Complex

N5125
202010

Wound Care
 q To be cognizant of factors that impede or
Learning promote wound healing
Outcomes q To be able to accurately assess a wound
q To incorporate the “critical components of
a skill’ when caring for a wound that
requires irrigating, the application of a
topical medication and packing
q To incorporate the “critical components of
a skill’ when obtaining a specimen for C&S
from the wound bed
q To appreciate personal meaning for
patients who require complex wound
care
 Complex Wound care:
Acute Wounds to Chronic
Acute Wounds: Go through predictable trajectory of healing.
All surgical incisions are considered as an acute wound – until
complications arise

Chronic Wounds: Stall in the trajectory. Usually in the inflammatory or

proliferation phase
• Can take months- years to heal
• Does not heal in an orderly, predictable process
Complications of Wound healing
• Malnutrition or hydration can impact collagen
synthesis, tensile strength and immune
function.
• Inadequate perfusion/oxygenation can
delay/inhibit vessel development, collagen
synthesis, tensile strength.

Complications:
• infection/abscess
• Dehiscence
• Evisceration
Complications of Wound Healing
INFECTION
• inhibits
wound healing by prolonging the inflammatory
response
Higher risk if:
• wound contains necrotic tissue
• contaminants near the wound
• reduced blood supply
• immuno-compromised: patients on corticosteroids or
chemotherapy
What to do:
• Notify physician and wound care nurse
• May require a C&S swab
• May require antibiotics (topical, po, IV)
 Signs and 1. Pain and tenderness around the site
2. Erythema (reddening around the site)
Symptoms of 3. Edema (swelling)
4. Induration (firmness of surrounding tissue)
Wound 5. Inflammation of wound edges
Infection 6. Purulent discharge
7. Warmth in surrounding tissues
8. Fever, chills
9. Foul odour
10.Elevated white blood cell count
11.Delay in healing
12.Increase in exudate
13. Friable tissue (Bright red granulation tissue
that bleeds easily)
14.New areas of slough or breakdown on the
wound surface
15.New Undermining (dead space under the
edges of wound)
Complications of Wound Healing
HEMORRHAGE
• If
occurs after initial scabbing may
indicate dislodged clot, slipped suture,
infection.
• May be related to medication history
(anti-coagulants)
• Can be internal or external
• Surgical wounds highest risk first 24-48h
Complications of Wound Healing
DEHISCENCE
Separation or disruption of wound edges creating an opening or gap
• Can involve only the epidermis or also deeper tissues
Higher risk if :
• Obese

• Coughing or sneezing
• poor nutrition/malnourished
• taking out sutures/staples out to soon
What to do:
• stop removing remaining staples/sutures
• apply steri-strips
• cover and notify physician
• May require re- suturing
Complications of Wound Healing
EVISCERATION
This is an emergency where deep tissues and organs
are exposed and protruding out through the wound
opening/gap
What to do:
• cover wound with sterile NS and abdominal pads
• (don’t dry out the intestines)
• call the surgeon
• place in Fowlers position, knees flexed
• NPO
• administer IV fluids
• perform vital signs
 Type of Wound • Etiology (if known), traumatic, pressure

Location • Anatomical position on body

Tissue • Pressure injury scale rating, involve only

Involvement dermis or also epidermis
Wound • type of tissue, granulation, necrotic,
Wound Bed
Assessment slough and approximate amounts
• measure length, width, size, depth, sinus
Wound Size tracts or tunneling
Exudate or • serous, sanguineous, serosang, purulent.
Odour
• induration, moisture, temperature, colour
Peri-wound Area and overall integrity

