Jeanne Lowe PhD, RN, CWCN

VA HSR&D Center of Excellence

Objectives:

•Describe skin function and structure

•Discuss normal phases of healing

•Identify factors that can interfere with normal healing

•Describe basics of wound assessment

•Discuss different categories of wound dressings

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Functions of the SkinProtectionThermoregulationSensationMetabolism Communication

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EpidermisDermis

Subcutaneous Fat

Muscle

Bone

Skin Structure

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Factors Contributing to Impaired Skin IntegrityCirculationNutritionCondition of the

EpidermisAllergiesInfections

Systemic DiseasesTraumaExcessive ExposureMechanical Forces

FrictionShearingPressure

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Phases of Wound HealingHemostasis and Inflammation

Platelets releasevasoactive substance

causing permeabilityenzymes that attract

leukocytesgrowth hormones that

influence fibroblastsWound develops

erythema and edema

Phases of Wound HealingWound “clean up”

Neutrophils arrivePhagocytosis

Macrophages appear within 3-4 daysPhagocytosisRelease of enzymes

that trigger fibroblast response

Stimulate angiogenesis

Wound RepairRegeneration of injured cells by cells of same type

(i.e. Epidermis, bone)

Replacement by fibrous tissue (fibroplasia, scar formation)

Fibroplasia (Proliferation)Occurs within the granulation tissue

framework (new blood vessels and loose collagen)

Proliferation of fibroblasts at site of injuryGrowth factorsCytokines

Surgical WoundIntentional injury that disrupts blood vessels and

causes clotting and cascade of events that leads to wound closure within 2 to 4 weeks

History of Surgery 18th Century surgeons were

apprentices of barbers and

butchers

Primary Closure

Patient Risk Factors for Post-Surgical Wound Complications

ObesityDiabetesImmunosuppressionCardiovascular diseaseSmokingCancerPrevious surgeryMalnutrition

Surgical Wounds: Complications

HemorrhageHematomasInfectionDehiscenceEviscerationFistula

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Incision Healing TimeEpithelial resurfacing complete at 2-3 days

No tensile strength, but impenetrable to bacteria

“Healing ridge” 5-9 daysLack of ridge = interventions to reduce incisional strain

Most dehiscences occur 5-8 days post-op, and about half are associated with infection

Incision Care Cover with dry sterile dressing 24 to 48

hours, then open to airGently wash between sutures/staples to

remove crustsReport persistent pain, bleeding,

erythema, wound edge separation or cloudy drainage

Wound Closure Aids

Steri-stripMontgomery strapsMedical StaplesSutures

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Steri-Strips

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Montgomery Straps

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Medical Staples

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Suture/Staple RemovalUsually removed 7-10 days post-opIncisions over areas with tension up to two

weeksIf concerned about incision dehiscence:

Remove every other oneSteri-strip

Wound DehiscenceFascial or Cutaneous

disruptionHeavy bacterial loadLong time-lapse since

woundingCrushed or ischemic

tissue – severe contused avulsion injury

Sustained high-level steroid therapy

Secondary Intention(includes chronic wounds)

Large tissue defectMore inflammationMore granulation tissueWound contraction - myofibroblasts

Factors Inhibiting Wound HealingMedication

Cortisone, and epinephrineMalnutrition

Protein & caloriesVitamin & mineral deficits

Zinc, Vitamin A, Vitamin C, Vitamin EDehydrationEdemaPerfusionChronic illness & other conditions

i.e. diabetes, CHF, immobility

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Principles of Wound CareKeep wound moist

Manage drainage

Fill deep wounds

Control bacterial load

Protect wound from trauma

Assess healing

Keep Wounds Moist Select dressings that maintain moisture.

Minimize time that wounds are open to air.

Add moisture to wound bed?

Maceration makes skin more fragile.

Excessive drainage requires nursing time.

Manage Drainage

Fill Dead SpaceFill wound with

dressing

Be careful not to over-fill (no rocks)

Control Bacterial LoadTake time to wash or

irrigate wounds to decrease bacterial load.

No need to scrub!

Protect From TraumaBe gentle to skin

Use non-stick dressings

Minimize tape

But . . .

Remember to protect yourself from splash

AssessKnow what is under

the dressing

Know typical healing pattern

Size matters

Document

Document findingsLocation

Size (length / width / depth)

Wound base

Drainage

Surrounding skin

Systemic infection

What we’re doing

Wound Documentation:Wound Base Descriptors

Granulation tissueRed, cobblestone/beefy.Only in full thickness

wounds

Epithelial tissueRegrowth of epidermisPink or pearly Smooth, shiny

Wound Documentation:Wound Base Descriptors

SloughNecrotic/avascular tissue.Moist.Can be white, yellow, tan, or

green.

EscharNecrotic/avascular.Black or brownHard or soft.Often leathery adherent tissue.

Wound Healing BasicsWounds do best in moist environment

not too wet, not too dryLoosely pack when needed

tight packing → injury to wound bed.Protect peri-wound skin

No Sting BarrierCleanse/irrigate before assessmentPre-medicate for pain prior to dressing changesIf culture is needed

cleanse wound thoroughly prior to swabbing swab in area of granulation/viable tissue if present. Never culture dressing!

