Wound Care

Passive irrigation

Passive irrigation is a method that involves a solution and gravity. The solution is introduced in a top-to-bottom fashion to allow it to flow by gravity along the full length of the wound to the absorbent pad beneath the patient. This allows micro-organisms, tissues, and any unwanted materials to run down and away from the wound gradually for better overall wound cleansing. Top-to-bottom irrigation can sometimes eliminate the need for mechanical cleansing with a gauze pad.

What are the different methods available for debriding a wound?

Types of debridement include mechanical, enzymatic or chemical, sharp, autolytic, and biosurgical. Mechanical debridement is achieved with the use of outside force to remove dead tissue (wet-to-dry gauze dressings, irrigation, whirlpool baths). Enzymatic or chemical debridement involves applying an enzyme to the surface of the skin to digest the necrotic (dead) tissue. Sharp debridement can be performed with the use of instruments such as a scalpel or scissors. Autolytic debridement uses the body's own mechanisms to remove dead tissue. It is achieved by applying a dressing that will trap moisture beneath it, thus accelerating the autolytic healing process. Biosurgical debridement involves the use of maggots to break down and ingest infected and necrotic tissue. Although controversial, biosurgical debridement has been shown to be safe, effective, and cost-effective.

How does ultrasound therapy affect wound healing?

Ultrasound therapy is believed to accelerate the healing process by stimulating cell activity. It is thought to be most effective when initiated early during the inflammatory phase of wound healing. Ultrasound therapy also helps relieve pain and edema during wound healing. It has been found to be effective in increasing the rate of resolution of bruises and in exerting bactericidal effects.

Melanoma ABC

Asymmetry Boders Color Diameter

Intrinsic factors that affect wound healing

Age plays a major role in wound healing. The major cell functions essential for the various phases of wound healing diminish with age. The epidermis thins, making it more prone to injury. The increased incidence of chronic illnesses as people age also contributes to poor wound healing. Most body cells perform better in an oxygen-rich environment, so it is always vital that the patient's environment promotes good oxygenation. Patients with suppressed immune systems have increased difficulty performing the cell functions needed for wound healing. Skin that has reduced sensation is also prone to injury and poor wound healing, as the patient is often unaware that an injury has occurred. These injuries are also difficult to repair because repeated trauma is difficult to avoid in the absence of pain or other indicators of injury. Although most intrinsic factors are difficult to change, they are nevertheless important considerations when treating a wound.

Alginate dressings

Alginate dressings are composed of calcium, calcium or sodium salts, or seaweed within a gel dressing. Alginates provide a moist environment for healing and good absorption of exudate, establish hemostasis, and do not adhere to the wound. They are helpful in treating wounds with large amounts of exudate including ulcers, donor sites, tunneling wounds, and some bleeding wounds. Do not moisten alginates before applying them to a wound. Contact with the wound bed should help activate the gel. And, to protect the wound bed fully, apply a secondary dressing.

Antibacterial agents

Antibacterial agents work to destroy bacteria and inhibit growth. Bacitracin is a common antibacterial ointment. Antibacterial gels and sprays have become increasingly popular for use in hand hygiene prior to wound-care procedures.

Antibiotic ointment

Antibiotic ointment has been used widely to treat infected wounds. Most antibiotic ointments have a clear color and a thick consistency. They work by inhibiting bacterial growth in wounds that are already infected. Some patients may develop resistance over time, particularly now that antibiotic-resistant organisms are so prevalent. Because of this, many healthcare providers no longer recommend extended treatment with antibiotic ointments for wound care. Common antibiotic ointments are neomycin and polymyxin B (Neosporin) and triple antibiotic ointment (a combination of bacitracin, neomycin, and polymyxin B).

Antifungal agents

Antifungal agents are typically used for fungal infections such as athlete's foot or yeast infections. Fungal skin problems cause a bright red, malodorous, painful rash and can appear nearly anywhere on the body. Antifungal agents can be delivered in powders or ointments. Powders should be applied to a clean dry surface to avoid clumping. Some patients can develop resistance over time, so be sure to monitor each patient's response to treatment. Some examples of antifungal agents are nystatin, ketoconazole, and miconazole.

Topical wound care Antiseptic agents

Antiseptics work by inhibiting or killing micro-organisms. Some examples of antiseptic agents are povidone-iodine (Betadine), silver agents, and hydrogen peroxide. These products are used both for wound care and for sterilizing instruments. Antiseptics are used to cleanse or irrigate wounds or within some wound dressings for additional coverage. Dressings saturated in antiseptics provide a sustained release of the agent over time, while also creating a moist environment for healing. Silver-impregnated dressings such as SilvaSorb and Aquacel can be placed within nearly any other type of dressing.

