Wound care Jana Hermanova

Wound classification By cause – intentional, unintentional By cleanliness – clean, contaminated, infected By depth – superficial, partial thickness, full thickness By color – red, yellow, black (the treatment is based on the color)

Clean, dry, low exudate Absorbent, perforated, film dressing Permeable adhesive film dressing

Clean – medium to high exudate Paraffin gauze Viscose primary dressing

Clean, exudating (granulating) Hydrocolloids Foams Alginates

Slough covered Hydrocolloids Hydrogels

Dry, necrotic Hydrocolloids Hydrogels

Types of wound healing Primary intention – rapid healing, no infection, well approximated, sutured edges (surgical wounds) Secondary intention – heal by granulation (burns, pressure ulcers, wounds with large pieces of missing skin), risk for infection Tertiary intention – the wound is left open to heal (infected wounds)

Complications of surgical wound Dehiscence – wound ruptures along surgical line

Factors affecting wound healing Nutrition – proteins, carbohydrates, vitamin A and C, zinc, iron, copper General physical health – DM, cancer, anemia, uremia, atherosclerosis, infection, malnutrition, smoking. Obesity, old age Medications – steroids, nonsteroidal medications

Goals of wound care Remove necrotic tissue to promote healing Prevent, eliminate or control infection Absorb drainage Maintain a moist wound environment Protect the wound from further injury Protect the surrounding skin from infection and trauma

Wound assessment Location Color Odor – foul (infection, necrosis) Moisture Exudate Wound bed Periwound condition Extent of pain Size – length, width, depth Undermining/tunneling Sinuses

Wound dressings Gauze Transparent adhesive films Hydrogel Hydrocolloid Nonadhesive Medicated Alginates

Gauze Can stick to the wound surface Use only for minor wounds or as secondary dressing

Semipermeable film Sterile polyurethane Transparent, allow for wound check For shallow wound with low exudate

Hydrogel Releases water to keep the wound moist Used for necrotic or sloughy wound beds Rehydrates and remove dead tissue Do not use on heavily exudating wounds aa

Hydrocolloids Turn into a gel when exudate is absorbed Promote debridement and healing Use in wounds with light to heavy exudate

Tulle Nonadhesive Flat, shallow wound Used in patients with sensitive skin

Silver containing dressings

Polyurethane or silicone foams Absorb large amounts of exudate Maintain moist wound Do not use on low exudating wounds

Hydrofibre Non-woven pad Interact with wound drainage to form a soft gel Used for packing, absorb exudate, provide moist environment

Wound cleaning Flushing Debridement – mechanical, chemical, enzymatic, surgical