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Basic Wound Basic Wound Assessment and Assessment and

ManagementManagementLPCH Pediatric Wound, Ostomy & Continence ServiceLPCH Pediatric Wound, Ostomy & Continence Service

ByBy

Claire Abrajano, RN, MSN, WOCN, PNPClaire Abrajano, RN, MSN, WOCN, PNP

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TerminologyTerminology Partial-thickness Partial-thickness

wound:wound: shallow wounds shallow wounds with tissue loss confined to with tissue loss confined to

skin layers (superficial)skin layers (superficial) Painful secondary to Painful secondary to

exposure of nerve endingsexposure of nerve endings Loss of epidermis and Loss of epidermis and

possibly part of dermispossibly part of dermis Red raw base OR pale Red raw base OR pale

moist base with visible moist base with visible epidermal “islets”epidermal “islets”

Heal by epithelializationHeal by epithelialization

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TerminologyTerminology

Full-thickness wound: Full-thickness wound: Involve the total loss of Involve the total loss of all skin layers and maybe all skin layers and maybe subcutaneous tissuesubcutaneous tissue Heal by granulationHeal by granulation

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TerminologyTerminology

Epithelialization:Epithelialization: the regeneration of skin to close the regeneration of skin to close a wounda wound

Granulation:Granulation: The growth of blood vessels and The growth of blood vessels and connective tissue in a woundconnective tissue in a wound

Maceration:Maceration: Excessive moisture in intact skin Excessive moisture in intact skin causing peeling and loss of integritycausing peeling and loss of integrity

Excoriation:Excoriation: liner scratch in the skin surface liner scratch in the skin surface

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Denuded Skin:Denuded Skin: loss of superficial layer loss of superficial layer

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Ulcer:Ulcer: deeper lesion extending into deeper lesion extending into the dermis or belowthe dermis or below

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Eschar:Eschar: Thick, leathery necrotic Thick, leathery necrotic tissuetissue

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Slough:Slough: Loose, stringy nonviable Loose, stringy nonviable tissuetissue

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WOUNDSWOUNDS

Basic AssessmentBasic Assessment LocationLocation Dimensions: Measure and record in Dimensions: Measure and record in

centimeterscentimeters LengthLength WidthWidth DepthDepth Undermining or tunnelingUndermining or tunneling

Slide sterile swab into opening and Slide sterile swab into opening and along the fascial plane until along the fascial plane until resistance met. Lay swab against a resistance met. Lay swab against a measuring guide.measuring guide.

Relate the location of the tunneling Relate the location of the tunneling by referring to the face of a clock by referring to the face of a clock (i.e. 3 cm of tunneling at 9 o’clock)(i.e. 3 cm of tunneling at 9 o’clock)

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Basic Wound Assessment (cont’d)Basic Wound Assessment (cont’d)

Condition of the wound bedCondition of the wound bed Signs of infection (erythema, induration, warmth, tenderness, pain, Signs of infection (erythema, induration, warmth, tenderness, pain,

drainage, foul odor)drainage, foul odor) Color of woundColor of wound Presence/absence of granulation tissuePresence/absence of granulation tissue Presence/absence of necrotic tissuePresence/absence of necrotic tissue

Color - black, yellow, tan, greenColor - black, yellow, tan, green Percent of wound bed covered by necrotic tissuePercent of wound bed covered by necrotic tissue

ExudateExudate Amount: small, moderate, largeAmount: small, moderate, large Color: serous, bloody, yellow, green, etc.Color: serous, bloody, yellow, green, etc. OdorOdor

Condition of surrounding skinCondition of surrounding skin Signs of infection or maceratonSigns of infection or maceraton RashRash

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Stages of Wound HealingStages of Wound Healing

Inflammatory Stage (1Inflammatory Stage (1stst few days) few days) Inflammation – WBC clean wound of debris & bacteriaInflammation – WBC clean wound of debris & bacteria Homeostasis – vasoconstrictionHomeostasis – vasoconstriction Platelets & thromboplastin form clotsPlatelets & thromboplastin form clots

