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• To recognise the holistic factors that need to be considered when assessing and managing wounds
• To enhance your awareness of the available tools that can be used to structure a wound assessment
• To acknowledge the importance of shared decision-making in developing wound care regimens
The assessment and management of impaired skin integrity as part of wound care is a common nursing task. Specific wound assessment tools may assist nurses to structure an assessment, but wider holistic factors also need to be considered. The TIMERS (tissue, inflammation and infection, moisture balance, edge, repair and regeneration, and social factors) tool offers a flexible approach to assessing wounds holistically and can be applied in all wound aetiologies.
This article provides nurses with an overview of the assessment and management of impaired skin integrity using the TIMERS tool. It also discusses the importance of shared decision-making between nurses and patients when formulating a wound care regimen.
Nursing Standard. doi: 10.7748/ns.2022.e11964Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated softwareCorrespondence
Carlin AS (2022) Essentials of wound care: assessing and managing impaired skin integrity. Nursing Standard. doi: 10.7748/ns.2022.e11964
Published online: 12 September 2022
The skin is the primary element of the integumentary system, which is defined as the body’s outer protective layer. In the human body, the skin consists of three layers: the epidermis, dermis and subcutaneous tissue. A person’s skin integrity may become impaired by destruction or disruption of the epidermis and/or dermis, which may result in the formation of a wound (Carlin 2022). A wound may affect all three layers of the skin and can be defined as a discontinuity or breakdown in the skin due to mechanical, thermal or physical damage by an external event, for example a laceration, abrasion or contusion (Mohil 2012).
Wounds are classified as either acute or chronic, although the use of the term ‘hard-to-heal’ has become increasingly common when describing chronic wounds (Atkin et al 2019, Murphy et al 2020). Acute wounds are described as those that heal in a reasonably expected time frame (Jull et al 2015), whereas chronic wounds are more challenging to define (Moffatt et al 2017). Chronic wounds may consist of tissue that has been compromised through an underlying disease such as diabetes mellitus or tissue breakdown through suboptimal perfusion as a result of oedema or impaired blood vessels, for example. Chronic wounds may also fail to heal due to a lack of awareness among healthcare professionals of the skin’s underlying pathophysiology and service delivery factors such as a lack of wound care training among healthcare professionals (Atkin et al 2019).
It has been estimated that the NHS managed 3.8 million wounds in 2017/2018, at an estimated cost of £8.3 billon (Guest et al 2020). In the UK, wound care is predominantly undertaken by nurses, so it is necessary that they are aware of the essential principles involved in this task (Pagnamenta 2017).
Various frameworks are available to aid wound assessment, but no one tool meets all the needs of nurses because a balance is required between the tool providing as much detailed information as possible and it being user-friendly (Greatrex-White and Moxey 2015).
Use of either the National Wound Assessment Form (Fletcher 2010) or the Applied Wound Management framework (Gray et al 2005) may support inexperienced healthcare professionals to undertake wound assessments (Greatrex-White and Moxey 2015). The National Wound Assessment Form is a useful standalone tool that includes extensive demographic information, as well as wound indicators such as tissue type, wound size and moisture levels (Fletcher 2010). Conversely, the Applied Wound Management framework can aid decision-making due to its logical approach, which includes the use of assessment descriptors and management options (Gray et al 2005, 2009).
The ‘TIMERS’ tool provides an alternative approach to wound assessment that is versatile, user-friendly and holistic. It is comprised of the following elements (Atkin et al 2019):
• Inflammation and infection.
• Moisture balance.
• Repair and regeneration.
• Social factors.
This article considers each element of the TIMERS tool to provide nurses with an overview of the assessment and management of common wound types.
Wound tissue is either viable or non-viable (devitalised). Table 1 shows the main wound tissue types.
|Tissue viability||Tissue type||Description||Wound bed preparation||Aim|
Debridement may be required to remove devitalised tissue and debris (Murphy et al 2020), and can be achieved through mechanical or autolytic means. Mechanical debridement usually involves the use of mechanical force such as pulsatile lavage or irrigation with a solution. Autolytic debridement is a more conservative approach that encourages a moist environment within the wound. This is usually achieved by the application of a moisture-retaining dressing to promote the removal of devitalised tissue through the debriding action of phagocytic cells (for example, white blood cells that engulf and destroy harmful bacteria) and enzymes (Joint Formulary Committee 2022, Manna et al 2022).
