Wound Care 101

Wound Classification
Etiology¹
Wound Care 101
Heather Grady, MPA, PA-C
CAPA Conference
October 9, 2014
Superficial wound
Involves only the epidermis
Partial-thickness wou nd
Affects the epidermis,
and may extend into the
dermis but not through it
DERMIS
SUBCUTANEOUS
Full thickness wound
Extends through the
dermis into tissues
beneath; adipose tissue,
muscle, or bone may
be exposed
MUSCLE
BONE
Acute and chronic
Depth¹
Superficial, partial-thickness, and fullthickness
Pressure ulcer staging
Comparison of superficial,
partial-thickness and fullthickness wounds
EPIDERMIS
Surgical/non-surgical
Wound Assessment Model1
Surrounding Skin
Asses for color, moisture, suppleness
Size
Measure
and/or
trace
wound
area.
Measure
depth
Wound
Assessment
Wound Bed
Assess for
necrotic and
granulation
tissue, fibrin
slough,
epithelium,
exudate, odor
Wound Edges
Assess for
undermining and
conditions of
margins
Wound Bed
Necrotic tissue – Eschar
– Dry, black or brownish devitalized tissue 4
Slough – Formed when a collection of dead
cellular debris accumulates on the wound
surface4
– Yellow or yellow-white, due to the large amounts
of leukocytes present
Eschar
Granulation tissue – Indicator of normal
healing in full thickness wound 4
– Bright red in color
Granulation
Tissue
Epithelialization – newly formed epithelial
cells that have a translucent appearance 4
– Usually whitish-pink or pinky-purple in color
Slough
1
Granulation Tissue4
Wound progression from slough to granulation tissue
Documentation –
Quantify the estimated
percentage of tissue
involved (e.g. wound
contains ± 50%
granulation tissue, ±
25% necrotic tissue and
± 25% fibrin slough)1
Healthy Granulation
Tissue
Bright Red
Moist
Unhealthy Granulation
Tissue
Dark red/blush
discoloration or pale
Dehydrated
Shiny
Dull
Does not bleed easily
Bleeds easily - fragile
Granulation tissue and epithelialized
tissue
Criteria for Indentifying
Wound Infection4,6
Exudate4,5
Exudate
Type
Color
Consistency
Descriptor
Significance
Serous
Clear
Thin watery
Clear fluid absence of
bloo d, pus debris
Normal
inflammatory/proliferative
phases of healing
Sanguinous
R ed
Thin watery
Bloo dy,composed entirely
of bl ood
Indicates new vessel
growth or disruption
Serosanguino us
Light red/pink
Thin watery
Bloo d mixed with clear
fluid
Normal
inflammatory/proliferative
phases of healing
Seropurulent
Cloudy yellow
Thin watery
Pus mixed with watery
fluid
May be first signs of
wound infection or
autolytic debridement
Purulent/Pus
Yellow/green
Thick, opaque
Pus, cloudy, viscous often
malo dorous
Wound Infection
Indicates wound infection
Surface
discoloration –
yellow/green hues
Increased
exudate
Cellulitis and
Inflammation
Friable granulation
tissue –
bleeds easily
Increased odor
Wound
Infection
Superficial
pocketing or
bridging of
wound base
Abscess
formation
Increased
discomfort and
tenderness
Wound
deterioration or
dehiscence
Non-Healing wound
Factors 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
2
Antibiotics
Systemic antimicrobial therapy should
be used when active infection can’t be
managed with local therapy4
– Fever
– Underlying deep structure infection
– Spreading cellulitis
Dressing Basics
Type and amount of drainage dictates
the type of dressing used
If a wound is too dry, hydrate the
wound with gels
If a wound has too much drainage, use
foams to absorb the moisture2,10
Wound Basics
Standard of care is no longer
wet-to-dry dressings
– This keeps wounds in a constant
inflammatory state, slowing
down wound healing2
With any wound, always take
care to protect the periwound
edges10
Don’t desiccate the wound
bed
Wound Margin &
Surrounding skin
Prolonged exposure
of the skin to
wound exudates
can result in skin
maceration
Indicates
– Wound dressing is not
being changed
frequently enough
– Dressing contains too
high a water content
– The absorptive
capacity of the
dressing is not
aligned to meet with
the exuding fluid
volume4
Film = Poly skin
Hydrogel = Duoderm gel
Hydrocolloid = Duoderm
Alginate = Aquacel, & Aquacel AG
Foam = Allyven foam – with and without adhesive
Specialty dressing
– M epitel – silicone contact layer
– M epilex foam – silicone foam dressing – with and without
adhesive border
– Polymem – foam dressing but with surfactant which
cleanses 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 away
moisture
– Anti-microbial – dressings with silver, Acticoat
3
Exceptions to the Rule
If the patient has decreased vascularity
and you want to keep the bacterial count
down
– Keep the wound dry and paint it with betadine
Eschar often can be used
as a physiologic dressing
(especially with wounds on the
feet) and wound will heal under
the eschar10
Wounds and Nutrition
Protein is essential for the formation
of new granulation tissue.
