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CASE STUDY
Use of a hydrogel dressing for
management of a painful leg ulcer
Ann Moody
Ann Moody is a tissue viability nurse for Morecambe Bay Primary Care Trust, Cumbria
W
ound healing is affected by many variables,
which must be assessed before treatment cn
commence. These include patient factors (e.g.
mental status, age, pain, mobility, nutritional status and comorbidities), wound factors (e.g.peri-wound skin status,
vasculitis, cellulitis, wound colour, odour, and incontinence), as well as the macroscopic and microscopic environments (Snyder, 2004). Evaluation of necrosis, infection,
nutrition, pressure, perfusion and tissue moisture balance
are also paramount (Snyder, 2004).
Because of the multitude of factors that can affect healing progress, wounds cannot be tended to in isolation. The
nurse needs to have an understanding of the process of
wound healing and have undertaken a full patient assessment before focusing on the patient’s wound. Recognising
and managing problems at the wound bed, e.g. necrotic
tissue and excess exudate, can result in a better prepared
wound bed and optimal healing (Dowsett, 2002).
It is important that any devitalized tissue is removed from
a wound as soon as possible. For most patients, the presence
of non-viable tissue is distressing as it can produce a noxious
odour and frequently an unacceptable discharge. The devitalized tissue provides a suitable culture medium for bacterial
growth, and wounds containing necrotic tissue are therefore
at risk of becoming clinically infected (Poston, 1996).
Wound exudate is all too often perceived as a clinical management problem. While this can be the case, it
should be recognized that exudate does fulfil an important
function in the healing process. Gradual acceptance of the
Email: [email protected]
benefits of moist wound healing, combined with the current goals of the ‘ideal’ moist environment, focus attention
on the role of exudates (Cutting, 2003). Although wound
exudate is necessary for healing, when its production
becomes excessive it becomes a problem, contributing
to skin maceration and delayed wound healing. Treating
the underlying cause of excessive exudate generation and
selecting appropriate dressings are the keys to effective
management (Watret, 1997).
Chronic wounds
This case study is of an 82-year-old lady who was widowed and lives alone
in a council house. A left lateral leg ulcer had developed over the gaiter
area, and the community team were asked to assess in 2004. The main
issues were her inability to tolerate compression (even when reduced)
because of the pain. Nevertheless, the community nurses had tried very
hard with compression, using different compression techniques at different
times to try to encourage her to persevere. The nurses felt they were
running out of ideas and therefore the tissue viability nurse (TVN) was
asked to assess the wound. The TVN recommended ActiFormCool dressing.
This article will examine the background for wound healing, provide the
rationale for the recommendation and describe the progress of the patient.
Most chronic wounds have become ‘stuck’ in the late
inflammatory phase of wound healing. For the normal
repair process to resume, the barrier to healing must be
identified and removed through application of the correct
techniques (Schultz et al, 2003). This can be distressing
and frustrating for patients who may have lived with such
a wound for many months or even years. The key to the
concept of wound-bed management is to prepare the
wound so that modern methods of promoting healing can
then be applied (Collier, 2002).
Chronic wounds are characterized by loss of skin or
underlying soft tissue and does not progress toward healing
with conventional wound care treatment. There are four
basic principles of chronic wound care:
wRemove debris and cleanse the wound
wProvide a moist wound healing environment through
the use of proper dressings
wProtect the wound from further injury.
wProvide substrates essential to the wound healing process.
The removal of devitalized tissue, particulate matter, or foreign materials from a wound—debridement—is often the
first goal of wound care. Debridement can be accomplished
surgically (instrument/sharp), chemically, mechanically or by
means of autolysis. Each procedure has distinct advantages,
disadvantages, indications for use and risks, and a combination of methods will often expedite the process while limiting the chance of complications (Fowler and van Rijswijk,
1995). Underlying the care of chronic wounds is the necessity to assess the wound on an ongoing basis. Changes in
wound care must be based on changing wound parameters,
and timely, complete and accurate wound assessments must
be documented (Frantz and Gardner, 1994).
KEY WORDS
Hydrogels
Leg ulcers w Pain w Compression w Hydrogel
Many different types of wound dressings are available.
