Skin and Wound Care

Care plans must include patient-centered concerns and preferences.

• Consider the patient's socio-economic, psychosocial, and wound-specific concerns.
• Assess and support individualized concerns:
  • Wound Concerns (i.e., pain, smell, drainage, frequency of dressing changes)
  • Activities of daily living
  • Psychological well-being
  • Smoking
  • Access to care, financial limitations
• Provide education and support to the patient and their circle of care to increase adherence to the treatment plan.

Wound etiology treatments^1,2,4

• Having an accurate diagnosis for a wound is important, as there are specific treatments for different wound etiologies. A wound can have a mixed etiology and therefore need treatment options that consider the different causes for the wound.
• Treatment options must take into consideration the goals of care, including the healability of the wound.^1-4,15
• Examples for treating the cause of a wound:
  • Venous leg ulcer is caused by increased and sustained edema in the legs; treatment must include decreasing the edema: compression therapy with vascular supply is adequate, ankle ROM exercises and elevation^4,6,7,17
  • Arterial Ulcer is caused by decreased blood flow resulting in ulceration; treatment includes exploring the option of revascularization^4,6,8
  • Pressure injury is caused by increased or prolonged pressure, friction, or shear over a bony prominence; treatment includes pressure redistribution practices and supports, and management of incontinence and moisture^4,9-11,24,25
  • Diabetic foot ulcer is caused by the factors and effects of chronic diabetes; treatment includes optimization of vascular supply, infection control, and pressure redistribution of plantar surface^4,12-14

Modify systemic factors affecting wound healing1-4

• Co-morbidity management (i.e., diabetes):
  • Appropriate glucose control
  • Nutrition
  • Medications
  • Vascular Supply

Risk reduction of barriers to healing

• Smoking
• Substance use and abuse

Debridement

• Removal of non-viable tissue from wound bed^1,2,4,19
• Wound healing is impaired when there is necrotic tissue covering the wound base; granulation and epithelial tissue cannot grow in the presence of necrotic tissue.
• Non-viable tissue provides an environment for bacterial growth.
• Debridement should only happen if there is adequate vascular supply to a wound.
• Debridement methods^{1,2,4,8,15,16,18}:
  • Sharp debridement: surgical and conservative; done by a qualified healthcare professional using instruments, only removing the devitalized tissue
  • Autolytic debridement: the body’s natural physiological process of neutrophils and macrophages to remove non-viable tissue
  • Enzymatic debridement: topical application of enzymes that break down non-viable tissue
  • Biological debridement: larvae and maggots secrete enzymes to break down necrotic tissue  
  • Mechanical debridement: involves mechanical force to remove non-viable tissue (i.e., irrigation with PSI of 4-15, wet-to-dry dressing). This method is non-selective with tissue removal and can cause trauma to the wound bed. It is not an encouraged wound practice.

Moisture management

• Advantages of moist wound healing^{1,2,4,15,16,19} (“not too wet, not too dry, just the moisture of your eye”):
  • Cells necessary for the wound healing process cannot function in a dry environment
  • Increased angiogenesis
  • Enhanced autolytic debridement
  • Increased epithelialization
  • Decreased pain
• Excess or insufficient moisture impairs the healing process and causes breakdown of the wound bed and surrounding skin.^{1,2,4,15,16,19}
• These tissue alterations increase the risk of bacterial damage from superficial critical colonization and deep/surrounding wound infection.^1,2,4,18
• Low moisture levels may also lead to necrosis and eschar formation, hindering wound re-epithelialization and closure.^1,4,16,21-23
• If a wound is too dry: use a hydrating dressing^1,2,22,23 (i.e., hydrogel).
• If a wound is too wet: use an absorptive dressing^1,2,22,23 (i.e, foam, alginate, hydrofiber, composite, hypertonic).
• If wound is “just right”: use a moisture-retentive dressing^1,2,22,23 (i.e., film, hydrocolloid, clear acrylic, light foam, hydrophilic wound paste).

Bacterial balance

• Bacterial balance (bioburden) is crucial for wound healing.^{1,2,4,15,16,18-20}
• Management of bioburden needs to address^{1,2,4,15,16,18-20}:
  • Optimizing the host response
  • Reducing the levels of micro-organisms in the wound
  • Optimizing the wound environment

Treatment^{1,2,4,15,16,18-20}

•  Optimize Residents' Healing Factors
  • Optimize management of co-morbidities.
  • Optimize nutrition and hydration status.
  • Minimize or eliminate risk factors for infection when possible.
  • Optimize wound environment.
  • Treat systemic symptoms (i.e., pain, fever).
• Contamination and Colonization
  • Implementation of universal precautions (i.e., good hand hygiene and use of appropriate personal protective equipment)
  • Aseptic dressing technique
  • Wound cleansing with every dressing change
  • Monitoring for wound infection (i.e., changes to size, pain scale, wound bed, etc.)
• Local Infection
  • Same as above, as well as:
    • Notify MD or NP
    • Removal of non-viable tissue by debridement (i.e., sharp, autolytic, enzymatic)
    • Topical antimicrobials (i.e., silver, PHMB, iodine, gentian violet and methylene blue, medical grade honey)
    • Manage exudate from wound (i.e., use of absorptive dressing)
    • Monitor for spreading infection and systemic infection
• Spreading Infection and systemic infection:
  • Same as above, as well as:
    • Appropriate antibiotic treatment
    • Monitor for S&S of systemic infection (i.e., lethargy or general malaise, fever or chills, changes in cognition or behaviour, change in glucose levels (for clients with DM), elevated heart rate and respiration)

Local wound care: healing wound^1-5,15

• Cleanse wound with every dressing change.
  • Normal saline or antiseptic solution can be used.
  • Use adequate force with cleansing.
• Debridement of non-viable tissue^1-5,15,19
• Managing moisture^1-5,15,22,23 (“not too wet, not too dry, just the moisture of your eye”)
  • Select dressing to support optimal moisture balance:
    • Too dry: add moisture (hydrogel)
    • Just right: moisture retentive dressing (film, hydrocolloid, light foam)
    • Too wet: absorptive dressing (foam, hydrofiber, composite, alginate)
• Manage infection (bioburden)^1-5,15,18
  • Monitor for signs and symptoms of infection.
  • Remove non-viable tissue.
  • Use appropriate topical antimicrobials.
  • Use appropriate systemic antibiotic.

Local wound care: non-healable or non-healing wound1-5,15

• If dry, stable eschar is present, do not remove; keep dry and intact. Paint with antiseptic (i.e., SoluPrep™, Betadine®).
• Manage moisture:
  • Keep dry; use absorptive wound dressing to manage exudate.
  • Do not add moisture unless it is for pain-relieving measures.
• Manage and prevent infection:
  • Monitor for signs and symptoms of infection.
  • Use topical antimicrobials.
  • Use conservative debridement to decrease risk of infection.