The correct dressing for wound management depends on the type of wound, tissue type in the wound bed and also on the stage of the healing process.
Wound healing comprises four stages in acute wounds and three stages in non-acute wounds.
1. Inflammatory Phase – debridement including removal of bacteria and dead tissue
Seen visually as slough, necrosis and exudate
2. Proliferation Phase – growth of new tissue into the wound including vascularisation, granulation, collagen production and epithelialisation.
Seen visually as growth of healthy red granular tissue to fill wound and pink epithelium to cover wound
3. Maturation Phase – re-organisation of the collagen matrix, reduction in vascular flow to area as need for oxygen reduces to normal levels.
Seen visually as scar tissue becoming paler, flatter and smoother
1. Wounds which are clean with granulation or epithelial tissue should not be routinely cleansed
2. Wounds with slough and exudate are likely to require cleansing at each dressing change.
3. Any surgical wound within the first 48 hours of surgery, or deep cavity wounds, should be cleansed with sterile sodium chloride 0.9%
4. Any other acute or chronic wound requiring cleansing should be irrigated with warm tap water; this can be done using a shower, a lined basin or a syringe.
5. Gauze swabs should not be used to rub or wipe across the surface of the wound to remove debris as this can cause trauma to new tissue.
6. The decision to use tap water to cleanse wounds should take into account the quality of water, nature of wounds and the patient’s general condition, including the presence of co-morbid conditions.
7. The decision to cleanse should be based on clinical judgment and consideration of the functions of cleansing:
- to remove debris from surface of wound, e.g. devitalised tissue, foreign bodies, dressing residue
- to rehydrate the surface of a wound in order to provide a moist environment
- to keep the skin surrounding the wound clean and free from excessive moisture
- to facilitate wound assessment so that the size and extent of the wound can be
- to minimise wound trauma when removing adherent dressing materials
- to promote patient comfort and psychological well-being
Debridement and desloughing
- Autolytic - use of dressings to provide the correct moist environment to allow proteolytic enzymes produced by the body to breakdown dead tissue
- Mechanical - use of moistened debridement wipe or soft pad to gently remove soft slough and surrounding tissue plaques
- Larval/maggots - use of maggots (greenbottle fly larvae, Lucilia sericata) which secrete proteolytic enzymes to breakdown dead tissue. Use where:
- slough is not debrididing with other methods
- speed of debridement is important
- difficult to assess extent of tissue damage, e.g. diabetic foot ulcer
- Sharp debridement - removal of dead tissue but leaving an edge of devitalised tissue in place, using sterile surgical instrument by competent staff. Use where speed of debridement is important and to reduce risk of infection from large areas of dead tissue
- Surgical debridement - removal of dead tissue down to a bleeding wound bed. Only performed by surgeons under general/local anaesthetic.
Moist Wound Healing and the Ideal Dressing
Providing a moist environment for wound healing is known to improve the healing of all types of wounds. A balance needs to be maintained between ‘too dry’ and ‘too wet’ both of which are detrimental to the wound healing process.
The ideal dressing needs to ensure that the wound remains:
- Moist with exudate, but not macerated;
- Free of clinical infection and excessive slough;
- Free of toxic chemicals, particles or fibres;
- At the optimum temperature for healing;
- Undisturbed by the need for frequent changes;
- At the optimum pH value.
As wound healing passes through its different stages, variations in dressing type may be required. (See page 4 and key code page 5 of the printed booklet for exudates levels and tissue type suitability.)
General Wound Management Guidance
The following guidelines are recommended when treating wounds:
- All wounds should be assessed and details documented on the NHS Lothian Wound Assessment and Treatment Chart on TRAK or paper format (code LU021)
- Always employ an holistic approach to wound care, e.g. investigate any underlying problems
- An appropriate timescale for redressing the wound should be decided for each individual patient/wound, taking into account the manufacturer’s instructions
- A multidisciplinary approach should be taken in wound care referring to appropriate specialists as required
- A clear explanation of the action of dressings/treatments must be explained to the patient
- Dressings which promote moist wound healing should not be used on the lower limbs of patients with suspected ischaemic changes (e.g. peripheral vascular disease), until fully assessed
- For fragile skin or painful wounds consider use of a medical adhesive remover, e.g. Medi Lifteez® / Peel Easy® / Appeel®
- Refer to Black Heel guidance for nectrotic heel management
- Do not reyhydrate ischaemic toes without vascular review