Barrier creams

Barrier creams are used for patients prone to skin breakdown from pressure, shear, or incontinence. They are intended for prevention and for resolving new-onset problems. Apply barrier creams several times a day on the skin over bony prominences or on areas prone to breakdown, such as the elbows, back, and buttocks. Some commonly used generic names for barrier creams are zinc oxide and vitamin A & D ointment.

Binders

Binders are a form of bandaging that provides support to the body area they surround. They are most often used on the abdomen following a surgical procedure with a large incision. They are made from woven cotton, synthetic, or elastic materials. Most binders require either Velcro closure or safety pins. If a patient's girth is too large for the largest binder available, use two or more binders attached length to length. Keep the underlying skin in mind when applying a binder. Binders that are too tight or have wrinkles could cause pressure areas on the skin beneath them. Assess binders every 4 hours and re-wrap them every 8 hours or sooner if needed. If the binder slips or becomes saturated with any body fluids, replace it.

Biologic therapy

Biologic therapy uses live organisms such as maggots or larvae to remove nonviable tissues. The larvae secrete proteolytic enzymes that help break down the dead and dying tissue. These enzymes also have some antibiotic properties to help reduce infection. Larvae therapy can help stimulate cell growth and granulation. Once the nonviable tissues are liquefied with proteolytic enzymes, the larvae digest them. Some providers also use leeches to increase blood flow to wounded limbs. Although beneficial and with few adverse effects, biologic therapy is not always available, is somewhat slower than sharp debridement, requires the removal and disposal of larvae, and is considered undesirable by some patients. Nevertheless, it is beneficial and cost-effective for treating lower-extremity ulcers and venous ulcers. This therapy is not recommended for wounds that do not have nonviable tissue.

Chemical debridement gels/ointments

Chemical agents that debride necrotic (dead) areas are typically used for pressure ulcers that have slough or eschar or for infected wounds with poor wound edges. These ointments are applied only to necrotic skin. Never place a chemical debridement agent on healthy granulating tissue as it can cause damage and pain. Most debriding agents have a bright or distinct color to make them easy to identify on the patient and on the dressing. Always place a dry dressing over the chemical debridement agent as it usually takes some time to be effective. Two commonly used debridement ointments are papain-urea chlorophyllin copper complex sodium (Panafil) and papain-urea (Accuzyme).

Wound healing phases for chronic wounds

Chronic wounds are classified as wounds with prolonged healing time; wounds that heal faster are classified as acute wounds. Wounds that are closed surgically heal through primary intention. The wound is approximated, that is, its edges are touching each other. This primary process does not allow the body to contract the tissue or form granulation tissue. Chronic wounds heal through secondary intention, a process during which the wound edges do not come together; instead the wound heals by the formation of granulation tissue, wound contraction, and epithelialization. Chronic wounds go through the same healing stages as acute wounds do, but the phases are often delayed. The inflammatory phase of chronic wounds is similar to that of acute wounds, but it involves either internal or insidious trauma to the tissue. Poor perfusion or lack of oxygen can also prolong the inflammatory phase of chronic wounds. The epithelialization phase of chronic wounds is characterized by inefficiency in the migration of keratinocytes for the formation of matrix and scar tissue. Chronic wounds also tend to have irregular wound edges, which inhibits cells from forming a matrix for healing. Chronic wounds have higher concentrations of fluid and proinflammatory cytokines, which slows the proliferative phase. Repeated trauma and infection during this phase can also contribute to poor wound healing. Some researchers suggest that remodeling can be slowed in chronic wounds as a result of uneven collagen deposition and lysis balance. In any case, chronic wound management requires a long-term multidisciplinary plan to address all extrinsic factors and thus promote wound healing.

How should I describe the color of the exudate coming from my patient's wound?

Describe the color, consistency, adherence, distribution, odor, and amount of exudate. Sanguineous/bloody exudate is bright red and thin in consistency. Serosanguineous exudate is light red to pink and is thin in consistency. Serous exudate is clear or light in color and thin in consistency. Seropurulent exudate is cloudy, yellow to tan, and thin in consistency. Purulent exudate is yellow, tan or green, opaque, and thick in consistency.

Drains

Drains are used in wound care to collect exudate, measure it, protect the surrounding skin, contain micro-organisms, and reduce the frequency of care. Drainage systems are either open or closed and are typically put in place during a surgical procedure, with subsequent nursing care until they are removed. Documentation for drains includes the amount of drainage, its appearance and odor, and the assessment findings for the surrounding skin.

