Wound Care - Reading Package - Oct 2015 PDF

Wound Care Workshop Reading Package
TABLE OF CONTENTS
INTRODUCTION .............................................................................................................................. 1
ANATOMY AND PHYSIOLOGY OF THE SKIN .................................................................................. 2
EPIDERMIS .................................................................................................................................. 3
DERMIS ....................................................................................................................................... 3
SUBCUTANEOUS LAYER ............................................................................................................... 4
WOUND HEALING PHASES ............................................................................................................ 5
HAEMOSTASIS ............................................................................................................................. 5
INFLAMMATORY PHASE ............................................................................................................... 5
PROLIFERATION PHASE .............................................................................................................. 6
MATURATION PHASE ................................................................................................................... 7
FACTORS AFFECTING WOUND HEALING...................................................................................... 8
SYSTEMIC FACTORS .................................................................................................................... 8
LOCAL FACTORS .......................................................................................................................... 9
NUTRITION ................................................................................................................................... 10
DIETICIAN INVOLVEMENT ......................................................................................................... 10
ASSESSMENT PARAMETERS ....................................................................................................... 10
NUTRIENT NEEDS WITH SKIN BREAKDOWN .............................................................................. 11
WAYS TO IMPROVE NUTRITIONAL STATUS – DIETARY IDEAS, NG/PEG TUBE, TPN................ 12
LOCAL WOUND ASSESSMENT ..................................................................................................... 13
3 TYPES OF WOUND CLASSIFICATIONS .................................................................................... 17
1. ACUTE VERSUS CHRONIC ...................................................................................................... 17
2. WOUND CLOSURE .................................................................................................................. 17
PRIMARY INTENTION ................................................................................................................. 17
SECONDARY INTENTION ............................................................................................................ 17
TERTIARY INTENTION ................................................................................................................ 17
3. WOUND BED TISSUE TYPES .................................................................................................. 17
WOUND BED PREPARATION ........................................................................................................ 19
TYPES OF DEBRIDEMENTS ........................................................................................................ 20
SURGICAL (SHARP) .................................................................................................................... 20
AUTOLYTIC ................................................................................................................................ 20
ENZYMATIC ............................................................................................................................... 20
MECHANICAL ............................................................................................................................ 20
BIO SURGICAL (LARVAL THERAPY) ........................................................................................... 21
WOUND CLEANSING .................................................................................................................... 22
WOUND CLEANSING SOLUTIONS ............................................................................................... 22
RECOMMENDED WOUND CLEANSERS ....................................................................................... 24
WOUND CLEANSING TECHNIQUES ............................................................................................ 24
WOUND SWAB COLLECTION ....................................................................................................... 26
CURRENT RECOMMENDATIONS ................................................................................................. 26
WOUND SWAB COLLECTION METHOD....................................................................................... 26
OTHER TYPES OF WOUND SWAB COLLECTION METHODS ........................................................ 27
CHRONIC WOUNDS: ..................................................................................................................... 28
ULCERS AND THEIR CLASSIFICATION ......................................................................................... 28
PRESSURE ULCERS AND THEIR PREVENTION ............................................................................ 28
LOWER EXTREMITY ULCERS ...................................................................................................... 37
ACUTE WOUNDS .......................................................................................................................... 43
SKIN TEARS ............................................................................................................................... 43
BURNS ....................................................................................................................................... 44
ADDITIONAL WOUNDS ................................................................................................................. 45
WOUND DRESSINGS CRITERIA .................................................................................................... 46
DRESSING CATEGORIES .............................................................................................................. 47
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ALGINATES ................................................................................................................................ 47
HYDROFIBERS ........................................................................................................................... 47
COMPOSITES.............................................................................................................................. 47
CONTACT LAYERS ...................................................................................................................... 48
FOAMS ....................................................................................................................................... 48
HYDROCOLLOIDS ....................................................................................................................... 49
HYDROGELS .............................................................................................................................. 49
GAUZE DRESSINGS .................................................................................................................... 49
SPECIALTY ABSORPTIVE DRESSINGS ......................................................................................... 50
TRANSPARENT FILMS ................................................................................................................ 51
WOUND FILLERS ....................................................................................................................... 51
SECUREMENTS .......................................................................................................................... 52
LOTIONS, OINTMENTS & CREAMS ............................................................................................. 52
ANTIMICROBIAL DRESSINGS ..................................................................................................... 53
ANTIFUNGAL AGENTS ............................................................................................................... 54
ADVANCED THERAPEUTIC MODALITIES ................................................................................... 55
NPWT .......................................................................................................................................... 56
WOUND MANAGEMENT SUMMARY ............................................................................................. 60
MANAGEMENT OF PAIN ASSOCIATED WITH RE-DRESSINGS ...................................................... 65
PATIENT EDUCATION .................................................................................................................. 66
HELP FOR THE QUIZ .................................................................................................................... 67
WOUND IMAGES – TEST YOURSELF ............................................................................................ 69
GLOSSARY .................................................................................................................................... 72
REFERENCES ................................................................................................................................ 74
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INTRODUCTION
The area of wound care is constantly evolving. Ongoing research has greatly increased the
understanding of the wound healing process, in both acute and chronic wounds. Along with this
increase in knowledge, an ever expanding range of wound specific dressings and therapeutic
products have been developed. The field of wound management has now become a specialized
area of nursing practice, but all nursing staff working in the clinical area need to maintain a
current, basic level of wound care knowledge in order to achieve the goal of optimal wound
healing for the patient.
The information in this pre-reading package is based on an extensive literature search. It

provides guidelines only, based on the current recommendations by wound management
authorities. These guidelines can be applied to most situations. Wound management guidelines
become quickly outdated as evidence from ongoing research projects and clinical experience is
published and requires staff nurses to be adaptable in their approach to wound care.
It is important to be aware that modern dressings are grouped into broad categories based on
their properties and actions. Products within each category can have significant differences
depending on the manufacturer, therefore it is important to read the manufacturer’s
instructions before using any unfamiliar product. Inappropriate use of these dressings may
actually impede wound healing.
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ANATOMY AND PHYSIOLOGY OF THE SKIN

The skin is a complex structure. It is part of the INTEGUMENTARY system, along with its
accessory structures - hair, nails, glands, smooth muscles and specialized nerve receptors for
stimuli such as touch, cold, heat, pain, and pressure. The skin is the largest organ of the body, in
surface area and weight. It ranges in thickness from 0.5mm to 4mm. The colour of the skin is
influenced by the presence of melanin, carotene and haemoglobin. The skin is composed of
TWO layers: Epidermis and Dermis and Hypodermis (Subcutaneous Tissue).
Skin Facts
▪ Skin is the largest organ of the body
▪ Can create 2 square meters
▪ Receives 1/3 of the body’s blood volume
▪ Every minute of the day we lose about 30,000 – 40,000 dead skin cells of the surface
▪ Human being sheds and re-grows outer skin cells about every 27 days – almost 1,000 new
skins in a lifetime
Functions of the Skin

▪ Protects from bacterial invasion and against external elements (Water, Chemicals,
Mechanicals & Ultraviolet Radiation)
▪ Prevents excessive fluid & electrolyte loss.
▪ Produces sebum, a lipid-rich oily substance, secreted by sebaceous glands, creating Acid
Mantle.
Acid mantle gives the skin a particular level of acidity characterized by pH:
- pH of skin is 4 to 5.5 (slightly acidic)
- Helps protect skin from “the elements” (such as wind or pollutants)
- Inhibits the growth of harmful bacteria and fungi
- If the acid mantle balance is disrupted or loses its acidity, the skin becomes more
prone to damage and infection
▪ Contains Melanin :
• Protection against UV rays
• Sun exposure increases melanin production.
• Levels of melanin depend on race and amount of sunlight exposure.
▪ Metabolism of Calcium:
• When exposed to ultraviolet radiation from sunlight, cells in the epidermis convert a
cholesterol-related steroid to vitamin D also known as cholecalciferol. The general
result is the maintenance of calcium and phosphorous levels in the bone and blood.
▪ Senses the environment, basic types of sensations:
• Pain
• Touch
• Temperature
• Pressure
▪ Maintains temperature (Thermoregulation):
• Primary Mechanisms: Circulation & Sweating
• Blood vessels supplying blood to the skin can swell or dilate (vasodilation) so that more
heat is carried by the blood to the skin where it can be lost to the air; or blood vessels
may shrink (vasoconstriction) to reduce heat loss through the skin once the body
temperature has returned to normal
▪ Holds the body “in shape”
▪ Involved in expression of emotions:
• Identification of a person
• Role in internal & external assessments of beauty
• Body image importance
EPIDERMIS
▪ Thin, outer layer
▪ Contains 4 principle types of epidermal cells:
• Keratinocytes produce:
– Keratin: a tough, fibrous protein that helps to protect the skin and under-lying tissues
from heat, microbes, and chemicals and it is responsible for cells regeneration and
repair.
• Melanocytes which produce the pigment melanin
• Langerhans cells which participate in immune responses
• Merkel cells believed to be involved in sensory reception
▪ It takes approximately 40 days for new cells to progress through to the top strata (stratum
corneum)
▪ The epidermis does not have a direct blood supply; all nutrients that feed these cells come
from the dermis. Only the deepest cells of the stratum basale receive nourishment
DERMIS
▪ Thicker, deeper layer
▪ Composed mainly of connective tissue containing collagen and elastic fibres
▪ The predominant cells present in the dermis are fibroblasts and macrophages
▪ Macrophages digest foreign material and release a protein that stimulates the formation of
fibroblasts
▪ Collagen synthesis is the major function of the fibroblasts
▪ Embedded in the dermis are blood vessels, lymph vessels, hair follicles, nerve endings,
sebaceous (oil) glands and ducts of sweat glands
▪ Functions:
• Strength
• Flexibility
• Assists in the regulation of body temperature
• Provides oxygen and nutrients to the epidermis and removes waste
SUBCUTANEOUS LAYER
The subcutaneous layer (hypodermis) is NOT a real layer of the skin but anchors the dermis to
underlying organs and tissues
▪ Composed primarily of adipose tissue
▪ Fibres that extend from the dermis anchor the skin to the subcutaneous layer, which in turn,
attaches to underlying tissues and organs
▪ Contains larger blood vessels, lymph channels and nerve trunks
▪ Functions:
• Provides cushioning against trauma
• Contributes to temperature control
• Serves as a storage for fat to be utilized in energy metabolism
• Gives contours to the body
WOUND HEALING PHASES

Wound healing is a complex process involving an organized cascade of interdependent cellular
and biochemical events. It commences immediately after tissue damage occurs, but the
mechanism and speed of healing, as well as the type of regenerated tissue formed, depends on
the type of wound. The wound healing response can be divided into distinct but overlapping
phases. The number and naming of these phases varies between wound cares authorities.
▪ Haemostasis
▪ Inflammatory phase
▪ Proliferative phase
▪ Maturation or remodelling phase
HAEMOSTASIS (5 - 10 minutes)
When tissue damage occurs blood vessels are injured. Haemostasis protects the body from
blood loss and exposure to bacterial contamination by:
▪ Vasoconstriction
▪ Leukocyte and platelet involvement
▪ Formation of fibrin and final blood clot
INFLAMMATORY PHASE (Begins at time of injury, lasts approximately 3-5 days)
Occurs immediately after injury and haemostasis has been achieved. Bradykinin and histamine
are released in response to both tissue damage and the clotting factors produced during
haemostasis. This results in vasodilation and increased capillary permeability. There is also an
influx of white blood cells to the area.
▪ Vasodilation: the wound area will have increased heat, swelling, erythema and pain
▪ Permeability: leads to increased exudate that contains nutrients, growth factors and enzymes.
▪ Leucocyte influx: predominantly neutrophils, monocytes and macrophages. Their function
is to protect against micro–organisms and secrete a variety of proteolytic enzymes capable
of liquifying non-viable tissue components and micro-organisms in the wound. The
neutrophils are short-lived (2-3 days) and become part of the wound exudate
The inflammatory phase prepares the wound bed for healing by removing foreign material
(debriding). This removal is called AUTOLYSIS. The wound bed needs to be sufficiently clean
before the proliferation phase can commence. However, inflammation can lead to tissue damage
if it last too long. Presence of dirt or other objects can extend the inflammation phase leading to
chronic wound.
PROLIFERATION PHASE (Lasts approximately 4-24 days)
This phase is primarily cell regeneration, which fills and covers the wound bed. An adequate
supply of oxygen and nutrients to the tissues is essential during this phase. The major processes
occurring during this stage are:
▪ Granulation: The production of new connective tissue occurs during this process.
Macrophages produce growth factors which stimulate the formation of fibroblasts.
Fibroblasts synthesize and deposit collagen protein and other extracellular material.
▪ Angiogenesis, or the development of new blood vessels, takes place just behind the
advancing edges of fibroblasts. The immature collagen produced by fibroblasts provides
vital structural support for new friable capillaries.
▪ Epithelialization: Epithelial cells proliferate and migrate across the new granulation tissue
to re-establish the epidermal barrier. These cells are silvery, white-pink in colour and first
occur at the wound edges. If there are any hair follicles present within the wound bed, the
epithelial tissue around them will also commence division and form islands of pink
epithelial tissue that migrates toward other islands which may be present.
▪ Contraction: During this process an open wound with tissue loss is reduced in area by the
inward migration of normal tissue. It appears to be mediated by myofibroblasts, which
contain smooth muscle fibrils that act around the wound margins to contract the wound.
MATURATION PHASE
This is the longest stage of wound healing and can last from three weeks to two years or longer.
▪ Fibroblasts are again dominant, as collagen type III, which is synthesised during granulation,
is replaced by the stronger collagen type I, giving the tissue greater tensile strength
▪ The collagen fibres thicken and re-orientate along lines of tissue tension
▪ As this collagen develops, there is a decreased demand for oxygen and nutrients within the
wound and therefore a reduction in the microvasculature
▪ The new tissue which develops is known as scar tissue, and will only ever reach between 70
- 80 % of the original tissue strength
▪ The initial scar is red and rosed, flattening and whitening occurs as its blood supply
decreases.
There are a wide variety of local and systemic factors that can interfere with the healing process,
many of which appear to arrest the wound in a particular phase of healing or impair the
functionality of the healed wound.
FACTORS AFFECTING WOUND HEALING

