Wounds

In 2020, the total cost of managing 3.8 million patients with a wound in the NHS was estimated to be £8.3 billion, an increase of approximately 8–9% per annum since 2015 (Guest, 2020). An estimated £2.7 billion was spent on wounds that healed (70% of wounds being treated) compared to £5.6 billion for wounds that did not heal (30%) within the year (Guest, 2020).

It is therefore vital that all clinicians know how to best assess and manage a variety of wounds to achieve positive outcomes for their patients.

A wound can be defined as:

Surgery and various types of trauma can cause these, along with the effects of prolonged pressure – in particular pressure/compression in combination with shear force (National Institute for Health and Care Excellence, 2023). Lower limb ulcers are wounds on the lower leg (below the knee) and foot that are slow to heal (National Wound Care Strategy Programme, 2020).

Symptoms depend on the aetiology of the wound, which should be identified during a structured holistic assessment process that incorporates the patient’s history with the completion of a wound assessment chart (Flanagan, 2013). The most common symptoms associated with wounds are:

• swelling
• pain and tenderness
• localised heat
• local change of skin colour (erythema)
• loss of function– not being able to use or move the affected area
• bleeding or oozing of blood and/or serous fluid

Wounds can be classified as:

Acute – ‘a wound that is healing as anticipated without complications such as minor trauma or surgery’ (Collier, 2003).

Chronic – a wound that is failing to heal as anticipated as a result of complications, such as dehydration, infection, the presence of comorbidities that could be adversely affecting the ‘normal’ wound healing process. Chronic wounds can also be referred to as ‘hard to heal wounds’ (Atkin et al, 2019).

Burns – ‘an injury to the skin or other organic tissue primarily caused by heat or due to radiation, radioactivity, electricity, friction or contact with chemicals’ (World Health Organisation, 2018).

Malignant – ‘the external manifestation of the infiltration of the skin, blood and lymph by cancerous cells’ (McMurray, 2003).

Initially, all wounds may be described as ‘acute’, since they are anticipated to progress through a ‘normal’ wound healing process. However, if the healing process becomes stagnant

All wounds and the surrounding skin should be assessed using a holistic framework which incorporates a systematic wound assessment model.

The holistic model for the assessment of patients with a wound requires clinicians to:

• involve patients in the decision-making process
• consult a multidisciplinary team and have an integrated approach
• consider the effects of all current medical conditions
• assess related wound bed/symptoms
• consider all aspects of the patient’s quality of life
• incorporate local trust values and policies

All wound assessments should be thoroughly documented to provide a baseline for subsequent reassessment and further documentation of the wound, as clinically indicated.

The process of wound assessment requires healthcare professionals to have:

• knowledge of relevant anatomy (skin) and physiology (‘normal’ wound healing process)
• the ability to identify factors that may interfere with the ‘normal’ wound healing process
• the ability to collect data that is both subjective (patient’s pain experience) and objective (wound dimensions)

Once the initial wound assessment process has been completed, healthcare practitioners should develop and document treatment objectives. These objectives should assist other practitioners involved with the patient’s care to understand the rationale for the chosen wound management products (eg wound cleansing solution, wound dressings). The treatment objectives should be reviewed and documented during each reassessment of the patient’s wound.

Treatment objectives will depend on the clinical signs and symptoms associated with the wound. Typical objectives may include:

• cleaning the wound, for example using wound cleansing solutions with antimicrobial properties, normal saline and sterile/tap water
• debriding/desloughing the wound bed
• rehydrating tissues
• reducing bacterial burden/minimising risk of biofilm
• managing/controlling wound exudate
• managing/controlling bleeding (within the wound margins)
• protecting the surrounding skin
• managing any associated symptoms, such as pain (especially if experienced during dressing changes)
• optimising the local wound healing environment
• optimising the patient’s healing potential

The overall aims of wound management

National Institute for Health and Care Excellence - https://www.nice.org.uk
National Wound Care Strategy Programme - https://www.nationalwoundcarestrategy.net
Leg Ulcer Forum (England and Wales) - https://www.legulcerforum.org
Society of Tissue Viability - https://societyoftissueviability.org/
European Wound Management Association (EWMA) - https://ewma.org/
European Pressure Ulcer Advisory Panel - https://www.epuap.org

References

Atkin L, Bućko Z, Conde Montero E, et al. Implementing TIMERS: the race against hard-to-heal wounds. J Wound Care. 2019:23(Sup3a)S1-S50. https://doi.org/10.12968/jowc.2019.28.Sup3a.S1

Calvin M. Cutaneous wound repair. Wounds. 1998;1(10):12-32.

Collier M. The elements of wound assessment. Nurs Times. 2003;99(13):48-49.

Coloplast Group. The triangle of wound assessment. 2023. https://www.coloplast.com/products/wound/triangle/ (accessed 2 May 2023)

Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair Regen. 2000;8(5):347-352.

Flanagan M. Wound healing and skin integrity: principles and practice. Blackwell: Wiley; 2013

Guest JF, Fuller GW, Vowden P. Cohort study evaluating the burden of wounds to the UK's National Health Service in 2017/2018: update from