wound physiology

158 Plastic Surgical Nursing ❙ July-September 2010 ❙ Volume 30 ❙ Number 3

Copyright © 2010 American Society of Plastic Surgical Nurses. Unauthorized reproduction of this article is prohibited.

often made on the basis of what is most familiar tothe provider and not necessarily on the basis ofwound assessment principles and comprehensivepatient evaluation. Successful management ofwounds is based on knowledge of basic wound heal-ing principles, thorough wound and patient assess-ment, and appropriate product selection.

There has never been a better time to becomeknowledgeable in wound healing. Recently, a taskforce for the Association for the Advancement ofWound Care determined that medical professionalsand the majority of the general public are not knowl-edgeable about current advances in wound care. Sur-prisingly, the misconceptions identified include thatpovidone iodine, hydrogen peroxide, and a woundleft open to air to dry are good for the wound (Asso-ciation for the Advancement of Wound Care, 2005;Loehne, 2006). Selection of appropriate products canhasten healing time and decrease pain, improve qual-ity of life, and get patients back to meaningful work.Appropriate product selection saves health careresources. When the normal phases of wound heal-ing are interrupted, chronic wounds develop, leadingto increased risk of infection, increased hospitalstays, and decreased quality of life. Chronic woundsaccount for a significant amount of health carespending in the United States, accounting for an esti-mated 5 billion to 9 billion dollars each year (Man-dracchia, John, & Sanders, 2001). Another importantdevelopment has been the 2007 changes to theprospective payment system by the Centers forMedicare & Medicaid Services, which impacts reim-bursement for preventable complications such asinfections and facility-acquired pressure ulcers.

The goal of this article is to provide an overviewof a holistic approach to wound-healing productselection based on not only wound assessment butalso assessment of the whole patient and the overallgoals of the plan of care.

The plastic surgery nurse is often confronted with variousacute and chronic wounds. Appropriate wound care can

facilitate healing, improve quality of life, decrease pain, andimprove cosmesis. Yet, with more than 5,000 products onthe market today, it can be difficult to choose the appropriateproduct. This article reviews some of the basic principles ofwound healing and patient assessment and then presentsa framework from which to develop a plan of care usingappropriate wound care products. Appropriate productselection based on patient assessment and clearly definedwound-healing goals can lead to improved healing andsaved health care resources.

The plastic surgery nurse is often confronted withvarious acute and chronic wounds, ranging frompressure ulcers and lower extremity wounds to burns,radiation injuries, traumatic injuries, malignancies,and surgical complications. Appropriate wound carecan facilitate healing, improve quality of life, decreasepain, and improve cosmesis; therefore, it is of greatbenefit for the plastic surgery nurse to be familiarwith the basic principles of wound healing as wellas the way to assist in product selection and appli-cation. With more than 5,000 wound care productsin the market today, product selection can be over-whelming. Decisions about product selection are

Wound Care for the Plastic Surgery NurseValentina S. Lucas, MS, RN, ANP-BCAnn W. King, MS, RN, CWON

Valentina S. Lucas, MS, RN, ANP-BC, Nurse Practitioner, Depart-ment of Surgery, Division of Plastic and Reconstructive Surgery,Virginia Commonwealth University Health System, Richmond.Ann W. King, MS, RN, CWON, Wound Care Team, Department ofSurgical Nursing, Virginia Commonwealth University Health System,Richmond.The authors wish to acknowledge Susan Beavers for her assistancein preparation of this manuscript.The authors have no conflict of interest.Address correspondence to Valentina S. Lucas, RN, ANP-BC,Department of Surgery, Division of Plastic and ReconstructiveSurgery, Virginia Commonwealth University Health System, PO Box 980154, Richmond, VA 23298 (e-mail: [email protected]).

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Plastic Surgical Nursing ❙ July-September 2010 ❙ Volume 30 ❙ Number 3 159


is the etiology of the wound, and what integumentarystructures are involved in it. Partial-thickness woundsinvolve loss of the epidermis and partial loss of thedermis. Remnants of epithelial structures such ashair follicles, sweat glands, and sebaceous glandsare still present in the remaining tissue (Mehendale& Martin, 2001). These wounds are typically highlyexudative. Pain is a common complaint in partial-thickness injury because of the exposure of thenerve endings in the dermis. Full-thickness woundsextend beyond the dermis, involving subcutaneoustissue, and can involve muscle, bone, or both.

Surgical or full-thickness wounds are oftendescribed as healing by primary, delayed primary, orsecondary intention. Primary closure describeswounds that are closed within hours of their cre-ation. Primary closure involves surgical reapproxi-mation of the wound’s edges, incorporating the use ofsutures, stables, or adhesives. Collagen deposition inthe wound provides strength. Coverage of the woundis accomplished through epithelialization (Glat &Longaker, 1997).

Delayed primary closure involves initial debride-ment of the wound for an extended period todecrease contamination and prevent infection. For-mal closure of the wound takes place several dayslater with suturing, stapling, or by another mecha-nism, such as skin grafting or flap closure (Glat &Longaker, 1997).