Severe protein malnutrition results in
– Slower wound healing
– Decreased immunocompetence
– Increased susceptibility to infection4,9
Wound Pain
Surveys have shown that clinicians
identify dressing removal as the most
painful part of dressing procedure and
that gauze is most likely to cause pain
Newer products were least likely to
cause pain and skin trauma. These
include hydrogels, alginates and
silicone dressings4,8
Aging Population
Patient population is getting older and the
disease processes associated with these
patients are increasing10
Medications and co-morbidities need to be
taken into account when addressing wound
care because they can impede wound
healing
Medications impact wound healing
– ie. steroids, NSAIDs, anti-coagulation
Co-morbid diseases also affect healing
– ie. COPD, DM, A-fib, pneumonia
Types of Dressings
Old School of Thought
Wet-to-Dry dressings
– Gauze is inserted wet, covered with dry gauze
and it dries out, then removed after adhering to
surface tissue2
– Typically intended for use in the debridement of
devitalized tissue from a wound bed 2 or to keep
a wound open that may have a small skin
opening but tunnels more deeply
Types of Dressings
New Technology
NPWT - Negative pressure
wound therapy12
– Creates an environment that
promotes wound healing by
secondary or tertiary intention
(delayed primary by:
Preparing the wound bed for closure
Reducing edema
Promoting granulation tissue
formation and perfusion
Removing exudate and infectious
material12
Advanced wound healing therapy
4
Skin Tears
Skin Tears
Seen mostly in older patients – skin
becomes thinner as we age
Address medications and co-morbidities
Surrounding edema will affect healing as
well
Treatment
1. Stop bleeding
2. Attempt to approximate skin edges
3. Don’t cause additional trauma to
surrounding skin
4. Can take up to 4 weeks to heal10
Hemostasis
Achieving hemostasis can be hard,
especially if patients are on anticoagulants such as Coumadin or
Plavix or if they are on steroids
May need products such as Surgicel or
other agents that help prevent
formation of hematoma
Steri-Strip Wound
Approximating Skin Edges
If skin edges or skin flap remains, attempt
to approximate
Apply skin prep first (or Benzoin) to skin
flap and intact skin
Hold in place with steri-strips, leaving a
space between each steri-strip to allow for
drainage
Cover with silicone dressing (Mepitel) that
helps absorb drainage and is less traumatic
Use Telfa, covered with Kerlix or Cling and
stockinette (great for use on extremities)10
Types of Dressings
Silicone Dressings
– Does not adhere to skin
– Great on fragile, thin skin
– Used on skin tears
5
Silicone Dressing
Additional Thoughts
Treat with antibiotic or antimicrobial if
concerned about infection or
contamination
Don’t apply a transparent dressing such
as op-site
Once evaluated, leave area alone for 5
days
May use xeroform as last resort
Complications
Skin flap doesn’t take
– Debride the area and treat as an open
wound
Hematoma
– Evaluate if it needs to be evacuated
Additional Dressings
Polymem – surfactant and glycerine
dressing 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 if
concerned about infection
– Bacitracin ointment on the face
– Triple antibiotic ointment on all other surfaces
– Cover with Telfa, silicone dressing or Polymem
Hematomas
To evacuate or not??
