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
