Download Guidelines on the General Principles of Caring for Patients with

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Any reference to specific products in the following text is by way of example only and
is not to be taken as constituting any form of recommendation or endorsement on the
part of CREST
These guidelines have been prepared by CREST
CREST is a small committee of doctors established under the auspices of the Central Medical
Advisory Committee, to promote clinical efficiency in the health service in Northern Ireland while
ensuring that the highest possible standard of clinical practice is maintained.
CREST wishes to express its appreciation to Mrs Mary Waddell and the working group for
producing this guidance, to all the members of the sub-groups and to all those who contributed
in any way to the development of these guidelines.
Special thanks are due to Mrs Heather Reid for the major contribution which she made to the
production of these booklets.
Further copies may be obtained from:
CREST Secretariat
Room 517
Dundonald House
Upper Newtownards Road
Belfast
BT4 3SF
Tel:
02890 524391
CREST Website
www.n-i.nhs.uk/CREST
GENERAL PRINCIPLES OF WOUND CARE
Table of Contents
Foreword
1.
Summary of Conclusions and Key Recommendations
Page
3
2.
Physiology of the Wound Healing Process
4
3.
Holistic Assessment
5
4.
The Role of Nutrition in Wound Management
6
5.
Local Wound Assessment
10
6.
Wound Bed Classification
13
7.
Wound Cleansing
14
8.
Treatment Objectives
15
9.
Selecting a Dressing
19
10.
Seven Principles for Selecting an Ideal Wound Dressing
20
Appendices
1.
Wound Observation Chart
23
2.
Dressings’ Formulary
26
3.
Guideline Development Sub-Group
40
4.
CREST Wound Management Group
41
Glossary
43
Useful Addresses
44
References: A full list of references and further reading may be obtained by contacting the
CREST Secretariat
Foreword
These consensus guidelines have been drawn up following an in-depth investigation of relevant
literature and expert opinion. They are designed to help practitioners base their clinical
decisions on the best information available and offer a structured approach to the assessment
and management of patients with wounds. Please refer to the guideline folder for further
information on the development process.
These guidelines are not meant to be a definitive guide to the management of specific wound
types, rather they contain information on the general principles of wound management principles which can be applied to most situations.
Before any clinical decision is taken, practitioners should take into consideration their local
circumstances, including patient preferences and any further knowledge of more recent
findings.
The authors would like to acknowledge all the practitioners who have taken the time to review
and comment on the guidelines.
1. SUMMARY OF CONCLUSIONS AND KEY RECOMMENDATIONS
A number of key recommendations highlighted throughout the report are listed below. Each recommendation is
graded so as to give the reader an indication of the type of evidence supporting it.
GRADE A
Requires at least one randomised controlled trial as part of the body of literature which is of overall
quality and consistency addressing the specific recommendation.
GRADE B
Requires availability of well conducted clinical studies but no randomised clinical trials on the topic
of recommendation.
GRADE C
Requires evidence from expert committee reports or opinions and/or clinical experience of
respected authorities. Indicates absence of directly applicable studies of good quality.
Assessment
•
•
Grade
C
A holistic patient assessment is an essential part of the
wound care process.
The systematic assessment of a wound is essential as it
provides baseline data on which to evaluate healing and
the efficacy of the treatment regime.
C
See Section
3
5
Management
•
•
•
•
•
•
•
•
•
•
Optimal nutrition facilitates wound healing, maintains
immune competence and decreases the risk of infection.
Nutritional assessment is essential to determine both
deficiencies or excesses of macronutrients and
micronutrients involved in the wound healing process.
Physiological Saline (0.9%) is the universal wound
cleansing agent of choice.
For chronic wounds such as leg ulcers ordinary tap water
can be used.
If wound cleansing is indicated the wound should be
gently irrigated rather than swabbed.
Saline and water used for cleansing should be warmed
at least to room temperature.
Antiseptics are toxic to human tissue and probably delay
wound healing.
Topical antibiotics are frequent sensitisers and should be
used with caution.
Systemic antibiotics should be used to treat clinical
infection.
Wound dressings should:
• Provide a moist wound environment;
• Manage excess exudate;
• Allow gaseous exchange;
• Provide a constant wound interface temperature;
• Protect the wound from pathogenic organisms;
• Protect the wound from contamination with
particulate matter;
• Protect the wound from trauma.
B
4
B
4.1
C
7
C
7
C
7
B
7
B
7
B
7
A
8
B
10
3
2. PHYSIOLOGY OF THE WOUND HEALING PROCESS
The word healing, used in a pathological context, refers to the body’s replacement of destroyed
tissue by living tissue. Wound healing is an extremely complex process involving different
biologic and immunologic systems. Injury triggers an organised cascade of cellular and
biochemical events which result in a healed wound.
For descriptive purposes, the wound healing response can be divided into distinct but
overlapping phases:
(i)
(ii)
(iii)
(iv)
Haemostasis;
Inflammatory phase;
Proliferative phase;
Maturation or remodelling phase.
(i) Haemostasis
Haemostasis protects the body from excessive blood loss and increased exposure to bacterial
contamination through:
-
Vasoconstriction;
-
Migration of leukocytes and platelets;
-
Formation of fibrin.
(ii) The inflammatory phase
This phase prepares the wound bed for healing by removing necrotic and foreign material. This
natural process is known as:
-
Autolysis.
(iii) The proliferative phase
This phase fills and covers the wound bed as quickly as possible through:
-
Granulation;
Contraction;
Epithelialisation.
(iv) The maturation or remodelling phase
During this phase the tensile strength of the healed wound is increased by the remodelling of
collagen.
4
3. HOLISTIC ASSESSMENT
A true healing environment accepts the person for their
individuality and holds their physical, mental, emotional,
social and spiritual needs in high regard. It is therefore,
achieved through a holistic health assessment and an
evidence based treatment plan.
The success of wound healing is known to depend on many intrinsic and extrinsic factors, e.g.
underlying disease, nutrition and psychological well-being. In order to create a healing
environment, all factors which adversely affect the health of the patient must be identified and,
where possible, rectified. Table 1 highlights some of the most common factors which can delay
healing.
Table 1 - Key Factors adversely affecting the healing process.
Intrinsic Factors
Advancing age
Extrinsic Factors
Poor surgical technique
Disease processes, e.g. diabetes, cancer
Poor wound care
Psychological factors
Malnutrition
- stress and anxiety
- sleep disturbances
Dehydration
Smoking
Drug Therapy
Radiotherapy
It is important to remember that in some instances wound healing is not always possible. In
these situations care must be directed towards physical and psychological comfort.
5
4. THE ROLE OF NUTRITION IN WOUND MANAGEMENT
Optimal nutrition facilitates wound healing, maintains immune
competence and decreases the risk of infection. Most wounds
tend to heal rather than not; however malnutrition and
clinically evident deficiencies are commonly associated with a
delayed healing response and increased rate of complications.