Need to really look at comorbid diseases
Hematomas are a
breeding ground for
bacteria; however,
evacuating a hematoma
leaves an open wound
and bleeding may persist
if patient remains on
anti-coagulant 10
When not evacuating wound
Silicone or antibiotic silicone dressing can
be used and it won’t disrupt the hematoma
but still allows for close monitoring
Cover the silicone dressing with a foam or
padded dressing to help protect the
hematoma
Patients must be monitored very closely
It will take time for the hematoma to be
reabsorbed
6
Evacuation
If eschar is forming then the wound will
need to be evacuated
If wound is evacuated, you must see the
base of the wound to fully evaluate it
Apply pressure if bleeding continues
once hematoma is evacuated
May need to use products such as coban
to assist with applying pressure10
Diabetic Foot Ulcers
Additional Problems with
Hematomas
Older patients may have vascular
insufficiency adding to edema and decreased
oxygenation to the tissues causing stagnant
blood
– Especially seen in patient with renal failure and
vascular insufficiency10
Antibiotics
– Don’t recommend antibiotics unless signs of
infection or contaminated process such as wound
occurred 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 Ulcers
Never what they appear, always look
benign
Usually associated with other
underlying diseases that affect healing
such as PVD and arterial disease
For this reason, must always assess
vascularity 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 of
foot) to r/o osteomyelitis. If unable to get
one of these imaging studies, get bone scan
Always probe wound
– The inflammatory
process is usually
delayed resulting in
possible undermining,
tunneling, fluid
collections 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 to
shoes.
Limb salvage – Refer directly to a podiatrist if
you do not see signs of healing (partner with
a podiatrist to help treat these types of
wounds)
Wound may need to be incised and drained
7
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 3-4
weeks before referring to podiatry
Types of Dressings
Alginate
– A dressing made from seaweed,
creating a gel form of dressing3
– Best used in moderate to highly
exudating wounds3
Recalcitrant Wounds
Types of Dressings
Hydrofiber
– Highly absorbent dressing made of 100%
hydrocolloid. The hydrocolloid is spun into
fibers that make a soft, non-woven fleece-like
dressing that comes as a sheet or ribbon3
– Used as an alternate to
alginate dressing. This
dressing retains a high
quantity of water without
releasing it, thereby
forming a thick
comfortable gel3
Types of Dressings
Hydrogels
– Comes as a sheet or a gel
– Sheets are used for shallow or low
exuding wounds3
– Gels are used for cavities and are
effective for desloughing and
debriding wounds. Gels have a high
water content which aids the
rehydration of hard eschar and
promotes autolysis in necrotic
wounds3
– To prevent possible maceration, a secondary
barrier film may be applied to peri-wound area3
Pressure Ulcers
Biofilm can develop and nothing can
impregnate it keeping wound in the
inflammatory stage
Wound will need sharp
debridement
Evolving field – Lab in
Texas will tailor
treatment based on
tissue specimen,
genetics, bloodwork and
location of wound
8
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 dark
red/purple/maroon, hard/bony surface,
won’t blanche
Pressure Ulcers
Stage 1 and 2
Early stages may start to evolve
Will start to look diffuse with edges
not well defined. Pink edges, purple
area may open up and evolve to an
open wound stage ulcer
Staging System
Should be used as an admission
diagnosis system only4,10
Not designed to capture changes that
occur during the healing process
Changes in the wound status should
be documented as area and depth
assessment, not “reverse staging”4,10
Treatment of Pressure Ulcers
Stage 1 and 2
Always off-load
Observe frequently
Silicone products will off-load and
absorbs drainage
– Some wounds may heal with silicone alone
May also use hydrocolloids (DuoDerm)
or Foam dressings
Stage 1
Stage 2
Types of Dressings
Hydrocolloids
– Waterproof, occlusive dressing that consists
of a mixture of pectin, gelatine, sodium
carboxymethylcellulose and elastomers 3
- Creates an
environment that
encourages autolysis
to debride wounds
that are sloughing or
necrotic3
Types of Dressings
Foams
– Dressing produced from polyurethane - soft,
open cell sheets3
– These are non-adherent and can absorb
large amounts of exudate3
– Also available impregnated with charcoal
(attracts and traps bacteria and odor) and
with waterproof backing3
Silver dressing
– Dressing impregnated with Silver – antimicrobial dressing
– Used to treat infected wounds
9
Considerations with Treatment
What is the causative agent of the ulcer?
