Journal of Community Nursing - page 28

28 JCN
2013,Vol 27, No 4
become established, helps to
reduce the risk of microorganisms
spreading to other patients. In the
community, the patient and their
informal carers will need to be
trained, as many will have an active
role in managing the wound.
Leakage of exudate through the
dressing (strikethrough) provides a
portal for the ingress of pathogens
into the wound (Thomas, 2010;
White, 2011). Clinicians should
select dressings that are able to cope
with elevated volumes of exudate
and the frequency of dressing
change should be increased (White,
2011). If soiling of the outer structure
of the dressing has occurred, the
dressing should be replaced.
Necrosis
The presence of necrotic material
within the wound provides a
nutrient-rich base for bacterial
proliferation (EWMA, 2006;
WUWHS, 2008) and a barrier
to topical antimicrobials and
antibiotics (Weir et al, 2011). This,
therefore, should be debrided
(WUWHS, 2008).
Similarly, the presence of high
volumes of bacteria-rich exudate
provides an environment for
proliferation (Adderley, 2010).
Wounds should be drained of this
fluid to reduce bacterial numbers
(WUWHS, 2008). Although it
is recognised that wound bed
cleansing is unnecessary at each
dressing change, the exception
is the infected wound, where
cleansing at dressing change may
be beneficial (Cutting, 2010). This
also offers the opportunity for
gentle debridement of the wound
bed, which, through its mechanical
action, reduces necrotic burden
within the wound and may
disrupt biofilms.
REDUCING BIOBURDEN
Reduction in wound bioburden is
a key element in the management
of the colonised or infected wound.
Guidelines on the management
of wound infection (EWMA, 2006;
WUWHS, 2008) have suggested
that topical antimicrobial dressings
may be useful in reducing wound
bioburden. Some have active agents
that disrupt bacterial proliferation
or are toxic to cells, whereas others
contain substances that bind
bacteria to the dressing.
In addition, the structure and
function of some dressings’ base
materials means that they are able
to effectively manage the negative
sequelae of wound infection (White,
2011). For example, absorbent
agents such as alginates, hydrofibres
and foam-based dressings can help
to reduce exudate volume, while
offensive odours may be neutralised
by charcoal-based products
(Williams, 2001).
Products based on the
antimicrobial agents iodine,
silver, honey and latterly
polyhexamethylene biguanide
(PHMB) are considered by many
to be the first line of treatment in
the management of bioburden,
particularly in chronic wound care,
as they have the following benefits:
Provide a high antimicrobial
concentration at the site of
infection (White et al, 2001;
Cooper, 2004)
Have bactericidal effects against
multiresistant organisms such as
methicillin-resistant
Staphylococcus
aureus
(MRSA) (Lawrence, 1998;
Sibbald et al, 2001)
Do not interfere with the
protective bacterial flora in other
parts of the body
Are less likely to produce an
allergic reaction.
Silver
Silver-based products have been
particularly successful in burns
(Klasen, 2000a; Klasen, 2000b;
Demling and DeSanti, 2001), and as
an antimicrobial in general wound
care (Armstrong, 2002; Clarke,
2003) with skin discolouration
(argyria) being the only visible side-
effect (Wright et al, 1998).
Silver ions are highly reactive
and affect multiple sites within
bacterial cells, ultimately causing
Expert opinion
Kate Arkley, Community RGN, Galway, Ireland
T
his is an excellent article
highlighting the clinical
challenges faced by community
nurses in the assessment and
prevention of wound infection. It
clearly demonstrates the complexities
of wound management, while
outlining the multiple levels of
knowledge and clinical judgement
required to prevent and treat wound
infection in clinical practice.
Changing demographics and
the increased likelihood of patients
presenting with comorbidities can
negatively influence the natural
healing process. From a clinical
perspective, the section on dressings
offers practical information to enable
effective decision-making.
The article emphasises the
need for clinicians to recognise
the difference between acute and
chronic infection. It is essential
that community nurses are able
to interpret wound bed changes
accurately. This knowledge will
determine the need for swab
collection if infection is suspected.
In my experience, the fact that
wound swabs need collecting post-
cleansing should be emphasised.
Also, the importance of providing a
detailed history on the request form
ensures that pertinent information,
including symptoms and current
medication, will be routinely
reported. This allows lab technicians
to perform informed microculture
and sensitivity lab testing.
This article is clear, concise and
provides an excellent reference
for community nurses attempting
to minimise wound infection and
promote healing in their practice.
WOUND CARE
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