WOUND ASSESSMENT,

DOCUMENTATION &
TYPES OF DRESSING
ABDUL MANAN BIN OTHMAN
BSc (Hons) NPD Northumbria, UK

Assistant Medical Officer

Champion Wound Care Unit
Kota Tinggi District Health Office
email: pppabdulmanan@yahoo.com
WHAT…..WHEN
WHO…WHERE…
HOW..
 GOAL IN WOUND CARE CYCLE

Start with the

patient

No

Identifying
Prevention Yes Healed wound
aetiology
Wound bed
preparation
Care Cycle

Treat & Perform TIME

evaluate assessment
TIME
interventions Agree goals
 WOUND ASSESSMENT SEQUENCE

1. Assess the patient

7. Manage exudate 2. Assess the region

and related of the wound
problems

6. Assess the 3. Assess the current

periwound skin dressing

5. Assess the wound 4. Assess the

base and edge exudate

(World Union of Wound Healing Societies 2007)

 TOWA
Wound bed
 Tissue type
 Exudate
 Infection

WOUND
Wound edge Periwound skin
 Maceration  Maceration
 Dehydration  Excoriation
 Undermining  Dry Skin
 Rolled  Hyperkeratosis
 Callus
 Eczema
 OUTLINE

• Wound assessment
• Wound cleansing
• Types of wound dressing
• Types of debridement
• Putting in together (Algorithm)
• Practise cases
WOUND ASSESSMENT
• Age (extreme of age)

• Disease and co-morbid (DM,

malignancy)

• Obesity

• Medication (steroid,
chemotherapy)

• Nutrition

• Impaired blood supply

(arterial and venous ulcer)

• Lifestyle (smoking)
 T.I.M.E
• A tool during wound assessment to
identify barriers to healing

• Implement a plan to remove barriers

and promote healing
 T.I.M.E
4 main components of wound bed
preparation:

1) Tissue Management
2) Control of Infection & Inflammation
3) Moisture Imbalance
4) Advancement of Epithelial Edge of the
wound
Source: International advisory board of wound bed preparation 2003
 1) TISSUE MANAGEMENT
• Pathology : defective matrix, non-viable tissue and cell
debris impairs healing

• Plan: Episodic or continuous debridement

• Effect of actions: restoration of wound base and

functional extracellular matrix proteins (chronic ->acute
wound)

• Clinical outcomes : Viable wound base

 HOW TO IDENTIFIED
VIABLE/ NON VIABLE
•4C FORMULA
-COLOUR
-CONSISTENCY
-CONTRACTION
-CIRCULATION
• non viable muscle/ tissue can
be identified by its dark color,
its mushy consistency, its
failure to contract when
pinched with forceps, and the
absence of bleeding from a
cut surface
 2) CONTROL OF INFECTION
& INFLAMMATION
• Pathology : high bacterial count/prolonged inflammation
-> ↑ cytokines & protease activity, ↓ growth factor activity

• Plan: -remove foci of infection (local/systemic)

- antimicrobials/antiinflammatory

• Effect of actions: low bacterial count & controlled

inflammation

• Clinical outcomes : bacterial balance and reduced

inflammation
PATHWAY OF WOUND
INFECTION
Contamination
Colonization
 pH
O2

O2

O2

pH
pH
O2

pH

Critical colonization
Infection
 BIOFILM
• Community of microorganisms encased
within an extracellular polymeric matrix,
which accumulates at a surface.
• It has been estimated that biofilms are
associated with 65 percent of
nosocomial infections.
• Play a significant role in a large number
of infections in humans.
• due to the intrinsic resistance of these
structures to antimicrobial agents and
host defense mechanisms, wound with
biofilm cannot be treated effectively
with antibiotic.
 3) MOISTURE IMBALANCE
• Pathology: dessication & excessive fluid- slows epithelial
migration and margin maceration

• Plan: moisture balance dressing, compression , negative

pressure dressing.

