Year 4 Study Guide · 2020. 8. 20. · Dermis: Composed of collagen fibers (provide skin strength),...
Transcript of Year 4 Study Guide · 2020. 8. 20. · Dermis: Composed of collagen fibers (provide skin strength),...
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Wound Care and Cleaning Year 4 Study Guide
Clinical Skills Teaching & Learning Centre Written by: Clinical Skills Lecturing Team
Reviewed by:
April 2020
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Contents Glossary ....................................................................................................................................... 4
Learning Objectives ..................................................................................................................... 5
Introduction .................................................................................................................................. 6
Surface Anatomy / Relevant Physiology ...................................................................................... 7
Epidermis: ................................................................................................................................. 7
Dermis: ..................................................................................................................................... 7
Hypodermis (subcutaneous tissue): .......................................................................................... 7
Methods of Wound Healing .......................................................................................................... 8
Primary intention ....................................................................................................................... 8
Secondary intention .................................................................................................................. 8
Tertiary intention ....................................................................................................................... 8
Phases of Wound Healing ............................................................................................................ 9
Factors affecting wound healing ................................................................................................ 10
Local Factors .......................................................................................................................... 10
Systemic Factors .................................................................................................................... 11
Types of Wounds ....................................................................................................................... 13
Burns and scalds .................................................................................................................... 19
Diabetic foot ulcers ................................................................................................................. 19
Leg ulcers .............................................................................................................................. 20
Pressure ulcers ....................................................................................................................... 20
Wound Assessment ................................................................................................................... 22
Preparation ................................................................................................................................ 23
Patient safety .......................................................................................................................... 23
Equipment .................................................................................................................................. 24
Principles of Wound Cleansing .................................................................................................. 24
.................................................................................................. Error! Bookmark not defined.
Cleaning a linear wound ......................................................................................................... 25
Cleaning a circular/ puncture wound (figure 32 A&B) ............................................................. 26
Procedure .................................................................................................................................. 27
Documentation ........................................................................................................................... 28
Post Procedure .......................................................................................................................... 29
Appendix A13 ........................................................................................................................... 30
Appendix B14 ........................................................................................................................... 31
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Appendix C ............................................................................................................................. 32
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Glossary
Debridement is the removal of devitalised or contaminated tissue from a wound
until healthy tissue is exposed.
Epithelialisation defined as a process of covering denuded epithelial surface and is
characterised by replication and migration of epithelial cells across
the skin edges in response to growth factors.
Escar is dead crusty tissue that falls from healthy skin as it develops on the
wound. The eschar can be tan, brown or black in colour making it
difficult for the wound to be classified and treated.
Granulation wound granulation is a new connective tissue that forms during the
wound healing.
Hypergranulating this is observed when granulation tissue grows above the wound
margin. This occurs when the proliferative phase of healing is
prolonged usually as a result of bacterial imbalance or irritant forces.
Maceration when tissue that has been moist for a prolonged period and
undergone deterioration. It may occur to the surrounding skin of a
wound if a dressing with a low absorptive capacity is used on a
heavily exuding wound.
Slough is devitalised tissue formed when dead cells and/ or bacteria
accumulate in the wounds. It is yellow/white in colour due to the high
number of leucocytes present in the wound and can be dry or moist
in consistency.
Stratum basale is the deepest layer of the epidermis.
Stratum corneum this is the most superficial layer of skin
Stratum granulosum this is the most superficial layer of the epidermis whose cells still
possess nuclei. It is composed of three to five layers of flattened
keratocytes
Stratum lucidum this is a clear, homogeneous, lightly staining, thin layer of cells
immediately superficial to the stratum granulosum. It is only present
in thick skin i.e. palms of the hands and soles of the feet.
Stratum spinosum this is the thickest layer of the epidermis. It contains several layers of
mitotically active polymorphous cells whose numerous processes
give this layer a prickly appearance
Wound is defined as “break in an epithelial surface that may be surgical or
accidental”1.
Wound contraction is the process in which the surrounding skin is pulled
circumferentially toward an open wound.
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Learning Objectives
Year 4 To understand the basic principles of wound cleaning.
To understand the principles of ANTT (Aseptic non touch technique).
To be able to apply a basic adhesive dressing and within Trust guidelines.
To be able to carry out basic wound closure safely following ANTT principles
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Introduction
The overall aim of this study guide is provide an overview of wound care principles guided by
evidence based practice and ANTT principles.
