WOUND ASSESSMENT AND

MODERN DRESSINGS
Presenter: Angela
Mentor: Dr Siek
 Definition
• A disruption in the continuity of epithelium, with or without
loss of underlying connective tissue, following external
injury or intrinsic factors.
Phases of wound healing
 Principles of Wound Bed Preparation
• Tissue
• Infection/inflammation
• Moisture
• Edge of wound

Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair Regen, 2000; 8(5): 347-52.
Schultz, G. S., Sibbald, R. G., Falanga, V., Ayello, E. A., Dowsett, C., Harding, K., Romanelli, M., Stacey, M. C., Teot, L. and
Vanscheidt, W. (2003), Wound bed preparation: a systematic approach to wound management. Wound Repair Regen, 11: S1–S28.
• Devitalized tissue/Debridement
• Infection/inflammation
• Moisture balance
• Wound Edge preparation

Sibbald RG, Woo KY, Ayello E. Wound bed preparation: DIM before DIME. Wound Healing Southern Africa 2008; 1: 29- 34.
Triangle of Wound Assessment (TOWA)

World Union of Wound Healing Societies (2016) Position Document. Advances in Wound Care: The Triangle of Wound Assessment.
Wounds International, London.
 Factors affecting wound healing
Local factors Systemic factors
Mechanical trauma Advanced age
Infection Malnutrition
Edema Obesity
Dessication and dehydration Diabetes mellitus
Lack of oxygen Anemia
Continued pressure Vascular insufficiency
Presence of necrotic tissue Immunosuppression

Presence of foreign bodies Smoking

sharp debridement
 Wound bed assessment
• Tissue - viable/nonviable
 Debridement
• Debridement is the process of removing devitalised tissue
and/or foreign material from a wound
• Types
– surgical/sharp
– autolytic
– enzymatic
– larval/biological
– mechanical
 Types
1) Surgical/sharp
- very large wounds
with a lot of necrotic
material and infected
material.
Example Advantages/Disadvantages
Advantages
• Excellent control over what and how much tissue is removed
• Fastest way to achieve a clean wound bed
• Can speed the healing process
Disadvantages
• Not cost-effective if an operating room is required
• General anesthesia carries its own risks
• Painful for the patient

2) Autolytic Semi-occlusive or Advantages

- not heavily occlusive dressings • No damage to surrounding skin; is selective for necrotic tissue
exudating wounds • transparent films • The process is safe because it uses the body’s natural processes to
• hydrogels rid the wound of necrotic tissue
• Easy to perform
• hydrocolloids • Very effective
• Not painful for the patient
Honey based Disadvantages
products • The process takes time (may take days to weeks)
• The wound must be routinely monitored for signs of infection
• Anaerobic growth may occur when an occlusive dressing is chosen
 Types Example Advantages/Disadvantages
3) Enzymatic Topical agents with Advantages
- wounds with a large collagenase • Works faster than autolytic debridement
amount of necrotic or • If properly applied, there is little risk to healthy tissue
eschar formation Disadvantages
• May be fairly expensive
• Care must be taken to ensure healthy tissue does not come in contact
with the chemical agent
• A secondary dressing may be required to absorb exudate
• Chemical debridement may cause some discomfort to the patient (i.e.,
burning sensation, increased wound pain)
4) Mechanical Wet to dry Advantages
dressings • Cost-effective
• Dressing changes are simple so the patient can be taught to change
Hydrotherapy or their own dressing
irrigation Disadvantages
• May remove healthy (healing) tissue as well as devitalized tissue
• Time-consuming as the dressings must be changed often
• Can be quite painful for the patient

5) Larval/biological Lucilia sericata

Phaenicia
sericata
Lucilia cuprina
 Wound bed assessment
• Infection/inflammation
– Contamination - Infection continuum
 Antimicrobial dressings
• Studies show that some iodine and silver preparations have bactericidal
effects even against multiresistant organisms such as methicillinresistant
Staphylococcus aureus (MRSA) (Landsdown, 2002; Romanelli et al, 2003;
Sibbald et al, 2003).
 Wound bed assessment
• Moisture imbalance
– Moisture balance is essential for positive outcomes in wound healing
– Dr. George D. Winter's research showed that, contrary to the conventional
wisdom at the time that wounds should be allowed to dry out and form scabs
to promote healing, wounds instead heal faster if kept moist.
– Types of exudates:

Winter, GD. Formation of the Scab and the Rate of Epithelization of Superficial Wounds in the Skin of the Young Domestic
Pig. Nature. 1962;193:293-294.
Hydrocolloids
Foam
Hydrofibers
 Negative pressure wound therapy (NPWT)
• Mechanism of action
– Removal of excess exudates
– Reduction of edema
– Increase in perfusion
– Promotes granulation tissue formation
– Reduction in bacterial load
– Enhances epithelial migration
• Contraindications
– Malignant wounds
– Untreated osteomyelitis
– Presence of necrotic and eschar tissue
– Non-enteric and unexplored fistulas
– Exposed blood vessels, anastomotic
sites, organs, or nerves
 Wound edge assessment
• Edge of wound
 Periwound skin assessment
• Surrounding skin
– Periwound skin is defined as skin within 4cm of the wound edge,
or any skin under the dressing
 Modern Dressings
• Main characteristic of maintaining the moisture level is the foremost
advantage of modern dressings.
• Primary dressing: Dressing that comes directly in contact with the wound bed
• Secondary dressing: Dressing used to cover a primary dressing when the
primary dressing does not protect the wound from contamination
• Occlusive dressing: Covers a wound from the outside environment and keep
nearly all wound vapors at the wound site
• Semi-occlusive dressing: Allows some oxygen and moisture vapour to
evaporate
 Choice of dressing
Purpose Dressings
Debridement Hydrogels
Hydrocolloids
Films
Antimicrobial Silver dressings
Iodine based dressings
Exudate control Hydrocolloids
Hydrofibers
Foam
Rehydration Hydrogels

Dry wounds Mild exudate Moderate exudate Heavy exudate

Films Films Alginates Alginates
Hydrogels Hydrogels Hydrofibers Hydrofibers
Hydrocolloids Foam Foam
Negative pressure Negative pressure
therapy therapy
Ostomy bags
 Semi-permeable film dressings
• Consist of a thin, polyurethane
membrane coated with a layer of
acrylic adhesive
• Suitable for wounds with no to low
exudate
• Semi-occlusive
• Autolytic debridement
• Highly elastic and flexible, and can
conform to any shape
• E.g. Opsite™, Tegaderm™,
Biooclusive ™
 Hydrogels
• Insoluble hydrophilic materials made from
synthetic polymers such as
polymethacrylates and polyvinyl pyrrolidine
• High water content (70-90 %) helps
granulation tissues and epithelium
• Suitable for wounds with no to low exudates
(chronic dry wounds, burns, pressure ulcers)
• Rehydration
• Autolytic debridement
• Usually requires secondary dressing
• E.g. Intrasite™, Nu-gel™, Aquaform™
polymers, sheet dressings, impregnated
gauze and water-based gels
 Hydrocolloids
• Combination of polymers held in a fine
suspension and often contain
polysaccharides, proteins and
adhesives
• Suitable for wounds with low exudates
• Polymers combine with the exudate
and form a gel-like mass
• Autolytic debridement
• Occlusive (cannot be used if wound or
surrounding skin is infected)
• Not indicated in neuropathic ulcers
• E.g. Duoderm®, Comfeel™, Hydrocoll®
 Alginates
• Made from calcium or sodium salts of
alginate acid, obtained from seaweed
• Suitable for wounds with moderate to heavy
exudates
• Absorbs exudates to form a strong
hydrophilic gel, forming a protective film and
minimizes bacterial contamination
• Activates macrophages to produce TNF-α
and accelerates healing10
• Require secondary dressings because it
could dehydrate the wound
• Not suitable for dry wounds
• E.g. Sorbsan™, Kaltostat™, Algisite™
10 Thomas A, Harding KG, Moore K Biomaterials. 2000 Sep; 21(17):1797-802.
 Hydrofibers
• Formed from a fibrous mat of
carboxymethyl chitin (CMC)
• Suitable for wounds with moderate to
heavy exudates
• Absorbs exudates to form a strong
hydrophilic gel, forming a protective film
and minimizes bacterial contamination
• Require secondary dressings
• Not suitable for dry wounds
• E.g. Aquacel™
 Foam dressings

