Abstract:
Pain, malodour and exudate from acute and chronic wounds can be catastrophic to the patient. Excessive exudate results in significant tissue damage to the wound bed and surrounding skin, reduces quality of life, and often requires costly specialist service input. Effective wound assessment and management including appropriate dressing choice is, therefore, paramount to ensure wound healing can take place in a timely manner. This observational evaluation explores 150 ward-based patients who presented with acute and chronic exuding wounds; it examines and evaluates the proposed benefits of the soft silicone foam dressing range over a 4-month period in an acute hospital setting. The outcomes of the evaluation were exudate management, maceration reduction, atraumatic application and removal, non-adherence and patient experience. The evaluation highlights not only an overall positive improvement in exudate management and maceration reduction, non-adherence, atraumatic application and removal but also emphasises the importance of a positive patient experience in the wound-care journey.
Key words: Wound exudate,Peri-wound maceration,Absorbency and protection , Non-adherence , Atraumatic wound care , Patient experience.
INTRODUCTION:
The body produces wound exudate as a response within the biological and chemical processes within the natural wound healing continuum, taking the wound through the key stages of inflammation, proliferation and maturation. Wound exudate is responsible for ensuring a moist environment is maintained, providing essential elements and cell nutrients such as electrolytes, growth factors, inflammatory mediators, matrix metalloproteinase and key growth factors. Where wounds are healing as expected, exudate levels tend to reduce over time along the wound healing continuum. Gardner states that when wounds are stuck within the chronic phase, excessive levels of exudate within the wound bed delays the healing process.This has a negative effect on the healing potential of cells when they are Sharon Dawn Bateman in the inflammation phase.Inappropriate levels of exudate can result from external and or internal events such as infection, pharmacology, and incorrect dressing product application which can have a detrimental effect on the vulnerable tissues such as increased maceration to the periwound skin, increased malodour and extension of wound borders through leakage . Jones highlights the ‘falling off’ of dressing products, which can be an issue when wounds have excessive and high exudate levels increasing maceration, leading to inconvenience to the patient, reduced credibility for the manufacturer and financial burden on the healthcare provider.
According to Thomas when managing wound exudate, dressing products can be classified as adherent, low adherent or non-adherent, with many new dressing formulations now being promoted as ‘atraumatic’; providing increased protection to the periwound skin and wound bed. Skin tearing or ‘skin stripping’ caused by overly adherent dressing products is traumatic to patients and results in negative physical and psychological wellbeing, with pain and discomfort in product application and removal being common side-adverse events.This increases demands
upon the clinician, patient, carer and diminishes healthcare resources. The avoidance of non-intentional damage to the patient’s wound and discomfort should be a priority, in order to reduce the negative impact on wound healing through resulting stress and anxiety .
Todays advanced wound care products, such as the soft silicone foam dressing, are manufactured with not only exudate containment in mind but also how the product adheres to the patient’s vulnerable skin, providing atraumatic removal without unnecessary trauma and stripping of the epidermis skin layer. Clinicians must therefore be mindful in ensuring that a robust assessment of the patient’s wound is undertaken in the first instance and that the product choice truly meets the needs of the patient and his or her wound to optimise wound healing .
Method：
A total of 150 patients, who were referred with low to highexuding wounds, were recruited over a 4-month period through the trust’s wound care service.
Following entry into the evaluation, alongside information provision, each patient’s wound was cleansed as required before being dressed with the appropriate soft silicone foam dressing.The pre-evaluation wound care continuum and dressing regimen were continued consistently;those wounds that required the foam as a secondary product would continue to deploy the same wound filler used before the evaluation, similarly with those wounds that were being managed with barrier films, creams, bandaging and compression therapy. It is essential in any evaluation to remove all variables that can affect outcomes . The wound assessment documentation was reviewed at day 7 of each of the 4 weeks by the lead nurse to ensure accurate up-to-date data collection.
Case1：
A 32-year-old male following surgical debridement for 2-week-old abscess Day 1. Following surgical debridement.
Discussion：
After the 4-week evaluation period, the final exudate assessments demonstrated a positive reduction in wound exudate levels representing progression along the wound healing continuum according to White and Gray . Figure 2 highlights an almost complete turnaround with regard to the cohort’s levels of exudate with less than 1% (n=1) with high exudate, 21% (n=32) with moderate exudate, 56% (n=84) with low exudate and 22% (n=33) with no exudate.
All of the recruits had no incidences of periwound skin maceration throughout the 4-week period, alongside no comments by the patients or the clinicians in the evaluation documents regarding incidences of leakage. Product wear time was dictated by the levels of exudate and dressing change accommodated accordingly in the assessment and re-evaluation processes.
Adhesive dressings have been shown to cause skin trauma and pain with both application and removal, according to Waring（2014）,alongside increased epidermal sensitivity and potential adverse reactions. Before the evaluation 78% (n=118) of the wounds had been using a designated adherent/non-adherent absorbent foam dressing product, which 100% of the patients preferred not to change back to. Pain scores were assessed at each dressing change using the McGill pain assessment tool . Pain scores were assessed and documented pre-, peri- and post-evaluation as is normal standard practice to allow comparison at start and end points. More than 98% of patients (n=148) had a pain score of between 1 and 10 at the stage of preparation for the first soft silicone foam dressing application, showing some degree of pain.At first dressing change 85% (n=129) had a level of 0 (no pain) with 15% (n=21) having pain scores of 1–3. At second change 100% (n=150) demonstrated a pain score of 0. It is worth noting that no changes to any pharmacological analgesia were implemented in the time frame and all normal care plans put in place before the evaluation started were adhered to.
Conclusion
The key focuses of healing a highly exuding wound are adequate absorption of exudate, non-adherence, the protection of surrounding tissues and the provision of an appropriate wound environment. Patient comfort, quality of life, education and adverse-reaction reduction are all key elements when ensuring the wound care journey is as effective and efficient as possible. High on the healthcare agenda is the active involvement of both patient and carer in day-to-day clinical care, with wound care practice being no exception. Patients and carers, where possible, must have a loud voice within clinical wound care decisions, choice of products and care environment if a truly holistic approach is to be achieved. This in turn will result in best-practice provision and resulting outcomes. This moderate sized cohort evaluation of an absorbent foam product,alongside patient informed choice in regards to their product use and direction of care, is an innovative addition to the many tools that clinicians have access to. Increasing the availability of evaluated products based on the above principles provides the clinician with the evidence base on which to provide appropriate care.
Bateman, Sharon Dawn. "150 patient experiences with a soft silicone foam dressing." British Journal of Nursing 24.Sup12 (2015): S16-S23.
