Our wound management starts with a thorough assessment of the wound and peri-wound skin.
One of our wound care specialists will be the caregiver to assess changes in a patient's skin and initiate wound care. Managing this, including wounds, can be challenging as patients present with diverse disorders and tissue damage can range from superficial to deep. But by applying a few basic principles, starting with a skin and wound assessment, our doctor can simplify the process and determine an appropriate treatment plan. The assessment should include the following components:
Wounds can be present over different anatomical parts of the body. However, the basic principles of choosing a wound dressing remain the same. In the United States, chronic wounds affect more than six million people, and this will grow in numbers due to our elderly and diabetic populations. Choosing the correct dressing will lessen the time of healing, provide cost-effective care, and improve the patient’s quality of life.
The goal is to help the wound heal as soon as possible by using an appropriate dressing material to maintain the right amount of moisture. When the wound bed is dry, use a dressing to increase moisture and if too wet and the surrounding skin is macerated, use material that will absorb excess fluid and protect the surrounding healthy skin.
Important criteria to consider before choosing a specific wound dressing are cleaning, absorbing, regulating, and the need to add medication. It is important to choose a dressing guided by the cost, ease of application, and clinician's preference.
Location can provide information regarding possible causes of the wound. For example, a wound over the sacral area in a bedbound or immobile patient could be a pressure injury, a wound in a lower extremity with accompanying edema could be a venous ulcer, and a wound on the plantar surface of the foot may be a neuropathic ulcer.
DEGREE OF TISSUE DAMAGE
Determining the degree of tissue damage in a wound will help to guide the care plan and will provide some information regarding the healing trajectory. Wounds can be described as partial thickness, with damage limited to the epidermal and/or dermal layers, or full-thickness with damage evident in the subcutaneous layers and below. For pressure injuries, the staging classification defined by the National Pressure Ulcer Advisory Panel (NPUAP) is used to describe the appearance of the wound and the extent of tissue damage.
TYPE OF TISSUE IN WOUND
The tissue in the wound bed can be described as viable or nonviable. Viable tissue can appear beefy red as with granulation tissue, or light pink in the case of new epithelial tissue. In contrast, the appearance nonviable or necrotic tissue varies: Eschar may be black, brown, or tan; fibrin slough is described as stringy or adherent and yellow in color.
Describe the size of a wound according to linear dimensions (length times width). Measure a wound's length using the head-toe axis; measure its width from side to side. If the wound has depth, measure from the deepest point of the wound to the wound surface using a sterile cotton-tip applicator.
WOUND EDGES AND PERI-WOUND SKIN
The outer edge of the wound can provide information regarding how long a wound has been present and may even assist in determining the etiology. Wounds over bony prominences with defined edges may be related to pressure. Venous wounds found on the leg are characterized by an irregular shape and undefined edges. Periwound skin can provide information about other factors that contribute to wound development or nonhealing. For example, weeping or excess wound drainage surrounding a venous ulcer can macerate peri-wound skin, giving it a wet, waterlogged appearance that may be soft and gray-white in color.
Note the presence or absence of signs and symptoms of local infection (erythema, induration, pain, edema, purulent exudate, wound odor) during the wound assessment. Keep in mind that patients with chronic wounds may not exhibit these classic signs and symptoms of infection due to the presence of biofilm. This extracellular polysaccharide matrix embeds microorganisms, delays healing, and renders infection difficult to diagnose.
The presence and intensity of pain associated with the wound can provide some important information regarding wound etiology and wound chronicity. However, the degree of pain may not correlate to the extent of the injury. Skin tears, for example, can be very painful because damage confined to superficial skin can expose nerve endings in the dermal layer.7 Conversely, patients with neuropathic ulcers on the plantar aspect of the foot and concomitant peripheral neuropathy may feel little or no pain, even if the wound is grossly infected.
IDENTIFYING WOUND ETIOLOGY
After the doctor conducts a thorough assessment of the wound and peri-wound skin, its etiology may become more evident. Common types of wounds encountered in the acute care setting include pressure injuries, venous ulcers, arterial ulcers, skin tears, diabetic foot wounds, and moisture-associated skin damage.
These are formerly known as pressure ulcers, which are defined by the NPUAP as localized damage to the skin and/or underlying soft tissue, usually over a bony prominence or related to medical or other devices. The injury can present as intact skin or an open ulcer and may be painful. The injury results from intense and/or prolonged pressure or pressure combined with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue. Pressure injuries are described according to the NPUAP staging system based on the damage that is clinically observed.
These are related to incompetence of the valves of the lower extremities, allowing blood to reflux into the superficial venous system and causing edema. Incomplete emptying of the deep veins can result in higher-than-normal pressure in the peripheral venous system of the lower extremities, which can eventually result in ulcerations.
These are result of severe tissue ischemia. One of the most common causes of lower extremity arterial disease and ulceration is atherosclerosis of peripheral arterial vessels.
DIABETIC FOOT WOUNDS
These are also called neuropathic ulcers. Peripheral neuropathy is present in over 80% of patients with foot ulcers. Neuropathy promotes ulcer formation by altering both pain sensation and pressure perception in the foot. Neuropathy can also alter the microcirculation and impair skin integrity. Once wounds occur, healing may be difficult to achieve, especially in patients with deep tissue or bone infections and in those with diminished blood flow to the foot.