Pain • pain scale

 Wound
Assessment
and
Treatment
Flowsheet
 Types of Wounds

Surgical Traumatic Venous Ulcer Arterial Ulcer Pressure Injury

• Typically heal via • Gunshot, stab, • Poor blood return • Tissue ischemia (Ulcer)
primary intention abrasions, skin leading to due to arterial • caused from
• All start acute but tear pooling of blood insufficiency compression of
can become • Acute or and increased • Usually found soft tissue
complex/chronic Chronic/Complex pressure legs, feet • can be found
• Usually found • Pale wound bed under bony
ankle to mid calf • Complex/Chronic prominence
• Complex/Chronic wound • Chronic/Complex
Wound Wound
 Wound Location

• Use correct anatomical positions: proximal, distal, lateral, midline,

anterior, posterior, etc.
• Be specific
 Tissue Involvement • obscured full
Pressure injury thickness skin and
tissue loss
Non-blanchable partial skin loss full full thickness • Non-blanchable
erythema of with exposed thickness skin and tissue deep red/purple
intact skin dermis skin loss loss discoloration
Tissue Involvement
Non-pressure Injury Wounds

Partial
thickness:
Involves only
the epidermis
Full thickness:
Includes
dermis and
epidermis
 Wound Bed
1. Type of tissue
• Granulation: healthy tissue, red and pebbly
• Pink/red: clean open tissue area
• Slough: Dead tissue, dry or wet, loose or attached, yellow- brown
• Eschar: Dead tissue, dry black/brown
2. Any foreign body (suture, mesh, hardware)
3. Underlying structures (facia, bone, tendon)
4. Wound bed not visible

Think about areas in percentages %

for your documentation

25% Pink/Red, 40% yellow slough and 35% brown slough

 Wound Size
Length: longest measurement
Width: perpendicular to length at the
widest point
Depth: deepest vertical measurement
Sinus Tract, tunneling, undermining:
measured with a sterile Q-tip, if exceeds
6cm, stop and notify physician.
Document according to a clock where
the patients head it 12 o’clock
Exudate
Describe colour, amount and consistency
Serous: Clear-yellow watery
Purulent: Cloudy, pussy, green/yellow
Sanguineous: Bloody
Serosanguineous: Pink, a mixture

Scant: Little bit ( < ¼)

Moderate: Medium (½)
Large amount: Soaked through

Odour
Assess odour after cleansing the wound
 Peri-wound area

Erythema Indurated Macerated Excoriated/ Callused

(redness) (firmness) (white, too Denuded
much (superficial
moisture) tissue loss)
Note: assess temperature, wound edge approximation and any other
unusual findings

Goal: to have peri-wound skin healthy and intact

 Braden Scale
Braden Risk & Skin Assessment Flowsheet

Sensory perception
Form ID:

Sensory Perception
Rev: July 2017

1. Completely Limited 2. Very Limited

Braden Scale for Predicting Pressure Sore Risk
Ability to respond Unresponsive (does not moan,
meaningfully to pressure flinch, or grasp) to painful stimuli,
related discomfort due to diminished level of
consciousness or sedation
OR
Page: 1 of 2
Responds only to painful stimuli.
Cannot communicate discomfort
except by moaning or restlessness,
OR
Has a sensory impairment which
3. Slightly Limited
Responds to verbal commands but
cannot always communicate
discomfort or need to be turned,
OR
Has some sensory impairment
4. No Impairment
Ability to respond meaningfully to
pressure-related discomfort
Responds to verbal commands,
has no sensory deficit which would
limit ability to feel or voice pain or
discomfort.

Limited ability to feel pain over
most of body
Moisture 1. Constantly Moist
Degree to which skin is Skin is kept moist almost constantly
exposed to moisture by perspiration, urine, etc.
limits the ability to feel pain or
discomfort over 1/2 of body
2. Very Moist
Skin is often but not always
moist. Linen/ continent briefs*
which limits ability to feel pain or
discomfort in 1 or 2 extremities
3. Occasionally Moist
Skin is occasionally moist,
requiring an extra linen/continent
Moisture
4. Rarely Moist
Skin is usually dry; linen only
requires changing at routine

