Journal of Community Nursing - page 26

26 JCN
2013,Vol 27, No 4
debris (foreign material and non-
viable tissue) and delays in seeking
appropriate medical attention
(WUWHS, 2008).
By their very nature, chronic
wounds remain open for prolonged
periods of time, offering bacteria
the opportunity to contaminate the
wound and multiply to levels at
which they have a negative impact
on healing. Many patients with
chronic wounds have underlying
conditions, such as diabetes, which
make tissue repair problematic and
affect the individual’s ability to
mount an effective defence against
bacterial attack. In addition, the
presence of high bioburden may
in itself slow the repair process
(Penhallow, 2005).
The diagnosis of wound infection
is based on the presenting clinical
signs and symptoms (Patel, 2010;
Cook and Ousey, 2011). The classic
signs are considered to be (Cutting
and Harding, 1994):
New or increasing wound pain
Local warmth
Purulent discharge.
There may also be wound
malodour and pyrexia (WUWHS,
2008). If infection spreads and
systemic infection is present,
pyrexia becomes more common
and erythema may spread from the
immediate wound area, tracking
towards the proximal lymph nodes
in particular. These, in turn, may
become swollen (lymphangitis).
An increase in wound size, wound
breakdown and/or dehiscence is also
likely to occur (WUWHS, 2008).
In chronic wounds, the presence
of infection may be less obvious.
Underlying conditions such as
sensory neuropathy and altered
immune-competence may mean
that signs become muted or hidden,
and systemic signs such as pyrexia
may not be present until the
infection is well-established (Ousey
and McIntosh, 2009). As well as
the more obvious signs, changes in
wound odour, increased exudate
volume and pain may all indicate
localised infection.
Within the wound, tissues
may become discoloured, more
friable and likely to bleed and
healing may be delayed or halted
altogether. When granulation does
occur, bridging (the formation of
strands of granulation or epithelial
tissue over non-healed tissue)
and pocketing (non-healing tissue
surrounded by active granulation)
may be observed (European Wound
Management Association [EWMA],
2006; WUWHS, 2008).
al, 2004). For patients displaying
overt systemic signs of spreading
infection, blood cultures should
be obtained and urgent expert
assistance sought (WUWHS, 2008).
Optimising the host reaction is a
key component in the prevention
and management of infection
(WUWHS, 2008), and thus it
is essential that the patient’s
nutritional and hydration status
is maintained.
Management of incontinence
will help prevent contamination
of the wound and any dressings
with faecal debris — particularly
significant when the wound is in
the pelvic region or on the leg.
For patients with diabetes, the
importance of tight glycaemic
control should be explained and, if
required, blood sugar levels should
be monitored more frequently. This
is particularly significant if infection
is present, as blood sugar levels may
become unstable.
Tissue oxygenation and vascular
perfusion should be optimised
(WUWHS, 2008), and to encourage
blood flow patients with known
vascular disease should be advised
to exercise (within the limits of
their condition). Where dependent
oedema is present, elevation of the
affected limb will reduce venous
congestion and assist local perfusion
by dispersing extracellular fluid.
Respiratory function and,
therefore, tissue oxygenation can
be improved by even moderate
exercise and postural improvement,
and patients that smoke should be
given advice and support to reduce
or stop.
Steps should be taken to reduce
contamination of the wound.
Adhering to universal precautions
when dressing the wound
prevents inoculation with potential
pathogens and, if infection has
‘The diagnosis of wound
infection is based on
presenting signs and
While microbiological analysis
(obtained from the culture of
swab samples) is a useful tool in
investigating the likely causative
organism — and is an essential
part of the clinicians’ armoury
in effectively managing infected
wounds — it has its limitations.
Cultures of any swab are likely to
reveal a number of bacterial species,
but whether these are responsible
for the infection or are simply
surface-colonising organisms is
debatable (Gilchrist, 1996).
Although wound swabbing is
the commonest investigation, it is
not without error and care must be
taken in interpreting its findings.
If infection is suspected (by clinical
signs in acute and chronic wounds
and/or when chronic wound healing
has stalled despite appropriate
treatment), swabs should be taken
after wound cleansing and removal
of non-viable tissue (WUWHS,
2008). The sample should be sent
to the laboratory accompanied by
a full patient and wound history to
aid analysis (WUWHS, 2008).
Despite the prevalence of
swabbing, wound biopsy is a
far more accurate method of
determining infection status, but
is rarely available in the general
community setting (Dowsett et
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