Wound Management

What is the definition of TIME?

TIME is a summary of the principles of wound bed preparation which involves debridement, actively manage challenging exudation of wounds in combination with associated infections, complications and restoring edge of wounds

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What does TIME stand for?

Tissue non-viable of deficient. Infection or inflammation. Moisture imbalance. Edge of wound, non-advancing or undermined

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What are the stages of wound healing? (1)

Haemostasis (initial vasoconstriction, release of clotting factors, fibrin clot formation, immediate). Inflammation (vasodilation, delivery of macrophages, phagocytosis, blood clot formation loosely units wound edges, day 1-4)

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What are the stages of wound healing? (2)

Proliferation (epithelial cells migrate bridging the wound, angiogenesis/growth of new capillaries, fibroblasts migrate along fibrin strands synthesising scar tissue, day 4-21)

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What are the stages of wound healing? (3)

Remodelling (develop tensile strength, collagen remodelling, vascular maturation and regression, day 21-year 2)

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What are the aims of TIME?

Remove actual/potential causes of delayed healing. Create the optimum local environment. Protect the individual from further skin damage. Relieve pain

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Describe features of tissue

Indicate phase of wound healing, determine treatment aims, influence dressing choice

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Describe features of tissue - necrosis

Non-viable. Ischaemic dead tissue. Slough/brown. Black necrotic. Can be eschar or soft. Wound left exposed (e.g. toes, no dressing, dead tissue needs to be removed, pressure ulcer - use medical honey). Patients may experience pain

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Describe features of tissue - slough

Non-viable. White/yellow/green in colour. Dead cells, bacteria, fibrin accumulated in the exudate can be found in patches

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Describe features of tissue - granulating

Viable. Red and granular. Balance of moist environment. Unhealthy granulation can be pale/dusky. Need to remove aspects which prevent wound healing. Wound heals from bottom upwards

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Describe features of tissue - epithelisation

Viable. Moist environment. Migrates from wound margins. Fragile. Sensitive to temperature

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What are the signs and symptoms of an infected wound?

Redness/erythema, heat, pyrexia, oedema, pain, pus, increased exudate, odour, non-healing wound

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Outline the process of infection/inflammation (1)

Contamination. Colonisation. Critically colonised. Infection (local - within one area, systemic - within the whole body). Bacteria present in wound and not multiplying, wound healing not delayed. Bacterial burden in wound bed

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Outline the process of infection/inflammation (2)

Increase immune response, initiated locally, delayed healing. Bacteria present in wound bed are multiplying, immune response locally and systemically, wound is painful, may increase in size

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Topical antimicrobial is used for which stage in infection/inflammation?

Critically colonised

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Topical and systemic antimicrobials are used for which stage in infection/inflammation?

Infection - local and systemic

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Describe features of moisture balance (1)

Wound exudate is produced as a normal part of the wound healing process. Managing exudate and maintaining a wound environment that is moist but not wet is a constant challenge. Too much exudate can prevent wound healing

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Describe features of moisture balance (2)

Cause maceration to the peri wound skin

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What are the types of exudates? (1)

Serous (clear/watery, bacteria may be present). Fibrinous (cloudy, contains fibrin strands). Purulent (milky-yellow/green, contains infective bacteria and inflammatory cells)

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What are the types of exudates? (2)

Haemopurulent (pink, red cells present, contains infective bacteria and inflammatory cells, blood present). Haemorrhagic (red - blood stained, red cells, major component)

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Describe features for edge of wound

Check if wound edges are advancing. Check if the wound is getting smaller. Wound edges in chronic wound may fail to migrate

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Describe features for edge of wound - undermining

Indicative of chronic wounds. Encourage cavity to fill with granulation tissue. To measure - check of undermining at each 'hr of the clock'. Insert sterile cotton tipped swab into undermining depth. Grasp swab at wound edges and measure against ruler

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Describe features for edge of wound - tracking

Narrow opening or passage that can extend in any direction. To measure - insert a sterile cotton tipped swab into the tunnel, grasp swab at the wound edge and measure against a ruler

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What is an acute wound?

Acute wounds occur as a result of surgery or trauma. Typically lasts around three weeks for minor wounds

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What is a chronic wound?

