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
