound itself.
Management of skin problems
Skin problem
Possible causes
Management options
Blistering or bullae
Dermatological problem
Pressure, friction
Oedema
Cellulitis
Determine underlying cause of blistering
Refer to dermatologist where appropriate
Protect blisters with low-adherent dressing
Remove sources of any pressure or friction
Excoriation
(loss of epidermis)
Contact dermatitis related to
excess exudate, urinary or
faecal incontinence, dressings,
perspiration, antiseptics
Consider skin protectants* or corticosteroid
ointments/creams depending on cause
Avoid routine use of antiseptics
Manage incontinence appropriately
Oedema
(shiny, taught skin)
Infection, heart failure, renal
disease, hepatic disease,
dependency and immobility
Address underlying cause of oedema
If clinically safe, elevate affected area/limb
Avoid adhesive dressings and tapes
Protect skin from trauma
Rehydrate skin if dry with emollient
Pressure, friction,
excoriation due to excess
moisture, infection,
contact dermatitis,
varicose eczema,
normal immune response
Treat underlying cause
Consider compression therapy for varicose
eczema
Consider corticosteroid ointments/creams
for eczema
Consider patch-testing if contact dermatitis
persists
Protect bony prominence if pressure-related
Consider systemic antibiotics if infection is
identified
Redness (erythema)
Skin fragility
Advancing age, long-term
corticosteroid use,
dermatological problems
Avoidance of adhesive dressings
Consider use of silicone-based dressings
Consider skin protectants*
Thickened scaly skin
(hyperkeratosis)
Venous hypertension
Lymphoedema
Other skin diseases e.g.
psoriasis
Treat underlying cause
Involve dermatologist where appropriate
Use bland, non-sensitising emollient
Remove skin scales with forceps
Maceration
(whitish, over-hydrated
skin)
Excess exudate
Improve management of exudate
Select dressings for exudate level
Do not exceed wear time of dressings
Use of skin protectants*
* Skin protectants can include cohesive wafers, powders, skin barrier films, stoma paste and zinc oxide paste
A large wound on the heel showing some
granulation tissue in the base, but white,
discoloured tissue to the surrounding skin
(maceration).
A venous leg ulcer with clear evidence of
raised granulation tissue above the surface of
the surrounding skin seen on the left side of
the wound.
Pain
Wound pain is often an underestimated problem in wound management.
However, it is frequently cited by patients as a significant factor affecting quality of
life. Pain can manifest itself in different ways such as:
■ Aching
■ Burning
■ Stinging
■ Throbbing.
It is important to identify if there is a neuropathic element to the pain as this can
cause the patient to have heightened sensitivity even to the smallest of stimuli. In
such cases referral to a pain specialist is recommended.
Management options include:
■ Skilled assessment and documentation. Consider a pain assessment tool to assist this
process. Determine the location, severity and frequency of the pain
■ Identify the underlying cause and manage appropriately (e.g. infection, dressing adherence,
the removal of dressings, ischaemia, inflammatory ulceration and oedema)
■ Involve the patient (e.g. the patient may wish to remove the dressing)
■ Appropriate analgesia according to local guidelines
■ Choose non-traumatising dressings which maintain optimum humidity at the wound bed
and do not cause pain on removal (e.g. hydrogels, silicone-based products)
■ Careful use of dressings that rapidly absorb exudate where the patient can experience a
‘drawing’ effect e.g. cadexomer iodine paste.
NOTE: Advice can be sought from a consultant dermatologist/dermatology nurse/stoma
therapist to assist in the management of problems of the surrounding skin.
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EXUDATE MANAGEMENT
ODOUR
Defining exudate
Wound exudate can be defined as wound fluid, with a high content of protein and
cells, that has escaped from damaged blood and lymphatic vessels. It is a
component of the normal wound healing process and is thought to accelerate
healing by creating a moist environment. Acute wound fluid is rich in growth
factors while chronic wound fluid also consists of degrading enzymes, which can
delay the healing process. Although exudate is required for healing to take place, if
present in excessive quantities, it can harm the surrounding skin and the wound
itself. Too little exudate is also detrimental to healing. A wound will produce more
exudate during the inflammatory phase of the wound healing process.
Common causes of excess exudate include:
■ Congestive cardiac disease
All wounds are associated with some degree of odour. However problems arise when
the odour becomes unpleasant and is then described as ‘malodour’. It is not limited
to specific types of wounds (e.g. fungating wounds) and all wounds have the
potential to produce an offensive odour. Malodour can be distressing for the patient
and family/relatives concerned and can interfere with social relationships and result in
isolation, loss of appetite and depression. The nurse is ideally placed to offer practical
support to reduce or even eliminate this problem.
