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Wounds

Tissue Viability

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Wound Assessment TIMES Wound Management Formulary Exudate Debridment Infection, biofilm and wound hygiene Haematoma Malignant Wounds Negative Pressure Wound Therapy Larvae Therapy Skin Tears Thermal Injury Diabetic foot wounds Moisture Associated skin damage Cellulitis Education

Wound Assessment

Assessment is the foundation of all clinical practice. Without a robust holistic assessment, it is difficult to achieve a clear management plan. This section provides information and tools to aid clinicians in clinical practice to support them to develop clear and achievable management plans.

Key Principles of using a Wound Assessment Tool

All wounds should initially be assessed to obtain base line data. This will include some form of measurement technique. If it is necessary to photograph a wound, obtain and record the appropriate consent.

When an individual has more than one wound, each wound should be assessed separately, and each wound should have a separate documented plan of care. It is good practice to allocate a numbering system in such instances as this will ensure that communication/documentation corresponds with the correct wound.

Consider factors which may delay wound healing.

Be aware of any known allergies and sensitivities that your patient/client has or subsequently develops. Such information should always be documented.

If infection is suspected take appropriate action and seek advice from either the Antimicrobial Pharmacist, Microbiologist or Infection Control Nurse.

The Scottish Wound Assessment and Action Guide along with the Wound Management Formulary can be used to aid your assessment of wounds and to help you to consider various treatment options for managing a wound.

The following guidelines are available to assist clinicians:

TIMES

The TIMES Framework is a structured, holistic approach to wound bed assessment and preparation. It considers:

  • T- Tissue: non-viable or deficient
  • I- Infection, inflammation or biofilm
  • M- Moisture imbalance
  • E- Edges of the wound: non-advancing, undermining
  • S- Surrounding skin

This framework should be used in addition to obtaining a complete and in-depth medical history and discussion with the patient (and relatives/NOK if appropriate). Regular assessment and review of wound surface area, depth and undermining are also crucial when formulating a management plan. Wound photography is an invaluable tool to monitor progress or deterioration in the wound.

Please find link to TIMES Model quick guide for further information.

Wounds UK, TIMES Model of Wound Bed Preparation, Quick Guide: wounds-uk.com

Wound Management Formulary

The Wound Management Formulary has been developed to provide clinicians with up to date, evidence-based guidance on wound assessment and management. The formulary provides a range of wound types, descriptions, treatment aims and advice on the most appropriate dressings to use, along with product information.

The formulary should be used to promote cost-effective prescribing of wound management products in NHS Forth Valley.

Product selection should be based upon a comprehensive and holistic assessment of the patient and their wound. Once the wound aetiology and the intended treatment outcome have been confirmed, an appropriate product can be selected. If a patients wound fails to progress as expected, then a referral to tissue viability should be considered.

Exudate

Exudate consists of fluid that has leaked out of blood vessels and closely resembles blood plasma. Exudate production forms part of the normal wound healing process and can be beneficial to healing, by:

  • Maintaining a moist wound healing environment
  • Carrying tissue-repairing cells and essential nutrients
  • Enabling autolytic debridement of the wound bed (natural removal of dead or devitalised tissue).

However, when in the wrong amount, in the wrong place, or of the wrong composition, exudate can delay healing and cause complications.

It is important to remember that exudate can be a good indicator of the state of a wound. Wound exudate should be monitored – in terms of several factors such as exudate amount, colour, viscosity (thickness) and odour – and any changes should trigger action. (Wounds UK, 2021)

Reference: Wounds UK (2021) Exudate Explained. Available to download from: wounds-uk.com

Debridement

Debridement is a critical component of best practice in wound management due to its significant impact on the healing process. It is vital that all wounds are debrided, as appropriate, unless contraindicated. This is particularly important for hard-to-heal wounds. The rationale for debridement lies in the removal of devitalised tissue, microbial and non-microbial components and biofilm from wounds. Devitalised tissue, such as necrotic tissue or slough, creates a barrier to wound healing and will reduce the antimicrobial efficacy of topical antiseptics. It hinders the migration of healthy cells and the formation of new blood vessels, impeding the wound’s ability to progress through the phases of healing. By removing devitalised tissue, debridement can reduce inflammatory processes while promoting the growth of healthy granulation tissue, which facilitates wound closure.  (Journal of wound care, 2024)

When is referral needed?
If any doubt exists as to the diagnosis or treatment pathway, referral for assessment and advice from the specialist tissue viability team should occur prior to debridement.

