Skin and Wound Care

Principles of Wound Healing

Wound prevention and management is a challenging healthcare need; there are many factors that affect and influence wound healing. Care plans need to be individualized, evidence-based and patient centered. There are guiding principles for wound healing and enablers to aid clinicians in the process of creating optimal wound care plans.

  • Care plans are developed based on findings from the comprehensive patient and wound assessments.1-4
  • Wound care goals should be developed in collaboration with the healthcare provider and client.
  • For care plan development, consider: patient-centered concerns, the cause of the wound, and local 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 treatments1,2,4

  • 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 elevation4,6,7,17
    • Arterial Ulcer is caused by decreased blood flow resulting in ulceration; treatment includes exploring the option of revascularization4,6,8
    • 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 moisture4,9-11,24,25
    • 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 surface4,12-14

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 bed1,2,4,19
  • 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 methods1,2,4,8,15,16,18:
    • 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 healing1,2,4,15,16,19 (“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 dressing1,2,22,23 (i.e., hydrogel).
  • If a wound is too wet: use an absorptive dressing1,2,22,23 (i.e, foam, alginate, hydrofiber, composite, hypertonic).
  • If wound is “just right”: use a moisture-retentive dressing1,2,22,23 (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 address1,2,4,15,16,18-20:
    • Optimizing the host response
    • Reducing the levels of micro-organisms in the wound
    • Optimizing the wound environment

Treatment1,2,4,15,16,18-20

  •  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 wound1-5,15

  • Cleanse wound with every dressing change
    • Normal saline or antiseptic solution can be used.
    • Use adequate force with cleansing.
  • Debridement of non-viable tissue1-5,15,19
  • Managing moisture1-5,15,22,23 - “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.

Wounds Canada's Wound Prevention and Management Cycle

Recommendations for Wound Prevention and Management

Wounds Canada’s Wound Prevention and Management Cycle outlines a process that supports patient-centered care. It guides clinicians through a logical and systematic approach for developing an individualized care plan.

1. Orsted HL, Keast DH, Forest-Lelande L, Kuhnke JL, O’Sullivan-Drombolis D, Jin S, et al. Best practice recommendations for the prevention and management of wounds. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 Jan 23]. 73p. Available from: https://www.woundscanada.ca/health-care-professional/education-health-care-professional/advanced-education/12-healthcare-professional/110-supplements.

2. British Columbia Provincial Nursing Skin and Wound Committee. (2018). Guideline: wound management for adults & children. [cited 2018 Nov 7]. Available from: https://www.clwk.ca/buddydrive/file/guideline-wound-management-2018-august/

3. Van Rijswijk L, & Eisenberg M. (2010). Wound assessment and documentation. In: Krasner DL, Rodeheaver GT, Sibbald G, Woo K (Ed.), Chronic Wound Care: A Clinical Source Book for Health Care Professionals (5th ed.). pp. 99-116. Malvern PA: HMP Communications

4. Sibbald G, et al. (2011). Special considerations in wound bed preparation 2011: An update. Advances in Skin and Wound Care, 24(9), 415-436

5. Sussman C. (2012). Assessment of the patient, skin and wound. In: C. Sussman and B.M. Bates-Jensen (Ed.), Wound Care - A Collaborative Practice Manual for Health Professionals (4th ed.). pp. 53-109. Philadelphia, PA: Lippincott, Williams & Wilkins

6. British Columbia Provincial Nursing Skin and Wound Committee. (2014). Guideline: assessment and treatment of lower leg ulcers (arterial, venous & mixed) in adults. [cited 2018 Nov 7]. Available from: https://www.clwk.ca/buddydrive/file/guideline-lower-limb-venous-arterial/

7. Franks P, Barker J, Collier M, et al. Management of patients with venous leg ulcer: challenges and current best practice, J Wound Care, 25; 6, Suppl, 1–67

8. Brogle A. (2010). Conservative management of arterial ulceration. In: J.M. McCulloch and L.C. Kloth (Ed.), Wound Healing Evidence-Based Management (4th ed.). pp. 256-278. Philadelphia. PA: F.A. Davis Company.

