Assess
Treat
Review
Notes
*Microbial-binding dressings have a DACC coating that can control microbial burden to prevent or manage infection in a way that is not expected to contribute to antimicrobial resistance. All treatments should be used per local policy and where clinically appropriate. See below for supplementary tables and references. Aetiology-specific varients of this pathway are available for diabetes-related foot ulcer s and venous leg ulcers.
Abbreviations
DACC=dialkylcarbamoyl chloride; TIMERS=Tissue, Infection/Inflammation, Moisture balance, Edge/epithelialisation, Regeneration and repair, Social factors
Aspects of a holistic patient assessment in hard-to-heal wounds
– adapted from TIMERS¹⁻⁶
Patient assessment
Comorbidities
Current medication
Functionality and mobility
Nutritional assessment
Skin assessment (including skin tone)
Social factors
Surgical and medical history
Local assessment
Ankle brachial index, toe brachial index and toe systolic pressure (lower leg)
Oedema
Skin perfusion
Skin temperature
Surrounding skin condition
Transcutaneous oxygen pressure
Vitals
Wound assessment
Aetiology and classification
Imaging as appropriate
Location, duration, size and depth
Odour
Pain (see guidance)
Periwound condition
Previous investigations and treatments
Tissue biopsy (if appropriate in ≥3 months duration or atypical presentation)
Tissue types on wound bed (necrotic, sloughy, granulation or epithelial)
Risk factors for wound infection
– adapted from the International Wound Infection Institute¹ ¹⁵ ¹⁶
Patient risk factors
Alcohol, smoking or illicit drug use
Conditions associated with hypoxia or poor perfusion (e.g. anaemia, cardiac disease, respiratory disease, peripheral arterial disease, renal impairment or rheumatoid arthritis)
Connective tissue disorders (e.g. Ehlers-Danlos syndrome)
Corticosteroid use
Immune disorders (e.g. acquired immune deficiency syndrome)
Lymphoedema
Malnutrition or obesity
Neuroarthropathy
Peripheral arterial disease (including ischaemia)
Peripheral neuropathy (sensory, motor and autonomic)
Poor adherence to treatment plan
Poorly controlled diabetes
Radiation therapy or chemotherapy
Wound risk factors
Atypical aetiology⁵
Duration of wound
Foreign body presence (e.g. drains, sutures or wound dressing fragments)
Haematoma
Impaired tissue perfusion
Increased exudate and oedema that is not adequately managed
Involvement of tissue deeper than skin and subcutaneous tissues (e.g. tendon, muscle, joint or bone)
Necrotic or sloughy wound tissue
Probing to bone
Wounds over bony prominences
Environmental risk factors
Hospitalisation (due to increased risk of exposure to antimicrobial-resistant microorganisms)
Inadequate hand hygiene and aseptic technique
Inadequate management of moisture (e.g. due to exudate, incontinence or perspiration)
Unhygienic environment (e.g. dust, unclean surfaces, or presence of mould/mildew)
Signs of sepsis²⁴
Sepsis is a life-threatening condition in which the body's response to infection causes injury to its tissues and organs. Organ dysfunction is a key component in any diagnosis of sepsis.
Act on any of the following red flags:
S. Slurred speech or confusion
E. Extreme shivering or muscle pain
P. Passing no urine (in a day)
S. Severe breathlessness
I. It feels like you are going to die
S. Skin mottled or discoloured
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