NPTE - Wounds

Wound Bed Preparation & Interventions

TIME Principle

Tissue

Infection/Inflammation

Moisture Balance

Edge of Wound

T (Time Principle)

Is the tissue

• Viable - choose dressing that promotes moist wound healing and fills dead space

• Nonviable - choose best debridement

I (Time Principle)

Address infection, excessive colonization, and edema

M (Time Principle)

• Dry - choose dressing that hydrates or promotes moisture

• Excessive Moisture - choose dressing that absorbs exudate/drainage

E (Time Principle)

Healthy would edges promote healing

Negative-pressure Wound Therapy (Vacuum assisted closure)

Helps maintain moist wound, control edema, increases localized blood flow, removes exudate, reduces infectious material

Hyperbaric Oxygen Therapy

• Patient breathes 100% O2 in chamber

• Reverses tissue hypoxia and facilitates healing due to enhanced solubility in the blood

• Indicated with compromised skin grafts, acute ischemia, osteomyelitis (bone infection), necrotizing infection, thermal burns, and wounds not healing due to hypoxia

• Contraindicated to untreated pneumothorax and patients on antineoplastic meds

Whirlpool Therapy

Not supported for wound care

Might be used for burn care

Wound Cleansing

• Removal of debris

• Cleanse initially and dressing change

• NaCl recommended

• Topical agents to lower surface tension

• Minimal mechanical force (gauze/cloth) or irrigation (squeeze bottle, pulsed lavage)

• NO harsh soaps, alcohol based, or harsh antiseptics

Wound Debridement

Remove tissue that interferes with healing

Wound Dressings

Based on wound bed color, depth, and exudate

Red Wound Bed Color

Support moist wound healing and prevent trauma to granulating tissues

Yellow/Black Wound Bed Color

Indicates presence of slough or necrotic tissue and needs debridement

Wound Bed Depth

Tunneling, undermining will need to be filled

Wound Bed Exudate Production

Select dressing that promotes moist wound healing and prevents maceration

Autolytic Debridement

Selective method that results in solubilization of necrotic tissue by phagocytic cells and proteolytic/collagenolytic enzymes

Autolytic Debridement Indications

• Individuals on anticoagulants

• Can’t tolerate other debridement

• Medically stable people

Autolytic Debridement Contraindications

• Infected wounds

• Immunosuppressed individuals

• Dry gangrene or ischemic wounds

Enzymatic Debridement

Selective method that promotes liquefication of necrotic tissue by topical preparation

Enzymatic Debridement Indications

• Moist necrotic wounds

• Eschar (thick leathery scab) after cross hatching

• Homebound individuals

• Can’t tolerate surgical debridement

Enzymatic Debridement Contraindications

• Ischemic wound ulcers

• Dry gangrene

• Clean, granulated wounds

Mechanical Debridement

Nonselective method removal by physical forces and may remove healthy tissue as well

Mechanical Debridement Indications

• Wounds with moist necrotic tissue or foreign material present

Mechanical Debridement Contraindications

• Clean granulated wounds

Sharp Debridement

Selective method using sterile instruments that removes tissue without anesthesia and little to no bleeding

Sharp Debridement Indications

• Scaring and leathery eschar

• Excision of moist necrotic tissue

• Biofilm removal

Sharp Debridement Contraindications

• Clean wounds

• Advancing cellulitis when sepsis

• Infection threatens life

• Anticoagulant

Surgical Debridement

For deep or complicated pressure ulcer, most efficient method. Selective that might remove healthy tissue as well

Surgical Debridement Indications

• Advancing cellulitis when sepsis

• Infection threatens life

• Clean wounds as preliminary procedure to surgical wound closure line

• Granulation and scar tissue may be excised

• Biofilm removal

Surgical Debridement Contraindications

• Cardiac disease, pulmonary disease, diabetes

• Severe spasticity

• Can’t tolerate surgery

• Short life expectancy

• QOL not improved

Ultrasound Debridement

Selective method with long wave low frequency between 20 to 50 Hz

Ultrasound Debridement Indications

• Selective removal desired

• Reduces bioburden

• Increase angiogenesis

• Wound bed prep for graft or flap closure

Ultrasound Debridement Contraindications

• Vascular abnormalities

• Precautions over nerves, infections

Biological Debridement

Rare, maggots produce enzymes and phagocytize tissue and bacteria

Transparent Film Dressing

Clear adhesive permeable to O2 and moisture vapor, but impermeable to water, bacteria, and environmental contaminants