A skin tear is defined by the International Skin Tear Advisory Panel (ISTAP) as a traumatic wound caused by mechanical forces (shear, friction, or blunt force), such as the mechanical force required to remove adhesives. Severity may vary by depth but does not extend through the subcutaneous layer. The doctor should use the classification system for skin tears developed by ISTAP to describe the degree of skin damage:
Type 1: no skin loss; a skin flap can be positioned to cover the exposed wound base.
Type 2: partial loss of the skin flap.
Type 3: total loss of the skin flap; the entire wound bed is exposed.
Moisture-associated skin damage (MASD) is defined as the inflammation and erosion of the skin that accompanies exposure to many different types of moisture, such as urine, perspiration, and wound drainage.15,16 Chronic exposure to moisture macerates the skin, impairing its protective mechanisms and disrupting normal skin flora, which can predispose the patient to cutaneous infections such as candidiasis. Incontinence-associated dermatitis (IAD), a subtype of MASD, is caused by chronic exposure to urine and/or liquid stool.
Once the wound is assessed and the etiology of the wound has been determined, the doctor can initiate topical therapy. Topical dressings create an environment that fosters the normal healing process. Bryant and Nix outline eight objectives for the caregiver to consider when selecting the most appropriate interventions.
PREVENTION & MANAGEMENT
One of the primary goals of topical wound care is to protect the wound base from outside contaminants such as bacteria. If the infection is evident in the wound, wound cultures should be considered and the need for topical antimicrobial/antiseptic products should be discussed with the primary provider.
Topical antibiotics destroy microorganisms; topical antiseptics inhibit microbial growth. Examples include cadexomer iodine, honey, silver sulfadiazine, and topical antibiotics. These products, which are covered with a secondary dressing, can be used in partial-thickness and full-thickness wounds that are infected or at high risk for infection. They should not be used long-term.
CLEANSE THE WOUND
Routine cleansing should be performed at each dressing change with products that are physiologically compatible with wound tissue. Normal saline is the least cytotoxic; when delivered at a pressure of 4 to 15 PSI, it is adequate to remove wound debris. Commercially available wound cleansers can also be used, but avoid hypochlorite solutions, betadine, hydrogen peroxide, and acetic acid in routine wound cleansing as these agents can be cytotoxic to fibroblasts.
DEBRIDE THE WOUND
If necrotic tissue is visible in the wound bed, removal of this devitalized tissue is indicated in most circumstances. One exception to this is stable, dry eschar on the heel. In this circumstance, leaving the eschar in place is recommended until the patient's vascular status can be determined.
Wound debridement can be accomplished with several different methods. Autolytic debridement, the slowest form of debridement, is accomplished through the use of moist topical dressings that foster autolysis of necrotic tissue. Enzymatic debridement is accomplished by applying the prescribed topical agent directly to the wound bed. It is usually applied daily and covered with a dressing such as a gauze, moistened gauze, or foam. Sharp wound debridement may be performed at the bedside (conservative wound debridement) or in the OR (surgical wound debridement) by a qualified healthcare provider. Wounds that are necrotic and showing signs of infection should be treated with sharp/surgical debridement as soon as feasible.
MAINTAIN APPROPRIATE MOISTURE
A moist wound environment has been shown to facilitate wound healing, reduce pain, and decrease wound infection. In wounds that are heavily draining, the nurse should apply the type of dressings that will help absorb excess drainage so that an appropriate level of moisture can be maintained in the wound bed.
ELIMINATE DEAD SPACE
Wounds that have depth need to be packed. Packing agents, such as normal saline and hydrogel-impregnated dressings, can keep the wound bed moist. In wounds that are too moist, alginate or Hydrofiber dressings can help control excess drainage. Packing material should be easy to remove from the wound base during each dressing change to avoid injuring healing tissue.
To manage odor, if present, the nurse should consult with the provider about the frequency of dressing changes, wound cleansing protocol, and the possible need for debridement or topical antimicrobials. The primary healthcare provider or wound care specialist should be consulted regarding treatment options to control wound odor.
MANAGE WOUND PAIN
Wounds that are painful should be thoroughly assessed for the presence of infection or other etiology (such as an associated fracture or a foreign object in the wound) and treated accordingly. The use of moisture-retentive dressings can help to decrease pain associated with dressing removal and can also decrease the need for frequent dressing changes in painful wounds.
PROTECT PERI-WOUND SKIN
Heavily draining wounds or the improper use of a moist dressing can lead to maceration of the peri-wound skin, altering tissue tolerance and damaging the wound edges. Skin barrier creams/ointments, skin protective wipes, or skin barrier wafers can be used to protect the peri-wound skin.
The selection of an appropriate topical dressing should be guided by the objectives described above. Always follow the manufacturer's guidelines in addition to your facility's policies and procedures for the specific use of these products. See Choosing a wound dressing for more details on common products used in the clinical setting.
Because wounds do not occur in isolation, wound management involves not only topical care but also attention to other systemic or local factors that can be contributing to wound development or impaired healing. Consider the following:
In the case of pressure injuries, minimizing pressure and shear must be part of the treatment plan.
With neuropathic wounds, decreasing the risk of further injury, especially in patients with diminished sensation, is an important educational intervention.
Controlling lower extremity edema in patients with venous ulcers through compression is a fundamental component of a successful treatment plan. Compression dressings and multilayer bandaging systems are the gold standard for venous ulcers.
Establishing adequate perfusion to the extremity in patients with arterial ulcers is essential to wound healing. Some patients will need revascularization to support healing.
In patients with skin tears, protecting the skin is a priority, especially in those with fragile skin or other risk factors.
In patients with a history of diabetes mellitus, glycemic control is an important factor to consider in wound development and wound healing.