Nutritional status?
– May need to add Ensure, Megace or tube feedings
Hydration?
Pressure Ulcers
Stage 3, Stage 4 and
Unstageable
Stage 3
Stage 4
– Is the patient dehydrated?
UTI?
Frequent pneumonia?
Local care is needed to heal wound but must also
find the underlying cause and address it4,10
There may be a short term cause such as a fracture
but if there is no short term cause, need to find the
reason for the ulcer
Treatment of Pressure Ulcers
Stage 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 and
debride wound
– If odorous, use ¼ strength Dakin’s solution on
gauze. This will improve odor and debrides.
Use for about 3-4 days.
Treatment of Pressure Ulcers
Stage 3 and 4
Unstageable
Autolytic Debridement
Results in little to no
pain or wound
trauma
However, it is a
slower method of
debridement
May be
contraindicated if
there is a high
bacterial burden in
the wound4
Abscess
Always protect periwound skin with
ointment (moisture retentive) to protect
healthy skin from maceration caused by
excessive drainage
– Calmoseptine or A&D ointment
Apply ointment under foam or ABD pad that
will allow the drainage to be soaked up
Can use fiber type fillers such as alginate or
hydrofiber to fill dead space
10
Road Rash
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
Must be very diligent to scrub all debris
from wound within first 24 hours
– If debris is not removed, patient will get tattoo
from wound
Shower daily with CHG (Chlorhexadine
Gluconate) 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 deters
dressing from sticking and dressing changes will
be less frequent
NPWT
(Wound VAC – Vacuum Assisted Closure)
Used for treatment
of open wounds
Negative pressure
therapy
Controls edema and
provides support to
incision/wound
Improves healing
and decreases
treatment time 12
Other Wound Care
Dakins solution
– Used for malodorous,
soupy wounds with
stringy/yellow debris
– Or used if you suspect
pseudomonas (greenish
appearance to wound or
drainage)
Non-healing wounds
– Always need biopsy to
r/o SCC or other
possible inflammatory
process
Creates an environment that
promotes wound healing12
Microstrain
Reduces edema
Macrostrain
Draws wound edges
together
Promotes perfusion
Promotes granulation tissue
formation
Cell mitosis/proliferation
Removes exudate
Removes infectious
materials
Fibroblast migration
11
Types of Wounds12
Chronic
Acute
Traumatic
Subacute
Dehisced Wounds
Partial-Thickness
Burns
Ulcers (such as
diabetic, pressure,
Venous)
Flaps and Grafts
VAC Dressing Types12
V.A.C.
