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Wound Care 101

Heather Grady, MPA, PA-C

CAPA Conference

October 9, 2014

Wound Classification

Etiology¹

Surgical/non-surgical

Acute and chronic

Depth¹

Superficial, partial-thickness, and full-thickness

Pressure ulcer staging

Comparison of superficial,partial-thickness and full-

thickness wounds

EPIDERMIS

DERMIS

SUBCUTANEOUS

MUSCLEBONE

Superficial woundInvolves only the epidermis

Partial-thickness woundAffects the epidermis,and may extend into thedermis but not through it

Full thickness woundExtends through thedermis into tissuesbeneath; adipose tissue,muscle, or bone maybe exposed

Wound Assessment Model1

WoundAssessment

Wound BedAssess for

necrotic andgranulationtissue, fibrin

slough,epithelium,

exudate, odor

Surrounding Skin

Asses for color, moisture, supplenessSize

Measureand/ortracewoundarea.

Measuredepth

Wound Edges

Assess forundermining andconditions ofmargins

Wound Bed

Necrotic tissue – Eschar– Dry, black or brownish devitalized tissue4

Slough – Formed when a collection of deadcellular debris accumulates on the woundsurface4

– Yellow or yellow-white, due to the large amountsof leukocytes present

Granulation tissue – Indicator of normalhealing in full thickness wound4

– Bright red in color

Epithelialization – newly formed epithelialcells that have a translucent appearance4

– Usually whitish-pink or pinky-purple in color

Eschar

Slough

GranulationTissue

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Wound progression from slough to granulation tissue

Granulation tissue and epithelializedtissue

Documentation –Quantify the estimatedpercentage of tissueinvolved (e.g. woundcontains ± 50%granulation tissue, ±25% necrotic tissue and± 25% fibrin slough)1

Granulation Tissue4

Healthy GranulationTissue

Unhealthy GranulationTissue

Bright Red Dark red/blushdiscoloration or pale

Moist Dehydrated

Shiny Dull

Does not bleed easily Bleeds easily - fragile

Exudate4,5

ExudateType

Color Consistency Descriptor Significance

Serous Clear Thin watery Clear fluid absence ofblood, pus debris

Normalinflammatory/proliferative

phases of healing

Sanguinous Red Thin watery Bloody,composed entirelyof blood

Indicates new vesselgrowth or disruption

Serosanguinous Light red/pink Thin watery Blood mixed with clearfluid

Normalinflammatory/proliferative

phases of healing

Seropurulent Cloudy yellow Thin watery Pus mixed with wateryfluid

May be first signs ofwound infection or

autolytic debridement

Purulent/Pus Yellow/green Thick, opaque Pus, cloudy, viscous oftenmalodorous

Indicates wound infection

Criteria for IndentifyingWound Infection4,6

Surfacediscoloration –

yellow/green hues

Increased odor

Superficialpocketing orbridging ofwound base

Wounddeterioration or

dehiscenceNon-Healing wound

Increaseddiscomfort and

tenderness

Abscessformation

Friable granulationtissue –

bleeds easily

Cellulitis andInflammation

Increasedexudate

WoundInfection

Wound InfectionFactors Increasing the

Risk of Infection4,7

Reduced perfusion

Large wound area/depth

Chronicity

Necrotic tissue

Foreign bodies

Metabolic disorders – diabetes mellitus

Alcohol abuse/smoking

Corticosteroid medications

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Antibiotics

Systemic antimicrobial therapy shouldbe used when active infection can’t bemanaged with local therapy4

– Fever

– Underlying deep structure infection

– Spreading cellulitis

Wound Basics

Standard of care is no longerwet-to-dry dressings– This keeps wounds in a constant

inflammatory state, slowingdown wound healing2

With any wound, always takecare to protect the periwoundedges10

Don’t desiccate the woundbed

Dressing Basics

Type and amount of drainage dictatesthe type of dressing used

If a wound is too dry, hydrate thewound with gels

If a wound has too much drainage, usefoams to absorb the moisture2,10

Wound Margin &Surrounding skin

Prolonged exposureof the skin towound exudatescan result in skinmaceration

Indicates– Wound dressing is not

being changedfrequently enough

– Dressing contains toohigh a water content

– The absorptivecapacity of thedressing is notaligned to meet withthe exuding fluidvolume4