It is important that nurses know what sort of dressing
Abstract
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Wound Care, June 2006
CASE STUDY
‘Hydrogel dressings can be
used on necrotic, sloughy,
granulating, and epithelializing
wounds (Figure 1) and can be
used in infected wounds if the
patient is receiving systemic
antibiotics and the dressing is
changed daily.’
is appropriate for a
patient’s highly exuding wound, as using
the wrong dressing can
lead to repeated dressing changes and soiling
of clothes and bedding
and will undermine
the patient’s faith in
care (Anderson, 2002).
Although
surgical
(sharp) debridement is
the most rapid and effective technique for removing devitalised tissue, topical enzymes, moisture-retentive dressings,
biosurgical therapy and vacuum therapy have been used as
alternative approaches to wound cleansing and preparation
(Bowler, 2002). However, the simplest and most cost-effective method of removing devitalised tissue is through autolytic debridement with wet dressings such as hydrogels.
On a molecular level, hydrogels are three-dimensional
networks of hydrophilic polymers. Depending on the type
of hydrogel, they contain varying percentages of water,
but do not altogether dissolve in water. Despite their high
water content, hydrogels are capable of additionally binding great volumes of liquid because of the presence of
hydrophilic residues. Hydrogels swell extensively without
changing their gelatinous structure and are available for use
as amorphous (without shape) gels and in various types of
application systems, e.g. flat sheet hydrogels and non-woven
dressings impregnated with amorphous hydrogel solution.
These products consist of hydrophilic homopolymers or
copolymers which interact with aqueous solutions, absorbing and retaining significant volumes of fluid. Flat sheet
hydrogel dressings have a stable crosslinked macrostructure
and therefore retain their physical form as they absorb fluid
(Vernon, 2003). The selected dressing in this case study was
a sheet hydrogel (ActiFormCool®, Activa Healthcare).
Hydrogels, in the form of amorphous gel, have been
successfully used for aiding debridement for longer than a
decade, their primary role being particularly rehydration of
dry necrotic wounds. Hydrogel dressings can be used on
necrotic, sloughy, granulating, and epithelializing wounds
(Figure 1) and can be used in infected wounds if the patient
is receiving systemic antibiotics and the dressing is changed
daily (Morgan, 1997). (However, if the infected wound is
producing copious amounts of exudate, applying an amorphous hydrogel may lead to maceration of the skin edges).
Hydrogels are therefore of value in a wide spectrum
of wounds (Flanagan, 1995). Most hydrogels have a high
water content of approximately 70% and it is this factor
that successfully promotes rehydration. Hydrogels also
have the ability to absorb some fluids from low exuding
wounds, However, if used in sloughy and highly exuding
wounds, hydrogels can begin to donate fluid to the wound
(Hampton and Collins, 2003) and this can increase the
fluid levels in the secondary dressings and may escalate
potential for this fluid to macerate the surrounding tissues. Slough is partly rehydrated necrotic tissue and also
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requires a moist environment if complete debridement is
to be achieved.
ActiFormCool
ActiFormCool dressings are two-sided, colourless, transparent hydrogels formed around a supporting blue polyethylene matrix and contain approximately 70% water with the
remaining 30% consisting of a swollen acrylic polymer
with phenoxyethanol as a preservative. The gel is permeable to water vapour, gases and small protein molecules,
but impermeable to bacteria. The cooling element of the
dressing provides a moist environment at the surface of the
wound and this has been found to reduce pain in painful
wounds (Hampton, 2004; Collins and Heron 2005).
ActiFormCool may be placed directly onto the surface of
an exudating wound and held in place with tape or a bandage, as appropriate. If additional absorbency is required, an
absorbent pad may be placed immediately over the dressing.
The dressing liner must always be left in place unless there is
a large volume of exudate. Painful wounds (where the pain
is actually in the wound, not in the surrounding tissues)
also benefit from a moist environment (Flanagan, 1997) as
the moisture ‘bathes’ nerve endings and can reduce pain.
The ActiFormCool hydrogel sheet moistens the wound
and slightly and temporarily drops the temperature of the
wound (data on file, Activa Healthcare) thereby soothing
painful tissues. The temperature then climbs to an optimum
condition to promote wound healing.