Degree to which skin is exposed to

Dampness is detected every time must be changed once a shift briefs* change approximately once intervals
patient is moved or turned. a day
Activity 1. Bedfast 2. Chairfast 3. Walks Occasionally 4. Walks Frequently
Degree of physical Confined to bed Ability to walk severely limited or Walks occasionally during day, but Walks outside room at least twice
activity nonexistent. Cannot bear own for very short distances, with or a day and inside room at least

moisture
weight and/or must be assisted without assistance. Spends majority once every two hours during
into chair or wheelchair of each shift in bed or chair. waking hours
Mobility 1. Completely Immobile 2. Very Limited 3. Slightly Limited 4. No Limitations
Ability to change and Does not make even slight Makes occasional slight changes in Makes frequent though slight Makes major and frequent changes

control body position changes in body or extremity
position without assistance
Nutrition 1. Very Poor
Usual food intake Never eats a complete meal. Rarely
body or extremity position but
unable to make frequent or
significant changes independently
2. Probably Inadequate
Rarely eats a complete meal and
Activity
changes in body or extremity in position without assistance
position independently
3. Adequate 4. Excellent
Eats over half of most meals. Eats a Eats most of every meal. Never

Degree of physical activity

pattern eats more than 1/3 of any food
offered. Eats 2 servings or less of
protein (meat or dairy products) per
day. Takes fluids poorly. Does not
take a liquid dietary supplement,
total of 4 servings of protein (meat refuses a meal. Usually eats a total
generally eats only about 1/2 of any
food offered. Protein intake includes
or dairy products) each day. of 4 or more servings of meat and
only 3 servings of meat or dairy Occasionally will refuse a meal, but dairy products. Occasionally eats
products per day. Occasionally willwill usually take a supplement when between meals. Does not require
take dietary supplement, offered, supplementation.

Mobility
OR OR OR
Is on a tube feeding or TPN
Is NPO and/or maintained on clear Receives less than optimum
regimen, which probably meets
liquids or IV's for more than 5 days amount of liquid diet or tube feeding
most of nutritional needs.
Friction and Shear 1. Problem 2. Potential Problem 3. No Apparent Problem

Ability to change and control body

Requires moderate to maximum assistance in Moves feebly or requires minimum assistance. Moves in bed and in chair independently
moving. Complete lifting without sliding against During a move skin probably slides to some and has sufficient muscle strength to lift up
sheets is impossible. Frequently slides down in extent against sheets, chair, restraints or other completely during move. Maintains good
bed or chair, requiring frequent repositioning with devices. Maintains relatively good position in position in bed or chair.
maximum assistance. Spasticity, contractures, chair or bed most of the time but occasionally

position
or agitation leads to almost constant friction. slides down.
Copyright. Barbara Braden and Nancy Bergstrom, 1988. Reprinted with permission. All rights reserved. *Adapted with permission of B. Braden.
Insert number for each section in correct box and add up column for Total Score; then determine Risk level
Determine Level of Risk DD/MM/YY

Nutrition
Time
Score Level of Risk
15 -18 L = Low Sensory Perception
13 -14 M = Moderate
Moisture

Usual food intake pattern

10 -12 H = High
9 or less VH = Very High Activity
Fraser Health Print Shop # 256849

Mobility
Consider clients with the following
Nutrition

Friction and Shear

conditions to be more likely to be at
higher risk: Friction and Shear
Existing skin breakdown
Total Risk Score
Age greater than or equal to 75 yrs
Diastolic pressure less than 60 Risk Level
Hemodynamically unstable
See Progress/Nursing Notes
Fever (Check box if required)
PVD/Diabetes
Obesity Initials

