This document discusses wound management and provides guidance on creating wound care plans. It begins with an overview of acute versus chronic wounds and the factors that can impede wound healing. The main types of wounds are then described - necrotic, sloughy, granulating, and epithelialized wounds. Key elements of a wound care plan are outlined, including cleaning the wound, possible debridement, exudate management, promoting healing, treating infections, and minimizing discomfort. The goal of wound care plans should be patient-centered and holistic to address the wound as well as the person's overall health needs.

1. ABC of Wounds management
Dr. Mahen Kothalawala MBBS, Dip in
Micro, MD, MPH(NZ),
Consultant Clinical Microbiologist
Teaching Hospital Kandy
SriLanka

2. Management of Wounds
Part one

3. Objective
• Types of wounds
• Mechanisms of wound Causation
• Wound healing –Phases
• Chronic Wounds
• Identification and classification of chronic
wounds
• Description of chronic wounds for the purpose
of documentation

4. Wounds
Acute Wounds Chronic Wounds
Cuts, Abrasions,
Lacerations Fail to pass
Contusions through normal
Punture healing process
Skin flaps and
Bites
Benbow ( 2005) Any wound >
3/12
considered a
chronic wound
They passes
through the
normal healing
process readily

5. acute wounds
• heal very easily
• It passes phases of wound healing
– Inflammatory phase
– Collagen building phase
– Remodelling Phase

6. Aim of management of acute wounds
• Healing without complications such as
infection and disfiguring
• Wound care
– Remove FB
– Dry or wet to dry dressing to cover the wounds
– Suturing if acute
– Bites - Prophylaxis

7. Antibiotics in acute wounds
• Only indicated if contaminated or evidence of
infection is demonstrated
• Evidence of infection (local)
– Redness
– Warmth
– Swelling
– Tenderness
– Local Lymphadenopathy

8. Acute wounds with abscess formation
• If abscesses are large need to be drained
• Smaller once – can manage with antibiotics
• Betadine*, Hydrogen Peroxide*, Saline, Spirit
can be used to cleanse the wound
• For chronic wounds * ********* may
interfere with granulation and epethelilised
tissues

9. Healing of acute wounds
• Wounds with minimal gaping – heals readily
with scarring
• Wounds with gaping or skin loss – heals with
Scar tissue formation and retraction

10. How do wounds heal
• Haemostasis
• Inflammation
• Proliferation or Granulation
• Remodelling or Maturation

11. Normal Healing Process… 11

12. Proliferative
Phase
Proliferation, Gra
nulation and
Contraction
Remodelling
Phase
Acute Wounds
Haemostasis &
Inflammatory
Phase
Healed Wound

13. Natural wound healing process

14. When Does a Wound Become
Chronic?
• healthy individuals with no underlying factors
an acute wound→ heal within three weeks
remodelling → over the next year or so
• When wound does not follow the normal
trajectory it may become stuck in one of the
stages and the wound becomes chronic.

15. Chronic Wounds
• Working Definition – wound lasting >3 months
• Chronic wound – Fail to heal due to various
local and systemic causes
– Healing process arrests at different levels of
healing
– Wound may appear at different colours

16. Chronic wounds
The wound healing cascade impairs and arrests at
different stages
Hemostasis CHRONIC WOUND
Platelet Aggregation
Neutrophil Immigration
Monocyte Immigration
Granulation
Re-epithelialization
Wound Closure
Scar Formation
Remodeling
Minutes Hours Days Weeks Months Years Time

17. Chronic wounds
• Normal healing process impaired
– Arrest at different levels –
– Remains at same stage without progressing to
wound healing
• Often an underlying cause remains and
undetected

18. Local and systemic factors that impede
wound healing
• Local factors • Systemic factors
• Advancing age and general immobility **
• Inadequate blood supply **
• Obesity ***
• Increased skin tension
• Smoking
• Poor surgical apposition
• Malnutrition ***
• Wound dehiscence
• Deficiency of vitamins and trace elements ***
• Poor venous drainage ** • Systemic malignancy and terminal illness Shock of any cause
• Presence of foreign body and foreign body • Chemotherapy and radiotherapy
reactions
• Immunosuppressant drugs, corticosteroids, anticoagulants
• Continued presence of micro-organisms &
Infection ** • Inherited neutrophil disorders, such as leucocyte adhesion
deficiency
• Excess local mobility, such as over a joint 18
• Diabetes and CRF***

19. Characteristics of a chronic wound
• May appear different colours at any given
time

20. Appearance of a chronic wound
20

21. Chronic Wounds Appearance
approach has been criticised for being too simplistic as wound healing is a continuum
and wounds often contain a mixture of tissue types.