Research has shown that there are a variety of systemic and local factors, which affect the
wound healing process
SYSTEMIC FACTORS
Nutrition: Refer to nutrition section
Disease Processes:
▪ Diabetes Mellitus: atherosclerosis affects the micro and macro circulation, leading to
reduction in oxygen delivery to the tissues inhibiting collagen synthesis and angiogenesis;
hyperglycaemia impairs phagocytosis; peripheral neuropathy causes decrease in sensation
with the risk of further skin breakdown and injury.
▪ Anaemia: reduces oxygen supply to tissues.
▪ Renal failure: ureamic patients are at higher risk of infection, wound dehiscence and delayed
granulation. Collagen deposition may be faulty in the presence of uraemia.
▪ Vascular disease: arterial / venous insufficiency results in poor circulation to the wound
reducing oxygen and nutrient delivery and clearance of cellular waste products. Inhibits
inflammatory response.
▪ Impaired cardiac function: results in impaired micro/macro circulation delaying healing
▪ Respiratory disease: impaired oxygenation results in decreased oxygen delivery to the
wound. Oxygen influences angiogenesis, epithelialisation and resistance to infection.
▪ Immunosuppression: many aspects of the inflammatory phase are affected leading to a
higher risk of infection.
Older Age:
▪ Dermal layer becomes thin
▪ Slower metabolism leads to a decreased inflammatory response
▪ Epithelialisation, collagen synthesis and capillary growth are delayed
▪ Sebaceous gland function is diminished leading to increased skin dryness
▪ Reduced elasticity and cohesion between the dermal and epidermal layers causing an
increased risk of damage to skin through shear and friction
Dehydration:
May lead to electrolyte imbalance and impaired cellular function. It is a particular problem in
patients with burns and fistulae
Medications:
Anti-inflammatory, cytotoxic, immunosuppressive and anticoagulant drugs reduce healing rates
by interrupting cell division or the clotting process, corticosteroids impair phagocytosis,
inhibit fibroblast proliferation; depress formation of granulation tissue; inhibit wound
contraction
Obesity:
Immobility and adipose tissue hinder supply to the site of injury
Smoking: Causes peripheral vasoconstriction
Stress (Pain / Insomnia):

Release of catecholamines causes vasoconstriction, impeding blood and nutrient supply to the
wound tissue
LOCAL FACTORS
Wound Specific:
▪ Dry wound environment: allows epithelial cells to dry out and die; impairs migration of
epithelial cells across wound surface.
▪ Necrotic tissue: the presence of slough and / or eschar predisposes it to infection and
inhibits the proliferative phase
▪ Oedema: fluid accumulation in area inhibits tissues from approximating.
▪ Foreign bodies: inhibit wound closure; increase and prolong the inflammatory response.
▪ Mechanical friction: damages or destroys granulation tissue.
▪ Wound bed temperature: it has been reported that wounds left exposed can have the surface
temperature drop to as low as 12º C. Cell activity is diminished when the temperature drops
below 28º C. It can take as much as 3 hours to increase the temperature and recommence
cell activity
▪ Infection: causes cell destruction and prolongs the inflammatory phase
Inadequate Wound Management:

▪ Use of potentially toxic substances destroys or inhibits cellular activity
▪ Traumatic dressing removal and / or cleaning: damages or destroys granulation tissue
▪ Too frequent dressing changes: increases risk of contamination and infection; decreases
wound bed temperature; potential for drying of wound bed; damage to intact tissue at wound
edges
▪ Inappropriate choice of dressing: potential for drying of wound bed; ineffective management
of excess exudates may lead to sloughing of new tissues and to maceration of the wound
edges
▪ Incontinence:
Risk of faecal or urinary contamination of the wound
NUTRITION
▪ Problem of malnutrition:
• 40% of hospitalised patients suffer from malnutrition.
• Malnutrition slows and can even stop the wound healing process and increase the risk
for pressure ulcer development. Malnourished patients have decreased collagen
production
• Malnutrition increases mortality and morbidity rate and decreases the quality of life
• To avoid malnutrition and wound complications, patients need adequate calories,
proteins and fluids
▪ The International Joint Commission (JCI) recommends a nutritional assessment be
completed within 24 hours of admission using Nutritional Risk Assessment Tool.
▪ Early Enteral Nutrition in surgical patients helps to decrease wound infection.
▪ Even obese patients can benefit from enriched beverages.
DIETICIAN INVOLVEMENT
▪ All at risk patients should be referred to dietician for nutritional interventions.
▪ All wound care patients should be followed closely by dietician until wounds are healed.
▪ All patients on NPWT should also be controlled/assessed by dietician (BJN, 1994)
ASSESSMENT PARAMETERS
Physical
▪ Assess for Sign and Symptoms of Malnutrition:
• Involuntary weight loss
• Muscle wasting
• Presence of oedema (no cardiac disease)
• Poor wound healing
• Glossitis, cheilosis-cracking at edges of mouth
• Hair loss
• Chronic infections
• Lethargy
• Poor skin turgor
▪ Healthy dentition
▪ Assess for dysphagia. People with dysphagia have difficulty swallowing and may also
experience pain while swallowing. Some people may be completely unable to swallow or
may have trouble swallowing liquids, foods, or saliva. Eating then becomes a challenge.
Often, dysphagia makes it difficult to take in enough calories and fluids to nourish the body.
▪ Assess for signs of dehydration:
• Dry mouth
• Cracked lips
• Sunken eyes
• Dark urine
• Poor skin turgor
• Trouble swallowing
• Smooth shiny tongue
Anthropometric (Measurements of the body)

▪ Weight and Height and calculate BMI
Biochemical Assessment
▪ Albumin
• Albumin is protein needed for the wound repair, white cells production, remodelling,
and collagen synthesis
• Long term measure of protein status
• At risk level <3.5 g/dL or less than 35 - 38 g/L
▪ Prealbumin
• Provides more current picture of protein status in patients who are critically or
chronically ill
• More expensive
• At risk level <16 mg/dL (160 mg/L).
▪ Transferrin
• Blood Plasma protein. The main function is to transport iron to different parts of human
body
• At risk level < 200 mg/dL
▪ Glucose
• Elevated glucose levels impair wound healing by impairing lymphocyte function, the
immune response, resulting in poor circulation and neuropathy
• Hyperglycaemia – Due to lack of insulin glucose cannot be turn into the fuel and cells
become starved for nutrients, and proteins and fats are used , resulting in catabolic state
Catabolism is non supportive of healing
• Recommended blood glucose levels by American Diabetes Association
- Preprandial plasma glucose 70-130 mg / dL ( 3.8 -7.2 mmol/L)
- Postpranadial plasma glucose <180 mg/dL (< 10.0 mmol/L)
• PSCC Guideline is to keep glucose level constantly between 6 – 8 mmol/L.
NUTRIENT NEEDS WITH SKIN BREAKDOWN

▪ Normal healing requires adequate protein, fat, carbohydrates, vitamins and minerals. .
▪ Calories need increase: 30-35kcal/kg/day
▪ Protein needs increase from 1.25 – 1.5 g/kg body weight.
▪ Proteins are made of amino acids. Amino Acids are the main building blocks of the human
cells:
Arginine: amino acid, building block of protein. Cannot be metabolised at an adequate rate
during stress, and therefore must be supplemented
Glutamine: amino acid, necessary for protein formation, maintains muscle mass, cannot be
metabolized at an adequate rate during stress, and therefore must be supplemented
▪ Fats are important for development and stability of cell membranes, and also active in
various aspects of the inflammatory response to injury.
▪ Fluid requirement are 1 ml / 1 kcal / 1kg or minimum of 1 500 ml/day unless medically
contraindicated. Additional fluids are needed for draining wounds, emesis, diarrhoea,
elevated temperature, and increased perspiration.
▪ Vitamins / Minerals are necessary for cellular metabolism:
• Fat soluble vitamins: not excreted by the body, remain in the liver and fat tissue until
they are used
a. Vitamin A – fat soluble and important in deposition of collagen
b. Vitamin D – calcium metabolism for building and maintaining bone structure
c. Vitamin E – antioxidant, protects vitamins A and C
d. Vitamin K – required for coagulation

• Water soluble: delivered from water components of food, carried in the bloodstream;
not stored in body; high levels excreted in urine.
a. Vitamin C - is a cofactor in collagen formation and fibroblast function. Deficiencies
result in delayed healing, capillary fragility, breakdown of wounds, lowered
threshold for pressure-induced injury, an impaired immune function.
b. Vitamin B – protein synthesis and fat
c. Vitamin E
• Minerals:
a. Copper - required for cross-linking of collagen; increases tensile strength
b. Iron - important in haemoglobin for transport of oxygen; important role in leukocyte
and collagen formation.
c. Zinc - protein synthesis, tissue repair
▪ Content of Intake:
• 55% Carbohydrates
• 30% Fat (There is a decreased risk for heart disease with age so fat is not as much of
concern) , recently Omega 3 and 6 are valued.
• 1.25 – 1.5 g of Protein / kg (if renal or liver status is poor, patient cannot tolerate high
protein supply)
• 10 – 20 g of Glutamine / day (amino acid / protein)
• 10 – 20 g of Arginine /day (amino acid / protein)
WAYS TO IMPROVE NUTRITIONAL STATUS – DIETARY IDEAS,

NG/PEG TUBE, TPN
▪ Small frequent amounts of food (use small bowl / plates presenting only small amount of
food at a time).
▪ Favourite foods (can liberalize diet as long as there are no adverse effects).
▪ Foods that are easy to chew & swallow
▪ Use fortified foods
▪ Patient teaching
▪ Nutrients dense beverages (Glucerna, Ensure)
▪ Vitamin / mineral supplements
▪ Pharmacological intervention – appetite stimulants (can be very expensive); anabolic
steroids (promotes protein build up and weight gain).
LOCAL WOUND ASSESSMENT

The purpose of wound assessment is to obtain baseline information and develop a treatment
plan. Regular re-assessment allows the effectiveness of the treatment to be evaluated, based on
whether wound healing is progressing or not. It is important to remember that the patient’s
general condition will impact on the healing process, so the patient’s physical assessment
findings and laboratory results should be taken into consideration when assessing the
effectiveness of the treatment plan
The following data should be recorded:

Location and wound shape:
▪ Round – pressure
▪ Jagged edges – shear or friction
▪ Irregular – vascular
▪ Linear – surgical
Wound is:
▪ Clean, Exposed, Active, Closed
Wound Types:
▪ Pressure Ulcer
▪ Arterial Ulcer
▪ Venous Ulcer
▪ Diabetic Ulcer
▪ Skin Tear
▪ Surgical Wound
▪ Burn
▪ Others
Tissue Types:
▪ Granulation
▪ Epithelialization
▪ Slough
▪ Necrosis
Percentage system is used to describe the amount of the tissue present in the wound. For
example: 30% of Necrotic + 70% of Slough
Surrounding:
▪ Macerated
▪ Erythematous
▪ Indurated
▪ Oedematous
▪ Discoloured
▪ Normal/Intact
▪ Warm / cool
▪ Dry
Size:
Linear Measurement – Length x Width x Depth
• Always measure and document in this order: Length, Width, and Depth.
• Reassess weekly.
• Size is documented in centimetres
• Consider the wound as the face of a clock:
12:00 points to the patient’s head, 6:00 points toward the patient’s feet
• Length = 12:00 – 6:00: patients head & feet as guide.
• Width = 3:00-9:00 side to side
• Measuring ulcers on the feet using the clock system – consider the heel as 12:00 and the
toes as 6:00.
• To obtain measurements, measure the longest 12-6 and 3-9 measurements and document
• Depth = distance from visible surface to the deepest area:
- Insert sterile cotton tip applicator into deepest portion of wound
- Grasp applicator with the thumb & forefinger at the point corresponding to the wounds
margin.
- Withdraw applicator while maintaining the position of the thumb and forefinger.
- Measure from tip of applicator to position of your finger on the applicator against
centimetre ruler.
- Note: It may be helpful to take several measurements in different areas to determine the
wound dimensions. Obtaining multiple measurements close together and recording the
average may improve accuracy.
• Undermining – is tissue destruction of underlying intact skin along wound margins.

Measure and document depth and direction using “Clock System”.
- Measure and document the deepest area/s.
- Insert sterile cotton tip applicator into the undermining and gently probe around
wound edges in clockwise direction.
- Once undermining was detected. Grasp the applicator where it meets the wound edge
with thumb and forefinger.
- Withdraw the applicator while maintaining the position of the thumb and forefinger.
- Measure from tip of applicator to position of your finger on the applicator against
centimeter ruler.
- Document using the “Clock System” with head = 12:00 (example: 2cm tunnel at
3:00, 1.5 cm undermining noted from 6:00 – 9:00)
- Other options for documentation of undermining:
Specific: Undermining noted from 9:00-1:00 o’clock, ranging from 2-4 cm,
deepest area is 4 cm at 10:00.
More Specific: Undermining noted along wound perimeter from 9:00-1:00.
9:00 – 2.8 cm
10:00 – 4 cm
11:00 – 3.6 cm
12:00 – 2.5 cm
1:00 – 2 cm
• Tunnelling/ Sinus Tract – is a blind ended channel that extends from any part of the
wound and may pass through subcutaneous tissue and muscle, common in dehisced
surgical wounds.
- Use sterile cotton tip applicator and gently insert tunnelled area.
- Grasp the applicator where it meets the wound edge with thumb and forefinger.
- Withdraw the applicator while maintaining the position of the thumb and forefinger.
- Measure from tip of applicator to position against centimetre ruler.
- Document using the “Clock System” with head = 12:00 (example: 4 cm tunnel at 3:00)
- Measure and document all tunnelled areas.
• Fistula – passage that formed between organs or cavities. Must be referred to the
physician.
Another approach to depth classifications:

▪ Superficial (Erosion) Epidermis has been damaged
▪ Partial thickness Epithelium and part of the dermis is destroyed
▪ Full thickness All of the epidermis and dermis is destroyed; underlying
structures such as muscle, tendon, bone may be involved
Exudate:
▪ Colour
▪ Consistency
▪ Amount
▪ It is difficult to accurately assess the volume of exudates and estimations can vary between
observers, therefore the following terms are used:
Dry / None: The wound does not produce exudate
Low / Scant: The wound bed is moist i.e. there is scant amount of exudate drainage
less than 25% of dressing size
Moderate: The surrounding skin is wet / involves 25-75% of dressing
High / Heavy / The surrounding skin is saturated (sometimes macerated) more than
Copious: 75% of dressing size
Note: The type and frequency of dressing may add to or deduct from the true level of wound
exudate.
Wound Odour:
May be caused by infection, necrotic tissue, or the use of certain dressing materials, in
particular, hydrocolloids. It is difficult to quantify the amount of odour, so suggested
descriptions are:
• No odour - None
• Odour present only on removal of dressing - Mild
• Odour permeates the room - Strong/Foul
Different stages of wounds: For example pressure ulcer stages.
Pain:
Follow PSMMC Pain Management Policy and appropriate Pain Management Tool and
Pain Management Flow Sheet. Assess Words, Intensity, Location, Duration,
Aggravating/Alleviating Factors and Interventions (WILDA).
Remember: The presence of pain at the wound site may indicate infection
3 TYPES OF WOUND CLASSIFICATIONS

