Title: Wound Management

Department: District Nursing Services and PSRACS

DEFINITIONS
Acute wound ..Is any surgical wound that heals by primary intention or any traumatic or surgical wound that heals by secondary intention
which proceeds through an orderly and timely reparative process that result in sustained restoration of anatomical integrity.
Chronic wound - ..Occurs when the reparative process does not proceed through an orderly and timely process as anticipated and healing
is complicated and delayed by intrinsic and extrinsic factors that impact on the person, the wound or the environment.

SCOPE
District Nursing Services, Palliative Care Services and PSRACS

CLINICAL ALERT
In order to determine the appropriate wound management the wound assessment should examine;
The type of healing
Tissue loss (size; linear measurement; photography; tracings)
Clinical appearance (See Appendix 1)
Location
Measurement dimensions
Exudate (Type; amount; odour; consistency)
Wound edges
Surrounding skin
Pain
Wound infection
Psychological implications of wounds and wounding

POLICY
Wound management must be a considered process. It is essential that nurses are not simply replacing dressing products. The aims of
wound management should be to:
1.
2.
3.
4.
1.

Define aetiology
Control factors affecting healing
Dressing selection
Maintenance/ Discharge planning

Define Aetiology

All wounds should have an aetiology ascribed to them and confirmed by relevant investigations and clinical assessments. In order to
ascertain the aetiology a comprehensive assessment should be performed that assesses the wound and the factors that affect the healing
process both physically and psychosocially.
In order to determine the appropriate wound management , the wound assessment should examine;
The type of healing
Tissue loss (size; linear measurement; photography; tracings)
Clinical appearance (See Appendix 1 and 2)
Location
Measurement dimensions
Exudate (Type; amount; odour; consistency)
Wound edges
Surrounding skin
Pain
Wound infection
Psychological implications of wounds and wounding
and be a multidisciplinary approach that involves and values other health professionals knowledge and skills in order to meet the complete
and complex needs of clients and residents.

Prompt Doc No: 3 Ver_1

Approval Date: 18 May 2010

Page 1 of 6

Due for Review: 18 May 2011

Title: Wound Management

Department: District Nursing Services and PSRACS

2.

Control Factors affecting healing

Factors that will influence the rate or capacity to heal should be assessed, documented and allowed for in the plan of care. (See Below)
General factors affecting healing

Local factors affecting healing

Underlying disease

Hydration

Vascularity

Wound management

Nutrition status

Wound temperature

Immune status

Pressure friction and shearing forces

Obesity

Foreign bodies

Disorders of sensation or movement

Wound infection

Psychological state

Pain levels

Radiation therapies
Drugs prescribed/recreational/alternative therapies
Allergies / sensitivities
(Carville, 2005)

Chronic wound management should also consist of a systematic review of the factors that affect the healing process. This is called Wound
Bed Preparation (WBP). This is presented as the acronym TIME and illustrated below.
TIME PRINCIPLES OF WOUND BED PREPARATION

CLINICAL
OBSERVATIONS

T
Tissue: nonviable
or
deficient

I
Infection or
inflammation

M
Moisture
imbalance

E
Edge of
wound: non
advancing
or undermined

Proposed pathophysiology

WBP clinical actions

Effect of WBP actions

Clinical
Outcomes

Defective matrix and cell

debris impair healing

Debridement (episodic or
continuous)
autolytic, sharp surgical
enzymatic mechanical
or biological
biological agents

Restoration of and
wound base and
functional
extracellular matrix
proteins

Viable wound
base

High bacterial counts

Inflammatory cytokines
protease activity
growth factor activity

Remove infected foci

topical / systemic
antimicrobials
anti-inflammatories
protease inhibition

Low bacterial counts or

controlled inflammation:
inflammatory cytokines
protease activity
growth factor activity

Bacterial
balance and
reduced
inflammation

Desiccation slows epithelial

cell migration
Excessive fluid causes
maceration of wound margin

Apply moisture balancing

dressings
compression, negative
pressure or other
methods of removing
fluids

Restored epithelial cell

migration, desiccation
avoided , oedema,
excessive fluid
controlled, maceration
avoided

