Wound Care Manual and Clinical Guidelines for Nurses
Published: 07 February 2019
Published: 07 February 2019
When faced with a complex instance of wound care, many first time or novice clinicians will ask, ‘What wound is this? What dressing should I use? How will this wound heal?’
An aspect of wound care management often overlooked is defining the wound itself.
The guiding principles of wound care have always been focused around defining the wound, identifying any associated factors that may influence the healing process, then selecting the appropriate wound dressing or treatment device to meet the aim and aid the healing process.
This structured approach is essential, as the most common error in wound care management is rushing in to select the latest and greatest new wound dressings without actually giving thought to wound aetiology, tissue type and immediate aim.
This overview of wounds and dressings will identify some of the most common wound types and guide you in setting your aim of care and selecting a product or device to achieve that aim.
The first thing to do before addressing any wound is to perform an overall assessment of the patient. An acronym used to guide this process, step by step, is H.E.I.D.I.:
So with this in mind and having completed a thorough overall assessment, the wound assessment can now be conducted.
Descriptors used to identify the tissue found in wounds are:
Once the types of tissue/s have been identified, the aim of treatment can be considered.
**Without a doubt, removal of necrotic tissue and management of infective tissue are two priorities in wound care.
Ideally the quickest (and often safest) way to remove necrotic tissue is to involve a surgeon who will then surgically debride the offending tissue.
If this is not possible, then a skilled clinician may be able to conservatively sharp debride the tissue to just above the viable base. If this is not possible then dressings known to aid autolytic debridement should be selected and used according to manufacturer’s instructions.
Infective tissue is best removed when possible by employing the same methods as above. Antibiotics need to be prescribed when the wound is causing systemic infection.
However, if the wound is locally infected or critically colonised, the clinician may choose to manage the infective tissue with debridement and topical antimicrobials (not topical antibiotics).
Another consideration if colonisation is of concern, is to use generalised body skin-antiseptic cleansers to reduce the possibility of bacteria colonising from one area to another.
Granulation tissue (firm, beefy red tissue) requires some exudate management and protection.
A dressing that maintains a minimally moist environment and protects the tissue, is generally required.
This soft, gelatinous, highly exuding tissue requires specific treatment. Some clinicians believe the use of silver nitrate (burning the tissue back) is the best option.
(It has been my experience that an approach to bacterial load, direct pressure and dressings that will manage moisture are more acceptable.)
The term used to describe pale, grey/brown/red granulation tissue.
The general approach is to use an antimicrobial and exudate-management dressing.
The pale, pink/mauve tissue usually found at the edges of wounds, healing by secondary intention, requires protection.
This tissue responds poorly to too much moisture and in most cases a dressing that protects this tissue from the effects of moisture is used. The use of barrier agents ensures this.
With the above information, it is now time to undertake wound care specific to the type of wound.
Most surgical wounds go on to heal in the normal pathway of:
Most surgery can be categorised into two groups: elective (‘clean‘) and emergency (this is often referred to as ‘dirty’).
A surgical wound of the latter category has a higher incidence of dehiscence or complications.
Dehiscence is defined as:
‘separation of the layers of a surgical wound, it may be partial or only superficial, or complete with separation of all layers and total disruption’ (Miller-Keane Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health 2003).
There are a number of well identified risk factors that can lead to wound dehiscence, including being overweight, increasing/advanced age, poor nutrition, diabetes, smoking and having had radiation therapy previously in the area.
The elective case has the opportunity to correct some of these risk factors, however the emergency case may not have such an opportunity.
The simple, straightforward suture line is generally treated with a dressing that will manage a small amount of anticipated, early inflammatory exudate and provide a waterproof covering.
All surgical wounds do require support and this is an important factor both for reducing oedema and ensuring patient comfort.
This type of dressing is generally left intact for five to seven days and then removed for inspection of the suture line, with the view to remove the staples or sutures as prescribed.
Suggested dressings to achieve the aims for simple suture lines include: Opsite™ and Mepore Pro™ .
Care of this simple suture line then involves continued support and hydration. For this, some surgeons prefer supportive adhesive flexible tape for ongoing scar hydration, such as Fixomull™ and Mefix™.
The dehisced surgical wound requires a thorough assessment of cavities or structures involved, as well as presence of foreign bodies, infection and/or necrotic tissue. Once these parameters have been considered, an aim can be set.
Removal of necrotic tissue and management of infection is paramount to move on to the wound healing phase.
Surgical debridement may leave large cavities or areas of raw tissue which can ideally be managed with a Topical Negative Pressure device. This wound care ‘vacuum cleaner’ will remove excess exudate and contain it in a canister, away from the wound surface.