Secondary intention is when wounds are allowedto heal by granulation tissue formation, wound con-traction, and epithelialization, as demonstrated inFigure 1. In most cases and in the absence of under-lying disease states that affect healing, most woundsleft without surgical intervention will eventuallyheal by secondary intention (Rivera & Spencer,2007). This process will be discussed further underthe stages of full-thickness wound healing.

Wounds can also be classified as acute or chronic.Acute wounds progress through the stages of wound

THE SKIN

The skin is the largest organ of the human body andconsists of two layers, the outermost layer or epider-mis and the innermost layer or dermis. These layersare separated by the basement membrane. Func-tions of the skin include protection from pathogens,ultraviolet radiation, and mechanical injury. Theskin protects against fluid loss and has an activerole in thermoregulation. The slightly acidic pH ofthe skin serves as a protective barrier against bacte-rial and fungal invasions. Metabolism, specificallythe production of vitamin D, takes place in the skin.The skin contains a vast supply of sensory nerves,providing sensory input on pain, temperature, pres-sure, and pleasure (Storch & Rice, 2005).

The epidermis measures less than 1-mm thick,is avascular, and regenerates itself about every 4 to6 weeks (Baranoski, Ayello, & Tomic-Canic, 2008;Watson, 2000). The epidermis has a relative uniformthickness over the body with a few exceptions,including the soles and palms, where it is approxi-mately 1.5-mm thick. On the eyelids, the epidermiscan be as thin as 0.1-mm thick (Odom, James, &Berger, 2000; Wysocki, 2007). Under the epidermislies the dermis, composed primarily of collagen andcontaining a rich blood and nerve supply as well asapocrine, eccrine, and pilosebaceous structures(Watson, 2000). The thickness of the dermis variesin different locations, but it averages about 2 mm.The dermal and epidermal layers are anchoredtogether by the basement membrane. Beneath thedermis is a layer of loose connective tissue called thehypodermis or subcutaneous layer whose primaryfunction is to attach the skin to the underlying struc-tures. The hypodermis layer is composed of adiposetissue and blood vessels that supply the dermis.Thickness of the hypodermis can vary dependingon body site. In certain disease states, such asWerner’s syndrome and scleroderma, the hypoder-mis layer may be largely absent (Wysocki, 2007).

As people age, basic changes in the skin takeplace. Epidermal and dermal thickness decrease andthe dermal–epidermal junction flatten, resulting in athinner epidermis and less resistance to shearingforces and trauma. Turnover of cells in the epidermisslows, decreasing cellular migration and prolifera-tion. There are decreases in vascularity, immuneresponse, and collagen and elastin fibers, all leadingto slower healing times and increased potential forinfection (Farage, Miller, Elsner, & Maibach, 2007).

PRINCIPLES OF WOUND HEALING—UNDERSTANDING THE LANGUAGE

When thinking about how wounds heal, it may beuseful to first think of what caused the wound, what

Figure 1. Wound healing by secondary intention, withgranulation tissue and healthy epithelialization on edges.


collagen. Once this provisional matrix is established,the keratinocytes at the wound edges and skinappendages can continue to proliferate and migrateto cover the wound. The wound is considered closedwith the establishment of a new epidermal covering(Ehrlich, 1998). Re-establishment of the basementmembrane between the epidermis and the dermisusually occurs 7–9 days after re-epithelializationand is essential for the re-establishment of skinintegrity and function (Li et al., 2007).

The remodeling phase begins at approximately24 days after injury and extends to 12 or moremonths after complete healing. In the earlier stagesof wound healing, fibroblasts produce type III col-lagen. Once the wound is closed, conversion oftype III collagen to type I collagen occurs, and duringthe next 12 or more months the granulation tissueproduced to heal the wound is converted to scar(Ehrlich, 1998; Li et al., 2007). Decreased capillaryvascularity and a gradual loss of fibroblasts occur.Tensile strength of a healed wound is usually 70%(Levenson et al., 1965).

ASSESSMENT OF THE PATIENT ANDASSESSMENT OF THE WOUND

Deciding what to put on a wound not only involvesa thorough wound assessment but also includes acomprehensive assessment of the patient andunderstanding of the etiology of the wound and thesurgical plan of the patient. Because the etiology ofa wound is often multifactorial, a holistic approachto assessment provides insight into the etiologic,systemic, and local factors that are commonlyinvolved in the pathogenesis of a wound (Nix, 2007)and aids in tailoring the plan of care to the individ-ual patient, not the individual wound.

A thorough health history is critical when plan-ning care for a patient with a wound. A completemedical history is of utmost importance. Includedin this history should be questions regarding thewound—how long the wound has been present,what caused it (if known), what has made it betteror worse, what is currently being used for woundcare, and what has been tried in the past. This infor-mation will give insight into what has worked forthe patient previously, as well as identify allergiesand co-morbidities that may impede healing. Table 1lists co-factors that may affect healing.