Proliferative Stage (~ 3 weeks or longer)Proliferative Stage (~ 3 weeks or longer) Granulation occurs – fibroblasts make collagenGranulation occurs – fibroblasts make collagen New blood vessels, wound contracts, epithelializationNew blood vessels, wound contracts, epithelialization

Maturation/Remodeling Stage (up to 2 yrs)Maturation/Remodeling Stage (up to 2 yrs) New collagen forms, change shape of wound, increasing New collagen forms, change shape of wound, increasing

tissue strength (80% of original)tissue strength (80% of original)

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Factors that Affect Wound HealingFactors that Affect Wound Healing

Perfusion/oxygenationPerfusion/oxygenation Nutritional StatusNutritional Status InfectionInfection CorticosteroidsCorticosteroids DiabetesDiabetes

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Wound Care Objectives: Wound Care Objectives: DIPAMOPIDIPAMOPI

D= D= DebrideDebride I= Identify and treat I= Identify and treat infectioninfection P= P= PackPack dead space— dead space— lightly!lightly! A=A=AbsorbAbsorb excess exudate excess exudate M= Maintain M= Maintain moistmoist wound surface wound surface O= O= OpenOpen or excise closed wound edges or excise closed wound edges P= P= ProtectProtect healing wound/surrounding skin from healing wound/surrounding skin from

infection /trauma infection /trauma I= I= InsulateInsulate

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Types of DebridementTypes of Debridement AutolyticAutolytic ChemicalChemical

Enzymatic (i.e. Accuzyme)Enzymatic (i.e. Accuzyme) Dakin’s solutionDakin’s solution

MechanicalMechanical Wet-to-dry dressings: works when dressing is removedWet-to-dry dressings: works when dressing is removed Irrigation: 35ml syringe with 19 angiocath or whirlpoolIrrigation: 35ml syringe with 19 angiocath or whirlpool

SharpSharp SurgicalSurgical ConservativeConservative

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Cleanse WoundCleanse Wound

Acute Traumatic Wound (lacerations or Acute Traumatic Wound (lacerations or abrasions)abrasions) Remove all foreign bodies/debrisRemove all foreign bodies/debris Clean while minimizing traumaClean while minimizing trauma

Clean WoundClean Wound Flush gentlyFlush gently

Necrotic or Dirty WoundNecrotic or Dirty Wound Remove while minimizing trauma of underlying Remove while minimizing trauma of underlying

tissuetissue

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Irrigation SolutionsIrrigation Solutions

The only acceptable wound-The only acceptable wound-cleansing solution is normal cleansing solution is normal saline solution (0.9% sodium saline solution (0.9% sodium chloride, or salt, in water)chloride, or salt, in water) Effectively removes Effectively removes

contaminants and has the same contaminants and has the same salt concentration as the fluid salt concentration as the fluid in cells, so it does not damage in cells, so it does not damage cells by pulling water out of cells by pulling water out of them.them.

InexpensiveInexpensive Readily availableReadily available

Alternative solution: Lactated Alternative solution: Lactated Ringer’sRinger’s

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Irrigation Solutions?Irrigation Solutions? Many previously accepted wound-cleansing Many previously accepted wound-cleansing

solutions have been found to be toxic to solutions have been found to be toxic to fibroblasts and lymphocytes, the cells fibroblasts and lymphocytes, the cells required to heal wounds.required to heal wounds.

These solutions include:These solutions include: Providone-iodineProvidone-iodine Acetic acid (vinegar)Acetic acid (vinegar)

Concentraton of 0.25% not Concentraton of 0.25% not cytotoxiccytotoxic

IodophorIodophor Hydrogen peroxideHydrogen peroxide Dakin's solution (sodium hypochlorite)Dakin's solution (sodium hypochlorite)

Concentration of 0.025% not Concentration of 0.025% not cytotoxic.cytotoxic.