9. British Columbia Provincial Nursing Skin and Wound Committee. Prevention of pressure injury in adults & children: guideline. 2017 November. [cited 2018 July 11]. Available from: https://www.clwk.ca/communities-of-practice/skin-wound-community-of-practice/buddydrive/

10. National Pressure Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: clinical practice guideline. Emilt Haesler (Ed.). Cambridge Media: Perth, Australia; 2014.

11. Norton L, Parslow N, Johnston D, Ho C, Afalavi A, Mark M, O’Sullivan-Drombolis D, Moffat S. Best practice recommendations for the prevention and management of pressure injuries. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 July 11]. Available from: https://www.woundscanada.ca/health-care-professional/education-health-care-professional/advanced-education/12-healthcare-professional/110-supplements.

12. Registered Nurses’ Association of Ontario (2013). Assessment and management of foot ulcers for people with diabetes (2nd ed.). Toronto, ON: Registered Nurses’ Association of Ontario.

13. British Columbia Provincial Nursing Skin and Wound Committee. (2018). Guideline: assessment and treatment of diabetic and neuropathic ulcers in adults. [cited 2018 Nov 7]. Available from: https://www.clwk.ca/buddydrive/file/guideline-diabetic-neuropathic-ulcers/

14. Botros M, Kuhnke J, Embil J, Goettl K, Morin C, Parsons L, Scharfstein B, Somayaji R, Evans R. (2017) Best practice recommendations for the prevention and management of diabetic foot ulcers. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017 [cited 2018 Nov 7]. 67p. Available from: https://www.woundscanada.ca/health-care-professional/education-health-care-professional/advanced-education/12-healthcare-professional/110-supplements.

15. British Columbia Provincial Nursing Skin and Wound Committee. Guideline: wound bed preparation for healable and non-healable wounds in adults and children. June 2015. [cited 2018 Jan 23]. Available from: https://www.clwk.ca/communities-of-practice/skin-wound-community-of-practice/buddydrive/

16. Sibbald RG, Elliott JA, Ayello EA, Somayaji R. Optimizing the moisture management tightrope with wound bed preparation 2015. Adv Skin Wound Care. 2015; (10):466-76

17. Registered Nurses Association of Ontario (2004). Assessment and management of venous leg ulcers. Toronto, Canada: Registered Nurses Association of Ontario.

18. International Wound Infection Institute (IWII) Wound infection in clinical practice. Wounds International 2016. Retrieved from: http://www.woundinfection-institute.com/2016/11/wound-infection-in-clinical-practice-update2016/

19. Albaugh K & Loehne H. (2010). Wound bed preparation/debridement. In McCulloch J.M. & Kloth L.C. (Ed.), Wound Healing Evidence-Based Management (4th ed.). pp 155-179. Philadelphia PA: F.A Davis Company.

20. British Columbia Provincial Nursing Skin and Wound Committee. Guideline summary - wound infection. Jan 2017. [cited 2018 July 11]. Available from: https://www.clwk.ca/communities-of-practice/skin-wound-community-of-practice/buddydrive/

21. Ennis WJ & Menses P. (2010). Complications in repair. In McCulloch J.M. & Kloth L.C. (Ed.), Wound Healing Evidence-Based Management (4th ed.). pp 51-64. Philadelphia PA: F.A Davis Company.

22. Sussman G. (2012). Management of the wound environment with dressings and topical agents In: C. Sussman and BM Bates-Jensen (Ed.), Wound Care A Collaborative Practice Manual for Health Professionals (4th ed.). pp. 502-521. Philadelphia, PA: Lippincott, Williams & Wilkins.

23. Krasner DL, Sibbald RG, Woo KY. (2018). Wound dressing product selection a holistic, interprofessional patient-centered approach (white paper). Wound Source. Retrieved April 15th, 2018 from: http://pages.woundsource.com/wound-dressing-product-selection-a-holistic-interprofessional-patient-centered-approach/

24. Registered Nurses’ Association of Ontario (2005). Risk assessment and prevention of pressure ulcers. (Revised). Toronto, Canada: Registered Nurses’ Association of Ontario

25. Registered Nurses’ Association of Ontario (2016). Assessment and management of pressure injuries for the interprofessional team, Third Edition. Toronto, ON: Registered Nurses’ Association of Ontario.