Having the patient medically optimized willdecrease complications that may result from thelisted co-morbidities. A patient’s nutritional statusshould never be ignored. Optimal albumin levelsshould be greater than 3.0 g/dl, total lymphocytecount should be greater than 1500, or both theconditions should be there (Attinger et al., 2006).Tight control of blood glucose level for patients

healing in a timely and predictable manner. Chron-ic wounds are those that do not follow the pre-dictable sequence of wound repair, often because ofcontinued trauma, shear forces, friction, infection,or pro-inflammatory stimuli (Storch & Rice, 2005).

THE PHASES OF WOUND HEALING

The classical model of wound healing is a complexprocess, orchestrated by various chemical mediatorsand cell types. Partial-thickness wounds, with injuryproceed through an orderly process of epithelialproliferation and migration. Epidermal keratinocytesreplicate and migrate from the wound edges andthe existing dermal appendages, hair follicles, andsebaceous glands, eventually covering the dermis.Collagen deposition is minimal and wound contrac-tion does not occur (Glat & Longaker, 1997; Li, Chen,& Kirsner, 2007).

Full-thickness wound healing is more complicat-ed and described as occurring in stages or phases.These phases do not occur in exclusion of each otherbut are dynamic and overlapping. The inflammatoryphase of wound healing begins within seconds ofinjury. Platelets are activated by the disruption ofblood vessels, and clotting factors are released.Platelets aggregate at the wounded site forming aclot to reestablish hemostasis. This clot also forms aprovisional matrix for the recruitment of cells to theinjured area (Doughty & Sparks-Defriese, 2007; Liet al., 2007). Platelets not only have a role in coagu-lation but also are the source of multiple chemicalmediators (cytokines) necessary for later angiogen-esis. Once hemostasis is achieved, the clot begins tobreak down, and vasoactive substances such as his-tamine and prostaglandins lead to vasodilatation andincreased blood vessel permeability. Vasodilatationand blood vessel permeability lead to the classicclinical presentation of edema, erythema, andwound exudate (Doughty & Sparks-Defriese, 2007).

Leukocytes, both neutrophils and monocytes, arerecruited to the wound by chemotactic factors(cytokines, growth factors) released during hemosta-sis and the degranulation of mast cells. Neutrophilsfunction in the wound bed as the first line of defenseto kill and phagocytize bacteria and nonviable pro-tein. Phagocytic macrophages in the tissue spacesbecome the predominant cell type during the latterpart of the inflammatory phase. These cells removedevitalized tissue and bacteria and produce growthfactors, which stimulate angiogenesis and the infil-tration of fibroblasts (Li et al., 2007).

Approximately 3–4 days after injury, the prolifer-ative phase begins. The characteristic finding duringthis stage of healing is the generation of granulationtissue. Granulation tissue is composed of an abun-dance of new capillaries, fibroblasts, and immature




an effective manner? If another person has agreedto do the wound care, how often will it need to bedone and can they commit to such a request? Homehealth care is a valuable option, but most insuranceplans have criteria for who qualifies for home healthcare and in many cases the number of visits is lim-ited. Knowing who will be doing what and what isavailable will assist the clinician in ensuring that theplan of care can be adhered to and outcomes of theplan can be evaluated effectively.

WOUND ASSESSMENT

Appropriate wound assessment provides the frame-work for establishing goals for wound healing.Begin first by identifying and documenting the cor-rect anatomical position of the wound. This maysound simple but is often overlooked in documenta-tion and is important for communication betweenmembers of the health care team. Wound locationmay also provide insight into possible etiology. Forexample, ulcerations on the lower extremity mayindicate a venous or arterial etiology. Wounds onplanter surface of the foot may be neuropathic innature. Wounds on the waist or thighs in a patientundergoing dialysis may indicate calciphylaxis.Wounds in the axilla or groin may be related tohidradenitis suppurativa.

The next step is to measure the wound. The sim-plest method, one that requires only a measuringtape or a ruler, is measurement of the length, width,and depth of the wound. Length is measured byplacing the ruler at the farthest two points from headto toe. Width is measured from the widest two pointsfrom side to side. Depth is typically measured byplacing a cotton-tipped applicator into the woundbed and then laying the applicator next to the ruler.

with diabetes is vital to ensure that the body canheal and fight infection.

An in-depth social history gives insight into whatmay motivate the patient to heal (employment,family, and recreational goals). Patients should beasked, “what is the most troublesome thing aboutyour wound” and “what would you like to see hap-pen over the following weeks and months?” Woundhealing is dynamic, and it can often be looked at asa series of small goals. It is important to explain theimmediate goal to the patient so they do not becomefrustrated when the wound has not healed as quick-ly as they might expect. Patient education beginningat the initial visit is instrumental to get full cooper-ation and compliance to the treatment plan.