Prior to addressing any wound it is essential to start with an overall assessment of the patient.
There are a couple of tools that can be identified to assist you with this assessment, for
example HEIDIE1, an acronym used to guide this process. This will be more useful in more
complex and chronic wounds.
Aseptic Non Touch Technique (ANTT) principles must be adhered to when cleaning and
dressing a wound to avoid contamination and minimise infection. This include:
• Key parts and key sites should be protected to prevent contamination of the wound.
• Working surfaces and areas should be cleaned and disinfected in accordance to local
policies.
• Thorough handwashing using the modified Ayliffe technique
• Use appropriate personal protective equipment (gloves, apron, etc.)
• Select appropriate equipment to maintain asepsis (e.g. sterile dressing pack) and ensure
that all packaging is intact and in date.
• Adhere to non-touch technique throughout the procedure.
• Post procedure, relevant equipment must be decontaminated (e.g. trolley) including hand
hygiene.
H History: the patient's medical, surgical, pharmacological and social
history
E Examination: general and focused (specific to the wound)
I Investigations: relevant blood results, radiological images to inform
your diagnosis and management plan
D Diagnosis: aetiology and pathology
I Implementation of the plan of care.
E Evaluation: monitor, assess progress and adjust management plan,
refer on or seek advice from a specialist practitioner and other senior
colleagues
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Surface Anatomy / Relevant Physiology
Figure 1 – Layers of the Skin
The skin is the largest organ of the body and it has a surface area of more than 2 square meters
and accounts for 6 to 8 lb (2.5 to 3.5 kg) of body weight 2. It has an extensive network of small
blood vessels for perfusion and nutrition.
It consists of three layers:
Epidermis: Outermost layer, which consists of five distinct sublayers (stratum basale, stratum
spinosum, stratum granulosum, stratum lucidum and stratum corneum) and is formed mainly by
keratinocytes (cells that are continuously generated and migrate from the underlying dermis);
serves as protective layer against water loss and physical damage
Dermis: Composed of collagen fibers (provide skin strength), elastin (provides elasticity), and
extracellular matrix (provides strength and pliability)
Hypodermis (subcutaneous tissue): Contains major blood vessels, lymph vessels, and
nerves.
Any break in the skin will result in a wound.
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Wound Classification
• Acute wound – is traumatic or surgical and moves throughgout the stages of healing
process predictable time frame3.
• Chronic wound does not progress through the normal stages of healing and is not
resolved over an expected period regardless of the cause 4.
Methods of Wound Healing5 Wound healing is the process whereby tissue damage is restored to its normal function. This
can occur in primary, secondary and tertiary intention.
Primary intention involves the union of the edges of a wound under aseptic conditions, for
example, a laceration or an incision that is closed with sutures or a skin adhesive.
Secondary intention occurs when a wound’s edges cannot be brought together. The wound
is therefore left open to allow healing to occur by contraction and epithelialisation. Wounds that
require secondary intention include surgical or traumatic wounds where a large amount of tissue
has been lost, heavily infected wounds, chronic wounds, and certain instances where a better
cosmetic or functional result will be achieved.
Tertiary intention, also referred to as delayed primary closure, occurs when a wound is left
open and is then closed primarily after a few days’ delay. This is usually once swelling or an
infection or bleeding has decreased.
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Phases of Wound Healing 5
A normal wound healing process follows a certain predictable pattern that can be divided into overlapping phases as outlined below.
Haemostasis and Inflammatory phase (days 1–6)
• This phase represents the tissue’s attempt to limit any damage
• There is immediate vasoconstriction and coagulation
• Increased vascular permeability mediated by histamine, nitric oxide and serotonin
• Co-ordination of the inflammatory and growth factor response by neutrophils (1–2 days)
• Macrophages are activated by fibrin, foreign body material, and exposure to hypoxic and
acidotic environment (2–4 days). Essential for progression to the proliferative phase
• Lymphocytes are also activated by the inflammatory response within the cells. They are less
numerous than macrophages and peak at 5–7 days post injury
Proliferative phase (days 3–21)
• Fibroblast and endothelial cells are the last cell populations to infiltrate the wound
• Capillary ingrowth (granulation tissue)
• Collagen synthesis with rapid gain in tensile strength
• Wound contraction
Remodelling or maturation phase (weeks 3–52 +)
• Scar formation is the ultimate of wound repair and it could take months to years to form a
mature scar through remodelling
• Gradual gain in tensile strength to 80% of normal
This diagram (figure 2) provides an illustration of the phases of wound healing.
