WOUND MANAGEMENT

Wound Management is much more than protocols and procedures. Every wound
healing success requires discipline, patience and organization.

From the first meet and greet with new resident(s) shall be assessed on admission
to our facility with the skin assessment+ risk assessment conducted by staff nurse.
It s clear that the assessment tools are just an accompaniment to clinical judgment
and physical exam need to be maintained as often as possible from first day.

Where residents are considered at risk of wound development this shall be

documented and a skin integrity care plan established. Also daily skin inspection
shall be performed by the staff and any issues shall be reported to the staff nurse
and an action plan to be implemented and improved.

Residents with capacity shall be provided with information and education about
the risk of developing different wounds. Residents shall be encouraged daily to
enjoy their stay into the nursing home.

Residents shall be regularly reassessed, 4 monthly or as per resident condition

change.

But in order the healing to be with best results we need to keep our mind focus on
that and always guide our care by the guidelines. This guide will help you to find
the optimal solution towards any wound challenge.
 IDENTIFICATION OF THE WOUND

Types of Wounds

 Vascular (arterial, venous, and mixed)

 Neuropathic (diabetic)
 Moisture-associated dermatitis
 Skin tear
 Pressure ulcer

Many wounds have mixed etiologies. There may be both venous and arterial
insufficiency. There may be diabetes and pressure characteristics.

Can you determine if the wound is acute or chronic? 

As long as it follows an expected rate of healing, any wound, regardless of

severity, can be considered an acute injury. This includes abrasions, lacerations,
incisions, burns and puncture wounds.

Causes

Acute wounds are caused by contact with rough, hard or sharp surfaces that
damages the skin or underlying tissue. Abrasions, for instance, are often the result
of scraping against a rough surface, while lacerations occur when sharp objects tear
the skin in an irregular or jagged way.

Signs

Symptoms of acute wounds vary, but common ones include pain, swelling, redness

and bleeding at the wound site.
What is a chronic wound?

Any acute wound can progress into a chronic one. If there’s no significant
evidence of healing within about four weeks, the wound has likely entered the
chronic stage and requires additional medical attention.

Causes

 Pressure on the affected area.

 Increased exposure to bacteria or trauma.
 Lack of blood supply, oxygen, nutrients or hygiene.
 Infection.

Incorrect treatment, poorly performed procedures or can stall the healing process.

Signs

Along with slow healing, other signs of a chronic wound include increases in
inflammation, exudate, swelling, pain and stiffness in the affected area.

Treatment

While treatments vary depending on the type of wound, Wound Source noted that
addressing the causes is often the first step to getting the injury back on the right
path to healing. For example, diagnosing and treating an infection may be the first
call of action when excess bacteria causes healing to slow.

Any wound you incur will require a treatment plan for proper healing, which will
likely involve daily dressing changes. 
UNDERSTANDING YOUR WOUND

A traumatic wound is a sudden, unplanned injury that can range from minor, such
as a skinned knee, to severe, such as a gunshot wound. Traumatic wounds include
abrasions, lacerations, skin tear, bites, burns, and penetrating trauma wounds.

Anyone can sustain a burn. Depending on the severity of the burn different
treatment concepts are required from first aid treatment to dedicated treatments in
special burns centers.

Preventing skin tears is essential to avoid. As aging occurs, the skin becomes more
prone to skin tear injuries.

Prevent skin tears by using:

 Proper lifting , positioning, transferring, and turning techniques to reduce or

eliminate friction
 Padding on support surfaces where the risk is greatest, such as bed rails and
limbs supports on a wheelchair
 Pillows and cushions to support patient
 A skin lotion applied to areas as risk
 Wraps such as stockinette or soft gauze, to protect area of skin where the
risk of tearing is high
 A skin barrier wipe (Jelonet) before applying dressings.

Moisture-Associated Skin Damage

Also called perineal dermatitis, diaper rash, incontinence-associated dermatitis

(often confused with pressure ulcers) .An inflammation of the skin in the perineal
area, on and between the buttocks, into the skin folds, and down the inner
thighs.Scaling of the skin with papule and vesicle formation: – These may open,
with “weeping” of the skin, which exacerbates skin damage. – Skin damage is
shallow or superficial and edges are irregular or diffuse. – Maceration or a
whitening of skin may also be observed. Results when epidermis is damaged and
bacteria are then able to penetrate beneath the surface.

