Back to Basics The Fundamentals of Wound Care and Dressing Selection Shannon S. Polson, MSN, MSW, RN, LCSW, PIP, CNL, CWCN, CFCN

Wound Assessment You must document all wounds on admission (8 hours-NPUAP) Assessment from head to toe Remove any devices or dressings that are obscuring the wound. When checking for blanching, finger method, 3 seconds. content/uploads/2014/08/Quick-Reference- Guide-DIGITAL-NPUAP-EPUAP-PPPIA- Jan2016.pdf

Wound Measurement Length Width Depth Tunneling Undermining

These are tunneled shafts that run out away from the wound. The erosion caused by shear and friction leaves a shelf. Undermining Tunneling

Wound Documentation Location Color Measurements Tunneling or undermining Status of the wound bed, surrounding skin and wound edges Drainage Odor Pain

The Functions of the Skin This organ provides: Sensation Thermal Regulation Metabolic function (Cholecalciferol D3) Communication Protection

Skin Immune Function As a barrier layer there are a variety of defenses found: –Outer acid mantle –Langerhans cells –Macrophages –Mast cells –Dendrocytes

Anatomy of the Skin - Epidermis Epidermis –Stratum corneum Age, disease –Stratum lucidum Found in thicker areas only –Stratum granulosum Active nuclei, hydration (UV filter) –Stratum spinosum Desmosome density –Stratum Germinativum (Basale) Rete ridges/pegs

Anatomy of the Skin – BMZ & Dermis Basement Membrane Zone –Dermal/epidermal Junction, blister formation Dermis –Papillary Dermis Dermal papillae –Reticular Dermis

Anatomy of the Skin -Hypodermis Hypodermis (Subcutaneous) –Adipose –Loose connective tissue –Fascia –Lymphatic vessels

Keys to Successful Wound Healing Proper classification of the wound Knowledge of the normal stages of the wound healing process based on type of wound Proper identification of the physiological stage of the wound at time of treatment Understanding of appropriate time frame for each stage in order to gauge delays in wound healing process

Wound Healing Factors involved in wound healing How –Regeneration –Scar formation –Primary, Secondary, Tertiary

Wound Healing Partial Thickness Full Thickness Acute Chronic

Proper Wound Bed Environment: Moist

Principles of Moist Wound Healing Debride necrotic tissue Identify and treat infection Wick exudate from tunnels and undermined wound areas Absorb excess exudate Maintain a moist wound surface Open the wound edges Protect from trauma or infection Insulate the wound

Systemic Factors that Affect Wound Healing Nutrition –Weight, lab values, absence of granulation tissue? –Calorie intake vs calorie needs –Vit C, zinc, multivitamin Hyperglycemia Steroids –>40 mg/day –May benefit from Vitamin A

Physiology of Partial Thickness Wound Healing Inflammatory response –Typically less than 24 hrs Proliferation of epithelial tissue –If dermal tissue is lost it coincides- fluid layer separates the two until the fibroblasts finish and the connective tissue grows upward. –MMPs and growth factors regulate Migration (resurfacing) Epithelial layers reestablish

Partial Thickness Wound

Full Thickness Wound Loss of epidermal and dermal layers Can come from bottom up as well as top down Subcutaneous, muscle, bones, fascia could be exposed Granulation (Scar formation)

Physiology of Full Thickness Wound Healing Inflammatory Stage Proliferation Maturation –remodeling Acute vs Chronic

Physiology of Full Thickness Wound Healing Inflammatory stage –1-4 days (3 days average) –Hemostasis Vasoconstricton- clotting pathways initiated Clotting causes the degradation of platelets that further signal fibrin to aggregate and release fuel stores. –Natural wound cleansing The influx of neutrophils, macrophages and fibroblasts begin to clean the wound bed.

Physiology of Full Thickness Wound Healing Complications of Prolonged inflammation: –Wound Dehiscence –Presence of infection –Hypertrophic scarring Factors affecting prolonged inflammation –Tissue that is devitalized –Bacteria –Hyperglycemia/diabetes –Imbalance of wound bed enzymes and cytokines

Physiology of Full Thickness Wound Healing Proliferation stage Epithelialization –2-3 days –In open wound delayed until formation of healthy granulation bed Granulation –Neoangiogenesis –Formation of ECM by fibroblasts –Peaks day 5-15, healing ridge day 5-9 post-op Contraction if wound edges are open –Not always ideal due to loss of mobility

Physiology of Full Thickness Wound Healing Possible complications to stall proliferation stage –Not adequate nutrition and materials for the fibroblast –Cytotoxic environment –Infection –Mechanical removal –Does pressure need to reduce?

Physiology of Full Thickness Wound Healing Maturation/Remodeling –New wound will never regain full tissue strength. –Synthesis of new collagen –Lysis of current collagen Hypertrophic – raised Keloid- grows beyond wound –Process adds strength 20%3 weeks 80% 3 months –Reduces area

Full Thickness Wound

Refractory Complications Chronic Full Thickness Wounds Inflammatory Phase There is a stall or breakdown in the process: Become stagnant or impeded –No bleeding –No hemostasis –No release of growth factors –Infection –Need debridement –Difference in wound fluid – more inflammatory

Refractory Complications Chronic Full Thickness Wounds Proliferative Phase –Same failure to progress but with granulation, the failure could be with granulation or epithelialization. –Raw ingredients missing Nutrition Perfusion –Not enough scaffolding –Too wide an area for successful epithelialization – graft –Must have open wound edges

Refractory Complications Chronic Full Thickness Wounds Maturation Phase –Location of wound –Pressure on wound –Repetitive injury –Loss of sensation

Eschar Nature’s Dressing If stable you may not debride it. Paint with betadine Is there infection or erythema? Is healing compromised in the patient?

Wound Culture- Levine Technique Normal Flora on the skin will contaminate the culture Flush with Normal Saline (NS) Viable tissue- find 1 square cm Moisten – Swab should be pre-moistened with NS before applied to area Use force to produce exudate when swabbing area of viable tissue Place culture in tube and send to lab

Simplifying Dressing Selection Using Classification Deep versus Shallow –>0.5cm is deep Dry versus Wet You don’t need a lot of product options on hand to manage wounds but it is recommended to have one or two solid options for each of the four categories.

Shallow and Dry

Deep Dry

Dressings that are Versatile Collagens Composites Impregnated dressings Wound fillers

Dressings for Dry Wounds Filler Dressing: Hydrocolloids Hydrogels: amorphous Non-adherent contact layer Follow with Cover Dressing

Shallow and Wet Wound

Deep and Wet Wound

Dressings for Chronic Wounds Filler Dressing Medical grade honey Collagens

Dressings for Wet Wounds Filler dressings Absorptives Alginates Foam Dressings Wound fillers such as Gold Dust Nonwoven gauze preferred Follow with a cover dressing

Types of Dressings A-Z Absorptives Alginates Antimicrobial Collagens Composites Contact layers Elastic Bandages Foam Dressings

Dressings Gauzes and non woven gauzes Hydrocolloids Hydrogels- amorphous, impregnated, sheets Impregnated dressings Medical grade honey Silicone gel sheets Transparent films Wound Fillers

References Bryant, R. A., & Nix, D. P. (2012). Acute and chronic wounds: Current management concepts. St Louis, MO :Elsevier Mosby. Emory University WOCNEC (2012). Skin and wound module. Atlanta, GA :Emory University.