1. ACUTE VERSUS CHRONIC
Wounds can be classified as acute or chronic. Acute and chronic wounds are intrinsically
different in terms of aetiology and biochemistry.
▪ Acute wounds are caused by trauma or as a result of surgery, and generally heal
uneventfully within the usually accepted time frame ( 6 weeks)
▪ Chronic wounds are forms of tissue destruction that generally result from underlying
pathogenic abnormalities. In these wounds, the normal process of healing is disrupted at
one or more points in the phases of wound healing. In most chronic wounds, the healing
process is thought to be impeded in the inflammatory phase ( more than 6-8 weeks)
2. WOUND CLOSURE
Wound healing is achieved by primary intention, secondary intention, or by tertiary intention,
the latter also known as delayed primary closure.
PRIMARY INTENTION
Involves the surgical alignment of the wound edges with sutures, staples or adhesive tapes, at
the time of injury. The healing process is hastened and scarring is minimized by creating direct
contact between wound edges. If the wound is contaminated primary closure may result in
infection.
SECONDARY INTENTION
The wound is not amenable to surgical closure due to a significant loss of tissue. As a result, the
wound is left to granulate and epithelialize from the wound bed and edges. Wounds healing by
secondary intention always require the application of a dressing with the aim of creating the
optimal moist wound healing environment. Pressure ulcers and leg ulcers are examples of
wounds healing by secondary intention.
TERTIARY INTENTION
Tertiary intention (delayed primary closure) is where the wound is closed surgically after
allowing a passage of time. The presence of, or high risk for developing infection, presence of
foreign bodies, or potential for damage to underlying organs on wound closure, are among the
reasons for delayed primary closure. An “open chest” is an example of healing by tertiary
intention.
3. WOUND BED TISSUE TYPES

Further classification is related to the wound bed tissue. More than one type of tissue may be
present in the wound at the same time. The type of tissue present will influence the choice of
dressing. The classifications are:
▪ Granulation - the wound is filled with highly vascular connective tissue. Granulation tissue
is usually red (often identified as “beefy red”), moist and has an uneven granular
appearance. Infected granulation tissue bleeds easily, has smooth, red pink colour or dusky
red colour.
▪ Epithelialization - the process by which the wound is covered with epithelial cells. This
process can be recognized by the presence of pink tissue which migrates from the wound
edges and/or from hair follicles. A moist wound surface is essential. Epithelialization
occurs 2-3 times faster in a warm, moist environment.
▪ Necrotic - dead tissue usually resulting from an inadequate blood supply. Necrotic tissue
changes colour from red to brown or black/purple, as it becomes more dehydrated. Finally,
it forms a black, dry, thick and leathery structure known as an eschar. This can be seen in a
wide variety of wounds. Its presence will delay healing.
▪ Slough - is the accumulation of dead cellular debris on the wound surface and is strongly
adherent to the tissue. It is thought to be associated with bacterial activity. It tends to be
cream or yellow in colour due to the high number of leucocytes present, but may also be
grey/green in colour. Its presence will delay healing.
WOUND BED PREPARATION

Wound bed preparation is a comprehensive approach utilised for chronic wounds that assists in
the removal of local barriers to healing and promotes the stimulation of the healing process.
Wounds are dynamic and although a wound may gradually approach a healed state, it may also
regress.
There are four major components that form a framework for a comprehensive approach to
achieve wound healing. Based on the work of the International Wound Bed Preparation
Advisory Board, an acronym was designed: TIME.
T = Tissue Management – the removal of necrotic burden in a chronic wound. Necrotic

burden includes non-vascularised tissue, bacteria, cells, and excessive exudate. Necrotic burden
tends to continually accumulate in a chronic wound.
I = Inflammation and Infection Control – recent clinical studies have shown that wound,
which do not heal, have a high bacterial bioburden. Bioburden is referred to as the number of
microorganisms on a contaminated object. This could imply that there is connection between a
high bacterial burden in the wound bed and the failure of chronic wounds to close. Decreasing
this bacterial burden is a vital element of wound bed preparation.
M = Moisture Balance – keeping the wound bed moist accelerates re-epithelisation. Chronic
wound exudate has been shown to interfere with the repair process. Wound exudate contains a
number of cells that can breakdown or damage essential extra-cellular matrix materials if not
held in check; i.e. Oedema in the lower extremities is often related to chronic venous
insufficiency.
E = Epithelial Edge Advancement – effective healing requires the re-establishment of an

intact epithelium and restoration of skin function. Evidence shows that the resident cells of
chronic wounds may have resulted in changes that impair their capacity to proliferate and move.
The overall goal is to achieve a stable wound, characterised by a well-vascularised wound bed
with minimal exudate. Wound bed preparation plays important role in wound healing process.
T = TISSUE MANAGEMENT
Necrotic Tissue
▪ Devitalised tissue impairs healing because it provides a growth medium for bacteria,
increasing the probability of infection. Dead tissue also produces endotoxins that inhibit the
migration of fibroblasts and keratinocytes into the wound.
▪ Presence of necrotic tissue prevents formation of granulation tissue, wound contraction, and
epithelialization.
Debridement
▪ Definition: The removal of dead devitalised contaminated tissue or foreign material from a
wound.
▪ The choice of debridement method will depend upon many factors including: the size,
position, type of wound, efficiency, and selectivity of debridement method, pain
management, exudate levels, and risk of infection and the cost of the procedure. In some
cases, it may be appropriate to use more than one method of debridement.
▪ Note: Stable (dry, adherent, intact without erythema) eschar (mainly present on the
heels) serves as the body’s natural (biological) cover and should not be removed.
.
TYPES OF DEBRIDEMENTS
SURGICAL (SHARP)
▪ Cutting away dead tissue using sterile scalpel or scissors, non-selective
▪ Fastest method to remove necrotic tissue
▪ Painful
▪ May damage viable tissue
▪ High risk of bleeding; mild to moderate bleeding can be controlled by application of
pressure and a haemostatic calcium alginate
▪ SHOULD ONLY BE PERFORMED BY STAFF TRAINED IN THIS PROCEDURE
Indication
▪ To remove death tissue or hyperkeratotic rim(callus) around diabetic foot ulcer
▪ Cross hatching of eschar is allowed
▪ Adjunct in combination with other methods
Contraindication
▪ Bleeding disorder
▪ Severe arterial insufficiency Arterial- brachial index (ABI ) < 0.5
▪ Malignant wound
▪ Stable dry eschar
AUTOLYTIC
▪ All wounds experience some degree of autolytic debridement during inflammatory phase
▪ Natural and highly selective process
▪ Endogenous proteolytic enzymes, mainly produced by neutrophils, break down necrotic
tissue
▪ May not take place fast enough to encourage rapid wound healing
▪ Moist wound bed environment required
▪ In chronic wounds, the process of autolysis becomes overwhelmed by high levels of
endotoxins released from the damaged tissue.
▪ Can result in production of excessive exudate
▪ Painless
▪ Use of any dressing that promotes moist: hydrogel, hydrocolloid, composites, honey,
hydrofibers, transparent films (minimal), alginates and foams.
Contraindication
▪ Large amount of necrotic tissue
ENZYMATIC
▪ Collagen enzymes (Xantyl/ Iruxol) are chemicals liquefying hard necrosis
▪ Highly selective, fast acting
▪ The exogenous enzymes work in conjunction with the endogenous enzymes
MECHANICAL
▪ Non-selective, physical method
▪ Easy to perform
▪ More rapid than autolytic or enzymatic

▪ Can damage healthy granulation tissue
▪ Methods:
• Wet-to-dry dressings: wet gauze placed onto wound bed, allowed to dry trapping
necrotic debris, which is removed with the gauze
• Pressurized irrigation: application of streams of normal saline under high or low
pressure, washes away debris, bacteria, necrotic tissue; excessive pressure may force
bacteria and debris further into the wound or damage viable tissue
• Gauze Swabbing
Additional:
• Ultrasound treatment
• Hydrotherapy
• Whirlpool therapy: powered irrigation loosens and removes surface wound debris,
bacteria and necrotic tissue. Risk of maceration and bacterial seeding
BIO SURGICAL (LARVAL THERAPY)

▪ Use of sterile fly maggots, maggots are left in wound 1-3 days
▪ Introduced in 1931
▪ Digest sloughy and necrotic material without damaging the surrounding healthy tissue
▪ Precise mechanism of action unclear but thought to be:
• Ingest and kill bacteria
• Secrete proteolytic enzymes
• Increase tissue oxygenation
▪ Some patients report pain with this treatment, Psychological consideration
WOUND CLEANSING
Wound cleansing methods and solutions are currently under debate. Research has shown that:
▪ Wounds that are healthy and free from debris do not need ritualistic cleansing.
▪ Inflammatory exudate is produced by all healthy wounds, and this exudate contains
substances which are essential for wound healing.
▪ In general, copious amount of exudate, even when clear, can be an early sign of increased
bacterial load or infection.
Indications
▪ To remove or decrease bacterial load
▪ To remove slough / necrotic tissue / debris
▪ To provide the ideal wound environment needed for normal healing process
Disadvantages
▪ Granulation tissue is easily damaged by even gentle wound cleaning
▪ Wound exudate contains substances which promote healing i.e. plasma, proteins and white
cells
▪ Wound cleaning increases exposure time resulting in heat loss and increased opportunity for
contamination
▪ Wound cleansing with cold/cool solutions decreases wound bed temperature
WOUND CLEANSING SOLUTIONS

Sterile Normal Saline (0.9% Sodium Chloride)
▪ Effectively removes contaminants
▪ Has the same sodium concentration as the cellular fluid, so does not damage cells by
removing water through osmosis
▪ Inexpensive
▪ Readily available
▪ No documented adverse effects
▪ Note: studies have shown bacterial growth may be present in multi-use saline containers
within 24 hours of opening
Antiseptic Solutions
Currently, the literature indicates much controversy regarding the use of antiseptic solutions.
There is evidence that antiseptic solutions may actually slow wound healing. Some of these
products are cytotoxic to fibroblasts, reduce white blood cell viability, decrease phagocytic
efficiency and retards wound contraction and epithelialisation. Many of these products are
drying agents as well as anti-microbial. Wound exudate is necessary to create an environment
which stimulates more rapid wound healing. Dry tissue tends to necrose and serve as a bacterial
medium. There are clinical studies which have shown that a wound maintained in a moist
environment (with exudate) has a lower infection rate than a wound which is dry.
Some evidence supports the selective use of antiseptics to stimulate previously

unresponsive chronic wounds and to treat critically colonized or infected wounds. If used
correctly, topical antiseptic agents, despite their cytotoxic properties, can be effective
antibacterial agents.
General disadvantages of antiseptic solutions

▪ Some are inactivated when coming into contact with organic matter (Povidone-Iodine)
▪ Needs to be in contact with bacteria for an extended period of time in order to kill it
▪ Frequent application is required to achieve effect
▪ Reported increase in pain and discomfort
COMMONLY USED ANTISEPTIC SOLUTIONS

Product
▪ Chlorhexidine 0.02% without Alcohol
▪ Aquaeous Povidone-Iodine 10% (Do not interchange with 1% Tincture of Iodine!!)
Additional Wound Cleansers

▪ Debrisan, Prontosan are now being introduced to the market. These products contain
surfactants and PHMB (type of chlorhexidine) which help lift bacteria and cellular debris as
well as to destroy biofilms. However they are not cost effective.
▪ Hydrogen Peroxide is considered for chemical cleaning not for antiseptic effect. Moreover,
an air embolism has been reported with the use of Hydrogen Peroxide 3% in large and open
wounds.
BIOFILMS
Biofilms are complex microbial communities containing bacteria and fungi. The
microorganisms synthesise and secrete a protective matrix that attaches the biofilm firmly to a
living or non-living surface. At the most basic level a biofilm can be described as bacteria
embedded in a thick, slimy barrier of sugar and proteins. The biofilm barrier protects the
microorganisms from external threats (Biofilms Made Easy, 2010).
RECOMMENDED WOUND CLEANSERS

The ideal cleansing solution remains controversial. The decision on which solution to use will
be influenced by:
▪ Type of wound
▪ Presence of infection
▪ Physician / Wound Care Resource Nurse preference
▪ Availability of products
The predominant current recommendations are:

▪ Sterile normal saline is the preferred cleansing solution for routine wound cleansing.
▪ Antiseptics should not routinely be used to clean wounds but may be considered when
bacterial load needs to be controlled.
▪ Ideally antiseptics should only be used for a limited period of time until the wound is clean
and surrounding inflammation reduced.
▪ If the wound is healthy with no obvious debris – do not clean.
WOUND CLEANSING TECHNIQUES

▪ Wounds should not be cleaned with cotton wool, as it leaves residual fibres.
▪ Swabbing should only be used for cleaning closed wounds or the intact skin surrounding in
an open wound.
▪ Use minimal mechanical force when cleansing the wound, unless mechanical wound
debridement is the aim.
▪ The cleansing solution ideally should be at room temperature to maintain a constant wound
temperature.
▪ Gentle pressure irrigation of open wounds, is the most effective method of wound cleansing.
Especially cavity type wounds. Irrigate using a 20 ml syringe with an 18 gauge PIV cannula
sheath. Care should be taken not to use excessive pressure as this may damage tissue and
force bacteria deeper into the tissue. Irrigate at least 4-6 times.
I = INFLAMMATION AND INFECTION CONTROL

A wound infection is defined as one of the complications that adversely affect the wound
healing process. Wound infection and breakdown of surgical and traumatic wounds still account
for considerable amount of misery, prolonged hospital stay and expense in nursing time,
dressings and antibiotics (Benbow, 2005).
You should be able to differentiate between:
Wound contamination – the presence of bacteria within a wound, but not multiplying; no host
reaction. All chronic wounds are considered to be contaminated.
Wound colonization – the presence within the wound of bacteria which multiply, but without
an associated systemic host reaction or a negligible host response. It is important to distinguish
between colonisation and infection since colonised wounds will heal without the need for
antibiotics.
Critical colonization – multiplication of bacteria causing a delay in wound healing usually

associated with an exacerbation of pain not previously reported but still with no overt host
reaction.
Wound infection – the deposition and multiplication of bacteria in tissue with an associated
systemic host reaction. Microbiologically, wound infection is recognized by presence of
1,000,000 organisms per gram of tissue.
Wound infection is a serious problem because, at the most fundamental level, infection stops a
wound from healing by:
▪ Prolonging the inflammatory phase
▪ Disrupting the normal clotting mechanisms
▪ Promoting disordered leukocyte function and ultimately preventing the development of new
blood vessels and formation of granulation tissue
Infection of the wound may lead to septicaemia and death.
Infection in chronic wounds such as leg ulcers, pressure ulcers often does not exhibit the
expected signs of infection, particularly in elderly people and those taking steroids medications,
which can lead to confusion and under or over treatment.
Early recognition of the signs and symptoms of wound infection will enable appropriate
interventions to be commenced. There are a number of indicators of infection; these include the
classic signs related to the inflammatory process as well as more subtle changes.
Classic Signs and Symptoms

