Wound Care and Dressings Overview

Purposes of Dressings

• Aid in hemostasis (stopping blood flow)
• Protect wound from microorganisms and contamination
• Absorb drainage
• Support or splint the wound site
• Protect the patient from seeing the wound if perceived as unpleasant
• Protect wound from mechanical injury
• Provide a moist environment for open wounds
• Debride wound (remove foreign matter and dead tissue)

Types of Wounds

• Closed Wounds: Tissue surfaces have been approximated (closed)
  • Surgical, even edges
  • Sutured, Stapled, Steri-Strips
  • Minimal or no tissue loss
  • Examples: Incision line, closed fracture
• Open Wounds: Uneven edges, irregular shape, considerable tissue loss
  • Wounds that cannot close completely, edges may not be together; may be wide open
  • Examples: Burn, pressure ulcer, severe laceration
  • May be touched only with sterile gloves or sterile forceps per CDC guidelines

Compare and Contrast: Primary and Secondary Wound Healing

• Primary Healing: Wound edges approximated
  • Healing time is shorter
  • Less scarring
  • Decreased risk for infection
• Secondary Healing: Wound edges open
  • Healing time is longer
  • Scarring is greater
  • Increased risk for infection

Types of Dressings

• Dry sterile: Dry gauze sponges
  • Cover and protect wound
  • Absorb drainage
  • Change dressing according to facility policy or if wet (need order from HCP)
• Wet-to-Dry: Moist dressing placed in wound and allowed to dry
  • Used for wound debridement
  • Need HCP order
  • How often should this type of dressing be changed and why?
• Drainage: Indicates wound status and potential infection
  • Need HCP order for wound culture

Types of Wound Drainage

• Serous: Clear, watery (plasma), due to mild inflammation
• Purulent: Thick yellow, green, tan, brown, caused by the presence of bacteria, abnormal
• Serosanguineous: Pale, pink, watery (mixture of clear and red fluid), common in surgical incisions
• Sanguineous: Bright red (indicates active bleeding), abnormal

Measuring a Wound

• Measure:
  • Length
  • Width
  • Depth
  • Diameter

Wound Management

• Drains: Used when drainage interferes with healing
  • Drain into dressing
  • Drainage tube to continuous suction
  • Surgical drains
• Wound Irrigation: Cleanse wound with sterile solution ordered by HCP
• Wound Packing: Gently debrides the wound when removed
  • Packing material and instruments must be sterile
  • Gently pack to the surface of the wound, do not pack too tightly:
    • Overpacking can cause too much pressure and impede circulation, delaying healing
    • Do not extend packing material over wound edges, onto healthy tissue
• Wet-to-Dry Dressing: Contact layer applied moist (not wet)
  • Saline, medicated solutions
  • Dries and absorbs debris
  • Mechanically debrides wound
  • Removal of dressing gently pulls off debris
  • May need to pre-medicate as it can be painful
• Negative Pressure Wound Therapy (Wound VAC): Closed system that uses localized negative pressure to:
  • Pull wound edges together
  • Remove fluid from the area
  • Stimulate granulation tissue formation

Dehiscence

• Partial or total separation of a surgical incision or wound closure, usually on the abdomen
• Often after suture removal
• Feels like "pulling", "tearing", or "giving way" sensation
• Risk factors: Poor nutritional status, infection, obesity

Evisceration

• Protrusion of an internal organ (usually bowel) through a wound or surgical incision, especially in the abdominal wall
• Preceded by a sudden discharge of serosanguineous fluid and a "tearing" sensation
• Must cover organ with sterile saline-saturated dressings and seek treatment

Factors Affecting Wound Healing in Older Adults

• Loss of skin turgor
• Skin fragility
• Decrease in peripheral circulation and oxygenation
• Slower tissue regeneration
• Decrease in absorption of nutrients
• Decrease in collagen
• Impaired function of immune system
• Presence of chronic illnesses
• Increased risk for infection

Implementing Dressing Change

• Observe for dressing adherence, elevating hand above trash bag for disposal
• Assess and observe characteristics of wound for:
  • Wound edges: Approximated, intact skin around wound
  • Drainage: COCA (color, odor, consistency, amount)
  • Descriptive terms: Erythema (red), warm, pain, edema, purulent exudate, drainage
• Prepare sterile field:
  • Add dressings, instruments, cleansing agent and sterile cup OFF the field
• Apply sterile gloves

Principles of Cleaning Wounds

• Clean to Dirty: Clean in the direction from the least contaminated area of the wound to the most contaminated area
  • Intact wound is considered the cleanest area
  • Skin is "less" clean; opened areas are less clean
• Gentle Friction: Use gentle friction when applying cleansing solutions
• Keep Forceps Tips Lower Than Handle: While cleaning the wound

Cleaning Closed Wounds

• One Stroke Per Sterile Gauze Pad: Clean wound from top to bottom
  • Center (wound), side (skin), side (skin)
• Three Steps:
  1. Clean the wound with forceps and gauze
  2. Clean around the wound with a separate gauze
  3. Apply new sterile dressing

Closed Wound - Normal Healing Expectations

• Well-approximated wound edges
• Slightly reddened (inflamed) for the first 48 hours
• May observe mild edema for the first 48 hours

Cleansing Open Wounds

• Begin cleansing from least contaminated area to the most contaminated area
  • "Dirtier" areas are usually due to infection or inflammation
• Center, Side, Side: Clean wound with 3 gauze pads

Completing Wound Dressing Change

• Add dressings to the incision/wound:
  • 4x4’s, ABD, tape, Montgomery straps
• Remove sterile gloves
• Label dressing with date, time, and initials
• Bag trash
• Perform hand hygiene
• Position patient for comfort
• Rearrange bedside area as needed
• Ensure patient safety
• Ask "Is there anything else I can do for you?"

Wound Cleaning Documentation

• COCA: color, odor, consistency, amount
• Condition of wound
  • Edges approximated
  • Drainage or exudate
  • Hemorrhage?