mental status, age, pain, mobility, nutritional status and co-
morbidities), wound factors (e.g.peri-wound skin status,
vasculitis, cellulitis, wound colour, odour, and inconti-
nence), as well as the macroscopic and microscopic envi-
ronments (Snyder, 2004). Evaluation of necrosis, infection,
nutrition, pressure, perfusion and tissue moisture balance
are also paramount (Snyder, 2004).
Because of the multitude of factors that can affect heal-
ing progress, wounds cannot be tended to in isolation. The
nurse needs to have an understanding of the process of
wound healing and have undertaken a full patient assess-
ment before focusing on the patient’s wound. Recognising
and managing problems at the wound bed, e.g. necrotic
tissue and excess exudate, can result in a better prepared
wound bed and optimal healing (Dowsett, 2002).
It is important that any devitalized tissue is removed from
a wound as soon as possible. For most patients, the presence
of non-viable tissue is distressing as it can produce a noxious
odour and frequently an unacceptable discharge. The devi-
talized tissue provides a suitable culture medium for bacterial
growth, and wounds containing necrotic tissue are therefore
at risk of becoming clinically infected (Poston, 1996).
Wound exudate is all too often perceived as a clini-
cal management problem. While this can be the case, it
should be recognized that exudate does fulfil an important
function in the healing process. Gradual acceptance of the
ound healing is affected by many variables,
which must be assessed before treatment cn
commence. These include patient factors (e.g.
benefits of moist wound healing, combined with the cur-
rent goals of the ‘ideal’ moist environment, focus attention
on the role of exudates (Cutting, 2003). Although wound
exudate is necessary for healing, when its production
becomes excessive it becomes a problem, contributing
to skin maceration and delayed wound healing. Treating
the underlying cause of excessive exudate generation and
selecting appropriate dressings are the keys to effective
management (Watret, 1997).
Most chronic wounds have become ‘stuck’ in the late
inflammatory phase of wound healing. For the normal
repair process to resume, the barrier to healing must be
identified and removed through application of the correct
techniques (Schultz et al, 2003). This can be distressing
and frustrating for patients who may have lived with such
a wound for many months or even years. The key to the
concept of wound-bed management is to prepare the
wound so that modern methods of promoting healing can
then be applied (Collier, 2002).
Chronic wounds are characterized by loss of skin or
underlying soft tissue and does not progress toward healing
with conventional wound care treatment. There are four
basic principles of chronic wound care:
w Remove debris and cleanse the wound
w Provide a moist wound healing environment through
the use of proper dressings
w Protect the wound from further injury.
w Provide substrates essential to the wound healing process.
The removal of devitalized tissue, particulate matter, or for-
eign materials from a wound—debridement—is often the
first goal of wound care. Debridement can be accomplished
surgically (instrument/sharp), chemically, mechanically or by
means of autolysis. Each procedure has distinct advantages,
disadvantages, indications for use and risks, and a combina-
tion of methods will often expedite the process while limit-
ing the chance of complications (Fowler and van Rijswijk,
1995). Underlying the care of chronic wounds is the neces-
sity to assess the wound on an ongoing basis. Changes in
wound care must be based on changing wound parameters,
and timely, complete and accurate wound assessments must
be documented (Frantz and Gardner, 1994).
Many different types of wound dressings are available.
It is important that nurses know what sort of dressing
Use of a hydrogel dressing for
management of a painful leg ulcer
Ann Moody is a tissue viability nurse for Morecambe Bay Primary Care Trust, Cumbria Email: Ann.Moody@mbpct.nhs.uk
This case study is of an 82-year-old lady who was widowed and lives alone
in a council house. A left lateral leg ulcer had developed over the gaiter
area, and the community team were asked to assess in 2004. The main
issues were her inability to tolerate compression (even when reduced)
because of the pain. Nevertheless, the community nurses had tried very
hard with compression, using different compression techniques at different
times to try to encourage her to persevere. The nurses felt they were
running out of ideas and therefore the tissue viability nurse (TVN) was
asked to assess the wound. The TVN recommended ActiFormCool dressing.
This article will examine the background for wound healing, provide the
rationale for the recommendation and describe the progress of the patient.
Leg ulcers w Pain w Compression w Hydrogel