Wound care: An overview
Anbarasi. N
Senior Nursing Educator, Kauvery Hospital, Alwarpet, Chennai
Wound
Break in skin or mucous membranes. Injury to any of the tissues of the body, especially that caused by physical means and with interruption of continuity is defined as a wound.
Skin Anatomy
Classification of wounds
- Intentional Vs. Unintentional.
- Open Vs. Closed.
- Degree of contamination.
- Depth of the of wounds
Classification of wounds
- Intentional vs. Unintentional wounds Intentional wound: occur during therapy. For example: operation or venipuncture.
- Unintentional wound: Occur accidentally. Example: Fracture in arm in road traffic accident
Open vs. Closed wound
- Open wound: the mucous membrane or skin surface is broken.
- Closed wound: the tissue is traumatized without a break in the skin.
Classification of wounds
- Degree of contamination Clean wounds: are uninfected wounds in which minimal inflammation exist, are primarily closed wounds.
- Clean –contaminated wound: are surgical wounds in which the respiratory, alimentary, genital, or urinary tract has been entered. There is no evidence of infection.
Degree of contamination Contaminated wounds: include open, fresh, accidental wounds. There is evidence of inflammation. Dirty or infected wounds: includes old, accidental wounds containing dead tissue and evidence of infection such as pus drainage.
Depth of the wound
- Partial thickness: the wound involves dermis and epidermis.
- Full thickness: involving the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone.
Types of wounds
- Incision: open wound, painful, deep or shallow, due to sharp instrument.
- Contusion: closed wound, skin appears ecchymosis because of damaged blood vessels, due to blow from blunt instrument.
Classification of wounds
Types of wounds
- Abrasion: open wound involving skin only, painful, due to surface scrape.
Puncture: open wound, penetrating of the skin and often the underlying tissues by a sharp instrument.
Assessment and Documentation
- Location
- Stage and Size
- Periwound
- Undermining
- Tunneling
- Exudate
- Color of wound bed
- Necrotic Tissue
- Granulation Tissue
- Effectiveness of Treatment
- This is a list of your basic criteria for assessment and documentation.
- It is important to note the effectiveness of the treatment. If the current treatment is not effective, then it needs to be revised.
Complications of wound healing
- Hemorrhage: some escape of blood from a wound is normal, but persistent bleeding is abnormal.
- Hematoma: localized collection of blood underneath the skin, and may appear as a reddish blue swelling.
Infection
Wound Treatment must focus on
- Greater patient satisfaction
- Trust
- Better adherence to treatment
- Improved emotional health
- Symptom resolving
- Better pain control
When might advance wound care be needed?
- Chronic wounds like diabetic foot ulcers, pressure ulcers, venous leg ulcers
- Large or deep wounds with poor blood supply
- Radiation-induced wounds
Surgical wounds with complications
Advanced wound care treatments include: all aimed at promoting healing in chronic or complex wounds that may not heal properly with standard care methods.
- Advanced wound care treatments include:
- Negative pressure wound therapy (NPWT), hyperbaric oxygen therapy (HBOT),
- Debridement,
- Compression therapy,
- Bioengineered skin substitutes,
- Growth factor therapy,
- Topical oxygen therapy,
- Platelet-rich plasma (PRP),
- Specialized dressings like collagen matrices or cellular matrices
Key points about advanced wound care treatments
- Negative pressure wound therapy (NPWT):
- Uses a vacuum dressing to draw out excess fluid from a wound, promoting blood flow and tissue granulation.
- Hyperbaric oxygen therapy (HBOT):
- Exposes the body to high concentrations of oxygen in a pressurized chamber, enhancing tissue oxygenation and healing.
- Debridement:
- Surgical removal of dead or necrotic tissue from a wound to facilitate healing.
- Compression therapy:
- Applies pressure to a wound area to improve blood flow and reduce swelling, often used for venous ulcers.
