Wound Care Management

Intentional wound

From planned treatment or therapy such as surgery, drain placement, mole removal, etc. Wound edges are clean and precise. Less risk of infection as wound is made in a sterile environment.

Unintentional wound

Occurs accidently such as trauma, burns, and skin tears. Wound edges likely jagged and not well approximated. Increase risk of infection as wound made in non-sterile environment.

Open wound

Skin surface is broken such as a laceration/cut, bite, puncture. Complications are increased risk of bleeding, infection, and tissue damage.

Closed wound

Tissue is traumatized without a break to the skin such as ecchymosis, hematoma, and crush injuries. Complications include internal bleeding, nerve damage, and compartment syndrome

Compartment syndrome

When swelling from a closed wound overwhelms body, causing potential nerve and muscle damage or rupture. Fasciotomy required to relive pressure.

Acute wound

Heal in a suspected amount of time (days-weeks).

Chronic wound

Wounds that fail to heal over an extended period. Ex. pressure ulcers. Increased risk for geriatric population, those with poor nutrition, and those who are immobile.

Phases of wound healing

1. Platelet response

2. WBC response (leukocytes for immune response and macrophages to engulf debris)

3. Fibroblasts come to form connective tissue over wound

4. Scarring period

Name the areas 1-4

1. Greater trochanter

2. Sacrum

3. Coccyx

4. Region of ischial tuberosity

Signs of wound infection

Warm, redness, swelling, discharge

Serous drainage

Clear drainage, indicates proper healing

Sanguineous drainage

Large amounts of blood. Usually post-op or in new injury.

Serosanguineous drainage

Serous fluid + blood

Purulent drainage

Tan-yellow-green fluid, indicates infection, contains large number of WBCs.

Autolytic debridement

Use of a dressing to cover wound, allowing the body’s own enzymes to loosen and liquify necrotic tissue. Slow, painless process.

Enzymatic debridement

Use of commercially prepared enzyme to speed up healing of wound. Still a slow process, but also painless.

Mechanical debridement

Use of external physical force to remove necrotic tissue. Can be painful but is quicker. Methods include wound irrigation, whirlpool therapy, moist to dry dressing.

Moist to dry dressing

Moist dressing on wound bed and dry dressing on top of moist allows for moisture and necrotic tissue to be pulled out. A type of mechanical debridement.

Surgical debridement

Surgeon scrapes off necrosis. Painful but very quick and effective.

Biological debridement - maggot therapy

Use of maggots in a wound to eat necrosis. Must document # of maggots pre-treatment so we don’t lose any.

Gauze

Consists of 3 layers, comes in 2×2 or 4×4. Used to protect wound and wick away moisture.

ABD pads

Bigger and thicker than gauze. Side with line faces out. Used for surgical wounds as they cover larger areas.

Kerlix

A wrap used as a secondary dressing to secure primary dressing/packing

Non-adherent dressings

Allows drainage to pass through but prevents outer dressings from sticking to wound bed. Places in contact with base of wound. Used a lot with staples, sutures, etc.

Transparent films

Allows visualization of the wound. Semi-permeable (adhesive). Remain in place for 4-7 days. Can be used as primary or secondary dressing. Commonly used for IV, central lines, catheters.

Hydrocolloids

Helps facilitate autolytic debridement by maintaining moist environment. Remains in place for 3 days. Allows for little exchange of oxygen between wound and environment. Used for partial/full thickness wounds, stage 2-3 pressure ulcers, non-infected wounds.

Characteristics of hydrocolloid dressings

Moisture retention, adhesive properties (has a self-adhesive layer that sticks to skin around wound but not the wound itself), absorption (absorbs exudate, good for wounds with moderate drainage), and barrier protection.

Hydrogels

Helps facilitate autolytic debridement by maintaining moist environment. Consists of a water-based gel in gel form, sheets, or gauze. Stays on for 24-72 hrs. Used for partial thickness wounds, stage 2-4 pressure ulcers, and infected wounds.

Characteristics of hydrogel dressings

Moisture retention, moisture promotion (ideal for dry or necrotic wounds to help slough off necrosis), and absorption (for low to moderate drainage).

Alginates

Contains alginic acid which is derived from seaweed. It is hydrophilic and forms a gel when it comes in contact with exudate. Facilitates autolytic debridement. Needs a secondary dressing. Can remain in place for 1-3 days. Used for partial to full thickness wounds, stage 3-4 pressure ulcers, and wounds with heavy exudate.

Characteristics of alginate dressings

Moisture absorption (can hold significant amounts of exudate, used for wounds with moderate to heavy drainage), gel formation, easy to remove, DO NOT USE WITH DRY/MINIMALLY DRAINING WOUNDS.

Foams

Foam covering that will not adhere to wound. It is used more protective/secondary. Highly absorbent. Remains in place for 3-5 days. Used for partial and full thickness wounds, stage 2-4 pressure ulcers, surgical wounds, and would prevention.

Characteristics of foam dressings

Maintains moisture, absorption (moderate amounts of exudate), cushioning, breathability (allows excess moisture to escape while still protecting the wound).

Clean technique vs sterile technique

Use sterile technique for surgical wounds and clean technique for unintentional wounds

Cleaning wounds with approximated edges

Clean top to bottom in up-down movement

Cleaning wounds with unapproximated edges

Clean from center to outside in circular motion

How to apply creams for wound care

Do NOT use fingers/hands. Always utilize cotton swabs or gauze

Do clean wound before or after taking a culture?

Clean wound before taking culture to assure that no outside bacteria is being obtained in the sample