ActiFormCool may be used as a wound contact layer,
providing cooling and soothing, as well as exudate absorption and retention and is primarily indicated for burns,
scalds, radiation therapy damage and epidermal damage.
ActiFormCool should not be used as a covering for deep
narrow cavities or sinuses.
ActiFormCool may be placed directly onto the surface of
an exudating wound and held in place with tape or a bandage, as appropriate. If additional absorbency is required, an
absorbent pad may be placed immediately over the dressing.
As with all wounds, frequent monitoring is required and
the dressing should be changed as often as the condition
of the wound dictates (Collins and Heron, 2005) or when
it becomes cloudy or opaque owing to the absorption of
wound exudate. In the treatment of an infected wound, it
may be necessary to change the dressing more frequently.
The case study
The patient, an 82-year-old lady, had a venous leg ulcer of 5
months’ duration on the left lateral gaiter area (Figure 1).
The ulcer was shallow, diffuse and exuding high amounts
of fluid, presenting initially with two management problems: that of a sloughy wound bed, and maceration to the
peri-ulcer skin. A key objective of the consequent wound
management plan would be to remove the slough and
promote the growth of granulation tissue (Gray et al, 2005)
while concurrently managing the exudate. Slough formation is common during the inflammatory stage and occurs
when a collection of dead cellular debris adheres to the
wound surface, creating a fibrous cover across the bed of
Wound Care, June 2006
CASE STUDY
Figure 1. July 2004. The ulcer had been unhealing for 5
months. It is macerated and painful.
the wound. Slough must first be removed from the wound
bed in order that an optimal environment may be achieved
to promote the formation of granulation tissue.
Maceration occurs when excessive amounts of fluid
remain in constant contact with the skin. Wound exudate,
while an essential component of the local wound healing
environment, can provide this excessive fluid. The enzymatic component of the exudate can lead to skin damage
and even an increase in size of ulcer.
The ulcer had previously been managed by the district
nurses who initially tried a 4-layer bandaging compression system. Despite the use of this compression, the ulcer
continued to produce large amounts of exudate and daily
visits by the nurses were required in order to manage it. As
time passed, the patients ability to tolerate the compression
produced by the 4-layer system declined. The compression was therefore changed over time to 3-layer, then to
short stretch bandages. Several factors contributed to the
patient’s changing response to compression, including pain
caused by the ulcer and despondency that the ulcer was
not healing.
The management of this patient raised a number of
concerns among the district nurses, and the team eventually concluded that with respect to this particular patient,
they were running out of ideas, although the problem still
remained. This prompted intervention by the tissue viability
nurse specialist (TVN).
The initial TVN assessment was made in July 2004
(Figure 1). Although the lady had an independent rubor,
with capillary refill when dependent, the toes blanched
when elevated, suggesting there may be an underlying element of arterial aetiology. However, there was no resting
or night pain reported.The limb was generally oedematous
and Doppler assessment gave an ABPI of 1.02. Taken on
balance it was decided that it was safe to compress. The
ulcers were wet, but the skin on the feet was dry.
Holistic assessment and a care plan tailored to reflect a
patient’s individual needs are an essential component of leg
ulcer management. Local documentation and guidelines
developed by the TVN take the assessor through a logical
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series of questions which considers many aspects of the
patient as a whole person: staring with height, weight and
blood pressure, the assessment proceeds through past medical history (including details of pregnancies), current medication and any known allergies, social details (e.g. support
networks, mobility, where they sleep (e.g. chair/bed) etc)
and progresses to undertake a general health assessment,
before examining the leg, skin and finally the ulcer. Very
detailed note is taken of the ulcer history (and any previous ulcer history) position of the ulcer, surrounding skin
condition, wound edges, depth, exudate and level of joint
mobility and pain. Only then is the Doppler assessment
used to support the clinical presentation of the ulcer, and
a diagnosis made. This holistic and systematic approach not
only supports a reliable diagnosis but has also been shown
to help achieve concordance: working with the patient to
address their main identified problems helps to formulate
a care plan which is more likely to be acceptable to the
patient and therefore adhered to.