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Figure 2 – Stages of wound healing
Factors affecting wound healing 5,6,7 The process of wound healing is not straightforward and often its rate and success is influenced
by a variety of factors categorised as local and systemic.
Local Factors • Oxygenation
Oxygen is essential as part of the wound healing process. It is involved in the wound
healing stages that are required for restoration of tissue function and integrity. Often in
chronic wounds, tissue hypoxia delays the healing process.
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• Infection
This is one of the most common causes delaying wound healing. The presence of
excess bacteria within the wound bed leads to prolonged inflammatory phase thus
interfering with epithelialisation, contraction and collagen deposition.
• Contamination
Poor aseptic technique when accessing and cleaning the wound could lead to
contamination and infection resulting in delayed wound healing.
• Foreign bodies such as fragments of clothing or unsuitable dressings, splinters, a piece
of glass could later cause wound infection. Adequate history will help identify possible
presence of foreign bodies depending on the nature of injury. Glass can be identified on
an x-ray but not wood.
• Venous insufficiency occurs when valves in leg veins fail and are not effectively returning
blood back towards the heart resulting in venous hypertension. This will often cause pain,
swelling. Oedema, skin changes and ulcerations. Affected tissues become poorly
nourished and fragile leading to very slow healing to existing wounds.
• Unsuitable dressings
If used, dressings that are not suitable for a particular wound could create unfavourable
conditions for wound healing. For instance if the wound has a lot of exudate, but the
dressing does not control this, there is a risk to the surrounding skin to be too wet
increasing the risk of developing maceration and infection.
• Interference by patient
If possible adequate education is needed for the patient to ensure that they do not
unnecessarily expose the wound or dressing which could lead to wound contamination
and infection.
Systemic Factors • Age
Age affects how the entire body functions and responds to internal processes; including
the structure and function of the skin, thus leading to delay in wound healing. As the body
cellular functioning and metabolism slows down with aging, so do the inflammatory
responses essential for wound healing. There is also an increased incidence of chronic
disease with aging such as, cardiovascular and metabolic diseases, malnutrition, and
vitamin deficiencies all contributing to delay in wound healing.
• Malnutrition – hypoproteinaemia, deficiencies especially vitamin C and zinc.
Lack of adequate nutrition to the body causes delay in wound healing due to lacking in
necessary nutrients to facilitate cell repair and growth.
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• Immunosuppression due to:
o Diseases (e.g. AIDS)
o Drugs (e.g. chemotherapy, corticosteroids, NSAIDs)
• Social factors
o Alcohol
o Smoking
o IV drug abuse
o General neglect
• Stress
Stress causes generalised physiologic responses that could delay wound healing.
• Chronic disorders such as:
o Metabolic disease – renal failure, hepatic failure
o Endocrine disease – uncontrolled diabetes mellitus can lead to reduced
inflammation, angiogenesis and collagen synthesis. It also results in large and
small vessel disease contributing to local hypoxaemia.
o Autoimmune disorders – rheumatoid arthritis, systemic lupus erythematosus
(SLE),
o Collagen disorders – e.g. Marfan, Ehlers Danlos, Osteoporosis
o Carcinomatosis / cachexia
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Types of Wounds 3,8 Management of wounds will vary according to Trust policy and local guidelines however in this
section, standard wound management approaches are discussed.
Necrotic Wound
Description: Black/brown tissue; hard eschar (Figure
3)
Management: Encourage a clean wound bed by
debriding the escar. Rehydrate
Primary dressing: Hydrogel e.g. Aquaform or
Intrasite gel; Honey-based dressing (figure 4)
Secondary dressing: Non adherent; padding or
bandage (figure 4).
Debridement - is the removal of devitalised or contaminated tissue from a wound until healthy
tissue is exposed. It therefore promotes wound healing.
Figure 4 - Primary and secondary dressings for a necrotic wound
Figure 3 - Necrotic wound
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Sloughy wound
Description: Green/ yellow pus dying tissue +/-
infection.
Management: Debride, treat and prevent local wound
infection. Reduce malodour and absorb excess
exudate.
