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Wound Management: General

The goal of wound management is
primarily restoration of function, which
requires minimizing risk of infection and
repair of injured tissue with a minimum of
cosmetic deformity.
Wound Assessment: Time of injury
After 3 hours, the bacterial count in a wound
increases dramatically. Wounds may be closed
primarily up to 18 hours after injury; clean
well and use clinical judgment.

Wounds up to 24 hours old on the face may be

closed after good cleaning. The blood supply in
this area is much better and the risk of infection
therefore much less. The risk of infection may
be reduced in wounds by use of tape closures
Wound Assessment
Wounds Requiring Debridement
A. Provide Basic General Wound Care
I. Assess and treat patient for systemic illness
(History, Focused Exam, Vital Signs)
II. Assess for diabetes and maintain Hb<7
III. Evaluate nutritional status and correct
deficiencies IV. Identify and treat infection
V. Upgrade Tetanus (and if indicated rabies)
VI. Assess and correct local hypoxia/ischemia
VII. Provide appropriate edema reduction
Wound Assessment
Wounds Requiring Debridement
• VIII. Provide method for off-loading any
weight bearing wound site
• IX. Educate patient and/or care taker about
appropriate wound care
• X. Facilitate provision of appropriate off-site
wound care
• XI. Ensure patient has primary care
assignment, and refer to appropriate
specialist as indicated
Wound Assessment
B. Assess Peri-wound Area
1. Do neurovascular examination
2. Evaluate and document the following findings in the
periwound area:
• Edema, localized swelling
• Erythema, cyanosis, pallor, discoloration
• Induration
• Tenderness
• Temperature-warmth/coolness
• Eschar
• Necrosis-wet. Dry
• Rashes
Wound Assessment
C. Assess the Wound Area
1. Evaluate following findings:
• Callous, Hypertrophic skin, Maceration, Necrosis,
Tracts, fissures, Undermining
Invagination/Evagination ,Re-epithelialization
2. Evaluated wound base:
• Clot/bleeding ,Granulation tissue, Fibrous
tissue,Vital structures (tendon, nerve, muscle, blood
vessels, bone, peritoneum, fascial sheaths, joint
capsule, cartilage, ect.), Foreign Bodies (glass,
suture, clips),Odor,Pus, drainage, discharge,
Tunneling, cavities, fistulas
Wound Assessment
3. Measure and Record Wound Size:
• Length, Width, Depth, Location of tracts,
tunneling, Length and diameter of tracts,
Acquire Photographs and Wound Tracings at
least weekly
Wound Assessment
Principles of wound management
1. Determine wound aetiology.
2. Identify and where possible eliminate or
control factors impairing healing.
3. Determine realistic and achievable long and
short term objectives.
4. Regularly monitor responses to management
regime and reassess as necessary.
6. Ensure optimal outcome achievement
7. Based on assessment plan wound
management regime in collaboration with
client; should be individually tailored a/c to the
person, health, social, economic, psychological
status, and wound characteristics
Healing Impairment: Intrinsic factors
• Increasing age, Diabetes, Liver failure,
Rheumatoid arthritis, Anaemia,
Inflammatory bowel, disease, Auto-
immune disorders, Reduced vascularity,
NSAIDS/SAIDS, Cytotoxics, radiotherapy,
Poor nutrition, Obesity, Reduced
sensation, Poor mobility
Healing Impairment: Extrinsic factors

• Moisture (eg incontinence), High

bacterial load /Infection, Wound
desiccation(dryness), Cooling of wounds
below 37oC, Pressure, shear and friction,
Foreign bodies
Old dressing: Assessment
Assessment of the old wound dressing is often
overlooked. The old dressing reveals vital
information in:
• determining the appropriateness of the
dressing products chosen and the wound
• provide information on the amount, colour and
consistency of wound exudate.
• If dressings are leaking or adhered to the
wound the dressing regime or frequency of
dressing changes may need to be altered.
Tools in wound assessment
Assess wound at every change of dressing to know
expected outcomes
• Regular and systematic documentation of wound
characteristics .
• Wound assessment chart a useful tool to ensure
that all wound characteristics are assessed and
• Photographs are an excellent wound
• documentation tool. Photographs may be used in
• addition to or in place of an assessment chart and
• provides a degree of detail that cannot be obtained
by written description or drawings.
Wound Characteristics: Assessment
• Wound size
• Tissue types: devitalised or necrotic
Necrotic: Black, hardened dead tissue. It
may be moist or dry.
Sloughy: Yellow, devitalised tissue.
Granulating: Red, healthy tissue.
Epithelialising: Pink tissue evident as
epithelium covers the wound.
Wound Characteristics: Assessment
Exudate: Following descriptions used to identify
exudate types:
Serous: clear fluid, straw coloured
Haemoserous: slightly blood stained serous fluid
Sanguineous: heavily blood stained or frank
Purulent: containing pus
Odour: Offensive odour indicates presence of
high levels of bacteria. Presence of necrotic
tissue produces a putrid smell which is the
result of anaerobic bacteria.
Wound Characteristics: Assessment

Surrounding skin: Assess following:

Maceration: Soft, white, moist skin due to
exposure to excessive moisture
Erythema: Redness which may or may not
blanch when pressed. Erythema may indicate
infection or pressure. Non blanchable erythema
is a heralding sign of tissue destruction.
Contact dermatitis: may result from sensitivity to
a dressing product, prolonged use of adhesive
dressings or or tapes, or prolonged exposure
of the skin to wound exudate.
Wound Characteristics: Assessment

Callous: Indicates pressure. commonly

occurs on the foot. Callous can also
mask a wound.