▪ Extended erythema
▪ Exudate – sudden increase
▪ Localised pain
▪ Localised heat
▪ Cellulitis (spread inflammation of the skin and subcutaneous tissue, lymph nodes swollen)
▪ Localised oedema
▪ Pyrexia
▪ Separation of wound edges / wound breakdown (dehiscence)
Additional Signs and Symptoms

▪ Delay in healing which was not previously present or anticipated
▪ Discolouration of tissues both within wound bed and at the wound margins
▪ Friable, bleeding granulation tissue despite gentle handling
▪ Abnormal odour
▪ Osteomyelitis
▪ Laboratory results / swabs / tissue biopsy, needle aspiration,WBC, ESR
WOUND SWAB COLLECTION

In most cases, wounds should not be cultured if no evidence of infection or impaired healing is
noted unless screening is being performed for colonization of multi – resistant micro-organism.
If infection is diagnosed, a properly obtained swab will provide the information that is needed
for most clinical situations (Sibbald 2003).
CURRENT RECOMMENDATIONS
A wound swab should only be taken when there are clinical signs of infection or as a clearance
from multi - resistant strains after antibiotic therapy (3 swabs for MRSA – 46, 72, 72 hrs) and (3
swabs for MDRO – 2 weeks, 1 week, 1 week). (Always refer to Infection Control Policy and/or
ID Team or call Infection Control practitioner 88197/88721).
The presence of slough or necrotic tissue alone is not an indication for taking a swab.
▪ It is recognized that the most practical and widely available method remains swab culture,
but if improvement is not seen, following recommended methods of specimen collection
should be used: tissue culture punch biopsy, deep curetting and needle aspiration.
▪ Quantitative sampling (tissue biopsy) has merits. Once bacterial load reaches 1 000 000
CFU/g* of tissue, wound healing is usually impaired. However, 20% of wounds colonized
with 100 000 CFU/g will heal. Moreover, normal skin flora, present in high quantity,
appears to enhance wound healing.
▪ On the other hand, some micro-organisms, (eg: beta-hemolytic streptocci, mycobacterium
tuberculosis, treponema pallidum, corynobacteria diphtheriae, brucella spp., bacillus
anthracis) can be detrimental in small numbers. Thus, quantitative microbiology does not
necessarily provide an unambiguous diagnosis of infection (Sibbald 2003).
*CFU – colony forming unit
WOUND SWAB COLLECTION METHOD

WOUND SWABBING GUIDELINES
Action Rationale
Follow procedure for aseptic technique. To determine if a wound swab required.
Remove wound dressing and assess wound bed
for clinical signs of infection.
Cleanse wound with sterile saline as per aseptic Wound cleansing reduces the risk of
technique procedure. introducing extraneous micro-organisms
into the specimen.
If the wound bed is dry moisten the tip of the To allow organisms to adhere to the
swab with sterile saline. swab increasing the amounts of available
pathogens for examination. Micro-
organisms will die on a dry swab.
If the wound is producing copious amounts of In heavily exudating wounds, the swab
exudate do not moisten the swab absorbs excess overlying exudate,
resulting in an inadequate swab.
Apply swab with light pressure to wound, bed To ensure that organisms embedded
and rotate the swab using Levine technique throughout the wound are isolated.
across 1cm² of viable tissue. When the tip is To identifying both anaerobic and
saturated, transfer immediately to the specimen aerobic pathogens.
container and send to the laboratory as soon as

possible.
Wound swabs should NOT be kept in the fridge. Wound swabs should be kept at room
temperature. To prevent, organisms from
being killed off.
Wash hands with soap and water / or alcohol gel To prevent cross infection.
on removal of gloves.
Continue aseptic technique. To maintain temperature of wound bed
Re-dress the wound with current prescribed and enable wound healing re-dress the
dressing. wound as soon as possible following
Contact Wound Care / Tissue Viability Team for wound swabbing.
advice.
On completion of the aseptic technique ensure all To ensure the relevant information is
documentation is completed. obtained by the Microbiologist.
Specimen forms must have information inclusive To ensure appropriate interventions are
of antibiotic therapy. Anti microbial dressing, undertaken.
length of time on treatment, where the swab was
taken and any other relevant medical history.
Do not swab eschar or slough.
Do not take swab from pooled exudates or from
wound dressings.
If pus or abscess noted, aspirate fluid from the
abscess cavity using a syringe and needle.
During debridement, obtaining deep curetting for
culture is appropriate (physician only)
OTHER TYPES OF WOUND SWAB COLLECTION METHODS

ONLY PERFORMED BY PHYSICIANS
▪ Tissue culture punch biopsy: Is the gold standard for wound cultures and is the most
definitive measurement of bacterial invasion; however they are invasive, skill-intensive, and
unavailable in many setting. Using a punch biopsy device, tissue is extracted from the
wound. The lab weighs the specimen, flames the surface to kill surface contaminants, and
grinds the tissue before placing in culture medium
▪ Needle aspiration: Fluid is contained from the wound using a 22 gauge needle with
multiple insertions into the tissue to obtain 10 ml of fluid. This method is best used when
local collections of tissue fluid or abscess formations exist close to the wound.
CULTURE TIPS SUMMARY

▪ Culture wound if multiple signs of infection are present
▪ Always clean wound prior to culture
▪ Do not use purulent matter to culture
▪ Do not swab over hard eschar
Obtain culture prior to initiation of antibiotics, if possible
CHRONIC WOUNDS:
ULCERS AND THEIR CLASSIFICATION
PRESSURE ULCERS AND THEIR PREVENTION
Terminology
▪ The ulcers are often referred as pressure sores, bedsores, or decubitus ulcers (from Latin
word decumbere, which means “to lie on one’s side”).
▪ National Pressure Ulcer Advisory Panel (NPUAP, 2007) definition of pressure ulcer is:
• A pressure ulcer is localised injury to the skin and/or underlying tissue usually over a
bony prominence, as result of pressure, or pressure in combination with shear and/or
friction and / or moisture over a period of time.
• A number of contributing or confounding factors are also associated with pressure ulcers
development; the significance of these factors is yet to be elucidated.
• Clinical Presentation:
- Pressure Ulcers are painful

- Usually develop over a bony prominence and are therefore circular in shape, will
however take on the shape of the object that caused the pressure.
STAGES IN SUMMARY
The Most Important Extrinsic Factors:

▪ Friction
• The force of rubbing two surfaces against each other.
• Friction without pressure causes damage to the epidermis and upper dermal layers only.
▪ Shearing (Shear Force)

• Friction accompanied with gravity causes shear. An internal, opposing motion of tissue
layers and bones.
• Shear is caused by gravity pushing down on the body and resistance (friction) between
the patient and a surface, such as the bed or chair. E.g. elevation of head of bed, and
sliding down in chair.
• Shearing of forces stretch or even tear the blood vessels.
• Shearing causes undermining and tunnelling.
▪ Moisture
• Incontinence – 65% of patients with pressure ulcers are incontinent and the odds
increase threefold in the presence of faecal contamination
Other types of breakdown related to a moisture – not to be confused with a pressure

ulcers:
▪ Perineal Dermatitis:
• Other names: Incontinence associated dermatitis (IAD), irritant dermatitis, heat rash or
diaper rash when noted in children.
Causes:
a. Inflammation of the skin from prolonged exposure to urine or stool.
b. Most common cause of nosocomial diarrhoea is Clostridium Difficile
c. Regular use of absorptive devices such as an incontinence briefs or pads, which
raises the pH of the underlying skin and increases production of perspiration.
The clinical characteristics:
a. Redness, blistering; lesions remain partial-thickness and free from necrosis (slough
or eschar).
b. The areas of redness may be patchy or consolidated.
c. Dermatitis associated with urinary incontinence tends to occur in the folds of the
labia majora in women or the scrotum in men, whereas dermatitis associated with
faecal incontinence tends to originate in the perineal area.
d. A full-thickness wound (tissue destruction into the subcutaneous tissue or deeper),
with or without necrosis (slough or eschar), reflects ischemic tissue damage and
would be classified as a pressure ulcer not as perineal dermatitis.
▪ Candidiasis (Candida Albicans):
• Normal flora in intestines, overgrowth related to stress, antibiotics, starts as yeasts and
changes to fungal, thrives in warm moist environment.
• Appears as macerated, eroded, erythematous skin, usually with satellite papules and
pustules.
- White skin – presents as bright to dull red central area with peripheral red vesicles
(satellite lesions).
- Dark skin – presents as a darker skin tone, may develop into dark red or purple hue.
• Candidiasis occurs most commonly in the axillae, groin, body folds, glutei folds, in
digital web spaces, on the glans penis, and beneath the breasts.
• Candidiasis on the skin is treated with topical azoles (e.g. Clotrimazole) or polyenes (e.g.
Nystatin) either alone or in combination with topical steroids (e.g. 1% Hydrocortisone in
Clotrimazole cream to the affected areas twice daily and as needed).
• Remove moisture
• Check other sources of infection, cutaneous candidiasis often accompanied by vaginitis,
oral thrush, cystitis, and bloodstream infections. Treat with oral Fluconazole (Diflucan).
Intrinsic Risk Factors – Same as systemic Factors

▪ Nutrition, Age, Co-Morbidities, Smoking etc….
Unavoidable Pressure Ulcers

• In critical care, hemodynamic instability may preclude turning or repositioning and lead
to unavoidable pressure ulcers.
▪ The National Pressure Ulcer Advisory Panel (NPUAP) definition of “unavoidable pressure
ulcer”:
• The individual developed a pressure ulcer even though the provider had evaluated the
individual’s clinical condition and pressure ulcer risk factors; define and implement
interventions that are consistent with individual needs goals and recognise standards of
practice; monitor and evaluate the impact of the interventions; and revise the approaches
as appropriate
Prevention of Pressure Ulcers

▪ Prevention is part of every aspect of wound care, regardless if a wound exists or not. Many
recommended practices regarding pressure ulcer prevention are nothing more than “good old
common sense”.
▪ Prevention requires a holistic approach from all members of the health care team, including
family.
▪ A formal comprehensive pressure ulcer prevention program (PUP) is essential to prevent
pressure ulcers. Program should include:
• Risk Assessment Tool (Braden Scale)
• Systematic skin assessment
• Reduction of risk factors
• Patient, family and staff education
• Written PUP Plan
• Written re-positioning schedule
• Tools:
1. The Braden Scale was developed in 1987 and comprises six subscales that reflect
degrees of sensory perception, moisture, activity, mobility, nutrition, friction, and
shear.
2. Each subscale is rated on a scale according to risk and the scores are then
totalled.
3. Lower scores indicate higher risk for pressure ulcer development. Has been
tested extensively in acute and long-term settings.
Example of Braden Scale:
▪ Interventions for Pressure Ulcer Prevention (PUP):

• Positioning:
- For immobile bed bound patients (meaning at risk), perform change of position at
minimum of every 2 hours. Some patients may require more frequent position
change due to high risk status. However, there is no adequate evidence to support 2
hourly turning theses (Hobbs 2004, Wanderwee 2006, Lindhom 2008). Some
guidelines still advice 2 hourly turning such as NPUAP, EPUAP (Those are well
recognized advisory boards).
- Use your judgement as well – repositioning should be determined by the results of
skin assessment and individual patient's needs.
- Positioning devices such as pillows, gel pillows and foam wedges should be used to
maintain position. These devices are also used to prevent bony prominences from
direct contact with one another
“Rule of 30”:
1. The “Rule of 30” means the head of the bed is elevated at no more than 30
degrees from horizontal level and the body is placed on a 30 degree laterally
inclined position, when repositioned to either side. If the head of the bed is
raised higher than 30 degrees for eating, watching television, etc., the head
should be returned to the original 30 degrees as soon as possible.
2. In the 30 degree laterally inclined position, the resident’s hips and shoulder are
tilted 30 degrees from supine and pillows or foam wedges are used to keep the
resident properly positioned without pressure over the trochanter or sacrum. If
tolerated, the prone position may also be used.
• Lateral position: improves venous return and cardiac output (Du-Pan 2004).
• Increases tissue oxygenation and tissue blood flow (Loat 2007, Kusan 2010).
- Use transfer / draw sheets / trapeze / hoists / slide sheets to decrease friction.
- Avoid positioning patient directly on skin breakdown.
- Do not massage reddened areas.
- Inspect skin daily or as required by the policy for reddened areas or breakdown
• Seating Interventions:
- Individuals who are willing and are able should be taught to redistribute their own
weight at least every 15 minutes in the chair.
- They can do chair push up to reduce the constant pressure over sacral area.
- If unable, reposition patient every 1 hour.
- Use pressure redistributing cushion while in chair.
Placing a foam or gel cushion on a sagging chair seat will not solve the problem.
The answer is to replace the sagging seat with a solid seat and cover it with the
appropriate pressure-reducing or pressure-relieving cushion.
• Support Surfaces should achieve pressure redistribution.

