Wound Assessment and Management – Step by Step Guide

The assessment and maintenance of skin integrity in the patient should be fundamental to the provision of care. 
Collaboration between the nursing team and treating medical team is essential to ensure appropriate wound management and facilitate optimal wound healing.

Accurate wound assessment and effective wound management requires an understanding of the physiology of wound healing, combined with knowledge of the actions of the dressing products available. It is essential that an ongoing process of assessment, clinical decision making, intervention and documentation occurs to facilitate optimal wound healing.

Physiology of a wound and wound healing

Wound classification-
Acute wound– is any surgical wound that heals by primary intention or any traumatic or surgical wound that heals by secondary intention. An acute wound is expected to progress through the phases of normal healing, resulting in the closure of the wound.  
Chronic wound– is a wound that fails to progress healing or respond to treatment over the normal expected healing time frame (4 weeks) and becomes “stuck” in the inflammatory phase. This pathologic inflammation is due to a postponed, incomplete or uncoordinated healing process. Wound healing is delayed by the presence of intrinsic and extrinsic factors including medications, poor nutrition, co-morbidities or inappropriate dressing selection.

Type of Healing-
Primary intention– the wound edges are held together by artificial means such as sutures, staples, tapes or tissue glue. There is minimal tissue loss and wounds heal with minimal scarring. Most clean surgical wounds and recent traumatic injuries are managed by primary closure.
Delayed primary intention– when the wound is infected or requires more thorough intensive cleaning or debridement prior to primary closure usually 3-7 days later. May be used for traumatic wounds or contaminated surgical wounds.
Secondary intention– spontaneous wound healing occurs through a process of granulation, contraction and epithelialisation. Results in scar formation and used as a method of healing for pressure injuries, ulcers or dehisced wounds.

Skin graft- removal of partial or full thickness segment of epidermis and dermis from its blood supply and transplanting it to another site to speed up healing and reduce the risk of infection.
Flap– the surgical relocation of skin and underlying structures to repair a wound. Flaps are named according to their tissue components and may include an anastomosis of blood supply to vessels attached to or at the affected site.

Wound healing is a complex sequence of events that can be broadly divided into two stages:
Haemostasis– is the rapid response to physical injury and is necessary to control bleeding. It involves the following components: 1. Vasoconstriction 2. Platelet response 3. Biochemical response
Tissue Repair & Regeneration– involves 3 phases:

1. Inflammation phase (0-4 Days) the body’s normal response to injury. This phase activates vasodilatation leading to increased blood flow causing heat, redness, pain, swelling and loss of function. Wound exudate may be present and this is also a normal body response.
2. Reconstruction phase (2-24 Days) the time when the wound is healing. The body makes new blood vessels, which cover the surface of the wound. This phase includes reconstruction and epithelialisation. The wound will become smaller as it heals.
3. Maturation phase (24 days-1 year) the final phase of healing, when scar tissue is formed. The wound is still at risk and should be protected where possible.

Initial approach

• Use an advanced trauma life support/ABCDE approach in life-threatening wounds
• Severe haemorrhage may require pressure, elevation and use of a tourniquet or arterial clamp/suture

Clean and debride wound

• Clean wound and area using multiple sterile gauze soaked in sterile saline 
• Anaesthetise: infiltrate 1% lidocaine subcutaneously around wound edges 
• Mechanical cleansing (debridement): remove any debris/contamination/foreign bodies/dead tissue. Use sterile gauze soaked in saline to scrub; and forceps and a scalpel to excise tissue if required.
• Pressure irrigation (can omit if wound is clean): squirt sterile saline into the wound using pressure (from syringe via green needle or from pressure infusion bag via orange cannula)
• Deep inspection: thoroughly re-inspect the whole of the wound (may need wound edge retraction), look at deep structures as able, and ask the patient attempt full range of movement to help look for tendon damage 
• Perform any further cleansing/irrigation if required – some wounds require more thorough debridement:
  • Wound debridement under general anaesthesia is required if large, extensive debris, lots of necrotic skin, dead muscle, contamination, underlying fracture or neurovascular compromise
  • Urgent surgical exploration is required if there is any possibility of nerve/vessel/tendon/organ damage

Closure options

• Immediate primary closure: immediate closure with sutures/clips/Steri-Strips/glue. This is only used if there is negligible skin loss, the wound is clean with no foreign bodies, <12 hours old (<24 hours for face wounds), and the edges come together easily without tension.
• Delayed primary closure: wound cleaned thoroughly, then dressed and left open for 48 hours. The wound is then reviewed for signs of infection, swelling and bleeding. If these are absent and the wound edges can be opposed without tension, the wound is sutured closed. This is used for contaminated wounds, contused/bruised wounds, infected wounds, or wounds >12 hours old. Antimicrobial dressings and prophylactic antibiotics should also be used for contaminated/infected wounds.
• Secondary intention: allow wound to close by itself, i.e. by granulation, epithelialisation and scarring. This is used for wounds with tissue loss preventing edge approximation, chronic ulcers and partial-thickness burns.
• Skin grafts: for significant skin loss (including most full-thickness burns)

Other aspects to management

• Infected or contaminated wounds require antibiotics
• Consider tetanus booster/immunoglobulin if patient is not up to date with tetanus vaccines (5 total) or high-risk wound 
• Consider rabies immunoglobulin if high risk wound in high risk area
• Analgesia, e.g. Entonox, morphine IV, regional anaesthesia
• If swelling likely – rest, ice, elevation for 24 hours
• Select appropriate dressing (a primary dressing is placed directly on wound and a secondary dressing is placed over this to provide further protection)
• Consider correcting any factors which may hinder wound healing, e.g. stop smoking/NSAIDs, give nutritional supplements

