Wound Care Health Article

KEY TERMS

Anabolic—Metabolic processes characterized by the conversion of simple substances into more complex compounds.

Catabolic—Metabolic processes characterized by the release of energy through the conversion of complex compounds into simple substances.

Cytokine—A protein that regulates the duration and intensity of the body's immune response.

Dermis—The thick layer of skin below the epidermis.

Epidermis—The outermost layer of the skin.

Exudate—Fluid, cells, or other substances that are slowly discharged by tissue, especially due to injury or inflammation.

Fibrin—The fibrous protein of blood clots.

Fibroblast—An undifferentiated connective tissue cell that is capable of forming collagen fibers.

Neutrophil—A type of white blood cell.

Scar—Scar tissue is the fibrous tissue that replaces normal tissue destroyed by injury or disease.

in the wound. These are referred to as wet to dry dressings. Generally a saline soaked gauze dressing is loosely placed into the wound and covered with a dry gauze dressing to prevent drying and contamination. It also supports autolytic debridement (the body's own capacity to lyse and dissolve necrotic tissue), absorbs exudate, and traps bacteria in the gauze, which are removed when the dressing is changed.

Preventing further injury is the third principle of wound care. This involves elimination or reduction of the condition that allowed the wound to develop. Factors that contribute to the development of chronic wounds include losses in mobility, mental status changes, deficits of sensation, and circulatory deficits. Patients must be properly positioned to eliminate continued pressure to the chronic wound. Pressure reducing devices, such as mattresses, cushions, supportive boots, foam wedges, and fitted shoes can be used to keep pressure off wounds.

Providing nutrition, specifically protein for healing, is the fourth principle of healing. Protein is essential for wound repair and regeneration. Without essential amino acids, angiogenesis, fibroblast proliferation, collagen synthesis, and scar remodeling will not occur. Amino acids also support the immune response. Adequate amounts of carbohydrates and fats are needed to prevent the amino acids from being oxidized for caloric needs. Glucose is also needed to meet the energy requirements of the cells involved in wound repair. Albumin is the most important indicator of malnutrition because it is sacrificed to provide essential amino acids if there is inadequate protein intake.

Preparation

Effective wound care begins with an assessment of the entire patient. This includes obtaining a complete health history and a physical assessment. Assessing the patient assists in identifying causes and contributing factors of the wound. When examining the wound, it is important to document its size, location, appearance, and the surrounding skin. The health care professional also examines the wound for exudate, necrotic tissue, signs of infection, and drainage, and documents how long the patient has had the wound. It is also important to know what treatment, if any, the patient has previously received for the wound.

Actual components of wound care include cleaning, dressing, determining frequency of dressing changes, and reeavaluation. Removing dead tissue and debris that impedes healing, is the goal of cleaning the wound. When cleaning the wound, protective goggles should be worn and sterile saline solution should be used. Providone iodine, sodium hypochlorite, and hydrogen peroxide should never be used, as they are toxic to cells.

Gentle pressure should be used to clean the wound if there is no necrotic tissue. This can be accomplished by utilizing a 60 cc catheter tip syringe to apply the cleaning solution. If the wound has necrotic tissue, more pressure may be needed. Whirlpools can also be used for wounds having a thick layer of exudate. At times, chemical or surgical debridement may be needed to remove debris.

Dressings are applied to wounds for the following reasons: to provide the proper environment for healing, to absorb drainage, to immobilize the wound, to protect the wound and new tissue growth from mechanical injury and bacterial contamination, to promote hemostasis, and to provide mental/physical patient comfort. There are several types of dressings and most are designed to maintain a moist wound bed:

• Alginate: made of non-woven fibers derived from seaweed, alginate forms a gel as it absorbs exudate. It is used for wounds with moderate to heavy exudate or drainage, and is changed every 12 hours to three days, depending on when the exudate comes through the secondary dressing.
• Composite dressings: combining physically distinct components into a single dressing, composite dressings provide bacterial protection, absorption, and adhesion. The frequency of dressing changes vary.
• Foam: made from polyurethane, foam comes in various thicknesses having different absorption rates. It is used for wounds with moderate to heavy exudate or drainage. Dressing change is every three to seven days.
• Gauze: available a number of forms including sponges, pads, ropes, strips and rolls, gauze can be impregnated with petroleum, antimicrobials, and saline. Frequent changes are needed because gauze has limited moisture retention properties, and there is little protection from contamination. With removal of a dried dressing, there is a risk of wound damage to the healing skin surrounding the wound. Gauze dressings are changed two to three times a day.
• Hydrocolloid: made of gelatin or pectin, hydrocolloid is available as a wafer, paste, or powder. While absorbing exudate, the dressing forms a gel. Hydrocolloid dressings are used for light to moderate exudate or drainage. This type of dressing is not used for wounds with exposed tendon or bone, or third-degree burns, and not in the presence of bacterial, fungal, or viral infection, active cellulitis or vasculitis, because it is almost totally occlusive. Dressings are changed every three to seven days.
• Hydrogel: composed primarily of water, hydrogel dressings are used for wounds with minimal exudate. Some are impregnated in gauze or non-woven sponge. Dressings are changed one or two times a day.
• Transparent film: an adhesive waterproof membrane that keeps contaminants out while allowing oxygen and water vapor to cross through, it is used primarily for wounds with minimal exudate. It is also used as a secondary material to secure non-adhesive gauzes. Dressings are changed every three to five days, if the film is used as a primary dressing.