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The Fundamentals of Wound Care and Dressing

Selection
Shannon S. Polson, MSN, MSW, RN, LCSW, PIP, CNL,
CWCN, CFCN
 Wound Assessment

You must document all wounds on admission (8

hours-NPUAP)
Assessment from head to toe
Remove any devices or dressings that are
obscuring the wound.
When checking for blanching, finger method, 3
seconds.
http://www.npuap.org/wp-
content/uploads/2014/08/Quick-Reference-
Guide-DIGITAL-NPUAP-EPUAP-PPPIA-
Wound Measurement

Length
Width
Depth
Tunneling
Undermining
 Tunneling
These are tunneled shafts that
run out away from the wound.

Undermining
The erosion caused by shear and
friction leaves a shelf.
Wound Documentation
Location
Color
Measurements
Tunneling or undermining
Status of the wound bed, surrounding skin and
wound edges
Drainage
Odor
Pain
The Functions of the Skin

This organ provides:

Sensation
Thermal Regulation
Metabolic function (Cholecalciferol D3)
Communication
Protection
Skin Immune Function

As a barrier layer there are a variety of defenses

found:
Outer acid mantle
Langerhans cells
Macrophages
Mast cells
Dendrocytes
Anatomy of the Skin - Epidermis
Epidermis
Stratum corneum
Age, disease
Stratum lucidum
Found in thicker areas only
Stratum granulosum
Active nuclei, hydration (UV filter)
Stratum spinosum
Desmosome density
Stratum Germinativum (Basale)
Rete ridges/pegs
Anatomy of the Skin BMZ & Dermis

Basement Membrane Zone

Dermal/epidermal Junction , blister formation
Dermis
Papillary Dermis
Dermal papillae
Reticular Dermis
Anatomy of the Skin -Hypodermis

Hypodermis (Subcutaneous)
Adipose
Loose connective tissue
Fascia
Lymphatic vessels
Keys to Successful Wound Healing

Proper classification of the wound

Knowledge of the normal stages of the wound
healing process based on type of wound
Proper identification of the physiological stage of
the wound at time of treatment
Understanding of appropriate time frame for
each stage in order to gauge delays in wound
healing process
Wound Healing

Factors involved in wound healing

How
Regeneration

Scar formation

Primary, Secondary, Tertiary

Wound Healing

Partial Thickness
Full Thickness
Acute
Chronic
Proper Wound Bed
Environment: Moist
Principles of Moist Wound Healing
Debride necrotic tissue
Identify and treat infection
Wick exudate from tunnels and undermined
wound areas
Absorb excess exudate
Maintain a moist wound surface
Open the wound edges
Protect from trauma or infection
Insulate the wound
Systemic Factors that Affect Wound Healing

Nutrition
Weight, lab values, absence of granulation tissue?
Calorie intake vs calorie needs
Vit C, zinc, multivitamin
Hyperglycemia
Steroids
>40 mg/day
May benefit from Vitamin A
 Physiology of Partial Thickness
Wound Healing

Inflammatory response
Typically less than 24 hrs
Proliferation of epithelial tissue
If dermal tissue is lost it coincides- fluid layer
separates the two until the fibroblasts finish and the
connective tissue grows upward.
MMPs and growth factors regulate
Migration (resurfacing)
Epithelial layers reestablish
Partial Thickness Wound
Full Thickness Wound

Loss of epidermal and dermal layers

Can come from bottom up as well as top down
Subcutaneous, muscle, bones, fascia could be
exposed
Granulation (Scar formation)
Physiology of Full Thickness Wound Healing