22. Wound healing continuum
Wound Healing Continuum (Gray et al. 2005) have
been developed. This tool incorporates intermediate colour
combinations
between the four key colours

27. Management of wounds
Part two

28. Objectives
• Identification of different types of wounds
• Characteristics of the wounds

29. Types of wounds
• Necrotic Wounds
• Sloughy Wound
• Granulating Wounds
• Epethililized Wounds
• Mixed type
• Infected wounds

30. Necrotic wounds

31. Necrotic tissue
• Necrotic tissue= Dead tissue = when it is dry
and hard known as eschar
• It prevents wound healing – Removal is
necessary – May lead to infection
• Once removed healing starts
• Removal needs to asses wound staging and it
mask the true size of the wound

32. Necrotic wounds
• Fails to heal
• Masks the true size and staging
• Prevents antibiotics from reaching the site
• Provide foothold for microbes to grow and
evade antibacterial or neutrophils – Bio film

33. Necrotic wound
• often appears black,
• may also appear brown or grey when
hydrated.
• Necrotic → initially be soft,
• dead tissue → lose moisture and become
dehydrated with the surface becoming hard
and dry

34. Sloughy wounds
• Slough – yellowish/Yellow brown fibrous tissues which tightly
adherent to the wound base (dead cells and wound debris)
• cannot be removed by washing
• slough is not necessarily indicative of clinical infection.
• Slough can be found as patches across the wound bed.
• Exposed tendons may mistaken for slough.
• Effect of slough in wound healing
– Presence of slough delays wound healing
– Predispose to infection –provide Foot hold to organisms to attach
– Prevents antibiotics/Antimicrobial agents from reaching the site

36. Slough in wounds
• should be removed to enable healing to take
place.
• referred to as ‘de-sloughing’.

37. Granulating Wounds
• Granulation tissue fills the wound as it is
healing.
• The tops of the capillary loops make the
wound appear red and granular.
• It is firm to the touch, painless and does not
bleed easily.

38. Granulating Wounds

39. Unhealthy Granulating Tissues
• Bright red granulation tissue, which bleeds
easily, may indicate infection (Bale and Jones
1997).

40. Epethilialized wounds
• Epithelial tissue is formed in the final stages of
healing.
• This tissue forms the new epidermis.
• Epithelial tissue is superficial pink/white tissue
that migrates across the wound from the wound
margin, hair follicles or sweat glands.
• It will cover the granulating tissue.
• In shallow wounds with a large surface area, islets
of epithelialisation may be seen.

41. Epethililized wounds

42. Infected wounds
• Wound infection is the most troubling
wound complication (Cutting 1998).
• Avoiding infection is vital in good wound
management.
• Therefore it is good practice to recognise
the contributing factors that precede a
diagnosis of infection.

43. Wound Infection Continuum
• The Wound Infection Continuum (Gray et al.
2005) recognises the various levels of bio-
burden in the wound
– Wound Contamination
– Wound Colonization
– Critical Colonization
– Wound Infection
– Spreading wound infection
– Wound Sepsis

44. Wound 1.Organims from sorrounding
Contamination skin- Regional flora-
CONS, Deptheroids, Anerobes
H
Wound an
Colonization d 3.Organisms from External
hy environment- HCW through direct or
Wound Surface ge indirectly –
in MRSA, Pseudomonas, Multiresistant
Critical e organisims etc
Colonization
Fecal and urinary management systems
Wound 2.Organisms from GIT and GUT
Infection Gram Negatives such as
E.coli, Klebsiella, Enterobacter, Aner
obes
Advance Wound
Infection

45. Wound Infection
• The presence of multiplying organisms within
a wound that overwhelm the host immune
response with associated clinical signs and
symptoms. (Kingsley 2001)
Organism
Density

46. Factors which influence wound
infection
• 1. The quantity of micro-organisms
• 2.quality –Virulence and antibiotic resistance
• 3. The patients resistance to the level of
bacteria in the wound( immune response)
• Microbial bio-burden within wounds can
range from
contamination, colonisation, critical
colonisation and infection.

47. Clinical Signs of wound infection
• Classical Signs
1. Increased pain
2. Copious amounts of exudate
3. Malodour
4. Cellulites
5. Pyrexia
6. Abscess Formation

48. Additional Signs
– Increase in size of wound
– Delayed wound healing
– General unwellness
– Dark discoloured granulation tissue
– Increased friability
– Pocketing at base of wound. (Cutting and Harding
1994).

