Wound Care Management

Acknowledgements: S. Thomson, E Wasserman and A Whitelaw for use of the Wound Care Management Guidelines Booklet 2012.

Patient assessment
Wound assessment
The ideal dressing
Frequency of dressing changes
Traditional wound healing methods
Classification and correct use of wound pharmaceuticals
Combinations/other
Clinically infected wounds
Malignant wounds

Wound management has undergone great change over the years. Many principles that were regularly practised for decades have been challenged and changed by medical research. Despite the confusion, a few principles need to be applied - the most basic one being the maintenance of a warm, moist wound healing environment to promote wound autolysis, fibroblastic activity, and the resultant formation of granulation and epithelialisation tissue. All modern wound management practice is centred around this basic fundamental.

Patient assessment

It is imperative before any specific wound regimen is considered, that a thorough patient assessment occurs. There are many factors that interfere with the wound healing process and these need to be identified and addressed at the first instance by a multi-disciplinary team. Examples of detrimental factors that can be altered are nutritional status, presence of systemic or local infection, sleep and stress levels, smoking, uncontrolled diabetes, anaemia and iatrogenic factors such as steroidal therapy. Factors that cannot be changed such as age and underlying medical condition need to be compensated for.

Wound assessment

The wound needs to be thoroughly assessed initially and at each dressing change and the following objective and subjective data recorded:

•  Location of the wound
•  Aetiology
•  Wound dimensions
•  Amount/ Colour/ Consistency/ Odour of wound exudate
•  Condition of surrounding skin
•  Pain levels
•  Colour of wound bed/ Stage of wound healing
•  Treatment objectives
•  Current treatment regimen

Recording such details on a designated chart is an efficient way of documenting wound management practice.

Some form of peripheral wound assessment should be performed and documented daily by recording on a chart. Dressings should not be removed for this purpose, but the chart should be thoroughly completed at each dressing change. Treatment objectives are likely to change as the wound progresses through the stages of wound healing.

The ideal dressing

After the wound has been thoroughly assessed, the GSH Wound Management Protocol will assist in determining a dressing regimen. The ideal dressing could take many forms, but the following elements will be consistently present:

Removal of excess exudate

Wound exudate is not harmful as it contains vital cells for wound autolysis and regeneration. If excess exudate is not absorbed by the dressing in place, however, maceration of surrounding healthy tissue can result which could lead to further tissue breakdown.

Maintenance of a moist wound environment

A moist wound interface is essential to facilitate wound autolysis and fibroblast proliferation (Winter,1962: Dyson,1988). Traditional dressings used in the management of wounds, e.g. gauze dressings; often allow the wound to dry out and cause trauma to granulation tissue on removal, delaying healing time.

Provision of a barrier to pathogens

Strike-through is the term used to describe the situation where wound exudate leaks through to the outside of a secondary dressing. If this occurs, pathogens have a direct pathway through this wet dressing, onto the wound surface, even though the dressing remains intact (Dealey,1994; Hallet & Hampton,1999). In this situation, the dressing must be replaced immediately. Modern wound products absorb such exudate more effectively and delay such an occurrence, although it can still occur.

Provision of thermal insulation

An optimal wound healing temperature is 37.5 degrees Celsius. If the temperature drops below 35 degrees or exceeds 40 degrees, mitotic activity is delayed for up to four hours (Torrance,1986; Myers, 1982;). Modern wound products are designed to be left intact for as long as possible to maintain this optimal temperature. Every time a dressing is changed, the temperature of the wound is markedly decreased. This is perpetuated by cold lotions being applied during the cleansing process. For this reason, it is recommended that normal saline be warmed prior to application.

Protection from mechanical trauma

Newly formed granulation tissue is very fragile. Dressings or dressing techniques which traumatise the wound can cause destruction of this precious tissue. All modern wound products you will encounter are non adherent to prevent such an occurrence. Traditional cleansing methods involving the wiping of the wound surface with cotton wool or gauze also cause such trauma, and hence, should be avoided. Irrigating a wound with a syringe filled with warmed normal saline is the preferred method.