Pressure redistribution is the ability of a support surface to distribute load over the
contact areas of the human body (pressure redistribution term replaces prior
terminology of pressure reduction and pressure relief).
1. Static support surface: maintains constant inflation by using materials that
conform to the body surface; do not move; does not require electricity to
function; non-powered.
2. Dynamic support surface: alternating inflation and deflation to spread the
pressure load over a large surface area; moves; require a motor or pump and
electricity to operate; powered.
- Place “at-risk” individuals on pressure-redistributing surfaces and not on an

ordinary hospital mattress.
Avoid the use of donut-type devices, doughnut rings; water filled gloves and artificial
sheep skin.
Support surfaces are divided into:
Static Dynamic
• Water Alternating pressure
• Gel Low air loss
• Foam Kynetic
• Air
1. Use a static support surface if a patient can assume a variety of positions without
bearing weight on a pressure and without “bottoming out”.
When the bony prominences come in contact with the mattress / frame beneath the
support surface – bottoming out has occurred and the support surface is no longer
providing therapeutic benefits.
To check for this: place your hand palm up with fingers outstretched, between the
support surface and underlying surface or frame.
The support surface should have about 1 inch/2.54 cm of un-compressed support
surface between the clinicians hand and the patient’s body.
Perform the test under bony prominences at various degrees of head elevation /
positions.
2. Use a dynamic support surface if the patient cannot assume a variety of positions
without bearing on a pressure ulcer, if the patient fully compresses the static support,
or if the pressure does not show evidence of healing.
When excess moisture or intact skin is a potential source of maceration and skin
breakdown, a support surface that provides airflow can be important in drying the
skin and preventing additional pressure ulcers.
Operating rooms
• Overlay gel mattresses should be used for all heavy, at risk patients and if procedure will
take longer then 90 minutes.
a. Elevate heels during surgery
b. Position patient in a different posture preoperatively and postoperatively to the
posture during surgery
• Assess moisture:
a. Incontinence: initiate bowel and bladder assessment & training program.
b. Liquid stool: assessment of bulk in diet, dietary changes; tube feeding formulas.
Clostridium Difficile (most common cause of nosocomial diarrhoea)
c. Clean and dry skin after each incontinent episode:
1. Avoid hot water
2. Side-effects of washing the skin with soaps or detergents of moderate or high
strength can alter the acid mantle
d. Use incontinent products that draws moisture away from the skin:
1. Indwelling catheter
2. External catheter
3. Briefs (Pampers)
4. Rectal bag / pouch
5. Bowel management system, e.g. www.hollister.com

6. Flexi-Seal Faecal management system e.g. www.convatec.com
7. Creams/ vaseline
e. Consider “open system” for incontinence management while in bed or at night:
Remove incontinence brief (pampers) and place an absorbent pad under the patient to
wick away moisture.
f. Maintain adequate nutrition
Education for Treatment and Prevention of Pressure Ulcers should be structured, organised,
comprehensive, and directed to all levels including health care providers, patients, family, and
caregivers.
LOWER EXTREMITY ULCERS
ARTERIAL NEUROPATHIC/ISCHEMIC VENOUS ULCERS

DIABETIC ULCERS
Predisposing Factors
• Peripheral Vascular Disease • Diabetic patient with • Valve incompetence in
(PVD) peripheral neuropathy and perforating veins
• Diabetes Mellitus microangiopathy • History of deep vein
• Advanced age (arterial/ischemic diseases) thrombophlebitis and
• Smoking thrombosis
• Muscle failure
(obesity,pregn, immobility)
• Advanced age
Anatomic Location
• Between toes or tips of toes • On plantar aspect of foot • On medial lower leg and
• Over phalangeal heads • Over metatarsal heads ankle
• Around lateral malleolus • Under heel • On malleolar area
• At sites subjected to trauma • Toes
or rubbing of footwear
Wound Characteristics
• Even wound margins • Calluses • Irregular wound margins
• Dry necrosis • Deep wound bed • Superficial wound
• Deep, pale wound bed • Granular tissue present • Pain alleviated by elevation
• Blanched or purpuric • Low to moderate drainage • Frequently moderate to
periwound tissue • Necrotic, dry, scaly skin heavy exudates
• Severe pain when elevated
or exercise
• No oedema
• Minimal exudates
Patient Assessment
• Thin, shinny, dry skin • Diminished or absent • Oedema
• Hair loss on ankle & foot sensation in foot • Dilated superficial veins
• Thickened toenails • Foot deformities (Charcot’s • Dry, thin and brown skin
• Pallor on elevation and joints) • Evidence of healed ulcers
dependent rubor • Palpable pulses, Warm, • Possible dermatitis – wet,
• Decreased temperature Oedema (only Neuropathic) dry, localised or general
• Absent or diminished pulses • Pulseless, not warm
(Ischemic ulcers)
• Skin fissures (entry of
infection)
• Erythema (sign of infection)
/ inflammation
ARTERIAL ULCERS
PATHOLOGY
Arterial ulcers are caused by arterial failure and occur in the elderly, smokers and diabetes.
These wounds arise because of inadequate perfusion and are very hard to heal because of the
lack of revascularisation. Arterial conditions are progressive, so early diagnosis and adequate
wound treatments are necessary to limit further tissue loss. A physical, bilateral assessment of
the lower legs, including determination of the ankle-brachial pressure index is suggested.
Arterial Leg Ulcers Appearance

Characteristic of arterial ulcers is a round ‘punched out’ shape and dry, poorly perfused wound
bed. The wound edge is smooth. The foot/leg may feel cold and be pale or bluish. The
surrounding skin is shiny and taut. The patient often complains of pain, especially after exertion
or elevation of the leg. A reduced ankle-branchial pressure index (ABPI) confirms the
diagnosis. A normal resting ankle - brachial pressure index is 0.9-1.3. This means that your
blood pressure at the ankle is the same or greater than the pressure at your arm.
Classification of arterial ulcer disease:

Wagner Scale can be applied
PATIENT MANAGEMENT
Revascularisation is an important option in the treatment of non-healing arterial ulcers. These
patients must be referred to a vascular surgeon for angiography and possible surgical treatment.
Patient education, changes in lifestyle and medical treatment are essential in addressing the risks
of arteriosclerosis. It is also important to address patient-related factors that delay wound
healing, such as nutritional factors and the use of nicotine.
WOUND MANAGEMENT
Dry necrotic eschars should not be removed routinely.
VENOUS LEG ULCERS
PATHOLOGY
Venous ulcers are caused by venous hypertension as consequence of poor valve function,
venous obstruction and/or failure of the muscle pumping function in the calf. Patients with
venous ulcers experience stress and pain, leading to reduced mobility. The chronic and
recurrent nature of venous has a significant effect on the patient’s quality of life.
VENOUS LEG ULCERS APPEARANCE

Venous ulcer is often superficial wounds on the inside of the lower leg (medial malleolus).
There is often oedema, hyper-pigmentation, and ‘white atrophy’ of the surrounding skin. Pain is
dull, aching, relieved by elevation and veins are distended. The shape and wound edge are
irregular. The wounds are often shallow, flat, sloughy and highly-exuding. ABI is > 0.9, which
is normal.
Classification of venous ulcer disease

• Class 0: No signs of venous disease.
• Class 1: Telangiectases or reticular veins.
• Class 2: Varicose veins.
• Class 3: Oedema.
• Class 4: Skin changes.
• Class 5: Healed ulcer.
• Class 6: Active ulcer.
PATIENT MANAGEMENT
First of all, it is important to obtain patient’s general assessment (lifestyle, smoking, underlying
diseases etc.)
LOCAL ASSESSMENT
Multi layer compression therapy together with moist wound healing therapy is the gold
standards in the treatment of venous ulcers. Bandaging with high pressure is ideal, but this
approach requires adjustment for patients with diabetes, arthritis, infection or an arterial
condition. There is no obvious difference in efficacy between the various multi-layer
compression systems, but short-stretch elastic bandages have advantages over highly elastic
bandages in mobile patients, while in patient with little mobility long-stretch bandages may
provide greater benefit.
Vascular ulcers are prone to infection with anaerobes so antimicrobial dressings are highly
recommended.
DIABETIC FOOT ULCERS
NEUROPATHIC FOOT ULCERS
The neuropathic foot is warm and has good blood flow and palpable pedal pulses. The different
types of neuropathy are:
• Autonomous neuropathy that causes the absence of sweating, causing dry skin, which can
lead to cracks.
• Motor neuropathy may mean that the hollow of the foot is unusually curved and that the toes
are bent into a claw, which places abnormal stress on the foot.
• Sensory neuropathy results in reduction or loss of sensation of vibration, painful and thermal
stimuli.
• The combination effects of neuropathy result in a high risk for the neuropathic foot of tissue
damage, ulcers, and of infection, despite good blood flow.
• Ulceration is generally found on the sole of the foot where there is high plantar pressure.
Thus, while diabetic neuropathy has many aspects, it is lack of sensation that is the most
dangerous and leads to the most problems when the complications of the diabetic foot are
considered.
DIABETIC ISCHEMIC FOOT ULCERS
Ischemia can be due to large vessel disease which can be dealt with by bypass or angioplasty. It
can also be due to small vessel disease, too distal to be bypassed by current methods. Diabetics
classically present with this peripheral small vessel disease. The ischemic foot is pale and cool
with absent pulses.
The death of tissues due to lack of blood supply provides a suitable environment for micro-
organisms, which cannot be killed by the natural body defences due to the lack of blood
supply. This means a very high risk of infections and gangrene.
Wagner ulcer grade classification system (diabetic foot ulcers)

• Grade 0: Pre-ulceration lesions, healed ulcers, presence of bony deformity.
• Grade 1: Superficial ulcer without subcutaneous tissue involvement, not infected
• Grade 2: Penetration through the subcutaneous tissue; may expose bone, tendon,
ligament, or joint capsule, often infected
• Grade 3: Osteitis, abscess, or osteomyelitis.
• Grade 4: Gangrene of digit.
• Grade 5: Gangrene of whole foot.
Untreated diabetic ulcers usually end up with mixed aetiology – referred to us as

neuroischemic ulcers.
PATIENT MANAGEMENT
Ensure appropriate prevention through good patient education, informing patients of the
possible risks. Planned intervention aimed at healing of diabetic ulcer is most effective in the
context of a multidisciplinary team (Wounds International Guidelines 2013).
• Effective Local Wound Care
• Infection Control
• Vascular assessment
• Testing for Loss of sensation
• Off Loading therapy
• Management of Underlying disease
• Optimal Diabetes Control
• Consult a doctor immediately if the feet are wounded or if other problems occur. (Podiatrist
– specialist for footwear might be contacted).
Some points to consider in education are:
• Cut nails correctly; seek assistance if impaired vision.

• Daily skin inspection, careful washing and drying
• Hydrate the feet with a skin cream to prevent cracks.
• Do not walk barefoot, even indoors.
• Wear comfortable shoes which do not cause any pressure marks on the feet.
ACUTE WOUNDS
SKIN TEARS
Skin tears are traumatic wounds. The epidermis with or without the dermis is removed by
mechanical means. Result of friction and /or shearing forces 9for example tanautic dressing
removal)
Risk factors
• Advanced age
• Compromised nutrition
• Cognitive impairment
• Poor mobility
Payne-Martin classification system for skin tears (ST)

• Category I: Skin tears without tissue loss
• Category II: Skin tears with partial (25%) tissue loss
• Category III: Skin tears with complete tissue loss
BURNS
Aetiology:
Burns are traumatic wounds that may be caused by exposure to thermal extremes, chemicals,
electricity, radiation or direct heat.
Burns are classified by the depth:

• First Degree: Damage is limited to the epidermis, causing erythema and pain.
• Second Degree: The epidermis and part of the dermis are damaged, producing blisters,
mild to moderate oedema, and pain.
• Third Degree: The epidermis and dermis are damaged; no blisters appear, but white,
brown, or black leathery tissue and thrombosed vessels are visible.
• Fourth Degree: Damage extends through deeply charred (burned) subcutaneous tissue
to muscle and bone.
Burns assessment involves estimation of percentage of total body surface area affected by
injury. Minor burns can be treated in Emergency Department. People, with more than 5% of the
total body area affected, should be hospitalised.
Pain may be more severe in superficial burns than full-thickness wounds because the nerve
endings are exposed.
As a first aid measure, the prompt application of cold water helps to stop the burning process.
Class I
ADDITIONAL WOUNDS
Hypertrophic Scars
• Skin burns / Individuals who are genetically prone.

• Scar tissue will form excess growth of fibrous tissue, which results in a bumpy or uneven
skin surface.
• Scarring will remain in the line of injury and does not outgrow the wounded area.
Keloids
• Hereditary
• Overgrowth of tissue at the site of a healed skin injury.
• Keloids are firm, rubbery lesions or shiny, fibrous nodules
Overgranulation
• When granulation ‘over grows’ beyond the surface of the wound, this is known as
overgranulation, also referred to as hypergranulation.
• Causes: occlusive dressings , collagens, infection, friction
WOUND DRESSINGS CRITERIA

M = MOISTURE BALANCE
E = EPITHELIAL EDGE ADVANCEMENT

For optimal wound healing, a warm, moist wound environment is required. Modern wound
dressings play a role in achieving this. The criteria for the ideal type of dressing are:
▪ Provides a Moist Environment

Wounds which are healed in a moist environment heal faster, are less inflamed and less
painful. There is more collagen production and better contraction, which results in less
scarring. The only possible exceptions are peripheral necrosis secondary to arterial
insufficiency (including high dose inotropes) e.g. necrotic toes and diabetic ulcers, where
the risk of rapid infection may be increased by a wet environment.
▪ Controls Excess Exudates
Although the wound surface should remain moist, excessive moisture causes maceration
and excoriation of the surrounding skin which may in turn lead to infection. The precise
balance that needs to be maintained by the dressing between moisture and absorbency is
still not certain.
▪ Atraumatic
Removal of adherent dressings can cause trauma to wounds. Traditional dressings such as
gauze have a tendency to adhere to the surface of wounds causing damage to newly
formed epithelium
▪ Thermal Insulation
A constant temperature of 37oC promotes both macrophage and mitotic (division of
mother cell into two identical daughter cells) activity during granulation and
epithelialisation
▪ Impermeable to Micro-organisms
Many modern dressings are bacteria-proof. This prevents airborne bacteria entering a
wound and also prevents contaminated exudate entering the environment and causing
cross-infection.
▪ Acceptability to Patient
The patient’s acceptance of a wound dressing is essential to enhance patient compliance
with the chosen dressing. Comfort, cosmetic appearance and practicality should all be
considered.
▪ Cost Effective
The cost of a dressing product alone should not be the deciding factor, but where all other
considerations are equal, choose the cheapest dressing.
DRESSING CATEGORIES
Dressing selection is complex. The categorization of wound management products is becoming
more complicated as new, different and combined dressings appear on the market. There is no
one dressing for each wound, rather there is a variety of dressings that the nurse can use to
provide the best conditions for healing (Daughty, 1992).
The range of products increases daily and now, with the advent of more advanced technologies
it becomes ever more difficult to justify and defend the choices made (Benbow, 2005).
Dressing is evolving from being passive – to interactive – to active – to intelligent.

