2019_WUWHS-Exudate_WINT web (2)
… Furthermore, if the exudate comes into contact with periwound skin, it can damage the skin and even cause wound expansion (Wounds UK, 2013). 10 Figure 2: Periwound maceration Periwound skin damage (photograph courtesy of Dr Periwound skin damage includes maceration and erosions of the skin surface (Figure 2). … Clinicians should expect to adjust management • and to be prepared to ‘step up’ and ‘step down’ treatment as needed to ensure that the appropriate treatment is used at the appropriate time 215 W O R L D U N I O N O F W O U N D H E A L I N G S O C I E T I E S CONSENSUS DOCUMENT Figure 5: Local management of wound exudate Local management of wound exudate Black necrotic Black/grey Slough Granulating Epithelialising d tissue Yellow, brown, grey or black Clean, red Mostly or n necrotic tissue u e o p Desiccated tissue w y Dessicated completely t t e due to ischaemia, devitalised tissue covered in n u a s n s i i e.g. an ischaemic and slough in the epithelial tissue t m o d toe or heel of wound bed; no Red, pink d e e b r a patient with ischaemia P diabetes e Moderate to high Moderate to high t l Dry Dry Low exudate Low exudate Dry/low exudate a e d v exudate exudate u e x l Falanga score 1 Falanga score 1 Falanga score 1 Falanga score 1 Falanga score 1 E Falanga score 2–3 Falanga score 2–3 • Keep dry • Remove eschar • Remove slough • Remove slough • Protect new • Protect new • Protect new • Refer for (debridement/ (debridement/ (debridement/ tissue tissue epithelial tissue s vascular autolysis) autolysis) autolysis) • Promote a • Absorb/contain • Prevent new m i moist wound excess exudate a assessment • Rehydrate • Rehydrate • Absorb/ tissue drying t n contain excess environment • Treat/prevent e wound bed wound bed out m periwound t exudate a e r • Treat/prevent maceration/ T periwound erosions maceration/ erosions • Low adherent • Hydrogel • Hydrogel • Alginate • Hydrogel • Alginate • Continue to contact layer dressing dressing dressing dressing dressing cover for 1–2 that does not • Foam dressing • Foam dressing • Carboxyme- • Low adherent • Carboxyme- weeks after retain moisture thyl-cellulose dressing thyl-cellulose complete epi- or rehydrate dressing • Hydrated dressing thelialization to cover area • Foam dressing polyurethanes • Foam dressing • Thin hydrocol- and to separate • Superabsorbent • Superabsorbent loid from adjacent dressing dressing • Low adherent tissues, e.g. • NPWT • NPWT dressing place between • Ostomy/fistula • Ostomy/fistula • Consider emol- toes appliances appliances lient • Consider apply- • Consider apply- • Implement s ing a periwound ing a periwound preventative n protectant protectant o measures as i t p indicated o n o i t Periwound skin damage/maceration: use low adherent contact layers or low adherent dressings, e.g. n e v silicone, and periwound skin protectant. … Journal of Clinical Microbiology 51(10): 1-6 (New Rochelle) 2(8): 438–47 Ganong WF (2005) Review of medical physiology. New York: McGraw-Hill McGuinness W, Vella E, Harrison D (2004) Influence of dressing changes on wound temperature. …
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