Primary dressing: Alginate or Bordered Hydrofibre
dressing e.g. Sorbsan, Aquacel, Allevyn (figure 6)
Secondary dressing: Bordered Hydrofibre, highly
absorbent wound dressing, padding or bandaging
(figure 7)
Figure 5 - Sloughy wound
Figure 6 - Primary dressings for a sloughy wound
Figure 7- Secondary dressings for a sloughy wound
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Granulating Wound
Description: Wound is moist, red or dark pink in
appearance
Management: The aim is to – protect the wound, absorb
excess exudate, prevent trauma to granulation tissue and
maintain a moist environment.
Primary dressing: Hydrocolloid foam e.g. Duoderm,
Hydrofibre or bordered hydrofibre, highly absorbent
dressings, and alginates (figure 9)
Secondary dressing: same as above, but including padding
and bandages (figure 10)
Figure 8 - Granulating wound
Figure 9 - Primary dressings for a granulating wound
Figure 10 - Secondary dressings for a granulating wound
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Epithelialising wound
Description: Cells are migrating and wound is getting
smaller and is healing
Management: the aim is to - protect newly formed
tissue; maintain wound temperature with infrequent
dressing changes; maintain a moist environment and
prevent pain
Primary dressing: Thin hydrocolloid semi-permeable
film e.g. Duoderm
Secondary dressing: not necessary unless if non
bordered dressing has been used. Foam, padding and
bandaging
These type of dressings are recommended to remain
in situ up to 7 days dependent on exudate levels. The
dressings should only be changed when clinically indicated, usually when exudate reaches 1 to
2 cms from the edge of the pad, which is clearly visible on the outer layer.
Figure 11 - Epithelialising wound
Figure 12 - Primary dressings for an epithelialising wound
Figure 13 - Secondary dressings for an epithelialising wound
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Hypergranulating wound (Hypergranulation)
Description: also referred to as overgranulation,
this is an excess of granulation tissue beyond the
amount required to replace the tissue deficit
incurred as a result of skin injury or wounding
(Tortora & Grabowski, 2000)
Management: the aim is to – encourage
subsistence of hypergranulation tissue; if possible
the cause should be eliminated; allow
epithelialisation
Primary and Secondary dressings are outlined in
figures 16 & 17 below.
Figure 14 - Hypergranulation
Figure 15 - Primary dressings for a hypergranulating wound
Figure 16 - Secondary dressings for a hypergranulation wound
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Infected wound
Description: Wound has odour, pus and
exudate, inflammation and pain.
Management: the aim to treat local infection
and make sure extra exudate is managed
Primary dressing: Antimicrobial dressings
such as Iodine/ silver/ alginate/ honey-based
dressing e.g. Aquacel AG
Secondary dressing: Foam sheet, bordered
dressing, bordered hydrofibre. Padding and
bandaging as required
Figure 17 - Infected wound
Figure 18 - Primary dressing for an infected wound
Figure 19 - Secondary dressings for an infected wound
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Other types of wounds that are likely to have delayed healing due to large amounts of tissue
loss and underlying chronic diseases. These include:
Burns and scalds
Effective and timely first aid and initial management are key in ensuring that long-term effects are minimised when managing burns9. When assessing a burn wound a Lund and Browder's assessment chart (figure 21) is used to assess the position, depth and area affected. The wound should be dressed with non-adherent dressing. NICE guidelines10, the National Standards for Provision and Outcomes in Adult and Paediatric Burn Care11, and local protocols must be adhered to when managing and treating burns.
Diabetic foot ulcers
The cause of the ulceration should be assessed such as diabetic
neuropathy, ischaemia or neuroischaemia12. The main aim here it to ensure
good control of blood sugars, relieve pressure from ulcerated areas and
dress wounds with absorbent non-adherent dressings such as foams or
alginate dressings. Local guidelines and protocols must be followed in the
management of diabetic foot ulcer.
Figure 20 - Burns
Figure 21 - The rule of nines and Lund-Bowder charts
Figure 22 - Diabetic foot ulcer
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Leg ulcers13 Assessment of leg ulcers includes using a Doppler ultrasound to establish the cause of the ulceration (venous or arterial) and the calculation of the ankle brachial pressure index (ABPI) by a trained and proficient practitioner. Venous ulcers often benefit from multilayer compression bandaging, with a non-adherent dressing as a primary layer.