Product SelectionFrequency of change

Ease of procedure

Caregiver ability

Availability of products

Cost/reimbursement factors

Dressing Purposes:To absorb drainageTo prevent contaminationTo prevent mechanical injury to the woundTo help maintain pressure to prevent

excessive bleedingTo provide a moist wound environmentTo provide comfort

Alginates/Fiber Gelling Dressings Antimicrobials Collagen Contact Layers Foams Gauze & Impregnated Gauze Hydrocolloid Hydrogels (Amorphous) Skin Sealants Topical Debriders Negative Pressure Therapy Compression Therapy

Topical Wound Care Products

Gauze Packing(Kerlix, Nu-gauze, 4 x 4s)

description - inexpensive, user dependent

indications - to fill deep defects to maintain moisture and absorb exudate, may be soaked with antibiotic solution

considerations - pack lightly, may cause surrounding wound maceration, may traumatize wound if allowed to dry

Contact Layer Dressings (Greasy gauzes, N-terface, Adaptic, Xeroform, Mepitel)

description - nonadherent, prevents trauma and permits exudate to “pass through” pores of dressing for absorption by a secondary dressing, inexpensive

indications - superficial wounds with minimal to moderate exudate

contraindications - if goal is to “clean up” wound

Hydrocolloids (Duoderm, Comfeel)

description - absorbs exudate, maintains moisture, insulates, protects from secondary infection, non-permeable

indications - or superficial wounds with minimal to moderate drainage

contraindications - infected woundsTypically changed every

3 - 5 days

Polyurethane Foam (Mepilex,Biatain, LyoFoam)

description - nonadherent foam, absorbs exudate, insulates, variable protection from environmental contaminants (outer layer water proof or water-repellent)

indications - superficial weeping wounds, cover for deep (packed) wounds

leave on for 3 - 5 days or change when cover-layer is at least

50% saturated

Hydrogels (solid gel sheets or amorphous gel)

description - nonadhesive, maintains moisture, protects wound and allows visualization, non-absorptive

indications - superficial wounds with minimal drainage; amorphous gel may be buttered on semi-dry red wound before applying moist dressing; good dressing for arterial ulcers

contraindications - heavily exudating wounds

Alginates / Fiber Gel (Kaltostat, Sorbsan, Medifil, Aquacel)

description - applied to wound dry but forms gel with absorption of exudate

indications - heavily exudating wounds to allow daily or QOD dressing changes

contraindications - minimally exudating wounds (it will stick to wound and dehydrate)

Moisture BarriersBarriers are products

that wick away moisture from skin

ContainZinc oxideDimethiconePetrolatumPolymer(i.e. SensiCare,

Proshield, Perineal wipes, No Sting)

Compression Therapy(Profore, SurePress, Jobst, Isotoner)

description – Single or multi-layer compression bandage or stocking usually applied over primary dressing

indications – management and treatment of venous leg ulcers. Can be left on for up to one week.

contraindications – do not use on patients with ABI <0.8 or on diabetic patients with advanced small vessel disease

Tapes and Adhesives

Consider gentleness to skin

Consider cost

Consider job to be done

Clinical InterventionsMonitor skin at every visitEvaluate type of skin care practicesAssess patient and/or caregiver abilityMinimize exposure of skin to moisture from

incontinence, perspiration, or drainageEvaluate need for specialty mattresses or

seating cushionsAssess nutritional status

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Nutritional DeficitsDetermine barriers to the patient eating sufficient quantities of quality food

Nutritionist consult? Diabetes education?

Moisture and incontinenceMinimize exposure to moisture and soilingUse briefs and underpads to wick away

moisture from skinTeach patients & caregivers to cleanse

skin at the time of soilingUrine & feces very caustic

Use barrier cream as necessary

Pressure Ulcer PreventionAssess for risk factors: immobility,

moisture & incontinence, inadequate nutrition, impaired sensation or perception, decreased activity, exposure to friction & shear

Incorporate risk assessment into plan of care

Monitor patient’s skin at each visit

Document Evaluation Is the skin intact? Is the wound healing? Did the interventions work or

not? If no progress at two-week assessment, time to

change interventions If yes, do you want to continue? If no, how do you want to revise? Does patient understand risk factors and wound care

plan?

89-year-old male with hx of COPD with chronic steroid use. Uses 2 L O2 at home and smokes 1/2 pack cigarettes a day. Hx. Includes DM, depression, and prostate cancer.

Presents to your clinic with right forearm wound after scraping arm against wheelchair.

Case Studies

49-year-old male with hx of IV heroin use. Smokes 2 packs cigarettes a day. Hx also includes Hep C, depression, and hypertension.

Presents to your clinic with fever, chills, and right lower limb wound that he has had for months.

Case Studies

46 year-old female admitted to hospital for elective surgery to remove renal growth. Morbidly obese, uses 2 L O2 at home, smokes 2 packs a day. Hx includes DM, depression, sleep apnea. Rarely gets out of bed at home (able to walk w/ assistance to bathroom).

Suspected deep tissue injury to sacrum present on admission. Wound surgically debrided.

Warning . . .

Case Studies

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