The basics of wound dressings

Dressing choices are vast and largely determined by the type of wound you are treating and the available materials. Dressing types range from simple dry gauze dressings to complex medication-impregnated bandages used for specific types of wounds. Assess the requirements for the particular wound, including the degree and amount of exudate, any infection, any necrotic (dead) tissue, and other factors. Some bandages are meant to be used with creams, chemicals, powders, and other topical agents. In any case, do not put a bandage on a wound without knowing how it will affect the wound and how it is going to heal the wound.

Dry dressings

Dry dressings are typically composed of some form of gauze pad that is secured to the wound by rolled gauze and tape or as a self-adherent bandage with a gauze center. Dry dressings are simple, inexpensive, and widely available and are an appropriate dressing choice for numerous types of wounds. They generally work well for wounds with small amounts of exudate, but they can stick to the wound bed of heavily exudative wounds or expose the wound to the outside environment. When removing dry dressings that appear stuck to the wound bed, it is helpful to pour some normal saline over the area to moisten the dressing for easier removal. Dry dressings may be applied both in sterile and in clean environments. Examples of sterile applications are surgical wounds and insertion sites of venous access devices. Sterile dressings help reduce opportunities for bacteria to enter or exit wounds, thus reducing the risks for infection and cross-contamination.

Electric stimulation

Electric stimulation Electric stimulation is used to help heal subcutaneous and deep-tissue structures. Some types of electric current therapy help by heating targeted tissues beneath the surface of the skin (unlike external heating sources such as hot packs and infrared treatments). Other electric current therapies promote circulation while stimulating the autonomic nervous system. Most types of electric stimulation are described with the term diathermy, of which the U.S. Food and Drug Administration has approved two classes: thermal and nonthermal. The strength of stimulation is determined by pulse frequency, pulse shape and duration, waveform, amplitude, and total exposure time. The benefits of diathermy include improved tissue perfusion, increased tissue metabolism, more antibiotic delivery to the tissues, a heightened effect of oxygen on microbes, and promotion of cellular processes. Short-wave electric stimulation is used widely to treat pain, edema, and soft-tissue injuries and to simulate cell growth.

Do not use Electric stimulation on:

Electric stimulation should be used with caution when treating patients who are heat-sensitive or have an inflammatory process. It should not be used at all: with metal or synthetic materials, as they can cause burn injuries or deflect some of the energy in moist environments (moist dressings, perspiration, adhesives) for patients who have a cardiac pacemaker, are pregnant, or are prone to bleeding over ischemic tissue or infected areas, especially with osteomyelitis (a bone infection) over immature bone transcerebrally

Wet-to-dry dressings

Historically, wet-to-dry dressings have been used extensively for wounds requiring debridement. While many providers now use more sophisticated dressings or negative-pressure wound therapy (NPWT), also known by a common brand name Vacuum Assisted Closure (V.A.C), wet-to-dry dressings are still in use in many facilities. To create this type of dressing, place a saline-soaked gauze or cotton sponge within a wound with exudate or drainage. As the dressing dries, it pulls exudate out of the wound. The disadvantages of wet-to-dry dressings are that they are nonselective with debridement; therefore, they take healthy as well as necrotic tissue with them. Wet-to-dry dressings may appear inexpensive initially because of the materials used, but the labor and frequency of dressing changes makes them fairly costly. Wet-to-dry dressings are time-consuming to apply and are generally painful to remove. Surrounding wound edges can become macerated because of the moisture contained in the dressing, and that can lead to enlargement of the wound's diameter. Cross-contamination is also an issue as the saturated gauze in wet-to-dry dressings does not provide any barrier to the environment, thus allowing organisms in and out of the wound easily.

Hydrocolloid dressings

Hydrocolloid dressings are used for autolytic debridement instead of the older wet-to-dry dressing technique. Hydrocolloid dressings have the benefit of some absorptive capabilities while still maintaining a moist wound healing environment. Hydrocolloid dressings do not allow oxygen to enter the wound, which can lead to anaerobic bacteria growth. Hydrocolloid dressings are not recommended for infected wounds but they are helpful for wounds that are vulnerable to infection. Do not use these dressings to treat dry gangrene or dry ischemic wounds. These dressings typically stay in place up to 7 days but may be changed more often if they become saturated. Hydrocolloid dressings are not transparent, so it is difficult to assess the wound without removing them. And, be sure to change them whenever the amount of exudate compromises the intended use.

