There are now six classifications of pressure injury. Stages one through four are much the same as they have been in the past, but with better descriptors. The two newly-added classifications are: unstageable and suspected deep tissue injury. More information on pressure injury prevention and management can be found at the Wounds Australia website. It is a given that when managing pressure injury risk and actual damage, the pressure is relieved, and attention is given to nutritional requirements.
A stage one pressure injury is an intact area of damage, so protection of the tissue and providing an environment for recovery is the aim. Adhesive foams can be employed if moisturising the area on each shift is not possible. Examples of adhesive foam include Mepilex Border™ and Allevyn Life™.
Stage two pressure injuries are relatively clean, superficial, partial-thickness injuries. Once again protection is important, however due to the break in the integument, the chosen dressing must also have some absorbent capabilities. Adhesive foams are generally appropriate here, unless the wound is located very close to the anus, in which case a thick barrier cream is often used. Conveen Critic Barrier Cream™ is one appropriate example.
Stage three injuries involve damage through to the subcutaneous tissue, with the presence of slough and soft, tenacious necrotic tissue, which will require debridement. Debridement can be as previously mentioned: managed by a surgeon, a skilled clinician or using dressings to aid autolytic processes. Dressings that aid this autolysis include: Flaminal Hydro or Forte™, Prontosan Gel™, Mesalt™ and Iodosorb™ powder or ointment. Whilst the autolytic process is taking place, the wound exudate will be higher in volume, so super absorbent pads will be required as the secondary dressing, for example Zetuvit Plus™.
Stage Four implies that the area of damage extends down through muscle, and bone may be exposed or palpable. These injuries are generally necrotic and malodourous, and as such, managing odour becomes the priority.
Metronidazole Gel™ will typically reduce odour in a few days. TenderWet Active™ is a preloaded pack of Ringers’ Lactate, that slowly drips into the wound, aiding autolytic debridement, and can safely be used with Metronidazole Gel™. If the patient is in otherwise good health, then surgery and Topical Negative Pressure devices would be used.
Although there are many types of leg ulcers, the most common are venous, followed by arterial, and then mixed venous arterial. The classic signs and symptoms of each of these ulcer types can be found in the Australian and New Zealand Clinical Practice Guideline for Venous ulcer prevention and management.
Venous ulcers are located in the lower third of the lower leg, and generally are superficial and weeping. The priority of care is managing the oedema and encouraging the epithelium to grow across the superficial break. Zinc paste bandages and compression bandages are the mainstay of treatment to achieve these goals. The zinc paste bandages may include products like Viscopaste™ or Gelocast™ .
If the wound has been present for a considerable length of time, then some bacterial involvement is likely, and so an antimicrobial is suggested such as Iodosorb Powder™. This could then be combined with a super absorbent pad such as Zetuvit Plus™.
Compression therapy selection is too complex for such a short publication, as this must be tailored to the patient. A safe and effective system from which to start however, is the use of straight, elasticated tubular bandages, for example Tubigrip™ or Tubular Form™. These must be applied from toes to knee after selecting the appropriate size according to the manufacturers guide. For further information on compression therapy, please refer to our Video Learning Activity on this topic.
When it comes to managing arterial ulceration, a vascular surgeon is best to consult as ideally some surgery can be performed to restore perfusion to the limb. It then becomes the attending clinician’s role to prevent infection. Generally the rule is: if the tissue is dry and ischaemic, then keep it dry. So Betadine™ lotion is used to achieve this and keep the eschar dry. If the tissue in the arterial wound is offensive, infected or malodourous, then a silver or cadexomer iodine may be used, such as Aquacel Ag™ or Iodosorb™ ointment.
Identifying the wound type, setting a clear aim for management, and then the selection of product or device, remains the mainstay of wound management principles. There are of course many other factors to be considered when addressing patients with wounds, and reviewing a wound in isolation of these other factors may lead to poor healing progress. Nutrition, skin care, patient motivation, financial circumstances, environment and psychological state, all play a part in wound healing. It is best to have structure in assessment in order to decipher the wound aetiology, look at factors influencing healing, address these as able, and then select a product based on the aim. Keep your formulary up to date with what is considered best practice and review the wound regularly to ensure progress.
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- Dowsett, C, Protz, K, Drouard-Segard, M & Harding, K 2015, ‘Triangle of Wound Assessment Made Easy’, Wounds International, London, UK, viewed 3 August 2016, www.woundsinternational.com
- European Wound Management Association 2016, ‘EMWA Position Documents (2002-2008)’, EWMA, Denmark, viewed 3 August 2016, ewma.org
- Leaper, DJ, Schultz, G, Carville, K, Fletcher, J, Swanson, T & Drake, R 2012, ‘Extending the TIME concept: what have we learned in the past 10 years?’, International Wound Journal, vol. 9, no. 2, pp. 1-19, viewed 3 August 2016, www.woundinfection-institute.com
- Vowden, K & Vowden, P 2002, ‘Wound Bed Preparation’, World Wide Wounds, UK, viewed 3 August 2016, www.worldwidewounds.com
- Wounds International 2016, Best Practice, London, UK, viewed 3 August 2016, www.woundsinternational.com
Jan Rice is a Registered Nurse with many years experience in surgical nursing. Jan is a member of the Venous Leg Ulcer Guideline Implementation sub-committee and the Pressure Injury Guidelines Development sub-committee. Jan obtained a Masters in Wound Care in 2009 and runs a wound clinic in a large Metropolitan General Practice — Ashwood Medical.Through her own business, Jan has been acting as a consultant to over 80 aged care facilities and a resource for Divisions of General Practice and surgeons within Victoria. Jan is an author of a book chapter on wound healing and has been a volunteer with Interplast since 1983. In 2006, she was awarded Fellowship to the Australian Wound Management Association.