Which intervention is part of the nursing interventions classification?

When conducting initial and ongoing wound assessments the following considerations should be taken into account to allow for appropriate management in conjunction with the treating team:

• Type of wound- acute or chronic
  
• Aetiology- surgical, laceration, ulcer, burn, abrasion, traumatic, pressure injury, neoplastic
  
• Location and surrounding skin
  
• Tissue Loss
  
• Clinical appearance of the wound bed and stage of healing
  
• Measurement and dimensions
  
• Wound edge
  
• Exudate
  
• Presence of infection
  
• Pain
  
• Previous wound management

See Clinical Guideline (Nursing): Nursing Assessment for more detailed nursing assessment information.

Considerations for Wound Assessment

Type of wound:

There is different terminology used to describe specific types of wounds: such as surgical incision, burn, laceration, ulcer, abrasion. They can be generally classified as either acute or chronic wounds.

Tissue loss:

The degree of tissue loss may be referred to in broad terms as:

• Superficial wound- involving the epidermis
  
• Partial wound- involves the dermis and epidermis
  
• Full thickness wound-involves the epidermis, dermis, subcutaneous tissue and may extend to muscle, bones and tendons.

There are classification systems for certain types of wounds such as Burns (Nursing Management of Burn Injuries Clinical Practice Guideline) and Pressure Injuries (Pressure Injury Prevention and Management Clinical Practice Guideline)

Wound bed clinical appearance:

• Granulating- is when healthy red tissue is observed and is deposited during the repair process. It presents as pinkish/red coloured moist tissue and comprises of newly formed collagen, elastin and capillary networks. The tissue is well vascularised and bleeds easily.
  
• Epithelialising- is a process by which the wound surface is covered by new epithelium, this begins when the wound has filled with granulation tissue. The tissue is pink, almost white, and only occurs on top of healthy granulation tissue.
  
• Sloughy- the presence of devitalised yellowish tissue is observed and is formed by an accumulation of dead cells. Must not be confused with the presence of pus.
  
• Necrotic- describes a wound containing dead tissue. The wound may appear hard, dry and black. Dead connective tissue may appear grey. The presence of dead tissue in a wound prevents healing.
  
• Hyper granulating- this is observed when granulation tissue grows above the wound margin. This occurs when the proliferative phase of healing is prolonged usually as a result of bacterial imbalance or irritant forces.
  

Wound measurement:

'Assessment and evaluation of wound healing is an ongoing process.  All wounds require a two-dimensional assessment of the wound opening and a three-dimensional assessment of any cavity or tracking' (Carville, 2017)

• Two-dimensional assessment- can be done with a paper tape to measure the length and width in millimetres. The circumference of the wound can be traced if the wound edges are not even - often required for chronic wounds. The clinical picture application with the use of the ‘Rover’ device within EMR can be utilised and added in the ‘LDA’ wound assessment flowsheet.
  
• Three-dimensional assessment- the wound depth is measured using a dampened cotton tip applicator.
  

Wound edges:

The edges of the wound are assessed for-

• Colour- pink edges indicate growth of new tissue; dusky edges indicate hypoxia; and erythema indicates physiological inflammatory response or cellulitis
  
• Evidence of contraction- wound edges coming together indicate the healing process is occurring. Raised or rolled edges- raised (where the wound margin is elevated above the surrounding tissue) may indicate hyper granulation tissue and rolled (where the edges are rolled down towards the wound bed) can inhibit healing.
  
• Changes in sensation- increased pain or the absence of sensation should be further investigated
  

Exudate:

Is produced by all acute and chronic wounds (to a greater or lesser extent) as part of the natural healing process. It plays an essential part in the healing process in that it:

• Contains nutrients, energy and growth factors for metabolising cells
  
• Contains high quantities of white blood cells
  
• Cleanses the wound
  
• Maintains a moist environment
  
• Promotes epithelialisation

It is important to assess and document the type, amount, colour and odour of exudate to identify any changes. Excess exudate leads to maceration and degradation of skin while too little can result in the wound bed drying out. It may become more viscous and odorous in infected wounds.

Surrounding skin:

The surrounding skin should be examined carefully as part of the process of assessment and appropriate action taken to protect it from injury.

Presence of infection:

Wound infection may be defined as the presence of bacteria or other organisms, which multiply and lead to the overcoming of host resistance. Infection can disrupt healing and damage tissues (local infection) or produce spreading infection or systemic illness. Infection adversely affects wound healing and may be the cause of wound dehiscence.
Local indicators of infection-

• Redness (erythema or cellulitis)
  
• Exudate- a change to purulent fluid or an increase in amount of exudate
  
• Malodor
  
• Localised pain
  
• Localised heat
  
• Oedema

Wound healing and clinical infection demonstrate inflammatory responses and it is important to ascertain if increases in pain, heat, oedema and erythema are related to the inflammatory phase of wound healing or infection.
If any of the above clinical indicators are present a medical review should be instigated and a Microscopy & Culture Wound Swab (MCS) should be considered.

Pain:

Pain can be an important indicator of abnormality. The pain associated with chronic wounds and wounds that require frequent dressing changes can be underestimated.
Accurate assessment of pain is essential with regard to choice of the most appropriate dressing. Assessment of pain before, during and after the dressing change may provide vital information for further wound management and dressing selection.

Wound Management

Guidelines for wound management: 

1. Promote a multidisciplinary approach to care.
   
2. Initial patient and wound assessment is important and whenever there is a change in condition.
   
3. Consider the psychological implications of a wound- especially relevant in the paediatric setting in relation to developmental understanding and pain associated with the wound and dressing changes.
   