Social history should include a discussion abouttobacco use or other detrimental substances. Tobaccoproduct (cigarettes and snuff) use can adverselyaffect wound healing in plastic surgery patients.Nicotine causes vasoconstriction, which decreasescutaneous blood flow. Proliferation of fibroblasts andmacrophages, vital cells involved in wound healing,is diminished by nicotine (Sherwin & Gastwirth,1987). Nicotine also has an effect on coagulationand has been associated with increased plateletadhesiveness, leading to microclots and decreasesin perfusion (Mosley & Finseth, 1977). Patientsshould be educated on the detrimental effects ofnicotine on wound healing and be directed toresources that may help them quit.

Having an understanding of who will be doingthe wound care and what resources are available toobtain wound products is of critical importance.Clinicians can prescribe various wound-healingmodalities, but if the patient cannot afford them,they will be of little benefit. Questions need to beasked (see Table 2) pertaining to insurance coveragefor supplies and home health. Do not assume thatinsurance will cover the cost of dressings. Often,there may be a deductible that needs to be met, orsupplies may not be covered at all. With cosmeticprocedures, rarely are wound supplies covered byinsurance companies. Another critical question is“who will be doing the wound care?” If it is thepatient, can they physically apply the dressings in

TABLE 1 Cofactors That May Affect Wound Healing

Insufficient oxygenation/perfusion Excessive Pressure

Venous/arterial disease Infection

Advancing age Diabetes

Immunosuppressive medications Smoking

Malnutrition Hypertension

Connective tissue disorders Age

Chemotherapeutic agents Stress

Irradiation Malignancy

TABLE 2 Questions to Consider to DetermineAccess and Ability to Perform Wound Care

1. What has been used for wound care in the past?

2. What has made the wound better or worse?

3. Can the patient visualize their wound?

4. Who will be doing the wound care? How often can theyassist in care?

5. Can the patients do their own wound care?

6. Is the patient or caregiver reliable to assess critical changesin the wound that may need immediate attention?

7. Is home health needed?

8. Can the patient afford the wound care productsrecommended by the provider?

9. Does their insurance cover wound supplies or homehealth visits?

10. Are specialty products, such as an air mattress, hospitalbed, or bedside commode, needed?



Measurements are usually reported as length bywidth by depth. Photographs of the wound can behelpful and give insight into wound progress thatmay not be captured in a measurement alone.

Evaluation of the wound bed should includeidentification of type of tissue present in the woundbed. Often, providers are unsure of what they see.Simply describing what you see can often be helpful.For example, you could say the wound is covered inyellow fibrinous slough, but if you are unsure, sim-ply saying that the wound bed is covered 100% withwet yellow tissue may be adequate enough. Woundsare often inappropriately staged because providersare unfamiliar with the staging guidelines. Allwounds can be described as either full- or partial-thickness. Pressure ulcers can be further describedaccording to stage. See Table 3 for a detailed descrip-tion of stages. It is important to remember that onlypressure ulcers are staged in this manner. A woundcovered with a black eschar does not indicate a stageIV pressure ulcer. One could not determine such adepth until the eschar is removed. In this case, sim-ply describing what you see is the best for documen-tation, identifying the underlying tissues (dermis,subcutaneous tissue, fascia, muscle, and bone) visi-ble. Wound beds can be described as having granu-lation tissue, having fibrin, having slough or escharpresent, having bone or tendon exposed, and havinghardware or mesh exposed. Wound exudate can beserous, serosanguineous, purulent, or seropurulent.Pay particular attention to the amount of exudate.Ask the patient how often they need to change the

dressing per day and whether the drainage soaksthrough. Does the drainage have an odor? A foulodor may indicate a heavy bacterial burden, andappropriate topical antibiotics, systemic antibiotics,or both may be needed.

Observe the skin surrounding the wound (peri-wound tissue). Is this tissue erythematous, macerat-ed, or excoriated from exudate? Is there surroundingerythema that may be either cellulitis or simply apart of the inflammatory response secondary to asurgical incision? Is there evidence of further trau-ma from the repeated removal of adhesive tape? Isthere evidence of contact dermatitis (rash) from top-ical therapies? All of these issues should play a rolein the deciding which product is right for the wound.

PRODUCT SELECTION

A systematic approach to wound care and productselection is often best because it incorporates assess-ment findings with healing goals while consideringspecific patient-centered concerns. Initially, anapproach was developed on the basis of wound bedpreparation, which included debridement (theremoval of necrotic or dead tissue in the wound), bac-terial balance, and moisture control (Sibbald et al.,2000). Assessment and treatment for the wound edgewas later added (Schultz, Barillo, Mozingo, & Chin,2004; Sibbald, Woo, & Ayello, 2008). For the purposeof this article, the authors will use the mnemonic,DIME (Debridement, Infection or Inflammation,Moisture Balance, Edge of Wound) which incorpo-rates all of these parameters as a framework forwound assessment and product selection.

THE DIME MODEL AND PRODUCTSELECTION

As health care practitioners, our goal is to assess thewound on the basis of the DIME model and thenrecommend wound care products on the basis of theneeds of the wound as well as of the patient. We willnow review the components of the DIME model.

