Madeleine Flanagan is a Principal Lecturer in the School of Postgraduate Medicine at the University of Hertfordshire in the UK. She is Programme Leader for the MSc Skin Integrity Skills & Treatment and MSc Dermatology Skills & Treatment and has developed an international reputation for the provision of innovative, inter-professional education for practitioners with a special interest in skin integrity, wound management and dermatology.

List of Contributors x

Preface xii

Acknowledgements xiv

Section 1 Principles of Best Practice 1

1 Evidence and Clinical Decision-making 3
Carolina Weller

Introduction: what is effective clinical decision-making? 3

What is evidence-based health care? 4

Common misperceptions about evidence-based practice 5

Challenges to changing practice 7

Factors influencing clinical judgement 8

Evidence-based practice: hierarchy of evidence 9

Evidence-informed decisions 11

Critical appraisal frameworks 11

Clinical guidelines 13

Summary 13

Useful resources 14

Useful critical appraisal frameworks 14

Further reading 15

References 15

2 Maintaining Skin Integrity 18
Arne Langøen and Janice Bianchi

Introduction 18

Impaired skin barrier function in the clinical setting 23

Management of vulnerable skin 27

Summary 30

Useful resources 30

References 30

3 Physiology of Wound Healing 33
Mary Martin

Introduction 33

Types of wound healing 35

Wound chronicity 35

Normal wound healing 36

Optimising healing: general factors 38

Optimising healing: local factors 39

Delayed wound healing 40

Tissue repair in chronic wounds 40

The inflammatory response 41

Proliferation of new tissue 43

Wound closure 45

Summary 48

Useful resources 48

References 48

4 Assessing Skin Integrity 52
Annemarie Brown and Madeleine Flanagan

Introduction 52

Assessing skin integrity 53

Listening: problem orientation and knowledge 53

Looking: problem clarification and knowledge construction 55

Touch: hands on fact finding 56

Smell: subconscious information gathering 57

Assessing wounds 58

Wound bed preparation 58

Data collection 60

Effective documentation 63

When to seek specialist help? 63

Summary 63

Useful resources 64

References 64

5 Principles ofWound Management 66
Madeleine Flanagan

Introduction 66

Principles of wound management 67

Effective wound management 67

Controlling bacterial burden: wound cleansing 68

Controlling bacterial burden: wound debridement 69

Autolytic debridement 69

Enzymatic debridement 69

Biosurgical debridement 70

Mechanical debridement 70

Sharp debridement 70

Hydrosurgical debridement 71

Ultrasound (acoustic pressure wound therapy) 71

Regulating moisture balance 71

Wound dressings 72

Passive inert dressings 74

Interactive dressings 75

Antibacterial dressings 79

Summary 83

Useful resources 83

References 83

6 Wound Infection 87
Valerie Edwards-Jones and Madeleine Flanagan

Introduction 87

Bacterial invasion of the skin 88

Wound pathogens 88

Factors increasing the risk of wound infection 90

The significance of bacteria within wounds 90

Significance of biofilms 92

Identifying wound infection 92

Microbiological assessment of wounds 93

Principles of managing infected wounds 95

Summary 99

Useful resources 99

References 99

7 Psychological Impact of Skin Breakdown 102
Patricia Price

Introduction 102

Psychological impact on the individual and society 103

Adaptation to chronic illness 103

Stress and skin disease 103

Depression 104

Adjustment to physical change/disfigurement 105

Coping strategies 105

Social support 106

Body image 106

Living with skin breakdown and chronic wounds: symptom management 107

Measuring impact of skin breakdown 108

Factors affecting treatment 109

Interventions 111

Clinical reflection 112

Summary 113

Useful resources 113

References 113

Section 2 Challenging Wounds 117

8 Pressure, Shear and Friction 119
Keryln Carville

Introduction 119

Prevalence and incidence 120

Pathophysiology 120

Risk factors 122

Psychological impact 122

Current best practice 123

Prevention strategies 123

Pressure ulceration: assessment considerations 123

Treatment strategies: pressure ulcers 128

Education and support 132

Criteria for specialist referral 133

Summary 133

Useful resources 133