Pressure ulcers A pressure ulcer is “localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to a medical or other device), resulting from sustained pressure (including pressure associated with shear). The damage can be present as intact skin or an open ulcer and may be painful”14. The NHS Improvement (NHSI) and the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance (EPUAP/ NPIAP/PPPIA) 15 have set out comprehensive guidance on management on prevention and management of pressure ulcers. Pressure ulcers (PU) are classifies as follows:
Classification Definition Image
Stage I pressure ulcer
Non-blanchable erythema
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Difficult to detect in people with dark skin tones.
Figure 24 - Stage 1 pressure ulcer
Stage II pressure ulcer Partial thickness skin loss
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister.
Figure 25 - Stage 2 pressure ulcer
Figure 23 – Venous leg ulcer
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Classification Definition Image
Stage III pressure ulcer Full thickness skin loss
Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss.
Figure 26 - Stage 3 pressure ulcer
Stage IV pressure ulcer Full thickness tissue loss
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.
Figure 27 - Stage 4 pressure ulcer
The best management for pressure ulcers is always prevention by identifying patients that are most at risk using a recognised scale (Waterlow or Braden Scale). For treatment, a systematic assessment should be completed and categorise the PU according to the table above. Referral to tissue viability services early is also key to help identify and prescribe appropriate dressing.
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Wound Assessment 16, 17 Accurate wound assessment is essential in ensuring appropriate patient and wound management. It is imperative to consider the following key factors as part of the assessment.
• Type of wound – is the wound acute or chronic?
• Aetiology – surgical, laceration, ulcer, burn, abrasion, traumatic, pressure ulcer, or neoplastic
• Location – this should be accurately documented on a body map (appendix C) using correct anatomical terms. A body map provides accurate visualisation of the exact location of the wound especially if a patient has multiple wounds in different locations. It is also useful to use anatomical terms when identifying the location for example using ‘right greater trochanter’ rather than right hip; and using standard clinical terms such as distal and proximal enhances clarity.
• Surrounding skin – this should be carefully examined to ensure that it is protected from deterioration and further injury.
• Tissue loss can be classified as: o Superficial wound – involving the dermis o Partial wound – involving the dermis and the epidermis o Full thickness wound – involving the epidermis, dermis, subcutaneous tissue
and may extend to muscle, bones and tendons.
• Wound bed appearance and stage of healing o Is the wound granulating, epithelialising, sloughy, necrotic, or hyper granulating? It
is also important to note the wound healing phase.
• Measurement and dimensions – ‘wounds require a two dimensional assessment of the wound opening and a three dimensional assessment of a cavity of tracking’16.
• Wound edge should be assessed for: o Colour: pink shows healthy new tissue; dusky indicate tissue hypoxia; and
erythema is evidence of cellulitis o Evidence of contraction: when wound edge start coming together, it indicates that
healing process has commenced. Raised edges are a sign of hyper granulation and rolled edges towards the wound bed can inhibit the healing process
o Altered sensation: if there is increased pain or reduced/absent sensation will require further investigation.
• Exudate – plays an important part in the wound healing process. It helps maintain a moist environment and provides the wound with essential nutrients, energy and growth factors. The wound exudate should be assessed for type, amount, colour, and odour to identify any changes. Excess exudate could cause maceration and degradation of skin and too little lead to the wound bed drying out. It is often viscous and offensive in infected wounds.
• Presence of infection – it can delay the process of wound healing and damage tissues and if left untreated could also lead to systemic infection. The following are a sign of
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infection; localised pain, redness, heat around the wound, oedema, and purulent exudate. A swab for culture and sensitivity may be required for appropriate treatment.
• Pain – healing wounds should not be painful therefore the presence of pain usually indicates inflammation or infection. Accurate assessment of pain is crucial to ensure that appropriate dressing is used. Appropriate analgesia should be prescribed to ensure patient comfort whether they experience pain constantly or during dressing change.
• Previous wound management methods need to be explored to inform current
assessment and management plan.
Preparation
Patient safety Introduce yourself
Check the patient’s identity and allergies
Explain what you want to do
Gain informed consent
Consider an appropriate chaperone
Adequate exposure maintaining dignity
Position the patient appropriately – consider moving and handling
Wear Personal Protective Equipment as you are coming into contact with bodily fluids
Wash your hands before and after you touch the patient (as per WHO guidelines)
Additional checks include:
Assess patient for pain and ensure that analgesia has been administered as required
Allow the patient to ask any questions that they may have and discuss any past problems (e.g.
fainting/ bleeding/ medication history)
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Equipment
Prior to collecting any equipment, it is good practice to see the patient first in order to assess
the wound, to ensure that the relevant dressings are used. Some of the specialised dressings
need a prescription. Tissue viability specialist nurses should be involved when dealing with
complex wounds for advice on the most suitable wound dressing products.
