Module Code: Wound Care Essentials
Section 1. Search strategy
Describe the strategy you used to retrieve the right resources to help you write your assignment. You must include the key words you used, the sources of your literature, the years searched and the type of literature you were looking for.
Harvard (2007) stated that a well-structured literature search is an effective way to get reliable evidence on the topic being searched. The intended sources that will be use are healthcare databases, systematic review libraries and specialist organisations.
In searching, keywords were created using Boolean logics AND, OR, NOT and phrases with quotations. The following are the list of keywords:
“Foot ulcer*” – CINAHL- retrieved – 1842 records
-COCHRANE lib – retrieved – 3 records
– PubMed – retrieved- 1770 records
“diabetic foot ulcer*” – CINAHL- retrieved – 844 records
COCHRANE – 2 records Cochrane reviews
PubMed – 46 records
“diabetes mellitus*” – CINAHL – 54940 records
PubMed – 32863 records
COCHRANE – 0 record
“diabetic neuropathy*” – CINAHL – 1003 records
PubMed – 802 records
COCHRANE – 0
IJDDC – 76 records
“assessment tool*” AND “diabetic foot ulcer*” – CINAHL – 24 results
PubMed – 2 results
COCHRANE – 0
International Journal of Diabetes in Developing Countries – 0 manage* AND “diabetic foot ulcer*” – CINAHL – 216 results
PubMed – 24 results
COCHRANE – 0
IJJDC – 0
manage* OR intervention* AND “diabetic foot ulcer*” – CINAHL – 224573 results
PubMed – 24 results
COCHRANE – 1131 results
IJJDC – 0
prevalence AND “diabetic foot ulcer*”- CINAHL – 64 results
PubMed – 9 records
COCHRANE – 0 record
IJJDC – 11 records
treatment* OR intervention* AND “diabetic foot ulcer*” – CINAHL – 316806
PubMed – 33 records
COCHRANE – 39911 records
IJDDC – 5 records
cost* AND “diabetic foot ulcer*” – CINAHL – 97 records
PubMed – 4 records
COCHRANE – 0
“evidence base*” AND “diabetic foot ulcer*” – CINAHL – 73 records
PubMed – 1 record
COCHRANE – 0
“care guideline*” AND “diabetic foot ulcer*” – CINAHL- 3 records
COCHRANE – 0
PubMed – 0
Eligible studies were identified by searching the Cochrane Library (November 8, 2010), Cochrane Wound group (2000 to November 1st week 2010), PubMed (2000 to November 1st week 2010), EBSCO CINAHL plus (2000 to November 2nd week 2010). Furthermore, reliable websites and links were used also such as www.intute.ac.uk, www.boperis.ac.uk, www.dh.gov.uk, www.library.nhs.uk, Wound Care Alliance, World Wide Wounds Electronic Journal, the Tissue Viability Society, and the International Journal of Diabetes in Developing Countries or www.ijddc.com.
Peer reviewed and published journals were used which are reliable and reviewed by other authors. There was no restriction on language of publications. All publications were no more than 10 years old.
Section 2. Wound aetiology
Select a common wound type (e.g. diabetic foot ulceration, pressure ulcer, leg ulcer, fungating wound, dehisced surgical wound), which you have cared for in your role as a qualified nurse. It may help to reflect on a patient you have cared for with this type of wound. Using contemporary literature to support your work, discuss:
What your chosen wound type is
How this type of wound develops (including contributory factors)
How this type of wound is recognised (common characteristics)
Who it affects
Prevalence in UK and home country
Approximate word count: 800
Your answer here:
One of the common types of wounds is diabetic foot ulcer. International Working Group on the Diabetic Foot (2010) defined diabetic foot ulcer in their research system as a full-thickness penetration of the dermis of the foot in a person with diabetes. According to Jeffocoate and Harding (2003) diabetic foot ulceration is a common complication of diabetes and it is disabling and frequently leads to leg amputation. It usually occurs as a result of neuropathic, vascular changes of a diabetic foot, foot deformities, plantar callus and smoking (NICE, 2010).