Due to the negative pressure, the wound edges are drawn in, helping to promptly reduce wound surface. This also reduces oedema, an important aspect to consider in all instances of wound care.
These wounds are generally acute and in most circumstances go on to heal almost regardless of what is done. Simple abrasions in particular, if not managed by a health professional, form a scab which eventually will drop off, revealing a healed area beneath.
The issue here however, is that this type of healing is slow and can result in an unacceptable scar.
The best management of an abrasion is to stop the bleeding, give the area a good clean with an antiseptic and then apply a mesh dressing that will protect the superficial raw area and allow new tissue to form quickly without being damaged when the first dressing is attended.
Mesh dressings for this purpose include: Mepitel™, Urgotul™, or Hydrotul™.
The secondary dressing on this mesh is generally a light absorbent adhesive pad, such as Cutipast Sterile™ or Primapore™.
A secondary waterproof dressing is generally not recommended for this first dressing due to the risk of infection – the excessive heat and moisture will create an environment conducive to bacterial growth.
At the next dressing change, if there are no signs of infection, then a waterproof dressing can be used as the secondary dressing.
After a thorough assessment, a small, simple laceration is generally managed with antiseptic cleansing, Steristrips™ and either a waterproof, light, absorbent dressing or a non-waterproof, light, absorbent, adhesive dressing, using the principles mentioned earlier about risk of infection.
More complex lacerations may be referred to an acute care facility or surgeon after initial assessment.
Foreign bodies and penetrating, deep lacerations may involve tendons and nerves, which will require specific specialised care.
The post-surgical wound will then need to be well managed to avoid infection. An antimicrobial dressing that is also absorbent and protective would be ideal.
Dressing examples include: Aquacel Ag™ and Aquacel Foam™ non adhesive, Actiflex™ and Mesorb™, Atraumann Ag™, and Zetuvit™.
The dressings should be fixed in place with a firm crepe bandage and appropriately-sized tubigrip.
There are now six classifications of pressure injury.
Stages one through four are much the same as they have been in the past but with better descriptors. The two newly-added classifications are: unstageable and suspected deep tissue injury.
More information on pressure injury prevention and management can be found at the Wounds Australia website.
**It is a given that when managing pressure injury risk and actual damage, the pressure is relieved, and attention is given to nutritional requirements.
A stage one pressure injury is an intact area of damage, so protection of the tissue and providing an environment for recovery is the aim.
Adhesive foams can be employed if moisturising the area on each shift is not possible. Examples of adhesive foam include Mepilex Border™ and Allevyn Life™.
Stage two pressure injuries are relatively clean, superficial, partial-thickness injuries.
Once again, protection is important, however due to the break in the integument, the chosen dressing must also have some absorbent capabilities.
Adhesive foams are generally appropriate here, unless the wound is located very close to the anus, in which case a thick barrier cream is often used. Conveen Critic Barrier Cream™ is one appropriate example.
Stage three injuries involve damage through to the subcutaneous tissue, with the presence of slough and soft, tenacious necrotic tissue, which will require debridement.
Debridement can be as previously mentioned: managed by a surgeon, a skilled clinician or using dressings to aid autolytic processes.
Dressings that aid this autolysis include: Flaminal Hydro or Forte™, Prontosan Gel™, Mesalt™ and Iodosorb™ powder or ointment.
Whilst the autolytic process is taking place, the wound exudate will be higher in volume, so super absorbent pads will be required as the secondary dressing, for example Zetuvit Plus™.
Stage Four implies that the area of damage extends down through muscle and bone may be exposed or palpable.
These injuries are generally necrotic and malodourous. Managing odour becomes the priority.
Metronidazole Gel™ will typically reduce odour in a few days. TenderWet Active™ is a preloaded pack of Ringers’ Lactate, that slowly drips into the wound, aiding autolytic debridement, and can safely be used with Metronidazole Gel™.
If the patient is in otherwise good health, then surgery and Topical Negative Pressure devices would be used.
Although there are many types of leg ulcers, the most common are venous, followed by arterial, and then mixed venous arterial.
The classic signs and symptoms of each of these ulcer types can be found in the Australian and New Zealand Clinical Practice Guideline for Venous ulcer prevention and management.
Venous ulcers are located in the lower third of the lower-leg and generally are superficial and weeping.
The priority of care is managing the oedema and encouraging the epithelium to grow across the superficial break.
Zinc paste bandages and compression bandages are the mainstay of treatment to achieve these goals. The zinc paste bandages may include products like Viscopaste™ or Gelocast™ .
