Wound management , assessment , and choice of dressing materials

review of skin anatomy, wound assessment, choice of dressing material and aseptic dressing technique

1. WOUND CARE
Introduction to wound

2. Definition
•an injury to living tissue in which the
skin is cut or broken. It can be an;
injury · lesion · cut · gash · laceration · 
tear · rent · puncture · slash · sore · graze
 · scratch · scrape · abrasion · bruise · 
contusion · trauma · traumatism
•A wound is defined as a physical injury
to the skin or mucous membrane.

3. Wound classification
•Acute wound- is any surgical wound that heals by
primary intention or any traumatic or surgical
wound that heals by secondary intention. An acute
wound is expected to progress through the phases
of normal healing, resulting in the closure of the
wound.
  
.
• heal uneventfully (with no
complications) in the predicted amount
of time.

4. Cont’d
•Chronic wound- is a wound that fails to progress
healing or respond to treatment over the normal
expected healing time frame (4 weeks) and becomes
"stuck" in the inflammatory phase. This pathologic
inflammation is due to a postponed, incomplete or
uncoordinated healing process. Wound healing is
delayed by the presence of intrinsic and extrinsic
factors including medications, poor nutrition, co-
morbidities or inappropriate dressing selection 
•might have some complications.

5. Other classifications
•Open/closed
•Septic /clean
•Penetrating i.e. stab, surgical wounds/ non i.e.
scrap, lacerations
•Others i.e. thermal, chemical, bites/ stings,
electrical

6. Cont’d
• pain, redness, swelling, bleeding and
loss or impairment of function to the
wounded area. Symptoms may
include fever, malodorous pus
drainage and heat, particularly in
cases of infection.

7. Type of Healing
•Primary intention- the wound edges are held together by
artificial means such as sutures, staples, tapes or tissue glue.
There is minimal tissue loss and wounds heal with minimal
scarring. Most clean surgical wounds and recent traumatic
injuries are managed by primary closure.
Delayed primary intention- when the wound is infected or
requires more thorough intensive cleaning or debridement
prior to primary closure usually 3-7 days later. May be used
for traumatic wounds or contaminated surgical wounds.

8. Cont’d
•Secondary intention- spontaneous wound healing occurs through
a process of granulation, contraction and epithelialization. Results
in scar formation and used as a method of healing for pressure
injuries, ulcers or dehisced wounds.
•Skin graft- 
removal of partial or full thickness segment of
epidermis and dermis from its blood supply and transplanting it to
another site to speed up healing and reduce the risk of infection.
Flap- the surgical relocation of skin and underlying structures to
repair a wound. Flaps are named according to their tissue
components and may include an anastomosis of blood supply to
vessels attached to or at the affected site.

9. Stages of wound healing-2
•Follows complex sequence of events and divided into 2
stages;
1.Hemostasis- is the rapid response to physical injury and
is necessary to control bleeding. It involves the
following components:
•Vasoconstriction- clot formation and act as a barrier
•Platelet response- release chemicals for next process
•Biochemical response

10. Cont’d
2. Tissue Repair & Regeneration- involves 3 phases:
•Inflammation phase (0-4 Days) 
the body's 
normal
 
response to
injury. This phase activates vasodilatation leading to increased blood
flow causing heat, redness, pain, swelling and loss of function.
Wound exudate may be present and this is also a normal body
response. a cellular inflammatory response acts
to remove any cell debris and pathogens present
•Reconstruction phase (2-24 Days) 
the time when the wound
is
 
healing. The body makes new blood vessels, which cover the
surface of the wound. This phase includes reconstruction and
epithelialization. The wound will become smaller as it heals.

11. Cont’d
•This occurs over the course of four different
processes:
•Epithelialization: This is the process of
creating new skin tissue in the various layers of
damaged skin.
•Angiogenesis: This is the creation of new
blood vessels in the area of the wound healing.
•Collagen formation: This is the building up of
strength in the tissue of the wound.
•Contraction: This is the reduction and
eventual closing of the wound size and area.

12. Cont’d
•Maturation phase (24 days-1 year) 
the final
phase of healing, when scar tissue is formed. The
wound is still at risk and should be protected where
possible.
•The body replaces the temporary
granular tissue from the early wound
with stronger scar tissue. As time goes
on, the scar tissue has an increased
concentration of collagen, which makes
it stronger

13. Factors That Inhibit Wound Healing
•Assessment of the patient is important for
wound management process.
•Factors may be local or general.