• Dressing trolley
• Dressing pack
• Sterile gloves (if not included in the dressing pack)
• Relevant dressing
• Sodium Chloride 0.9% solution for irrigating the wound
• Documentation (local policy to be followed)
• Hand gel
• Apron
• Non sterile gloves
• Disinfectant wipes
Principles of Wound Cleansing18 The main aim of wound cleansing is provide optimum conditions locally to promote the wound
healing processes. It is important to assess the wound prior to cleansing in order to make an
informed decision. If the wound is clean, with minimal exudate, and showing sign of
granulation, unnecessary repeated cleaning might adversely affect wound healing as new tissue
might be damaged.
The temperature of the wound should not be allowed to fall due to prolonged wound exposure
during the procedure. This might lead to reduced cellular activity and resulting in delay in wound
healing.
Sodium Chloride 0.9% is an ideal solution for wound cleansing as it has similar osmotic
pressure to that already in the cells. It is non-toxic but effective in diluting bacteria. There is now
an increased use of tap water for irrigating chronic wounds as research has showed no
difference in the healing and infection rates between tap water and 0.9% sodium chloride.
However local organisational policies must be followed.
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Irrigation of the wound rather than wiping is seen as less harmful particularly to new tissue.
Especially aggressive cleaning using a gauze swab could potentially damage granulation tissue.
It is also worth knowing that wound cleansing is not recommended at all for certain wounds e.g.
gangrenous wounds. Such wound are recommended to be left dry to promote autolytic
debridement 19, 20. In chronic wounds however cleansing using a gauze is essential as it helps
remove residue i.e. creams/ emollients from previous dressings thus allowing clinicians a good
view of the wound for adequate assessment 18.
Always seek advice from your supervisor when deciding cleansing by wiping or irrigation.
Cleaning a linear wound (fig. 30)
Please note that only wipe the wound directly if required i.e. if
there is slough that requires removing.
Stroke 1 – wipe the area directly over the wound with a single
stroke moving from top to bottom, and then discard the wipe.
Discard the used gauze into the clinical waste bag.
Stroke 2 – on the patient's right side (or left), wipe the area next
to the wound with a single stroke, and then discard the wipe.
Stroke 3 – on the patient's left side (or right), wipe the area next
to the wound with a single stroke and then discard the wipe.
Stroke 4 & 5 – continue according to the diagram following However if the wound is clearly infected
and has purulent discharge the strokes will usually move in the opposite direction (starting from
outside inwards).Starting away from the area of infection and working towards it.
Figure 30 - Linear wound cleaning
Figure 28 - Wound cleaning by wiping Figure 29 - Wound cleaning by irrigation
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Cleaning a circular/ puncture
wound (figure 31 & 32)
Stroke 1 - Starting at the centre of the
wound, swab the area in an outward
circular spiral. Then discard the swab.
Stroke 2 - From the spot where the
first stroke ended, continue swabbing
(wiping) in an outward circular pattern
for about one and one-half revolutions.
Then discard the swab.
Stroke 3 - From the spot where the second stroke ended, continue swabbing (wiping) in an
outward circular pattern for about one and one-half revolutions. Then discard the swab.
Continue cleaning the area, if needed, until the area around the wound has been cleansed.
However if the wound is clearly infected and has purulent discharge the concentric circles will
usually move in the opposite direction (starting from outside inwards).Starting away from the
area of infection and working towards it – so as not to spread the discharge over healthy tissue
(figure 32).
Figure 31 - Circular wound cleaning
Figure 32 - Circular wound cleaning
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Procedure
Figure 33 - Step by step procedure for wound cleaning and dressing
Step by step procedure for wound cleaning and dressing 1. Wash hands 2. Clean the trolley 3. Thoroughly wash
your hands with soap and water
4. Don apron
5. Select and check equipment for expiry and packaging integrity. Place on bottom shelf of clean trolley
6. Open the sterile pack and all relevant equipment without contaminating key parts
7. Use yellow waste bag (or non-sterile gloves) to remove loosened dressing
8. Wash hands
9. Apply sterile gloves
10. Clean wound using non-touch technique
11. Apply relevant dressing
Thank the patient and ensure they are left comfortable
12. Dispose of equipment, waste & then gloves
13. Clean trolley 14. Wash hands
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Documentation Once the procedure has been completed, it is essential to document accurately and clearly,
figure 34 shows an example of paperwork that can be used, this may vary from Trust to Trust.