4. Determine the goal of care and expected outcomes.
   
5. Respect the fragile wound environment.
   
6. Maintain bacterial balance- use aseptic technique when performing wound procedures.
   
7. Maintain a moist wound environment
   
8. Maintain a stable wound temperature. Avoid cold solutions or wound exposure.
   
9. Maintain an acidic or neutral pH.
   
10. Allow a heavily draining wound to drain freely.
    
11. Eliminate dead space but don’t pack a wound tightly.
    
12. Select appropriate dressings and techniques based on assessment and scientific evidence.
    
13. Instigate appropriate adjunctive wound therapies- e.g. compression, splinting and pressure redistribution equipment, off-loading orthotics.
    
14. Follow the principles for managing acute and chronic wounds. (Carville, 2017)

Acute Wound Management

Wound cleansing

The goal of wound cleansing is to:

• Remove visible debris and devitalised tissue
  
• Remove dressing residue
  
• Remove excessive or dry crusting exudates
  
• Reduce contamination 

Principles of wound cleansing:

• Use Aseptic Technique procedure- a non-touch technique is used to protect key parts and key sites. If a key part or key site is to be touched directly then sterile gloves must be worn. Note: when using a disinfectant on a key site (e.g. skin) or key part (e.g. injection port) it must be allowed to dry.
  
• Cleansing should be performed in a way that minimises trauma to the wound as new epithelial cells and vessels are fragile.
  
• Irrigation is the preferred method for cleansing open wounds. This may be carried out utilising a syringe in order to produce gentle pressure and loosen debris. Gauze swabs and cotton wool should be used with caution.
  
• Wounds are best cleansed with sterile isotonic saline or water, warmed to body temperature.
  

Choice of dressing

A wound will require different management and treatment at various stages of healing. No dressing is suitable for all wounds; therefore frequent assessment of the wound is required. 

Wound healing progresses most rapidly in an environment that is clean, moist (but not wet), protected from heat loss, trauma and bacterial invasion.

• Much research has demonstrated that moisture control is a critical aspect of wound care.
  
• The appropriate dressing can have a significant effect on the rate and quality of healing.
  
• The appropriate dressing will help to minimize bacterial contamination and pain associated with wound care.

There are a multitude of dressings available to select from. Effective dressing selection requires both accurate wound assessment and current knowledge of available dressings (Ayello, Elizabeth A)

Wounds healing by Primary Intention

These wounds require little intervention other than protection and observation for complications.
Recommended dressings include:

• Dry non-adherants
  
• Island dressings
  
• Semi-permeable films
  
• Hydrocolloids
  
• Foams
  

Wounds healing by delayed primary intention

Occurs when the wound is contaminated or infection is suspected. These traumatic or surgical wounds require intensive cleaning before healing can occur. Debridement using irrigation may be required.
Recommended dressings include:

• Normal saline compresses
  
• Amphorous hydrogels or hydrogel impregnated gauzes to assist with debridement
  
• Calcium alginate ropes or ribbons
  
• Hyrofibre ropes or ribbons
  
• Drainable wound/ostomy appliances when large amounts of exudate is present
  
• Foams

Absorbent or protective secondary dressings will be required for most wounds- it is important to ensure that the surrounding skin is protected from maceration. A skin barrier wipe can be used.

Wounds healing by secondary intention

Acute surgical or traumatic wounds may be allowed to heal by secondary intention- for example a sinus, drained abscess, wound dehiscence, skin tear or superficial laceration.
Dressing selection should be based on specific wound characteristics. Referral to Stomal Therapy should be considered to promote optimal wound healing.

RCH Dressing Selection Resources

Chronic wound management

Determine the aetiology for inhibition of wound healing. Address or control the factors identified for example: presence of infection, poor nutritional status, appropriate dressing selection, moist wound environment. 

Dressing selection should be based on the specific wound characteristics and referral to Stomal Therapy should be initiated to promote optimal wound healing. Advanced wound therapies may be required to be utilitised e.g surgical debridement, application of a negative pressure dressing, hyperbaric therapy.

Ongoing Management

Discharge planning

Parents and carers should be given a plan for the ongoing management of the wound at home.  A range of appropriate dressing products can be obtained from the RCH Equipment Distribution Centre.

For more complex wound care needs involvement of the inpatient care coordinators may be required to make appropriate referrals to Wallaby or an alternative for ongoing wound management at home. 

Medical teams managing patients may request specific wound care and follow up to occur at RCH via Specialist Clinics- this may also include Nurse Led Clinics or patients may be referred to their local GP for wound follow up.

Documentation within the EMR

It is an expectation that all aspects of wound care, including assessment, treatment and management plans, implementation and evaluation are documented clearly and comprehensively.
Documentation of wound assessment and management should be completed in the EMR under the ‘flowsheet’ activity, utilising the ‘LDA tab’ (Lines, Drains, Airway Assessment) or by utilising the Avatar acitivity.
Click on the ‘Add New LDA’ button to search for the correct wound type e.g. Burn, Surgical Incision, and Pressure Area. The ‘LDA’ tab or Avatar can be used to monitor and record progress of the wound through its stages of healing. Clinical pictures can be added to the assessment utilising the ‘Rover’ Device.

Wound care and dressing changes can also be ordered/preplanned utilising the ‘Orders’ activity.

EMR Learning Resources and Tip Sheets:

Companion Documents

Links

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
  

Evidence Table

Please remember to read the disclaimer 

The development of this clinical guideline was coordinated by Kirsten Davidson, EMR Lead Nurse Educator. Approved by the Clinical Effectiveness Committee. Current as of March 2019.

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