38 | Nursing in Practice | Autumn 2023
A wound surface area reduction of approximately 40 % in this time frame is the benchmark for positive progression , with less than 40 % being a possible red flag for problematic healing . 17 Measurement methods vary in practice but tracing surface area using acetate wound dressings is considered the more accurate . 17 , 10 Wound photography is an important tool as it offers a visual record of wound bed health .
Wound infection All open wounds will be contaminated with common microorganisms but not all become infected , and most will progress to healing . 18 Infection slows healing and increases complications and mortality in patients with leg ulcers . 19 Therefore , identifying patients at higher risk of infection , such as the immunosuppressed , is important to reduce further complications . 19
The diagnosis of infection in wounds can be challenging . The clinical presentation of local wound infection is categorised into covert ( subtle ) and overt ( classic ) symptoms ( see Table 2 ). These may be masked in patients who are immunocompromised and / or have reduced vascular perfusion , as seen in arterial or mixed-aetiology disease .
Wound swabbing Wound swabbing determines sensitivities or resistance to medical therapies such as antibiotics when a wound is infected , and cellulitis / systemic infection is present ( see Table 2 ). 18 Swabbing is not advocated as routine practice as it can be misleading in a laboratory testing environment . Swabbing the surface of a wound bed may only identify superficial microorganisms without picking up on those in deeper wound tissue ( biofilms ). 17 Clinical judgement based on wound symptoms is a more
13 , 18 effective diagnostic tool .
Compression therapy Venous hypertension is a treatable condition . The National Wound Care Strategy Programme ( NWCSP ) 2 recommends patients be given compression therapy immediately on presentation to prevent longer-term challenges to healing . Strong compression therapy is considered the gold standard for timely healing and improved outcomes . 2 Refer to local formularies for guidance on hosiery and bandage systems .
According to the NWCSP , compression therapy is essential as it :
• Controls internal inflammation that causes venous ulceration .
• Reduces and controls the pathophysiology of venous ulceration .
• Helps venous leg ulcers heal more quickly . 5
• Can aid pain relief through reducing lower-limb swelling , improving mobility and ulcer bed blood flow .
Once compression therapy has been deemed safe , the health professional should then assess :
• The level of compression to apply . This depends on the level of compression delivered and product used ( see Table 3 ). 13 It is contraindicated in suspected or diagnosed arterial disease . Local protocols should be followed . 14
• Choice of compression product should be based on the following considerations : 13 the presence of swelling in the lower limb ; levels of wound fluid ( exudate ); lower limb shape and location of ulcer ; patient ’ s height ; and psychological and lifestyle considerations .
Compression products Health professionals should have received appropriate
Table 2 Clinical indicators of local wound bed infection 18
Covert ( subtle changes at the ulcer bed ) Overt ( classic symptoms )
Raised , red granular-looking tissue ( hypergranulation )
Tissue that looks inflamed ( friable ) and bleeds easily on cleansing or dressing removal
Increasing exudate in the absence of oedema Delayed wound healing beyond expectation
training in therapy selection and be deemed competent in safe application . 2 Manufacturer guidelines must be followed and support sought from industry partners .
• Hosiery compression kits : include two layers , with both delivering up to 40mmHg when applied together . Some kits have a stiffer fabric and are better suited to patients with lower-limb oedema ; others have less stiff fabric and are ideal where there is no oedema . 4 This system can help promote self-care and reduce ulcer recurrence post healing .
• Bandage compression systems : there is a range of systems , designed to deliver mild to strong compression . They comprise : 13 , 4 - Inelastic / short-stretch bandages - Elastic / long-stretch bandages - Multicomponent system ( two to four layers ) - Two-layer system .
• Wrap compression garments : these deliver mild-strong compression . Different systems apply depending on lower-limb shape and swelling . They can help promote self-care . There is ongoing research into the effectiveness of these products in venous leg ulcer healing . 20
Lower limb skin management These steps are important for lower limb skin and wound care : 2
• Wound bed cleansing and debridement of dead tissue .
• Cleansing of the lower limb to remove wound exudates , dressing residue and dead skin , to encourage emollient uptake .
• Daily emollient therapy routine ( where compression regime allows ) as per local formulary to maintain the natural skin barrier . Consider barrier products if peri-wound skin is damaged or is vulnerable to damage by exudates .
• Advice on general lifestyle choices , improving nutritional intake , lower-limb exercises and supported self-care .
• Symptom management such as pain relief .
• Providing education and literature to the patient to explain their clinical diagnosis and rationale for compressive therapy .
Redness around the wound ( erythema ) > 2cm
Local warmth
Table 3 Compression descriptors in line with mmHg delivered 25
Mild Moderate Strong Very strong ≤ 20mmHg 20-40mmHg 40-60mmHg > 60mmHg
Swelling and smelly ( purulent ), thick exudate Wound deteriorating despite best practice
Further reading 1 European Wound Management Association ( EWMA ) ( 2003 ) Understanding compression therapy . EWMA : London . inyurl . com / EWMAcompression . 2 Keast D et al . International Wound Infection Institute ( IWII ). Wound Infection in Clinical Practice . Wounds International March 2022 . tinyurl . com / IWII-infection 3 Nichols E . Wound Assessment Part 1 : How to measure a wound . Wound Essentials 2015 ; 10 ( 2 ): 51-55 . tinyurl . com / Nichols-wound 4 National Wound Care Strategy Programme ( NWCSP ). Recommendations for Lower Limb Ulcers . 2018 . tinyurl . com / NWCSP-ulcers . 5 Timmons J and Bianchi J . Disease progression in venous and lymphoevenous disease . The need for early identification and management . Wounds UK 2011 ; 4 ( 3 ): 59-71 . tinyurl . com / Timmons-Bianchi 6 Hopkins A et al . Best Practice Statement : Holistic management of venous leg ulceration ( 2nd edition ) November 2022 . Wounds UK . London . tinyurl . com / Hopkins-holistic . 7 Whayman N . Doppler Assessment . Getting it right . Wound Essentials 2014 ; 9 ( 2 ): 48-52 . tinyurl . com / Whaymandoppler