Wound nutrition is essentially whole body nutrition and its goal is to maintain body mass, limit
weight loss and provide adequate nutrients to promote healing. Nutritional intake should be
varied and balanced to provide all the essential nutrients.
A significant number of studies have investigated the potential value of specific nutrients in
regulating wound healing as follows :
Kcalories (energy) Provision of adequate kcalories is the primary concern in facilitating wound
healing. Excess kcalories may lead to obesity, itself a complicating factor for wound
healing, whilst insufficient kcalories from fat and carbohydrate may result in protein being
used as an energy source.
Protein deficiency impairs wound healing by inhibiting fibroblast proliferation and collagen
synthesis. An inadequate protein intake, often in conjunction with excessive losses of
protein via heavily exudating wounds, will lead to a deficiency which can prolong the
inflammatory response and result in oedema secondary to hypoalbuminaemia, thereby
impairing the healing process. The value of various amino acids has been investigated :-
Glutamine is essential for immune system function. Its requirement is increased during
injury or disease and it appears to help decrease protein catabolism frequently seen
with injury.
Arginine enhances wound collagen deposition and protein synthesis. It also stimulates
insulin and growth hormone secretion, two products known to be closely related to
wound healing.
Vitamin C (ascorbic acid) deficiency results in very little collagen deposition and markedly
retarded gain in tensile strength. It has been shown that the elderly tend to have low
plasma ascorbate concentrations as do smokers and patients with liver disease and
cancer. The Vitamin C status of hospitalised patients deteriorates during hospital stay.
This suggests that the combination of injury or sepsis with marginal Vitamin C status may
determine alterations in wound healing of clinical relevance. Intake to prevent deficiency is
clearly indicated.
6
Zinc The role of zinc in cellular proliferation and protein synthesis has been well established.
The potential role of zinc supplementation in wound healing has been investigated; healing
appears to be accelerated only in patients with low serum zinc levels. Hospitalised
patients are potentially at risk of zinc deficiency due to decreased food intake and
increased losses due to diarrhoea, fistulae and malabsorption.
Vitamin A promotes re-epithelialisation and granulation of a wound and seems to counteract
the deleterious effects of glucocorticoids on wound healing. Patients with severe injuries
or those receiving steroids could benefit from supplementation.
Iron is vital in collagen metabolism and for oxygen transport. Deficiency due to poor intake and
blood loss may result in iron deficiency anaemia which, unless corrected, will delay wound
healing.
Fluid intake should be given important consideration as dehydrated skin becomes inelastic,
fragile and more susceptible to breakdown.
Other nutrients which have important functions in association with wound healing include
vitamin E, vitamin K, vitamin B complex, copper, manganese, chromium and essential fatty
acids.
Poor nutrition leading to nutrient deficiencies will interfere with wound healing, mostly by
delaying the healing response. Evaluation of a patient’s nutritional status through assessment
and the provision of a nutritionally appropriate diet is one of the first principles to healing.
4.1 NUTRITIONAL ASSESSMENT
Nutritional assessment is essential to determine both
deficiencies or excesses of macronutrients (carbohydrate, fat
and protein) and micronutrients (vitamins, minerals and trace
elements) involved in the wound healing process. It also
provides an important base line of data on which to evaluate
the adequacy of nutritional intervention.
The need for a detailed nutritional assessment and dietetic intervention is usually determined by
nursing and/or medical staff. This should involve screening patients to identify those who are
malnourished or at risk of developing malnutrition, which in itself acts as a predisposing factor
for delaying wound healing and increasing the risk of wound related complications.
7
The process of screening is referred to as nutritional risk assessment, and referral to a state
registered dietitian is indicated by a combination of the following:
•
more than 10% weight loss in less than 3 months;
•
body mass index of less than 20 kg/m2 or greater than 30 kg/m2;
•
inability to consume sufficient nutrients to meet requirements due to:
-
poor appetite, that is consumption of less than 1/2 of meals;
-
difficulties in chewing and/or swallowing necessitating altered texture meals;
-
patient unable to take food/fluid by the normal oral route as it is deemed unsafe.
•
malabsorption due to abnormal gut function, such as diarrhoea and/or vomiting;
•
increased nutritional requirements due to disease or injury.
Many hospitals and community trusts now have access to nutrition risk assessment tools, which
should be used whenever possible, in line with the British Association for Parenteral and Enteral
Nutrition (BAPEN) recommendations.
On referral to the dietitian a more detailed assessment should involve:
•
assessment of present nutritional status;
•
calculation of nutritional requirements;
•
calculation of actual nutrient intake;
•
biochemical analysis to identify specific micronutrient deficiencies with:
-
tissue breakdown, for example, pressure sore formation or wound dehiscence;
-
slow to heal wounds, that is wounds which show no signs of improvement within 5-6
weeks;
-
patients who have not been receiving their optimal nutritional requirements.
8
4.2 TREATMENT OBJECTIVES
(i)
(ii)
Prevent clinical nutrient deficiencies by ensuring that the patient is provided with optimal
nutritional care through one or more of the following:
•
a varied, balanced diet;
•
nutritional supplements;
•
multivitamin and mineral preparations;
•
enteral tube feeding;
•
parenteral nutrition.
Correct specific nutrient deficiencies as detected through biochemical investigations and
clinical observation, with pharmacological doses of the nutrient concerned. Evidence of
clinical efficacy of such nutritional supplementation is limited, the consequence being a
lack of consensus as to whether to supplement and in what dose. The most abundant
information exists regarding Vitamin C, iron and zinc.
A range of doses for
supplementation suggested in the literature is provided below:
Vitamin C
- 100-1000 mg per day (adjust with response) for example, 500mg of
ascorbic acid once per day.
Zinc
- 50 mg maximum per day (adjust with response), for example, 200mg
Solvazinc® once per day.
Iron
- 100-200 mg per day (adjust with response), for example, 200 mg of
ferrous sulphate (dried) three times per day.
Specific micronutrients if supplemented, without biochemical evidence of a deficiency state
and in too high a dose could interfere with the absorption of other important nutrients and
result in complications of toxicity.
Biochemical parameters should be reviewed and vitamin and/or mineral supplementation
discontinued only when nutrient deficiency states are corrected and other sources provide
sufficient quantities of the concerned nutrients. This will prevent rebound deficiency states
particularly notable with regard to Vitamin C.
(iii)
Control total calorie intake in the obese patient to reduce weight and/or prevent further
weight gain.
(iv) Ensure dietary intake is conducive to optimal glycaemic control in patients with diabetes.
9
5. LOCAL WOUND ASSESSMENT
The systematic assessment of a wound is essential as it
provides baseline data on which to evaluate healing and the
efficacy of the treatment regime.