Film = Poly skin

Hydrogel = Duoderm gel

Hydrocolloid = Duoderm

Alginate = Aquacel, & Aquacel AG

Foam = Allyven foam – with and without adhesive

Specialty dressing– Mepitel – silicone contact layer

– Mepilex foam – silicone foam dressing – with and withoutadhesive border

– Polymem – foam dressing but with surfactant whichcleanses the wound, does not absorb a lot of drainage

– Interdry AG – polyester cloth with silver impregnated in it,kills fungus and bacteria inside skin folds and wicks awaymoisture

– Anti-microbial – dressings with silver, Acticoat

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Exceptions to the Rule

If the patient has decreased vascularityand you want to keep the bacterial countdown– Keep the wound dry and paint it with betadine

Eschar often can be usedas a physiologic dressing(especially with wounds on thefeet) and wound will heal underthe eschar10

Wound Pain

Surveys have shown that cliniciansidentify dressing removal as the mostpainful part of dressing procedure andthat gauze is most likely to cause pain

Newer products were least likely tocause pain and skin trauma. Theseinclude hydrogels, alginates andsilicone dressings4,8

Wounds and Nutrition

Protein is essential for the formationof new granulation tissue.

Severe protein malnutrition results in

– Slower wound healing

– Decreased immunocompetence

– Increased susceptibility to infection4,9

Aging Population

Patient population is getting older and thedisease processes associated with thesepatients are increasing10

Medications and co-morbidities need to betaken into account when addressing woundcare because they can impede woundhealingMedications impact wound healing– ie. steroids, NSAIDs, anti-coagulation

Co-morbid diseases also affect healing– ie. COPD, DM, A-fib, pneumonia

Types of DressingsOld School of Thought

Wet-to-Dry dressings– Gauze is inserted wet, covered with dry gauze

and it dries out, then removed after adhering tosurface tissue2

– Typically intended for use in the debridement ofdevitalized tissue from a wound bed2 or to keepa wound open that may have a small skinopening but tunnels more deeply

Types of DressingsNew Technology

NPWT - Negative pressurewound therapy12

– Creates an environment thatpromotes wound healing bysecondary or tertiary intention(delayed primary by:

Preparing the wound bed for closureReducing edemaPromoting granulation tissueformation and perfusionRemoving exudate and infectiousmaterial12

Advanced wound healing therapy

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Skin Tears Skin TearsSeen mostly in older patients – skinbecomes thinner as we ageAddress medications and co-morbiditiesSurrounding edema will affect healing aswellTreatment1. Stop bleeding2. Attempt to approximate skin edges3. Don’t cause additional trauma to

surrounding skin4. Can take up to 4 weeks to heal10

Hemostasis

Achieving hemostasis can be hard,especially if patients are on anti-coagulants such as Coumadin orPlavix or if they are on steroids

May need products such as Surgicel orother agents that help preventformation of hematoma

Approximating Skin Edges

If skin edges or skin flap remains, attemptto approximateApply skin prep first (or Benzoin) to skinflap and intact skinHold in place with steri-strips, leaving aspace between each steri-strip to allow fordrainageCover with silicone dressing (Mepitel) thathelps absorb drainage and is less traumaticUse Telfa, covered with Kerlix or Cling andstockinette (great for use on extremities)10

Steri-Strip Wound Types of Dressings

Silicone Dressings

– Does not adhere to skin

– Great on fragile, thin skin

– Used on skin tears

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Silicone Dressing Additional Thoughts

Treat with antibiotic or antimicrobial ifconcerned about infection orcontamination

Don’t apply a transparent dressing suchas op-site

Once evaluated, leave area alone for 5days

May use xeroform as last resort

Complications

Skin flap doesn’t take

– Debride the area and treat as an openwound

Hematoma

– Evaluate if it needs to be evacuated

Additional Dressings

Polymem – surfactant and glycerinedressing that won’t stick to the wound– Can be left on for 7 days– Ok to shower with dressing in place– Good for contaminated wounds to keep the

wound clean

Ointments – apply antibiotic ointment ifconcerned about infection– Bacitracin ointment on the face– Triple antibiotic ointment on all other surfaces– Cover with Telfa, silicone dressing or Polymem

HematomasTo evacuate or not??