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Even though the cause of diabetic peripheral neuropathy is uncertain, it is known that the nerve function of a diabetic patient degenerates in response to metabolic changes, pressure and ischaemia (Alexander, Fawcett & Runciman, 2000). On the other hand, the presence of high sugar level in the blood such as sorbitol can cause osmotic swelling and subsequent damage to the nerve cell, increase the risk of vascular disease and can also give rise to neuropathy and increase the risk of infection (Falanga, 2005; Watkins, 2000). Pendsey (2010) stated that the neuropathy in diabetic patients is manifested in the motor, autonomic and sensory components of the nervous system.
In motor neuropathy, the innervations of the intrinsic foot muscles are damaged that leads to an imbalance between flexion and extension of the diabetic foot. It also affects the muscles required for normal foot movement altering the distribution of forces during walking. This creates anatomic foot deformities that make abnormal bony prominences and pressure points and causing skin reactive callus at the sites of abnormal load. It then gradually causes skin breakdown and ulceration (Pendsey, 2003).
In sensory neuropathy, it affects the peripheral sensation, subsequently loss of sensation that makes the patient unable to feel trauma to their lower extremities. Patient will also feel heaviness, insensitivity to heat, cold and pressure. It is estimated that 45-60% of all diabetic ulcerations are due sensory neuropathy (Frykberg, Zgonis, Armstrong et al., 2006). According to Alexander et al (2000) when mechanical forces continue to be applied on the affected area, it leads to inflammation, abscess formation and, eventually, ulceration. This is also the reason many wounds go unnoticed and get worse progressively since the affected area is continuously subjected to repetitive pressure and shear forces from ambulation and weight bearing without noticing it.
In autonomic neuropathy the peripheral nerve function is affected, which controls the distribution of blood through arteriolar vessels. One of the signs and symptoms is decreased perspiration in the lower extremities which make the skin becomes dry and increasingly prone to fissures (Alexander et al. 2000).
Moreover, poor blood supply to the foot or ischaemia is another significant risk factor for diabetic foot ulceration, which according to Frykberg et al. (2006) it often occurs in combination with loss of sensation and the researchers also said that an estimated 45% of diabetic ulcers are due to ischaemia and neuropathy.
Diabetic foot ulcer is commonly found in areas where the abnormal pressure distribution arises from disordered foot architecture. It is usually located on hallux, first metatarsal and fifth metatarsal heads, and under the heel (Grey, Enoch & Harding, 2006). The precipitating causes of foot ulceration and infection are friction in ill fitting or new shoes, untreated or self treated callus, foot injuries, burns, corn plaster, nail infections and heel friction in patients confined to bed (Watkins, 2003).
According to International Working Group on the Diabetic Foot (IWGDF) diabetes is global epidemic with devastating human, social and economic consequences. The disease claims many lives and places a severe burden on healthcare systems and economies everywhere, with the heaviest burden falling on low and middle income countries such as Philippines. It is estimated that 250 million people worldwide have diabetes, equating roughly 6% of the adult population with the age group 20-79 years. The number is expected to reach about 380 million by 2025, representing 7.1% of the adult population. This is due to the current lifestyles which is lack of exercise and not having a proper diet.
A survey conducted by Morgan, Currie, Smithers, Butler and Peters (2000) revealed that foot problems occur in nearly 20% of diabetic patients. Two-thirds of lower extremity amputations are performed in diabetic patients alone, and a majority of these are preceded by a foot ulcer. Nwabudike and Ionescu-Tirgoviste (2008) set out a study to identify the clinical parameters associated with foot ulceration in diabetic patients. The study suggested that older age diabetic patient poses the risk of developing foot ulcer because of decreased ability to self care, including personal daily foot examinations. This is also a result of poor vision and impaired mobility which also predispose patients to trauma. The study also shows that most patients with ulcer were type 2 diabetic patients and this correlates with the age of the patient group. The average duration of diabetes the patients have was of 11.5 years. It is twice more common in males may be due to the active nature of the activities that men are engaged compared to women, increasing the likelihood they may suffer from trauma. In Nwabudike (2008) research, it also showed that lack of awareness of the disease process and personal care increasing the likelihood that the ulcers may degenerate and leads to gangrene and amputation.