There is a need for interactive work between dressing industry and clinicians.
ALGINATES
▪ Description – Derived from different types of seaweed, spun into rope or flat dressing
forms.
▪ Action – contain calcium – haemostatic effect
• Absorb exudates from wound
• Promote moist wound healing
• Autolytic
• Filling effect
▪ Indications
• Full or partial thickness wounds with moderate to heavy exudates
• Bleeding wounds
• Fungating wounds
▪ Frequency:
• Change as needed, follow exudate level (1 – 7 days).
▪ Examples: Kaltostat, Algivon (with Honey).
▪ Tips
• Cover with secondary dressing (silicon and atraumatic).
• Do not pack forcibly to the wound.
• Can lay over wound edges.
HYDROFIBERS
▪ Description – made of sodium carboxymethylcellulose, which interacts with wound exudate
to form a gel
▪ Indications – Absorption, Filling, Autolytic Debridement, Moist
▪ Contraindications:
• Heavy bleeding
▪ Frequency: Follow exudate level (1-7 days)
▪ Example: Aquacel Aq
COMPOSITES
▪ Description – combination of 2 or more physically distinct products manufactured as a
single dressing that provides multiple functions.
▪ Indications
• Primary or secondary dressing
• Partial to full thickness
• Minimal to heavy exudates
• Granulating tissue or necrotic tissue – autolytic
▪ Frequency – As needed, follow exudate (1-7 days)
▪ Examples - Mepore, Mepilex Border, Allevyn Adhesive, Permafoam,
▪ Tips
• Require border of intact skin to anchor the dressing
• Cannot be cut
• Use cautiously with fragile skin (the old version)
CONTACT LAYERS
▪ Description – Thin, non-adherent sheets placed directly on an open wound bed to protect
the wound tissue from direct contact with other agents or dressings applied to the wound.
They are porous to allow wound fluid to pass through for absorption by an overlying
dressing.
▪ Indications
• Fragile wound tissue
• Pain at dressing change
• Secondary dressing adhering to wound bed
• Primary dressing for partial and full thickness, exudative wounds, donor sites, split-
thickness skin grafts, skin tears
▪ Contraindications
• Not recommended for eschar covered wounds, or thick (viscous) exudate.
▪ Frequency
• Change once a week ( can stay up to 14 days)
▪ Examples: Mepitel, Adaptic
• Can overlap the surrounding skin without causing damage

• May cut to fit
• Require secondary dressing
• Does not need to be removed with every dressing change
FOAMS
▪ Description – Sponge like polymer dressing with or without a waterproof outer layer, non-
adherent.
▪ Indications
• Full or partial thickness wounds
• Moderate to heavily exuding wounds (various absorption rates of the different foams on
the market)
• Granulating wounds
• Necrotic tissue could be softened - autolytic
• Hypergranulating tissue
• Dry eschar
▪ Frequency
• Every 1 -7 days and as needed (according to exudate)
▪ Examples: Allevyn Adhesive, Mepilex , Tielle, PermaFoam
▪ Tips
• Some of foam products require a secondary dressing (Tubular Bandage)
• Excellent for autolytic debridement and thermal insulation
HYDROCOLLOIDS
▪ Description – Adhesive, moldable wafer made of a carbohydrate-based material with
waterproof occlusive outer layer.
• Hydrocolloid sheet dressing are available in various thicknesses.
▪ Indications
• Non-infected wound with scant to moderate drainage
• Necrotic or granulating wound
• Protect intact skin or newly healed wound
• Partial or full thickness wound
• Infected wounds
• Heavy exudate
• Exposed tendon or bone
• Fragile surrounding skin
• Fungal lesions or herpetic lesions
• Deep tunnels, tracts and undermining
▪ Frequency: Change every 1-7 days depends on exudate level
▪ Examples: DuoDerm , Hydrocoll
▪ Tips
• Warm dressing prior to application for adherence, hold in place 30-40 seconds upon
application
• May be used under compression.
• Produces odour
HYDROGELS
▪ Description – Most of these dressings contain 90% water in a gel base. They are available
in a sheet or gel form, or impregnated gauze.
• Hydrogels are usually clear or translucent in colour and vary in viscosity or thickness.
They are non-adherent to the wound base.
▪ Indications
• Dry or slightly moist wound
• Cooling painful wounds
• Partial and full thickness wounds
• Granulating, eschar, slough
• Abrasions
• Minor burns
• Radiation skin damage
• Moderate and heavy exudate
▪ Frequency – Daily / follow exudate level ( max. up to 3 days)
▪ Examples:
• Intrasite Gel, Hydrosorb Gel, NuGel, Normlgel, DuodermGel
Tips:
• Care must be taken to avoid macerating surrounding skin / cover only with transparent
sheet
• Does not absorb
GAUZE DRESSINGS
▪ Gauze dressings - are made from woven and non-woven fibers of cotton, rayon, polyester,
or a combination of these fibers.
• Woven gauze should not be cut. Loose fibres and strings may get lost in wound and
delay healing.
▪ General characteristics: moderately absorptive, cost-effective, and easily available, may be
combined with topical products other types of dressings.
▪ Gauze dressing is not able to evaporate properly and it may create wound maceration.
▪ Despite the benefits of the newer dressing products, gauze is still the most widely used
wound care dressing especially for wet to dry debridement (mechanical debridement)
▪ Procedure Wet to Dry Debridement:
• Moisten gauze with normal saline.
• Squeeze out excess saline from pre-moistened gauze, open the gauze, and place over the
wound bed. The square weaves in the gauze should be in direct contact with wound
surface, enabling the necrotic tissue to become trapped in the gauze.
• Cover with dry dressing.
• Removal: Every 4-6 hours. Gauze should be dry upon removal. DO NOT MOISTEN.
Firmly pull dried gauze out of wound bed at a right angle.
▪ Gauze dressings (whether dry or moistened with saline) are substandard for optimal wound
care.
▪ Impregnated Gauze Dressings – Vaseline/Gauze impregnated dressing less popular. They

dry out too quickly and granulation tissue grows inside them.
▪ Mesalt – intended for the management of heavily discharging or/ and infected wounds in the
inflammatory phase and deep cavity wounds such as pressure sores and surgical wounds.
How Mesalt works: The discharge from the wound releases the sodium chloride from the
dressing. Mesalt effectively stimulates the cleansing of wounds in the inflammatory phase
by absorbing exudate, bacteria and necrotic material from the wound, thereby facilitating the
natural wound healing process. Made of an absorbent, viscose/polyester non-woven gauze
impregnated with sodium chloride.
▪ Inadine – 10% Iodine impregnated gauze , dries fast
▪ Grassolind, Solvaline, Jelonet - Vaseline absorbent fine mesh gauze. Clings and conforms
to the wound without sticking. Conformable, soothing and hypoallergenic. Occlusive,
indicated for use of fistulas, stomas, chest tube incisions, skin grafts, circumcisions,
abrasions, burns, umbilical cords, thoracic wound or incisions.
▪ Actilite – gauze impregnated with Manuka Honey
▪ Bactigras – impregnated with Chlorhexidine Acetate 0.5% + Vaseline.
▪ Wrapping Gauze
• Tubular Elastic Net Bandage: tubular stretch net made form nylon and rubber mix;
stretches well beyond its relaxed length and diameter, applying gentle pressure to keep
bandages securely in place.
• Used as a secondary dressing
• In cases of very sensitive skin when any adhesive dressing might cause
irritation/abrasion of the skin.
Available in a broad range of sizes
Example: TubiFast, Elastinet, Uni-Grip.
SPECIALTY ABSORPTIVE DRESSINGS

▪ Description – multi-layered dressing that consist of highly absorptive fiber layers, such as
absorbent cellulose, cotton, or rayon.
▪ Action
• Absorb
• Moist wound healing
• Autolytic debridement
▪ Indications
• Heavy drainage
• Full or partial thickness, necrosis, slough
• Dry wound
▪ Frequency – Every 1-7days – depends on exudate level
▪ Examples: Hydrofibres, Composites,Foams, Melonin, Alginates, Telfa
TRANSPARENT FILMS
▪ Description – Transparent adhesive sheet of polyurethane. They are moisture vapour,
permeable (Allow one-way passage, moist vapour out of dressing but allows nothing in).
Waterproof.
▪ Indications
• Flat partial thickness non-draining wound
• Intact skin as a protection
• Eschar to promote debridement
• Moderate to heavy exudates
• Third degree burns
• Fragile skin
• Suspected infection, fungal infection, active herpetic lesions
▪ Frequency: Every 1-7 days
▪ Examples: Tegaderm, Opsite, Hydrofilm, Leucomed T, Visulin, Episil film (silicon)
▪ Reminders
• Need approximately 1-2 inch/ 2.54-5cm border of intact skin
• Skin must be clean and dry
• Apply without tension or stretching
• Removal: Stretch parallel to skin
WOUND FILLERS
▪ Description – Agents manufactured in a variety of forms, including pastes, granules,
powders, beads, ribbons and gels to fill wound.
▪ Indications
• Fill dead space
• Antimicrobial effects – some of them
• Can be used in conjunction with foams, composites, hydrocolloids, NPWT
• Absorptive
• Provide moist environment
• Autolytic debridement
▪ Frequency: Every 1-7 days (depends on infection and exudate level)
▪ Examples: Iodoflex, Iodosorb ointment, Honey, Flamazine cream, Hydrogels, even
Hydrofibres and Alginates
▪ Tips: Absorptive capabilities vary with type of filler
SECUREMENTS
▪ TAPES – used to secure dressings in place
• Paper: general purpose; gentle to skin, porous and highly breathable, holds well on damp
skin (Omnipor, 3M Micropore)
• Soft Cloth: soft, stretchy, conformable tape that is easy to use and easy on the skin; easy
perforated rolls or convenient pre-cut sizes, have more stretch in the cross-direction on
the bias; polyester fabric; conforms well over joints to move with patient and water
resistant. (Leukoplast, 3M Durapore)
• Transparent: easy to tear, sticks well to itself, easy to use with gloves, excellent initial
adhesion - Omni film
• Silicon: Siltape
▪ Application Tips
• The direction of the stretch should be considered when securing a dressing or tubing to
an area that is at high risk for distension, oedema, hematoma formation, or movement.
• Applying soft cloth tape parallel to the incision appears to be associated with fewer skin
tension injuries than taping perpendicular to the incision.
• Apply the tape without tension to clean dry skin, gently but firmly stroking the surface to
maximise adhesion.
• Tape should extend at least 1.25 cm beyond the dressing.
• Tape should not be pulled or stretched when applied.
• Do not encircle a limb completely with a tape.
• If swelling does occur, loosen and re-fasten or replace tape to relieve the tension.
▪ DEVICES – designed to specifically secure or stabilise catheters, drains, tubes or dressin

Wound Margin Approximators – adhesive backed strips used to approximate wound
margins or connect lacerated tissue in place of suturing. Examples: Steri-Strips, Urgostrips.
Cohesive bandage: self-adherent – materials that stretch and conform to body contours,
providing compression
Stockinette
Wrapping Gauze
LOTIONS, OINTMENTS & CREAMS

Skin Sealants – Liquid Skin Protectors
▪ Liquid skin protectors provide a plastic type film over the skin that protects the skin from
moisture and from tape damage. Skin sealants are liquid barrier films made of polymers and
solvents. The solvent evaporates after the product is applied to the skin, leaving behind a
protective film.
▪ Examples: Cavilon Barrier Film.
Moisture Barrier Ointments

▪ Cream, gel, ointment, or paste preparations formulated to protect the skin from excessive
moisture.
▪ Creams are water-based preparations, whereas ointments are oil-based preparations and have
a longer lasting effect than creams because they are more occlusive. The oil component of
ointments is typically petrolatum; creams tend to contain lanolin.
▪ Ingredients vary but most common are dimethicone, petrolatum (oil based) and zinc oxide.
▪ Examples: Aloe Vesta protective ointment, Calmoseptine ointment, Critic Aid paste, A & D
ointment, Avalon ointment, Sudo cream, B-Panthene ointment.
Moisturisers
▪ Cream, gel, liquid, or ointment used to soften and add moisture to the skin.
▪ Lubricants (e.g. emollient creams and petrolatum) trap insensible losses of moisture,
maintaining stratum moisture.
▪ Moisturisers contain humectants (substance that promotes retention of moisture), such as
glycerine, methyl glucose esters, lanolin, or mineral oil that replace oils in the skin.
▪ Lanolin has high moisture retention properties. When used as moisturiser, the products
should be applied after bathing while the skin is damp, not wet (after partially drying). This
helps trap any moisture in the skin as a result of bathing, providing a good reservoir for skin
hydration.
ANTIMICROBIAL DRESSINGS
HONEY
First used in Australia 1999. Manuka Honey (Leptospermum Scoparium) is monofloral product
collected by bees only from Tea Trees or Manuka Bush native to New Zealand or Southeast
Australia. Manuka plant is the Máori name used in New Zealand for Tea Tree.
Action:
• High osmosis due to high glucose level inhibits microbial growth and fights odour.
• Provides moist healing - moist promotes autolytic debridement
• Low pH of 3.5 caused by Gluconic Acid inhibits microbial growth
• MethylGlyoxal (MGO) is kind of phytochemical component with antiseptic effect.
• Glucose Oxidase added to honey by bees during its production turns to Hydrogen Peroxide.
Hydrogen Peroxide is activated as the Honey is diluted by exudate. Hydrogen Peroxide has
cleansing and antiinflammatory effect.
• Hydrogen Peroxide is released 1000 times less than the traditional 3% solution of Hydrogen
Peroxide.
▪ Indications: all wounds

▪ Contraindications: allergy to bee venom
▪ Frequency: Infected - daily, than 2 – 5 days or follow WCRN/Physician orders
▪ Products: Activon Tube cream, Algivon – impregnated alginate, Actilite - gauze mesh
Honey was found to have broad antimicrobial activity and ability to disrupt P. Aeruginosa
in biofilm by blocking substance called Lectin.
SILVER
Silver containing products are impregnated with silver ions. When these products are placed on
a wound the silver is activated and released to the wound or bacteria are trapped into the
dressing and killed there.
Silver can help only with superficial infection and should not be used on clean wounds or
as a prevention.
▪ Indications
• Infected wounds / primary dressing
• Known sensitivity to silver products
• Not recommended for use in neonates or premature infants - may cause kernicterus
(form of brain damage caused by excessive jaundice)
▪ Examples
• Mepilex Ag: self-adhesive foam impregnated with silver
• Flamazine: Silver Sulphadiazine cream 1%, do not use for more than 10days (contains
local antibiotics)
• Atrauman Ag: Silver impregnated gauze
• Aquacel Ag: Contains 1.2% of Ag. Hydrofiber
• Silverlon : Fabric impregnated with ionic silver
• Acticoat
IODINE
▪ Inadine: 10% Povidone - Iodine, glycol mesh (short effect)
▪ Iodosorb ointment – which is cadexomer of iodine. Showed broad spectrum micro activity
by providing slow, continous release of iodine. Effective in treatment of Diabetic Ulcers.
PHMB – Polyhexamethylene Biguanide:

▪ Suprasorb – X with PHMB
▪ NPWT Gauze with PHMB
Bactigras – Chlorhexidine Acetate 0.5% + Vaseline
Mesalt – Sodium impregnated gauze; does not contain antiseptics. High sodium level is able to
provide chemical debridement and has bactericidal activity.
ANTIFUNGAL AGENTS
▪ Many suitable creams can be obtained over the counter without a doctor’s prescription.
▪ Examples:
Miconazole
Clotrimazole [Lotrimin]
Econazole [Spectazole]
Ketoconazole [Nizoral]
▪ Suggested in WUHWHS 2012 that antifungal medication can be topped up with

barrier cream.
ADVANCED THERAPEUTIC MODALITIES

▪ Hyperbaric Oxygenation (Multiplace & Monoplace chambers)
▪ Grafting – Integra (artificial skin)
▪ Genes
▪ Drugs – ACE , Doxycycline, Sex hormones
▪ Single use NPWT
▪ Silicone dressing – painless, atraumatic products: Silicon layers and edges can help with
scar tissue. Examples: Mepilex Border
▪ Collagens
• Action
- Encourages deposition and organisation of newly formed collagen fibres and
granulation tissue in the wound bed
• Frequency – Varies, dependent on brand
• Examples: Promogran Matrix, Promogram Prisma
▪ Other specific medications:

• Regranex – FDA approved medicine that contains platelet derived growth factor. Use for
diabetic ulcers.
• Santyl (Iruxol)
- Native protein collagens
- For removal of dead skin from wounds and burns
NPWT
NPWT – Negative pressure wound therapy
VAC – Vacuum assisted closure
NPWT is the application of negative pressure to a wound. Traditional dressings absorb exudate
but the material remains within the wound until the dressing is changed; NPWT removes the
exudate from the wound continuously. The application of controlled levels of negative pressure
has been shown to accelerate debridement and promote healing in many different types of
wounds.
The system involves applying a specialized open-cell structure foam and drainage tube to the
wound, which is then sealed with an adhesive membrane and attached to a controlled vacuum
device. The plastic membrane prevents the in drawing of air and allows a partial vacuum to
form within the wound, reducing its volume and facilitating the removal of fluid. The foam
ensures that the entire surface area of the wound is uniformly exposed to the negative pressure
effect, prevents occlusion of the drainage tube by contact with the base or edges of the wound,
and eliminates the theoretical possibility of localised areas of high pressure and resultant tissue
necrosis.
NPWT Panel was established and can be accessed easily – www.npwtexperts.com
Types of Interfaces used:

▪ GranuFoam (black): a hydrophobic (water repellent), open cell foam which allows
exudate to be removed through it. It is less dense than PVA foam and is reticulated, which
means all the pores are in communication with each other. This design allows for increased
distribution of sub-atmospheric pressures across the wound bed. It works well on all types
of wounds
▪ Versa-Foam (white): a hydrophilic (water attracting), open pore foam but with increased
density, which still allows for exudate to be removed through it. The increased density
restricts in-growth of granulation tissue, and creates a higher tensile strength. It is pre-
moistened with sterile normal saline and is relatively non-adherent. May be used in tunnels
and shallow undermining due to the tensile strength; painful wounds or when pain is
experienced with the use of the “black” foam; shallow wounds; and wounds with rapid
granulation tissue growth. Its protective design is also beneficial for areas with exposed
tendon or bone
▪ Silver Foam
▪ Gauze impregnated with PHMB (Chlorhexidine) – recently introduced to the market.