Assessment and evaluation should be carried out at regularly stated intervals and the process
should be clearly documented. The following data should be recorded:
5.1 Site of Wound
It is important to record the site of the wound for the following reasons:
•
•
accurate record keeping differentiates between wounds;
the position of a wound may suggest its pathology, for example, venous leg ulcers tend to
occur in the gaiter area, whilst ulcers on the foot are usually due to ischaemia or diabetes.
5.2 Wound Measurement
The accurate measurement of the physical size of a wound is vital for assessing the progress of
healing.
Although there are many different ways of measuring wounds the most simple and accessible
methods include:
(i)
(ii)
(iii)
•
•
•
ruler based assessment, e.g. (maximum) width x depth x breadth;
transparency tracings;
photography/Grid Camera.
In general cavity wounds should be gently probed to establish the extent of undermining
and/or the depth of hidden extensions. Caution should be exercised where the wound
overlies sensitive structure e.g. bowel.
Measurements should be recorded in millimetres or centimetres.
Weekly measurements are usually sufficient.
Note: In some instances a sinogram or x-ray will be required to establish the full extent of
the wound.
10
5.3 Surrounding Skin
The condition of the skin surrounding the wound provides important information about
underlying disease and the effectiveness of current treatment regimes. For example, pink
tissue on the wound margins may indicate epithelialisation; cool, shiny, hairless skin on the
lower leg may indicate arterial disease; maceration may indicate an ineffective dressing regime.
In some instances a sinogram or x-ray will be required to
establish the full extent of the wound.
In general, the shape of the wound’s edge is an unreliable discriminant of a wound’s progress.
However, a rolled (lipped) edge may indicate malignancy or another aetiology and may require
biopsy.
5.4 Wound Bed
The appearance of the wound bed is said to indicate both the stage of healing and the health of
the wound. The wound bed must be thoroughly assessed as tissue type often provides the
rationale behind the main treatment objective. For example a red granulating wound will require
protection whilst a black necrotic or a yellow sloughy wound will probably require some form of
debridement.
One of the most effective ways to describe tissue type is by its colour. In general:
• Eschar = Black tissue
• Slough = Yellow tissue
• Granulation = Red tissue
• Epithelialisation = Pink tissue
Although the colour system is not perfect, for example, yellow tissue does not always indicate
slough, it is easy to use and aids communication. The type of tissue on the wound bed can be
further quantified through percentages, e.g. 50% red/granulation tissue + 50% yellow/slough.
5.5 Exudate
A knowledge of the level and type of wound exudate is extremely important as it, in conjunction
with the type of tissue on the wound bed, will influence dressing choice.
The level and type of exudate tends to be described subjectively. In order to improve
communication it may be helpful to standardise the meaning behind the subjective descriptions.
For example, wound exudate may be described as:
Serous
Sanguinous
Serosanguinous
Purulent
Clear fluid with apparent visual absence of blood, pus or other debris;
Bloody, appearing to be composed entirely of blood;
Blood mixed with obvious quantities of clear fluid;
Pus like in appearance, cloudy and viscous.
11
It is very difficult to devise an accurate method of describing the level/amount of wound
exudate. However, the following terms may be useful:
Dry
The wound does not produce exudate;
Low
The wound bed is moist, i.e. there is scant or small amounts of exudate;
Moderate The surrounding skin is wet and there is exudate in the wound bed;
High
The surrounding skin is saturated (sometimes macerated) and the wound is bathed
in fluid.
Note: The dressing regime may add to or detract from the true level of wound exudate.
5.6 Wound Odour
Malodour may cause the patient to suffer social or psychological isolation. It can also cause
physical symptoms such as nausea and vomiting and this can result in severe nutritional
deficits.
Wound odour may be caused by infection, necrotic tissue or the use of certain dressing
materials. The cause must be established and where possible rectified, e.g. treat infection,
remove necrotic matter, change dressing regime.
Odour is very subjective and difficult to quantify. However, the following descriptive terms may
be useful:
•
•
•
none;
smell only noticeable on dressing removal and disappears when the dressing is discarded;
smell fills the room.
5.7 Wound Pain
Although pain is subjective, its location, frequency and severity can be helpful in determining the
presence of underlying disease, the exposure of nerve endings, the efficacy of local wound care
and psychological need. Visual or verbal rating scales can help patients to communicate the
level of pain which they are experiencing. Local pain management policies should be
implemented.
Please refer to Appendix 1.
12
6. WOUND BED CLASSIFICATION
NECROTIC
Necrotic – This is a necrotic heel. Note the
hard, black, dry, leathery eschar.
SLOUGHY
Sloughy – Note the soft yellow tissue on the
wound bed.
GRANULATING
Granulating – Note the healthy red tissue on
the wound bed.
OVERGRANULATION
Overgranulation – Note the exuberant raised
red tissue.
EPITHELIALISING
Epithelialising 1 – Note the pink tissue at the
wound edges moving over the healthy
granulating tissue.
EPTIHELIALISED
Epithelialising 2 – Same
epithelialised 5 months later.
wound
fully
13
7. WOUND CLEANSING.
Considerable debate surrounds this area of wound care. There are, however, a number of key
points that should be adhered to when cleansing wounds.
•
Wounds that are healthy and free from debris do not require
ritualistic cleansing. However if dead tissue or foreign debris
are present the wound should be cleaned as this matter may
support the growth of pathogenic organisms. Inflammatory
exudate is produced by all healthy wounds. This exudate
contains important substances which are essential for wound
healing e.g. growth factors.
•
If cleansing is indicated, the wound should be irrigated using,
for example, a syringe rather than swabbed - swabbing can
result in the breakdown of fragile granulation/epithelialising
tissue.
•
Physiological saline (sodium chloride 0.9%) is the only solution
which is recommended for all wound types - recent studies
indicate that physiological saline is compatible with human
tissue and is unlikely to cause cellular damage. However,
some experts recommend ordinary tap water for the cleansing
of chronic wounds such as leg ulcers.
•
Studies indicate that saline and water should be warmed to
body temperature (37 C) - cold solutions slow down cellular
repair. However, many practitioners will find it difficult to
achieve this ideal in the practice setting. Therefore, it is
recommended that cleansing solutions are kept at a minimum
of room temperature.
•
There is at present debate about the use of topical antiseptics
and antibacterials in wound care. Some argue that topical
antibiotics and antiseptics have an important role to play within
clearly defined areas in wound care, while others stress that
antiseptics may have toxic effects on tissues and may delay
wound healing. Therefore, at present, the cautious use of such
chemicals in wound care is recommended.
Note! Instigate general infection control precautions when caring for all patients with
wounds e.g. hand washing, plastic aprons and gloves.
14
8. TREATMENT OBJECTIVES
Treatment objectives for wounds by their wound bed classification.
8.1 Necrotic Wounds
Description:
Necrosis is a term used to describe dead (ischaemic) tissue, e.g. eschar and slough.