Moisture
Balance

Migrating keratinocytes
and responsive wound
cells.
Restoration of
appropriate protease
profile

Advancing edge of
wound

Non migrating keratinocytes

Nonresponsive wound cells
and abnormalities in extra
cellular matrix or abnormal
protease activity

Reassess cause or
consider
corrective therapies
debridement
biological agents
adjunctive therapies

Adapted from Schultz GS, Sibbald RG, Falanga V, et al., and Mark Granick, MD1; Joseph Boykin, MD2; Richard Gamelli, MD3; Gregory Schultz, PhD4; Mayer Tenenhaus, MD5 Wound
Repair and Regeneration (2003); 11:128

Prompt Doc No: 3 Ver_1

Approval Date: 18 May 2010

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Title: Wound Management

Department: District Nursing Services and PSRACS

3.

Dressing Selection

The aim of the dressing is to provide an environment that supports and is beneficial to the healing process. Nurses must have a sound
understanding of wound physiology and the healing process as well as a working knowledge of the product categories their indications and
contraindications and the skill level to perform the interventions. The ideal dressing ;

Removes excess exudate

Maintains a moist wound healing environment

Allows gaseous exchange if appropriate

Provides thermal insulation of wound

Provides a barrier to pathogens

Does not promote infection

Does not shed fibres or leak out toxic substances

Does not cause a sensitivity or allergic reaction

Protects against mechanical trauma eg pressure, shearing forces

Allows removal without traumatizing new tissue

Is easy to apply

Is comfortable to wear

Is adaptable to body parts

Does not interfere with body function

Is cost effective
4.

Maintenance/ Discharge planning

Plan for optimal outcomes and/or maintenance of healed wound. The following factors should be incorporated into the current plan of care as
well as the discharge plan

Prevention of recurrence

Maintaining quality of life while wound healing

Adequate pain relief regime

Economic considerations

Psychological impact of wound

Discharge planning needs to include the following information:

Client education on lifestyle factors and health status

When preventative actions are required e.g. compression therapy

Behaviour modification to protect healed wound and surrounding skin

When to seek medical or nursing advice

Encouragement to client to seek early intervention and advice

Provision of information on obtaining ongoing medical/dressing supplies

Assessment clients ability to understand and carry out instructions; in relation to their wound care

Assessment of clients willingness to adhere to and/or comply with the instructions provided; in relation to their wound care.

Assessment of the clients economic ability to continue with wound dressings and/or treatments

PATIENT INFORMATION

Residents and clients should be involved in all aspects of there wound healing. Education of factors that can facilitate healing, as well
as factors that impede healing should be explained to each person.

Discharge planning should begin at the commencement of wound management and include any preventative physical, social or
psychological factors that the resident or client should address or be aware of at the time of wound healing or discharge from service.

EXPECTED OUTCOME

To provide relevant evidence based wound care management / treatments to residents/clients, that will optimise wound healing.

Wound care management/treatments will be a wholistic approach that includes nutrition, medications, client activity levels and other
factors that influence rates of healing.

An evaluation of wound progress will be attended as follows;

Acute wounds every fortnight

Chronic wounds every month
At any time that a wound changes in an unexpected way.(i.e becomes infected, wound deteriorates or a failure to continue healing
(stasis)

Prompt Doc No: 3 Ver_1

Approval Date: 18 May 2010

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Due for Review: 18 May 2011

Title: Wound Management

Department: District Nursing Services and PSRACS

A wound assessment chart will be completed;

At the time of the initial assessment

At any dressing change
Following any change in treatments with rationale for such change recorded. (Eg. Change in dressing products)