• Effect of actions: restored epithelial migration and

avoidance of maceration

• Clinical outcomes : moisture balanced for wound healing

 4) ADVANCEMENT OF EPITHELIAL
EDGE OF THE WOUND
• Pathology : non-migrating keratinocytes, non responsive
wound cells, abnormal protease activity and ECM
• Plan: reassess cause (T.I.M, extrinsic factor) and consider;
debridement, skin grafts, biologic agent

• Effect of actions: migrating keratinocytes and responsive

wound cells

• Clinical outcomes :advancing epithelial edge

 Peri Wound Skin Classification
Grade Type Description
0 Normal skin
1 At risk skin
2 A Dessication
(Exudate Centred)
B Maceration
C Allergy
3 Inflammed
4 Infection
5 Atypical
Dr. Harikrishna K.R.Nair 2015
Source: International advisory board of wound bed preparation 2003
WOUND
COLOUR
MODEL
 Site – sacral region Pink – Epithelial tissue

Size 12 x 8 x 1 cm Red – granulation

tissue

Black – necrotic tissue

Exudate – moderate
(purulent) with odour
Yellow - slough

Edges - undermining
 OUTLINE

• Wound classification
• Wound assessment
• Wound cleansing solution
• Wound dressing material
• Putting in together (Algorithm)
• Practise cases
 WOUND DRESSING
SOLUTIONS
•Non Antiseptic Solutions
•Antiseptic Solutions
• Wound cleansing is a process of
removing inflammatory
contaminants from the wound
surface
• These contaminants can impede
healing and increase risk of
infection
• The contaminants are:
Necrotic tissues
Excess exudates
Foreign objects
Infected tissues
 NON-ANTISEPTIC SOLUTIONS
• Commonly used non-antiseptic
solutions are:

Normal Saline
Water for irrigation
Normal Saline
• Preferred cleanser for most types of wounds (physiologic
and safe).
• Less effective in dirty and necrotic wounds.
• Not advisable in MRSA and Pseudomonas infected wound.
(peter et al 2008)
• Once the container is opened, it should be used within 24
hours.

Water for irrigation

• Less physiologic compared to normal saline but still safe to
be used.
• Can be used in MRSA and Pseudomonas infected wounds.
 ANTISEPTIC SOLUTIONS
• Antiseptic solutions are used to clean the
wound which are dirty and infected.
• Commonly used antiseptic solutions are:
 Chlorhexidine gluconate 1:200 in Aqueous
solution
 Super-oxidized solution
 Polyhexamethylene biguanide (PHMB) solution
Chlorhexidine gluconate 1:200 in Aqueous
solution

• Effective against Gram positive bacteria,

fungi and also enveloped viruses.
• Less effective against Gram negative
bacteria.
• Has both bactericidal and bacterostatic
action.
• Readily available in healthcare setting.
 Super-oxidized solution

• Good bactericidal, virucidal, fungicidal and

spongicidal.
• Also blocks the inflammatory process.
• May help in biofilm removal.
• Two components in this solution are oxidized
water and chlorine.
• The oxidized water is broken down into
oxygen, ozone and other oxidized species.
• Costly.
Polyhexamethylene biguanide (PHMB)
solution

• Helps to soften and remove the

slough.
• It can remove and reduce the
biofilm formation.
• Less painful.
• Costly.
• These solutions besides painful on application also
cause harm to the normal tissues if used as
dressing solutions (cytotoxic), however a short
term use may be permissible

 Povidone iodine
 Hydrogen peroxide
 Sodium hypochlorite
 Acetic acid
 Eusol
 OUTLINE

• Wound classification
• Wound assessment
• Wound cleansing
• Types of wound dressing material
• Putting in together (Algorithm)
• Practise cases
 Types of wound
dressing material
MODERN DRESSINGS
FILM
HYDROGEL
HYDROCOLLOID
CALCIUM ALGINATE
FOAM
HYDROFIBER
HYDROFIBER AG / SILVER
• People are often unreasonable and self-centered
FORGIVE THEM ANYWAY..if you are kind, people may
accuse you of ulterior motives..BE KIND ANYWAY…if you
are honest, people may cheat you.. BE HONEST
ANYWAY…if you find happiness, people may be
jealous..BE HAPPY ANYWAY..the good you do today
may be forgotten.. DO GOOD ANYWAY…give the world
your best and it may never be enough…GIVE YOUR
BEST ANYWAY…for you see, in the end it is between
YOU AND GOD…it was never between you and them
anyway…….

• Mother Teresa
 ‘WOUND
HEALING WITH
PASSION’
-LEARN -HELP -HEAL
TERIMA KASIH