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INSIGHT Devising a treatment programme to address the challenges of excess exudate Joy Tickle Lt d The biggest burden...

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INSIGHT

Devising a treatment programme to address the challenges of excess exudate Joy Tickle

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The biggest burden of chronic wounds, however, falls on patients and families. As mentioned above, increases in exudate production and bacterial burden can lead to pain, discomfort and anxiety due to increased dressing changes (Edwards, 2013).

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A chronic heavily exuding wound can have a devastating impact on a patient’s quality of life, often resulting in symptoms such as increased pain, depression, anxiety and stress, as well as a loss of independence and social isolation. For community nurses, wounds with high levels of exudate can incur increasing costs, both in time and resources. It is imperative to heal these wounds as quickly as possible and the community nurse should undertake a robust and holistic assessment before implementing a clear and evidence-based management plan, potentially including wound debridement and the use of an effective absorbent dressing in combination with compression therapy, where appropriate, to manage exudate. This article examines the development of chronic wounds and the problem of excess exudate production specifically, before going onto look at the benefits of one particular superabsorbent dressing (Flivasorb®; Activa Healthcare/L&R). The author uses extensive evidence as well as clinical expertise to provide an overview of the dressing, and presents a case study to demonstrate its benefits in practice.

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KEYWORDS:

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 Chronic wounds Exudate  Superabsorbent dressings

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chronic wound is defined as one that does not heal in an orderly sequence or predictable timeframe and fails to progress along the wound-healing continuum. In the UK alone, there were recently estimated to be 1.3 million chronic wounds, of which 153,000 were pressure ulcers, 253,000 dehisced surgical wounds, 169,000 diabetic foot ulcers and 730,000 leg ulcers (Guest et al, 2015). A leg ulcer is defined as a wound between the knee and the ankle that takes more than two weeks to heal (National Institute for Health and Care Excellence [NICE], 2016).

The cost of wound management to healthcare providers in the UK is estimated to be between £4.5–5.1 billion per year, two-thirds of which is incurred in the community setting. In hospitals it is estimated that between 25–40% of beds are occupied by Joy Tickle,tissue viability nurse specialist; clinical lead, Shropshire Community NHS Trust

patients with wounds (Posnett et al, 2009). This financial burden can only have a negative impact on the already over-stretched NHS budget, particularly as NHS England’s Five Year Forward View (NHS England, 2014) outlined plans to introduce cost savings to close a funding gap of £30 billion by 2020/21. The burden of chronic wound management can also put enormous pressure on clinicians, particularly community nurses. Chronic wounds are associated with increased exudate levels, which if not managed properly can lead to a greater risk of wound infection, skin maceration and delayed healing (Tickle, 2016). For the community nurse, wound chronicity leads to more patient appointments and an increased use of resources and wound dressings, with 61-64% of the cost associated with the management of venous leg ulcers, for example, related to community nursing visits (Guest et al, 2015).

Similarly, patients often experience psychosocial problems such as embarrassment and a loss of dignity when a chronic wound leaks exudate and becomes malodorous (Faucher et al, 2012). As well as the emotional impact, a chronic wound will also frequently involve the patient having to wear oversized clothes/footwear to accommodate wound dressings and disguise any exudate leakage, which can impact on mobility (Persoon et al, 2004). Leakage may also impact upon the patient’s everyday household duties as it can increase the amount of laundry and personal hygiene needs, which may be physically challenging for some patients (Tickle, 2016).

CLINICAL CHALLENGES. It is important that community nurses remember that wound exudate is a natural and vital component of the wound-healing process, which is generated as a part of the natural wound inflammatory response and proliferative phase and, in the author’s experience, is essential for the reparative process. When a wound becomes chronic, however, this can involve changes in the volume and viscosity of wound exudate, resulting in significant clinical challenges for the patient and the community nurse.

Bacterial load

Increased exudate is associated with the presence of biofilms, surface-attached communities of microorganisms that are encased in a JCN 2016, Vol 30, No 5

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Tissue non-viable

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Inflammation and/or infection

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Moisture balance

Figure 1. The TIME acronym indicates potential barriers to wound healing.

CASE STUDY

WOUND MANAGEMENT

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Leg ulceration

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The location of the wound may also influence the level of exudate, for example, venous leg ulcers and lower limb oedema involve high fluid volumes due to underlying

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This increased exudate and slough escalates the bacterial burden, which increases the risk of critical colonisation and or wound infection (Vowden et al, 2015).

