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Out on a limb

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Out on a limb

Don’t keep wound care at arm’s length. The category can offer the pharmacy team a host of opportunities, ranging from optimising the management of chronic wounds like leg ulcers to providing first aid advice on treating minor injuries in the home

 

Learning objectives

After reading this feature you should be able to:

  • Explain the general measures for managing both acute and chronic wounds
  • Understand the key factors to consider when choosing a wound dressing
  • Advise patients on self-care steps to improve wound healing and prevent leg ulcer recurrence

 

A wound is defined as a physical injury to the body where the skin or mucous membrane becomes damaged, lacerated or broken. Wounds may be classified as either acute or chronic, which has important implications for both initial management and ongoing care.

Acute wounds result from tissue damage by trauma (e.g. a cut, graze or burn) and typically progress through the three normal phases of healing (inflammatory, proliferative and maturation) in a timely fashion, leading to successful closure of the wound.

In contrast, chronic wounds are those that fail to progress or respond to treatment over the normal four-week healing time frame, becoming “stuck” in the early inflammatory phase of healing1. A large proportion of the wounds seen in clinical practice are chronic and include leg ulcers, pressure wounds and diabetic wounds.

Venous leg ulcers

Venous leg ulcers (a common type of chronic wound) develop due to persistently high blood pressure in the leg veins causing swelling, thickening and damage to the surrounding skin, which eventually breaks down to form an ulcer. In the UK, an estimated one in every 500 people is currently suffering with venous leg ulcers2. These chronic wounds are typically managed by nurses – either in the patient’s home or at the GP surgery. Pharmacists should be aware that patients are more prone to venous leg ulcers if they are elderly, obese, immobile or have varicose veins2.

Wound care

The optimal approach for managing each type of wound varies and is beyond the scope of this article. That said, pharmacists should be aware of the general rules for the management of acute wounds commonly experienced by customers, such as cuts and minor burns3:

  • Assess and identify
  • Clean and decontaminate
  • Stop the bleeding
  • Close the wound
  • Dress the wound
  • Bandage.

Managing chronic wounds is more complex and requires confirmation of the underlying pathophysiological cause. This may include investigations for arterial or venous aetiology and blood and urine testing. Venous leg ulcers, for example, can resemble similar wounds caused by poor circulation or nerve disorders.

To exclude peripheral vascular disease as the cause, the Ankle Brachial Pressure Index (ABPI) must be measured and rechecked regularly – a ratio less than 0.8 indicates poor circulation. Choice of dressing for a chronic wound will hinge on both the wound type and the level of exudate. If true venous pathology is found to be at work (as in the case of venous leg ulcers), graduated compression therapy will also be required.

Current thinking

It was previously thought that wounds should be kept uncovered and dry to allow the injured area to scab over and heal. However more recent research has shown that this approach increases the chances of scarring and also possibly the risk of infection and reinjury4. As a result, moist wound healing is now considered the standard of care to achieve accelerated healing with minimal complications4.

The TIME acronym (developed by the Wound Healing Society) encapsulates the latest thinking on impaired wound healing and provides a simple yet systematic method for managing chronic wounds, such as venous leg ulcers5,6:

T = Tissue

The initial step in the management of any wound is to remove non-viable or deficient tissue that will impair the healing process. This technique is known as debridement.

I = Infection or Inflammation

An infected wound requires treatment to prevent wound healing delays and reduce pain and discomfort for the patient.

M = Moisture

Moisture in the wound is vital to enhance the autolytic process and act as a transport medium for key growth factors during epithelisation. It is important to choose a dressing that provides the right balance of moisture for optimal wound healing.

E = Edge of wound

Wound healing progress and the general condition of the wound require regular monitoring. A useful general measure of how well a wound is healing is the wound edge – if the extent to which the wound edge advances into healthy epithelial tissue has reduced, this is indicative of healing.

Treating minor injuries in the home

Many everyday injuries in the home, including superficial wounds like cuts and grazes and minor burns, can be dealt with using simple first aid products available over the counter.