Trailed in PSMMC.
Aims of NPWT Therapy

• Reduce localised interstitial oedema.
• Increase localised blood flow.
• Promote granulation tissue formation.
• Reduce bacterial colonisation.
• Provide a moist wound healing environment.
• Enhance epithelial migration.
• Uniformly draw the wound closed.
Indications
• Pressure ulcers (Stage III, IV).
• Diabetic ulcers.
• Statis ulcers.
• Dehisced surgical wounds.
• Open chest stabilisation / splinting effect.
• Flaps and graft.
Contraindications
▪ Fistulae
▪ Necrotic tissue eschar
▪ Osteomyelitis (untreated)
▪ Malignancy in the wound
▪ Systemic steroids
▪ Non-compliant patient
Precautions
▪ Active bleeding
▪ Anticoagulant therapy
▪ Do not place dressing directly over exposed vessel
Application of NPWT as per Policy and Procedure

▪ Contact layer can be used to protect exposed organs or fresh granulation tissues.
▪ For infected wounds, ACTICOAT/SILVERLON (silver containing dressing) can be used, but
AQUACEL AG is not recommended as the gel formation may impede drainage.
▪ Cut foam to the shape of the wound; brush with the hand, around the edges of cut surfaces to
remove any small loosened fragments; ensure wound bed and areas of undermining are
completely covered to enhance its effectiveness. More than one piece of foam may be
required; if so all pieces must touch to ensure even distribution of the negative pressure.
▪ Do not cut the foam bigger than the wound.
▪ Do not press the foam manually into the wound.
▪ If the skin surrounding of the wound is fragile, place strips of hydrocolloid dressing or
barrier films around the wound edges to prevent further damage.
▪ Apply the transparent adhesive membrane directly on top of the sponge, overlapping the
wound edges by at least 3 – 5 cm. Do not stretch drape when applying.
▪ Cut a 1- 2cm hole (not a slit) in the membrane equal to the size of the drainage tube and
attached the tube. Avoid tubing placement over bony prominences.
▪ Remove backing labelled 1 on the TRAC Pad and carefully position over the hole in the drape.
▪ Remove support liner on TRAC pad labelled 2. Apply gentle pressure around the TRAC pad to
ensure complete adhesion
▪ Connect tubing to the drainage canister

▪ Recommended initial settings:
• Set negative pressure at 125mmHg
• Set continuous negative pressure
• Set intensity level at 10mmHg/sec ONLY for VAC.
▪ When suction applied, observe the foam for shrinkage into the wound. This indicates that
there is a patent seal.
▪ Remove gloves and discard.

▪ Perform hand hygiene.
▪ Insert canister into the VAC® machine until it locks into place.
▪ Ensure clamp on each tube is open.
▪ Initiate therapy
▪ Leave in situ for 48-72 hours if removal is not clinically indicated. If the wound is infected
it should be changed daily.
▪ If the foam has adhered to the wound bed, soak with warmed normal saline before removal
(not recommended)
Special Points
▪ If more than one piece of foam is applied to the wound, it must be clearly documented to
ensure all pieces are removed thus preventing complications e.g. sepsis.
▪ Length of treatment varies with the goal of therapy; some wounds may be ready for
secondary closure after 1 week, alternative and/or adjunctive treatment should be
considered.
▪ IT IS IMPORTANT TO FOLLOW MANUFACTURER’S INSTRUCTIONS.
RENASYS GO - Negative Pressure Wound Therapy
VAC Device
Updated Version of KCI VAC device called Info VAC
PICO, single use NPWT device
WOUND MANAGEMENT SUMMARY

EPITHELIALIZING WOUNDS
What is the aim of the treatment?
▪ Keep wound bed moist
▪ Provide thermal insulation
▪ Protect against injury
▪ Prevent scarring
Cleanse: No need
Management
▪ All dressings which maintain a warm moist protective environment e.g. contact layers,
transparent films, composites, hydrogels, hydrocolloids, honey, collagens and foams.
Dressing reducing scars – Mepiform, Honey, and Growth Factors. Also rapid healing is
important to prevent scar formation.
▪ The level of exudate will influence the choice of dressing. However epitheliazing wound do
not exudates anymore: Frequency: 3-7 days
GRANULATING WOUNDS
Description
Granulation tissue is usually red (“beefy red”) in colour, moist and has an uneven granular
appearance. Unhealthy, infected granulation tissue often looks dark or pale and bleeds very
easily.

▪ Absorb excess exudate
▪ Protect wound from injury and bacterial invasion
▪ Prevent overgranulation
Cleanse: Normal Saline irrigation can be done but not necessarily.
Management
▪ The choice of dressing will depend on the depth of the wound and the amount of exudate
▪ Low exudate:
• Hydrogel, hydrocolloid, foam, transparent films, honey, contact layers, collagens,
composites
• Medium to heavy exudate:
• Alginate, foam, specialty absorptive dressing, honey, composites, hydrofibres, collagens,
contact layers
▪ Change dressings 3-7 days; follow exudate level
OVER GRANULATING WOUNDS

Description
An over granulated wound has a shiny red appearance of granulation tissue rising above the
wound margins, with little evidence of epithelial tissue formation. Wound must be reviewed by
a physician prior to treatment, to confirm accurate tissue identification and to prescribe

appropriate treatment.

▪ Reduction in size of over granulation tissue
Management
▪ Choose a dressing which will apply light pressure which is Foam dressing, Honey,
Composites
▪ Topical corticosteroid
▪ Silver nitrate pencil (obsolete)
▪ Surgical excision
▪ Mesalt
Tips: Hydrocolloids and collagen cause hypergranulation
HYPETROPHIC SCARS / KELOIDS

▪ Fast HEALING is the best
▪ Honey
▪ Mepiform / Adaptic / Advasil(silicon dressings)
▪ Human growth factor (Juvista, Renovo)
SLOUGHY WOUNDS
Description
Slough is a term used to describe the accumulation of dead cellular debris on the wound surface.
It tends to be yellow in colour due to large amounts of leucocytes present. It may also be
grey/green in colour. The presence of slough will delay healing.
Note: Yellow tissue which is organized in appearance is not always indicative of slough - it may
be subcutaneous tissue, tendon or bone.

▪ Debridement
▪ Fill dead space
Cleanse: Saline irrigation/ Antiseptics if infection confirmed
Treatment:
▪ Debridement
▪ Antimicrobial dressings
▪ Secondary: Specialty Absorptive, Foams, Thick Hydrocolloids
▪ Frequency: Follow exudate level / infection level (1 – 3 days)
NECROTIC WOUNDS
▪ Debridement
▪ Keep wound bed moist following debridement
▪ Reduce Infection
Management
▪ Debridement: Surgical / Autolytic / Mechanical
▪ When necrotic tissue has been removed, the choice of dressing will then be based on the
underlying tissue
INFECTED WOUNDS
▪ Identify and reduce microorganisms in the wound
▪ Debride necrotic tissue
▪ Clean wound
▪ Fill undermining/tunnels
▪ Absorb excess exudates
▪ Manage odour
▪ Relieve pain/discomfort
Cleansing: Saline / Antiseptics
Management
▪ Treat the wound according to the type of tissue on the wound bed
▪ Swab for ‘Organisms and Sensitivities’. The presence of bacteria in a wound does not mean
that it is infected – remember that all chronic wounds are colonised by micro organisms. Do
not diagnose a wound infection on the wound swab result alone. Look for local and
systemic signs of infection
▪ Systemic antibiotics may be ordered by the physician. Not indicated if only local signs of
infection present, but this should be discussed with the medical staff
▪ Antimicrobial dressings – follow instruction of Physician or WCRN
▪ Secondary dressing as required –follow instruction of Physician or WCRN
▪ Review need for antimicrobial dressing daily
▪ Avoid occlusive dressings if anaerobic infection is suspected or cultured (occlusive
dressings are thought to promote an anaerobic environment such as Hydrocolloids)
NAPPY RASH - PERINEAL DERMATITIS

Management
▪ Clean and dry skin after each incontinent episode
▪ Avoid hot water or saline
▪ Use skin cleanser without need of aggressive scrubbing, pH 4-7
▪ Draw moisture away – external catheters, rectal pouch
▪ Use open system- open pamper or only incontinent pad
▪ Oxygen flow without pressure (latest research – not really effective)
▪ Ointments: Avalon, SudoCcream, Antifungal if suspected fungal infection, Manuka Honey
SKIN TEARS
▪ Skin Tears are the removal of epidermis with or without dermis by mechanical means. Can
be caused by tape removal, strongly adhesive dressing, during inappropriate patient’s
handling, and with the fragile skin.
Management
▪ Control bleeding – Kaltostat, Specialty Absorptive Dressing, Pressure
▪ Cleanse
▪ Assess degree of tissue loss, remaining flap
▪ Assess surrounding
▪ Realign flap
▪ Apply Steri–Strips or Contact Layer (Mepitel) cover with secondary dressing (Foams,
Composites, Wrapping gauze)
▪ Do not attempt to force Steri-Strip or edges of the wound together
▪ On haematoma and open part you can apply Hydrogels
▪ Consult Plastic Surgeon
▪ Change every 3 - 7days
MACERATED SKIN
Description
Skin surrounding wound edge is soft, soggy, white in colour and wrinkled.

▪ Protect skin surrounding wound from exudate
Management
▪ Protect skin with barrier cream e.g. thin hydrocolloid, transparent film, sprays
▪ Check that the current wound dressing regime is absorbing excess exudate. Maceration
generally does not occur in low exudating wounds, unless dressings have been left insitu for
too long or wound dressing material, e.g. hydrogel or topical cream has spread onto the
surrounding skin
▪ Treat underlying cause of exudates (consider more frequent dressing changes)
BURNS
▪ First Aid
• Cold running water
• Pain killer
• Remove source of heat
• Apply cling plastic for transfer debridement if needed
▪ In Unit
Clean
• Irrigation with Saline or antiseptic solution
▪ Dressing
• Debridement (if needed)
• Antimicrobial (Acticoat, Silverlon, Honey, Flamazine)
• Contact layer (Mepitel)
• Composites, Foams, Wrapping Gauze, Specialty Absorptive dressing
▪ Frequency: Follow exudate level and infection level
Arterial Ulcers
• Wound treated as per wound bed type / exudate / infection
Tips:
• Dry eschar keep intact – protection
• Hard to heal – lack of circulation
• Surgical intervention needed – revascularization, ABPI measurement to be done
• Lifestyle – stop smoking, diet….
Venous Ulcers
Wound treated as per wound bed type / exudate / infection

Tips:
• Control underlying venous disease
• Skin hydration
• Control edema
• Compression therapy – 40 mmHg at the ankle
Diabetic Ulcers
Wound treated as per wound bed type / exudate / infection
Tips:
• Peripheral Neuropathy is the main cause
• Podiatrist involvement
• Callus may serve as protection
MANAGEMENT OF PAIN ASSOCIATED WITH

RE-DRESSINGS
The pain associated with re-dressing wounds can largely be alleviated by accurate wound
assessment and choice of appropriate dressings. Suggestions for the relief of pain during
dressing changes include:
▪ Warm the cleansing solution to body temperature

▪ Irrigate the wound rather than swabbing with gauze
▪ Apply a dressing which will create a moist, non-adherent wound contact layer
▪ Moisten adhered dressings prior to removal
▪ Where appropriate, avoid adhesive tape or film dressings and use body stockings or
retention bandages
▪ Administer analgesia prior to the procedure if previous dressing changes have caused the
patient pain
▪ Perform the procedure gently
In cases of severe wound pain associated with dressing change, the physician should be
informed as it may be necessary to refer to a specialist to investigate the possible root cause of
pain e.g. nerve involvement, deep wounds or fistulas involving other tissues such as bone.
Refer to the PSMMC Nursing Pain Policy and Procedure (2011).
PATIENT EDUCATION
Effective Patient Education :
▪ Patient education is one of many important responsibilities of health care workers.