Another consequence of increased exudate and slough is more frequent dressing changes due to exudate strikethrough and leakage, as well as subsequent periwound maceration caused by the enzymes contained within the exudate. Frequent dressing changes can lead to skin stripping (Drewery, 2015), and these types of periwound skin damage can increase pain and discomfort for the patient (Vowden et al, 2015).

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strong extracellular matrix formed of carbohydrates, proteins and/or DNA. Biofilms form an extremely effective protective barrier against antibodies, antibiotics and antimicrobial agents (Schultz and Dowsett, 2012), and mature biofilm colonies can form in 2–4 days, perpetuating the inflammatory response and resulting in increased exudate and slough (masses of dead cells that collect in the exudate) and wound degeneration.

Compression therapy is the ‘gold standard’ treatment for venous leg ulceration and is also effective in the management of lower limb oedema. It is therefore imperative that community nurses implement an effective wound assessment and management plan alongside compression therapy.

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impaired venous return/ lymphatic drainage. This, in turn, can lead to non-healing ulceration, ‘weeping’ oedema, skin excoriation/maceration and increased risk of wound/skin infection (NICE, 2016).

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To effectively assess and manage wounds it is essential that community nurses first address all the factors that might act as a barrier to wound healing. The TIME acronym may assist clinicians when considering these barriers (Figure 1), including the presence of non-viable tissue; inflammation and infection;

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Ms L is a 70-year-old woman with chronic leukaemia who presented to the tissue viability service with a 12-month history of chronic lower limb ulceration. On presentation the wound bed consisted of a combination of sloughy and necrotic tissue with high levels of exudate and malodour, while the limb itself was distorted in shape. Debridement of the wound was difficult due to pain and discomfort experienced by the patient (Figure A). Following assessment, a treatment plan was implemented using a Monofilament Fibre debridement pad (Debrisoft®; Activa Healthcare/L&R) to debride the wound bed with minimal discomfort to the patient. This allowed speedy removal of the devitalised tissue and assisted in reducing bacterial burden. The author decided to use a superabsorbent dressing (Flivasorb®; Activa Healthcare/L&R), mainly to allow the effective management of the high levels of exudate being produced by the wound and to reduce the amount of dressing

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strikethrough, which would contribute to improving the patient’s quality of life. The author also began to apply inelastic compression bandaging (Actico®; Activa Healthcare/L&R) to help manage the exudate levels. The conformable properties of the Flivasorb dressing ensured that it it was comfortable underneath the compression therapy and did not affect the sub-bandage pressures exerted by the compression. Within two weeks, the wound showed reduced exudate levels, increased granulation tissue and improved periwound skin condition,

while the patient commented that the dressing increased her comfort levels (Figure B). The reduction in exudate levels and management of the patient’s distorted limb shape meant that the compression bandaging could then be changed to a compression hosiery kit (Leg Ulcer Hosiery Kit®; Activa Healthcare/L&R). This case shows that a reduction in exudate levels when managing leg ulcers can trigger a review not only of the type of dressing selected, but also the type of compression. This can bring about reductions in clinicians’ time and improve quality of life for the patient.

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Compression therapy

Compression therapy using either bandages or hosiery is designed to support the veins in the lower limb and increase circulation in the legs. Compression is fundamental to controlling lower limb oedema, managing venous ulceration and skin changes, and reducing exudate. Compression also improves limb shape and reduces wound size.

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By obtaining a clearer picture of the wound’s status, an appropriate and timely treatment regimen can be implemented. When considering which method of debridement to use, e.g. mechanical, sharp or autolytic, it is important that the community nurse chooses one that is effective, safe, and acceptable to the patient.