Hydrofiber dressings

Hydrofiber dressings are similar to alginate dressings in their absorptive properties. However, hydrofiber dressings do not affect hemostasis. Hydrofiber dressings are composed of the polymer carboxymethylcellulose, a substance that can absorb exudate vertically. These dressings are manufactured in sheets to place in wounds that have considerable exudate. The sheet materials swell on contact with exudate, thus absorbing the unwanted material. Cut these dressings to a size just larger than the wound cavity and use a secondary dressing over them.

How should I assess a new wound?

Include the wound's location, age, size, stage or depth, presence of tunneling, signs of attributes that impair healing (necrosis, erythema), signs of attributes that aid in healing (wound edges, granulation), exudate characteristics, pain, and temperature. Assess size using a ruler or other device to measure the exact dimensions of the wound, including its depth. Describe the wound's age in days, weeks, or months. Location should reflect anatomic references. Document the amount, color, and odor of any exudate. Every additional component you report when assessing a wound can help contribute to the correct diagnosis, treatment, management, and, ultimately, healing of the wound.

What is the difference between a hydrogel and a hydrocolloid dressing?

Hydrogel dressings are gauze or sheet dressings containing water- or glycerin-based amorphous gel. The high water content of hydrogel dressings makes them difficult to use for wounds that have considerable exudate. Hydrogel dressings provide a moist healing environment and promote granulation and autolytic debridement. Hydrogel dressings can help reduce pain and can be used for infected wounds as well. Some do require a secondary dressing as they can dehydrate easily. Hydrocolloid dressings are occlusive or semiocclusive dressings made of gelatin, pectin, or carboxymethylcellulose. Hydrocolloid dressings provide a moist healing environment and autolytic debridement. Some hydrocolloid dressings adhere to the skin around the wound or leave a residue on the wound. Hydrocolloid dressings are self-adherent and help minimize skin trauma, but they can injure fragile skin during removal.

Hydrogel dressings

Hydrogel dressings are used for autolytic debridement, or promoting the body's own natural functions of removing necrotic tissue. Hydrogel dressings work by maintaining a moist wound environment. This dressing type is used for wounds with necrosis, infection, moderate amounts of exudate, and a need for a moist healing environment. Do not use hydrogel dressings to treat dry gangrene or dry ischemic wounds. A disadvantage is that hydrogel dressings are costly. You'll change these dressings every day or every other day and more often if they become saturated. Be sure to change them whenever the amount of exudate compromises the intended use.

What are the risks of using whirlpool baths for wound treatment?

Hydrotherapy can have cardiac, vascular, and pulmonary system effects and can cause tissue damage and wound infection. Whirlpool therapy can be especially dangerous for patients who have heart failure or venous insufficiency and for those who take medications that alter cardiac function, such as beta blockers. The risk of pneumonia from inhaled water vapors increases with age and pulmonary risk factors; of course, this can be minimized by having patients wear a mask during treatment. For all patients, take their vital signs before, during, and after treatment. Also, keep in mind that the risk of tissue damage rises dramatically with prolonged exposure to the water environment. The risk of wound infection from contaminated water has been reported in various degrees of incidence. Despite this, hydrotherapy for wound treatment is still widely used, with the proposed caution of proper disinfection of the tub between uses.

Hydrotherapy

Hydrotherapy for wound care involves the use of heated, moving water. Hydrotherapy increases circulation, skin temperature, and cellular processes (including growth), and it reduces pain and inflammation. Water temperature is extremely important to monitor as excessive heat can cause vital cardiopulmonary complications and physiologic stress. Keep the water temperature between 36.5° and 40° C (97.7° and 104° F) for therapeutic healing. Also, be sure to measure the patient's vital signs before, during, and after whirlpool therapy. Hydrotherapy is contraindicated for clean, granulating, or epithelializing wounds because the agitation of moving water can disrupt healing. New skin grafts and tissue flaps should not be exposed to hydrotherapy. Macerated ulcers can become enlarged if exposed to the agitation of hydrotherapy. Also, patients who have any health problems where changes in vital signs could have especially adverse effects are not appropriate candidates for whirlpool therapy. Patients on chronic anticoagulation or with hypertension may not tolerate the temperature changes. Hydrotherapy is also contraindicated when there is edema, phlebitis, or dry gangrene and for patients who are lethargic, unresponsive, or febrile. Patients who are incontinent of feces and/or urine should not undergo hydrotherapy due to contamination issues.

