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Contents

List of Contributors x Preface xii Acknowledgements xiv Section 1 Principles of Best Practice 1 1 Evidence and Clinical Decision-making 3 Carolina Weller Introduction: what is effective clinical decision-making? 3 What is evidence-based health care? 4 Common misperceptions about evidence-based practice 5 Challenges to changing practice 7 Factors influencing clinical judgement 8 Evidence-based practice: hierarchy of evidence 9 Evidence-informed decisions 11 Critical appraisal frameworks 11 Clinical guidelines 13 Summary 13 Useful resources 14 Useful critical appraisal frameworks 14 Further reading 15 References 15 2 Maintaining Skin Integrity 18 Arne Langoen and Janice Bianchi Introduction 18 Impaired skin barrier function in the clinical setting 23 Management of vulnerable skin 27 Summary 30 Useful resources 30 References 30 3 Physiology of Wound Healing 33 Mary Martin Introduction 33 Types of wound healing 35 Wound chronicity 35 Normal wound healing 36 Optimising healing: general factors 38 Optimising healing: local factors 39 Delayed wound healing 40 Tissue repair in chronic wounds 40 The inflammatory response 41 Proliferation of new tissue 43 Wound closure 45 Summary 48 Useful resources 48 References 48 4 Assessing Skin Integrity 52 Annemarie Brown and Madeleine Flanagan Introduction 52 Assessing skin integrity 53 Listening: problem orientation and knowledge 53 Looking: problem clarification and knowledge construction 55 Touch: hands on fact finding 56 Smell: subconscious information gathering 57 Assessing wounds 58 Wound bed preparation 58 Data collection 60 Effective documentation 63 When to seek specialist help? 63 Summary 63 Useful resources 64 References 64 5 Principles ofWound Management 66 Madeleine Flanagan Introduction 66 Principles of wound management 67 Effective wound management 67 Controlling bacterial burden: wound cleansing 68 Controlling bacterial burden: wound debridement 69 Autolytic debridement 69 Enzymatic debridement 69 Biosurgical debridement 70 Mechanical debridement 70 Sharp debridement 70 Hydrosurgical debridement 71 Ultrasound (acoustic pressure wound therapy) 71 Regulating moisture balance 71 Wound dressings 72 Passive inert dressings 74 Interactive dressings 75 Antibacterial dressings 79 Summary 83 Useful resources 83 References 83 6 Wound Infection 87 Valerie Edwards-Jones and Madeleine Flanagan Introduction 87 Bacterial invasion of the skin 88 Wound pathogens 88 Factors increasing the risk of wound infection 90 The significance of bacteria within wounds 90 Significance of biofilms 92 Identifying wound infection 92 Microbiological assessment of wounds 93 Principles of managing infected wounds 95 Summary 99 Useful resources 99 References 99 7 Psychological Impact of Skin Breakdown 102 Patricia Price Introduction 102 Psychological impact on the individual and society 103 Adaptation to chronic illness 103 Stress and skin disease 103 Depression 104 Adjustment to physical change/disfigurement 105 Coping strategies 105 Social support 106 Body image 106 Living with skin breakdown and chronic wounds: symptom management 107 Measuring impact of skin breakdown 108 Factors affecting treatment 109 Interventions 111 Clinical reflection 112 Summary 113 Useful resources 113 References 113 Section 2 Challenging Wounds 117 8 Pressure, Shear and Friction 119 Keryln Carville Introduction 119 Prevalence and incidence 120 Pathophysiology 120 Risk factors 122 Psychological impact 122 Current best practice 123 Prevention strategies 123 Pressure ulceration: assessment considerations 123 Treatment strategies: pressure ulcers 128 Education and support 132 Criteria for specialist referral 133 Summary 133 Useful resources 133 Clinical guidelines 133 Organisations 133 Further reading 133 References 133 9 Diabetic Foot Disease 136 Jan Apelqvist Introduction 136 Aetiology 137 Psychological impact 139 Principles of diabetic foot ulcer management 140 Diabetic foot ulceration: assessment considerations 140 Assessment of vascular status 143 Assessment of wound infection 143 Management of diabetic foot ulcers 145 Vascular intervention 145 Foot surgery and amputation 146 Debridement 147 Infection in diabetic foot wounds 147 Osteomyelitis 148 Offloading non-weight-bearing 148 Wound dressings: special considerations 149 Foot care 149 Education and support 150 Provision of specialist diabetic foot services 151 Criteria for specialist referral 151 Summary 151 Useful resources 151 References 152 10 Chronic Ulcers of the Lower Limb 155 Jeanette Muldoon Introduction 155 Epidemiology 155 Comorbidities and underlying pathologies 156 Rheumatoid arthritis and vasculitis 156 Venous leg ulceration 156 Factors that affect venous return 158 Rarer leg ulcer aetiologies 160 Psychological impact 161 Principles of managing leg ulcers 161 Leg ulceration: assessment considerations 161 Vascular assessment for arterial disease 164 Management of chronic oedema in leg ulcers 166 Wound dressings: special considerations 168 Prevention of ulcer recurrence 169 Education and support 170 Provision of specialist services 