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Newer mechanical debridement tools use Monofilament Fibre Technology TM (Debrisoft®; Debrisoft® Lolly; Activa Healthcare/L&R) to effectively remove dead tissue, slough and hyperkeratosis, facilitating gentle debridement within minutes. From the author’s clinical experience, all staff (and carers/patients) can successfully debride wounds/skin using monofilament fibre pads due to their simplicity. As well as the clinical benefits, using monofilament fibre pads can reduce nursing time and promote increased skill-mix within the clinical team as different levels of staff are able to use them (NICE, 2014; Tickle, 2016). Early and regular wound debridement is likely to accelerate wound healing and is associated with reductions in odour, bacterial burden, slough and exudate as a result of

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Maintaining healthy skin is also extremely important. Patients with lower limb conditions such as oedema, or underlying venous or lymphatic complications may present with skin changes such as hyperkeratosis (dry scaly areas of skin), dermatitis and cellulitis, which, if not managed effectively can lead to leaking ‘weepy’ limbs and chronic ulceration. These symptoms can be managed with regular cleansing and debridement, lower limb elevation, and compression therapy (Scottish Intercollegiate Guidelines Network [SIGN], 2010).

In cases of lower limb oedema, particularly where exudate or leaking is a challenge, cohesive inelastic bandages are recommended as they reduce oedema more quickly than elastic bandages, therefore having a positive impact on exudate reduction (Atkin and Tickle, 2016). This is due to the higher standing and working pressure and lower resting pressure of inelastic systems (e.g. Actico®, Activa Healthcare/L&R), which improves patient comfort at the same time as increasing the effectiveness of the calf muscle pump (where the muscles in the calf help to return blood to the heart during walking) (Wounds UK, 2014).

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Once the wound has been successfully debrided, the community nurse is able to:  Assess the tissue type(s) within the wound  Record the wound size and depth  Assess the condition of the periwound skin/tissue.

Skin care

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Devitalised tissue must be effectively debrided to assist tissue repair (Strohal et al, 2013); not only does this optimise wound healing, but it also allows the clinician to have a clearer picture of the wound and surrounding skin (Stephen-Haynes and Callaghan, 2012). Devitalised tissue (including necrosis and slough) may lead to increased bacterial bioburden/ infection, malodour and increased pain and distress for patients, all of which impede wound healing.

In a recent survey of 475 clinicians, 87% reported that exudate production reduced in a very short period of time when following a twoweek biofilm pathway incorporating Debrisoft. This is most likely because the biofilm had been managed (Morris et al, 2016).

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Debridement

biofilm disruption (Vowden and Vowden, 2011).

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uncontrolled moisture balance (too much or too little moisture in the wound); and any changes in the wound edges or surrounding skin.

Before beginning compression, however, it is imperative that the community nurse undertakes a robust assessment of the patient and their wound/skin, as well as performing a vascular assessment to make sure there are no contraindications, such as arterial disease. The choice of compression therapy will depend upon the outcomes of the assessment, the clinician’s knowledge and skills, the available resources and patient choice. For example, assessment may indicate that a patient with a heavily exuding wound initially requires compression bandaging; whereas lower exudate levels may be more suited to a hosiery kit.

Hosiery kits

When limb distortion and exudate volumes have been successfully reduced with compression bandaging, the patient can be stepped across to an effective alternative such as a leg ulcer hosiery kit. The use of hosiery kits has been endorsed by a recent randomised control trail, the Venus IV trial, which highlighted that the use of active compression hosiery kits are a viable and cost-effective alternative to graduated compression bandages, with the added benefit of reducing recurrence rates, an effect believed to be related to the promotion of patient self-care (Ashby et al, 2014).

Dressing selection

Moist wound healing is essential and requires a balance between excessive moisture and the wound bed becoming too dry (White and Cutting, 2006). Effective dressing selection is an important component in achieving this balance. It is essential that the community nurse fully understands that dressing selection should be tailored to the condition of the wound and the type and amount of exudate being produced (Dowsett, 2012); furthermore, they should understand the composition and mode of action of dressings that have been designed to manage exudate so that they can select the most appropriate dressing and apply it effectively and efficiently. For example, while foam dressings are commonly used to control exudate, their fluid-handling capacity may be inadequate, which can mean the

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Pain relieving properties

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Suprasorb X +PHMB ®

The right properties for managing wound pain with infection 1 Gilliver, S. (2009) PHMB: a well-tolerated antiseptic with no reported toxic effects. Journal of Wound Care/Activa Healthcare Supplement. 2 Eberlein, T. et al. (2012) Comparison of PHMB-containing dressing and silver dressings in patients with critically colonised or locally infected wounds. Journal of Wound Care, Vol.21 (1), p. 12-15.