REFERENCES
Benton, N., Harvath ,T. A, Flaherty-Robb M, Medcraft, M, McWhorter, K., McClelland ,F., Joseph, C., Mambourg, F. (2007) Managing
Chronic, Non-healing Wounds Using a Research-Based Protocol Journal of Gerontological Nursing 11(33) 38- 45.
Carville, K (2005) Wound Care Manual. (5th Ed). Silver Chain Foundation. Western Australia
Enoch S, Price P, (2004) Cellular, molecular and biochemical differences in the pathophysiology of healing between acute wounds, chronic
wounds and wounds in the aged. Accessed via http://www.worldwidewounds.com/2004/august/Enoch/Pathophysiology-of-healing.html
On 22/10/2009.
Falanga V,(2004) Wound bed preparation: science applied to practice. European Wound Management Association (EWMA). Position
Document: Wound Bed Preparation in Practice. London: MEP Ltd.
Gardner M (2003) Wound Healing: Uneventful Process or Complex Medical Problem Requiring Specialized Treatment and Care? Accessed
via http://www.infectioncontroltoday.com/articles/402/402_231feat3.html on 22/10/2009.
Granick ,M., Boykin, J., Gamelli , R.,, Schultz G, Tenenhaus , M. (2006) Towards a common language: surgical wound bed preparation and
debridement. Wound Rep Regeneration 14: S1 S10
Hess, CT; Kirsner, R (2003) Orchestrating Wound Healing: Assessing and Preparing the Wound Bed
Advances in Skin & Wound Care.16 (5):268-270.
MacLellan, D.G (2000) Chronic wound management. Australian Prescriber 23 (1) 6-9
Royal District Nursing Service Manual Community care services Wound Management.CCS.N.WOU.01P.
Schultz, G.S., Sibbald, R,G., Falanga, V., Ayello, E,A., Dowsett, C. , Harding ,K., Romanelli , M., Stacey, M.C., Teot, L., Vanscheidt , W.
(2003) Wound bed preparation: a systemic approach to wound management; Wound Rep Regeneration. 11:128

AUTHOR/S
Cathy Anne Duncan Latrobe Community Health Service Gippsland Regional Wound Project
Marianne Cullen - Latrobe Community Health Service Gippsland Regional Wound Project Clinical Nurse Consultant

VALIDATION
Gippsland Regional Wound Management Steering Committee

Prompt Doc No: 3 Ver_1

Approval Date: 18 May 2010

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Due for Review: 18 May 2011

Title: Wound Management

Department: District Nursing Services and PSRACS

APPENDIX 1 - WOUND BED TISSUE TYPE

Necrotic

Prompt Doc No: 3 Ver_1

Sloughy

Granulating

Epithelialising

Approval Date: 18 May 2010

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Infected

Fungating
Maladorous

Due for Review: 18 May 2011

Title: Wound Management

Department: District Nursing Services and PSRACS

APPENDIX 2 STAGES OF PRESSURE ULCERS

Stage 1
Observable pressure-related alteration(s) of intact skin whose indicators
as compared to the adjacent or opposite area on the body may include
changes in one or more of the following; Skin temperature (warmth or
coolness), tissue consistency (firm or boggy feel) and or sensation (pain
or itching). The ulcer appears as a defined area of persistent redness in
lightly pigmented skin, whereas in darker skin tones, the ulcer may
appear with persistent red, blue or purple hues.

Stage 2
Partial thickness skin loss involving the epidermis and or dermis. The ulcer
is superficial and presents clinically as a abrasion, blister or a shallow
crater.

Stage 3
Full thickness skin loss involving damage or necrosis of subcutaneous
tissue that may extend down to, but not through underlying fascia. The
ulcer presents clinically as a deep crater with or without undermining of
adjacent tissues.

Stage 4
Full thickness tissue loss with extensive destruction, tissue necrosis or
damage to muscle, bone or supporting structures (for example, tendon or
joint capsule). Undermining and sinus tracts may also be associated with
stage 4 pressure ulcers.

Australian Wound Management Association (2001) Clinical Practice Guidelines for the prediction and Prevention of Pressure Ulcers. Cambridge Publishing WA.

Prompt Doc No: 3 Ver_1

Approval Date: 18 May 2010

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Due for Review: 18 May 2011