49. Investigations for wound infection
• When wounds are not healing in the expected
way and display signs and symptoms of infection
or for the presence of multi-resistant bacteria
such as MRSA (Gilchrist 2001).
• Three types of Investigations
– Deep tissue biopsy –During surgery(Bowler et al
2001).
– Wound Fluid Sampling
Aspiration using aseptic technique from deep
– Wound Swabs

50. Indications for wound swabs
• Wound swabs are generally preferred when
– Wound fails to heal as anticipated
– When evidence of infection present
– Suspecting drug resistance

51. Management of wounds
Part three

52. Objective
• Care of different types of Wounds

53. Care depends on
• Type of wound
• Amount and type of of Exudate
• Presence of critical colonization or evidence of
infection

54. Care of necrotic wound
• Necrotic wound
• As areas of necrosis interfere with healing
process, need to remove it through any of the
following means
– Mechanical Debridement –Wet to dry dressings
– Autolytic Debridement- Occlusive dressing and wound
exudate will debride by its enzymatic relations
– Enzymatic Debridement –By sofetneing slough by
using enzymes –Iruxol and Papaya
– Bio logical Debridement –Maggots therapy
– Surgical Debridement –Surgeons blades

55. Care of Exudative wound
• Dry wound
• Mildly exudative wound
• Moderately exudative wound
• High exudative wound
• Care of periwound area

56. Care of Sloughy wound
• De-sloughing
• Prevention of slough formation
• Enhance granulation

57. Care of granulating wounds
• Care of granulation tissue – avoid dry or wet to dry
dressings
• Prevent over granulation
• Prevent infection
• Exudate management and care of peri-wound area
• Skin grafting or skin substitutes

58. Care of Epethelialized wounds
• Same as in granulating wounds

59. Care of infected wounds
• Reduce bio burden –Cleansing, reduction of
necrotic and sloughy tissue
• Local antiseptics – rotational
• Local antiseptics- cedoxomer
iodine, crystalline silver, PHMB
• Exudate management
• Care of periwound area

60. Antibiotics
• For spreading infection and or evidence of
systemic infection
• Take blood cultures
• Treated with Broad Spectrum antibiotics
intravenously.
• Topical antimicrobials - used to reduce wound
bio burden (EWMA 2006).

61. Antimicrobials
• Topical antiseptics/Antibacterials
• The range of topical antimicrobial agents currently used
includes
– chlorhexidine,
– products containing iodine (cadexomer iodine and povidone
– iodine) and
– products containing silver (silver sulfadiazine and
silverimpregnated
– dressings) (EWMA 2006).
– The antiseptic/antimicrobial polyhexamethylene biguanide (also
known as polyhexanide or PHMB)
• .

62. Management of wounds
Part four

63. Care Planning .
Overall strategy and scope of the
treatment plan depends on patient’s
condition, prognosis, and reversibility of
the wound.

64. Appropriate Goals
• Prevent complications or the deterioration of an
existing wound
• Prevent additional skin breakdown and protection of
the surrounding skin
• Minimize harmful effects of the wound on the
patient’s overall condition
• Promote wound healing and achieve cure
• Prevention of wound from recurring and life style
modification

65. Patient Cantered – Holistic –Total care -Not only
dealing with person with a wound itself- need to address
chronic wound pts other needs, diseases, and
psychosocial wellbeing
Wound Care Plan
(WCP)
Inter-diciplinary
Needs Participation of
multitude of disciplines

66. Basic elements in wound care plan
• Cleanse Debris from the Wound
• Possible Debridement
• Manage Exudate
• Promote Granulation and Epithelialization
When Appropriate
• Possibly Treat Infections
• Minimize Discomfort

67. A. Cleanse Debris from the Wound
Cleansing agents
– Flowing Water –Requesting pt to bath before dressing change
– Normal Saline***
– Commercial Cleansers
– Hydrogen Peroxide
– Povidone iodine
– Hypochlorite solution
– Sterile vinegar solution
– Mechanical Cleansers –Whirl pools
– Salt dips
Aims
• Reduce bio burden
• Reduce dead and dying debris
• Clean the wound

68. 2. Possible Debridement
• Mechanical
• Autolytic
• Enzymatic
• Biological
• Surgical