Reference: Journal of wound care (2024) Best Practice for wound debridement. International consensus document.

Please follow the links below for further information and guidance of debridement.

Infection, biofilm and wound hygiene

Please follow the links below for more information on wound infection, biofilms and wound hygiene

Haematoma

A haematoma is a collection of blood which is located outside the blood vessels. They can be found under the skin within a soft tissue and display as a purple-coloured bruise. Sometimes, haematomas may not show up as a bruise and can be deeply located. Deeply located haematomas can be felt as a spongey or rubbery lump. Haematomas are usually caused by an injury to blood vessel walls (such as veins or arteries) which allow the blood to escape and collect to form a lump. These usually occur following blunt force injury such as a fall. However, sometimes haematomas can develop without trauma, so-called spontaneous haematomas. Sometimes haematomas are associated with pain / discomfort, but sometimes they cause no symptoms at all (asymptomatic) and simply present as a lump. Asymptomatic haematomas can resolve themselves with self-care such as resting, applying an ice pack to the area, compression and elevation. However, if the haematoma is symptomatic, then surgical drainage may be necessary to relieve pressure.

Please see FV Haematoma Pathway for mor information:

Malignant Wounds

It is estimated that there are currently more than 3 million people living with cancer in the UK, a figure that is predicted to rise to 3.5 million by 2025, 4 million by 2030 and 5.3 million by 2040 (Macmillan Cancer Support, 2024). Diagnosis rates are thought to have risen by 12% since the early 1990s (Cancer Research UK, 2024). Patients with cancer often suffer from lesions or wounds, which may be chronic, and may be caused by either the disease itself or because of cancer treatment. These wounds present unique challenges for the patient, their family and the multidisciplinary team treating them (Pramod and Rice, 2023).

Reference: Ousey K, Pramod S, Clark T et al (2024) Malignant wounds: Management in practice. London: Wounds UK.

Please see the below guidelines and best practice guidelines for the management of Malignant wounds:

Negative Pressure Wound Therapy

Negative Pressure Wound Therapy (NPWT) is the use of controlled suction to promote healing. ‘VAC’ is often used generically to denote NPWT and means ‘Vacuum assisted closure.’ NPWT is helpful for promoting healing in circumstances where tissue perfusion is compromised, and in some cases where excessive exudate cannot be controlled by other means.

NPWT involves applying a suction force (i.e. vacuum) across a sealed wound, using a reticulated foam interface or specified types of gauze.  Both the suction effect and the mechanical forces generated at the interface with the wound lead to a variety of changes in the wound, positively influencing the healing process.

Use of Topical Negative Pressure (TNP) therapy should only be used in conjunction with Tissue Viability Service or on the recommendation of medical staff.  Costs can be expensive but vary between manufacturers. TNP should only be used by nurses competent in its use.

Please follow the links below for further information and guidance.

Larvae Therapy

Larval Therapy uses the larvae of the greenbottle fly species Lucilia sericata to remove non-viable tissue and bacteria from non-healing, slow to heal or infected wounds. The larvae, which are applied to the wound in a contained dressing, produce proteolytic enzymes that break down any necrotic tissue, slough or biofilm present in the wound.

Skin Tears

Skin tears are acute, traumatic wounds caused by the mechanical forces of shear, friction or trauma, including the removal of adhesives, resulting in a partial or complete separation of the outer skin layers from the inner tissue (ISTAP, 2018). They can occur anywhere on the body but are most seen on the hands, arms and lower legs. 70–80% of skin tears occur on hands or arms. Skin tears can be painful and distressing for the patient.

It is estimated that prevalence of skin tears may be underreported and in fact be greater than pressure ulcers. The ageing population means that incidence of skin tears is increasing (elderly patients have fragile skin and are at increased risk)

Skin must be protected in at-risk patients and skin tears managed to avoid further damage and prevent progression from an acute to a more chronic, potentially hard to heal wound.

Thermal Injury

Burns may be thermal, electrical or chemical and may be associated with other injuries. The majority of cases will present to A&E and be referred directly to the burns unit at St John’s hospital. Some however may present at their General Practice where most minor burns can be managed, assuming that sufficient burns care experience is available.