Section 3. Wound Assessment
Identify features of your chosen wound aetiology (wound type) that are commonly identified during the assessment process. Now select one of these features and critically discuss different ways of assessing this problem. You must link your discussion to the contemporary wound care literature.
Here is a list of wound features commonly identified during assessment:
Wound bed tissue e.g. slough, necrotic tissue
Your discussion must make clear which aspect of wound assessment you have chosen and include an exploration of the different options available for measuring, describing and documenting it.
Approximate word count: 500
Your answer here:
Accurate wound assessment is essential for the appropriate and realistic planning of goals and interventions for patients with wounds (Collier, 2003).
Diabetic foot wound has two classifications, the neuropathic foot ulcer and neuroischemic foot ulcer. Differentiating between these entities is essential because their complications are different and they require different therapeutic strategies (Pendsey, 2007). Neuropathic wound has no sensation and foot is warm to touch with intact pulses. The ulcerations are usually located on tips of toes and plantar surfaces under metatarsal heads. It also shows oedema, local necrosis and sepsis. On the other hand, ischaemic ulcer is painful upon rest and usually diminished sensation over period of time. Moreover, the foot is not warm to touch and has no pulse. The ulcerations are often located on margins of foot especially on the medial surface of the first metatarsophalangeal joint and over the lateral aspect of the fifth metatarsophalangeal joint. They also develop on the tips of the toes and heels. Signs of sepsis, necrosis or gangrene are also noted.
An established clinical tool TIME which is adapted from Watret (2005) is being used for assessing the wound bed. The acronym stands for tissue, infection, moisture balance and advancing or undermining epithelium.
Necrotic tissue, slough and eschar are non-viable tissues that can be found on diabetic ulcer that needs to be removed through debridement while the presence of epithelial tissue and granulation tissue in the wound suggests healing. The unhealthy granulation tissue often dark in colour and frequently bleeds on contact are signs of infection. Moisture in the wound bed needs to be assessed too. Moist is known to stimulate healing by promoting granulation and encouraging debridement, nevertheless, moisture balance should be maintained to prevent the wound from becoming too dry and too moist which could delay wound healing. In addition the wound edges and environment will be assessed for migrating epithelial cells which is a good sign of healing or maceration which suggest poor care.
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Infection is a major factor that affects the time healing of all wounds. Jeffcoate and Harding (2003) said that infection can cause substantial deterioration and delay wound healing. Infection is an invasion and growth of pathogenic microorganisms in the body. Diabetic foot infection is divided in three categories: superficial and local, soft tissue and spreading or cellulitis, and osteomyelitis (Jeffcoate & Harding, 2003). The classic signs of infection are: heat, redness, swelling and pain. Other signs such as increase exudates, delayed healing, odour, and abnormal granulating tissue are also suggesting infection (Grey et al, 2006).
Cutting et al (2005) and Edmonds (2005) used a checklist for identifying infection in diabetic foot ulcers. In the checklist, there are four areas; under it are the signs and a box opposite to it to check if certain signs are present.
Clinical signs of infection:
Cellulitis- acute inflammation of tissue
crepitus in the joint
increase in exudates volume
probes to bone.
Systematic signs of infection:
Probe to bone test:
no bone involvement
wound swab required
wound biopsy required.
Furthermore, the wound infection continuum of Gary, White, Cooper and Kingsley’s (2005; 2010) is also use to measure the extinct of infection. It is also a useful adjunct in identification of treatment objectives. The scoring is from 3-0; score of 3 means spreasing infection and 0 is colonised. Moreover, Gray et al (2010) also have the wound exudates continuum; it identifies presence of infection since excessive exudates suggest infections.