Treating the underlying cause of
excess exudate:
■ Effective management of wound infection
by systemic antibiotics and/or topical
antimicrobials
■ Leg elevation if the wound affects the
lower limb (not indicated in severe
arterial impairment or heart failure)
■ Compression bandages can be used
in the management of venous
hypertension and lower limb oedema
where severe arterial impairment has
been excluded
■ Consider radiation therapy for fungating
wounds.
High leg elevation can be effective in reducing
exudate production and accelerating the
healing of venous leg ulcers.
■ Dependency limb oedema
■ Extensive tissue loss
Strike-through
Exudate may leak through to the outer dressing, bandage or patient’s
clothing/bedding/furniture (also known as ‘strike-through’) and the patient may try
to renew or reinforce the dressing because it is saturated in exudate. This may
have a significant impact on psychological well-being. Treatment options include:
■ Hepatic impairment
■ Wound infection/colonisation
■ Wound type (e.g. venous leg ulcers).
Determining levels of exudate
Determining levels of exudate is an extremely difficult task. It is largely subjective, and
various descriptions related to volume or signs such as +, ++, +++ are frequently
used. Correctly identifying clinical signs associated with the level of exudate
production within a wound is a vital component of the assessment process. It can
yield useful clues and indicators about the condition, stage and progress of a wound.
It is good practice to document exudate in terms of the quantity (none, light,
moderate, heavy), and type (purulent [pus-like], serous [watery], or blood-stained).
If the wound is infected, the colour of the exudate may change from a straw colour
to a green or cream colour. Malodour may also be present.
Regular wound assessment should record quantity, type and colour of exudate.
The nurse’s role in wound management should focus on achieving an optimal level
of exudate at the wound bed to maximise the potential for healing and address
problems such as odour, strike-through and condition of the surrounding skin. In
some cases it may be necessary to obtain a medical opinion to identify the cause
and treatment of ongoing problems related to exudate.
■ Always select the correct size of dressing which overlaps the wound appropriately and change
dressings as required
■ Avoid dressings designed for low exudate as the primary contact layer e.g. films,
hydrocolloids, most hydrogels
■ Avoid exceeding wear-time of dressings as saturated products can induce maceration or
excoriation
■ Consider vacuum assisted wound closure (topical negative pressure therapy) for wounds with
extensive tissue loss
■ Consider wound drainage bag systems or stoma appliances if dressings are unable to contain
quantity of exudate
■ Use highly absorbent dressings such as alginates, capillary dressings, foams, hydrofibres.
Condition of surrounding skin
Where excess exudate is present the surrounding skin is often whitish in colour
(macerated) or is erythematous (reddened) caused by excoriation from exudate,
which may lead to irritant contact dermatitis. This can cause pain and skin
breakdown.
Other management options include:
■ Nutritional support as the patient may have lost considerable amounts of protein
■ Physiotherapy
■ Psychological support as the patient may be depressed.
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Causes of odour
Odour is usually caused by the breakdown of devitalised tissue (necrosis or slough).
The presence of necrosis or slough within a wound increases the potential for wound
infection. Bacteria easily proliferate in this medium, producing different odours
according to the strain. Occasionally it may be the soiled dressing which is
malodorous rather than the wound itself. Sometimes malodour develops within a
wound as a result of infection, however malodour alone is not always diagnostic of
wound infection.
Management options
Effective management relies on identifying the underlying cause of the malodour. Try
to approach the problem sensitively, as the patient may feel ashamed or
embarrassed.
■ Constant patient support and reassurance
■ Consider antibiotic therapy if infection has been identified as the primary reason for malodour.
Consider use of topical metronidazole where anaerobic bacteria are identified
■ Dressing changes as often as needed
■ Effective management of exudate to avoid strike-through. Consider alginates, capillary
dressings, foams, hydrofibres, stoma appliances and topical negative pressure therapy
■ Removal of sloughy/necrotic tissue
■ Consider dressings that reduce odour (e.g. charcoal)
■ Use of occlusive dressings to contain exudate
■ Use of deodorisers – however they do not remove the odour, they merely mask it
■ Consider methods such as honey, sugar paste and maggot (larval) therapy. Research into the
effectiveness of these methods is currently being undertaken.
FURTHER READING
Cameron, J. Wound management. Skin allergy problems in patients with chronic leg ulcers. British
Journal of Community Nursing 1999; 4(1): 6-12.
European Wound Management Association (EWMA). Position Document: Pain at Wound Dressing
Changes. London. Medical Education Partnership 2002. (Also available at www. tendra.com)
Fletcher, J. Exudate theory and the clinical management of exudating wounds. Professional
Nurse 2002; 17(8): 475-78.
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