Burns that do require formal assessment, with or without admission to the burns unit, include all paediatric burns over 5% total body surface area (TBSA) or adults burns over 10%. All chemical burns and significant electrical burns should also be referred. Burn wounds in certain areas of the body are prone to infection and / or poor functional or cosmetic outcome if poorly managed and should therefore be assessed in the burns unit. These areas include the head, hands, perineum and feet. All but the smallest of full thickness burns should be referred for immediate assessment regarding the need for debridement and grafting.

All chemical burns should be referred urgently especially hydrofluoric acid burns.

In children and vulnerable adults, any burn where the circumstances are not clear or there is a suspicion of neglect or abuse should be referred and admitted for investigation.

What to refer:

  1. Acute thermal burns- urgent referral to on call plastic surgery team (SpR) via St John’s Hospital switchboard.
  2. Chemical burns – as above.
  3. Electrical burns – as above.
  4. Chronic burn wounds that are slow to heal – urgent referral.
  5. Burn scars that are symptomatic or affecting function or aesthetics.

What not to refer:

  1. Minor superficial or superficial partial thickness burns wounds where sufficient experience exists in the general practice.

How to refer:

For emergency burn referrals contact the on-call plastic surgeon at St John’s Hospital or the Royal Hospital for Sick Children.

Please see FV Thermal Injury Guidance for full details and contact details.

Burns First Aid:

Diabetic foot wounds

Diabetic foot ulcers should be treated by a multi-disciplinary foot care team as this can reduce amputation rates. Refer urgently to the hospital foot service (Urgent SCI Gateway referral to ‘Diabetic foot Pathway’.

This referral pathway is for specialist review of patients with diabetes who have a foot problem. It is primarily for patient with diabetic foot ulcers. If the ulcer is above the ankle please do not use this pathway.

If the foot appears to have acute ischaemia (pale, pulseless, cold, painful or paraesthetic), this is an acute vascular emergency and should be referred for inpatient assessment through the Vascular Oncall Team based at the Queen Elizabeth University Hospital (0141 201 1100, ask for Vascular Registrar on call).
If the foot is globally swollen, hot and red (often with pain in a previously painless foot), this also requires acute admission. Please refer to urgent inpatient assessment through the Medical Oncall Team (GP Referral line 01324 566123).

If the patient has an ulcer and is systemically unwell then consider acute admission for urgent review. Please refer for inpatient assessment through the Vascular Oncall Team based at the Queen Elizabeth University Hospital (0141 201 1100, ask for Vascular Registrar on call.

Please see below for more information:

Moisture Associated skin damage

Moisture Associated Skin Damage (MASD) is a complex and increasingly commonly recognised condition. Overexposure of the skin to bodily fluids can compromise its integrity and barrier function, making it more permeable and susceptible to damage (Gray et al, 2001; Woo et al, 2017). Individuals with MASD experience persistent symptoms that affect quality of life, including pain, burning and pruritis (Gray et al, 2011; Woo et al, 2017). MASD is classified as an irritant-contact dermatitis; see Table 1 (WHO, 2020). Common irritants can include urine, stool, perspiration, saliva, intestinal liquids from stomas and exudate from wounds. As such, MASD is an umbrella term and forms of MASD may be subdivided into four types:

  • Incontinence associated Skin damage
  • Peristomal (relating to colostomy, ileostomy, ileal conduit, urostomy, suprapubic catheter or tracheostomy.
  • Intertriginous Skin damage (intertrigo: where two skin areas touch or rub together
  • Peri wound skin damage

Please see resources related to Moisture Associated skin damage:

Barrier Product Application Guides

Cellulitis

Cellulitis is an infection of the deeper layers of skin and the underlying tissue. It can be serious if not treated promptly.

The infection develops suddenly and can spread through the body quickly. Severe infections can spread deep into the body and can be life threatening.

Most cases are successfully treated with antibiotics at home, although sometimes it needs to be treated in hospital.

For more information, please follow the links below:

Resources for HCPs on the treatment of cellulitis in NHS Forth Valley:

Education

NPWT can be arranged for Health Care Professionals through company representatives: please contact them to arrange VAC training for your area.

VAC

PICO

In an Emergency call 999 for health advice and reassurance call NHS24 on 111.
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