14. Local factors
Wound management practices- the goal is to optimize
the wound environment so healing progresses
   
Moisture balance- dressings are designed to promote
moist wound healing
•Wound temperature and pH- a constant temperature of
approximately 37’C has been shown to have a
significant effect on healing along with the impact of
maintaining a neutral or acidic pH to reduce the risk
of bacterial colonization and opportunistic infection

15. Cont’d
Infection- replication of organisms within a
wound with subsequent host injury
 
Pressure, friction and shearing, limited
mobility
Presence of foreign bodies

16. General factors
Underlying disease- diabetes, autoimmune disorders,
anaemia and malignancy. The reason these conditions
impair healing include- impaired collagen,
impairment of angiogenesis, delayed infiltration of
inflammatory cells, macrophages and lymphocytes,
due to decreased host resistance, poor cutaneous or
epidermal vasculature.
Impaired perfusion and hypoxia- cardiac conditions,
smoking, shock and haemorrhage

17. Cont’d
Malnutrition- inadequate supply of protein,
carbohydrates, lipids and trace elements and vitamins
essential for all phases of wound healing
Body mass index
Disorders of sensation or movement- cerebral palsy,
movement disorders, peripheral neuropathies, spina bifida
Medications- NSAIDs, chemotherapy,
immunosuppressive drugs, corticosteroids

18. Cont’d
Radiation therapy
Stress, anxiety and depression
Increasing age
 

19. Wound Assessment
Areas to assess for appropriate management.
Type of wound- acute or chronic
Aetiology- surgical, laceration, ulcer, burn,
abrasion, traumatic, pressure injury, neoplastic
Location and surrounding skin
Tissue Loss

20. Cont’d
Clinical appearance of the wound bed and stage of healing
Measurement and dimensions
Wound edge
Exudate
Presence of infection
Pain
Previous wound management

21. Considerations for Wound Assessment
•1. There is different terminology used to
describe specific types of wounds: such as
surgical incision, burn, laceration, ulcer,
abrasion. They can be generally classified as
either acute or chronic wounds.

22. Cont’d
2. Tissue loss: The degree of tissue loss may be
referred to in broad terms as:
Superficial wound- involving the epidermis
Partial wound- involves the dermis and
epidermis
•Full thickness wound-involves the epidermis,
dermis, subcutaneous tissue and may extend to
muscle, bones and tendons.

23. Cont’d
3. Wound bed clinical appearance:
Granulating- is when healthy red tissue is observed and is
deposited during the repair process. It presents as
pinkish/red coloured moist tissue and comprises of newly
formed collagen, elastin and capillary networks. The tissue
is well vascularised and bleeds easily.
•Epithelialising- is a process by which the wound surface is
covered by new epithelium, this begins when the wound has
filled with granulation tissue. The tissue is pink, almost
white, and only occurs on top of healthy granulation tissue

24. Cont’d
Sloughy- the presence of devitalised yellowish tissue is observed
and is formed by an accumulation of dead cells. Must not be
confused with the presence of pus.
Necrotic- describes a wound containing dead tissue. The wound
may appear hard, dry and black. Dead connective tissue may appear
grey. The presence of dead tissue in a wound prevents healing.
Hyper granulating- this is observed when granulation tissue grows
above the wound margin. This occurs when the proliferative phase
of healing is prolonged usually as a result of bacterial imbalance or
irritant forces.

25. Cont’d
•4. Wound measurement:
•'Assessment and evaluation of wound healing is an ongoing process.
  All
wounds require a two-dimensional assessment of the wound opening and
a three-dimensional assessment of any cavity or tracking' (Carville, 2017)
• The wound measurement  at the initial assessment is
critical to calculate any change in wound size over
time. Wound dimensions  should become smaller as
the wound heals with growth of granulation tissue and
new blood vessels, reduction in tissue edema and
migration of new epithelium from the edges (Keast et al
2004)
•Determine treatment effectiveness
•3dm-imaging 2dm tape

26. Cont’d
Two-dimensional assessment- can be done with a paper
tape to measure the length and width in millimetres. The
circumference of the wound can be traced if the wound
edges are not even - often required for chronic wounds.
The clinical picture application with the use of the
‘Rover’ device within EMR can be utilised and added in
the ‘LDA’ wound assessment flowsheet.
Three-dimensional assessment- the wound depth is
measured using a dampened cotton tip applicator.

27. Cont’d
5. Wound edges:
The edges of the wound are assessed for-
Colour- pink edges indicate growth of new tissue; dusky edges
indicate hypoxia; and erythema indicates physiological
inflammatory response or cellulitis
Evidence of contraction- wound edges coming together indicate
the healing process is occurring. Raised or rolled edges- raised
(where the wound margin is elevated above the surrounding
tissue) may indicate hyper granulation tissue and rolled (where the
edges are rolled down towards the wound bed) can inhibit healing.

28. Cont’d
•Changes in sensation- increased pain or the
absence of sensation should be further
investigated

29. Cont’d
•6. Exudate:
Is produced by all acute and chronic wounds (to a greater or lesser
extent) as part of the natural healing process. It plays an essential part
in the healing process in that it:
Contains nutrients, energy and growth factors for metabolising cells
Contains high quantities of white blood cells
Cleanses the wound
Maintains a moist environment
Promotes epithelialisation

30. Cont’d
•It is important to assess and document the
type, amount, colour and odour of exudate to
identify any changes. Excess exudate leads to
maceration and degradation of skin while too
little can result in the wound bed drying out. It
may become more viscous and odorous in
infected wounds.