Cuts and grazes

These first require thorough cleansing to remove dirt and debris from the wound. Rinsing the wound under running tap water is usually sufficient but some customers may prefer to use a specific wound wash product. If the wound is bleeding, gentle pressure should be applied with a clean, lint-free bandage or cloth for five minutes.

After drying the area, an OTC antiseptic cream or ointment can then be smoothed over the wound. Surfactant antiseptic products are particularly beneficial for grazes, which typically contain dirt, gravel and other foreign materials, increasing the risk of infection.

The final step is to dress the wound to protect it and prevent against infection. Options for dressing cuts and grazes include traditional adhesive plasters, spray plasters, low adherent dressings (e.g. Melolin) and hydrocolloid dressings (e.g. Compeed).

Skin closure dressings may be required for deeper cuts but care must be taken when using in elderly patients as they often have thinning skin. Some specific OTC plasters and dressings are now also available formulated with silver ions, which possess broad-spectrum antimicrobial activity3.

Minor burns

Minor burns can usually be self-treated safely but large first and second-degree burns (covering an area of more than 3-4cm) and all third-degree burns require medical attention. The first step with any burn or scald should be to hold the wound under cool running water for a minimum of 10 minutes or until the pain subsides.

Burn spray products are also available which, applied to the burn or scald, can alleviate pain and aid with cooling. After removing jewellery, watches and clothing from the affected area, the cooled burn or scald should then be dressed.

Advise customers to use a sterile gauze bandage or clean lint-free dressing to prevent infection; specialised burn plasters are also available OTC. Specific types of dressing available from the pharmacy for burns and scalds include gauze-impregnated dressings and vapour-permeable films. When managing burns in the pharmacy environment it is also important to exercise key precautions:

  • Never apply lotions, ointments or creams to a burn
  • Avoid adhesive dressings unless specifically indicated for burns
  • Do not attempt to remove jewellery or clothing if it has adhered to the skin
  • Burn blisters should be left intact and not burst.

Minor injuries

Minor injuries, such as strains and sprains, can also be effectively managed with OTC products and self-care techniques. To relieve pain, NSAIDs (e.g. ibuprofen or diclofenac) can be recommended, but should not be used until at least 48 hours after the injury as they can hamper the healing process2. Topical analgesia applied direct to the injury is also a good option for sprains and strains – treatments available include topical NSAIDs, rubefacients, heat therapy and cooling sprays. PRICE (protection, rest, ice, compression, elevation) therapy should be recommended to patients for self-care of their injury. For the first 72 hours after sustaining a strain or sprain, customers should also avoid HARM (heat, alcohol, running and massage).

 

Choice of dressing

Patients with both acute and chronic wounds will often obtain their dressing from a pharmacy – so ensuring the most appropriate product is chosen, and used correctly, is important. No single dressing is suitable for all wounds and different dressings may be needed at different stages of healing. Pharmacists should consider the following key principles of wound care when advising patients on dressings1:

  • A moist environment must be maintained at the junction between the wound and the dressing
  • The dressing needs to be able to control excess exudate – the aim is to achieve a moist, not wet, environment
  • Good adhesion to the skin is important but the dressing should not stick to the wound, shed fibres or cause trauma to the wound or surrounding tissue on removal
  • It is important that the dressing fully shields the wound from the outside, erecting an effective barrier to bacterial infection
  • The dressing must be sufficient to keep the wound sterile
  • A dressing can be chosen that aids debridement if there is necrotic or sloughy tissue in the wound – but care must be taken with debridement in patients with ischaemic wounds
  • The wound should be kept as close as possible to normal body temperature and not allowed to get too hot or too cold
  • When applied, the dressing should feel comfortable and not impair normal movement and function
  • For diabetic patients, a dressing should be chosen that allows for regular inspection of the wound
  • Dressing materials should be non-flammable and non-toxic.

Managing leg ulcers

With venous leg ulcers alone costing the NHS an estimated £400m a year, ensuring patients adhere to the treatment plan devised for their individual wound is key7. Without effective wound management, many leg ulcers will heal slowly, or not at all. Although nurses usually dress and clean the wound weekly, the likelihood of a venous leg ulcer healing is low if just ordinary dressings or support stockings alone are used8.