However, within the field of wound care the term tends to be used to describe dead tissue
which is black/brown in colour.
Note: Hard, black, dehydrated, leathery necrosis is known as ESCHAR
Aim of Treatment:
•
debridement and management of exudate
Management Techniques:
•
•
•
•
debridement with a scalpel (see footnote);
dressings* which promote autolysis, e.g. hydrogels, hydrocolloids;
enzymes (efficacy of some enzymes has been questioned);
larvae (if necrosis is soft/wet);
*
The choice of dressing will depend on the depth of the wound and the amount of exudate.
Necrotic tissue prolongs healing and in most situations should be removed (debrided). The
true size of the wound may not be apparent until this necrotic tissue is removed. However, in
certain situations debridement may not be appropriate. This decision is usually made when a
limb or digit is ischaemic and amputation is not possible. This wound cannot be healed. In
order to prevent malodour and infection the necrotic tissue should be kept as dry as possible.
Patients usually like the limb covered for cosmetic reasons.
There is evidence to suggest that for some wounds, removing eschar is not necessary e.g.
small areas of eschar on heels and toes. If the eschar is hard and dry and the surrounding
skin is not inflamed then the eschar may be left intact. It should be inspected daily for any
signs of deterioration.
Note! Debridement with a scalpel should be undertaken with caution and health care
professionals should only do so if appropriate training and experience has been
gained.
15
8.2 Sloughy Wounds
Description:
Slough is a term used to describe the accumulation of dead cellular debris on the wound
surface. It tends to be yellow in colour due to large amounts of leucocytes present.
Its presence will delay healing.
Warning! - Yellow tissue is not always indicative of slough. You may be looking at
subcutaneous tissue, tendon or bone.
Aim of treatment:
•
debridement and management of exudate
Management Techniques:
•
•
•
•
*
sharp debridement with a scalpel [see note on debridement in section 8.1];
*dressings which promote autolysis, e.g. hydrogels, hydrocolloids, alginates, larvae;
enzymes (efficacy of some enzymes has been questioned);
larvae.
The choice of dressing will depend on the depth of the wound and the amount of
exudate.
16
8.3 Granulating Wounds
Description:
Granulation is the process by which the wound is filled with highly vascular connective tissue.
Granulation tissue is usually red and moist and has an uneven granular appearance.
Unhealthy infected granulation tissue often looks dark and bleeds very easily.
Aim of Treatment:
•
•
•
keep wound warm and moist;
manage exudate;
PROTECTION.
Management Techniques:
•
*
All dressings* which maintain a warm moist environment, e.g. hydrogels, hydrofibre,
hydrocolloids, alginates, foam dressings.
The choice of dressing will depend on the depth of the wound and the amount of exudate.
8.4 Epithelialising Wounds
Description:
Epithelialisation is the process by which the wound is covered with epithelial cells. This
process can be recognised by the presence of pink tissue which migrates from the wound
edges and / or the remnants of hair follicles in the wound bed.
Epithelial cells will only migrate over living granulation tissue. Epithelialisation occurs 2 - 3
times quicker in a warm moist environment.
Aim of Treatment:
•
•
•
keep wound warm and moist;
manage exudate;
PROTECTION.
Management Techniques:
•
*
all dressings* which maintain a warm moist environment, e.g. low - adherent dressings,
vapour-permeable films, hydrogels, hydrocolloids, alginates, foams.
Dressing choice will depend on the level of exudate.
17
8.5 Infected Wounds
Description:
Infection occurs when organisms deposited in the wound evoke a reaction from the host, i.e. antigenantibody response.
Signs of infection may include:
•
delayed healing / dehiscence;
•
increased wound pain;
•
malodour (an acrid or putrid smell is highly indicative of an anaerobic infection);
•
abscess / sinus formation;
•
localised swelling, redness or heat;
•
increased level of exudate / purulent discharge;
•
pyrexia, rigours or tachycardia.
Aim of Treatment:
•
patient will be free from pain, discomfort and infection;
•
to promote wound healing.
Management Techniques:
•
general infection control precautions, e.g. hand washing, plastic aprons and gloves;
•
swab for ‘Organisms and Sensitivities’;
•
SYSTEMIC ANTIBIOTICS;
•
unless advised otherwise, treat the wound according to the type of tissue on the wound bed;
•
it may be prudent to avoid all occlusive dressings if anaerobic infection is suspected or cultured
(occlusive dressings are thought to promote an anaerobic environment);
•
daily dressings.
The presence of bacteria in a wound does not mean that it is infected - remember that all
chronic wounds are colonised by micro organisms. Do not diagnose a wound infection on the
wound swab result alone, look for local and systemic signs of infection. Patients with an
infected wound require a systemic antibiotic.
Examples of Aerobic and Anaerobic Bacteria Cultured from Wounds
Aerobic Bacteria
Beta-haemolytic Streptococci
Escherichia coli
Klebsiella
Proteus
Pseudomonas
Staphylococcus Aureus & MRSA
Staphylococcus Epidermis
Anaerobic Bacteria
Bacteroides
Clostridium tetani
Clostridium welchii (gas gangrene)
18
9. SELECTING A DRESSING
When selecting a dressing consider:
•
stage of healing
•
aetiology;
•
tissue involved;
•
the patient’s general health and environment.
Before applying the dressing consider:
•
the treatment objective;
•
the site of the wound;
•
the size of the wound;
•
the frequency of the dressing change;
•
comfort and cosmetic appearance;
•
where and by whom the dressing will be changed;
•
if the dressing is available on the drug tariff.
Note: Where all other considerations are equal, choose the cheapest dressing.
Never apply a dressing or lotion in ignorance.
contraindications, precautions and warnings.
Be aware of the manufacturer’s recommendations,
Remember that you are accountable for the decisions you make!
Note: A formulary of wound dressings may be found in Appendix 2
19
10. SEVEN PRINCIPLES FOR SELECTING AN IDEAL WOUND
DRESSING.
The ideal dressing will:
•
provide a moist environment;
•
manage excess exudate;
•
allow gaseous exchange;
•
provide a constant wound interface temperature;
•
protect the wound from pathogenic organisms;
•
protect the wound from contamination with particulate matter;
•
protect the wound from trauma.
Principle 1: Provide a Moist Wound Environment
Arising from the seminal work of George Winter in 1962, the phrase ‘moist wound healing’ has
been coined to describe an optimum environment for wound healing. It was observed that
wounds covered with an occlusive dressing healed twice as fast as those left to dry out.
Under dry conditions the bed of an open wound rapidly dries out and forms a scab made up of
dead and dying cells. New epidermal cells have to burrow beneath the scab to find a moist layer
to allow movement across the wound. In a moist environment epidermal cells are able to slide
across the surface of the wound because the dressing maintains humidity on the wound
surface.