Need to really look at co-morbid diseases

Hematomas are abreeding ground forbacteria; however,evacuating a hematomaleaves an open woundand bleeding may persistif patient remains onanti-coagulant10

When not evacuating wound

Silicone or antibiotic silicone dressing canbe used and it won’t disrupt the hematomabut still allows for close monitoring

Cover the silicone dressing with a foam orpadded dressing to help protect thehematoma

Patients must be monitored very closely

It will take time for the hematoma to bereabsorbed

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Evacuation

If eschar is forming then the wound willneed to be evacuated

If wound is evacuated, you must see thebase of the wound to fully evaluate it

Apply pressure if bleeding continuesonce hematoma is evacuated

May need to use products such as cobanto assist with applying pressure10

Additional Problems withHematomas

Older patients may have vascularinsufficiency adding to edema and decreasedoxygenation to the tissues causing stagnantblood– Especially seen in patient with renal failure and

vascular insufficiency10

Antibiotics– Don’t recommend antibiotics unless signs of

infection or contaminated process such as woundoccurred in dirt (think fungus or yeast)

– Suggest using Augmentin or Bactrim– Keflex is not a good option on soft tissue,

especially on lower extremity wounds

Diabetic Foot Ulcers Diabetic Ulcers

Never what they appear, always lookbenign

Usually associated with otherunderlying diseases that affect healingsuch as PVD and arterial disease

For this reason, must always assessvascularity leading to wounds

If there is no blood flow under wound,it WON’T heal

Assessing Diabetic Ulcers

Always do 3 view x-ray or MRI (especially offoot) to r/o osteomyelitis. If unable to getone of these imaging studies, get bone scan

Always probe wound– The inflammatory

process is usuallydelayed resulting inpossible undermining,tunneling, fluidcollections or edema

Treatment of Diabetic Ulcers

Always evaluate shoes!

– Inside and out

– Look for dirt, foreign bodies, etc.

Perform neuro exam

Off-load foot. May need to add foam toshoes.

Limb salvage – Refer directly to a podiatrist ifyou do not see signs of healing (partner witha podiatrist to help treat these types ofwounds)

Wound may need to be incised and drained

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Treatment continued

Treat wound with antimicrobial agents

Hydrofiber, alginate or anti-microbial gels

Evaluate for proper management of DM

If you see signs/symptoms of infection,refer out to vascular surgeon, podiatry,Infectious Disease, etc.

If no evidence of infection, may treat for 3-4weeks before referring to podiatry

Types of Dressings

Hydrofiber– Highly absorbent dressing made of 100%

hydrocolloid. The hydrocolloid is spun intofibers that make a soft, non-woven fleece-likedressing that comes as a sheet or ribbon3

– Used as an alternate toalginate dressing. Thisdressing retains a highquantity of water withoutreleasing it, therebyforming a thickcomfortable gel3

Types of Dressings

Alginate

– A dressing made from seaweed,creating a gel form of dressing3

– Best used in moderate to highlyexudating wounds3

Types of Dressings

Hydrogels– Comes as a sheet or a gel

– Sheets are used for shallow or lowexuding wounds3

– Gels are used for cavities and areeffective for desloughing anddebriding wounds. Gels have a highwater content which aids therehydration of hard eschar andpromotes autolysis in necroticwounds3

– To prevent possible maceration, a secondarybarrier film may be applied to peri-wound area3

Recalcitrant Wounds

Biofilm can develop and nothing canimpregnate it keeping wound in theinflammatory stage

Wound will need sharpdebridement

Evolving field – Lab inTexas will tailortreatment based ontissue specimen,genetics, bloodwork andlocation of wound

Pressure Ulcers

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Pressure Ulcers

Currently classified into 4 stages– Discussions to change classification to

suspected deep tissue injury

Stage 1 and Stage 2– More from shearing and friction

Stage 3 and Stage 4– Deep tissue injury

Suspect deep tissue injury if darkred/purple/maroon, hard/bony surface,won’t blanche

Staging System

Should be used as an admissiondiagnosis system only4,10

Not designed to capture changes thatoccur during the healing process

Changes in the wound status shouldbe documented as area and depthassessment, not “reverse staging”4,10

Pressure UlcersStage 1 and 2

Early stages may start to evolve

Will start to look diffuse with edgesnot well defined. Pink edges, purplearea may open up and evolve to anopen wound stage ulcer

Stage 1 Stage 2

Treatment of Pressure UlcersStage 1 and 2

Always off-load

Observe frequently

Silicone products will off-load andabsorbs drainage

– Some wounds may heal with silicone alone

May also use hydrocolloids (DuoDerm)or Foam dressings

Types of Dressings

Hydrocolloids

– Waterproof, occlusive dressing that consistsof a mixture of pectin, gelatine, sodiumcarboxymethylcellulose and elastomers3

- Creates anenvironment thatencourages autolysisto debride woundsthat are sloughing ornecrotic3

Types of Dressings

Foams– Dressing produced from polyurethane - soft,

open cell sheets3

– These are non-adherent and can absorblarge amounts of exudate3

– Also available impregnated with charcoal(attracts and traps bacteria and odor) andwith waterproof backing3

Silver dressing– Dressing impregnated with Silver – anti-

microbial dressing

– Used to treat infected wounds

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Considerations with Treatment

What is the causative agent of the ulcer?