No absolute definition of a chronic wound. Chronic - failure to heal or show signs of healing, 4 weeks or 8-12 weeks (depend on author). Chronic wounds fail to trigger initial cascade of healing and are often caused by an infection

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Which type of approach is used when assessing a wound

Use a holistic approach

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State features of the holistic wound assessment (1)

HEIDI. History (medical, surgical, pharmacological, social). Examination (total body and then wound). Investigations (bloods, X-rays, scans). Diagnosis (likely or definite). Intervention (plan of care)

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State features of the holistic wound assessment (2)

Medical history, age, psychological, peripheral, vascular disease, diabetes, medication, malignancy, stress, environmental, decreased oxygen levels, smoking alcohol, obesity, continence, nutritional status, mobility

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What are the aspects of wound bed preparation?

Necrosis and slough (interrupts granulation, focal point for bacteria), debridement (gradual process, check methods) and optimal healing environment. (If the wound is not kept clean, it will not heal)

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What are the debridement methods for devitalised tissue?

Autolytic (dressings, honey). Sharp (bedside removal of non-viable tissue). Surgical (theatre removal of non-viable tissue). Bio-surgical (larvae). Mechanical (fibre pad). Enzymatic (collagenous based products)

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Why clean wounds?

Remove contaminants. Remove debris and foreign bodies following trauma. Remove dressing materials. Remove excess exudate and help malodour. Remove crusting and hyperkeratosis from edges and surrounding skin. Removing superficial slough

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Which solutions are used to clean wounds? (1)

Tap water (used extensively in leg ulcer clinics and first aid at home). Normal saline (used for clean, contaminated and colonised wounds)

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Which solutions are used to clean wounds? (2)

Antimicrobial (used for critically colonised, infected wounds, may be used in dirty wounds and those at risk of infection)

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What are the consequences of not using solutions are body temperature?

Delayed healing, taking up to 40 minutes for the wound to return to normal temperature and up to 3 hours for mitotic cell division to restart

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Why dress a wound?

Create a warm, non-toxic, moist environment. Promote haemostasis. Promote autolytic debridement. Protect from further injury. Prevent infection. Reduce pain. Minimise and contain odour. Protect surrounding skin. Control/contain exudate. Improve QOL

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What are the aspects of an ideal dressing?

Maintains a moist environment. Controls temperature/pH of wound. Doesn't adhere to wound bed. Requires infrequent changing. Impermeable to bacteria. Allows gaseous exchange. Has good absorption qualities. Non-toxic, provides patient comfort

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What are the dressing categories?

Film, hydrocolloid, hydrofibre, alginate, antimicrobial, foam, non-adherent, absorbent pads, super absorbent, adhesive removers, skin barrier, wound cleansing solutions, post op dressing, bandaging

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Describe features of film dressings

Usually made from polyurethane, transparent, semi-permeable, flexible, adhesive, act as a physical barrier, no/low level exudate. For superficial wounds/those expected to heal without complication

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Describe features of hydrocolloid dressings (1)

Sodium carboxymethlcellulose, pectin, gelatin (animal). Flat, occlusive, adhesive, dry/low levels of exudate, leave on for up to 7 days. Promotes moist wound healing. Promote autolytic debridement. Encourages granulation

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Describe features of hydrocolloid dressings (2)

Not to be used in diabetic foot ulcers. These dressings are not to be used to prevent pressure. Used for granulating wounds, wounds that contain a high % of slough/necrotic tissue, superficial burns, pressure ulcers. (Consider religious beliefs)

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Describe features of hydrofibre dressings (1)

Sodium carboxymethylcellulose. Absorbs moderate to heavy exudate. Fluid is locked in and not released with pressure. Encourages granulation. Provides a moist healing environment. Autolytic debridement. Used for exudating wounds, leg ulcers

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Describe features of hydrofibre dressings (2)

Also used for category 2-4 pressure ulcers, partial thickness burns, surgical wounds

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Describe features of kaltostate alginate dressings (1)

Non-woven or fibrinous and non-occlusive. Calcium alginate or calcium sodium alginate. Derived from brown seaweed. Form a soft gel in contact with wound exudate. Highly absorbent and suitable for use on exuding wounds

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Describe features of kaltostate alginate dressings (2)

Promotion of autolytic debridement (of debris in very moist wounds). Alginate dressings also act as haemostatic, should not be used in heavy bleeding. Moderately-heavily exuding wounds. Alginate rope can be used in sinus

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Describe features of antimicrobials - medical honey

100% Manuka honey. Antimicrobial, anti-inflammatory, promotes debridement in sloughy and necrotic wounds. Promotes moist wound healing environment. Reduces malodour. Used for infected/sloughy/necrotic/malodorous