31. Cont’d
•7. Surrounding skin:
•The surrounding skin should be examined
carefully as part of the process of assessment
and appropriate action taken to protect it from
injury.

32. Cont’d
•8. Presence of infection:
•Wound infection is presence of bacteria or other
organisms, which multiply and lead to the
overcoming of host resistance.
•Infection disrupt healing and damage tissues (local
infection) or produce spreading infection or systemic
illness.
Local indicators of infection-
Redness (erythema or cellulitis)
 

33. Cont’d
Exudate- a change to purulent fluid or an increase in
amount of exudate
Malodor
Localised pain
Localised heat
Oedema

34. Cont’d
•Wound healing and clinical infection demonstrate
inflammatory responses and it is important to
ascertain if increases in pain, heat, oedema and
erythema are related to the inflammatory phase
of wound healing or infection.
 
If any of the above clinical indicators are present
a medical review should be instigated and a
Microscopy & Culture Wound Swab (MCS)
should be considered.

35. Cont’d
•9. Pain:
•Pain can be an important indicator of abnormality.
•Accurate assessment of pain is essential with
regard to choice of the most appropriate dressing.
Assess pain before, during and after the dressing
change toprovide vital information for further
wound management and dressing selection.

36. WOUND MANAGEMENT
•Guidelines for wound management
•Promote a multidisciplinary approach to care.
•Initial patient and wound assessment and whenever there
is a change in condition.
•Consider the psychological implications of a wound-
especially relevant in the paediatric setting in relation to
developmental understanding and pain associated with the
wound and dressing changes.
•Determine the goal of care and expected outcomes.

37. Cont’d
•Respect the fragile wound environment.
•Maintain bacterial balance- use aseptic
technique when performing wound
procedures.
•Maintain a moist wound environment

38. Cont’d
•Maintain a stable wound temperature. Avoid cold
solutions or wound exposure.
•Maintain an acidic or neutral pH.
•Allow a heavily draining wound to drain freely.
•Eliminate dead space but don’t pack a wound tightly.
•Select appropriate dressings and techniques based on
assessment and scientific evidence.

39. Cont’d
•Instigate appropriate adjunctive wound
therapies- e.g. compression, splinting and
pressure redistribution equipment, off-loading
orthotics.
•Follow the principles for managing acute and
chronic wounds.) (Carville, 2017

40. Acute Wound Management
Do wound cleansing-use of fluids to remove surface
contaminants from previous dressings and create an environment
to promote healing.
The goal of wound cleansing is to:
Remove visible debris and devitalised tissue
Remove dressing residue
Remove excessive or dry crusting exudates
Reduce contamination
 

41. Cont’d
Principles of wound cleansing
•Use aseptic technique-sterile gloves,
disinfectant
•Gently to minimize trauma
•Clean with warmed hypotonic saline

42. Cont’d
Choice of dressing
•A wound will require different management
and treatment at various stages of healing.
•No dressing is suitable for all wounds;
therefore frequent assessment of the wound is
required.
 

43. Cont’d
Dressings reserve moisture.and they are
different .
The appropriate dressing can have a significant
effect on the rate and quality of healing.
The appropriate dressing will help to minimize
bacterial contamination and pain associated
with wound care.

44. Cont’d
•Wounds healing by Primary Intention
Recommended dressings include:
Dry non-adherants
Island dressings-used post op for protection, and absorb
excess fluid
Semi-permeable films-to o2 co2 vapour, do not allow h20 to
pass through. Use in lacerations for 5-7 days
Hydrocolloids-superficial wounds with discharge. It absorbs
Foams-create a moist environment ie in soft necrotic tissue

45. Delayed primary intention
Normal saline compresses
Amphorous hydrogels or hydrogel impregnated gauzes
to assist with debridement
Calcium alginate ropes or ribbons
Hyrofibre ropes or ribbons
Drainable wound/ostomy appliances when large amounts
of exudate is present
Foams

46. secondary intention
•Stomal Therapy should be considered to
promote optimal wound healing in sinus,
drained abscess, wound dehiscence, skin tear
or superficial laceration.

47. Chronic wound management
•Address what inhibits wound healing.
•Dressing selection should be based on the specific
wound characteristics.
•Stomal Therapy should be initiated to promote optimal
wound healing.
•Advanced wound therapies may be required e.g
surgical debridement, application of a negative pressure
dressing(attach a vacuum pump and tubing to remove
excess exudate , hyperbaric therapy(high oxygen).
•.

48. complications
•Infections: Wound infection presents with pus drainage,
foul odor, fever, dull throbbing pain, mild swelling and
heat at wound site.
•Inflammation: Inflamed wounds are hot, red, painful,
swollen and hard to move.
•Scarring: Regenerated cells have different
characteristics and fibrous tissue that can heal the
wound, but may leave a scar behind.
•Loss of function: Many wounds can be disabling and
life threatening if a major organ, blood vessel or nerve
was damaged. Either way, while the wound is still fresh
or healing, the affected limb or area will lose its
functionality until all lost or damaged tissue is repaired