Wounds which are healed in a moist environment heal faster, are less inflamed and less painful.
There is more collagen production and better contraction which results in less scarring.
Principle 2: Manage Excess Exudate
Although the effective management of exudate is probably the most common problem
encountered by practitioners involved in wound care, the composition and function of wound
fluid is generally not well understood.
From the physiology of wound healing, the presence of serous fluid in an open wound plays a
vital part in the healing process:
•
it provides essential nutrients as an energy source for actively metabolising cells;
•
it contains growth factors which actively promote healing;
•
it serves as a transport medium for white cells;
•
it helps to ensure that the wound surface does not become excessively dry.
Although the wound surface should remain moist, excessive moisture causes maceration and
excoriation of the surrounding skin which may in turn lead to infection. The precise balance that needs to
be maintained by the dressing between moisture and absorbency is still not certain.
20
Principle 3: Allow Gaseous Exchange
Successful wound healing is dependent upon good oxygen resources.
In the early stages of wound healing tissue oxygen is extremely low (<10mm Hg) indicating the
absence of a working microcirculation. A low oxygen tension is thought to stimulate fibroblast
replication and angiogenesis, and hence the production of granulation tissue thus helping to
improve the circulation and raise the tissue oxygen.
Once tissue oxygen improves (>10mm Hg collagen can be synthesised) the wound healing
process can continue.
The presence of exudate or debris on the wound surface may inhibit gaseous exchange through
the dressing. It would be fair to say that the wound does not rely on atmospheric oxygen for its
oxygen.
Principle 4: Provide A Constant Wound Interface Temperature
A constant temperature of 37 C promotes both macrophage and mitotic activity during
granulation and epithelialisation.
Cells and enzymes function at normal body temperature. Reduced interface temperatures
inhibit the activity of phagocytic cells and significantly affect cell mitosis.
Principle 5: Protect the Wound from Pathogenic Organisms.
One of the major functions of intact healthy skin is to protect underlying structures from invasion
by micro-organisms. A wound disrupts the integrity of the skin and provides a potential pathway
for pathogenic organisms to enter the body. Wound infection can cause delayed healing and if
infection is not controlled it may lead to cellulitis, bacteraemia and septicaemia.
Many modern dressings are bacteria-proof. This not only prevents airborne bacteria entering a
wound but also prevents contaminated exudate being released into the environment and
causing cross-infection. Moistened or leaking dressings can provide a pathway for bacteria to
travel in both directions. It has been shown in vitro that motile bacteria such as Pseudomonas
can pass through a moist dressing in a few hours. This has been termed “strike-through” and
requires immediate dressing change.
21
Principle 6: Protect the Wound from Contamination with Particulate Matter
It is well documented that the presence of debris in the wound may delay wound healing and
act as a focus for infection. Foreign matter introduced into the skin causes an inflammatory
response and can lead to the formation of fibrous tissue, scarring and hypertrophy. It is
undoubtedly true that fibres from certain dressings used in wound care can become
incorporated into wounds, however some feel there is a need for more research into the
detrimental effects of this particularly to ensure that any residual chemicals left after complex
manufacturing processes do not inversely affect wound healing.
Principle 7: Protect the Wound from Trauma.
One of the priorities of wound management is to protect the wound from any further trauma. It
has been reported that removal of adherent dressings can cause trauma to wounds. It is well
documented that traditional dressings such as gauze have a tendency to adhere to the surface
of wounds causing damage to newly formed epithelium. Adherence occurs either because (a)
the wound exudate becomes incorporated into the dressing and dries or (b) granulation tissue
grows between the structure of the dressing.
Manufacturers of wound dressings have tried to overcome this problem by applying facing
layers to dressings which attempt to prevent adherence to the wound.
22
Appendix 1
Wound Observation Chart - sample
Note:
The following chart has been devised to show how local wound care information can be
recorded using a common language. It is not a holistic wound assessment chart and it is
not meant to be definite or all inclusive.
Professionals may use the chart as it stands or adapt it to meet the needs of their patients and
Trust.
23
Open Wound Observation Chart
Name: …………………………………
Unit No: …………. Ward…………..
Consultant/ GP:
Type of wound:
Date
Maximum size
(in centimetres or
millimetres)
Wound Bed
(state approx %)
NB. Other may include
tendon, muscle, bone.
Referrals (where appropriate):
Dietitian:
Date: …../…../…..
Other: ……………. Date: …../…../…..
Other: ……………. Date: …../…../…..
Allergies:
Wound site:
………………….
Length
………………...
Length
…………………...
Length
Depth
Depth
Depth
Width
Width
Width
Wound traced Yes/
No
Photograph Yes/
No
(Black) Necrosis
(Yellow) Slough
(Red) Granulation
(Pink) Epithelialising
Other ……………….
Wound traced Yes/ No
Photograph Yes/ No
Wound traced Yes/ No
Photograph
Yes/ No
Necrosis
Slough
Granulation
Epithelialising
Other ……………….
Necrosis
Slough
Granulation
Epithelialising
Other ……………….
Surrounding skin
Healthy/ Blistered/
Dry/ Scaly/
Wet or Dry Eczema/
Macerated/ Red & Hot
Exudate (colour)
Serous/ Sanguinous/
Serosanguinous/
Purulent
Exudate (amount)
Dry/ Low/ Moderate/
High
Odour
None/ Only present
when dressing is
removed/ Fills the
room
Wound Pain
(frequency)
None/ Only at
dressing change/
Intermittent/
Continuous
Wound Pain (Patient's
Perception)
Use Pain Scale
Signature
24
Date
Infection (only complete
this section if
appropriate)
Suspected/ Present
…………………
…………………
…………………
Swab taken (date)
……/……/…..
……../……../……
……../……../….
Result/ Organism(s)
isolated
……………………………
……………………………
………………………….
…………………………..
………………………………
……………………………..
Action taken
……………………………
……………………………
…………………………
………………………..
………………………………
……………………………..
…………………
…………………
…………………
Signature
Date
Recommended
Dressings/ Bandages
Rationale
Maximum Wear time
Sign
Additional Notes
Sign.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Please evaluate progress in the Nursing Care Plan.
25
Appendix 2
FORMULARY OF WOUND DRESSINGS
Primary wound dressings are dressings applied directly onto a wound and these can be divided
into a number of different generic classes.
•
Non or low-adherent dressings
•
Semi-permeable films
•
Hydrogels
•
Hydrocolloids
•
Hydrofibre
•
Alginate dressings
•
Foams
•
Odour absorbing dressings
•
Paraffin Tulle
•
Polysaccharide bead dressings
•
Antibacterial agents
In the following formulary, products within each class are described and information is given on
indications and contraindications.
For information regarding the legal category of the products included e.g. ‘prescription only
medicine’, refer to BNF.
26
1.
