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