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KEY POINTS &RPPXQLW\QXUVHVVKRXOGFRQVLGHUWKHIROORZLQJZKHQSURYLGLQJH[XGDWHPDQDJHPHQW Assessundertake a robust and holistic assessment, considering any factors which act as a barrier to wound healing (TIME is a useful acronym to remember in this.) Debridement aids wound assessment, and regular use is likely to accelerate wound healing and is associated with reductions in odour, bacterial burden, slough and exudate. Debrisoft® is a safe, fast and effective option for debridement



Dressmoist wound healing is essential and requires a balance between excessive moisture and the wound bed becoming too dry – effective dressing selection is an important component in achieving this. An effective absorbent dressing should: support moist wound healing, absorb and retain exudate, reduce bioburden, prevent skin maceration/excoriation, facilitate patient comfort and improved quality of life, assist in optimising healthcare resources, and work effectively under compression. Flivasorb® is shown to deliver these benefits.



Compress compression is fundamental to controlling lower limb oedema, managing venous ulceration and reducing exudate. Where exudate is a challenge, cohesive inelastic bandages such as Actico® are recommended. When limb distortion and exudate volumes have been successfully reduced, leg ulcer hosiery kits, such as Activa® or ActiLymph® Hosiery Kits, are an effective solution for continuing care.

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Wound dressings vary in the way they absorb and retain exudate, for example, simple absorptive dressing materials take up fluid into spaces in their structure by wicking the exudate laterally, across the dressing (or in

some cases vertically into the dressing) and are aided by moisture vapour transmission (a type of evaporation). However, to help solve the problem of fluid retention within the dressing, other products form a gel or use fibres/ particles to trap or ‘lock-in’ exudate and its components (e.g. bacteria and proteases), helping to influence the composition of exudate in the wound (World Union of Wound Healing Societies [WUWHS], 2007).

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nurse needs to perform more frequent dressing changes; also, foam dressings may struggle to contain fluid under pressure, eg under compression bandaging (Jones, 2016).

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Suitable for use underneath FRPSUHVVLRQWKHUDS\

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Conducive to moist wound healing

Attributes of an H;HFWLYH absorbent dressing

Assist in preventing complications and optimising healthcare resources

Figure 2. Main attributes of an effective absorbent dressing. JCN 2016, Vol 30, No 5

An effective absorbent dressing selection will make a real contribution to the healing progress of the wound and, most importantly, the comfort, and quality of life for the patient (Stephen-Haynes, 2011). The crucial attributes of an effective absorbent dressing are shown in Figure 2.

FLIVASORB®

Prevent skin maceration/excoriation

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Often, dressing products combine different materials, and techniques resulting in a wide range of products that vary considerably in their fluid-handling characteristics and abilities (Romanelli et al, 2010). It is particularly important that community nurses consider a dressing that retains fluid effectively when it is used under compression. If not, the pressure may cause fluid to leak from any dressing used, causing the harmful exudate to make contact with the wound/skin.

The Flivasorb® (Activa Healthcare/ L&R) range of dressings offers the community nurse the choice of a conformable superabsorbent dressing that acts as a primary dressing for the management of moderately-toheavily exuding superficial wounds. Flivasorb is indicated for use in the following wound types: ` Pressure ulcers ` Arterial ulcers ` Venous leg ulcers ` Leaky legs ` Diabetic ulcers ` Postoperative wounds which heal

WOUND CARE

by secondary intention  Fistula exit sites.

flat edges conform well to healthy skin and facilitate application

The dressing’s polyethylene wound contact layer helps to prevent adhesion to the wound bed and periwound skin (meaning an additional primary wound contact layer is not required under Flivasorb), while the superabsorbent cellulose core successfully absorbs and locksin exudate (Figure 3). This results in less risk of leakage, and maceration/ excoriation to the periwound skin and increased comfort and confidence for the patient. This capturing of exudate also locks away protease enzymes that can delay wound healing (Wiegand et al, 2009a;b). Flivasorb’s outer layer protects the patient’s clothes from leaking exudate.

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flexible wound contact layer prevents adhesion to the wound distribution layer absorbed exudate is evenly distributed and quickly conducted into the absorbent core

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Specific benefits of Flivasorb include (Wiegand et al, 2013):  Ability to absorb and retain of large amounts of exudate  Low rewet  Prevention of maceration and excoriation  Reduction of bioburden  Effective underneath compression.

and less clinician time as well as improved patient quality of life (see case study). The main benefits of Flivasorb are shown in Table 1.