▪ Teach directly, face to face and with time for repetition of information.
▪ Have patient perform return demonstration.
▪ Break the material into manageable pieces. Most people can remember no more than seven
new facts.
▪ Use simple words for medical terms.
• Pressure ulcer – bedsore
• Wound - sore
• Oedema - swelling
• Slough - dead tissue/skin
• Granulation - new skin
• Bacteria - germs
• Dressing - bandage
• Odour - smell
▪ Provide reinforcement of your teaching by providing audio or visual materials that may be
reviewed at a later time.
▪ Be sure the spoken words are at the appropriate level to ensure comprehension.
▪ If possible, tape a lesson, and then give the tape to the patient for reinforcement at home.
▪ Look for the patient’s strengths and make the most of them:
• If patient is college educated or enjoys reading, printed materials may be most effective.
• Internet links or appropriate YouTube videos.
▪ Sit when teaching and allow visualization of your face and lips as you speak. Speak slowly.
▪ Eliminate background noise (intercoms and paging systems may mask conversation);
▪ Schedule teaching sessions at frequent intervals to assess competency.
▪ With the patient’s permission, include family members when possible for support at home.
▪ Document teaching on Multi-disciplinary form and on Wound Care Discharge Checklist.
▪ PUP Booklets
HELP FOR THE QUIZ

The choice of dressing will depend on what the aim of treatment is and what is available in
PSMMC:
▪ Types of Debridement available in PSMMC? Autolytic: Hydrocolloids, Hydrogel, Honey,
Hydrofibers, Alginates, Foams, and Composites.
Mechanical, Surgical, Enzymatic
▪ Which dressing absorb exudates? Alginates, Hydrofibres, Foams, Specialty Absorptive dressings,
Composites
▪ Moisten wound bed? Hydrogels, Hydrocolloids; Honey, Foams, Transparent
films(minimal), Specialty Absorptive, Advanced modalities
▪ Eliminate infection? Silver, Honey, Iodine, Sorbact, Mesalt, Advanced Modalities
▪ Fill cavities? Alginates, Hydrofibres, Hydrogels, Iodosorb, Honey cream, Flamazine.
▪ Provide thermal insulation? Any dressing but the best is thick Foam
▪ Protect? Transparent films, Composites, Foams, Hydrocolloids, Contact layers
CLOSED SURGICAL WOUNDS (ACUTE)

What is the aim of the dressing?
▪ Protect
▪ Provides balanced moist environment
▪ Absorb exudates
Management
▪ A freshly sutured surgical wound is susceptible to invasion by surface bacteria and
contamination during the first 48 hours. If no drainage is present, leaving the sterile dressing
applied in the operating room in place is preferable
▪ The choice of dressing will depend on the amount of exudate
• Composite dressing (Mepilex Border), foams (Mepilex).
▪ Initial sternotomy dressing (mainly seen in PSCC) can stay in place for 5 days post surgery
unless there is evidence of strike through bleeding or the dressing is not intact.
Follow ACICU Wound Care Guidelines Post Operative
All Surgical wounds should be dressed with honey net (Actilite) covered with Mepilex Border
silicon (atraumatic) dressing from OR.
Adult Sternotomy Wounds
1. The initial sternotomy wound dressing is left intact up to 5 days post surgery unless there is
evidence of strike through bleeding or the dressing is not intact.
2. On the first dressing:
• If wound is intact, dry and closed: Clean the wound with sterile gauze soaked in Normal
Saline. Use one gauze for each wipe and start from clean to dirty or from incision to left
and right site of the wound (Refer to Nursing Policy Procedure No 6010 – W – 003 point
4.5)
• If wound is oozing or gapping inform physician, and irrigate with Normal Saline (using
20mls syringe and 18G PIV cannula sheet) and re-apply Mepilex Border silicon dressing
or follow physician order.
• Wound swab should be taken as ordered by physician and staff nurse should follow the
Nursing Policy Procedure No 6010-W-001 point 4.3 and Appendix 2)
• Chest drain sites are dressed as for sternotomy wound dressing.
(May refer patient to wound care nurse if required)
NB! All dressings should be changed immediately if there are signs of:
• Strike-through bleeding or oozing
• Wet from bed bath
• Non -adherent
Adult Leg Wounds

Donor leg wound are dressed as for sternotomy wound dressing.
Leg wound elastic bandages can be removed first day post-surgery.
Anti-embolic stocking should be applied after 48 hours.
− Date and time the initial OR dressing on admission, i.e. Sternotomy and Leg wounds.
− Enter all information on a Wound Care Chart in the ICIP.
Prepared by: Jacqueline Alagarsamy, Nurse Clinician, ACICU

Reviewed by: Iveta Constantine, Nurse Clinician 3.7 [accessed 24th June 2014].
Approved by ACICU Physicians [July 2014].
WOUND IMAGES – TEST YOURSELF
Figure 1 ________________________________ Figure 2 ________________________________

________________________________________ ________________________________________
________________________________________ ________________________________________
Figure 3 ________________________________ Figure 4 ________________________________

________________________________________ ________________________________________
________________________________________ ________________________________________
Figure 5 ________________________________ Figure 6 ________________________________

________________________________________ ________________________________________
________________________________________ ________________________________________
Figure 7 ________________________________ Figure 8 ________________________________

________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
Figure 9 _______________________________ Figure 10 _______________________________

________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
Figure 11 ________________________________ Figure 12 _______________________________

________________________________________ ________________________________________
________________________________________ ________________________________________
Figure 13 ________________________________ Figure 14 _______________________________

________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
Figure 15 _______________________________
________________________________________ Figure 16 _______________________________
________________________________________ ________________________________________
________________________________________ ________________________________________
________________________________________
Answers:
1. Pressure Ulcer
2. Pressure Ulcer
3. Keloid
4. Venous Ulcer
5. Surgical Wound
6. Keloid
7. Arterial Ulcer
8. Venous Ulcer
9. Diabetic Ulcer
10. Diabetic Ulcer
11. Arterial Ulcer
12. Skin Tear
13. Diabetic Ulcer
14. Burn
15. Hypetrofic Scar
16. Burn
GLOSSARY
Anthropometric: refers to comparative measurements of the human body.
Acrid: Bitter
Angiogenesis: In the proliferative phase of healing new blood vessels infiltrate the wound and
endothelial budding forms capillaries.
Apoptosis: Self destruction of cells or cell death which is part of the normal process of control
of growth.
Autolysis: The term used for the natural, spontaneous process of devitalised tissue being
separated from viable tissue.
Cellulitis: Is a diffuse inflammation of connective tissue with severe inflammation of dermal
and subcutaneous layers of the skin characterized by fever, redness, swelling and local pain.
Chronic Wound: A wound that has remained unhealed for 6 weeks.
Colonisation: The presence and multiplication of micro-organisms without a corresponding
host reaction.
Contamination: The presence of micro-organisms without multiplication.
Contraction: The drawing together of a wound edge when a wound is healing by secondary
intention.
Debridement: The removal of devitalised or contaminated tissue.
Dehiscence: The breakdown of a surgically closed wound.
Epithelializing: Process, by which the wound is covered with new epithelial cells.
Erythema: A redness of the skin caused by congestion of capillaries in dermis due to injury,
infection, inflammation or hyperaemia.
Eschar: Hard, dry, leathery necrotic tissue generally found in pressure ulcers. The tissue has
been occluded of blood and dies. It then dehydrates and becomes eschar.
Exudate: Serous fluid which has passed through the walls of a damaged or overextended vein.
Made up of serum, leucocytes and wound debris. Often contains growth factors if the wound is
acute, may contain bacteria, dead white cells etc if the wound is chronic. Exudate is exacerbated
when oedema or hydrostatic pressure is present. Bacteria indirectly cause vaso-permeability,
and this result in increased exudate production. Some exudates are necessary for a moist wound
environment.
Fibroblast: A large, flat cell that secretes most of the matrix (extracellular) material of areolar
and dense connective tissues. An immature collagen producing cell.
Fistula: A passage that has formed between two organs e.g. bowel and skin.
Friable: Easily damaged - a wound that bleeds when touched.
Gangrene: Is a complication of necrosis (cell death) characterized by the decay of body tissue,
which becomes black and/or green and malodorous. It is caused by infection or ischemia.
Granulation: During the proliferative phase of healing, this is the bright red tissue formed
from new capillary loops or "buds" which are red/deep pink and moist with a "bumpy"
appearance.
Hemosiderin: Is an iron – storage complex.
Hydrophilic: Readily absorbing moisture.
Hydrophobic: Not readily absorbing water; repels water
Hyperemia: Redness
Hypergranulation (Over granulation): Excessive lying down of new blood vessels creating a
bulge of highly vascular tissue which bleeds easily. The granulation tissue forms beyond the
level of the surface level of the wound and prevents epithelialisation from occurring.
Infection: The deposition and multiplication of bacteria in tissue with an associated systemic
host reaction.
Ischial Tuberosity: Prominent downward protuberance of the hip bone. It is a part of ischial
component and pelvic girdle.
Intertrigo: Is a rash that usually affects the folds of the skin.
Kernicterus: Is a form of brain damage caused by excessive jaundice because of high bilirubin
levels.
Lysis: The action of breaking down.
Maceration: A softening or sogginess of the tissue owing to retention of excessive moisture,
which presents as moist, red/white and wrinkled.
Macrophages: Develop from monocytes and are capable of engulfing bacteria and cellular
debris by phagocytosis. May be fixed (reside in a particular tissue) or wandering (migrate to
sites of infection or inflammation).
Mitotic: Phase of the cell cycle – the division of the mother cell into two cells.
Necrosis: Death of one or more cells, or of a portion of tissue or organ, resulting from
irreversible damage. Necrotic tissue is often black/brown in colour and leathery in texture.
Occlusive: Impermeable to air or water.
Overgranulation: see Hypergranulation.
Permeable: Permitting passage of substances through a membrane or other structure.
Phagocytes: divided into two general classes:
▪ Microphages: polymorphonuclear leukocytes that ingest chiefly bacteria
▪ Macrophages: mononucleated cells (histiocytes and monocytes) that are largely scavengers
ingesting dead tissue and degenerated cells.
Phagocytosis: The engulfment and digestion of bacteria and other foreign particles by a cell.
Primary dressing: The dressing that is in contact with the wound bed.
Pus: A fluid produced in infections, made up of exudate, bacteria and phagocytes which have
completed their work.
Putrid: Rotten.
Rayon: Is a manufactured fibre made of cellulose.
Secondary dressing: A dressing that is applied on top of a primary dressing. Secondary
dressing may be indicated to secure a non-adhesive primary dressing; to retain moisture within
the wound environment; to provide increased absorption; to provide increased protection to the
wound.
Sinus tract (or tunnel): A channel that extends from any part of the wound and may pass
through subcutaneous tissue and muscle, common in dehisced surgical wounds.
Semi-permeable: Permeable to water vapour and small ions or molecules, but not to larger
molecules and colloids.
Slough: The term for the thick yellow layer which often covers the wound and is strongly
adherent to it. Its presence can be related to the end of the inflammatory stage of healing when
dead cells have accumulated in the exudate.
Strikethrough: Wound exudate appearing on the outer surface of the wound dressing.
Undermining: Tissue destruction that occurs around the wound perimeter, underlying intact
skin.
REFERENCES
▪ Benbow, M., (2005). Evidence-Based Wound Management. Philadelphia: Whurr Publisher.
▪ Miller, Ch. N., Craville, K., Newall, N., Kapp, S., Lewin, G., Karimi, L., Santamaria, N.,
(2010). Assessing Bacterial Burden in Wounds: Comparing Clinical Observation and
Wound Swabs. International Wound Journal. 8 (1).
Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1742-481X.2010.00747.x/pdf
[accessed 10th July 2014].
▪ Ruth, A. B., and Denise, P. N., (2007). Acute & Chronic Wounds: Current Management
Concepts. 3rd ed. Philadelphia: Mosby Elsevier.
▪ Wound Care Education Institute, (2010). Skin and Wound Management Course: Seminar
Book. Canada [accessed 6th February 2011].
▪ Wounds International, (2013). International Best Practice Guidelines: Wound Management

in Diabetic Foot Ulcers. UK: Wounds International.
Available from: http://www.woundsinternational.com/pdf/content_10803.pdf
▪ Wounds International, (2012). Made Easy: Exit Site Wounds. UK: Wounds International.
▪ Wounds International, (2011). Made Easy: Hard to Heal Wounds. UK: Wounds
International.
▪ Wounds International, (2011). Made Easy: Iodine. UK: Wounds International.

Available from: http://www.woundsinternational.com/pdf/content_9860.pdf [accessed 10th
July 2014].
▪ Wounds International, (2010). Made Easy: Biofilms. UK: Wounds International.

Available from: http://www.woundsinternational.com/pdf/content_8851.pdf [accessed 10th
2014].

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The information in this pre-reading package is based on an extensive literature search. It

ANATOMY AND PHYSIOLOGY OF THE SKIN

Functions of the Skin

WOUND HEALING PHASES

INFLAMMATORY PHASE (Begins at time of injury, lasts approximately 3-5 days)

PROLIFERATION PHASE (Lasts approximately 4-24 days)

FACTORS AFFECTING WOUND HEALING

Smoking: Causes peripheral vasoconstriction

Stress (Pain / Insomnia):

Inadequate Wound Management:

Anthropometric (Measurements of the body)

NUTRIENT NEEDS WITH SKIN BREAKDOWN

d. Vitamin K – required for coagulation

WAYS TO IMPROVE NUTRITIONAL STATUS – DIETARY IDEAS,

LOCAL WOUND ASSESSMENT

The following data should be recorded:

• Undermining – is tissue destruction of underlying intact skin along wound margins.

Another approach to depth classifications:

Different stages of wounds: For example pressure ulcer stages.

3 TYPES OF WOUND CLASSIFICATIONS

3. WOUND BED TISSUE TYPES

WOUND BED PREPARATION

T = Tissue Management – the removal of necrotic burden in a chronic wound. Necrotic

E = Epithelial Edge Advancement – effective healing requires the re-establishment of an

▪ More rapid than autolytic or enzymatic

BIO SURGICAL (LARVAL THERAPY)

WOUND CLEANSING SOLUTIONS

Some evidence supports the selective use of antiseptics to stimulate previously

General disadvantages of antiseptic solutions

COMMONLY USED ANTISEPTIC SOLUTIONS

Additional Wound Cleansers

RECOMMENDED WOUND CLEANSERS

The predominant current recommendations are:

WOUND CLEANSING TECHNIQUES

I = INFLAMMATION AND INFECTION CONTROL

You should be able to differentiate between:

Critical colonization – multiplication of bacteria causing a delay in wound healing usually

Infection of the wound may lead to septicaemia and death.

Classic Signs and Symptoms

Additional Signs and Symptoms

WOUND SWAB COLLECTION

*CFU – colony forming unit

WOUND SWAB COLLECTION METHOD

container and send to the laboratory as soon as

OTHER TYPES OF WOUND SWAB COLLECTION METHODS

CULTURE TIPS SUMMARY

- Pressure Ulcers are painful

The Most Important Extrinsic Factors:

▪ Shearing (Shear Force)

Other types of breakdown related to a moisture – not to be confused with a pressure

Intrinsic Risk Factors – Same as systemic Factors

Unavoidable Pressure Ulcers

Prevention of Pressure Ulcers

Example of Braden Scale:

▪ Interventions for Pressure Ulcer Prevention (PUP):

• Support Surfaces should achieve pressure redistribution.

- Place “at-risk” individuals on pressure-redistributing surfaces and not on an

Support surfaces are divided into:

5. Bowel management system, e.g. www.hollister.com

LOWER EXTREMITY ULCERS

Figure 1 Figure 2

Figure 3 Figure 4