Wound care

Assessment

MEASURE acronym
- Measure (length, width, depth, and area)
- Exudate (quantity and quality): serous, serosanguineous, sanguineous, seropurulent, purulent
- Appearance (wound bed, including tissue type and amount): granulation, fibrin, slough, eschar
- Suffering (pain type and level)
- Undermining (presence or absence)
- Reevaluate (monitoring of all parameters regularly)
- Edge (condition of edge and surrounding skin)

Management

Care Plan

Appropriate management includes patient factors, local wound factors, and environmental measures, and requires regular reassessment

Patient Factors

Manage comorbidities (e.g. diabetes, arterial disease, etc)
Address risk factors when possible
Optimize nutrition and hydration
Manage other infections
Treat symptoms
Provide psychosocial support
Prescribe appropriate antibiotics
Create and individualized management plan
Educate the patient and family

Local Wound Factors

See below for more information
Prevent infection using aspetic technique and universal precautions
Drain wounds
Ensure good wound hygiene and protection
Manage exudate
Optimize wound bed
- Debride non-viable tissue
- Disrupt biofilm
- Clean with each dressing
- Use appropriate antimicrobial dressings
- Use appropriate antiseptic therapy (each should have at least a 2 week trial)

Environmental Factors

Ensure a clean environment for wound care
Store equipment safely
Educate patient and caregivers
Review policies and procedures

Regular Reassessment

Follow wounds over time for changes
Make adjustments as necessary to management plan

Local Wound Care

Wound Cleansing

Saline, sterile water, tap water, or liquid antiseptics (povidone-iodine, etc)
- The antiseptic solutions often disrupt or penetrate biofilm
- Antiseptics include povidone-iodine, PHMB, OCT, HOCl/NaOCl
If infection suspected, use antiseptic or surfactant
Irrigate with gentle pressure; do not scrub

Debridement

Removing necrotic or devitalized tissue, including slough, pus, debris, etc, can help healing
- Moist necrotic tissue is an excellent medium for bacteria
Selective (only non-viable tissue) generally preferred over non-selective debridement
Specific techniques include:
- Mechanical: most common. Physically removes the tissue.
  - Wet-to-dry dressing: apply wet tissue, allow to dry, then remove. This causes pain and is discouraged
  - Irrigation: with 4-15 psi can dislodge bacteria and debris. Can be done with syringe and 18-19 gauge needle
  - Polyacrylic microfibre pads: now out of favour
  - Low-frequency ultrasound
- Autolytic: allows body's own immune system to get rid of dead tissue (e.g. liquefaction of eschar)
  - Scoring or crosshatching the eschar with a scalpel
  - Using dressings that promote autolysis
  - Must keep wound clean
- Enzymatic: the use of exogenous proteolytic substances such as collagenase
  - Dry eschar must be kept moist for the enzymes to work
- Surgical: converts a chronic non-healing wound into an acute wound by a surgeon in an OR
- Conservative sharp: removal of devitalized tissue with a scalpel or scissors
- Chemical: e.g. sodium hypochlorite (NaOCl), but is non-selective and can damage healthy tissue
- Hydrosurgical: uses specialized tools and a surgeon
- Biological/biosurgical: maggots

Bacterial Balance

Antimicrobial includes both antibiotics and antiseptics
Bacterial burden ranges from contamination to colonization, local infection, spreading infection, and finally systemic infection
- Intervention is required for any infection
- Biofilm should be considered for any infection

Topical Antimicrobials

Includes gential violet, methylene blue, honey, iodine, PHMB, silver, and hydrophobic agents
- These reduce bacterial burden or disrupt biofilm
- May be used prophylactically, as well
- Iodine is contraindicated in breastfeeding and pregnant women, and in renal disease, and should be used with care in patients with thyroid disease

Moisture Balance

The goal is for the wound to be moist enough to promote healing without being so wet as to promote maceration and irritation
Primarily done using occlusive dressings

Wound Dressing

The primary dressing is that which is in direct contact with the wound bed, and is covered by the secondary dressing which may help to contain exudate

Selection

By tissue type
- Epithelium or granulation tissue
  - Healing wound
    - Dressing or combination that can remain in place as long as possible to maintain an appropriate moisture balance
    - Acrylic, calcium alginate, film/membrane, foam, gauze (used for daily dressing changes only), gelling fibre, hydrocolloid, hydrogel, non-adherent synthetic contact layer
  - Non-healing wound: acrylic, film/membrane, foam, gauze (used for daily dressing changes only), hydrocolloid
  - Non-healing wound with friable or inflamed tissue: biologic dressings with protease inhibitors, calcium alginate, silver compounds ibuprofen-impregnated dressings
  - Non-healing wound without inflamed tissue: iodine compounds, honey
- Slough or eschar
  - Healing wound
    - Support autolytic debridement and absorb excess exudate
    - Acrylic, calcium alginate, film/membrane, foam, gauze (for mechanical debridement), gelling fibre, hydrocolloid, hydrogel, hydrophilic dressing, hypertonic
  - Non-healing
    - Gauze ± chlorhexidine derivative
    - Non-adherent synthetic contact layer ± iodine compound
By amount of exudate
- Wound too dry
  - Add moisture, require less frequent dressing changes, and prevent trauma with changes
  - Acrylic, film/membrane, hydrocolloid, hydrogel, hydrophilic dressing, non-adherent synthetic contact layers
- Wound too wet
  - Absorb moisture, more frequent dressing changes, protect surrounding tissue from moisture
  - Calcium alginate, foam, gauze (daily dressing changes), gelling fibre, hypertonic
By type of exudate
- Serous: foams, gauze, gelling fibres
- Serosanguineous: calcium alginate, absorbable hemostatic agents, non-adherent synthetic contact layers
- Purulent: charcoal, antimicrobial dressings
By periwound tissue
- Macerated or excoriated
  - Dry and protect the periwound tissue
  - Films/membranes, hydrocolloids, hydrophilic dressing
For infection, consider antimicrobial agents and hypertonic dressings
For wound pain
- Choose primary dressing to prevent adherence to the wound bed or prevent periwound maceration
- Foam dressing with ibuprofen, hydrogel, non-adherent synthetic contact layer
For deep, undermining, or tunneling wounds
- Dead space should be filled by packing
- Calcium alginate (except for tunneling wounds), specialized foam dressings, gauze, gelling fibre, hypertonic gauze ribbon

Locally-Available Brands

Acrylic: Tegaderm Absorbent Clear Acrylic Dressings
Foam: Mepilex Foam, Aquacel Foam
Hydrocolloid: Tegaderm Hydrocolloid Dressings
Non-adherent: Adaptic, Inadine