For the clinician, these properties result in reduced dressing changes

Flivasorb is also available as an adhesive dressing (Flivasorb®

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Benefit

Figure 3. Functions of Flivasorb’s different layers.

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Table 1: Key benefits of Flivasorb

Steinlechner et al, 2008

Protease modulation

In-vitro tests have shown SAP-containing wound dressings are able to bind considerable amounts of elastase-reducing enzyme activity, significantly inhibit MMP activity and produce a strong, possibly irreversible bonding of both proteases.

Wiegand et al, 2008; 2009a; 2009b

Antibacterial/ antifungal properties

In-vitro studies have shown strong antimicrobial and antifungal activity.

Wiegand et al, 2009a,b; 2012

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The dressing’s superabsorbent polymers (SAP), have been shown in-vitro to be more than twice as absorbent when compared to the other absorbent dressings with a cellulose core (without SAP).

Reduction of Using Flivasorb leads to fewer dressing changes, dressing changes less nursing time, less use of dressing varieties and improved quality of life.

Adhesive; Activa Healthcare/L&R), which combines the tried-andtested benefits of Flivasorb, with the convenience and comfort of a skinfriendly, flexible adhesive membrane. This is ideal for pressure ulcers, cavity/sinus wounds and dehisced surgical wounds.

Evidence Evidence

Absorbency and retention

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absorbent core with superabsorber binds large amounts of wound exudate evenly in fixed superabsorber particles blue nonwoven clothing protection protects clothing and bed sheets against soiling

Paule, 2009; Eberlein and Abel, 2009

Improved periwound skin condition

Flivasorb protects the wound bed and periwound Dee and Dalby, 2009; Paule, 2009; Prouvost, 2009 skin and leads to a significant reduction in redness and broken surrounding skin. Maceration of the periwound skin was shown to have disappeared within two days in one study.

Effective under compression

Billingham, 2009; Collarte and It has been demonstrated both in-vitro and in clinical evaluation that Flivasorb will absorb under Lear, 2010; Lewis, 2010; Pidcock, compression. Flivasorb is an excellent choice for 2011 patients with chronic oedema and lymphorrhoea.

Various case studies have demonstrated the efficacy of Flivasorb in practice. Faucher et al (2012) investigated the use of Flivasorb in 15 patients with highly exuding wounds, finding a reduction in periwound maceration and reduced dressing change; while Verrall et al (2010) looked at 16 patients with highly exuding wounds and also found that using Flivasorb resulted in reduced dressing change frequency, which, in turn, reduced the cost of treatment for each patient. Verall et al (2010) also highlighted the dressing’s effectiveness under compression and positive impact on healing progression.

CONCLUSION Wounds with high levels of exudate can seriously impact the patient’s quality of life, with problems including strikethrough, odour and JCN 2016, Vol 30, No 5

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REFERENCES

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Ashby RL, Gabe R, Ali S, et al (2014) VenUS IV (Venous leg Ulcer Study IV) - compression hosiery compared with compression bandaging in the treatment of venous leg ulcers: a randomised controlled trial, mixed-treatment comparison and decision-analytic model. Health Technol Assess 18(57): 1–293

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Atkin L, Tickle J (2016) A new pathway for lower limb ulceration. Wounds UK 12(2): 32–6 Billingham R (2009) The management of Lymphorrhoea with Flivasorb® and Actico®. Available online: www. activahealthcare.co.uk/casestudies-files/ FS009-R-Billingham-The-managementof-Lymphorrhoea-with-F.pdf Collarte and Lear, 2010 http://www. activahealthcare.co.uk/casestudies-files/ FS018-Collarte-and-Lear-Use-ofsuperabsorbent-and-antimicrob.pdf Dee and Dalby, 2009 http://www. activahealthcare.co.uk/casestudies-files/ FS010-A-Dee-The-use-of-Flivasorb-in-

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Why not go online and take your individual learning further by testing your knowledge of this topic in the INSIGHT section of the new, FREE JCN e-learning zone (www.jcn.co.uk/ learning-zone)? If you answer the accompanying online questions correctly, you can download a certificate to show that you have completed this JCN e-learning unit on excess exudate.