In the case of this patient, the main issues were pain,
and quality of life relating to the amounts of exudate. Leg
ulcers, in particular, have been shown to have a significant
impact on patients’ quality of life, with experience of pain
being the most overwhelming feature. In addition patients
have found the effects of coping with leakage and odour
from wet dressings to be particularly distressing and at
times unbearable, often leading to social isolation (Charles,
1995; Walsh, 1995; Neil and Munjas, 2000; Douglas, 2001;
Rich and Mclachlan, 2003).
Following the initial assessment in July 2004, a hydofibre
dressing was applied to the ulcer bed to act as a soothing
wound contact layer. It was also capable of desloughing,
absorbing exudate and providing an optimal environment
for granulation to take place. This was combined with a full
compression bandage system which should aid venous return,
reduce oedema and further help to control exudate levels.
Unfortunately during the following 3 months the
patient was unable to tolerate the compression because
of discomfort at the ulcer bed, and between July and
October the wound began to obviously deteriorate, the
ulcer extending in size and maceration developing to the
peri-ulcer skin (Figure 2).
Figure 2. October 2004. Maceration and an increased
ulcer size indicate deterioration.
Wound Care, June 2006
CASE STUDY
This was not an easy case but it was certainly a successful
one from this perspective.
Conclusion
This case study shows that there are simple solutions to problems within wound care, but that requires careful thought
and assessment of the individual patient. In this instance,
ActiFormCool was the ideal dressing and led to concordance
of the patient and healing of the wound.
BJCN
Figure 3. May 2005. The wound is all but healed at this
point.
A decision was made by the TVN to change the primary wound contact dressing to ActiFormCool, because
of its properties of soothing pain. ActiFormCool has a
high absorption capacity (Hampton, 2004) and can be
cut to the shape of the wound if required. This ensures
that the peri-wound area does not become macerated.
ActiFormCool also helps with pain reduction (Collins
and Heron 2005; Hampton, 2004) and when pain is
reduced quality of life is improved (Hampton and Collins,
2003). ActiformCool’s ability to donate moisture to a
wound would also provide an agent to deslough the
wound by autolysis.
ActiFormCool suited the patient – pain was reduced,
and exudate levels managed, and she became able to tolerate therapeutic compression. By the next TVN review
in February 2005 dressing changes were reduced from
daily to every third day. The following TVN review was
made in May 2005. The community nurse visits had
now been reduced to twice weekly and the wound was
almost healed.
Since the patient was experiencing repeated minor trauma injuries to her leg when inexperienced carers applied
the Class 2 compression hose, a decision was made by the
TVN to modify the treatment and it was changed to using
two liners from the Activa 2-piece kit: since the white liner
is extremely easy to put on trauma was avoided. However,
as the liner only applies 10mmHg pressure, a second
liner was applied over the first giving a total pressure of
approximately 20mmHg. This approach enabled compression therapy to continue where otherwise it may have had
to be abandoned. This is not recommended practice for
compression, but it was the only method that the patient
would tolerate. Figure 3 (dating from May 2005)shows the
skin to be clear of maceration and the ulcer all but healed.
The wrinkles show that although the compression was
not the recommended method, it worked for this lady and
reduced the oedema, which led to the natural wrinkling of
the compressed tissues.
Wound Care, June 2006 Anderson I (2002) Practical issues in the management of highly exuding
wounds. Prof Nurse 18(3): 145–8
Bowler PG (2002) Wound pathophysiology, infection and therapeutic options.
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Collier M (2002) Wound-bed management: key principles for practice. Prof
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Collins J, Heron A (2005) Stages of wound healing: applications in practice
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Key Points
wHolistic assessment is essential to identify and address all the factors
affecting the formation and healing of a wound.
wWounds cannot always be treated in the ideal way.
wTreatment should aim to achieve the best fit between the clinical priorities
and the patient’s needs, which may not be the same.
Regular reassessment is needed to monitor the wound. Changes in the
wound may require changes to the treatment regime.
wIn this case, ActiFormCool and reduced compression were able to address
the patient’s needs for exudate control and comfort
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