Follow up

• Give patient wound advice
• Injured limbs need elevation for 24-48 hours
• Arrange follow-up for: wounds for delayed primary closure (to close), diabetic or immunocompromised patients (to review healing), burns (to look for infection)
• Suture removal:

Head and face	5 days
Upper limb/trunk/abdomen	7 days
Lower limb/diabetic/immunocompromised	10 days

Wounds requiring special management

Burns

• Initial assessment
  • Test sensation, blanching and check tetanus status
  • Determine the % body surface area involved using rule of 9’s (head 9%, arm 9%, leg 18%, trunk front 18%, trunk back 18%), palmar surface (patient’s palm and fingers = 0.8%) or a Lund and Browder chart (more accurate, especially in children)
  • Classify burn by determining depth: 

Classes of burns

Class	Characteristics	Management
Superficial	Red and dry, blanches with pressure (like sunburn)	Simple moisturiser/Aloe vera gel
Partial-thickness (superficial/deep)Need re-epithelialisation ± granulation to heal	Red and moist, with blisters, does not blanch	See text below
Full-thickness	White/grey/scalded, insensate, solid, dry	Skin graft

• Initial management for all major burns should begin with an ABCDE  approach
  • Airway burns: call anaesthetist and intubate patient as soon as possible  
  • Breathing: give all patients 100% oxygen through a humidified non-rebreather mask; nebulisers for smoke inhalation
  • Circulation: site 2 large bore cannulas and commence IV fluid resuscitation 
    • The Parkland formula estimates fluid requirements in 24 hours
      • Fluid requirement (ml) = 4 × total burn surface area (%) × body weight (kg)
      • 50% of this is given in the first 8 hours and 50% in the next 16 hours
      • Children should also be given maintenance fluids
  • Disability: check responsiveness, give strong analgesia
  • Exposure: examine entire skin and look for other injuries
    • Large area burns: cover with sterile sheets or cling film until specialist review
    • Minor burns: immerse in cool water for 30 minutes (or cover with cool sterile saline soaked towels)
• Further management of partial-thickness burns
  • Use systemic (never topical) analgesia if required
  • Cleanse with soap and water, then thoroughly rinse
  • Scrub off any necrotic tissue
  • Dress simple low-exudate burns with multiple layers of low-adherent impregnated tulle gauze. Cover this with a sterile non-adherent absorbent pad dressing and secure with bandages or dressing fixing tape.
  • Review in 48 hours to look for signs of infection
  • Re-dress every 2 days
• Blisters: leave intact unless they are open/contaminated (fully debride) or are large/prevent dressing (sterile aspiration) 
• Burns requiring specialist opinion/admission: full thickness burns (need skin graft); >10-15% body surface area or if elderly/significant comorbidities (risk of significant fluid loss); hands (put in bag with paraffin and keep moving); face (use Vaseline); genitalia/perineum (admit as difficult to dress); burns over major joints; chemical (‘irrigate, irrigate, irrigate!’); electrical (spare skin); inhalation injuries (airway risk); circumferential burns (risk of compartment syndrome)

Puncture wounds

• X-ray if any possibility foreign body
• If wound is deep and contaminated, it needs wide debridement in theatre
• If not, use simple debridement and irrigation
• Follow-up is required 

Bites

• Cat and human bites are worst
• High risk of tendon injury and joint contamination leading to risk of septic arthritis
• Most require aggressive surgical management, often followed by delayed primary closure/healing by secondary intention
• Give antibiotics for 5 days

Others

• Gunshot wounds are usually treated with thorough debridement and delayed primary suture
• Facial injuries should ideally be sutured by a plastic surgeon– use fine sutures and remove after 2-5 days
• Crushed tissues need to be elevated for 7-10 days to reduce swelling prior to closure (risk of compartment syndrome)

References

• Ayello, Elizabeth A. (2006) New Evidence for an Enduring Wound-Healing Concept: Moisture Control: Journal of Wound, Ostomy and Continence Nursing: November-December 2006 – Volume 33 – Issue – p S1–S2
• Carville, K. (2017) Wound care Manual- 7th Edition. Osborne Park, Western Australia: Silver Chain Foundation.
• Standards for Wound Prevention and Management. 3rd edition (2016). Cambridge Media: Osborne Park, WA
• Benbow, M., Wound care: ensuring a holistic and collaborative assessment. British Journal of Community Nursing, 2011: p. S6-16
• Australasian College for Infection Prevention and Control, Aseptic Technique Policy and Practice Guidelines. 2015, ACIPC.
• S. Guo & L.A. DiPietro Factors Affecting Wound Healing J Dent Res. 2010 Mar; 89(3): 219–229.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2903966/
• Australian Wound Management Association Inc. (August 2011). Bacterial impact on wound healing: From contamination to infection. Position Paper, Version 2.
• Kanji S1, Das H2.Advances of Stem Cell Therapeutics in Cutaneous Wound Healing and Regeneration Mediators Inflamm. 2017;2017:5217967. doi: 10.1155/2017/5217967. Epub 2017 Oct 29.
• Jones RE, Foster DS, Longaker MT. Management of Chronic Wounds- 2018. JAMA. 2018;320(14):1481–1482. doi:10.1001/jama.2018.12426 https://jamanetwork.com/journals/jama/fullarticle/2703959
• Siddiqui AR, Bernstein JM. Chronic wound infection: Facts and controversies Clinics in Dermatology Volume 28, Issue 5, September–October 2010, Pages 519-526 https://www.sciencedirect.com/science/article/pii/S0738081X10000337
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