Chemical-impregnated dressings

Many manufacturers provide dressings that are impregnated with chemicals or agents intended to speed up the healing process. Examples are povidone-iodine (Betadine), silver, petroleum, collagen, and antibiotics. Some chemical-impregnated dressings come in sheets that require secondary dressings. Remember to use specialty dressings only for wounds that are likely to respond to the agent within the dressing. Consider cost, availability, and the potential for allergic reactions before using these dressings.

Mechanical cleansing

Mechanical cleansing involves the use of gauze and a cleansing solution to clean contaminated wound areas. Excessive scrubbing of a wound can be painful, however, and can also remove healing tissue. Mechanical cleansing with sterile instruments is called debridement and is generally effective. Biologic debridement, another effective method, involves the use of larvae or maggots to help remove necrotic tissue.

Extrinsic factors that affect wound healing

Medications can affect wound healing, especially those that inhibit platelet action, such as aspirin, and those that suppress the immune system, such as corticosteroids. Cancer treatments are another factor, as they are meant to cause cell destruction and suppress the immune system. Inadequate nutrition is yet another factor; a lack of dietary protein, vitamins, and iron can slow healing time. Stress can also affect wound healing by altering the body's ability to respond to injury. The brain can release chemicals, hormones, and other substances that can alter chemical processes during wound healing. Irradiation and chemotherapy can damage the skin, reduce the inflammatory response, and ultimately slow wound healing. Infection can dramatically slow the process of healing by prolonging the phases of wound healing. Repeated trauma during wound healing can slow progression by extending the phases of wound healing. Wounds that affect underlying tissues often require additional time to heal. Ultimately, it is important to account for extrinsic factors and promote the best possible environment for wound healing.

How does negative-pressure wound therapy accelerate wound healing?

Negative-pressure wound therapy (NPWT), also known by a common brand name Vacuum Assisted Closure (V.A.C), distributes negative pressure over the entire wound surface to help drain excess debris and exudate, reduce bacterial count, decrease edema, and increase capillary blood flow. This modality combines the benefits of both open and closed or moist traditional dressings. NPWT involves placing a foam dressing over an acute or chronic wound and attaching it to a device designed to exert negative pressure over the area.

I have a patient who has a chronic wound and poor nutritional status. What fluids other than water can I offer her to help increase her hydration status? How can dehydration make my patient's wound worse?

One important component of fluid hydration is increasing the number of times you offer patients fluids (not just with meals). Alternatives to water are popsicles, flavored gelatin, soup, sorbet, ice cream, milk, and ice chips. Always continue to assess hydration status when caring for patients who have wounds. Dehydration can lead to weight loss, dry skin, altered sensation, rapid pulse, and decreased venous pressure, body temperature, and blood pressure. All of these factors can increase your patients' risk for developing wounds and impair wound healing.

Closed drainage systems

One type, the Jackson-Pratt (JP) drain, has a small bulb on the end of a plastic tube with a plug that allows removal of drainage. Compressing the bulb after emptying it and before replacing the plug generates enough pressure to facilitate drainage. Recompression is indicated when the bulb fills with drainage or is no longer compressed. Many facilities specify routine times for checking the bulb and documenting the drainage amounts. Another type of closed system is a portable wound suction device that applies negative pressure to the wound (trade name: Hemovac). This type of system incorporates a larger, disc-shaped reservoir for collecting drainage. This type of drainage system has a pouring spout for emptying the collection reservoir.

Open drainage systems

Penrose drains are used commonly as open drainage systems for wound care. An absorbent dressing is applied to the area to collect drainage and to keep the area dry. Drawbacks of open systems are difficulties in assessing the amount of drainage and in controlling the transmission of micro-organisms from both the outside environment and from the wound itself. Open drainage systems use a small plastic tube that collapses easily and has a safety pin or clip attached to keep it in place. Closed drainage systems use compression and suction to remove drainage and collect it in a reservoir. Closed drainage systems reduce the risk of infection and allow more accurate measurement of drainage.

Phototherapy

Phototherapy involves the use of light or radiant energy to heal wounds. Radiant energy is defined as energy delivered as electromagnetic waves. Radiant energy is absorbed through the skin tissue, so darker pigmented or denser skin will be more resistant to phototherapy. Phototherapy for wound healing is typically delivered by ultraviolet (UV) light, visible energy, or infrared energy. All three types of phototherapy are delivered by a laser or with lamp technology. Early UV exposure causes inflammation, an increased vascular response in the skin tissues, heightened ATP (energy) synthesis, cell proliferation, and bactericidal effects. Prolonged exposure is not recommended, as it has been shown to cause skin cancer. Indications for phototherapy include acute or chronic wounds, slowly healing or nonhealing wounds, and infected or colonized wounds. Phototherapy should not be used over cancerous growths, over the thyroid gland, during pregnancy, or without eye protection in place.