If the wound has been present for a considerable length of time, then some bacterial involvement is likely, and so an antimicrobial is suggested such as Iodosorb Powder™. This could then be combined with a super absorbent pad such as Zetuvit Plus™.
Compression therapy selection is too complex for such a short publication, as this must be tailored to the patient.
A safe and effective system from which to start however, is the use of straight, elasticated tubular bandages, for example Tubigrip™ or Tubular Form™.
These must be applied from toes to knee after selecting the appropriate size according to the manufacturers guide.
When it comes to managing arterial ulceration, a vascular surgeon is best to consult as ideally some surgery can be performed to restore perfusion to the limb. It then becomes the attending clinician’s role to prevent infection.
Generally the rule is: if the tissue is dry and ischaemic, then keep it dry. So Betadine™ lotion is used to achieve this and keep the eschar dry.
If the tissue in the arterial wound is offensive, infected or malodourous, then a silver or cadexomer iodine may be used, such as Aquacel Ag™ or Iodosorb™ ointment.
The assessment should include:
The actual aetiology of the wound may assist in making decisions regarding the propensity for healing.
For example, category 1 and 2 skin tears should heal within one month, whereas category 3 skin tears may take up to six weeks, depending on location.
If a skin tear is not healed within these time frames, then re-assessment of the whole wound and patient is required.
Consideration should also be given to the fact that the wound may have progressed beyond repair and manifested into something such as a skin cancer.
Pressure injuries may never heal if the patient is failing to consume adequate food and fluids to maintain body functions and assist tissue growth.
An additional complication could be underlying involvement of the bone (known as osteomyelitis) in deep pressure injuries.
If osteomyelitis is not managed appropriately by a qualified physician, it may result in serious sequelae and the possibility of the wound never healing.
Ulceration of lower legs is often complex as the diagnosis may not have been made.
Venous ulcers can heal with compression therapy, however conversely some arterial ulcers may deteriorate if compression is used.
Therefore having a knowledge of the characteristics of venous and arterial ulcers is imperative to ensure appropriate decision-making regarding management of these wounds.
Having reviewed how to appropriately assess wounds, you are now ready to consider factors influencing healing, which is an important aspect of wound care.
It is important to remember that healing may not be the final goal of care for all wounds, when underlying factors need to be addressed.
As there are many factors to consider when trying to manage a complex, slow-to-heal wound, the following factors are not an exhaustive list, and not necessarily presented in order of priority, however it is generally considered that nutrition is paramount in order to achieve healing.
Cellular growth is dependent on adequate intake of protein, vitamin C, zinc and iron.
There are other nutrients required that also play an important role, but these four are often considered vital.
The formula to calculate a normal protein intake for a healthy adult woman is 0.75g per kilogram of bodyweight per day, and 0.84g per kilogram of bodyweight per day for healthy adult men. However, when a chronic non-healing wound is present or the individual is pregnant, breastfeeding, or over the age of 70 years, it increases to approximately 1-2g per kilogram of bodyweight per day (National Health and Medical Research Council 2014).
The recommended dietary intake (RDI) of vitamin C for a normal healthy adult is 45mg per day, however in an individual with a chronic wound, this increases to approximately 100-200mg per day (National Health and Medical Research Council 2014).
Normal RDI of zinc is 8mg in healthy adult women, and 14mg per day for adult men. However, as with protein and vitamin C, this increases to an RDI of 15-25mg per day in individuals with a complex, slow-healing wound.
Iron intake is also necessary for wound healing. The RDI of iron is greater in women during the menstrual years, with 18mg per day advised to support healthy functioning. For women greater than 51 years of age, and all healthy adult men, the intake is recommended to be 8mg per day. To boost wound healing however, and in women who are pregnant, the RDI for iron can be as high as 30mg per day.
There is no doubt that a healthy, balanced diet of fresh fruit, vegetables, meat, fish and chicken is invaluable to keep the body functioning well.
Issues can arise in older adults who fail to fulfil the RDIs for the required nutrients, and this is when wounds in older adults may fail to heal due to lack of appropriate nutrients.
In these instances, supplementation may be required in order to provide these essential nutrients.
Additional factors that may influence healing include:
For a chronic wound to progress to the healing phase, health professionals must be able to clean the wound as thoroughly as possible without causing further pain to the patient.
The words ‘cleansing‘ and ‘debridement‘ are often used interchangeably, however they are two distinct terms to describe different management processes:
The application of a fluid that is then wiped across the wound area with gentle strokes to aid in the removal of any loose, unwanted product or agent.
The removal of dead or devitalised tissue, particulate matter, and foreign bodies from a wound bed. Debridement is generally accepted as a necessary precursor to the formation of new tissue.