Determine what it is. Is it pressure or moisture?

• May be difficult to distinguish between moisture-associated skin damage and

pressure ulcer.

• Unlike moistureassociated skin damage, a pressure ulcer usually has distinct

edges.

 Boots, boot straps, oxygen/endotracheal tubes, stockings, and other devices

can also lead to pressure-induced ischemia on the skin.
 These are counted separately for incidence and prevalence

An appropriate management of incontinence, perspiration or exudate must be

ensured. Most of the time, skin barrier products are used so as to manage the level
of moisture next to the skin in conjuction with a skin care routine to keep the skin
clean and dry. It is essential to wash the skin with a non-perfumed soap with a
natural pH balanced and to avoid oil based creams if the patient must use
continence products as they can affect the level of absorption of the product.

Pressure Ulcer- localized injury to the skin and/or underlying tissue usually over
a bony prominence, as a result of pressure, or pressure in combination with shear.

A pressure sore refers to skin or tissue damage that occurs when there is decrease
blood circulation due to pressure in a specific area.

Initially, slight redness on the affected area can be noticed (the first sign of tissue
damage). The tissue underneath perishes due to poor blood supply. Various skin
layers, muscles and bones can be affected. Areas that are particularly at risk are the
sacrum, heels, elbows and shoulder blades.
Pressure sores can be mostly avoided through preventive measures such as formal
risk assesment and specific risk mitigation (pressure relief, preventive skin care) by
minimizing risk factors.
Once a pressure sore has developed, it is important to draw up a coordinated
treatment plan to induce healing and eliminate all the disruptive factors. The basic
prerequisites for wound healing must be met. These include a clean wound,
functioning circulation and adequate nutrition in terms of both calories
and nutrients, along with adequate fluid intake. The latter is often a problem in
elderly people (as a a basic rule, daily fluid intake should be 40 ml per kg of body
weight).

Depending on the extent of tissue damage, pressure ulcers are categorized into four
stages:

Stage 1 
The skin is not broken, but the redness does not turn white when touched.

Stage 2
Damage involves the epidermis, dermis, or both. Clinically, the damage appears as
an abrasion or blister. The surrounding skin may be reddened.

Stage 3
Damage extends through all the superficial layers of the skin, fat tissue, right to
and including the muscle. The ulcer appears as a deep crater.

Stage 4
Damage includes destruction of all soft tissue structures and bone or joint
structures.

Anyone can develop a pressure sore, but elderly, bed-ridden, paralyzed and
malnourished patients are at higher risk.

Identifying individuals at risk of pressure ulcers and initiating preventive measures

are vital steps in reducing pressure ulcer incidents. The individual risk of
developing a pressure ulcer can be determined by using risk assessment tools such
as the Braden Scale.

The Braden Scale is a rating scale made up of 6 sub-scales that asses:

 Sensory / perception (ability to respond meaningfully to pressurerelated
discomfort) 
 Moisture (degree to which the skin is exposed to moisture)
 Activity (degree of physical activity)
 Mobility (ability to change and control body position)
 Nutrition (usual food intake pattern)
 Friction and shear

The most important aspect in prevention and treatment of pressure sores is

certainly pressure relief. This can be best achieved by frequent patient
repositioning and mobilization, but also using adequate mattresses or specific
pressure-reducing  equipment. Appropriate treatment should include thorough
wound cleansing, avital tissue removal and a wound environment free of urine and
feces. Stage 3 and 4 ulcers often require surgical debridement.

In some cases, pressure ulcers can develop very fast - sometimes it can occur
within only one hour.

In order to prevent pressure ulcers, different measures can be adopted, such as:

 Pressure ulcer risk assessment

Whenever a patient enters a ward and the risk of pressure ulcer development
cannot a priori be excluded, it must be properly assessed with a validated pressure
ulcer risk assessment tool such as e.g. the Braden scale. According to the level of
risk, appropriate preventive measures must be implemented in due course.