Clinical guidelines 133

Organisations 133

Further reading 133

References 133

9 Diabetic Foot Disease 136
Jan Apelqvist

Introduction 136

Aetiology 137

Psychological impact 139

Principles of diabetic foot ulcer management 140

Diabetic foot ulceration: assessment considerations 140

Assessment of vascular status 143

Assessment of wound infection 143

Management of diabetic foot ulcers 145

Vascular intervention 145

Foot surgery and amputation 146

Debridement 147

Infection in diabetic foot wounds 147

Osteomyelitis 148

Offloading - non-weight-bearing 148

Wound dressings: special considerations 149

Foot care 149

Education and support 150

Provision of specialist diabetic foot services 151

Criteria for specialist referral 151

Summary 151

Useful resources 151

References 152

10 Chronic Ulcers of the Lower Limb 155
Jeanette Muldoon

Introduction 155

Epidemiology 155

Comorbidities and underlying pathologies 156

Rheumatoid arthritis and vasculitis 156

Venous leg ulceration 156

Factors that affect venous return 158

Rarer leg ulcer aetiologies 160

Psychological impact 161

Principles of managing leg ulcers 161

Leg ulceration: assessment considerations 161

Vascular assessment for arterial disease 164

Management of chronic oedema in leg ulcers 166

Wound dressings: special considerations 168

Prevention of ulcer recurrence 169

Education and support 170

Provision of specialist services 170

Criteria for specialist referral 171

Summary 171

Useful resources 171

Further reading 172

References 172

11 Lymphoedema 175
David Keast

Introduction 175

Pathophysiology 176

Risk factors 178

Psychological impact 179

Current best practice 179

Prevention strategies: risk factor management 180

Lymphoedema: assessment considerations 180

Treatment strategies 184

Education and support 189

Provision of specialist services 190

Criteria for specialist referral 190

Summary 190

Useful resources 190

References 191

12 MalignantWounds 193
Wayne Naylor

Introduction 193

Malignant wounds: aetiology 194

Psychological impact 195

Principles of palliative wound management 196

Malignant wounds: assessment considerations 196

Management of malignant wounds 198

Education and support 204

Provision of specialist services 204

Criteria for specialist referral 204

Summary 205

Useful resources 205

References 205

13 Skin Integrity and Dermatology 208
Julia Schofield

Introduction 208

Prevalence and incidence of skin disease 209

Quality of life 209

Cost of skin diseases 209

Management principles 210

Important common skin problems and their management 211

Provision of dermatology specialist services 220

Summary 221

Useful resources 222

Further reading 222

References 222

14 Surgical Wounds 224
Alan Widgerow

Introduction 224

Classification of surgical wounds 224

Principles of surgical wound management 227

Surgical wounds: assessment considerations 227

Preoperative management 228

Intraoperative management 229

Postoperative management 230

Wound closure 231

Management of surgical scars 234

Common reconstructive surgical options 236

Education and support 237

Criteria for specialist referral 238

Summary 238

Useful resources 239

References 239

15 NeglectedWounds 242
Kim Deroo, Lesley Robertson-Laxton, Sabina Sabo and Arlene A. Sardo

Introduction 242

BODY PIERCINGS 242

Risk factors (post-piercing infection) 243

Factors delaying healing 243

Complications 243

Principles of wound management 243

Practical management 243

Practical tips 244

Healing rates 244

Criteria for specialist referral 244

Summary 245

Further reading 245

References 245

BULLOUS PEMPHIGOID 245

Risk factors 245

Differential diagnosis 245

Clinical features 245

Factors delaying healing 246

Complications 246

Principles of wound management 246

Practical management 246

Criteria for specialist referral 246

Summary 246

Further reading 247

References 247

CALCIPHYLAXIS 247

Risk factors 247

Differential diagnosis 247

Clinical features 247

Factors delaying healing 248

Complications 248

Principles of wound management 248

Practical management 248

Criteria for specialist referral 248

Summary 248

Further reading 249

References 249

FISTULAS 249

Risk factors 249

Diagnostic procedures 249