Principles Of Wound Care

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Principles of wound careProf Mokoena2013!1

GOALS OF LOCAL WOUND TREATMENT Wound bed preparationsConvert to surgically clean woundDebride necrotic tissueTreat / prevent local infectionProtect surrounding tissueProtect wound against trauma eg with splintsAbsorb excess exudateDrain excess fluid eg blood or pus!2

ASSESSMENT OF THE WOUND Assess general condition of patient Assess local wound- length, breadth and depth- cleanliness or otherwise- vitality of tissues- infection and extent- surrounding tissues!3

MANAGEMENT PLANOptimise Systemic Condition- nutrition- medication- oxygenation- diabetic control- immune suppression status- infectionRational local treatment!4

Treatment of a wound Best treatment is prevention– Surgical incision properly placed andexecuted– Use appropriate prophylaxis and correcttechnique– Care of ischaemic and diabetic feet– Care of pressure areas including egcorrect intra-op positioning and protection!5

DECONTAMINATION OF WOUNDS Copious irrigation and scrubbing ofcontaminated wound eg after MVA Diversion of excreta eg colostomy Control fistula effluent eg use woundmanagement bag or vacuum -assistedclosure (VAC) system!6

WOUND DEBRIDEMENT Mechanical or surgical Chemical eg aserbine Autolytic (moist dressing)!7

ANTISEPTIC WOUND TREATMENT Do not put into a wound what you would notput into your own eye Inorganic halide and alcohols eg chlorideand iodine base of antiseptics banned Organic antiseptic at correct strength egPovidone Iodine!8

IDEAL WOUND DRESSING Moisture retentivePerspirativeAbsorptiveProtective from traumaThermal insulationMicrobial barrierNon-traumatic removal!9

MOIST WOUND CARE IMoist wound heal faster than dry wounds-Winter demonstrated benefit of moist woundhealing in superficial incised wound in 1962!-Dyson et al demonstrated similar benefit infull thickness accidental lacerations in 1988!10

MOIST WOUND CARE IIMoist wound heal faster than dry wounds Dryness dessicates inflammatory cells and newepithelium Moist healing accelerates inflammatory process Epithelial cells migrate easily across moist woundsurface Moist environment enables proteolyses of deadtissueCaveat: Guard against maceration of normaltissuesDry dressing removes new epithelium on changing!11

MONITORING OF WOUND CARECould care hinder healing - YES frequent changes of dressing inappropriate dressing material Inappropriate antiseptic dry dressing too frequent wound inspection Take off only if:– Dressing soiled (saturated with moist)– Excessive pain– Surrounding tissue shows excessive inflammatory response– If bleeding present!12

PROPHYLAXIS AGAINST INFECTIONGeneral AntisepsisAntimocrobial Application- local (mostly used)- systemicChoice of antimicrobial Therapy!13

Choice of wound dressings Skin grafts (SSG, full thickness, flaps)Hydro colloidsHydrogelsAlgenatesImpregnated dressings eg silver/antibioticSkin substitutesAmniotic membraneXenograft!14

WOUND DRESSINGS Films eg Opsite, TegadermHydrocolloids eg Granuflex, ComfeelHydrogels eg Intrasite gel, ElastogelFoams eg AllevynImpregnates eg AdapticAbsorptive powders or pastes eg Hydrogram!15

DRY WOUND DRESSING Sticks to wound New epithilialisation destroyed on removal Causes pain on changing!16

VACUUM ASSISTED WOUNDCLOSURE Low pressure continuous suction Indications– High exudate– Discharging fistula– Large dead space New device no adequate scientific tests!17

Macrophage preparations fordecubitus ulcer treatment Geriatric decibutal ulcerMonocytes derived macrophage application27% vs 6% healing of conventional methodsHealing faster after macrophage application!!18

WOUND DRESSING (I) - cs SkinH2O and bacteria “breathes”Acute Partial or Thickness “dry”wounds!19

WOUND DRESSING (II) s-Hydrophilic colloid particlesGranuflexComfeelIntrasiteAbsorbant, Debrides byAutolysis, Promotes healingProtects- Acute or Chronic any thickness!20

WOUND DRESSING (III) - HYDROGELSCompositionExamplesFunctionsIndications- 80 % - 99 %H2O linked polymers egacrilamides, polyethyleneoxide- Intrasite gelElastogel- Creates moist environment, lowabsorbancy- Acute or chronic non-exudative!21

WOUND DRESSINGS (IV) - FOAMSCompositionExamplesFunctionIndications- Hydrophic or Hydrophobicpolyurethane gel or film- Allevyn- High Absorbency, ‘Debrides,’“breathes”- Acute or chronic exudativeor slough!22

WOUND DRESSING (V) - - Gauze mesh impregnatewith moisturizer orantimicrobial- Adaptic- Biobrane- Promotes healing or antimicrobial- Acute or chronic partialthickness minimal exudate!23

WOUND DRESSINGS (VI) – ABSORPTIVE POWDERS AND PASTESCompositionExamplesFunctionsIndications- Starch copolymers colloidalhydrophilic particles- Hydrogran- High absorbancyDebrides- Chronic full thickness withcopious exudate, slough!24

WOUND DRESSINGS (VII) – BIOLOGIC blems- Natural skin / membranes- Amniotic membraneXenogeneic skin (pig)- Biologic cover- Large burns- Infection (not rejection)!25

WOUND DRESSINGS (VIII) – WOUND MANAGEMENT BAGCompositionExamplesFunctionsIndications- Oversize “stoma” bag- Hollister- Collection of fistula or hig volexudate- Complex wounds with fistula!26

Summary Assess wound quality– Classify wound– Assess local tissue health, perfusion and sepsis– Correct abnormalities and optimise health Assess patient health and quality– Nutrition status– General health status esp. O2 carrying capacity– Immune status esp. HIV/DM– Correct abnormalities and optimize health!27

MOIST WOUND CARE I Moist wound heal faster than dry wounds - Winter demonstrated benefit of moist wound healing in superficial incised wound in 1962! - Dyson et al demonstrated similar be

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Figure 1. The wound bed preparation care cycle. Figure 2. Fixed yellow slough on a wound bed. Prevention Healed Start with the patient Treat & evaluate TIME interventions Perform TIME assessment Agree goals Identifying wound Wound bed aetiology preparation Care cycle Yes No Wound bed preparation - TIME in contex 58-70TIME.indd 6 17/10/05 10 .