Section 4. Wound Management
Using the same wound feature that you identified in Section 3; critically discuss the different ways there are of managing this problem.
Your discussion must include:
The different types of wound care dressings, products and treatments that could be used to manage this problem
Other appropriate/related aspects of patient care such as nutrition and positioning
How the patient experience can be improved
Now select one of your identified dressings and answer the questions in the product information table below:
Product information table
Name of dressing (the company name)
AQUACEL Ag Hydrofiber (Convatec, Hull, UK)
Category of dressing (the generic name)
Hydrofiber Wound Dressing with Ionic Silver
Indications for use
Use on acute and chorin wounds, including burns, surgical wounds, diabetic foot ulcers, pressure ulcers, and leg ulcers
Aquacel Ag Hydrofiber should not be used on individuals who are sensitive to or who have had an allergic reaction to the dressing and its components such as Na Carboymethylcellolose and silver. It’s not compatible with oil-based products, such as petrolatum jelly.
2″x 2″, 4″x4.7″, 6″x6″, 8″x12″, 75″x18″, 39″x18″
Adhesive or non-adhesive?
Secondary dressing needed required
Moisture retentive dressing such as DuoDERM Extra Thin or Versiva
Approximate word count: 1000
Your answer here:
Management of diabetic foot ulcers are removal of callus, eradication of infection, and reduction of weight bearing forces, often requiring bed rest with the foot raised (Alexander, Fawcett & Runciman, 2000).
A large proportion of patients with diabetic foot ulceration will develop infection, including osteomyelitis or bone infection and gangrene (O’Meara et al, 2006; McIntosh, 2007). An infected diabetic ulcer needs immediate medical attention. Jude (2007) stated that infection is a major factor that delays wound healing of a diabetic ulcer. It may be necessary to undertake surgical debridement and drainage of pus. Then a wound swab will be taken from the floor of the ulcer after the callus has been removed. A culture of the excised tissue may provide more accurate information (Watkins, 2003). This will help identify the infective microorganisms and the appropriate antibiotic therapy to be given (Alexander et al., 2000).
According to Watkins (2003) patients with superficial ulcer infection can be treated with oral antibiotics such as amoxicillin, flucloxacillin and metronidazole. Since the most likely organisms to infect superficial ulcer are staphylococci, streptococci, and sometimes anaerobes. For patients with deep infections should be hospitalised and started on broad-sprectrum antibiotics. Surgical debridement should then be carried out, which should include all the devitalised tissues, sloughed tendons, and infected bones.
Jude (2007) said that diabetic foot ulcers generally have multiple organisms isolated from within the wound and methicillin-resistant Staphylococcus aureus (MRSA) is an important vancomycin and teicoplanin can be given to patients infected with MRSA. Anyhow, linezolid can be an alternative which can be administered orally.
Furthermore, various topical antimicrobials, antiseptics, and antibiotics have been used also in treating infected diabetic foot ulcer. Topical antibiotics like neomycin, bacitracin, neomycin, gentamycin, polymyxin B, mupiricin, fusidic acid, and topical antiseptics are also used in infected foot ulcers. Although antiseptics and antibiotics are widely used, there is insufficient evidence for their use in diabetic foot ulcers (Jude, 2007). Lipsky, Holroyd & Zasloff (2008) studies showed that pexiganan cream can be used as an effective alternative to oral antibiotic therapy in treating mildly infected diabetic foot ulcer and might decrease the risk of selecting antimicrobial-resistant bacteria.