The primary goals of debridement are to remove devitalised tissue, decrease odour, reduce infection risk and stimulate the wound edges to promote viable epithelial tissue growth, which will subsequently support healing and thereby enhance the patient’s quality of life (Strohal et al 2013, Manna et al 2022). However, debridement may not always be appropriate (Atkin et al 2019); for example, caution must be taken in patients with inadequately perfused lower limbs, autoimmune conditions, bleeding disorders and those taking anticoagulants. There is also a risk of pain, particularly when using mechanical debridement, although a topical anaesthetic such as lidocaine hydrochloride can be considered (Murphy et al 2020).
To ensure effective wound monitoring and to identify the tissue type within the wound, the nurse should document any significant features, including exposed tendon, bone, muscle or foreign bodies.
Biofilm is a thick, ‘slimy’ layer comprised of a microbial colony that can form in the wound bed and is a barrier to wound healing. Biofilm should be removed and Murphy et al (2020) recommended a technique termed ‘wound hygiene’, whereby the wound and surrounding skin is cleansed and the wound edge refashioned. Rather than focusing solely on devitalised tissue, refashioning is a form of debridement that involves the removal of any necrotic, curled, rolled, dry, callused or hyperkeratotic tissue at the wound edges, thereby minimising the development of biofilm colonies (Murphy et al 2020).
Any fresh viable tissue in the wound should be protected from infection and considered for moist wound healing. This technique involves the wound being occluded with a dressing, which leaves it neither too wet nor too dry, thus supporting the ideal conditions for wound healing (Atkin et al 2019).
Wound healing takes place in four stages (Carlin 2022):
• Haemostasis – at the point of injury. Vasoconstriction and blood clotting commence.
• Inflammation – 5-10 minutes after the injury. Vasodilation and increased capillary permeability enable inflammatory cells to enter the wound, controlling bleeding and preventing infection.
• Proliferation – three days to three weeks after the injury. Angiogenesis (development of new blood vessels) and granulation begin to take place.
• Maturation – 21 days to two years after the injury. The collagen fibres mature and scar formation begins.
Inflammation is likely to occur up to five days following the injury. However, it can be possible to mistake early inflammation as wound infection, particularly in chronic wounds (Carlin 2022). Characteristics of infection include heat, redness, swelling, pain, increased exudate, malodour and potentially pyrexia (Lister et al 2020). However, vasodilation in the inflammatory phase will also result in swelling, redness, heat and pain due to stimulation of the nerve endings (Carlin 2022).
The nurse can differentiate between inflammation and infection through the use of wound swabs and by observing for further symptoms associated with wound infection, such as increased heat and malodour. Generally, a wound swab should be obtained using the Levine technique, which involves the nurse first cleaning the wound area with saline (antiseptic should not be used), then rotating the swab under pressure over a 1cm2 area for five seconds to extract exudate (Copeland-Halperin et al 2016, Public Health England 2018). Where necessary, local laboratories will be able to offer guidance to nurses on swabbing.
Samples of pus from the wound are preferrable to swabs, but may need to be extracted by a medical professional (Public Health England 2016). Any suspected wound infection can also potentially be investigated through venous blood sampling. Swabs are recommended for secondary bacterial infections of eczema where there is deterioration despite the use of antibiotics (National Institute for Health and Care Excellence (NICE) 2021). The results of a swab may assist in prescribing decisions, including the selection of narrow-spectrum antibiotics for infected eczema and in critically colonised wounds (NICE 2021).
The practice of wound cleansing with tap water or sterile saline as a means of preventing and controlling infection remains controversial due to a lack of clear evidence. For example, a Cochrane review by McLain et al (2021) concluded that there was insufficient evidence to advise wound cleansing in venous leg ulcers. However, in post-operative wounds, NICE (2020) guidelines recommend using sterile saline for wound cleansing up to 48 hours following surgery.
It is important for the nurse to explore the patient’s wound-cleansing priorities with them, particularly if they are self-managing their wounds. It may be more appropriate for the patient to use a clean technique rather than an aseptic non-touch technique, particularly since additional training is required to maintain an aseptic non-touch technique. A clean technique is a modified aseptic non-touch technique which aims to avoid the introduction of microorganisms to the wound site through use of single-use non-sterile gloves and tap water (Lister et al 2020). The use of tap water when cleansing chronic wounds does not increase infection rates (Fernandez and Griffiths 2012), and bathing limbs affected by venous leg ulcers in warm tap water may improve the patient’s well-being (McLain et al 2021).