Why do pressure ulcers never change in stage, even though they seem to go through different stages as they heal?

Pressure ulcer staging criteria have been used to describe the depth and degree of tissue damage caused by pressure. The current recommendation from the National Pressure Ulcer Advisory Panel is to use the stage I to IV criteria, with the addition of two more stages for deep tissue injury and unstageable pressure ulcers. The reason that ulcers cannot reverse in stage is that, as ulcers heal, the natural tissues are replaced with granulation and scar tissue, which is not the same as the original tissue present prior to the development of the ulcer.

How can I help reduce the pain associated with wound dressings?

Selecting the correct type of dressing can help. In general, keeping some moisture within a wound reduces pain. Choose dressings that have enough adhesive to stay in place but will not be too difficult to remove. Absorptive dressings can help decrease excessive moisture, which can otherwise lead to maceration and additional pain. Packing wounds too tightly or wrapping a bandage too tightly can also increase pain. Change dressings infrequently (unless otherwise prescribed) to reduce pain. When a patient is still experiencing considerable pain with dressing changes, consider offering premedication and providing a relaxing environment prior to dressing changes. Complete pain assessment prior to and after dressing changes to help plan alternative methods of delivering wound care.

Skin cleansers

Skin cleansing agents work to remove micro-organisms while protecting the integrity of the skin. Some preparations require rinsing while others are meant to dry and remain on the skin. Some skin cleansers are intended for full body use while others are formulated for specific areas such as hair or perineal areas. Specific uses are specified in the product name (body wash, shampoo). Consider the appropriate product for environments where the patient may not be able to be moved easily for a full shower or bath or for patients who have vulnerable skin.

Foam dressings

Some dressings have additional foam padding to protect wound fields. These foam dressings are absorptive and provide a moist healing environment while protecting wounds that resulted from pressure, friction, or shear. These dressings are used widely for early-stage pressure ulcers. Most foam dressings are self-adherent, so take care to avoid damaging the surrounding skin when applying and removing these dressings.

pressurized cleansing

Some wounds require pressurized solutions for adequate cleansing coverage. Most wound solutions delivered at a minimum of 8 psi via a syringe or a catheter can achieve this.

Wound-closure materials

Sutures, staples, and synthetic glue are all used to close the wound edges of acute, noninfected wounds. Sutures are made from a variety of materials; removal time typically varies with the depth of the wound and its location. Some areas (such as the face) require early removal to reduce the risk of scarring. To remove sutures, wear clean gloves and use a removal kit with scissors and tweezers. Staples are typically removed with a sterile staple remover that looks like an uneven pair of scissors. The remover works by pinching the staple in the center so the ends of the staple lift out of the skin for easy removal. New topical glues are used for superficial wounds that may not require sutures or staples, but wound edges must be approximated for healing. Topical glues typically slough off within 7 to 10 days of application. All three forms of wound closure can be reinforced with adhesive skin closures (Steri-Strips™) to help keep wound edges together. These closures fall off on their own after 7 to 10 days and should not be removed any sooner. Depth of injury, injury location, cost, availability, and allergies to materials are all factors in determining which closure material to use.

Tape

Tape is commonly used to help secure dressings to wounds. It is available in paper, plastic, or cloth varieties. Always remove tape carefully as it can adhere to and damage the underlying skin. Some tapes leave sticky adhesives on the skin, which you can remove with adhesive remover wipes. Many patients have sensitivities to tape, so use it sparingly. For patients who have significant allergies to tape, use rolled gauze to surround a bandage then secure its edge to the rest of the bandage with hypoallergenic tape. You can also secure some dressings with cloth netting products.

The basics of wound assessment

Wound assessment includes both an accurate history and a physical examination. When taking a wound history, ask pertinent questions that will yield data about the wound's onset, any acute injury or known cause, associated symptoms (pain, itching), changes over time, and any major health problems that might affect wound development or healing.

Pressure ulcers staging

The National Pressure Ulcer Advisory Panel's (NPUAP's) pressure ulcer staging system is used universally to describe the severity of pressure ulcers. Recently revised, the NPUAP guidelines define six different stages. Suspected deep tissue injury is the first category. Although not considered a stage, it pertains to tissue with discolored but intact skin caused by damage to underlying tissue. Stage I is defined as non-blanchable redness caused by pressure or shear typically over a bony prominence. Stage II involves partial-thickness skin loss with a visible ulcer. Stage III involves full-thickness tissue loss without exposed muscle or bone. Stage IV involves full-thickness tissue loss with exposed bone, muscle, the possibility of tunneling, and sometimes eschar (black scab-like material) or slough (tan, yellow, or green scab-like material). The final stage of the NPUAP system is the "unstageable" variety of ulcers whose stage cannot be determined because eschar or slough obscures the wound.