D: Debridement

Debridement addresses the need for removal of non-viable, necrotic, or dead tissues, senescent cells, andbiofilms in the wound. Nonviable tissue presentsas slough or eschar (Figure 2). Slough is usually grayor yellow and can be soft, moist, or stringy; it can beloosely or firmly attached. Eschar is usually black orbrown and tends to be thick or leathery. Nonviabletissue impedes wound healing because it fostersinfection, keeps wounds “stuck” in the inflammatoryphase of healing, prevents contraction of the wound

TABLE 3 Pressure Ulcer Stages

Stage 1 Intact skin with nonblanchable redness of a localized area usually over a bony prominence.In darker pigmented individuals, blanchingmay not be as noticeable and may appeardarker than surrounding tissue.

Stage 2 Partial-thickness loss of the dermis. Appears as a shallow open ulcer with a red, pink woundbed or blister.

Stage 3 Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is notexposed. Slough may be present but doesnot obscure the depth of the tissue loss. Mayinclude undermining and tunnel.

Stage 4 Full-thickness tissue loss with exposed bone, tendon, or muscle.

Deep Tissue Purple or maroon localized area of discolored Injury intact skin or blood-filled blister due to dam-

age of underlying soft tissue from pressureand/or sheer.

Unstageable Full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar

Note. From Prevention and Treatment of Pressure Ulcers: Quick Refer-ence Guide, by European Pressure Ulcer Advisory Panel and NationalPressure Ulcer Advisory Panel, 2009, Washington, DC: National PressureUlcer Advisory Panel.



Biological/maggot therapy debridement is a methodof debridement whereby sterile larvae are obtainedfrom specialized laboratories and introduced intothe wound. Maggot secretions appear to selectivelydissolve necrotic tissue, reduce bacteria, reduceinfection, and promote granulation; however, mag-gots cannot penetrate hard, dry eschar (Gray, 2008;Sherman, 2002).

I: Infection or Inflammation

During acute wound healing, the inflammatoryresponse, as discussed earlier, is a normal steptoward healing. The expected signs and symptomsof the normal inflammatory response are erythema,swelling, increased temperature, and pain (Gardner,Frantz, & Doebbeling, 2001; Sibbald, Orsted,Schultz, Coutts, & Keast, 2003). Inflammation canalso be a sign of a high bacterial burden or infec-tion (Figure 3). All wounds contain bacteria along acontinuum from contaminated to colonized to crit-ically colonized to infected. Contaminated woundscontain a low number of nonreplicating bacteria.Colonized wounds contain replicating bacteriawithout a host reaction. Critically colonizedwounds have an increasing number of bacteriaresulting in delayed local wound healing. Infectedwounds have an even greater number of bacteriathat have invaded tissue and caused a host reaction(Sibbald et al., 2003).

Knowledge of the existence of biofilms (a com-munity of different bacteria existing together in anextracellular polymeric glue like substance) hasadded to our understanding of wounds that areresistant to healing. This substance protects the

bed, and hinders epithelization across the wound bed(Baharestani, 1999; Sibbald et al., 2008). Debride-ment is not always a single intervention and is oftenthe basis of wound healing strategies. There are fivemethods for debridement: autolytic, mechanical,enzymatic, surgical/sharp/excisional, and biological/maggot.

Autolytic debridement is a process wheremacrophages and proteolytic enzymes in the woundliquefy and separate nonviable tissue. This processcan occur naturally or be assisted by dressings(Schultz et al., 2003). Dressings that facilitate thisprocess include hydrogels and occlusive or semi-occlusive dressings such as film/transparent dressingsand hydrocolloids.

Mechanical debridement involves physical force toremove the necrotic tissue but must be used withcaution because it may harm healthy granulating tis-sue. Examples of mechanical debridement includehydrotherapy/whirlpool, wound scrubbing, and wet-to-dry dressing. Wet-to-dry dressings imply thatmoist gauze is packed into the wound and allowed todry and attach to the wound (necrotic and healthytissues). Debridement takes place when the driedgauze is removed. This method is nonselective andoften painful and is no longer an acceptable meansof mechanical debridement (Centers for Medicare &Medicaid Services, 2004; Ovington, 2001).

Enzymatic debridement is the use of pharmaco-logically produced proteolytic enzymes, which areapplied to the wound bed to remove nonviable tis-sue. Collagenase is currently the only licensed prod-uct and is thought to work by destroying the colla-gen bonds that bind nonviable tissue to the wound.

Surgical/sharp/excisional debridement is the use ofscalpels, forceps, scissors, or laser to remove nonvi-able tissue. A physician or health care professionalwith specialized training in sharp/excisional debride-ment may perform this debridement (according to thestate’s practice act).

Figure 2. Necrotic wound.