Non or Low-Adherent Dressings
Three main types are available:
(A) Knitted Viscose Dressings
•
consist of a knitted open structure which allows a free passage of exudate, e.g. NA
Dressing®, Tricotex®.
A knitted viscose dressing coated with silicone is also available e.g. N.A. Ultra®.
(B) Perforated Film Absorbent Dressings
•
consist of a film bonded onto an absorbent layer. The film is perforated allowing passage of
exudate into the absorbent pad, e.g. Release®, Melolin®.
(C) Non-adherent Silicone Dressings
•
is a highly conformable silicone covered mesh, e.g. Mepitel®.
Indications:
•
These are low-adherent sterile dressings which can be used for lightly exuding superficial
wounds.
Contra-indications:
Type B should not be used on wounds which produce copious exudate as the exudate
may become trapped under the dressing leading to maceration and inflammation of the
surrounding skin;
•
should not be used on necrotic or sloughy wounds.
Other Points:
•
sometimes adherence can be a problem. Always moisten the dressing with saline before
removal.
27
2.
Semi-permeable Adhesive Film Dressings:
•
consist of a thin transparent sheet of polyurethane coated with a layer of acrylic adhesive;
•
permeable to water vapour and oxygen but impermeable to micro-organisms.
•
examples include Bioclusive®, Opsite®, Tegaderm®.
Indications:
•
can be used on shallow wounds - in the treatment of superficial pressure sores, donor
sites, post-operative wounds and a variety of minor/superficial injuries;
•
can be used as a protective dressing to prevent skin breakdown due to friction or
continuous exposure to moisture;
•
frequently used as a secondary dressing for other products.
Contra-indications:
•
not for use on deep wounds, infected or heavily exuding wounds.
Other Points:
•
handling this dressing may be difficult. Removal can be traumatic to surrounding skin and
should be carried out carefully - follow manufacturers’ instructions. Watch out for
maceration of surrounding skin.
28
3.
•
Hydrogel Dressings:
consist of insoluble polymers which are hydrophilic and which contain large amounts of
water;
•
can donate liquid to produce a moist environment at the surface of the wound. Can
absorb excess exudate;
•
examples include Comfeel Purilon Gel®, Granugel®, Intrasite Gel®, Nu-gel®, Sterigel®.
Indications:
•
cleansing sloughy and necrotic wounds by rehydrating dead tissue and encouraging
autolytic debridement. Can be used in many different types of wounds including pressure
sores, leg ulcers and surgical wounds;
•
treatment of inflamed painful wounds, e.g. radiotherapy burns;
•
treatment of extravasation injuries.
Contra-indications:
•
not recommended for heavily exuding wounds.
Other Points:
•
a secondary dressing is needed;
•
some hydrogels contain preservatives which can cause allergic reactions in sensitive
individuals;
•
may be used on clinically infected wounds but must be changed daily.
29
4.
•
Hydrocolloid Dressings
consist of gel-forming agents such as carboxymethylcellulose, applied to a flexible foam or
film sheet. The dressings are self-adhesive and absorb liquid in the presence of wound
exudate to form a gel;
•
different hydrocolloid dressings vary in their composition and physical characteristics;
•
examples include Comfeel Plus®, Duoderm extra thin®, Granuflex®, Tegasorb®.
Indications:
•
management of light to moderately exuding wounds including pressure sores, leg ulcers,
minor burns and donor sites;
•
cleansing of sloughy and necrotic wounds by rehydrating dead tissue and encouraging
autolysis.
Contra-indications:
•
not recommended for very heavily exuding wounds;
•
not recommended for wounds which are infected with anaerobic organisms.
Other points:
•
over granulation may occur and may necessitate changing to a more permeable dressing;
•
hydrocolloid dressings are self adhesive and waterproof;
•
dressings can be left in place for up to seven days depending on the amount of wound
exudate;
•
hydrocolloids which contain gelatin may be contraindicated in strict vegans.
30
5.
Hydrofibre Dressing:
•
composed of sodium carboxymethycellulose spun into a fibre;
•
these highly absorbent fibres absorb and retain significant amounts of exudate;
•
as they absorb exudate the dry fibres convert into a gel sheet;
•
hydrofibre is a new class of dressing. At the moment only one Hydrofibre, i.e. Aquacel®
exists.
Indications:
•
management of all types of moderate to highly exudating wounds.
Contraindications:
•
dry dressing will be of limited value in a dry wound.
Other Points:
•
may be used on an infected wound so long as it is changed daily;
•
flat dressing should overlap the surrounding skin by at least 1 cm as the dressing shrinks
slightly as it absorbs exudate;
•
dressing can be left in place for up to seven days depending on level of exudate.
31
6.
•
Alginate Dressings:
consist of sodium and calcium salts of alginic acid in a sterile absorbent fibrous dressing;
NB. Alginic acid is a polymer containing mannuronic and guluronic acid residues.
•
alginates rich in mannuronic acid e.g. Sorbsan® form soft flexible gels whereas those
which are rich in guluronic acid e.g. Kaltostat® form firmer less mobile gels;
•
when in contact with exudate alginates absorb moisture and produce a moist hydrogel;
•
some alginates are licensed haemostats e.g. Kaltostat® and Algosteril®.
Indications:
•
management of highly exudating wounds;
•
filling cavities;
•
bleeding wounds.
Contra-indications:
•
alginate dressings are not suitable for dry wounds.
Other Points:
•
may be used on infected wounds but the dressing must be changed daily;
•
alginates are easily removed from the wound bed by irrigation with saline;
•
narrow sinuses and diabetic foot ulcers must be lightly packed as the dressings may
prevent free drainage;
•
some alginates require a secondary dressing, others do not e.g. Kaltoclude® and Sorbsan
SA® have a secondary adhesive film membrane.
32
7.
•
Polyurethane Foam Dressings
many different types of ‘foam’ dressings are available. Each has special characteristics
which alter the absorbency of the product - see manufacturers’ instructions;
•
all contain a hydrophilic, absorbent polyurethane foam. Some contain an outer waterproof,
bacteria-proof backing e.g. Tielle®;
•
common examples include Lyofoam® range, Allevyn® range, Tielle® and Spyrosorb®.
Indications:
•
low to moderately exudating wounds.
Contra-indications:
•
not suitable for very dry wounds;
•
Spyrosorb® should not be used on clinically infected wounds.
Other Points:
•
dressing may be left in situ for up to seven days;
•
most foam dressings can be used on clinically infected wounds (refer to manufacturers
specific instructions).
33
8.
Odour Absorbing Dressings:
Two main types :
(A) Charcoal Dressings
•
contain activated charcoal which is able to filter and absorb malodorous chemicals which
are liberated from wounds;
•
examples include CliniSorb®, Carbonet®.