Granufoam
Dressing
Reticulated (open) pore
Polyurethane ideal for:
Deep acute wounds
Traumatic wounds
Diabetic & Pressure ulcers
Draining or dry wounds
Flaps and grafts (with nonadherent)
V.A.C. White
Foam Dressings
Dense (higher tensile strength) openpore Polyvinyl Alcohol ideal for:
Tunneling/tracts/undermining
Painful wounds
Wounds requiring controlled growth
of granulation tissue
Superficial wounds
V.A.C.® Drape
Easy as…1…2…Blue
Reticulated (open) celled Polyurethane
micro-bonded with silver to provide a
protective 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
V.A.C. Canisters
99.9% of pathogens
eliminated Within the
first 30 minutes
Contraindications 12
Do not place foam dressings of the V.A.C.®
Therapy System directly in contact with
exposed blood vessels, anastomotic sites,
organs, or nerves
Malignancy in the wound
Untreated osteomyelitis
Non-enteric and unexplored fistulas
Necrotic tissue with eschar present (after
debridement V.A.C. Therapy may be used)
Sensitivity to silver
Warnings, Precautions and Safety Tips
Protect Vessels and Organs: All exposed
or superficial vessels and organs in or
around the wound must be completely
covered and protected prior to the
administration of V.A.C.® Therapy
Protect Tendons, Ligaments and Nerves:
Tendons, ligaments and nerves should be
protected to avoid direct contact with
V.A.C. Foam Dressings. These structures
may be covered with natural tissue, meshed
non-adherent material, or bio-engineered
tissue to help minimize risk of desiccation
or injury12
12
Warnings, Precautions and Safety Tips
Dressing Application
V.A.C. Therapy On: Never leave a V.A.C. Dressing in
place without active V.A.C. Therapy for more than
2 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 an
unopened sterile package and restart V.A.C.
Therapy; or apply an alternative dressing at the
direction of the treating clinician
Bleeding: With or without using V.A.C. Therapy,
certain patients are at high risk of bleeding
complications
1000 mL Canister: DO NOT USE the 1000 mL canister on
patients with a high risk of bleeding or on patients
unable to tolerate a large loss of fluid volume.
MRI, X-Ray & HBO12
Basic Dressing
Target Pressure 125 mmHg
(125-175 white foam)
Continuous first 48 hrs
Intermittent if tolerated
Dressing change every 48-72 hrs
Framing: Wounds with Small
Openings
Tunneling: White foam and
GranuFoam
Target Pressure 125 mmHg
(125-175 white foam)
Continuous
Dressing change every 48-72 hrs
Bridging
Target Pressure 125 mmHg
(125-175 white foam)
Continuous first 48 hrs
Intermittent if tolerated
Dressing change every 48-72 hrs
13
Resources
Final Thoughts
Wound assessment is as important as
treating the wound itself
Type and amount of drainage now
dictates the type of dressing used
Take care to protect the periwound area
Identifying and treating the underlying
cause aids in the overall management
of chronic and acute wounds
KCI Advantage Center
1-800-275-4524
24/7!
Reps On-Call
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Service Consultants
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References
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Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare
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Ovington, LG. Hanging Wet-to-Dry Dressings Out to Dry. Advances in Skin & Wound
Care. Vol 15 No 2. March/April 2002:79-86.
Pain Dictionary. (2009). Retrieved September 14, 2013, from http://lesspain.com/en/Pain-Dictionary
Smith & Nephew. Wound Bed Preparation: A Guide to Advanced Wound Management
Mulder, GD. (1994) Quantifying wound fluids for the clinician and researcher.
Ostomy/Wound Management; 40(8):66-69.
Flanagan, M. (1997) Wound Management, Churchill Livingstone
Schultz, GS, Sibbald GR, Falanga, V, et al. (2003) Wound Bed Preparation: A systematic
approach to wound management. Wound Repair and Regeneration; 11(2): 1-28.
Moffatt, C, Franks, P, Hollinworth, H. (2002) Understanding wound pain and trauma: an
internationtal perspective. EWMA Position Document: Pain at Dressing Changes: 2-7
Mazzotta MY. (1994) Nutrition and wound healing. Journal of American Podiatry
Medical Association; 84: 456-462.
P Milnes, WOCN. Personal Communication, August 13, 2013.
Mölnlycke Health Care. www.molnlycke.com
KCI Product Information. 1998-2013. http://www.kci1.com/KCI1/home
Medline Product Information. http://www.medline.com/
ConvaTec Product Information. http://convatec.com/
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