During my placement in the community with the district nurses I had the opportunity to observe at leg ulcer clinic. At this clinic I had the opportunity to observe the dressing of a venous leg ulcer. Wound expert (2006) suggests treatment should consist of keeping the ulcer infection free, absorbing the excess discharge and managing the patient’s medical problems. The aim of the patients care plan is to promote healing. A Zoologist named George Winter (1927 – 1981) studied wound healing in a domestic pig and later became interested in wound dressings.Winter observed that wounds covered with an occlusive dressing healed faster than those left to dry out (Winter 1962, cited in Bale and Jones, 2006).
It was from Winters work that the principles of moist wound healing used today was developed. The adoptions of various techniques throughout time to cleanse wounds and promote healing have included topical treatments such as the use of boiling oil, honey, diluted wine and seawater. In clinical practice, the principles of wound cleansing have been misunderstood resulting in the unsuitable and ritualistic use of cleansing solutions (Morison et al, 1997).Nurses sometimes do not question as to why they are cleansing the wound (Bale and Jones 2006). Before Cleansing of the wound is undertaken, the nurse should take into account the natural wound healing involves the bactericidal activity and growth factors present in the wound exudates (Chen et al 1992, cited in Bale and Jones 2006). Removal of wound exudate through inappropriate cleansing and drying may only reduce those vital components for the healing tissue with the principles of moist wound healing.
Wound cleansing is also done to remove bacteria (Thomlinson 1987, cited in Bale and Jones 2006). And this is not possible or desirable. Wounds need to be cleansed to remove surplus exudate, slough, debris or necrotic tissue and remnants of dressing material, in order to promote patients comfort (Bale and Jones 2006). The patients original care plan was to renew the dressing every week, administer antibiotics as prescribed, monitor wound for improvement, encourage the patient to eat a balanced healthy diet, with adequate nutrition to promote and sustain wound healing.The dressing consisted of a hydrogel called aquaform used to promote a moist wound environment.
To debride and deslough the wound used with ‘Biatain’ a non adhesive absorbent foam dressing with vapour-permeable film backing. Designed to absorbed large amounts of exudates. They do not stick to the wound and do not break down in the wound bed. Once enough exudate has been absorbed, these dressings provide a moist wound environment. These dressings also protect against physical trauma due to the padding. The use of this dressing regime was showing little improvement after three months.
The majority of the wound surface was covered in slough, a small amount of the wound was necrotic, it was quite odourous, and it caused the patient quite a lot of pain. Reassessment of the wound care plan occurred due to the lack of improvement. The decision was to continue with the ‘aquaform’ (applied directly to the wound bed), to continue keeping the wound moist. Then a ‘k-lite knitted viscose elastomer bandage for light support, which is placed under ‘k-soft’. This is a bandage made of cotton wool and this provides padding to prevent further physical trauma.Then ‘actico’ which is a short stretch compression bandage and control and reduce lymphoedema (applying compression as advised by Wound Expert, 2006).
Compression is not suitable for patients with an ABPI of less than 0. 8 the overall effect is the wound is moist occluded, which is based on best evidence.