The epithelialization phase

The epithelialization phase provides temporary protection at the site of injury to keep outside organisms from entering and causing infection. Keratinocytes make up the basic cell structure of the layers of the dermis and the epidermis (along with other internal structures). In response to injury and acute inflammation, inflammatory cytokines are released to activate a proliferation cycle. Epithelialization typically begins at the wound's edges and gradually moves upward to form a fully covered surface. Moist environments help promote this process. Once formed, remodeled skin has no more than 80% of the strength of the original skin. During the epithelialization phase, where the scar is not fully formed, the strength is only 15% that of the original skin. Allowing this sensitive skin area to heal is important as repeated trauma will prolong the inflammation and lead to poor scar formation.

The inflammatory phase

The inflammatory phase begins once the skin (and sometimes underlying tissues) is injured and continues for about 24 hours. The major characteristics of the inflammatory phase are skin color changes, heat, swelling, pain, and loss of function. This immune system reaction to an injury protects the body from infection and expedites healing. The coagulation cascade is initiated to promote clotting and thus stop any bleeding. Platelets, fibrin, fibronectin, and other components of the coagulation cascade work to establish hemostasis. Also present are white blood cells, primarily neutrophils, lymphocytes, and macrophages, plus plasma proteins and mast cells. The active inflammatory phase also involves the complement system, whose proteins help move defense cells to the location of injury. Neutrophils are white blood cells that typically arrive early to an injury and work to kill bacteria. The higher the bacteria count, the longer the neutrophil count remains elevated. Macrophages are responsible for components of both the inflammatory and proliferative phases of wound healing. Macrophages secrete growth factors, promote phagocytosis (ingestion of debris), assist with autolytic debridement, and release nitric oxide to kill bacteria. Mast cells work as secretory cells. The primary substance secreted is histamine, which increases vascular dilation and stimulates collagen formation at the site of a scar. Mast cells can contribute to short-term edema as a result of injury. Following an acute injury, the body responds by increasing perfusion to the location of injury, which results in a subsequent increase in temperature. The process of inflammation is complex, with multiple cells playing roles to ensure that the proper equipment is in place to promote wound healing and reduce infection.

The proliferative phase

The proliferative phase of wound healing restores skin integrity by filling in the wound with new tissue. New blood vessels form within the wound by extending from the wound's edges; this is called angiogenesis. The fragile and highly permeable capillaries that form first allow easy passage of fluid, often leading to some swelling. Once this capillary system is created, it completes a matrix that covers the entire wound bed. The result is granulation tissue, bright red tissue that is a sign of wound healing but is also prone to bleeding with any trauma. Fibroblasts work to restore connective tissue to the wound bed. The matrix is referred to the scaffolding on which a scar is formed and skin integrity is restored. Once the matrix is formed, collagen begins to be deposited. Although a rough scar is formed during this phase, it is still very vulnerable to trauma. Therefore, dehiscence and evisceration are risks during this phase of healing. Contraction of the wound's edges also begins during the proliferative phase through the work of myofibroblasts.

The remodeling phase

The remodeling phase completes the wound healing process and often takes several years. Beginning and overlapping with the proliferation phase, remodeling works to form and lyse collagen within a scar to help increase strength and skin integrity. It is during this phase that the initial 15%-strength scar eventually regains 80% of the skin's original strength. During the remodeling phase, scar tissue changes in appearance. In light-skinned individuals, the scar's color changes from pink or red to a white color as vascular changes occur. The diminished need for additional worker cells to repair the site reduces the need for additional vascular support. Scar tissue also becomes more flexible as it ages.

Transparent film dressings

Transparent film dressings have a thin layer of plastic that covers the wound area. This dressing type provides no absorption but does create a barrier to the environment. Transparent dressings do allow some oxygen exchange to reduce anaerobic bacteria growth and a wet environment to promote healing. Transparent film dressings are commonly used for wounds with dry eschar or for superficial skin tears but are not recommended for infected wounds. Removal of transparent dressings can cause damage to underlying skin, and the uniform application can cause maceration of wound edges.