Figure 3. Infected wound.



bacteria and makes it resistant to destruction by thebody’s own immune system or by external means(Wolcott, 2007; Wolcott, Cutting, & Ruiz, 2008).Some studies have found that 60% of chronicwounds contained biofilms (James et al., 2008).Treatment must involve multiple modalities includ-ing frequent debridement, topical antimicrobialssuch as silver or cadexomer iodine, and systemicantibiotics (Wolcott et al., 2008). Wound infectionultimately depends on the specific micro-organism, themicrobial load/number (the presence of 10–5 micro-ogranisms per gram of tissue or greater), and theability of the host to fight the infection. A woundculture may be necessary to identify the specificorganism and its number. Tissue biopsy (quantita-tive sampling) is considered the gold standard inmicrobial analysis, but there is growing evidencethat qualitative swab cultures may adequately corre-late with tissue biopsy (Sapico et al., 1986; Sibbaldet al., 2003; Wheat et al., 1986). Acute and chronicwounds manifest signs of infection differently (seeTable 4). Wound care product/treatment options toaddress problems of infection include debridement,topical antibiotics, topical antiseptics, and topicalelemental antimicrobials.

Debridement, believed to be the most importanttreatment to reduce the bacterial burden (Rodeheaver& Ratliff, 2007), is needed because bacteria thrive in dead tissue and its removal facilitates healing.Management of biofilms is facilitated by debride-ment as well (Wolcott et al., 2008).

Topical antibacterials have limited use in clinicalpractice and their use should be based on the spe-cific organism to decrease the risk of sensitivityreactions and resistance. Topical antibiotics shouldnot be used for more than 2 weeks. Mupirocin andgentamicin are effective for gram-positive bacteria.Bacitracin and neomycin are effective against gram-positive and gram-negative organisms, but their useshould be with caution as neomycin is a commonsensitizer and can result in a contact dermatitis(Rodeheaver & Ratliff, 2007; Sibbald et al., 2003).Topical metronidazole, classified as antibacterial,antiprotozoal, and amebicidal, is an exceptional

antibiotic for treating anaerobic bacteria in wounds.Topically, it is not known to cause antibiotic resist-ance. Metronidazole is used commonly off-label infungating malignant and foul smelling wounds tokill bacteria. This can reduce odor, drainage, andpain for the patient (Paul & Pieper, 2008).

Topical antiseptics are generally inexpensive andhave multiple targets (unlike antibiotics). Bacterialresistance is not typically a concern. Although fre-quently used in the past, their use is controversialbecause of their cytotoxicity to both microbes andhealthy cells. However, Dakin’s solution, at a dilutedconcentration of 0.0125%, was found to cause littledamage to healthy tissue (Vick, Propst, Bozeman, &Wysocki, 2008). Antiseptics act on the wound sur-face, without penetrating tissue. Considering therisk—benefit ratio, the use for short periods of timemay be helpful if the goal is to reduce the bacterialburden when there is little healthy tissue present inthe wound bed. Topical antiseptics are not appro-priate for clean wounds and they should not be usedto irrigate wounds. Common topical antisepticsinclude acetic acid, sodium hypochlorite (Dakin’ssolution), alcohol, povidone iodine (Betadine),chlorhexidine, and hydrogen peroxide (Rodeheaver& Ratliff, 2007; Sibbald et al., 2003; White, Cutting,& Kingsley, 2006).

Topical antimicrobials include silver-containingproducts, cadexomer iodine, methylene blue andcrystal violet combination and manuka honey.Destruction of the tissue under the wound edge isknown as underming. Wound tunneling can bethought of as a channel which extends from thewound bed through subcutaneous tissue or muscle(Nix, 2007). Measurement of undermining and tun-neling can be carried out by placing a cotton tippedapplicator under the edge of the wound or into thetunnel to mark the extent of the depth. Then theapplicator can be placed next to a rular to obtain anexact measurement. These products have proved tobe bacteriostatic against a wide range of microbesand do not harm healthy tissue. Silver is incorporat-ed into many antimicrobial dressings such as algi-nates, foams, hydrofibers, and sponges. The cadex-omer iodine bead donates iodine to the wound bedwhile absorbing excess exudate. Available in oint-ments or sheets, cadexomer iodine is most appropri-ately suited for wounds that are moderately to highlyexudative (Pieper, 2009; Sibbald et al., 2003; Stotts,2007).

M: Moisture Balance

The modern evolution of wound care is often said tohave begun in the 1960s with research showing theadvantages of moist wound healing. Moist woundshealed almost twice as fast as the wounds with drytissue (Winter, 1962). A moist wound environment

TABLE 4 Signs of Wound Infection

Acute Chronic

Advancing erythema Increased serous drainage

Fever Delayed or slowed healing

Warmth Discoloration of granulation tissue

Swelling Granulation tissue that bleeds easily

Pain Pocketing at base of wound

Purulent exudate Foul odor

Increase in pain

Wound breakdown



E: Edge of Wound—Nonadvancing or Undermined

Problems with the wound edge involve its inabilityto achieve epidermal migration or epithelialization.A healthy wound edge should appear as a taperededge between the epithelium and the granulationtissue. This allows epithelialization, a pearly whiteextension of tissue on the wound bed. An unhealthywound edge may be caused by hyperproliferationand nonmigrating cells at the wound margin, non-responsive wound cells, abnormal protease activityor to an extracellular matrix that does not allowepidermal migration. The edge may present as non-advancing, undermined, hypertrophic, rolled (epi-boly), callused, macerated, or a “cliff-like” edge. Awound edge that is impeding healing often needsevaluation by a surgeon (Schultz et al., 2003, 2004).