Figure 34 - Wound care document
Documentation type varies between organisations and it may on paper or electronic, however the following details are essential:
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• Patient details – name, date of birth, hospital number, ward or department
• Date and time of the procedure
• Using a body map appendices 3 will ensure that the position of the wound is accurately
recorded
• Wound dimensions (length X width X depth)
• Wound bed appearance (necrotic, slough, macerated, granulating (red), or epithelializing
(pink))
• Skin around the wound (e.g. intact, dry, oedema)
• Exudate level (none, low, moderate or high). Also comment if ir is increasing or decreasing
in amount.
• Odour
• Factors affecting wound healing
• Bleeding (none, slight, moderate, or heavy). State if this is due to dressing change.
• Pain (using the scoring system)
• If infection suspected, state if swab taken and if treatment has been prescribed.
• Once completed the recording should be signed by both the student and their supervisor.
Post Procedure Clear post procedure care should be documented in the patient’s notes. Instructions of ongoing
care of the wound should be recorded to ensure that the wound is cleaned and dressed
appropriately. Patient education is also key to ensure compliance.
Patients should be informed to:
Keep dressing clean and intact as required (dependent on type of wound and dressing).
Seek medical advice if there are any signs of infection (redness, exudate or heat etc.)
Take analgesia as needed.
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Appendices
Appendix A13
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Appendix B14
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Appendix C Body map
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Bibliography & Further Reading Gartner L. Textbook of Histology. Chapter 14, Integument 5th Edition. Pages 333-354 [Retrieved from: https://www-clinicalkey-com.liverpool.idm.oclc.org/student/content/toc/3-s2.0-C20140021375 Jul 2020] Kirk, R. M. Basic Surgical Techniques E-Book. [ClinicalKey Student]. Retrieved from https://clinicalkeymeded.elsevier.com/#/books/9780702049101/ Grey JE, Enoch s, Harding KG ABC of wound healing - Wound assessment. British Medical Journal Vol 332. 4th February 2006 pp. 285-288 World Health Organisation. WHO guidelines on hand hygiene in health care. 2009 https://www.who.int/infection-prevention/tools/hand-hygiene/en/ https://www.clinicalskills.net Adult Procedures https://www.bing.com/videos/search?q=how+to+clean+a+wound&&view=detail&mid=31E39C5BC2FBA225734B31E39C5BC2FBA225734B&rvsmid=25DF5038C80042D6803B25DF5038C80042D6803B&FORM=VDQVAP
References 1. Hampton S. Wound management 4: Accurate documentation and wound measurement.
Nursing Times; 111: 48, p16-19. 2015. Available from https://www.nursingtimes.net/clinical-archive/tissue-viability/wound-management-4-accurate-documentation-and-wound-measurement-23-11-2015/
2. Gallo R Human skin is the largest epithelial surface for the interaction of microbes. Journal of Investigative Dermatology. Issue 137, p1213-1214. 2017. Available from https://pubmed.ncbi.nlm.nih.gov/28395897/ DOI:10.1016/j.jid.2016.11.045