Ultrasound

Ultrasound therapy is used to deliver a mechanical vibration to skin tissues to stimulate cell growth. High-frequency (short-wave) ultrasound causes thermal and nonthermal effects that stimulate cell growth and enhance transdermal drug delivery. Low-frequency (long-wave) ultrasound can penetrate deeper tissues while also stimulating cell growth. Ultrasound is thought to accelerate the inflammatory phase of healing but in some cases can induce inflammation. Ultrasound therapy is indicated for edema, pain, skin tears, ulcers, bruising, poor circulation, deep tissue injury, and bacterial infection. It is also useful for debridement. It should not be used to treat previously untreated cellulitis with an ischemic response, when there is uncontrolled pain, or when there are metal components in the wound area.

The basics of wound cleansing

Wound cleansing is a technique that is generally similar for the various wound types (with some exceptions). Cleansing usually involves a liquid solution (often normal saline solution) to help rid the wound area of necrotic tissue, exudate, blood, or debris. Cleansing methods include passive irrigation, mechanical irrigation, and pressurized irrigation. Whirlpool tubs are sometimes categorized as a form of wound cleansing and care, although access, cost, and some issues with controlling the environment can interfere with the practicality, safety, and effectiveness of whirlpools. Consider the environment and your patient's comfort and safety when you cleanse a wound. The procedure can be painful for the patient, depending on the type of injury, so be sure to assess and treat pain prior to and after any wound-care activity. Place a clean pad below the wound to help collect the drainage and keep the surrounding area clean and dry.

Wound fillers

Wound fillers are manufactured as pastes, powders, gels, and beads for providing a moist healing environment beneath dressings. Some help soften underlying necrotic tissue to speed up debridement. Fillers are helpful for deep wounds with some exudate and are less useful with dry wounds.

How does wound healing from primary intention differ from healing by secondary intention?

Wound healing by primary intention involves the closure of a surgical wound (incision). Primary intention involves epithelialization; the wound generally heals quickly with minimal scar formation. Wound healing by secondary intention follows a predictable sequence of inflammation, epithelialization, proliferation, and remodeling, in other words, the body's natural, uninterrupted process for healing a wound. Do not confuse secondary intention with approximation, which is a term used to describe wound edges that are touching (as when a surgical wound is closed).

The anatomy and physiology of wound healing

Wounds are a result of injury to the skin. Although there are many different methods and degrees of injury, the basic phases of healing are essentially the same for most wounds. They are the inflammatory phase, the epithelialization phase, the proliferative phase, and the remodeling phase. But there are also intrinsic (internal) and extrinsic (external) factors that can influence wound healing, as well as variations for acute versus chronic wounds.

physical assessment of wounds

Your physical assessment of wounds involves the use of several senses as you note visually perceived changes, temperature and textural changes, and odors. Your visual assessment includes shape, size, depth, colors, exudate, bleeding, any tissue that impairs healing (necrosis, erythematous or infected tissue, tunneling, edema), and any tissue that helps with healing (granulating tissue, clean wound edges). Temperature changes range from very warm (typical with infection) to very cold (vascular compromise). Textural changes include roughened or raised wounds or deep wounds that interrupt the natural contour of the skin. Odors, a very important component of wound assessment, can help you detect specific infectious organisms or suggest the cause of the wound. A large variety of wound assessment tools are available. The use of rulers or other measuring tools are considered standard practice, although the exact method recommended may vary with the wound and from facility to facility. Several assessment tools are also available to help you assess present wounds as well as the risk for future wounds.

Negative pressure wound therapy (NPWT)

is used to provide debridement and removal of exudate. This therapy applies suction to a wound area. This technology cleanses the wound, reduces bacterial counts through debridement, promotes granulation and epithelialization, and stimulates cell growth. It is used for treatment of wounds in all healthcare settings including hospital, extended care and home. This type of therapy is used for infected wounds and has a profound effect on salvaging limbs and speeding up wound-healing times. Negative pressure wound therapy is cost-effective as it does not usually require surgical application. It also is time-efficient, as it typically takes 15 to 30 minutes for a nurse or a physical therapist to apply the device. This type of therapy applies negative pressure to a special porous foam or gauze dressing that is sealed in place with a transparent adhesive tape. Exudate is removed by negative pressure and stored in a collection container that is a part of the NPWT system. Caution is advised when using the device with patients who have decreased sensation, are taking anticoagulants, or have wounds with tracts or tunneling. When activated, the NPWT therapy unit will make noise as it delivers negative pressure to the wound and typically cycles through on and off states as it manages the removal of fluid and exudate. Therapy can be set for continuous or intermittent negative pressure dependent on specific therapy needs.