Pressure Injury Risk Assessment: the Please turn page over to see Head-to-Toe Skin Assessment Flowsheet

higher the score the lower the risk

 Braden Scale Prevention Strategies
1. Repositioning schedule
2. Position patient in 30 degree lateral
position (rather than flat)
3. Use pillows to prevent direct contact
between bony prominences
4. Heels are provided with pressure
offloading (pillow under legs)
5. If appropriate maintain HOB at 30
degree
Skin Assessment for pressure injury:
6. If in chair, redistribute pressure points at
• Completed at minimum once per
least once and hour
shift
7. Ensure skin is dry after each
• Full Head to toe skin assessment,
• Use protective skin cream
including under medical devices &
(according to hospital policy)
between skin folds
8. Educate patient and caregiver on
• Tissue at risk for breakdown will not
prevention strategies
blanch
 Wound Treatment Plan

1. Wound Care
Nurse notes
2. Wound Care
Flowsheet
3. Nurses’ Notes
4. Physician
orders

• What types of dressings to use

• How often to change the dressing
• Expected goals
 Wound Treatment Plan:
Effective Dressings
• Controls moisture and drainage
• Promotes healing (granulation/ epithelialization)
• Promotes circulation
• Prevents infection
• Debrides dead tissues
• Fills in dead space
• Protects wound from pain and provides thermal insulation
• Cost effective
Wound Treatment Plan:
Moisture Balance
• Helps granulation tissue form
• Decrease bacterial growth
• Helps with debridement
• Decrease amount of
eschar/black slough
• Decreases pain
Drainage Amount
Dressing Type None Small Moderate large
Transparent Film
Hydrocolloid
Hydrogel
Foam
Composite
Wound Treatment Plan:
Evaluation
If there is not noticeable
improvement of the wound within
three weeks or if there are signs of
infection or deterioration, consider
appropriate treatment plan
changes or consult a Wound
Clinician or Physician
Positive outcomes:
• Wound decreasing in size
• Granulation tissue increasing
• Wound edges contracting
• Decrease in drainage
• Adequate moisture balance
 Wound Irrigation
Purpose: Clean open surgical wounds or chronic
wounds
• Introducing cleaning solution into the wound
• Agitates and washes away exudate, debris,
slough, necrotic debris and tissues that may
contain bacteria while maintaining healthy
tissue
Indications:
• Wounds that require moist healing
• Wounds that have a cavity, undermining, sinus,
or a tract
Contraindications:
• Wounds with an endpoint that cannot be
reached with a 15cm sterile Q-tip
• Wounds which require Dry treatment
• Sinus/ tract in which irrigation fluid cannot be
retrieved
 Wound Irrigation
Equipment
Equipment:
• Cleaning solution (usually NS or
Sterile Water, check physicians
order)
• 35mL syringe
• Wound tip catheter (19G angio
cath)
• PPE: clean gloves (gown and
googles if splash risk)
• Waterproof pad
• Sterile dressing tray
• Sterile dressing supplies
 Wound Irrigation Guidelines

• irrigate sinus tracts first

• top to bottom in zig zag pattern
• irrigate until clear returns
• wick or dab pooled saline
• Irrigate from cleanest to dirty
• The tip of the syringe must remain
2.5 cm above the wound
• Soft catheters are attached to the
syringe for deep wounds
• Cleansing solution should be room
temperature
 Wound Packing
Purpose: Eliminating dead space by loosely filling
in the wound
• Aids in debridement
• Encourages growth of granulation tissue
starting from the base
• Protects wound edges
Indications:
• Wounds with a cavity depth greater than 1 cm
• wounds with a sinus, tunnel and/or
undermining with known endpoints.
Contraindications:
• Undermining, tracts, tunnels extending beyond
15cm, unless directed by Physician
 Wound Packing Equipment
Equipment:
• Clean/ sterile gloves (check hospital
policy)
• Sterile dressing tray
• Sterile dressings (gauze, tapes,
treatments etc)
• Packing strip
• Wound Irrigation equipment
• Cotton Q-tip for measuring
• PPE
Wound Packing Guidelines
• Pack wounds that the depth or tract is
1” or deeper
• Level with surrounding skin surface
• Pack wounds loosely (fluff)
• Do not stuff/over pack can lead to
decreased blood flow, pain, leading to
further damage
• Pack undermining/sinus tracts
• Use a single piece of packing wherever possible
• Always document the number of pieces of packing that was used (in/out)
• Always leave a tail, you can use a steristrip to secure to patients skin
• May require barrier protection on peri-wound skin
Wound Culture and Sensitivity