Dressings also play an important role in managing infected diabetic foot ulcers. There are various dressings available in the market nowadays. The selection of a dressing will depend on the condition of the ulcer. Most infected diabetic foot ulcers produce copious amount of exudates and pus. Dressings are used to control exudates, maintain a moist wound healing environment and eradicated the microorganisms that cause infection. The appropriate dressings for infected wounds with exudates are foam, alginates, hydrofiber, and hydrocolloids that are combined with silver ion. Silver has been shown to have bactericidal properties and has been used in wounds as an antimicrobial for more than century. It acts by impairing the bacterial electron transport system and some of its DNA function. It kills the microbes on contact through multiple mechanism of action, such as inhibiting cellular respiration, denaturing nucleic acids, and altering cellular membrane permeability. Nowadays, Silver ions have been incorporated in hydrofiber, foam, hydrocolloid, and alginate dressings (Bergin & Wraight, 2006).
Concreet Foam dressings with silver can be used during inflammatory phase following debridement and desloughing. It also kills microorganisms on the wounds. It is very absorbent that can be left undisturbed for 3-4 days. However, it can cause a drying effect on the wound if there are too little exudates.
Hydrofiber dressings such as Aquacel Ag absorb the exudates, protecting the edges of the wounds from maceration at the same time kills the bacteria in the wound. Alginate dressings is use as a primary dressing and for packing wound, it is good for deeply ulcerated wound with high exudates. Another dressing is hydrocolloid; it is best use on wounds with granulating and epithelialising wounds that with low to moderate amounts of exudates.
The primary dressings therefore should be either foam-based such as Contreet foam (Coloplast;Humlebaek, Denmark) or hydrofiber AQAg (Aquacel Ag; Convatec, Chester,UK), both of which will absorb the exudates. A moisture retentive dressing can be used as a secondary dressing such as DuoDERM Extra Thin or Versiva. One advantage with the hydrofiber dressing is its capacity to hold wound exudates and microorganisms within its fibres where the bacteria are then eradicated by the ionic silver (Jude, 2007). In addition, the used of hydrofiber dressing in exudating wounds has been proven with research. Jude also implied to improved outcomes in infected diabetic foot ulcers and ulcers that are colonised, one should consider silver dressings as an essential adjunct to wound care to improve its wound bed and to facilitate healing. Studies also revealed that patients treated with AQAg primary dressing showed improved healing and more overall ulcer improvement with less deterioration in the ulcer.
Once the acute situation has resolved it will be necessary to ensure redistribution of the weight-bearing forces on the vulnerable foot by the use of specially constructed shoes or moulded insoles. Application of a total contact plaster cast, lightweight scotch cast boot, or air cast boots may help healing. These conform to the contours of the foot, thereby reducing shear forces on the plantar surface. Great care must be taken, especially with the fitting of plasters, to prevent chafing and subsequent ulcer formation elsewhere on the foot or ankle (Watkins, 2003). If recurrence of neurophatic ulceration is to be avoided, regular follow-up by a chiropodist will be required. An ongoing podiatry to remove excess callus and provide nail care regular assessment, look for active lesions and treat immediately, detect and manage deformities, callus, skin cracks, and discoloration, simple sensory test, examine pulses such as dorsalis pedis and posterior tibial, assess ankle reflex and assess other sensory modalities (Alexander, Fawcett & Runciman, 2000).
The patient’s experience will be improved by having a highly structured care. The patient’s infected ulcer shows healing improvement and prevent from amputation. Understanding the diabetic foot, the proper examination of the patient’s feet, investigations to classify the foot ulcers, and proper management techniques using a team approach, along with preventive steps, will go a long way in limb salvage and prevention of foot amputation (Pendsey, 2010).
Section 5. Evidence based guidance
Identify a contemporary source of evidence based guidance (i.e. a clinical guideline) which could be used as a basis for providing a high standard of care to patients with this type of wound. Critically discuss how the guidance given in this document might influence your nursing practice including whether you believe there are any omissions or recommendations made that would be difficult to manage in your own clinical setting (Phillipines). You must clearly state the full reference of your chosen guideline document and link your work to other healthcare literature where appropriate.
Approximate word count: 500
Your answer here:
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