Transcript DEEP DRY WOUNDS

Wound Care
Overview
Carolyn Watts MSN,RN, CWON
February 16, 2007
Definition
A wound is a break in the integrity of
the skin.
Phases of Wound Healing
Inflammatory (immediate)
 Fibroblastic (day 4-20)
 Maturation (6-12 months)
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Factors Which Impact Wound
Healing
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Tissue perfusion and oxygenation
Nutritional status
Presence or absence of infection
Diabetes Mellitus
Corticosteroid administration
Immunosuppression
Age
Stress
Other systemic factors
Topical therapy
Waldrop & Doughty, Acute and Chronic Wounds, 2000
Patient Assessment
Medical/Surgical History
 Medications (include OTC)
 Nutritional Assessment
 Pain
 Psychosocial Assessment
 Cultural/ethical considerations
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Wound Assessment
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Location
Stage/Classification
Size (LxWxD in cms)
Sinus Tract(s)
Undermining
Exudate
Necrotic Tissue
Granulation Tissue
Signs/Symptoms of Infection
Periwound Skin
Acute Wounds
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Classification
 Partial
Thickness (involve epidermis/dermis
only)
 Full Thickness (involve subcutaneous tissue
and possibly underlying structures)
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Usually heal following normal wound
healing pathways
Chronic Wounds
Pressure Ulcers
 Venous Stasis Ulcers
 Arterial Ulcers
 Neuropathic Ulcers
 Usually have impaired healing
mechanisms
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Pressure Ulcers
Venous Stasis Ulcer
Arterial Ulcer
Neuropathic Ulcer
Topical Therapy: Principles
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Remove necrotic tissue and foreign bodies or
particles
Identify and eliminate infection
Obliterate dead space
Absorb excess exudate
Maintain a moist wound surface
Provide thermal insulation
Protect the healing wound from trauma and bacterial
invasion
Doughty, Acute and Chronic Wounds, 1992
Types of Topical Wound Dressings
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Hydrocolloid dressings
Hydrogel dressings
Alginate dressings
Transparent film dressings
Foam dressings
Absorption dressings
Gauze dressings
Composite dressings
Biologic dressings
Other
SHALLOW DRY WOUNDS
Need hydrating dressing + cover dressing
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Options:
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Amorphous hydrogels (Carrasyn V gel)
Sheet hydrogels (ClearSite)
Tegaderm Clear Acrylic Absorbent Dressing Transparent
dressings
DEEP DRY WOUNDS
Need hydrating filler dressing +
cover dressing
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Filler dressing options:
 Amorphous
gel (Carrasyn V gel) to wound bed, lightly
pack with damp saline gauze
 Gel soaked gauze packed lightly into wound bed
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Cover dressing options:
 Gauze
and/or ABD with hypoallergenic tape (paper or
stretchable cloth)
SHALLOW DRAINING WOUNDS
Need absorbent dressing + cover
dressing
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Options:
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Foam dressings with adhesive border (Allevyn Island)
*minimal drainage
Sheet alginate w/ silver, adhesive foam (Allevyn Island)
or wrap gauze (Kerlix roll) *moderate drainage
Hydrofiber (Aquacel) w/ adhesive foam (Allevyn Island)or
wrap gauze (Kerlix roll) *heavy drainage
Nonadherent contact layer (Adaptic, Mepitel, or Mepilex
Transfer) w/ gauze cover dressing and tape.
DEEP DRAINING WOUNDS
Need absorbent filler dressing + cover
dressing
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Filler dressing options:
 Calcium alginate with silver (Acticoat Absorbent rope
or sheet), if antimicrobial needed
 Hydrofiber (Aquacel)
 Damp cotton gauze (Kerlix 4x4), pack loosely
Cover dressing options:
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Gauze, ABD/tape (if wound exposed to contaminants use
transparent dressing – Tegaderm)
Waterproof foam dressing (Allevyn Island)
Specialty Dressings
Ionic silver dressings
 Synthetic skin substitutes
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Specialty Products
Wound Care Product Selection
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Wounds are dynamic and will require different
approaches during healing process
Continually reassess patient and wound
Topical therapy is one part of your role - must
eliminate cause and support host
Continually educate yourself on products to make
informed choices
Work with specialty nurses (WOCN or Plastics) to
develop plan of care