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Describe features of foam dressings (1)

Made from polyurethane or silicone. Adhesive or non-adhesive. Absorb and draw moisture away. Semi permeable. Low-moderate exudate levels. Different shapes. Leave in place for up to 7 days

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Describe features of foam dressings (2)

Used for low exudation wounds, minor cuts, burns, granulating wounds

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Describe features of non-adherent dressings (1)

Knitted viscose rayon (cellulose) sheet with silicone coating. Protects wound bed. Needs a secondary dressing. Nil absorbent qualities. Do not leave for too long - may dry out

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Describe features of non-adherent dressings (2)

Used for granulating wounds, lacerations, surgical wounds, under VAC, painful wounds

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Describe features of Zetuvit absorbent pads (1)

Non-irritant absorbent dressing pad. A non-adherent, non-woven polypropylene material. Soft cellulose fluff, a tissue layer for distribution of exudate

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Describe features of Zetuvit absorbent pads (2)

Hydrophobic, blue non-woven polypropylene layer on the backing of the dressing used as protection against contamination

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Describe features of sorbian sana super absorbent

Supports autolytic debridement. Maintains a moist wound environment. Promotes tissue formation. Absorbs wound exudate and locks it in. Permits pain-free dressing changes

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What is the Appeell remover used for?

Facilitates the quick and easy removal of stoma bags and other adhesive appliances

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Describe features of Cavilon spray and cream (1)

Clinically proven to provide up to 72 hours. Protects intact or damaged skin from bodily fluids, adhesives and friction. Long-lasting, for more comfortable and cost-effectiveness care. Sterile, non-cytotoxic, alcohol-free, sting-free. Hypoallergenic

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Describe features of Cavilon spray and cream (2)

Cavilon cream to apply BD. Cavilon spray to apply every 48 hours. Cavilon advanced skin protectant twice weekly

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Describe features of medi-honey barrier cream

Helps the body's natural wound cleansing processes in three key ways which have been shown to have wound healing benefits - maintain moist environment, aid in cleansing wound of debris, reduce wound pH

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Describe features of pro-shield spray and cream (1)

Pro-shield plus - smooth, greaseless and fragrance free moisture barrier, effective on intact/injured skin associated with incontinence

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Describe features of pro-shield spray and cream (2)

Pro-shield foam and spray - gentle, pH balanced, non-aerosol, no-rinse moisturising cleanser, minimises irritation/dryness of skin. Product formulated to help eliminate odour, break down dried stool, reduce need to scrub delicate tissue

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Describe features of Steripod normal saline

Used for topical irrigation of traumatic and surgical wounds. Sterile solution of 0.9% w/v NaCl in purified water, packed into polyethylene capsule

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Describe features of Prontosan solution antimicrobial (1)

For cleansing, rinsing, moisturising of acute/chronic skin wounds. Prevents formation of biofilm. Reduces healing time. Removes/prevents formation of biofilm. Prevents infections. Facilitates gentle dressing replacements

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Describe features of Prontosan solution antimicrobial (2)

Compatible with commonly used wound dressings. Prontosan wound irrigation solutions can be used for preventing infections in acute/chronic wounds including - traumatic wounds, post-operative wounds

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Describe features of Prontosan solution antimicrobial (3)

Chronic skin ulcers (venous, diabetic, pressure ulcers), 1st and 2nd degrees burns

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Describe features of Tegaderm + pad for surgical wound (1)

Convenient, all in one sterile dressing reduces application time. Waterproof barrier which allows patients to bathe/shower without removing dressing. Unique, non-adherent pad won't stick to wound

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Describe features of Tegaderm + pad for surgical wound (2)

Allowing normal wound healing processes to occur with less pain and trauma. Breathable film allows skin to function normally with good exchange of moisture vapour and oxygen

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Describe features of Hospicrepe bandages

White, textile elastic cotton crepe bandage, provides light support, may be washed, and sterilised

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Describe features of softban cotton wool bandages

Non-adhesive bandage used to provide some padding within a dressing. Thin layer of cotton wool usually placed on top of the initial dressing but underneath a protective cohesive or adhesive bandage

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What must be carried out on each dressing change?

An assessment. Check if the wound is healing, if the current dressing plan is working. Use wound measurements, TIME wound assessment, holistic assessment of patient (changes in condition), documentation, handover (effective communication)

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Wound Management

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