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 Classification  Partial 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