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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
ClassificationPartial 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