Best Practice in Wound Management.
During my practice in a nursing home, I had the opportunity to observe and carry out the dressing of a venous leg ulcer. Wound expert (2001) suggests treatment should consist of keeping the ulcer infection free, absorbing any excess discharge, maintaining a moist wound environment, supplying compression, promoting activity and managing the patient’s medical problems. The aim of the patient’s care plan was to promote healing.
A Zoologist named George Winter (1927 –1981) studied wound healing in the domestic pig and later became interested in wound dressings. Winter observed that wounds covered with an occlusive dressing healed faster than those left to dry out (Winter, 1962, cited in Bale and Jones, 1997). It was from Winter’s work that the principles of moist wound healing used today, was developed.
The adoption of various techniques throughout time to cleanse wounds and promote healing have included topical treatments such as the use of boiling oil, honey, diluted wine, and seawater.
In clinical practice, the principles of wound cleansing have often been misunderstood, resulting in the unsuitable and ritualistic use of cleansing solutions (Morison et al, 1999). Nurses sometimes do not question as to why they are cleansing the wound (Bale and Jones, 1997).
Before cleansing of the wound is undertaken, the nurse should take into account that natural wound healing involves the bactericidal activity and growth factors present in the wound exudate (Hohn et al, 1977 and Chen et al, 1992, cited in Bale and Jones, 1997). Removal of wound exudate through inappropriate cleansing and drying may only reduce these vital components for the healing tissue and conflicts with the principles of moist wound healing. Wound cleansing is also done to remove bacteria (Thomlinson, 1987, cited in Bale and Jones, 1997), and this is not possible or desirable. Wounds need only be cleansed to remove surplus exudate, slough, debris or necrotic tissue and remnants of dressing material, in order to promote patient comfort (Bale and Jones, 1997).
The patient’s original care plan was to renew the dressing every three days, administer antibiotics as prescribed, monitor wound for improvement, encourage the patient to drink one Entera (200mls) a day to boost protein intake and check full blood count for any sign of anaemia and discuss with General Practitioner.
The dressing consisted of a hydrogel called ‘nugel’, used to promote a moist wound environment (best practice according to Winter, 1962, cited in Bale and Jones, 1997 and Wound Expert, 2001) and to debride and deslough the wound used with ‘Tielle’, a hydropolymer adhesive with a polyurethane backing. The design of polyurethane dressings ensures absorption of large amounts of exudate. They do not stick to the wound and do not break down in the wound bed. Once enough exudate has been absorbed, these dressings provide a moist wound environment, however, it is not advised to use this dressing on low exudating wounds as they could cause scab formation. These dressings also protect against physical trauma due to the padding (Casey, 2000).
The use of this dressing regime was showing little improvement after three months. The majority of the wound surface was covered in slough, a small amount of the wound was necrotic, it was quite odourous, and it caused the patient quite a lot of pain.
Reassessment of the wound care plan occurred due to the lack of improvement. The decision was to continue with the ‘nugel’ (applied directly in to the wound bed), to continue keeping the wound moist. Then a ‘viscopaste’ bandage is applied to give a soothing effect, which is placed under ‘soft ban’. This is a bandage made of cotton wool and this provides padding to prevent further physical trauma. Then a crLpe bandage is placed over the ‘soft ban’. The crLpe bandage provides support and a low level of pressure to prevent swelling (applying compression as advised by Wound Expert, 2001). Cleansing of the wound only occurs if urine or faces have contaminated it, or if there is excess exudate, slough, debris, or necrotic tissue and remnants of the dressing material (as advocated by Bale and Jones, 1997). The overall effect is the wound is moist and occluded, which is based on best evidence. Before the wound is redressed, painkillers are administered to the patient, to prevent unnecessary pain and promote her comfort.