3. Dougherty, Lisa, et al., editors. The Royal Marsden Manual of Clinical Nursing Procedures. John Wiley & Sons, 2015.
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7. Bishop A. Role of oxygen in wound healing. Journal of Wound Care; 17: 9, 399-402. 2008. DOI: 10.12968/jowc.2008.17.9.30937
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8. Jones J. Choice of dressings directed by wound appearance. 2015. https://www.clinicalskills.net/node/223 [accessed 01.07.2020]
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10. National Institute for Health and Care Excellence (NICE) Burns and Scalds. 2019 Available from https://cks.nice.org.uk/topics/burns-scalds/#!organizationalbarriers
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13. Joseph E. Grey, Stuart Enoch, Keith G. Harding. Abc Of Wound Healing: Venous And Arterial Leg Ulcers. BMJ: British Medical Journal [Internet]. 2006 [cited 2020 Aug 18];332(7537):347. Available from: https://search-ebscohost-com.liverpool.idm.oclc.org/login.aspx?direct=true&db=edsjsr&AN=edsjsr.25456108&site=eds-live&scope=site
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20. Lloyd Jones M Wound cleansing: has it become a ritual or is it a necessity? British Journal of Community Nursing. Wound Care Supplement. S22–26. 2012. Available from https://lohmann-rauscher.co.uk/downloads/clinical-evidence/Wound_cleansing_is.pdf
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Picture Credits
Figure 1 The layers of the skin. Talley, Nicholas J, MBBS (Hons)(NSW), MD (NSW), PhD (Syd), MMedSci (Clin Epi)(Newc.), FRACP, FAFPHM, FAHMS, FRCP (Lond. & Edin.), FACP, FACG, AGAF, FAMS, FRCPI (Hon), Talley & O'Connor's Clinical Examination, Chapter 43, 799-825 Copyright © 2018
Figure 2 Stages of wound healing. Adobe photo library. Reproduced with permission
in June 2020 Figure 3 to 19 Various wound types and suggested dressings. Reproduced with
permission from clinicalskills.net https://www.clinicalskills.net/node/ Figure 20 Burn Hand https://i1.wp.com/www.edokita.com/wp-
content/uploads/2018/06/burns-1.png?resize=500%2C400 burn hand Figure 21 The rule of nines and Lund-Bowder charts
http://image1.slideserve.com/2952400/the-rule-of-nines-and-lund-browder-charts-n.jpg
Figure 22 Diabetic foot ulcer. Grey JE, Enoch S, Harding KG ABC of wound healing - Wound assessment. British Medical Journal Vol 332. 4th February page 287
Figure 24-27 Scottish Adaptation of the European Pressure Ulcer Advisory Panel (EPUAP) Pressure Ulcer Classification Tool
Figure 28-32 CSTLC team Figure 33 Images from CSTLC, clinicalskills.net and ANTT©
List of Figures Figure 1 – Layers of the Skin ....................................................................................................... 7
Figure 2 – Stages of wound healing ........................................................................................... 10
Figure 3 - Necrotic wound .......................................................................................................... 13
Figure 4 - Primary and secondary dressings for a necrotic wound ............................................ 13
Figure 5 - Sloughy wound .......................................................................................................... 14
Figure 6 - Primary dressings for a sloughy wound ..................................................................... 14
Figure 7- Secondary dressings for a sloughy wound ................................................................. 14
Figure 8 - Granulating wound ..................................................................................................... 15
Figure 9 - Primary dressings for a granulating wound ................................................................ 15
Figure 10 - Secondary dressings for a granulating wound ......................................................... 15
Figure 11 - Epithelialising wound ............................................................................................... 16
Figure 12 - Primary dressings for an epithelialising wound ........................................................ 16
Figure 13 - Secondary dressings for an epithelialising wound ................................................... 16
Figure 14 - Hypergranulation ..................................................................................................... 17
Figure 15 - Primary dressings for a hypergranulating wound ..................................................... 17
Figure 16 - Secondary dressings for a hypergranulation wound ................................................ 17
Figure 17 - Infected wound ........................................................................................................ 18
Figure 18 - Primary dressing for an infected wound ................................................................... 18
Figure 19 - Secondary dressings for an infected wound ............................................................ 18
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Figure 20 - Burns ....................................................................................................................... 19
Figure 21 - The rule of nines and Lund-Bowder charts .............................................................. 19
Figure 22 - Diabetic foot ulcer .................................................................................................... 19
Figure 23 – Venous leg ulcer ..................................................................................................... 20
Figure 24 - Stage 1 pressure ulcer ............................................................................................. 20
Figure 25 - Stage 2 pressure ulcer ............................................................................................. 20
Figure 26 - Stage 3 pressure ulcer ............................................................................................. 21
Figure 27 - Stage 4 pressure ulcer ............................................................................................. 21
Figure 28 - Wound cleaning by irrigation...................................... Error! Bookmark not defined.
Figure 29 - Wound cleaning by wiping ......................................... Error! Bookmark not defined.
Figure 30 - Linear wound cleaning ............................................................................................. 25
Figure 31 - Circular wound cleaning .......................................................................................... 26
Figure 32 - Circular wound cleaning .......................................................................................... 26
Figure 33 - Step by step procedure for wound cleaning and dressing ....................................... 27
Figure 34 - Wound care document ............................................................................................. 28