Inflammatory Stage
Proliferation
Maturation remodeling

Acute vs Chronic
 Physiology of Full Thickness
Wound Healing

Inflammatory stage
1-4 days (3 days average)
Hemostasis
Vasoconstricton- clotting pathways initiated
Clotting causes the degradation of platelets that further signal
fibrin to aggregate and release fuel stores.
Natural wound cleansing
The influx of neutrophils, macrophages and fibroblasts begin to
clean the wound bed.
 Physiology of Full Thickness
Wound Healing
Complications of Prolonged inflammation:
Wound Dehiscence
Presence of infection
Hypertrophic scarring
Factors affecting prolonged inflammation
Tissue that is devitalized
Bacteria
Hyperglycemia/diabetes
Imbalance of wound bed enzymes and cytokines
 Physiology of Full Thickness
Wound Healing
Proliferation stage
Epithelialization
2-3 days
In open wound delayed until formation of healthy
granulation bed
Granulation
Neoangiogenesis
Formation of ECM by fibroblasts
Peaks day 5-15, healing ridge day 5-9 post-op
Contraction if wound edges are open
Not always ideal due to loss of mobility
 Physiology of Full Thickness
Wound Healing

Possible complications to stall proliferation stage

Not adequate nutrition and materials for the fibroblast
Cytotoxic environment
Infection
Mechanical removal
Does pressure need to reduce?
 Physiology of Full Thickness
Wound Healing
Maturation/Remodeling
New wound will never regain full tissue strength.
Synthesis of new collagen
Lysis of current collagen
Hypertrophic raised
Keloid- grows beyond wound
Process adds strength
20%3 weeks
80% 3 months
Reduces area
Full Thickness Wound
 Refractory Complications Chronic Full
Thickness Wounds

Inflammatory Phase
There is a stall or breakdown in the process:
Become stagnant or impeded
No bleeding
No hemostasis
No release of growth factors
Infection
Need debridement
Difference in wound fluid more inflammatory
 Refractory Complications Chronic Full
Thickness Wounds
Proliferative Phase
Same failure to progress but with granulation, the
failure could be with granulation or epithelialization.
Raw ingredients missing
Nutrition
Perfusion
Not enough scaffolding
Too wide an area for successful epithelialization
graft
Must have open wound edges
 Refractory Complications Chronic Full
Thickness Wounds

Maturation Phase
Location of wound
Pressure on wound
Repetitive injury
Loss of sensation
Eschar
Natures Dressing

If stable you may not

debride it. Paint with
betadine
Is there infection or
erythema?
Is healing
compromised in the
patient?
 Wound Culture- Levine Technique

Normal Flora on the skin will contaminate the

culture
Flush with Normal Saline (NS)
Viable tissue- find 1 square cm
Moisten Swab should be pre-moistened with
NS before applied to area
Use force to produce exudate when swabbing
area of viable tissue
Place culture in tube and send to lab
 Simplifying Dressing Selection Using Classification

Deep versus Shallow

>0.5cm is deep
Dry versus Wet
You dont need a lot of product options on hand
to manage wounds but it is recommended to
have one or two solid options for each of the four
categories.
Shallow and Dry
Deep Dry
Dressings that are Versatile

Collagens
Composites
Impregnated dressings
Wound fillers
Dressings for Dry Wounds

Filler Dressing:
Hydrocolloids
Hydrogels: amorphous

Non-adherent contact layer

Follow with Cover Dressing

Shallow and Wet Wound
Deep and Wet Wound
Dressings for Chronic Wounds

Filler Dressing
Medical grade honey
Collagens
Dressings for Wet Wounds

Filler dressings
Absorptives
Alginates
Foam Dressings
Wound fillers such as Gold Dust
Nonwoven gauze preferred

Follow with a cover dressing

Types of Dressings A-Z

Absorptives
Alginates
Antimicrobial
Collagens
Composites
Contact layers
Elastic Bandages
Foam Dressings
Dressings

Gauzes and non woven gauzes

Hydrocolloids
Hydrogels- amorphous, impregnated, sheets
Impregnated dressings
Medical grade honey
Silicone gel sheets
Transparent films
Wound Fillers
 References

Bryant, R. A., & Nix, D. P. (2012). Acute and

chronic wounds: Current management
concepts. St Louis, MO :Elsevier Mosby.
Emory University WOCNEC (2012). Skin and
wound module. Atlanta, GA :Emory University.