Nutritional status?– May need to add Ensure, Megace or tube feedings

Hydration?– Is the patient dehydrated?

UTI?

Frequent pneumonia?

Local care is needed to heal wound but must alsofind the underlying cause and address it4,10

There may be a short term cause such as a fracturebut if there is no short term cause, need to find thereason for the ulcer

Pressure UlcersStage 3, Stage 4 and

Unstageable

Stage 3 Stage 4

Unstageable

Treatment of Pressure UlcersStage 3 and 4

Clean wound bed– Surgical debridement– Autolytic debridement (hydrocolloids)– Transparent dressings (op-sites) – soften up

eschar to allow for debridement later– Medical grade honey if no bee allergy (Manuka

Honey - Medline)– Hypertonic solution/pad can be used for

sloughing wound – will withdraw fluid anddebride wound

– If odorous, use ¼ strength Dakin’s solution ongauze. This will improve odor and debrides.Use for about 3-4 days.

Autolytic Debridement

Results in little to nopain or woundtrauma

However, it is aslower method ofdebridement

May becontraindicated ifthere is a highbacterial burden inthe wound4

Treatment of Pressure UlcersStage 3 and 4

Always protect periwound skin withointment (moisture retentive) to protecthealthy skin from maceration caused byexcessive drainage– Calmoseptine or A&D ointment

Apply ointment under foam or ABD pad thatwill allow the drainage to be soaked up

Can use fiber type fillers such as alginate orhydrofiber to fill dead space

Abscess

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Abscesses

If patient thinks it is a spider bite,always I&D, open wound and pack– Must be drained– Likely MRSA or Staph

Skin poppers– Iodasorb gel or Cadoximer Iodine for

treatment– Easy for patient to do themselves and

protects against many organisms– Sustained released of orange fluid – placed

on wound bed and absorbs drainage– Comes in a tube that is applied to wounds

by patient– Ok to shower

Road Rash

Road Rash

Must be very diligent to scrub all debrisfrom wound within first 24 hours– If debris is not removed, patient will get tattoo

from wound

Shower daily with CHG (ChlorhexadineGluconate) for 2 weeks

Apply Xeroform over the area then a gel pad– This will absorb the fluid and is more

comfortable for the patient because it detersdressing from sticking and dressing changes willbe less frequent

Other Wound Care

Dakins solution– Used for malodorous,

soupy wounds withstringy/yellow debris

– Or used if you suspectpseudomonas (greenishappearance to wound ordrainage)

Non-healing wounds– Always need biopsy to

r/o SCC or otherpossible inflammatoryprocess

NPWT(Wound VAC – Vacuum Assisted Closure)

Used for treatmentof open wounds

Negative pressuretherapy

Controls edema andprovides support toincision/wound

Improves healingand decreasestreatment time12

Creates an environment thatpromotes wound healing12

Microstrain

Reduces edema

Promotes perfusion

Promotes granulation tissueformation

Cell mitosis/proliferation

Fibroblast migration

Macrostrain

Draws wound edgestogether

Removes exudate

Removes infectiousmaterials

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Types of Wounds12

ChronicAcuteTraumaticSubacuteDehisced WoundsPartial-ThicknessBurnsUlcers (such asdiabetic, pressure,Venous)Flaps and Grafts

VAC Dressing Types12

V.A.C.