NOTE: Commercially prepared solutions are NOTE: Commercially prepared solutions are not regulated by the FDA, and many have not regulated by the FDA, and many have been found to be cytotoxic.been found to be cytotoxic.

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Manage ExudateManage Exudate

Wounds heal faster if kept moistWounds heal faster if kept moist Excessive exudate will macerate peri-wound skinExcessive exudate will macerate peri-wound skin

May promote fungal growthMay promote fungal growth

Wet dressing attract bacteriaWet dressing attract bacteria Product selection is importantProduct selection is important

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Pack Dead Space—Lightly!Pack Dead Space—Lightly!

Observe for cavities, sinuses and tracts in woundObserve for cavities, sinuses and tracts in wound Design a treatment protocol to ensure dressing Design a treatment protocol to ensure dressing

fills these areasfills these areas Wound may close prematurely Wound may close prematurely Predispose to later abscess and wound Predispose to later abscess and wound

breakdownbreakdown

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Protect Wound and Surrounding Protect Wound and Surrounding SkinSkin

Surrounding skin needs to be able to regenerate Surrounding skin needs to be able to regenerate epithelial cells to close woundepithelial cells to close wound

May be macerated, dry, infected (fungal)May be macerated, dry, infected (fungal) Work to restore “normal” skin integrityWork to restore “normal” skin integrity Protect wound from additional traumaProtect wound from additional trauma Insulation: normal body temperature at wound Insulation: normal body temperature at wound

surface reduces vasoconstriction and enhances surface reduces vasoconstriction and enhances cellular activitycellular activity

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Which Dressing?Which Dressing?

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Selecting a DressingSelecting a Dressing

Examine the woundExamine the wound Decide which characteristics of the wound needs Decide which characteristics of the wound needs

immediate treatmentimmediate treatment

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Factors to ConsiderFactors to Consider

Cover vs FillerCover vs Filler Amount of absorption requiredAmount of absorption required Impact of occlusionImpact of occlusion Impact of adhesionImpact of adhesion Cost/availability/usageCost/availability/usage

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Selecting a DressingSelecting a DressingDeep & ExudativeDeep & Exudative

Goal:Goal: Fill dead space; absorb exudate; Fill dead space; absorb exudate; maintain moisture; support autolysis if maintain moisture; support autolysis if necrotic; protectnecrotic; protect

Need: Need: Absorptive Filler + cover Absorptive Filler + cover dressingdressing

Deep & DryDeep & Dry

Goal:Goal: Fill dead space; maintain moisture; Fill dead space; maintain moisture; protectprotect

Need:Need: Hydrating filler + cover dressing Hydrating filler + cover dressing

Shallow & ExudativeShallow & Exudative

Goal:Goal: Absorb exudate; maintain Absorb exudate; maintain moisture; support autolysis if necrotic, moisture; support autolysis if necrotic, insulate and protectinsulate and protect

Need:Need: Absorptive cover dressing (May Absorptive cover dressing (May add small amount of filler)add small amount of filler)

Shallow & DryShallow & Dry

Goal:Goal: Maintain (or create) moisture; Maintain (or create) moisture; protect, insulateprotect, insulate

Need: Need: Hydrating or moisture retentive Hydrating or moisture retentive cover dressingcover dressing

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Selecting a DressingSelecting a DressingDeep & ExudativeDeep & Exudative

Filler:Filler: Ca Alginates, gauze, cavity dressing Ca Alginates, gauze, cavity dressing

Cover:Cover: Gauze pad, ABD, etc., transparent Gauze pad, ABD, etc., transparent thin film, Polyurethane foamthin film, Polyurethane foam

Deep & DryDeep & Dry

Filler:Filler: Amorphous gel, damp gauze packing Amorphous gel, damp gauze packing

