Approaches to Complex Wound Care Tralee Lashley Medicines

Approaches to Complex Wound Care Tralee Lashley Medicines Management Appliance Nurse Ipswich east and west Suffolk clinical commissioning group

The skin… Facts… • Largest organ • The body’s main protection • In order to function it needs: • Blood Supply • Oxygen Supply • Nutrients

If you can understand the levels of wound healing you can understand which dressing to put on…

Factors affecting skin integrity Biological • Natural Aging – Collagen Loss • Nutrition • Hemostasis • Co-morbidities • Mobility • Medications Social • Environment • Skin Condition • Skin Care Regime • Clothing • Culture • Financial • Language Barrier Psychological • Mental Health Depression Anxiety • Personal Neglect • Understanding

Assessing Types of wounds consider: before – during – after Acute Surgical Chronic Skin tear / Laceration Primary Leg ulcer – arterial/venous Infection secondary Pressure / moisture / Diabetic ulcers burn Autoimmune / melanoma

Do you see like me? What do you see. . ?

Wound bed preparation - Time! cleanse – debride – dress

Tissue viable wound base • NECROTIC TISSUE - ESCHAR/SLOUGH - AUTOLYTIC/SHARP • GRANULATION • EPITHELISATION • BONE/TENDON

INFECTION / INFLAMMATION • REDUCE • SWAB Consider frequency change, dressing type, environmental impact and internal factors – diabetes/immunosuppressed. • DOCUMENT/PHOTO • ANTIMICROBIAL • PROTEASE INHIBITOR • COMMUNICATE • REMOVE COMPRESSION **SILVER DRESSINGS MAX 2 WEEKS**

The impact of Biofilm formation Over 90% of chronic wounds contain biofilms with an active mixed bacterial & Fungal colonisation living within. Which Wounds are Affected? Inflammatory stage

What is a biofilm – how does it act? • Bactria – Staph, Strep, E-coli, pseudo • Rapid attachment and colonisation • Static inflammatory stage (bodies natural resistance – Proteinases • Chronic wound status

Identifying a biofilm What to look for: • Static or deteriorating wound/ulcer for over 4 weeks • Inflammation • Increased exudate levels • Gel like/shiny appearance – can lift off when mature

Assess – plan – implement evaluate

Physical debridement http: //lohmann-rauscher. co. uk/woundcare/Debrisoft

moisture • SKIN INTEGRITY • LOW – HIGH ABSORBENCY • EXCORIATION • MACERATION • APPROPRIATE SECONDARY DRESSING/COMPRESSION • CONCORDANCE • FREQUENCY • NPWT - PICO Assess level of exudate when considering absorbency and type of dressing required.

Pico negative pressure wound therapy

EDGES • MIGRATION • DEBRIDE • PROTECT • CONTAIN EXUDATE • TUNNELLING • SKIN GRAFT Always consider the peri-wound skin and the use of a skin sealant when assessing how to dress then wound.

Acute to chronic three causes to delayed healing: underlying cause, new factor, treatment issue

Arterial deficiency • DIABETES • ISCHAEMIC LIMB • NEUROPATHY • HIGH BACTERIAL LOAD • DIABETES – GLUCOSE • PRESSURE • CAN RAPIDLY DETERIORATE

Assess and plan Considerations. . • Colour/warmth/sensation/move ment • Pain – claudication • Glucose stability • Time observations • Below 0. 8 apbi implement. . • doppler • Off load pressure • Appropriate footwear • Maintain skin integrity • Appropriate dressing choice • Communicate • **Do not compress** onward referral to vascular

Skin lesions • MOISTURE • PRESSURE • PEMPHIGOID • BENIGN / MALIGNANT NHS. STOPTHEPRESSURE. CO. UK

Assess and plan Considerations. . Moisture: • Skin care regime/inco aids Pressure: • Sskin bundle approach Autoimmune: • Skin protocol Malignancy: • Emergency plan in place implement. . • Pressure ulcer assessment - risk • Barrier/emollient review • communicate • Onward referral to dermatology • Hospice referral

Venous insufficiency • NON-HEALING BELOW KNEE WOUND AFTER 2 WEEKS • BECOMES CHRONIC IF REMAINED UNHEALED AFTER 4 WEEKS • 26 -69% REOCCURRENCE IN 12 MONTHS • 60 -85% VENOUS ULCERS • HTTPS: //WWW. ENGLAND. NHS. UK/LEADIN GCHANGE/LCAV-INACTION/VIDEOS/#RIGHTCARE • LEGS MATTER. ORG

Assess and plan Considerations. . • Consider leg ulcer referral/assessment at 2 weeks • If no signs of arterial disease – can apply class 1 compression hosiery • Doppler should be performed: 3 -6 monthly with active ulcer under compression. 6 -12 monthly with compression hosiery post healed ulcer • Do not compress if infection/dvt present implement. . • Onward referral to leg ulcer clinic • Perform full leg ulcer assessment • Follow leg ulcer pathway • Doppler & compress above 0. 8 abpi • Onward referral to Lymphodema clinic

Treatment – apie! • Assess the problem • Forward planning - Care plan – 2 weekly reviews Implement • Correct dressing regime 2 week quantities / skin care • address the cause… internal/external • Medication / diet / haematology status / pressure / skin care • Treat – Compression / pressure relief / antimicrobial / steroid / emollient evaluate • Onward referral – gp/dermatology/vascular

Dressings – 2 week quantity Aim for a balanced moist environment! What do you want to achieve -What's on the formulary… Gels Alginates Hydro fibres Antimicrobials Low Absorbents – superabsorbent Ordering system - Think quantities / size / frequency / comfort Order form - Exception reporting form

Documentation • Plan ahead – 2 weekly care plans • Photography / measurements • Time • Record smart! • Assessments – waterlow / must / wound • What action you will take. . • Incident forms

References Time framework http: //www. woundsinternational. com/media/issues/122/files/content_86. pdf Biofilms Attinger, Christopher, and Randy Wolcott. “Clinically Addressing Biofilm in Chronic Wounds. ” Advances in Wound Care 1. 3 (2012): 127– 132. PMC. Web. 24 June 2018 Phillips PL, Wolcott RD, Fletcher J, Schultz GS. Biofilms Made Easy. Wounds International 2010; 1(3): Available from http: //www. woundsinternational. com Wounds UK 2017 Best Practice Statement: Making day-to-day management of biofilm simple http: //lohmann-rauscher. co. uk/downloads/clinical-evidence/BPS%20 Biofilm%20 WUK%2020171495020504. pdf Wounds uk 2017 Breaking the cycle of chronic wound biofilm – the importance of wound bed preparation http: //lohmann-rauscher. co. uk/downloads/clinical-evidence/Vicki-Brookes-FINAL. pdf Wound and skin care formularies • https: //www. westsuffolkccg. nhs. uk/clinical-area/prescribing-and-medicines-management/dressings-and-stoma/ • http: //www. ipswichandeastsuffolkccg. nhs. uk/GPpracticememberarea/Clinicalarea/Medicinesmanagement/CCGFormularies/Woundcare andstoma. aspx