The presence of exudate in a wound is normal and can aid autolytic debridement, provide nutrients to the wound bed and enable epithelial cell movement (Lister et al 2020). Epithelial cell movement typically starts at the wound edges (Murphy et al 2020) and in moist environments, skin cells are able to ‘skate’ across the surface of the wound bed to enable contraction. However, in the author’s clinical experience, a common misconception among healthcare professionals is that leaving a wound open to dry promotes healing. In fact, research suggests that a moist wound environment enables faster healing (Winter 1962, Hinman and Maibach 1963). Winter (1962) found that full thickness wounds in pigs contracted more rapidly in a moist wound environment that was provided by an occlusive dressing, and scars were smaller, compared with wounds left exposed to the air. Despite the age of these studies, the principle of moist wound healing is still considered best practice (Carlin 2022).
To support a moist wound environment, the nurse should consider the use of various products and moist wound dressings such as hydrogels, hydrocolloids, alginates and foams, in combination with monitoring exudate levels. Excessive levels of exudate may contribute to a type of moisture-associated skin damage known as periwound maceration. Liquid barrier films can assist the nurse to protect the skin from moisture-associated skin damage (Bodkhe et al 2021).
In practice, the patient’s priorities should inform the nurse’s decision-making with regards to exudate management. For example, it has been identified that patients often prefer dressings that are comfortable and flexible, and that they are confident will not leak or smell (World Union of Wound Healing Societies 2020). Superabsorbent dressings can absorb and retain medium-to-high levels of exudate (Mahoney 2019), whereas foam dressings support low-medium levels of exudate (Joint Formulary Committee 2022). Patients may request a dressing that is not too ‘bulky’ or conspicuous (World Union of Wound Healing Societies 2020), and nurses should also consider the patient’s skin tone. Dressings tend to be pale in colour and this can be useful when assessing bleeding and exudate. However, if a patient with a darker skin tone feels self-conscious about the dressing colour, then the nurse should consider using a transparent dressing, depending on the wound’s exudate level. The use of thin transparent hydrocolloid dressings are only recommended for non or low-exuding wounds and misuse can lead to moisture-associated skin damage (Wounds UK 2021).
The nurse should document wound measurements such as length, width and depth, since these are vital when seeking to establish the progress of a wound (Gray et al 2005, Fletcher 2010). If a wound edge fails to repair despite appropriate management, specialist interprofessional input may be required to identify the potential cause, such as inadequately managed diabetes or a compromised vascular system.
A range of specialist healthcare professionals may be able to provide guidance; for example, people living with non-critical limb ischaemia should be referred to a foot protection service (NICE 2019), while podiatrists are skilled in sharp debridement and vascular assessment, and could refashion a patient’s wound edges if there are adequate levels of perfusion. Tissue viability nurses can also provide guidance. For example, in the case of a patient undergoing palliative care and who had developed a fungating wound and deteriorating wound edges, the tissue viability nurse might recommend non-invasive conservative management aimed at increasing the patient’s comfort, rather than wound closure.
Common methods of wound repair include:
• Primary intention – where the wound edges are brought together using clips or sutures, for example in acute surgical wounds (Doughty and McNichol 2016). Figure 1 shows a three-day-old traumatic skin tear treated using primary intention. Primary intention was attempted using skin closure strips; however, swelling resulted in slight wound dehiscence (a rupture along the surgical incision). Consequently, primary intention was only partially effective on this occasion.
• Secondary intention – where the wound edges cannot be brought back together and the wound is left to heal naturally, following the four stages detailed previously (Lister et al 2020). For example, an endoanal pilonidal sinus may be left open to enable drainage and healing from the wound base via secondary intention (Talini et al 2015).
• Tertiary intention or delayed closure – where the wound is initially left open, then closed once swelling has reduced; for example, Fournier’s gangrene (a rare type of life-threatening bacterial infection affecting the external genitalia or perineum) may be treated by tertiary intention (Papadimitriou et al 2015).
As part of a holistic assessment, the nurse should consider the patient’s socio-economic status – such as their educational attainment, work history, environment, social group and family dynamics – and patient-related factors (Atkin et al 2019). For example, patients with chronic wounds may have a reduced quality of life, social isolation, limited access to healthcare and low health literacy (Atkin et al 2019). In addition, factors such as obesity, suboptimal nutritional status and arterial insufficiency may negatively affect wound healing (Jockenhöfer et al 2016).