Transparent Film Dressing Indications

• Stage 1 and 2 PU

• Secondary dressing sometimes

• Autolytic debridement

• Skin donor sites

• Cover for hydrophilic powder and paste preparations and hydrogels

Transparent Film Dressing Advantages

• Visual evaluation of wound without removal

• Impermeable to external fluids and bacteria

• Transparent and comfortable

• Promotes autolytic debride

• Minimize friction

Hydrocolloid Dressing

Adhesive wafers containing particles that interact with wound fluid to form a gel mass over the bed

Hydrocolloid Dressing Indications

• Protection of partial thickness wounds

• Autolytic debride

• Wounds with MILD exudate

Hydrocolloid Dressing Advantages

• Moist environment

• Non adhesive to healing tissue

• Conformable

• Impermeable to bacteria

• Min to mod absorption

• Waterproof, reduces pain, easy to apply, time saving, diminish friction

Hydrogel Dressing

Water based gel insoluble to water

Hydrogel Dressing Indications

• Partial and full thickness wounds

• Wounds with necrosis and slough

• Burns and tissue damaged by radiation

Hydrogel Dressing Advantages

• Soothing and cooling

• Fill dead space

• Rehydrate

• Autolytic debride

• Min to Mod absorption

• Conforms, transparent to translucent, nonadherent, used when infection present

Foam Dressing

Semipermeable membranes that are either hydrophobic or hydrophilic

Foam Dressing Indications

• Partial and full thickness wounds with MIN to MOD exudate

• Secondary dressing for wounds with packing for more absorption

• Protection and insulation

Foam Dressing Advantages

• Insulates and provides padding

• Non adherent and conformable

• Minimal to Heavy exudate

• Easy to use and for deep cavities

Alginate Dressing

Dressing derived from seaweed to react with wound exudate to form a hydrophilic gel mass over wound area

Alginate Dressing Indications

• MOD to LARGE exudate

• Exudate and necrotic wounds

• Packing and absorption

• Infected and noninfected

Alginate Dressing Advantages

• Absorb up to 20x weight in exudate

• Fills dead space

• Supports debridement in presence of exudate

• Easy to apply

Gauze Dressing

Cotton that is absorptive and permeable to water and O2

Gauze Dressing Indications

• Exudative Wounds

• Dead space, tunneling, or sinus tracts

• Exudate and necrotic tissue

• Wet to Dry - mechanical debride

• Continuous Dry - heavily exudating wounds

• Continuous Moist - protection of clean wounds, autolytic debride, delivery of topical needs

Gauze Dressing Advantages

• Used with appropriate solutions to keep wounds moist

• Infected wounds

• Mechanical debridement

• Cost effective for large wounds

• Effective delivery if kept moist

Repositioning in Bed

Every 2 Hours

Repositioning in WC

Every 15 minutes

Transparent Film Disadvantages

• Nonabsorptive

• Difficult application

• Channeling/wrinkling

• Not to be used on wounds with fragile surrounding skin of infections

Hydrocolloid Dressing Disadvantages

• Nontransparent

• May change shape with heat/friction

• Odor and yellow drainage on removal

• Not for heavy exudate, sinus tracts, exposed bone, fragile surrounding skin

Hydrogel Dressing Disadvantages

• Most require secondary dressing

• Not for heavy exudate

• May dry out and adhere to wound bed

• May macerate surrounding skin

Foam Dressing Disadvantages

• Nontransparent

• Nonadherent foam requires secondary dressing

• Poor comfort with deep wounds

• Not for dry eschar or wounds with no exudate

Alginate Dressing Disadvantages

• Require secondary dressing

• Not for dry or light exudating wounds

• Can dry wound bed

Gauze Dressing Disadvantages

• Delayed healing if used improperly

• Pain on removal

• Labor intensive

• Require Secondary dressing

• Avoid direct contact with granulating tissue

• Increase infection rate

Braden Measurement

Six-item pressure sore risk assessment scale (score range from 6-23); 18 and lower indicate progressive risk

• Mild Risk 15 to 18

• Mod Risk 13 to 14

• High Risk 10 to 12

• Very High Risk <9

Wagner Measurement

Designed to assess the depth and tissue involvement of diabetic foot ulcers

• Grade 0: Intact Skin

• Grade 1: Superficial Ulcer

• Grade 2: Deep ulcer to tendon, fascia, ligament, joint capsule, or bone

• Grade 3: Deep ulcer with abscess or osteomyelitis

• Grade 4: Gangrene or portion of forefoot

• Grade 5: Gangrene or major portion of foot

University of Texas Classification System

• Grades

  • 0: Epithelialized Wound

  • 1: Superficial Wound

  • 2: Wound penetrates to tendon or capsule

  • 3: Wound penetrates to bone or joint

• Stages

  • A: No infection or ischemia

  • B: Infection present

  • C: Ischemia present

  • D: Ischemia and infection present