Because of the multitude of wound care productsavailable, clinicians should become familiar withthe categories of dressings and their functions.Selection of the appropriate product should proceedbased on the wound bed assessment. Understandingeach product category and each category functionwill further assist in more specific product selec-tion. Table 5 organizes dressing and interventioncategories based on the DIME model.

A WORD ABOUT PAIN

A discussion of wound care would not be completewithout mentioning the issue of pain. Pain is one ofthe most common complaints of patients with acutewounds (Moffatt, Franks, & Hollinworth, 2003).Increased pain has been associated with decreasedhealing times (McGuire et al., 2006). One group foundthat almost 80% of patients with acute wounds andlikewise close to 80% of patients with chronic woundsreported that their dressing change had been either

facilitates a more effective inflammatory phase. Itimproves granulation, tissue formation, and angio-genesis; promotes earlier wound contraction; andimproves epithelialization (Brett, 2006a; Maddenet al., 1982; Rovee, Kurowsky, Labun, & Downes,1972; Winter, 1962).

Wound moisture management can be a delicatebalance, depending on the needs of the wound. Ifthe wound moisture balance is adequate, maintainit. If the wound is too dry (see Figure 4), add mois-ture. If the wound is too wet (see Figure 5), absorbmoisture. Wound products are categorized accord-ing to their effect on moisture levels. The goal is topromote moist wound healing while managing thedetrimental effects of excess exudate (Brett, 2006b;Schultz & Mast, 1998). Chronic and highly drainingwounds need wound care products to absorb orremove the unhealthy drainage.

Wound care product options that maintain ordonate moisture include hydrogels, film/transparentdressings, hydrocolloids, and continuously moistsaline gauze. Wound care products that absorbmoisture include foams, alginates, and impregnatedsodium chloride gauze.

If a saline moist gauze dressing is used as astandard dressing to maintain a moist woundenvironment, it must not be allowed to dry. Thesaline gauze dressing can act as an osmotic dress-ing, drying the wound. In addition, there isincreased wound fluid evaporation with salinegauze dressings, which leads to a lowering of tis-sue temperature, and the construct of gauze dress-ings provides no barrier function and allows thepenetration of bacteria. Researchers have foundthat gauze dressings are in fact more costlybecause of labor cost, frequent dressing changes,and delayed healing. While a gauze continues tobe the most widely used wound dressing, wound-healing experts are encouraging the use of moreadvanced wound care products (Ovington, 2001).

Figure 4. Dry wound.

Figure 5. Highly draining wound.



moderately or severely painful (Meaume, Teot,Laszreth, Martini, & Bohbot, 2004). Preventing painand additional trauma to the wound site during dress-ing changes should be considered when planning care.

Appropriate dressing selection can play a criticalrole in decreasing pain during dressing changes. Anon-adherent petrolatum/oil emulsion gauze allowsfor a non-adherent contact layer and allows forwound exudate to pass through. Soft silicone-based

dressings can be useful as they do not adhere to thewound or surrounding tissues and in many casescan allow for a decrease in the number of dressingchanges required. Hydrocolloids protect the sur-rounding skin and in many cases can provide asemi-permanent layer that tape can be applied tofor prevention of tape-induced trauma. Choosingdressings that require less frequent chances may behelpful as well.

TABLE 5. Selection of Wound Products or Interventions Based on DIME Model

Wound Bed Preparation Category/Intervention Description/Function

D - DebridementAutolytic

Mechanical

Enzymatic

Surgical/sharp/excisional

Biological/maggot therapy

I - Infection or InflammationAntibacterials (topical)

Antimicrobials

Antiseptics

M - Moisture BalanceProducts to maintain or provide

moisture to a wound

Products to absorb excess drainage

E - EdgeProducts/interventions to facilitate

epidermal migration or epithelization

Transparent film

Hydrocolloid

Hydrogel

Wet to dry dressing

Wound scrubbing

Hydrotherapy/whirlpool

Collagenase ointment

Bedside or operating room

Sterile maggot larvae

Bacitracin

Gentamicin sulfate

Metronidazole

Mupirocin

Silver

Cadoxemer iodine

Methylene blue/crystal violet

Polyhexamethylene biguanide

Manuka honey

Hypochlorites (Dakin’s solution)

Acetic acid

Transparent film dressing

Hydrogel

Hydrocolloid

Continuously moist saline gauze

Alginate

Foam

Sodium chloride dressing

Wound drainage collector

Negative pressure wound therapy

Debridement

Skin grafts

Biological agents

Semipermeable, polyurethane membrane

Composed of gel-forming polymers

Gel or sheet, water, or glycerine based

No longer acceptable for debridement

Utilize gauze or instrument

Risk of trauma to wound bed and cross contamination

Disrupts the collagen bonds that hold the necrotic tissue in the wound bed

Utilize scalpel, scissors, and other instruments

Available from specific laboratories

Topical antibacterials should be specific to targeted organism. Risk of resistancewith prolonged usage.

