Wound management

• Wound


  Normal skin structure is broken or destroyed, with varied severity & depth
• Gauze, lint, & cotton wool been used for centuries, but there have been significant advances in wound management in the last 2 decades
• The human cost of wounds includes pain, suffering, loss of dignity and loss of earnings
• Wound healing

  Involves proliferation, migration and biosynthetic activity of many different cell types: platelets, fibroblasts, white blood cells
• Cytokines


  Control the time course and extent of activity in the wound healing process
• Normal wound healing


  1. Hemostasis

  2. Inflammation

  3. Proliferation

  4. Remodeling/maturation
• Hemostasis


  • Vasoconstriction: Constrict the flow of blood to the damaged area
  • Platelet aggregation: repair vessel damage by clotting - activating coagulation cascade
  • Coagulation cascade (fibrin formation/thrombus): Stabilise platelet plug
• Inflammation


  • Neutrophil infiltration & monocyte differentiation into macrophages
  • Lymphocyte infiltration
  • Clot formation & inflammation - Swelling, heat, pain, redness - 4-6 days problematic if extended
  • Intended to cleanse the wound from pathogens & foreign bodies & prevent infection - macrophages & white blood cells
• Proliferation


  • Dermal repair & epidermal regeneration to close wound surface re-epithelialization; angiogenesis
  • Fibroblasts produce collagen (III) & other matrix components-collagen synthesis & extracellular matrix formation
  • Granulation tissue: granular appearance (red/pink) - if dark/bleeds easily - possible infection
• Remodeling/maturation


  • Scar formation & wound strengthening
  • Vascular maturations & regression
  • Collagen remodelling: Collagen in proliferative phase is converted to collagen I→ stiffer & makes wound stronger
  • 21 days after the first wound forming and only 80% of original strength regained.
  • Fibroblasts removed by apoptosis
• A wound is not healed unless it is red and clean
• Patient-related (intrinsic) factors leading to delayed healing

  • Age
  • Concurrent disease
  • Smoking
  • Pharmacological agents
  • Nutrition
• Wound-related (extrinsic) factors leading to delayed healing

  • Moisture
  • temp
  • Oxygenation
  • pH
  • Infection
  • contamination or irritant
• Partial thickness wound


  Epidermis + part of dermis
• Full thickness wound


  Epidermis + dermis & possibly subcutaneous tissue, muscle
• Types of acute wounds

  • Bite
  • Burn
  • Puncture
  • Incision
  • Laceration
  • Abrasion
• Types of chronic wounds

  • Pressure ulcers
  • Leg ulcers
  • Diabetic foot ulcers
  • Fungating malignant wounds
• Appearance of wounds


  • Pink: Epithelialisation
  • Red: Granulation
  • Yellow: Devitalised tissue (slough)
  • Green: (infected)
  • Black: necrotic (eschar)
• Management of traumatic wounds

  1. Assess the casualty

  2. Address the wound

  3. Consider the accident & underlying issues
• Traumatic wounds


  • Body is subject to a force which exceeds strength of skin or underlying tissue
• Zones of a burn injury

  • Zone of Coagulation
  • Zone of Stasis
  • Zone of Hyperaemia
• Total burn surface area (TBSA)


  Extent of a burn injury expressed as depth & total burn surface area calculated as % of body surface area
• Initial burn management


  1. Immerse in cold running water for at least 20 min

  2. Elevate injured limbs, esp hands

  3. Remove any jewellery or clothing, unless stuck to the burn, before the area begins to swell

  4. Wrap patient in blanket to prevent hypothermia & shock

  5. Cover the area loosely with cling film, lengthways
• Blisters


  Small painless blisters should be left intact, large/problematic blisters should be de-roofed by a healthcare professional
• Classification of surgical wounds

  • Clean
  • Clean/Contaminated
  • Contaminated
  • Dirty
• Pre- and intra-operative care

  1. Identify risk (e.g. MRSA screening)

  2. Patient shower prior to surgery

  3. Disinfect skin before incision, aseptic technique during surgery

  4. Antibiotic prophylaxis
• Surgical wound care


  1. Aseptic, no-touch technique for changing dressings

  2. Minimum frequency of dressing changes - 1st at 48 hr unless clear signs of complications

  3. Sterile saline for wound cleansing

  4. If surgical site infection suspected, intervention & release of pus a priority
• Properties of an ideal postoperative dressing

  • Effective waterproof barrier to bacterial contamination
  • Allows gaseous exchange
  • Allows monitoring of wound & peri-wound skin
  • Adherence for easy, atraumatic removal
• Wounds healing well are usually left exposed a few days after surgery, and showering is generally okay 48 hours after surgery, but avoid bathing if a surgical drain is in place
• Removal of stitches/staples depends on the area of the body, usually 7-14 days after surgery, and is usually done in primary care by a GP or practice nurse
• Chronic wound


  A wound in which the normal process of healing is disrupted during one or more of the phases previously described
• Causes of chronic wounds

  • Alterations in amounts of growth factors, cytokines, proteases
  • Oxidative damage by free radicals
  • Condition-specific factors e.g. neuropathy in diabetes, ischaemia in peripheral vascular disease
  • Accumulation of necrotic tissue or slough - bacterial biofilm protected from immune system & systemic/topical antibiotics
  • Infection
• Pressure ulcers

  Localized areas of tissue damage from sustained mechanical loading (> 32 mmHg) of the skin & its underlying structures
• Pressure ulcer risk assessment

  Within 6 hours of admission, in community setting as part of district nurse's first visit
• Leg ulcers


  An area of loss of skin below the knee on leg/foot which takes >6 weeks to heal, usually due to vascular causes
• Venous leg ulcers


  • Shallow with irregular edges & extend almost around circumference of the leg
• Management of venous leg ulcers

  1. Provide optimum wound environment allowing reduction of venous hypertension

  2. Graduated compression to reverse changes in the skin

  3. Avoid topical applications as much as possible due to risk of venous eczema
• Diabetic foot ulcers


  Predisposed to physical trauma & foot ulceration due to a combination of peripheral neuropathy & vascular insufficiency
• Diabetic foot ulcer management

  Metabolic control, debridement, reduction of pressure, management of infection, dressing selection, patient education
• Fungating malignant wounds


  Cancerous infiltration of the skin, with a process of both ulcerating & proliferative growth