GranufoamDressing

Reticulated (open) porePolyurethane ideal for:Deep acute woundsTraumatic wounds

Diabetic & Pressure ulcersDraining or dry wounds

Flaps and grafts (with non-adherent)

V.A.C. WhiteFoam Dressings

Dense (higher tensile strength) open-pore Polyvinyl Alcohol ideal for:Tunneling/tracts/underminingPainful wounds

Wounds requiringcontrolled growthof granulation tissue

Superficial wounds

Reticulated (open) celled Polyurethanemicro-bonded with silver to provide aprotective barrier to reduce aerobic,gram-/+ bacteria, yeast and fungi. Ideal for:• Deep acute wounds• Traumatic wounds• Diabetic & Pressure ulcers• Draining or dry wounds• Flaps and grafts (with non-adherent)12

99.9% of pathogenseliminated Within thefirst 30 minutes

V.A.C.® DrapeEasy as…1…2…Blue

V.A.C. Canisters

Contraindications12

Do not place foam dressings of the V.A.C.®

Therapy System directly in contact withexposed blood vessels, anastomotic sites,organs, or nerves

Malignancy in the wound

Untreated osteomyelitis

Non-enteric and unexplored fistulas

Necrotic tissue with eschar present (afterdebridement V.A.C. Therapy may be used)

Sensitivity to silver

Warnings, Precautions and Safety Tips

Protect Vessels and Organs: All exposedor superficial vessels and organs in oraround the wound must be completelycovered and protected prior to theadministration of V.A.C.® TherapyProtect Tendons, Ligaments and Nerves:Tendons, ligaments and nerves should beprotected to avoid direct contact withV.A.C. Foam Dressings. These structuresmay be covered with natural tissue, meshednon-adherent material, or bio-engineeredtissue to help minimize risk of desiccationor injury12

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Warnings, Precautions and Safety Tips

V.A.C. Therapy On: Never leave a V.A.C. Dressing inplace without active V.A.C. Therapy for more than2 hours. If therapy is off for more than 2 hours,remove the old dressing and irrigate the wound.Either apply a new V.A.C. Dressing from anunopened sterile package and restart V.A.C.Therapy; or apply an alternative dressing at thedirection of the treating clinicianBleeding: With or without using V.A.C. Therapy,certain patients are at high risk of bleedingcomplications1000 mL Canister: DO NOT USE the 1000 mL canister onpatients with a high risk of bleeding or on patientsunable to tolerate a large loss of fluid volume.MRI, X-Ray & HBO12

Dressing Application

Target Pressure 125 mmHg(125-175 white foam)Continuous first 48 hrsIntermittent if tolerated

Dressing change every 48-72 hrs

Basic DressingTunneling: White foam and

GranuFoam

Target Pressure 125 mmHg(125-175 white foam)

ContinuousDressing change every 48-72 hrs

Framing: Wounds with SmallOpenings

Target Pressure 125 mmHg(125-175 white foam)Continuous first 48 hrsIntermittent if tolerated

Dressing change every 48-72 hrs

Bridging

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Final Thoughts

Wound assessment is as important astreating the wound itself

Type and amount of drainage nowdictates the type of dressing used

Take care to protect the periwound area

Identifying and treating the underlyingcause aids in the overall managementof chronic and acute wounds

Resources

KCI1.com

KCI Advantage Center1-800-275-4524

24/7!

Reps On-Call

Territory Manager

Service Consultants

References1. Van Rijswijk L. Wound assessment and documentation. In: Krasner DL, Rodeheaver GT,

Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for HealthcareProfessionals. 3rd ed. Wayne, Pa: HMP Communications; 2001:104.

2. Ovington, LG. Hanging Wet-to-Dry Dressings Out to Dry. Advances in Skin & WoundCare. Vol 15 No 2. March/April 2002:79-86.

3. Pain Dictionary. (2009). Retrieved September 14, 2013, from http://less-pain.com/en/Pain-Dictionary

4. Smith & Nephew. Wound Bed Preparation: A Guide to Advanced Wound Management

5. Mulder, GD. (1994) Quantifying wound fluids for the clinician and researcher.Ostomy/Wound Management; 40(8):66-69.

6. Flanagan, M. (1997) Wound Management, Churchill Livingstone

7. Schultz, GS, Sibbald GR, Falanga, V, et al. (2003) Wound Bed Preparation: A systematicapproach to wound management. Wound Repair and Regeneration; 11(2): 1-28.

8. Moffatt, C, Franks, P, Hollinworth, H. (2002) Understanding wound pain and trauma: aninternationtal perspective. EWMA Position Document: Pain at Dressing Changes: 2-7

9. Mazzotta MY. (1994) Nutrition and wound healing. Journal of American PodiatryMedical Association; 84: 456-462.

10. P Milnes, WOCN. Personal Communication, August 13, 2013.

11. Mölnlycke Health Care. www.molnlycke.com

12. KCI Product Information. 1998-2013. http://www.kci1.com/KCI1/home

13. Medline Product Information. http://www.medline.com/

14. ConvaTec Product Information. http://convatec.com/