Antimicrobials inhibit microorganism growth, including, bacteria, virus, fungus.

Nonselective targets, inexpensive, can be cytotoxic to healthy tissue at variousconcentrations.

Semipermeable, polyurethane membrane

Composed of gel-forming polymers

Gel or sheet, water or glycerine based

Do not allow gauze to dry in would bed

Absorbs up to 20x weight, becomes gel

Hydrophilic polyurethane, wicks upward

Osmotic effect

Pouching system

Promotes healing and collects drainage

Excisional debridement or silver nitrate sticks to treat rolled edges

To facilitate epithelialization of large areas

To provide foundation for epithelialization



Wounds closed primarily, as well as abrasionsand partial-thickness wounds, may benefit fromprophylactic topical antibiotics. Bacitracin, neomycinsulfate, silver sulfadiazine, and triple antibioticointment (combination of bacitracin zinc, neomycinsulfate, and polymyxin B) are mostly popular. Baci-tracin is effective against gram-positive organisms,anaerobic cocci, and Clostridia. Triple antibioticointment is bacteriocidal against gram-positive andgram-negative organisms but should be used withcaution as it has been found to cause allergic sensi-tization. Additional benefits of these productsinclude maintenance of a moist wound bed, pre-venting dressing adhesion to the wound bed andfacilitating suture removal (Dire, Coppola, Dwyer,Lorette, & Karr, 1995; Markovchick, 1992).

The plastic surgery nurse is frequently chargedwith care of split-thickness skin grafts and theirdonor sites. When looking at a split-thickness skingrafts recipient site, once the primary post-operativebolstering dressing is removed, wound care prod-uct selection should follow the basic principles out-lined earlier. Frequently, donor recipient sitesrequire a non-adherent dressing that allows exu-date to pass through, such as a petrolatum/oilemulsion gauze or a fenestrated silicone sheet. Thedonor site, however, can be a bit more complicated.Donor sites frequently cause more discomfort forthe patient because the harvested skin leads to awound with exposed dermis and therefore exposednerve endings. These wounds typically are highlyexudative, at least in the first 3–4 days after graftharvest. Dressing selection should be based on theabsorbent qualities (Beldon, 2003). Because donorsites heal by re-epithelialization, principles ofmoist wound healing apply to facilitate migrationof epithelial cells across the wound bed. Donor sitesare frequently associated with a considerableamount of discomfort due to exposure of nerveending in the dermis. Patients will benefit fromdressing that are comfortable, allow them to show-er, and do not require frequent dressing changes(Beldon, 2003). Based on the wound assessment,hydrocolloids, alginates, hydrofibers, nonadherentfoams and silicone dressings are all good choicesfor donor sites.

CONCLUSION

This article briefly reviews the basics of wound careand product selection. The dynamic nature ofwound healing dictates that no one dressing willmeet all of the wound’s needs throughout theprocess. Frequent re-evaluations are necessarywhen planning care and choosing a dressing.

The importance of understanding the needs andresources of individual patients and families cannot

NOT ALL WOUNDS NEED ADVANCED PRODUCTS

While the purpose of this article was to educateplastic surgical nurses on appropriate dressingselection for wounds, it is important to rememberthat most plastic surgery patients heal in a timelymanner post-operatively without complications.For patients with closed acute surgical wounds, rec-ommendations typically consist of showering andusing a mild soap and covering any surgical woundor drain site with a dry dressing. The use of a non-adherent gauze, petrolatum-impregnated gauze, orsilicone-based product will reduce the risk of adher-ence to the surgical site and allow for exudate topass through. There is no evidence to support thatshowering should not take place while drains arein place. In fact, Reid and Dumanian (2003) explainthat patients may be more compliant and comfort-able with their drains if allowed to shower in theimmediate post-operative period.

Figure 7. Rolled (epiboly) edges.

Figure 6. Wound undermined edges.



be underestimated. This allows for planning carethat is patient-centered and achievable. The patientand family must be full partners in wound care andtreatment decisions. The more the patient isinvolved in the process and understands the treat-ment plan, the more the opportunities for compli-ance (Sibbald et al., 2000). Inability to performwound care or obtain dressings surely indicatesthat the plan needs to be re-evaluated. Successfulwound healing outcomes are achieved only if all ofthe key players involved in every aspect of thepatients care are communicating and working as ateam.

Gone are the days of choosing products and ther-apies because “that’s the way we have always doneit.” Planning wound care on the basis of accuratewound assessment as well as clearly defined goals ofwound healing is where clinicians need to be prac-ticing. Understanding dressing category propertiesand applying that to a comprehensive assessmentwill allow for appropriate wound care productselection that not only promotes wound healing butalso is cost-effective and evidenced-based.

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