- Bioengineered skin substitutes:
- Artificial skin grafts made from cells or collagen matrices to replace damaged tissue.
- Growth factor therapy:
- Applying growth factors topically to stimulate cell proliferation and wound healing.
- Topical oxygen therapy:
- Using oxygen-releasing products to increase oxygen levels at the wound site.
- Platelet-rich plasma (PRP):
- Injecting concentrated platelets from the patient’s blood to promote tissue regeneration.
Wound Dressing
The material which is applied to the surface of the wound to cover it is called a dressing.
- 1ry – dressing which touches the wound
- 2ry – dressing used to cover the primary dressing
Types of wound dressings
- Gauze dressings
- Tulle
- Hydrocolloid dressings
- Hydrogel dressings
- Foam dressings
- Transparent film dressings etc..
Gauze
- Cheap
- Freely available
- Dry
- Painful on removing
- Damage epithelium
Ideal wound dressing
Dressings are applied to wounds for the following reasons
- To provide a protective cover
- To maintain moisture
- To reduce pain
- To absorb exudates
In addition, an ideal dressing has the following features:
- Does not induce pain or itching
- Easy to change
- Allows gaseous exchange
- Cheap
- Freely available
Wound Dressing:
- Cheap
- Freely available
- Easy removal (E.g) Vaseline
Hydrogel Dressings:
- Made up of primarily water in a polymer to maintain moist wound base
- Used in dry wounds
- Should not be used in exudating wounds.
Silver dressings
Antimicrobial to reduce bio burden of wound through slow release of silver ion into the wound
E.g.: Acticoat, Biatin Ag, Atruman Ag
Diagnosis
Impaired Skin Integrity Impaired Tissue Integrity
- Risk for Infection
- Pain Imbalanced Nutrition, Less than body requirements
- Overall strategy and scope of the treatment plan
- Depends on patient’s condition
- Reversibility of the wound.
- identify the likelihood of the wound healing and the benefits of pursuing a specific treatment plan.
- Document all factors that may affect healing.
- Keep in mind that under ideal circumstances a wound needs at least 2 to 4 weeks to show evidence of healing.
In many terminally ill patients we do not expect a wound to heal, so aggressive intervention may not be appropriate
Risk Assessment Alterations in mobility Level of incontinence
- Nutritional status
- Alteration in sensation or response to discomfort
- Co-morbid conditions
- Medications that delay healing
- Decreased blood flow to lower extremities when ulceration is present
- The assessment should include the patient’s skin condition, as well as those conditions which increase the risk for skin breakdown and influence the potential for wound healing.
- Alterations in the patient’s mobility
- The patient’s level of incontinence and nutritional status
- If there is any alteration in sensation or response to discomfort
- These conditions will influence the patient’s propensity for skin breakdown and also the potential for healing.
Nursing Intervention
- Wound care nursing interventions include assessing the wound, cleaning it, applying dressings, and providing nutrition.
- The goal of wound care is to create a healing environment that promotes the growth of new tissue and prevents infection.
- Wound assessment
Identify the wound: Note the type of wound, its size, and the condition of the surrounding tissue
Consider internal and external factors: These include age, blood supply, nutritional status, and lifestyle factors like smoking
Take a history: Learn about the patient’s overall health and any underlying conditions
Wound cleaning
Wash hands: Wash your hands before touching the wound
Clean the wound: Use a soft cloth with water, saline, or pH neutral soap to remove debris and exudate
Debride: Remove any damaged skin, blisters, or loose tissue, Wound dressing
Apply a dressing: Use a sterile dressing to protect the wound and promote healing
Consider the type of dressing: Fabric tape, tape, tubular bandages, and bandages can all be used
Nutrition
Assess nutritional status: Work with a dietitian to create a nutritional plan that includes supplements if needed
Ensure hydration: Hydration is important for wound healing Wound closure
Use sutures, staples: These can be used to close lacerations and surgical wounds