Avoidance of fibres or toxic substances

Fibres in a wound from cotton wool, gauze, or similar products, interfere with the wound healing process. In effect, such fibres act as foreign bodies. To this end, cotton wool should not be used for wound cleansing or drying. Wounds do not have to be dried, as a moist environment is optimal. Surrounding skin can be dried with gauze squares. Many studies have identified skin disinfectants (antiseptics) to be toxic to fibroblasts, and thus an inhibiting factor to granulation tissue formation (Leaper,1988; Goldheim, 1993; Flanagan, 1997; Ferguson, 1993) Antiseptics have no place in the treatment of clean granulating wounds. Dressing products impregnated with an antiseptic or antibiotic can be considered to have the same negative effect on wound healing.

Cost Effectiveness

The continual need for economic rationalisation is an on-going concern for all health professionals. New generation wound products are often condemned for their perceived expense. There is a need for one to think laterally in this regard to discover that these products, when used correctly, have the potential to save the health budget a great deal of expense. Two of the main features of these products is that they increase the rate of wound healing, and need to be replaced infrequently. One of the most expensive commodities on any unit is nursing time. 

A dressing that is changed 1-2 times a week, as opposed to daily or twice daily, saves the unit a great deal of expenditure on nursing time and disposable dressing products such as dressing packs, saline etc. In addition, a faster healing rate results in a reduced length of stay which also results in savings. A comparative costing audit will provide objective data to support the cost effectiveness of new generation products.

Hypoallergenicity

The ideal dressing is hypoallergenic. Most new generation wound products will claim to have this property but one needs to be aware that it is impossible to predict this with all patients.

Ease of use, adaptability, comfort

It is essential that the dressing in place has these qualities in order to be accepted by patients and colleagues. Many products are available specifically for use around difficult body parts. Time spent in choosing appropriate products will increase the longevity of the product as it will be less likely to peel off prematurely.

Frequency of dressing changes

Standard daily dressing changes are contraindicated with new generation dressing products unless the wound is infected. These dressings are designed to be left in situ until leakage or strike through occurs, which could be up to five to seven days.

Traditional would healing methods

Traditional wound healing practices involving the use of dry dressings are no longer advocated for use on granulating wounds as they do not create a moist wound environment which has been identified as an essential factor in the promotion of wound healing. The traditional gauze dressing also has the potential to dehydrate the wound surface and to traumatise granulation tissue on removal. 

Many other traditional wound healing theories exist including exposing the wound to air and sunlight, and allowing scab formation to occur. The former practice results in the wound cooling down and drying out which will impair fibroblast proliferation and the formation of granulation tissue. Pathogens may also enter the wound at this time which could be potentially harmful. The practice of allowing eschar to form on the wound surface impairs the wound healing process as this acts as a barrier to migrating epithelial cells. The application of a dressing which promotes a moist wound healing environment will prohibit the formation of eschar. 

If an eschar is present on a wound surface, it must be removed. Mechanical debridement is the most effective way of achieving this, although the application of a hydrogel will rehydrate the eschar, causing it to become softer and able to be easily lifted off with forceps. Hydrocolloids also have debriding properties.

Classification and correct use o wound pharmaceuticals

This section will provide a brief outline of the properties, correct use of, indications and contraindications of some of the major generic categories of new generation wound dressings. All of these dressings promote thermal insulation and a moist wound healing environment.

GENERIC DRESSING TYPES

•  Semi-permeable films
•  Hydrogels
•  Foams
•  Hydrocolloids
•  Alginates
•  Vacuum Assisted Closure
•  Combinations

GENERAL PRINCIPLES OF DRESSING SELECTION

•  Consider / moderate causative factors
•  No single dressing is appropriate for all stages of wound healing
•  Selection- take into account
  • causative factors
  • presence of infection
  • cost
  • patient acceptability
  • ease of use

Combinations/Other

The above section has provided an overview of the main generic dressing types. Obviously many more exist on the market alongside combinations of different groups. Refer to product guidelines in Wound Management Reference Folder in unit areas for more specific product descriptions.

