Wound Care Overview

Carolyn Watts MSN,RN, CWON

February 16, 2007

Definition

A wound is a break in the integrity of the skin.

Phases of Wound Healing

Inflammatory (immediate) Fibroblastic (day 4-20) Maturation (6-12 months)

Factors Which Impact Wound Healing

Tissue perfusion and oxygenation Nutritional status Presence or absence of infection Diabetes Mellitus Corticosteroid administration Immunosuppression Age Stress Other systemic factors Topical therapy

Waldrop & Doughty, Acute and Chronic Wounds, 2000

Patient Assessment

Medical/Surgical History Medications (include OTC) Nutritional Assessment Pain Psychosocial Assessment Cultural/ethical considerations

Wound Assessment Location Stage/Classification Size (LxWxD in cms) Sinus Tract(s) Undermining Exudate Necrotic Tissue Granulation Tissue Signs/Symptoms of Infection Periwound Skin

Acute Wounds

ClassificationPartial Thickness (involve epidermis/dermis

only)Full Thickness (involve subcutaneous tissue

and possibly underlying structures) Usually heal following normal wound

healing pathways

Chronic Wounds

Pressure Ulcers Venous Stasis Ulcers Arterial Ulcers Neuropathic Ulcers Usually have impaired healing

mechanisms

Pressure Ulcers

Venous Stasis Ulcer

Arterial Ulcer

Neuropathic Ulcer

Topical Therapy: Principles

Remove necrotic tissue and foreign bodies or particles

Identify and eliminate infection Obliterate dead space Absorb excess exudate Maintain a moist wound surface Provide thermal insulation Protect the healing wound from trauma and bacterial

invasion Doughty, Acute and Chronic Wounds, 1992

Types of Topical Wound Dressings

Hydrocolloid dressings Hydrogel dressings Alginate dressings Transparent film dressings Foam dressings Absorption dressings Gauze dressings Composite dressings Biologic dressings Other

SHALLOW DRY WOUNDS

Need hydrating dressing + cover dressing Options:

Amorphous hydrogels (Carrasyn V gel) Sheet hydrogels (ClearSite) Tegaderm Clear Acrylic Absorbent Dressing Transparent

dressings

DEEP DRY WOUNDS

Need hydrating filler dressing + cover dressing

Filler dressing options: Amorphous gel (Carrasyn V gel) to wound bed, lightly

pack with damp saline gauze Gel soaked gauze packed lightly into wound bed

Cover dressing options: Gauze and/or ABD with hypoallergenic tape (paper or

stretchable cloth)

SHALLOW DRAINING WOUNDS

Need absorbent dressing + cover dressing Options:

Foam dressings with adhesive border (Allevyn Island) *minimal drainage

Sheet alginate w/ silver, adhesive foam (Allevyn Island) or wrap gauze (Kerlix roll) *moderate drainage

Hydrofiber (Aquacel) w/ adhesive foam (Allevyn Island)or wrap gauze (Kerlix roll) *heavy drainage

Nonadherent contact layer (Adaptic, Mepitel, or Mepilex

Transfer) w/ gauze cover dressing and tape.

DEEP DRAINING WOUNDS

Need absorbent filler dressing + cover dressing

Filler dressing options: Calcium alginate with silver (Acticoat Absorbent rope

or sheet), if antimicrobial needed Hydrofiber (Aquacel) Damp cotton gauze (Kerlix 4x4), pack loosely

Cover dressing options: Gauze, ABD/tape (if wound exposed to contaminants use

transparent dressing – Tegaderm) Waterproof foam dressing (Allevyn Island)

Specialty Dressings

Ionic silver dressings Synthetic skin substitutes

Specialty Products

Wound Care Product Selection

Wounds are dynamic and will require different approaches during healing process

Continually reassess patient and wound Topical therapy is one part of your role - must

eliminate cause and support host Continually educate yourself on products to make

informed choices Work with specialty nurses (WOCN or Plastics) to

develop plan of care