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Inflammation and infection (or bacterial burden)

It is generally agreed that all chronic wounds harbour a variety of bacteria to some degree and this can range from contamination through colonization to infection. There is also a stage between colonization and infection called ‘critical colonization’ where the bacterial load has reached a level just below clinical infection (Collier 2002). When a wound becomes infected, it will display the characteristic signs of heat, redness, swelling, pain, heavy exudate and malodour. The patient may also develop generalized pyrexia. However, immunosuppressed patients, diabetic patients or those on systemic steroid therapy may not present with the classic signs of infection. Instead, they may experience delayed healing, breakdown of the wound, presence of friable granulation tissue that bleeds easily, formation of an epithelial tissue bridge over the wound, increased production of exudate and malodour and increased pain (Cutting 1998, Gilchrist 1999). Careful wound assessment is essential to identify potential sites for infection, although routine swabbing of the area is not considered to be beneficial (Donovan 1998).

Methods available for the management of wound infection or to decrease the bacterial burden in the wound include debridement, antimicrobial dressings, for example those containing iodine or silver, topical negative pressure therapy and antibiotic therapy. Honey and essential oils have also been used and there is a growing body of literature to this effect. Appropriate antibiotic treatment of the infection should be determined from a positive wound swab(s).

Moisture balance

wound exudate usually performs a useful function of cleaning the wound and providing nutrients to the healing wound bed. However, in the presence of excess exudate, the process of wound healing can be adversely affected. This is especially so in chronic wounds where wound fluid may actually prevent the proliferation of cells vital to wound healing, such as fibroblasts, keratinocytes and endothelial cells (Vowden and Vowden 2002).

The control of oedema or lymphoedema and lessening the bacterial burden on the wound will undoubtedly help in the reduction of wound exudate. However, if the methods for achieving these goals are unsuccessful or contraindicated then exudate must be managed through the use of wound management products. These include such products as absorbent wound dressings (e.g. alginates, hydrofibre, foams), non-adherent wound contact layers with a secondary absorbent pad, wound manager bags and topical negative pressure therapy (White 2001). It is also vital to protect the skin surrounding the wound from maceration by excess exudate and excoriation from corrosive exudate. Useful products for skin protection include ointments/pastes (e.g. zinc oxide BP), alcohol-free skin barrier films and thin hydrocolloid sheets used to ‘frame’ the wound.

Edge non-advancement

The clearest sign that the wound is failing to heal is when the epidermal edge is not advancing over time (Dowsett and Ayello 2004). In this case a thorough assessment should commence using the TIME principles and interventions.

Principles of wound cleaning

The aim of wound cleaning is to help create the optimum local conditions for wound healing by removal of excess debris, exudate, foreign and necrotic material, toxic components, bacteria and other micro-organisms.

If the wound is clean and little exudate is present, repeated cleaning is contraindicated since it may damage new tissue, decrease the temperature of the wound unnecessarily and remove exudate (Morison 1989). A fall in the temperature of the wound of 12°C is possible if the procedure is prolonged or the lotions are cold. It can take 3 hours or longer for the wound to return to normal temperature, during which time the cellular activity is reduced and therefore the healing process slowed (Collier 1996).

Sodium chloride (0.9%) is a physiologically balanced solution that has a similar osmotic pressure to that