69. C. Manage Exudates
• Identify the level of moisture
• Manage exudates by dressings
Nature of Exudate Type of wound Aim of exudate Method /Agent
management
No exudate Dry Keep the base Hydrocoloid agent
moist Intrasite
Need occlusive and
non occlusive
dressing
Mild exudate Moist Keep the wound Absorb moisture
moist
Moderate Wet Keep the wound in Absorb moisture
moist state by Form dressing
reducing exudate
Heavy Wet +++ Keep the wound Absorb
moist

70. D. Promote Granulation and
Epithelialization
• Granulation enhancers
• Minimal Dressing changes to reduce
disturbances to the granulation
• Avoid usage of substances which impede
granulation tissues

71. E. Treat infections
• Systemic antibiotics
• Local Antiseptics to the wound
• Rotational antiseptics etc

72. F. Minimize discomfort
• Pain relief
• Psychological support
• Family education and create conducive
environment
• Social support

73. WCP include
• Initial Assessment and Documentation
• Identifying the risk factors
• Optimize Local wound care
– Selection of Dressing
• Systemic therapy and nutritional supplementation
– Diabetes control
– Antibiotics if indicated
• Follow up and progress assessment periodically
• Change the plan if not improving
• Re-asses
• Empower the pt and family members

74. WCP Step one
Assessment and documentation

75. Initial Assessment and documentation

77. Assessment and documentation
• It is ongoing process
• Initial assessment – at the time of first
presentation
• At every dressing changes – need to asses and
document the state of wound to monitor
progress

79. WCP-Step two
• General Assessment of pt characteristics
• Ht, Weight, QI, BP, Skin color
• Past medical history
• Investigation done previously
• Drug and allergic history

80. • Chronic Wound Care: 10
Pearls for Success

81. Chronic Wound Care: 10 Pearls for
Success!!
Dr. Gary Sibbald, BSc, MD, MEd, FRCPC (Med), FRCPC (Derm), MACP, FAAD, MAPCA
1. For those with Diabetes for wound healing and further
prevention:
A - Check A1c - greater than 9% will affect wound healing.
Recommended is less than 7%.
B – Blood Pressure
C - Cholesterol
D - Diet
E - Exercise
F - Foot care - Check both feet at each appointment, shoes
should be professionally fitted, consider chiropody.
S- Smoking

82. • 2. For those with Venous Ulcer Disease -
Compression bandaging is for treatment,
stockings are for prevention.
– (Exudate/creams will damage the integrity of the
stockings).
– COMPRESSION IS FOR LIFE! The right
compression is the one the patient will wear

83. 3. For those with any distal neuropathy - Shoes
should be professionally fitted.
4. Smoking Cessation -IMPORTANT FOR ALL! -
each cigarette decreases leg circulation for
30% for an hour or increase sympathetic tone
for 8 hours
5. If wounds not decreased by 30% in size by
week 4, unlikely to heal by week 12. Consider
biopsy or a comprehensive re-assessment

84. 6.Query Infection? Culture using the Levine
technique (Compress wound with normal saline
for 10 minutes, press swab into a clean
granulated area to express fluid and rotate 360
degrees
7. Treat the cause! Consider all the possible
contributors to non-healing:
Drugs, Occult, Diabetes, Systemic Disease (e.g.
diabetes anemia, vascular
disease), smoking, non-adherence

85. • 9. Treat the wound!
Debridement, Infection, Moisture
Balance, and then Edge
• 10. Interdisciplinary collaboration -
Physicians, Nursing, Chiropody, OT, PT, Dieticia
n, and Caregivers.

86. Wound Care
• Complex
• Yet Acheivable

87. Case one -Documentation

88. Patients Name – RMW
67 yr
Diabetic pt
From Maharagama
A retired Clerk
Date of Clerking -21/5/2012
Wound –Medial side of the rt leg
Extending from Medial Maleolus
region
Maximum Length – 13 cm
Maximum Width -8 cm
Maximum Depth 2mm
Surface area - 39 cm2
Stage 11
Per-iwound Area –black Discoloration
+
No undermining
No tunnelling No evidence of Redness surrounding skin
Exudate – Mucoid Mild No regional Lymphadenopathy
No evidence of infection Venous Insufficiency
Smell – Not offensive
Colour of the wound bed –Mixed General – Mobile pt Afebrile
Necrosis 5%
Not anemic- 9.8g/dl
Granulation 30%
Slough 15%
Epethelialized 5%

89. Step Two
• General 168cm
• 84kg
• 160/100 kg
• Past medical history – DM for 20 yrs on regular therapy
• Past history of similar illness
• Drugs- On tolbutamide
• HT- No drugs
• FBS- 130 mg/dl