 Changing the position frequently

Being able to change the bed lying position as much as possible is one of the best
way to prevent pressure ulcers. It is highly recommended to change position and
alternate between back and sides at least every 2 hours. Most of the time, pillows
are used to elevate the parts of the body which are highly exposed to the
development of pressure ulcers such as heels, ankles or even the knees. However,
if the patient has already a pressure ulcer, it must be avoided to lie or sit on it as it
could worsen the ulcer.(2)  If the patient is not able to turn himself, he must be
assisted by a healthcare professional. Wheelchair-bound patients are recommended
to change their position at least every 15 to 30 minutes. 
 Skin assessment

A regular skin assessment must be performed so as to check any sign of pressure

ulcer development. Every skin changes must be documented in order to prevent a
pressure ulcer formation.(2) 

 Nutrition and hydration monitoring

It is important to check the patient’s weight and monitor any changes. Having a
well-balanced diet  can help to reduce the risk of developing pressure ulcers.  For
patients who have already developed pressure ulcers, they will have to consume
food with high calories such as eating cheese, fish meat and eggs in order to heal
more easily.  If necessary, patients must consult a dietician in order to solve out
some nutrition, chewing and swallowing problems as well as to find a balanced
diet routine.(2)(3) 

 Perpendicular force

Compresses tissue – Restricts blood flow – Causes ischemia and necrosis –

Ruptures cells and vessels – Causes tissue deformation

 Force parallel to the skin

Stretches and distorts internal tissue – May cause occlusion of vessels

perpendicular to skin surface

classification system:

– 6 stages or categories:

 Stage I
 Stage II
 Stage III
 Stage IV
 Unstageable Suspected deep tissue injury (sDTI)

• Base staging on the type of tissue visualized or palpated.

• Do not reverse stage when documenting a healing pressure ulcer.

Remember the Bariatric Patient

  Check between the skin folds and thighs: – Rash – Maceration – Infection
(bacteria or candidiasis) – Breakdown
 Pressure ulcers may be in unusual locations.

A surgical wound is a cut or an incision in the skin that is usually made using a
scalpel during surgery. Surgical wounds are typically closed with stitches, staples
or surgical glue.

Post surgical wound care involves skin cleansing, protecting and monitoring, the
objective is to prevent complications and enable rapid wound healing.

In most cases, with good care, the surgical incisions will completely heal within
approximately 2 weeks.

Most surgical wounds heal by primary intentions.

Characteristics:

 The wound is closed immediately after the intervention

 Good approximation of wound edges (stitches, staples, or adhesive tape)
 Primary wound healing occurs within hours of repairing a full-thickness surgical
incision.
 Normal epithelial cell migration across the incision occurs within 24 – 48h
 Minimizes scarring
 Examples: well-repaired lacerations, well-reduced bone fracture, healing after flap
surgery

However, 1 – 3 out of every 100 patients that underwent surgery develop a surgical
site infection.

Therefore, in addition to the correct wound management, it is important to

monitor the wound for complications:
 Hemorrhage
 Hematoma formation
 Edema
 Dehiscence
 Occlusion of blood supply resulting in necrosis
 Hyper-granulation

WOUND ASSESSMENT

Time and Wound Management

T =Tissue both in and around the wound— granulation, slough, necrotic black,
pink, mix.

I =Infection. Any open area always has the potential for infection.

M= Moisture (exudate). This determines type of dressing needed to maintain

balance.

E =Edges. Are they contracted, rolling, undermining

Document

• Length, width, and depth

• Location

• Stage

• Exudate (amount, color, and consistency)

• Tunneling and/or undermining

• % of each type of tissue in wound (granulation, epithelial, eschar, slough,

fibrinous)

• Wound edges (attached, not attached, rolled under, irregular, callous)

Right Assessment and Right Care Plan to ensure the Right Care

Selecting Dressings and Treatment

Based on—

• Overall medical condition of patient

• Location of wound
• Size of wound
• Wound etiology
• Wound bed tissue involvement
• Exudate amount
• Pain management
• Living arrangements

List of detailed dressings on annex.