Choice of dressing for a chronic wound will hinge on both the wound type and level of exudate

Compression therapy is now considered the cornerstone of effective treatment for venous leg ulcers and works by counteracting the raised blood pressure in the leg veins, affording the ulcer the best chance to heal. Several clinical studies have confirmed the effectiveness of compression therapy in improving healing outcomes in patients with leg ulcers7. As many as 70 per cent of venous leg ulcers can be healed within 12 weeks if compression bandaging is used – but the bandages must be removed and reapplied every week in order to be effective8.

At the start of compression therapy, between two and four layers of bandaging is applied to the ulcerated leg, exerting the highest pressure at the ankle and tapering off in tightness towards the knee and thigh. Despite the bandaging, patients should still be able to move and rotate their ankle. If patients experience changes in foot colour or temperature, or increasing pain, they should be instructed to consult their nurse or GP as the compression therapy may have been applied too tightly.

Most venous leg ulcers will also be covered with a dressing before applying the compression bandages. The ulcer dressing helps to create the optimal environment for wound healing, as well as improving patient comfort and absorbing exudate. The dressing is changed weekly at the same time as the compression bandages.

After gentle washing to remove accumulated dead tissue and debris (some patient may require more extensive debridement), a simple non-adhesive dressing is applied to the ulcer. Although many patients are able to change their ulcer dressings themselves, applying compression bandages is a skilled procedure that must always be carried out by a nurse specifically trained in leg ulcer management.

Pharmacists’ role in leg ulcers

In addition to treating the wound itself, maintaining preventative measures is equally essential to stop venous leg ulcers recurring. Recurrence is a significant issue, with over one in four patients likely to develop a further venous ulcer within the subsequent two years – and it is here that pharmacists can play a key role2.

To prevent leg ulcers from recurring, patients must wear compression support stockings during the daytime for at least five years after the ulcer has healed. Pharmacists can advise on both stocking selection and sizing, and re-emphasise to patients the importance of adherence. Ideally, customers should be encouraged to wear the highest strength (3) compression stockings – but if these prove too uncomfortable a less compressing class (2 or 1) can be recommended as an alternative.

For all leg ulcer sufferers it is always better to wear any kind of compression stocking than none at all but remind patients that medical compression stockings are not the same as support tights or socks bought from clothing shops. Compression stockings should fit below the knee and be changed every six months, after which time the elastic begins to weaken.

Pharmacists can also provide practical recommendations to venous leg ulcer sufferers that may help to speed the rate of wound healing. Key advice includes:

  • Keep active: Immobility worsens venous leg ulcers and associated symptoms such as oedema
  • Keep the affected leg elevated: Patients should aim for three to four 30-minute periods a day where they lie down with the affected leg raised (also elevate when sleeping)
  • Wear comfortable fitting footwear and protect the leg from injury
  • Use emollient frequently: Patients prescribed emollients for varicose eczema (skin itching and irritation associated with the venous ulcer) should be advised to apply it as often as possible as the rubbing action boosts circulation in the leg
  • Use compression bandaging as instructed and only remove if instructed to do so by a healthcare professional.

 

Key facts

  • Acute wounds typically heal within four weeks, while chronic wounds become stuck in the inflammatory phase of healing
  • Moist wound healing is now considered the standard of care for all wounds
  • Pharmacists can help to identify and address local and systemic factors that can delay wound healing

References

  1. RCH Clinical Guidelines (Nursing): Wound Care.
  2. NHS Choices
  3. Sussman G (Director of the Wound Research Foundation of Australia). Wound Care Module. Published by Australian Government Department of Veteran Affairs (DVA) and Monash University.
  4. Terrie Y. First aid products for wound care. Pharmacy Times. Published online May 11, 2010
  5. Werdin F et al. Evidence-based management strategies for treatment of chronic wounds. Journal of Plastic Surgery 2009; 9:169-179
  6. Ousey K et al. Understanding the importance of holistic wound assessment. Practice Nursing 2011; 22(6):308-314
  7. Dolibog P et al. A comparative clinical study on five types of compression therapy in patients with venous leg ulcers. Int J Med Sci 2014; 11(1):34-43
  8. Patient UK
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