• Made up of hydrophobic and hydrophilic

foam
• Hydrophobic properties of outer layer
protect from the liquid
• Suitable for moderate to heavy exudative
wounds
• Not suitable for dry wounds
• Semi-occlusive
• Cushioning effect
• E.g. Lyofoam™, Allevyn™ and Tielle™
 Medicated dressings
• Silver impregnated dressings
– Antimicrobial
– May be combined with alginates/ CMC, foam
dressings
– E.g. Aquacel AgTM
• Iodine based dressings
– Antimicrobial
– E.g. IodosorbTM
• Collagenase and papain based ointments
– Enzymatic debridement
– E.g. DebridaceTM
 Types Actions
Inert NA cotton wool • Protect new tissue growth
dressings • Absorb minimal exudate
Polyurethane film • Moisture control
• Breathable bacterial
barrier
• Transparent (allow
visualisation of wound)
Hydrogels • Rehydrate wound bed
• Moisture control
• Promote autolytic
debridement
Hydrocolloids • Absorb fluid
• Promote autolytic
debridement
Alginates/CMC • Absorb fluid
• Promote autolytic
• debridement
• Moisture control
• Conformability to wound
bed
Indications
Dry or low-exuding wounds
• Primary dressing over superficial,
low-exuding wounds
• Secondary dressing over alginate or
hydrogel for rehydration of wound
bed
• Dry/low- to moderate-exuding
wounds
• Combined presentation with silver
for antimicrobial activity
Clean, low- to moderate-exuding
wounds
• Moderate- to high-exuding wounds
• Special cavity presentations in the
form of rope or ribbon
• Combined presentation with silver
for antimicrobial activity
Precautions/Contraindications
• Use as contact layer on superficial
low-exuding wounds
• Will not cope with moderate or higher
levels of exudate
• Do not use on patients with
fragile/compromised periwound skin
• Do not use on moderate- to high-
exuding wounds
• Do not use on highly exuding wounds
or where anaerobic infection is
suspected
• May cause maceration
• Do not use on dry/necrotic wounds or
high-exuding wounds
• May encourage overgranulation
• May cause maceration
• Do not use on dry/necrotic wounds
• Use with caution on friable tissue
(may cause bleeding)
• Do not pack cavity wounds tightly
 Types Actions Indications Precautions/Contraindications

Foams • Absorb fluid • Moderate- to high-exuding wounds • Do not use on dry/necrotic wounds
• Moisture control • Special cavity presentations in the or those with minimal exudate
• Conformability to wound form of strips or ribbon
bed • Low-adherent versions available for
patients with fragile skin
• Combined presentation with silver
or PHMB for antimicrobial activity
Foam-like • Absorb fluid • Moderate- to high-exuding wounds • Do not use on dry/necrotic wounds
hydroactive • Moisture control • Special cavity presentations in the or those with minimal exudate
dressings • Conformability to wound form
bed • Low-adherent versions available for
• Similar but not the same patients with fragile skin
as a foam
Silver Antimicrobial action • Critically colonised wounds or • Some may cause discolouration
clinical signs of infection • Known sensitivity to silver
• Low- to high-exuding wounds • Discontinue after 2 weeks if no
• Combined presentation with foam improvement and re-evaluate
and alginates/CMC for increased
absorbency
Iodine • Antimicrobial action • Critically colonised wounds or • Do not use on dry necrotic tissue
• Debrider clinical signs of infection • Known sensitivity to iodine
• Healing stimulation • Low- to high-exuding wounds • Short-term use recommended
• 3 months (there is a risk of systemic
absorption in larger wound with
prolonged use)
 References
1. Leaper DJ, Harding KG. (1998) Wounds: Biology and Management. Oxford University Press.
2. Hutchinson J (1992). The Wound Programme. Centre for Medical Education: Dundee.
3. Classification of surgical procedures by risk of infection (Mangram et al., 1999)
4. Lazarus GS, Cooper DM, Knighton DR, et al. Definitions and guidelines for assessment of wounds
and evaluation of healing. Arch Dermatol. 1994;130(4):489–493.
5. Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds. Wound
Repair Regen, 2000; 8(5): 347-52.
6. Schultz, G. S., Sibbald, R. G., Falanga, V., Ayello, E. A., Dowsett, C., Harding, K., Romanelli, M.,
Stacey, M. C., Teot, L. and Vanscheidt, W. (2003), Wound bed preparation: a systematic approach to
wound management. Wound Repair Regen, 11: S1–S28.
7. Sibbald RG, Woo KY, Ayello E. Wound bed preparation: DIM before DIME. Wound Healing Southern
Africa 2008; 1: 29- 34.
8. World Union of Wound Healing Societies (2016) Position Document. Advances in Wound Care: The
Triangle of Wound Assessment. Wounds International, London.
9. Winter, GD. Formation of the Scab and the Rate of Epithelization of Superficial Wounds in the Skin of
the Young Domestic Pig. Nature. 1962;193:293-294.
10. Thomas A, Harding KG, Moore K Biomaterials. 2000 Sep; 21(17):1797-802.