Purpose: to obtain microbiological data from the

wound to determine antimicrobial treatment, if
required.
• Indicate sensitives and resistances

• Inappropriate swab technique will lead to the

collection of an inaccurate sample.
Indications: three or more indicators of wound
infection (systemic/local)
• an obvious change, over a 24 hour period, in any
of the indicators of wound infection
• diabeticor immunocompromised patients who
present with one indicator of wound infection
(systemic/local)
Wound Culture and Sensitivity
Procedure
1. Follow procedure for wound irrigation
• antimicrobial cleansing solution cannot be not used
2. Ensure excess cleansing solution is removed
3. Swab the wound bed with the sterile C&S swab using adequate pressure and
rotating the swab to extract fluid from within the wound tissue
4. Avoid touching/swabbing necrotic tissue, wound edges or peri-wound skin
5. Reapply dressing as needed
6. Remove gloves and wash hands
7. Label swab container and complete the C&S requisition and include: location
of wound, indicate if patient is on any antibiotics/antimicrobials (medications,
ointments or dressings)
8. Send the C&S swab to lab as soon as possible as a delay may alter results
Asepsis • Sterile technique or no-touch technique must be
used in all acute care settings.
• Clean technique may be used for chronic wounds
in long-term-care settings.
• STERILE GLOVES may be preferred if packing a
large or complex wound
• Cleansing clean to dirty
• One gauze for every cleaning swipe
• Keep extra supplies only for one patient, clearly
labelled with name , date and type of product

FOLLOW HOSPITAL
POLICY
 Optimizing Patient Comfort
• Pain assessment
• Analgesic prior to dressing change
• Provide regular and prn pain analgesics
• Distraction techniques
• Comfortable patient position

• Never use gauze to clean the wound bed

(damages wound bed)
• To remove the old dressing – moisten with
NS
• Reduce painful adhesive removal:
• Use paper tape/Montgomery ties
• Can use protective boarder
• Remove tape in the direction of hair
growth
 Documentation
1. Wound care flowsheet
Example of Documentation: 2. Braden Scale
The patient’s wound to right mid- 3. Nursing notes
shin measures about 4 cm x 2 cm
and ~ 1mm deep. Wound base is
~ 20 % Black slough, 20 % yellow
slough, 60 % red granulation tissue
and appears dry. Small amount of
serous drainage noted on old
dressing. Mild swelling and redness
to wound edges. Wound edges
are dry and thick. No foul odor
noted. Pt reports mild pain when
irrigating with NS. Hydrocolloid
dressing applied as per wound
care treatment plan.
Knowledge exercise
Mrs. Simpson is 85 years old, very weak, skinny and frail,
incontinent and bed-ridden. She is admitted to the
hospital for pneumonia. She needs to sit up in bed to help
her breathe, but she keeps sliding down the bed.

1) What risk factors does she have to

develop a pressure ulcer?

1) How often would you want to

asses her skin?

1) What are some strategies to

prevent pressure ulcers?
In 1. Quiz #6 Complex Wounds at HOME
• Open on Brightspace from March 3, 2020
Preparation @ 1230HR to March 8, 2020 @ 2000HR
for Next 2. Clinical competency: wound irrigation
Week • Bringyour wound care kits
• Review online module for wound
assessment (for extra practice)
3. ATI exam March 10 Room A217
•0830 sharp
•Photo Identification for the sign in process
•70 questions, 70 minutes
•ATI 2019A and 2019B assessments due by
March 9, 2020 @ 2000