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Faucher N, Safar H, Baret M, et al (2012) Superabsorbent dressings for copiously exuding wounds. Br J Nurs 21(Suppl 12): S22–8

INSIGHT... for individual e-learning and CPD time

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Edwards J (2013) Dealing with woundrelated pain at dressing change. J Comm Nurs 27(4): 36–42

Guest JF, Ayoub N, McIlwraith T, Uchegbu I, Gerrish A, Weidlich D, Vowden K, Vowden P (2015) Health economic burden that different wound types impose on the UK’s National Health Service. Available online: http://bmjopen. bmj.com (accessed 7 October, 2016) Eberlein T, Abel M (2009) Superabsorbent wound dressings in clinical practice: problem solving in heavy exuding wounds. Available online: www. activahealthcare.co.uk/casestudies-files/ FS012-Eberlein_-Abel-Superabsorbentwound-dressings-in-c.pdf

Jones J (2012) Flivasorb & Flivasorb Adhesive: how to guide. Wound Essentials Available online: www.wounds-uk.com (accessed 7 October, 2016)

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The Assess Dress Compress concept has been developed by Activa Healthcare/L&R.

Dowsett C (2012) Management of wound exudate. Independent Nurse Available online: www.independentnurse.co.uk (accessed October 7, 2016)

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This author has examined the development of chronic wounds and the problem of excess exudate production specifically, before looking at the benefits of the superabsorbent dressing Flivasorb, which has been shown to demonstrate enhanced exudate control, reduced nursing time and periwound skin maintenance. JCN

Drewery K (2015) Is Kliniderm foam silicone a suitable, cost-saving alternative to other silicone foam dressings? Wounds UK 11(2): 98

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It is important to heal these wounds as quickly as possible and the community nurse needs to understand how to perform an holistic wound assessment before implementing an evidence-based management plan, including wound debridement and the the use of an effective absorbent dressing and, where appropriate, compression therapy to manage exudate (see key points box).

a-highly-exuding-wou.pdf .

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periwound skin maceration. This also involves increasing costs for community nurses, both in terms of their own clinical time and wider healthcare resources.

Lewis M (2010) Chronic oedema — a patient’s perpetual journey for treatment. Available online: www.activahealthcare. co.uk/casestudies-files/A062-M-LewisChronic-Oedema-A-patients-perpetualjour.pdf Lurton Y (2011) Superabsorbent dressings for exudate control. Available online: www. activahealthcare.co.uk/casestudies-files/ FS022-Superabsorbent_dress.pdf Morris C, Timmons J, Sykes R (2016) The management of chronic wound biofilm with a monofilament fibre debridement biofilm pathway: results of an audit. Poster presented at The World Union of Wound Healing Societies - Florence, Italy NICE (2014) The Debrisoft monofilament debridement pad for use in acute or chronic wounds. Available online: www. nice.org.uk (accessed 7 October, 2016) NICE (2016) Leg ulcer — venous. Available online: http://cks.nice.org.uk/leg-ulcervenous#!topicsummary (accessed 7 October, 2016) NHS England (2014) Five Year Forward View.

D Then, add the article and certificate to your free JCN revalidation e-portfolio, as evidence of your continued learning — safely, securely and all in one place: www.jcn.co.uk/revalidation

Also, for further e-learning opportunities, why not check out our online Products in Practice learning modules on Flivasorb® and Debrisoft® by visiting: www.jcn.co.uk/ learning-zone

Available online: www.england.nhs.uk (accessed 7 October, 2016) Paule A (2009) The Management of Maceration in a Nursing Home Environment. Available online: www.activahealthcare.co.uk/ casestudies-files/SXP021-A-PauleThe-management-of-maceration-in-aNursing.pdf Persoon A, Heinen MM, van der Vleuten CJM, et al (2004) Leg ulcers: a review of their impact on daily life. J Clin Nurs 13(3): 341–54 Pidcock (2011) Lymphovenous disease: a condition for life...not suffering for life. Available online: www.activahealthcare. co.uk/casestudies-files/A069-L-PidcockLymphovenous-disease-A-conditionfor-li.pdf Prouvost L (2009) The performance of a superabsorbent dressing in the management of exudate and maceration. Available online: www.activahealthcare.