• A person’s skin integrity may become impaired by destruction or disruption of the epidermis and/or dermis, which may result in the formation of a wound
• Wound care is predominantly undertaken by nurses, so it is necessary that they are aware of the essential principles involved in this task
• The TIMERS tool can be used to structure a wound assessment and is comprised of: tissue, inflammation and infection, moisture balance, edge, repair and regeneration, and social factors
• Shared decision-making and open discussions with the patient about any proposed wound care regimen are integral to supporting their adherence to management
Shared decision-making is a joint process that enables nurses to support patients to reach a decision about their care (NICE 2022). Shared decision-making and open discussions with the patient about any proposed wound care regimen are integral to supporting their adherence to management. Adherence or concordance implies that the patient has taken an active part in the decision-making process and made a choice, rather than being passive or obedient (Price 2008). Nurses should recognise and address factors that can contribute to non-adherence, such as: patients’ limited understanding of wounds and their management; patients forgetting or not wanting to take medicines; and patients’ preferences, for example not wearing compression hosiery because it does not fit with their preferred shoes (Moffatt et al 2017).
Exploring the patient’s readiness for change and the use of motivational interviewing may assist the nurse to improve adherence and thus support wound healing (Callender et al 2021). Motivational interviewing is a collaborative and person-centred form of guidance, which aims to strengthen an individual’s motivations to make behavioural changes (Miller and Rollnick 2009). For example, the nurse might use motivational interviewing to encourage a patient with a leg ulcer and oedematous limbs to consider limb elevation when resting to manage excess fluid.
Initial care-planning discussions with the patient should identify the aims of care. In the author’s clinical experience, these aims of care may include pain relief, reduction of bioburden and/or malodour, protection of granulation or epithelial tissue, exudate absorption and debridement. Once the aims of care have been established by the nurse and the patient, wound care products may be required to achieve these aims. It may be useful for the nurse to consider dressing selection as a prescribing decision, because this raises their awareness of the associated risks (Carlin 2018). For example, povidone-iodine dressings might be useful for reducing bioburden, but they are contraindicated in people with thyroid disorders and infants aged under 32 weeks (Joint Formulary Committee 2022). Therefore, a holistic assessment including the patient’s medical history is fundamental to ensuring safe and effective wound care.
A care plan should also outline the patient’s primary and secondary dressings and the associated rationale for use, since this will provide clear information for other nurses and healthcare professionals. For example:
• Primary dressing – povidone-iodine impregnated gauze. Rationale – to reduce bioburden and protect granulation tissue in a skin tear on the patient’s left elbow.
• Secondary dressing – foam dressing. Rationale – to improve the patient’s comfort, protect the elbow tissue and absorb minimal levels of exudate.
Wound ‘ownership’ and encouraging patients to take control of their own health are fundamental to promoting self-care (Lusher 2020). Therefore, where possible, nurses should encourage patients to consider self-care products that are multipurpose and easy to use. An example might be a spray-on primary wound dressing, which supports a moist wound environment and has antimicrobial properties (Elliott 2019).
For practical wound care guidance for patients, nurses should consider accessing the National Wound Care Strategy Programme resources available at: www.nationalwoundcarestrategy.net/nwcsp-publications-and-resources. These resources can be combined with the nursing considerations for self-care in patients with wounds shown in Box 1.
• Is the patient or their family members and/or carers physically and emotionally able to undertake a wound care regimen, including dressing changes?
• Can the patient reach the wound area safely and effectively?
• Does the patient have the adequate eyesight and dexterity levels required to undertake the regimen?
• Is the patient willing, competent, confident and able to raise concerns about the wound care regimen if required?
• Are any wound-related care plans clear and do they factor in the patient’s level of health literacy?
(Adapted from Barrett et al 2020)
It is essential that nurses seeking to provide evidence-based wound care can undertake appropriate assessments in patients with impaired skin integrity. Specific tools that can assist with wound assessment include the Applied Wound Management framework (Gray et al 2005) and National Wound Assessment Form. However, a generic system such as the TIMERS tool may offer greater versatility and insight into the holistic factors that may affect wound healing and management. Nurses should ensure they use shared decision-making with patients to enhance their adherence to management and their ability to self-care for wounds.
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