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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. 1 2 3 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. 4 5 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. 6 © MEP Ltd, 2003