Clinically infected wounds 

Once an infection is established in a wound, very specific wound management follows. Such a diagnosis should ideally be substantiated by a microbiology report on a wound swab. (NB: When taking a wound swab, it is essential that the wound be irrigated with normal saline prior to the swab being taken.) If a wound shows clinical signs of infection, and the patient is systemically unwell, the Western Cape Antibiotic Recommendations booklet will guide the choice of empiric systemic antibiotics. 

When culture and sensitivity results become available any appropriate changes should be made. Topical antibiotic application is controversial in most instances, as such substances may interfere with the wound healing process. Topical antiseptics are not recommended in most instances as they can be rapidly deactivated in the presence of wound exudate. Application of silver sulphadiaside cream is advocated, however, in limited situations, such as in the presence of pseudomonas, as it has sustained release properties. 

Alongside the systemic administration of specific antibiotics, daily saline irrigation and dressing changes are required in the treatment of infected wounds. This is the only instance in the utilisation of new generation wound care products where the frequency of dressing changes can be pre-determined. This is also the one scenario where the application of traditional gauze dressings is a cost effective option due to the frequency of dressing changes.

A diet high in protein, or protein supplements should be ensured (as in all situations where tissue repair is required).

Malignant wounds 

Due to their underlying aetiology, these wounds are unlikely to heal. Hence, the following recommended guidelines for treatment can differ markedly from non-malignant wounds. More information can be obtained from the Radiotherapy Department (at GSH, Sr. Grehan bleep 1044)

If the wound appears clean, Vaseline scraped (use a limited amount) onto gauze is applied daily. Wounds are cleaned with saline when necessary using an irrigation method. If slough is present, substitute ichthammol ointment (spread thinly over gauze) for Vaseline.

Fungating wounds are rinsed with normal saline and an ichthammol ointment dressing is applied. Acriflavine can be substituted if ichthammol induces pain. Large amounts of exudate are contained by using incontinence pads or nappies held in place with elastomesh.

Malodorous malignant wounds are irrigated with hydrogen peroxide and rinsed with sodium bicarbonate in water (deodorising effect). Ichthammol ointment or glycerine and ichthammol lotion is then applied sparingly. Metronidazole powder can be used in conjunction with this treatment. This regime is recommended for a period of 3-4 days only. Residual odour can be eliminated with application of eucalyptus oil on clothing or outer dressing.

Povidone iodine products are not recommended for use on malignant wounds.

References

• Cherry, G.W., Ryan, T.J. (1985) Enhanced wound angiogenesis with a new hydrocolloid dressing. Royal Society of Medicine International Congress and Symposium Series; 88: 5-14
• Collier, M. (1997) Know How: a guide to vacuum-assisted closure. Nursing Times (supplement); Jan 1997
• Dealey, C. (1994) The Care of Wounds. Oxford: Blackwell Science.
• Dyson, M. et al (1988) Comparison of the effects of moist and dry conditions on dermal repair. Journal of Investigative Dermatology; 91 (5) 435- 439
• Ferguson, A. (1993) Wound Infection: the role of antiseptics. Accident and Emergency Nursing; 1: 79-86
• Flanagan, M. (1997) Wound Management. Edinburgh: Churchill Livingstone.
• Hallet, A., Hampton, S. (1999) Huntington: Wound Care Society.
• Hutchinson, J. McGuckin, M. (1990) Occlusive Dressings: A microbiologic and clinical review. American Journal of Infection Control; 18 (4): 257-268
• Leaper, D. (1988) Antiseptic toxicity in open wounds. Nursing Times; 84: (25)77-79
• Miller, M. Glover, D. (1999) Wound Management theory and practice Nursing Times Books; London
• Myers, J.A.. (1982) Wound Healing and the use of a modern surgical dressing. Pharmaceutical Journal; 2 103-4
• Thomas, S. (1990) Wound Management and Dressings. Pharmaceutical Press, London
• Torrance, C. (1986) The physiology of wound healing. Nursing; 5: 162-166 
• Winter, G.D. (1962) Formation of the scab and rate of epithelialisation of superficial wounds in the skin of a young domestic pig. Nature; 193: 293- 294