90. Team
• Surgeon
• Wound Care Practioner
• Nursing officer
• Physician
• Physio-therapist
• Nutritionists
• Attendant

91. Empower the patient and responsible
family member
• Teach the correct way to dressing
• Irrigation
• Compression

92. 100
Progress Assessment (two weekly)
80
60
40
20
0
Week 1 Week 3 Week 5 Week 7 Week 9
Necrosis Slough Granulation Epethililization
-20
Linear (Necrosis) Linear (Slough) Linear (Granulation)

93. Dressings
• Objectives
– Type of Dressings
– Selection of dressings
– Dressing recommendation

94. Dressings
• When a wound is infected → expensive
dressings useless
• Management of exudate, pain is very
necessary.
• Additionally debridement of necrotic or
sloughy tissue can alter the wound
environment significantly and help to reduce
the overall bioburden and reduce odour
(EWMA 2006).

95. Dressing Selection
• Primary Dressing – A dressing that touches the
wound
• Secondary Dressing – Keeps the primary
dressing in site – Fasten it to the wound
• Some dressings function as primary dressings
only
• Some could function as primary and
secondary dressings as well - adhesive

96. Dressing Selection
• Depend on
– Type of wound
– Patient preference/Dr preference
– Stage of healing of the wound
• Proliferation or Granulation phases
• Remodelling or Maturation phases
• Presence or absence of Infection or Colonization –Bio
film

97. Dressing Selection
• Depending on wound healing passes through its
different stages different types of dressings may
be required
• Normally moist environment will enhance wound
healing
• Exudate provide moist healing
• Too much of exudate,
– interfere with wound healing-leads to autolysis by the
action of enzymes in the exudate
– Inhibits-granulation and epethilization

98. Ideal wound dressing for moist wound
healing need to ensure....
• Wound remain moist– not macerated
• Wound need to remain free from active infection
• Free from toxic materials of the dressing
Papaya and Komarika
• To maintain the wound at optimum temperature
for healing
• Undisturbed by the frequent need for dressing
changes
• Maintain optimum PH conducive to wound
healing

99. Advanced wound dressing
• Are designed to control the environment around
wound -↑ healing
• Mainatainance of moisture balance
– Some donate fluid to keep wound moist (ex
Hydrogels)- used for dry wounds
– Some maintain moisture or retain moisture without
donating or loosing (Hydro colloids)
– Some designed to absorb excessive moisture (Alginate
and foams)
• Fight Infection/Critical Colanization/
– Silver impregnated dressings
– Iodine containing dressings/powder/cream etc

100. Practice which need be discouraged
• Irritant solutions
• Irritant cleansers
• Frequent de-sloughing or using de-sloghing
agent

101. Desloughing
• Hydrogels, hydrocolloids and medical grade
honey can be used to autolytic debridement
for difficult to heal ulcers
• Sterile larvae- can be used to bio surgical
debridement

102. Dressings
• Two types
• Inactive Dressings
• Active dressings

103. Inactive dressings
• Dry dressings
• wet to dry dressings
• Polyurethane film dressing –Breathable and
non breathable film dressings
• Vasline tules
• Antibiotic impregnated tules
103

104. Dry dressing and wet to dry dressing
• Gauze dressing
• Can be medicated or non medicated
• Good for acute wounds

105. Dry dressings……
1. Tend to absorb wound moisture
2. Tightly Adherent to granulation Tissue –
will break upon removal
105

106. Vaseline Gauze
PU Film Dressings
106

107. Film dressings and tules
• Not shown to be better than dry dressings
• Only advantage – no breaking of granulation
tissues

108. Active dressings
• Plays a role in wound healing
– Provide a covering,
– enhance granulation tissue formation,
– Reduce slough formation
– Inhibits bacteria
– Keep wound moist
– Some provide growth factors
108

109. Examples
• Hydrogels –fibre and Foams
• Hydrocellular dressings
• Foams
• Alginates
• Crystaline Silver and Slow Iodine releasing
materials
109

110. Hydrogel
• Cross linked gel dressing
– Flexigel
– Intrasite
• Keep the wound moist
• Suitable to mildly exudating wounds and to
dry and necrotic wounds
110

111. Foam dressing
• Suitable for mild to moderate exudating
wounds
• Adsorbs exudate rapidly and enhance
thickness
111

112. Forms
• Used for cavities and fill the dead space
(cavitating lesions)
• Promote healing from the edge
112

113. Alginate Dressing
Adsorbs excessive moisture
113

114. • Summary