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. Define aetiology
2. Control factors affecting healing
3. Dressing selection
4. Maintenance/ Discharge planning

1. 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 Due for Review: 18 May 2011
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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 Proposed pathophysiology WBP clinical actions Effect of WBP actions Clinical
OBSERVATIONS Outcomes

T Defective matrix and cell Debridement (episodic or Restoration of and Viable wound
debris impair healing continuous) wound base and base
Tissue: nonviable
or  autolytic, sharp surgical functional
enzymatic mechanical extracellular matrix
deficient
or biological proteins
 biological agents

I High bacterial counts Remove infected foci Low bacterial counts or Bacterial
Infection or
↑Inflammatory cytokines  topical / systemic controlled inflammation: balance and
↑protease activity antimicrobials ↓ inflammatory cytokines reduced
inflammation
↓ growth factor activity  anti-inflammatories ↓ protease activity inflammation
 protease inhibition ↑ growth factor activity

M Desiccation slows epithelial Apply moisture balancing Restored epithelial cell Moisture
cell migration dressings migration, desiccation Balance
Moisture
imbalance
Excessive fluid causes  compression, negative avoided , oedema,
maceration of wound margin pressure or other excessive fluid
methods of removing controlled, maceration
fluids avoided

E Non migrating keratinocytes Reassess cause or Migrating keratinocytes Advancing edge of

Nonresponsive wound cells consider and responsive wound wound
Edge of
and abnormalities in extra corrective therapies cells.
wound: non
advancing
cellular matrix or abnormal  debridement Restoration of
protease activity  biological agents appropriate protease
or undermined
 adjunctive therapies profile

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); 11:1–28

Prompt Doc No: 3 Ver_1 Approval Date: 18 May 2010 Due for Review: 18 May 2011
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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 Due for Review: 18 May 2011
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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. 11:1–28

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 Due for Review: 18 May 2011
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Title: Wound Management

Department: District Nursing Services and PSRACS

APPENDIX 1 - WOUND BED TISSUE TYPE

Necrotic Sloughy Granulating Epithelialising Infected Fungating

Maladorous

Prompt Doc No: 3 Ver_1 Approval Date: 18 May 2010 Due for Review: 18 May 2011
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Title: Wound Management

Department: District Nursing Services and PSRACS

APPENDIX 2 – STAGES OF PRESSURE ULCERS

Stage 1 Stage 2
Observable pressure-related alteration(s) of intact skin whose indicators Partial thickness skin loss involving the epidermis and or dermis. The ulcer
as compared to the adjacent or opposite area on the body may include is superficial and presents clinically as a abrasion, blister or a shallow
changes in one or more of the following; Skin temperature (warmth or crater.
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 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 Due for Review: 18 May 2011
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