Cover:Cover: Gauze pad, ABD, etc., transparent Gauze pad, ABD, etc., transparent thin filmthin film

Shallow & ExudativeShallow & Exudative

Hydrocolloid, polyurethane foam, Ca Hydrocolloid, polyurethane foam, Ca Alginates, gauzeAlginates, gauze

Shallow & DryShallow & Dry

Amorphous or solid gel, thin hydrocolloid, Amorphous or solid gel, thin hydrocolloid, polyurethane foam, transparent thin film, polyurethane foam, transparent thin film, non-adherent gauze, impregnated gauze non-adherent gauze, impregnated gauze dressings (vaseline gauze or Xeroform)dressings (vaseline gauze or Xeroform)

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Pediatric Pressure PrinciplesPediatric Pressure Principles

< 1 meter square < 1 meter square OcciputOcciput

School ageSchool age Sacrum and CoccyxSacrum and Coccyx

Heels in supineHeels in supine Toddler and upToddler and up

Ischial ulcersIschial ulcers For wheelchair bound school For wheelchair bound school

age and upage and up

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Decreasing Pressure RiskDecreasing Pressure Risk

Gel E donuts or water bagsGel E donuts or water bags Sheepskin Sheepskin Egg crateEgg crate Specialty beds with air Specialty beds with air

mattressmattress

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Treating Pressure Treating Pressure SoresSores

No matter the location, remove the No matter the location, remove the source of pressuresource of pressure

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Treatment: Heel SoresTreatment: Heel Sores

Skin prep, double coats, Skin prep, double coats, elevate heel – pressure elevate heel – pressure reliefrelief

No adhesive products No adhesive products If scabbed, use antibiotic If scabbed, use antibiotic

ointment to edges of ointment to edges of scab onlyscab only

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Treatment: OccipitalTreatment: Occipital

Shave first no matter which dressing usedShave first no matter which dressing used No scabNo scab

Skin prep and tegadermSkin prep and tegaderm

Scab Scab Skin prep and tegaderm orSkin prep and tegaderm or Antibiotic ointment or silvadene and telfa Antibiotic ointment or silvadene and telfa

(dependent on(dependent on erythema and risk)erythema and risk)

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Treatment: OccipitalTreatment: Occipital

Calcium alginate Calcium alginate For deeper debridementFor deeper debridement

Hydrocolloid once wound cleanHydrocolloid once wound clean

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Treatment: Sacral and CoccygealTreatment: Sacral and Coccygeal

Intact skin only.Intact skin only. No blister, scab or open skinNo blister, scab or open skin Skin prepSkin prep

Open skin, no escharOpen skin, no eschar Skin prep and hydrocolloid or tegadermSkin prep and hydrocolloid or tegaderm

EscharEschar Debride with silvadene and gauze or wet to dry Debride with silvadene and gauze or wet to dry

dressingdressing

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Preventive Care for Perineal RashPreventive Care for Perineal Rash

AquaphorAquaphor VaselineVaseline Diaper aid creamDiaper aid cream

DesitinDesitin Vitamin A&D creamVitamin A&D cream

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Thicker Barrier Creams for Moderate Thicker Barrier Creams for Moderate to Severe Perineal Rashto Severe Perineal Rash

Points to considerPoints to consider May use Vaseline over Desitin or other skin barrier May use Vaseline over Desitin or other skin barrier

creams that are thicker in consistency (i.e. Sensicare creams that are thicker in consistency (i.e. Sensicare cream)cream)

Warm soaks and remove 2 times/day.Warm soaks and remove 2 times/day. Do not remove barrier creams with every diaper Do not remove barrier creams with every diaper

change. Cleanse area of stool and reapply throughout change. Cleanse area of stool and reapply throughout day.day.

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Case Example 1: How would you Case Example 1: How would you manage this wound?manage this wound?

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Case Example 2Case Example 2

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Case Example 3Case Example 3

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Case Example 4Case Example 4