Jackie Stephen Haynes

I'm Jackie Stephen Haynes and I'm Visiting Professor at Birmingham City University and I'm Consultant Nurse in Worcestershire Health and Care NHS Trust. We use a wound assessment tool. Our tool is based on the acronym of TIME, T being for tissue and I for inflammation infection, M for managing the exudate and E for considering the edge of the wound. So obviously for myself and for the providing the staff education we encourage people to think about T in in terms of the tissue, the type of tissue that you've actually got in the wound and the amount of that different type of tissue and we try to get them to attribute a percentage for each amount of the different types of tissue that they've got. For example, sloughy tissue, granulation tissue, you might have, hopefully you might have some epithelialisation but you may have necrotic tissue. So trying to get cutting people to, and I think perhaps percentages of the overall wound. are particularly helpful, I think in terms of getting the patient on board but in terms of monitoring. We also encourage people to measure in terms of the centimetre, the size of the wound and we're talking about the length and the width and we would use a centimetre probe to measure the depth of the wound. So that's covering T for tissue, I for infection and inflammation and obviously I think that key is about picking up those cues of those very subtle signs of infection that might be easily missed. If we're thinking about managing the exudate and if we can think about the volume and the viscosity, so how much exudate have we got and how thick is that exudate and how are we hoping we're gonna manage that exudate? Or are we thinking our wound is quite dry and we need to do something that's gonna rehydrate it? And I tend to think of how long would an appropriate dressing last for, in terms of trying to consider the wear time in terms of the amount of exudate. So for example, somebody said, we're dressing a wound three times a day. Well, yes, but if you put a piece of gauze on, that might be why. But if you've got an appropriate dressing and you're still doing that, you know you've got a really high volume of exudate. The other thing is obviously that is looking overall at your limb size, and if you've got swelling, you're gonna have more exudate, aren't you, coming from your wound. For us, it's about thinking about what's the edge of the wound and what does the edge of your wound look like? Is it rolled? Is it flat? What's the shape of your wound? So looking very much at that peri-wound edge. And then I want them to just think, is there redness around that peri-wound edge and what else might that indicate? I also want them to think about going away from the peri-wound edge but going to the general skin on the lower leg. What's that lower leg looking like? What's that skin? can you do in terms of assessing that skin and applying some element of nursing care, whether it's washing or applying emollients etc to improve that. And then for us we've got a wound assessment tool that we would document those things on. We also ask people to be clear about on that form about what their objectives are of their wound management and what type of product is going to be appropriate to try to help them to achieve those outcomes. If we are talking a venous ulcer of course we know that somebody does have sloughy tissue we know that compression can help to remove that. So for me it's about that monitoring and I suggest people are undertaking that at least on a weekly basis and if we have somebody who's got a very chronic wound and we're not seeing very significant changes that they're undertaking that and they're documenting that on a monthly basis. Sometimes where you've lost subcutaneous tissue you get a rolled edge and so where that happens you're very less likely to get that wound to be healing across. And the other thing you have to think of is, is there a reason why that wound has started to almost roll round, curl round on itself? Sometimes it's because a wound is too dry. Sometimes it's because we've perhaps left a wound exposed for too long a period. And sometimes it's because we've got a chronic wound that actually hasn't provided any covering over the centre and they're rolling at the edges. And it should really be an indicator to somebody to be thinking, this wound isn't going to progress in a normal manner, what things can we do to try and assist with wound healing? Part of ours is the wound assessment tool that we've got is we then consider and we assess whether they've got pain and if we've got a screening tool on our general wound assessment tool, yes or no, if the patient has we've got a specific one page which asks the patients about the type of pain they've got, things that help with it, things that make it worse, to try to get the patients to work with us to say what are the things that are going to help, what are the things that we now aggravate and what can we do to avoid those. So we've got a specific pain assessment tool based on the original work done by Hollingworth and the work published in Yuma about assessing and managing pain and getting staff aware around considering pain when they're changing dressings in terms of removal, in terms of using warm saline, in terms of applying dressings, with care, taking care. And the other thing is sometimes just taking time out, always making sure patients are offered adequate analgesia. And I'm a real fan of getting people using TENS machines, because actually I find they're very beneficial in patients who've got lower leg problems, and actually often they're on a whole raft of analgesia already, and I find TENS machines really good. I see wound assessment fitting in with our overall leg ulcer assessment. Yeah, we would be asking them about nutrition. In fact, we would screen patients for nutrition and I would say anybody who's got a chronic wound for longer than six weeks, I'd want them to have a full blood count. I want to know what their ESR, white cell count and plasma protein. I always want to screen for anemia and the type and the cause of anemia and I expect those things to be done for all the patients that present with what I would call a chronic wound, frequently a leg ulcer. I think if you're going to do a Doppler ultrasound and you're going to do an assessment of the leg, bear in mind we're, for example, now using the Doplex ability and so we're now able to undertake our ultrasound in less than five minutes to get a good record with the patient, you know, just lying down, is that we're able to do that on patients we weren't previously of course, which is a good bonus, and we're able to do that quite quickly. That speeds the process up. I personally think you probably need to allow at least 45 minutes to do an assessment and to explain to the patient. We have and should be supplying all patients with patients' information and highlighting areas that are particularly relevant. Ours are based on a question and answer format and approved by our patient forum.