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Posnett J, Gottrup F, Lundgren H, Saal G (2009) The resource impact of wounds on healthcare providers in Europe. J Wound Care 18(4): 154-61 Romanelli M, Vowden K, Weir D (2010) Exudate Management Made Easy. Available online: www.woundsinternational.com (accessed 7 October, 2016)

Absorbent dressings with superabsorbent polymers: a new generation of wound dressings. Available online: www. activahealthcare.co.uk/casestudies-files/ FS001-Steinlechner-et-al-Absorbentdressings-with-supera.pdf Tickle J (2016) A new pathway for lower limb ulceration. Wounds UK Available online: www.wounds-uk.com (accessed 7 October, 2016) Verrall D, Coulbourn A, Bree-Aslan C (2010) Evaluating a super-absorbent dressing (Flivasorb) in heavily exuding wounds. Br J Nurs 19(7): 449–53

SIGN (2010) Management of chronic venous leg ulcers: a national clinical guideline. Available online: www.sign.ac.uk (accessed 7 October, 2016)

Vowden K, Vowden P (2011) Debridement Made Easy. Available online: www. wounds-uk.com (accessed 7 October, 2016)

Stephen-Haynes J (2011) Managing exudate and the key requirements of absorbent dressings. Br J Community Nurs 16(3 Suppl): S44–9

Vowden P, Bond E, Meuleneire F (2015) Managing high viscosity exudate. Wounds International Available online: http:// www.woundsinternational.com (accessed October 7, 2016) White R, Cutting K (2006) Modern exudate management: a review of wound treatments. World Wide Wounds Available online: www.worldwidewounds.com (accessed October 7, 2016)

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Stephen-Haynes J, Callaghan R (2012) The role of an active debridement system in assisting the experienced clinician to undertake an assessment and determine appropriate wound management objectives. Clinical poster presented at EWMA, 2012.

Wiegand C, Abel M, Ruth P, Hipler UC (2009a) Polyacrylate-superabsorber binds inflammatory proteases in vitro Available online: www.activahealthcare.co.uk/ casestudies-files/FS003-Wiegand-et-alPolyacrylate-superabsorbers-bind-inf.pdf Wiegand C, Abel M, Ruth P, Hipler UC (2009b) A polyacrylate-superabsorber inhibits the formation of ROS/RNS in-vitro. Available online: www. activahealthcare.co.uk/casestudies-files/ FS013-Wiegand-A-polyacrealatesuperabsorber.pdf

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Schultz G Dowsett, C (2012) Wound Bed Preparartion revisited.Wounds International 391: 27–9

absorbs proteases, which delay the healing process (elastase, MMP-2). Available online: www.activahealthcare. co.uk/casestudies-files/FS002-

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co.uk/casestudies-files/FS017-LProuvost-The-performance-of-asuperabs_dressing-.pdf

Wiegand C, Abel M, Muldoon J, et al (2013) SAP-containing dressings exhibit sustained antimicrobial effects over 7 days in vitro. J Wound Care 22(3): 120–7 Wounds UK (2014) Two-component compression: Concordance, evidence and clinical use. Wounds UK Available online: www.activahealthcare.co.uk (accessed October 11, 2016)

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WUWHS (2007) Wound exudate and the role of dressings: a consensus document. Available online: www.woundsinternational.com Wiegand C,half Abelpage M, Ruth P, Hipler (2008) V1.3 06/10/2016 Flivasorb half page advert (JCN) ADV119 V1.3.qxp_Flivasorb advert (JCN)UC ADV119 12:55 Page 1 ® (accessed October 11, 2016) The superabsorber Vliwasorb irreversibly Steinlechner E, Rohrer C, Abel M (2008)

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JCN 2016, Vol 30, No 5

ADV119 V1.3

STUDY DAYS & EXHIBITION 2017

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NEW AGENDA INCLUDES SESSIONS WITH A FRESH APPROACH TO WOUND CARE MANAGEMENT

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Cardiff

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Stoke City Football Club

Leicester

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Tuesday 6 June

Southampton

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Wednesday 5 July

Falkirk

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Wednesday 6 September

Maidstone

Mercure Maidstone Great Danes Hotel

Wednesday 27 September

Esher

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 FREE ATTENDANCE FOR ALL PRIMARY CARE NURSES  PRESENTED BY LEADING CLINICIANS  COVERS THEORY AND PRACTICAL SKILLS FOR COMMUNITY PRACTICE  EXHIBITION WITH LATEST PRODUCTS, DEMONSTRATIONS AND SAMPLES  ATTENDANCE CONTRIBUTES TO REVALIDATION

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