Indications:
all malodorous wounds
Contra-indications:
see manufacturers’ instructions
Other Points:
•
the odour absorbing property of activated charcoal is reduced once the charcoal becomes
wet with exudate;
•
some charcoal dressings are primary dressings, others are secondary dressings - read
manufacturers instructions;
•
be aware that some of these ‘primary’ dressings will adhere to the wound bed if the wound
is allowed to dry out;
•
may be used on infected wounds but should be changed on a daily basis.
•
once malodour is noted the dressing should be changed.
(B) Metronidazole Gel
•
contains the antibiotic metronidazole;
•
metronidazole is particularly effective against anaerobic bacteria (anaerobic bacteria are
usually responsible for the production of malodour);
•
examples include Metrotop® 0.8% and Anabact® 0.75%
Indications:
•
malodorous fungating tumours;
For other indications, refer to manufacturer’s instructions.
Contra-indications:
•
•
patients who are hypersensitive to metronidazole;
pregnant or lactating mothers.
Other Points:
•
•
indiscriminate use of metronidazole may lead to the development of resistant microorganisms;
dressing should be changed 1 - 2 times per day.
34
9.
•
Paraffin Tulle Dressings:
consist of yellow or soft white paraffin impregnated into an open weave cotton , or cotton
and viscose fabric;
•
a ‘low loading’ paraffin tulle, e.g. Paratulle® contains 90 - 130 g of paraffin per square
metre of cloth;
•
‘traditional’ paraffin tulle, e.g. Jelonet® contains not less than 175g of paraffin per square
metre of cloth.
Indications:
•
clean superficial wounds.
Contra-indications:
•
heavily exudating wounds.
Other Points:
•
newly formed capillary loops may grow through the open weave of the paraffin tulle fabric.
If this happens the newly formed tissue will be traumatised as the dressing is removed;
irrigating the dressing is of little benefit as paraffin is hydrophobic.
35
10.
Polysaccharide Bead Dressings:
•
consist of highly absorbent hydrophilic beads;
•
some bead dressings contain cadexomer iodine;
•
examples include the Debrisan® range and Iodoflex®.
Indications:
•
sloughy, exudating wounds;
•
iodine bead dressings are recommended for infected, exuding wounds.
Cautions/Contra-indications:
•
debrisan beads can be very difficult to remove, it may be better to avoid same in
narrow/sinus type wounds;
•
•
iodine based products should not be prescribed for patients:
•
with a known sensitivity to iodine;
•
with a history of thyroid disorders;
•
who are pregnant/breast feeding;
•
on lithium or sulphonylureas.
no more than 150g of Iodoflex® should be used per week and treatment duration should
not exceed three months.
Other Points:
•
when iodine is used up , the colour of the dressing changes from brown to white;
•
frequency of dressing change will depend on the level of exudate.
36
11.
Antimicrobial Agents:
For ease of reference these products have been divided into three groups: antibiotics,
antibacterials and antiseptics.
(A) Topical Antibiotics:
Topical antibiotics are not recommended due to:
-
development of resistance;
-
high incidence of sensitivity reactions which delay healing;
-
open weave dressing into which products are impregnated.
Common topical antibiotics used in wound care include neomycin sulphate (Cicatrin®), fusidic
acid (Fucidin Intertulle®) and framycetin (Sofra-Tulle®). These products should be removed
from general use.
(B) Antibacterials:
Examples include metronidazole gel (see section 8) and silver sulphadiazine cream.
Silver Sulphadiazine:
•
a hydrophilic cream containing silver sulphadiazine 1%w/w;
•
silver ions kill bacteria by causing structural changes to the bacterial cell surface;
•
sodium sulphadiazine inhibits folic acid synthesis;
•
inhibits the growth of most pathogenic bacteria in vitro.
Indications:
•
treatment of choice for prevention of Gram-negative sepsis in patients with burns;
•
most Pseudomonas and Staphyloccus Aureus infections.
Contraindications:
•
sensitisation;
•
use with caution in patients who have renal or hepatic problems;
•
should not be used at or near term in pregnancy or on premature or newborn infants as
sulphonamides can cause kernicterus;
•
leucopenia may occur.
Other Points:
•
argyria has been reported with excessive use;
•
do not apply cream to healthy/intact skin as maceration will occur
37
(C) Antiseptics: thought to harm healthy tissues. They should not be used for routine wound
cleansing.
Traditional antiseptic cleansers include cetrimide, chlorhexidine, potassium permanganate,
povidone-iodine, proflavine, antiseptic creams are also available e.g. sudocrem®.
Product
Cetrimide
Benefit
useful in A&E as its
emulsifying and detergent
properties help lift dirt and
grit out of wounds
Chlorhexidine
solution is said to be
effective against a wide
range of Gram positive and
negative organisms, some
viruses and fungi but not
spores.
Potassium
Permanganate
used as an astringent in
concentrations of 1 in
8,000 to 1 in 10,000 to
cleanse and deodorise
eczematous type reactions
Povidone – Iodine
•
low toxicity
Solutions:
•
active against gram
Betadine®, Videne®
positive and gram
Dressings:
negative organisms
Inadine
•
active against spores
and fungi
Problems
• toxic to fibroblasts even at low
concentrations
• causes skin irritation
• pseudomonas may thrive in stored
solutions
• alcoholic solution will cause
permanent damage to new tissue
• sensitivity may occur
• must not come into contact with
mucous membranes and meninges
• efficacy of chlorhexidine
impregnated dressing has been
questioned
• acquired resistance with Proteus
mirabilis and PS aeruginosa has
been reported
• irritant to mucous membranes
• stains the skin and clothing brown
• may be detrimental to wound
healing
• lack of evidence on clinical
effectiveness
• alcoholic solutions must not be used
on broken skin
• sensitivity to iodine based products
• not recommended for prophylaxis or
routine use in chronic wounds
• antibacterial effect is reduced by
contact with pus and exudate
• not recommended for pregnant or
lactating mothers because of risk of
elevated serum iodine levels
• no more than 4 Inadine® dressings
should be applied at any one time
due to absorption of iodine
38
Product
Proflavine
Antiseptic Creams
e.g. Sudocrem®
Benefit
mildly bacteriostatic
against gram positive
bacteria but less
effective against gram
negative bacteria
Problems
• hypersensitivity reactions reported
occasionally
• a water in oil emulsion of proflavine
cream has little or no antibacterial
activity
• studies show that calcium alginate
dressings are superior to proflavine in
the treatment of acute surgical
wounds and abcesses in terms of
dressing comfort and bacterial
clearance.
• some ingredients are irritant to the
skin and mucous membranes
• hypersensitivity reactions have
occurred
• not recommended as less complex
products are available.