There are many methods of wound debridement; some are readily accessible to the majority of clinical staff, however others require specialist training or application and may only be found in specialty clinics or acute care facilities.
The most common method of removing necrotic tissue from a wound is using the body’s own naturally occurring enzymes and fluid. This is referred to as autolysis. Moist wound therapy assists in this process, although some moist agents can increase the risk of maceration.
Wound care dressing products that assist in aiding autolytic debridement include:
Biological debridement uses specifically-bred larvae to phagocytose the necrotic tissue and aid in its removal. This process is not commonly used as patients are generally not comfortable with having maggots put on their wounds.
Chemical agents for debridement are no longer available in Australia. Whilst there are some being used overseas, none of these have yet been approved for use in Australia.
There are a few enzyme products available around the world but the only one currently available in Australia is ‘Flaminal’. This product is a mixture of calcium alginate and two naturally occurring enzymes found in saliva-lactose peroxidase and glucose oxidase.
Mechanical debridement can involve several different methods. Sharp surgical is the gold standard of mechanical debridement, and involves having a surgeon remove all of the necrotic tissue so that the vascular bleeding wound bed is exposed. Conservative sharp wound debridement is the next best option, and is usually carried out by a skilled clinician such as a wound consultant or podiatrist. Another mechanical method of debridement includes using a high pressure irrigation device, which literally blows off the necrotic tissue.
By performing excellent gentle wound cleansing and debridement, health professionals can assist with wound healing by removing any necrotic tissue which may be impacting the treatment goals.
Simple debridement that can be undertaken by all health professionals involves gentle circular movements over the wound with dry gauze, which may lift some debris.
Using forceps to gently scrape the tissue may also help lift debris off the wound.
Naturally, all of these aforementioned methods require a thorough assessment of the patient and their pain both during and after the dressing procedure.
When managing a complex, slow-healing wound, it is important to remember that there are occasions when wound debridement is not appropriate, and symptom control is more suitable.
For example, dry eschar does not always need to be removed – in some cases it acts as its own dressing.
Should the body decide to separate the eschar from the tissue below it, the eschar then usually provides a well-demarcated edge from which to work.
It is imperative to ensure that the correct dressing, and dressing regime, has been chosen to optimise wound healing.
When your assessment reveals that the wound is heavily soiled, necrotic tissue is present, and/or there is the potential of bacterial colonisation, then more regular dressings will be required.
In many cases, these heavily colonised wounds will require daily dressing changes.
If the decision has been made to change a dressing daily, then consideration on product choice becomes imperative as costs will rise unless less expensive dressings are selected.
Once the necrotic tissue has been removed and healthy granulation tissue is present, the aim dramatically changes to one of protection.
The goal here is to disturb the tissue as little as possible, in order to allow the body to heal itself.
Products chosen at this time can remain in situ for four to five days, or even as long as seven days, depending on the absorbent capacity and nature of the wound interface material.
Foam dressings are usually the best product to achieve these parameters.
One of the crucial aspects of a dressing regime is assessment and re-assessment.
Assessment at each dressing change involves looking for changes in tissue type and exudate volume and type, any reduction in odour, changes in wound size, and reduction of pain.
These will not occur simultaneously, so deciding which parameter to check each week will be left to the attending clinician. However, the most important signs to measure wound healing include improvements in tissue quality, and reduction of odour and exudate volume.
With continued best practice interventions, these signs indicate that the wound will most likely go on to heal.
In evaluating the effectiveness of a treatment regime, the health professional should be able to clearly state the wound type and what the treatment aims were.
Without establishing these factors, the aim/s and product selection are random and not based on best practice recommendations.
Wounds that generally do not heal unless surgical/medical intervention is possible include arterial ulcers, skin cancers and tumours, and wounds as a result of an autoimmune disorder.
Dressings play a less significant role in the management of these wounds, and healing is almost totally dependent on managing the overarching problem.
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Jan Rice is a Registered Nurse with many years of experience in surgical nursing. Jan is a member of the Venous Leg Ulcer Guideline Implementation sub-committee and the Pressure Injury Guidelines Development sub-committee. Jan obtained a Masters in Wound Care in 2009 and runs a wound clinic in a large Metropolitan General Practice — Ashwood Medical. Through her own business, Jan has been acting as a consultant to over 80 aged care facilities and a resource for Divisions of General Practice and surgeons within Victoria. Jan is an author of a book chapter on wound healing and has been a volunteer with Interplast since 1983. In 2006, she was awarded Fellowship to the Australian Wound Management Association.