17.1 Wound Management

Contact details for Tissue Viability

Northern Devon Healthcare NHS Trust

Royal Devon and Exeter NHS Foundation Trust

Goals of wound therapy

Using evidence based treatment to ensure:

  • pain free dressing change and promotion of patient comfort between dressing changes
  • reduction of infection risk by using principles of asepsis
  • promotion of wound healing
  • treatment of any identified clinical infection
  • improvement in systemic conditions
  • protection against trauma
  • maintenance of clean wound bed
  • maintenance of wound temperature
  • the enhancing of the physiological environment
  • removal of loosening necrotic and slough tissues with an active debridement methodology
  • protection against infection
  • minimising of pain
  • production of good cosmetic results
  • maximum cost effectiveness
  • that the treatment / care plan is acceptable to patient and/or carer

An ideal wound dressing should be:

  • non-adherent
  • impermeable to bacteria
  • capable of maintaining a high humidity at the wound site
  • able to remove excess exudate
  • thermally insulating
  • non-toxic and non-allergenic
  • comfortable and conformable
  • capable of protecting the wound from further trauma
  • require infrequent dressing changes
  • cost-effective long shelf-life
  • available both in hospital and in the community
It should also:
  • control exudate
  • control bleeding
  • ease related pain
  • clean and debride the wound
  • protect newly formed tissue
  • optimise the healing potential

When selecting a dressing it is necessary to:

  • choose the appropriate dressing
  • choose the appropriate size and shape to avoid waste
  • check the Summary of Product Characteristics (data sheet) for wear time, contra-indications and application tips
  • check the shelf-life and storage details and use the stock in rotation
When considering prescribing/recommending a dressing pack, remember:
  • dressing packs should only be used where clinically indicated and in line with employing organisation policies, procedures and guidelines.
  • there is no component of any dressing pack which should be left in permanent contact with the wound. Dressing packs containing cotton wool balls should not be used due to fibre-shed.
  • dressing packs can be obtained through Web Basket.
Additional factors to be considered:
  • Clinical effectiveness / evidence of product choice
  • Cost implications of contact dressing
  • Cost implications of secondary dressing
  • Practitioner time
  • Frequency of dressing change
  • Implications of dressing on prescribing budget

Additional information:

  • When prescribing or recommending products for prescribing, consideration of the patient's needs paramount and the quantities should be sufficient to reflect the patient's requirements but minimise waste
  • The prescribed dressings are the property of the named patients to whom they have been dispensed and must not be used for another patient
  • Dressings that are for single use must not be resealed for re-use
  • As part of professional practice you are required to keep updated in accordance with The Code-Standards of Conduct, Performance and Ethics for Nurses and Midwives
  • You must ensure you are familiar with the product you are using or prescribing
  • You must ensure that you work within the guidelines in accordance with manufacturer's instructions
  • You must work within all relevant policies, protocols and guidelines of the organisation

Basic principles of wound care management

Before treatment takes place it is essential to make a full assessment of:

  1. The whole patient
  2. The wound and its underlying aetiology
  3. The environment and social conditions

The assessment must be completed in accordance with your employing organisations policies, procedures and guidelines.

All documentation must be completed in accordance with national and professional guidelines on record keeping.

1 – The whole patient

  • General health and chronic diseases
  • Mobility
  • Nutritional status
  • Sensory functioning
  • Circulatory system
  • Pain
  • Medication
  • Psychological factors
  • Patient's level of understanding about the wound and its treatment

2 – The wound

  • First assessment
  • Wound type
  • Wound site(s)
  • Size/Depth
  • Allergies
  • Previous treatments
  • Duration of wound
  • Nature of wound bed identifying tissue types and % coverage
  • Exudate
  • Odour
  • Pain, type, frequency, site
  • Wound margin
  • Surrounding Skin
  • Infection

3 - The environment and social conditions

  • The home environment and social conditions may influence wound healing
  • Patients should be encouraged to participate in their own care and empowered to make informed decisions. Reference to the Mental Health Capacity Act 2005 may be appropriate. This needs to be documented within the individuals' clinical records of your employing organisation

Subsequent assessments

  • All wounds must be reviewed on each dressing change and any deterioration in the wound bed or surrounding tissue, or any sign of clinical infection, a reassessment must be untaken by a registered nurse
  • The date for reassessment will be indicated in the patients care plan and will include the date for measurement/tracing/photographs to establish progress

Complex wound management

There is an increased need to manage more complex wounds both within and without the secondary / acute setting.

Registered practitioners need to understand the numerous cellular processes which take place in the wound repair process to enable them to make informed decisions regarding dressing selection.

Correct usage of modern dressings will facilitate the function of the wound healing process rather than just cover a wound.

Correct use of debridement and surrounding skin care plus correction of underlying pathology along with the correct usage of modern dressings will result in improved patient comfort, correct wear time, effective use of nurse time and a reduction in cost.

Managing complex wounds may require specialised nurse input which you may want to consider if difficulties are experienced.

Four stages of wound healing

Stage 1 – Inflammation

A local reaction to tissue damage. It is an important part of the body's defence mechanism and also an essential part of the healing process.

Signs of inflammation are redness, heat, pain and swelling.

The coagulation cascade is activated initially following an injury. Vasoconstriction occurs preventing excessive blood loss. A clot is formed over the wound.

Tissue injury and clotting activation stimulates the release of vasoactive substances such as prostaglandins and histamine, causing vasodilation and increased capillary permeability to serum and blood cells. Fluid flows into the injured tissue, the fluid contains plasma proteins, white blood cells and platelets, and is known as exudate.

Platelets in the exudate release growth factors, prostaglandins, adhesive glycoproteins and fibronectin, which initiate the promotion of cell migration and wound site access via vasodilation and increased capillary permeability, and production of the extracellular matrix.

The signature cells of this phase are leucocytes. The first to arrive are neutrophils, which engulf and destroy any bacteria found at the wound site. Macrophages arrive later and destroy bacteria and damaged tissue around the wound.

Stage 2 – Reconstruction

The macrophages move from the first stage into this stage. They produce growth factors, which attract fibroblasts, which divide and produce collagen fibres. These collagen fibres gradually become organised to give the wound elasticity. Fibroblasts also contract the wound.

It has been suggested that this process of contraction could be responsible for as much as 40-80% of the closure of the wound.

Macrophages also produce angiogenesis factor, which instigates the process of angiogenesis (growth of new blood vessels). Capillaries beneath the wound sprout buds, which grow towards the surface and then loop back over again to the capillary. These loops supply oxygen and nutrients to the wound. The wound fills up with new tissue and a new capillary network is formed. The number of macrophages and fibroblasts gradually decreases.

Stage 3 – Epthelialisation

Epithelial cells begin to move across the wound bed. These epithelial cells respond to the chemotactic stimuli from within the wound bed. When epithelial cells meet they stop dividing and moving, a process known as contact inhibition. Epithelial cells move best in a moist environment.

Stage 4 – Maturation

Wound becomes less vascular. Epithelialisation is now complete. After a period of time the scar tissue gradually remodels and begins to look like normal tissue. The scar flattens. It should be remembered that although great strides have been made in understanding the healing process, it is still incompletely understood.


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