170 Criteria for specialist referral 171 Summary 171 Useful resources 171 Further reading 172 References 172 11 Lymphoedema 175 David Keast Introduction 175 Pathophysiology 176 Risk factors 178 Psychological impact 179 Current best practice 179 Prevention strategies: risk factor management 180 Lymphoedema: assessment considerations 180 Treatment strategies 184 Education and support 189 Provision of specialist services 190 Criteria for specialist referral 190 Summary 190 Useful resources 190 References 191 12 MalignantWounds 193 Wayne Naylor Introduction 193 Malignant wounds: aetiology 194 Psychological impact 195 Principles of palliative wound management 196 Malignant wounds: assessment considerations 196 Management of malignant wounds 198 Education and support 204 Provision of specialist services 204 Criteria for specialist referral 204 Summary 205 Useful resources 205 References 205 13 Skin Integrity and Dermatology 208 Julia Schofield Introduction 208 Prevalence and incidence of skin disease 209 Quality of life 209 Cost of skin diseases 209 Management principles 210 Important common skin problems and their management 211 Provision of dermatology specialist services 220 Summary 221 Useful resources 222 Further reading 222 References 222 14 Surgical Wounds 224 Alan Widgerow Introduction 224 Classification of surgical wounds 224 Principles of surgical wound management 227 Surgical wounds: assessment considerations 227 Preoperative management 228 Intraoperative management 229 Postoperative management 230 Wound closure 231 Management of surgical scars 234 Common reconstructive surgical options 236 Education and support 237 Criteria for specialist referral 238 Summary 238 Useful resources 239 References 239 15 NeglectedWounds 242 Kim Deroo, Lesley Robertson-Laxton, Sabina Sabo and Arlene A. Sardo Introduction 242 BODY PIERCINGS 242 Risk factors (post-piercing infection) 243 Factors delaying healing 243 Complications 243 Principles of wound management 243 Practical management 243 Practical tips 244 Healing rates 244 Criteria for specialist referral 244 Summary 245 Further reading 245 References 245 BULLOUS PEMPHIGOID 245 Risk factors 245 Differential diagnosis 245 Clinical features 245 Factors delaying healing 246 Complications 246 Principles of wound management 246 Practical management 246 Criteria for specialist referral 246 Summary 246 Further reading 247 References 247 CALCIPHYLAXIS 247 Risk factors 247 Differential diagnosis 247 Clinical features 247 Factors delaying healing 248 Complications 248 Principles of wound management 248 Practical management 248 Criteria for specialist referral 248 Summary 248 Further reading 249 References 249 FISTULAS 249 Risk factors 249 Diagnostic procedures 249 Clinical features 249 Factors delaying healing 249 Complications 249 Principles of wound management 250 Practical management 250 Criteria for specialist referral 250 Summary 250 Further reading 251 References 251 NECROTISING FASCIITIS 251 Risk factors 251 Differential diagnosis 251 Clinical features 252 Factors delaying healing 252 Complications 252 Principles of wound management 252 Practical management 252 Criteria for specialist referral 253 Summary 253 Further reading 253 References 253 PYODERMA GANGRENOSUM 253 Risk factors 253 Differential diagnosis 254 Clinical features 254 Factors delaying healing 254 Complications 254 Principles of wound management 254 Practical management 254 Criteria for specialist referral 254 Summary 255 Further reading 255 References 255 SELF-INFLICTED WOUNDS (SELF-HARM) 255 Risk factors 255 Differential diagnosis 255 Factors delaying healing 255 Clinical features 255 Complications 256 Principles of wound management 256 Practical management 256 Criteria for specialist referral 257 Summary 257 Further reading 257 References 257 SKIN TEARS 257 Risk factors 257 Differential diagnosis 258 Factors delaying healing 258 Clinical features 258 Complications 258 Principles of wound management 258 Practical management 259 Criteria for specialist referral 259 Summary 259 Further reading 259 References 259 Section 3 Improving Skin Integrity Services 261 16 Reducing Wound Care Costs and Improving Quality: A Clinician s Perspective 263 Theresa Hurd Introduction 263 Health economics: a clinician s perspective 264 Barriers to best-practice wound care and prevention 265 The costs of wound care 266 Best-practice wound prevention and care programmes 267 Clinical results 268 The impact of best-practice wound prevention and care on health economics 272 Redesigning clinical care, business and information processes 274 Indirect economic benefits 274 Summary 275 Useful resources 275 References 276 17 Dressings: The Healing Revolution 278 Douglas Queen and Keith Harding Introduction 278 Evolution of new wound dressing technologies 279 The healing revolution 280 Dressing evolution led by technology: an example 282 Patient-centred dressing evolution: an example 282 Advanced wound technologies 283 The future: wound care as a clinical specialty 284 Summary 287 Useful resources 287 References 287 Index 291

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