39
Appendix 3 - Guideline Development Sub-Group
Mrs Jeanette Collins
Sister, Dermatology Unit,
Craigavon Area Hospital Group Trust
Mrs Dawn Connolly
Research Project Nurse
Craigavon Area Hospital Group Trust
Mrs Jeannie Donnelly
[Chairman]
Tissue Viability Nurse,
Royal Hospitals
Mrs Kay Kane
Nurse Manager,
South & East Belfast Community Trust
Mrs Elizabeth Moore
Senior Dietitian,
Royal Hospitals
Dr Jane Whiteman
Senior Pharmacist,
Greenpark Health Care Trust
Miss Ruth Woodmartin
Chief Dietitian,
Greenpark Health Care Trust
40
Appendix 4 - CREST WOUND MANAGEMENT GROUP
Mrs Mary Waddell
[Chairman]
Director of Nursing
Eastern Health & Social Services Board
Dr John Andrews
Consultant Physician
United Hospitals Trust
Mrs Lilian Bradley
Leg Ulcer Advisor
Ulster Community & Hospitals Trust
Miss Jackie Campbell
Senior Podiatrist
Newry & Mourne Trust
Dr Vanessa Chambers
Pharmacist
DHSS
Mrs Janette Collins
Dermatology Ward Sister
Craigavon Area Hospital Group Trust
Mrs Dawn Connolly
Research Project Nurse
Craigavon Area Hospital Group Trust
Miss Jill Cundell
Chief Podiatrist
Homefirst Community Trust
Mrs Jeannie Donnelly
Tissue Viability Nurse
Royal Hospitals
Dr Brid Farrell
Consultant in Public Health
Southern Health & Social Services Board
Dr Colin Fitzpatrick
Medical Advisor
Eastern Health & Social Services Board
Dr PJ Fox
General Practitioner
Ballymena Health Centre
Mr Paul Gawley
Orthotist, Bullen Health Care
Musgrave Park Hospital
Mrs Dianne Gill
Pharmacy Services Manager
United Hospitals Trust
Mr Stephen Guy
Pharmacist
Royal Hospitals
Professor Randal Hayes
Consultant Physician
Belfast City Hospital Trust
Mrs Marilyn Higgin
Specialist Health Visitor
Belfast City Hospital Trust/
South & East Belfast Community Trust
Dr Carmel Hughes
Lecturer, School of Pharmacy
Queens University, Belfast
Dr Hilary Jenkinson
Consultant Dermatologist
United Hospitals Trust
Mrs Kay Kane
Nurse Manager, Community Nursing
South & East Belfast Community Trust
41
Dr James Kelly
Consultant Physician
Sperrin Lakeland Trust
Mr Bernard Lee
Consultant Vascular Surgeon
Belfast City Hospital Trust
Dr Jill Mairs
Regional Procurement Pharmacist
Eastern Health & Social Services Board
Dr Carolyn Mason
Assistant Director of Nursing
Eastern Health & Social Services Board
Dr Barry Mitchell
General Practitioner
Lodge Health, Coleraine
Ms Andrée McCollum
Director of Pharmaceutical Services
Eastern Health & Social Services Board
Miss Alyson Moore
Chief Dietitian
Royal Hospitals
Mrs Elizabeth Moore
Senior Dietitian
Royal Hospitals
Dr Kenneth Moles
Consultant Physician
Altnagelvin Hospital Trust
Mrs Bronagh Monaghan
Chief Podiatrist
Belfast City Hospital Trust
Mrs Mary O’Hare
Research Pharmacist
Royal Hospitals
Mrs Heather Reid
Project Manager
Eastern Health & Social Services Board
Dr Keith Steele
General Practitioner
Dunluce Health Centre, Belfast
Ms Kathryn Turner
Pharmaceutical Advisor
Eastern Health & Social Services Board
Dr Jane Whiteman
Senior Pharmacist
Greenpark Health Care Trust
Mrs Anne Witherow
Tissue Viability Nurse
Altnagelvin Hospital Trust
Miss Ruth Woodmartin
Chief Dietitian
Greenpark Health Care Trust
CREST REPRESENTATION
Dr Philip McClements
Deputy Chief Medical Officer, DHSS
Convenor of CREST
CREST SECRETARIAT
Miss Angela Lowry
Mrs Isobel Scott
Mr Gary Hannan
42
Glossary of Terms
Abscess
a collection of pus which has localised and is confined within tissues or an organ.
Aerobes
organisms which need oxygen to survive.
Anaerobes
organisms which do not need oxygen to survive.
Angiogenesis
the process by which new blood vessels are formed.
Autolysis
the natural breakdown of devitalised tissue.
Cellulitis
a spreading non-suppurative infection of soft tissue.
Colonisation
the presence and multiplication of micro-organisms at a particular site without
detrimental effect.
Contamination
the presence of micro-organisms (no multiplication).
Contraction
the drawing together of a wound edge when a wound is healing by secondary
intention.
Cytotoxic
deadly to cells.
Debridement
the removal of devitalised tissue and foreign matter from a wound.
Dehiscence
the breakdown of a surgically closed wound.
Exudate
a fluid produced in wounds, made up of serum, leucocytes and wound debris.
Fibroblast
an immature collagen producing cell.
Gangrene
the death of tissue because of anoxia.
Haemostasis
arrest of haemorrhage.
Infection
damage to body tissues by micro-organisms or by poisonous substances released
by the organism.
Lysis
the action of breaking down.
Maceration
a softening or sogginess of the tissue surrounding a wound edge.
Necrosis
the death of previously viable tissue.
Pus
a fluid produced in infections, made up of exudate, bacteria and phagocytes which
have completed their work.
Synthesis
building up.
43
Useful Addresses
European Tissue Repair Society
Secretariat: G Gabbiani, Department of Pathology, University of Geneva,
1 Rue Michel Servet, 1211 Geneva 4, Switzerland. Tel: 41 22 229 377
European Wound Management Association
PO Box 864, London SE1 8TT
Tel: 0171 872 3496
The Leg Ulcer Forum
Centre for Research and Implementation of Clinical Practice
Wolfson Institute of Health Sciences
Thames Valley University
32-38 Uxbridge Road, London W5 2BS
Tel: 01753 534585
The Tissue Viability Society
Glanville Centre, Salisbury District Hospital, Salisbury Wilts SP2 8BJ
Tel: 01722 336262 Ext. 4057
The Venous Forum
Royal Society of Medicine, 1 Wimpole Street, London W1M 8AE
Tel: 0171 290 2900
The Wound Care Society
PO Box 170, Huntingdon PE18 7PL
Tel: 01480 434401
The Wound Management Association of Ireland
11 Beech Park Avenue
Castleknock
Dublin 15
UK Wound Care Journals
Journal of Tissue Viability (Tissue Viability Society) – subscription
Journal of Wound Care (Macmillan Magazines) – subscription
Nursing Journal of the Tissue Viability Society - supplement in Nursing Standard
Wound Care, in Association with the Wound Care Society - supplement in Nursing Times
44