Wound Assessment
and Dressing
Selection
Noreen Campbell RN BScN MA IIWCC Lt CSW
TCS Systems
North Saanich, BC, Canada
Wound Healing Process
Maturation/Remodeling
Day 21 - 2 years
Epithelialisation
Proliferation
Day 4-21
Inflammation
Day 1-4
Hemostasis
immediate
Kane
Homeostasis – first 24 hours
Inflammation 1-4 days
Proliferation day 4 - 21
Fibrin, Collagen Bridge to Skin
• Yellow, caramel like surface, pain
• Granulation peeking, epithelial starting
6
Epithelialization
Maturation/Remodeling up to 2
years
• Normal
• Hypertrophic
– With incision
• Keloid
– Extends to
normal
tissue
Well healed scar – always a scar…weaker tensile strength
Potential for Healing
Individual assessment
Wound
Care
Tissue depth?
Probe…
10
Infection
•
•
•
•
Heat
Redness
Swollen
Pain
– Not with
neuropathy
– Blood Sugars
elevated
11
Infection: Assess Clean Wound
• Wound
Cleansing
– Potable tap
water
– Saline
– Boiled
cooled water
• Mild soap
– Dove no dye
or perfume
Cochrane Review 2011 water for
cleansing
Wound Imperatives and
Antimicrobials
Product
Function
Cost * CDA 020114
Promogran
Prisma is above
with silver
MMP binding
ON the wound “let it dance
with the wound”
Promogran 28 sq cm
$23.95 123 sq cm
$55.95
Prisma 28 sq cm
$26.95
Iodosorb
Cochrane level support red.
cadexomer iodine Infection, promote healing,
but pain reports may limit
use
Ointment $21.95 10
Gm
Paste $58.95not
recommended
Inadine povidone
iodine
Non-adherent sheets
9.5x9.5cm $2.30
Silver dressings
Support of efficacy lacking
Expensive 4x4” $18.95
Honey dressings
Support of efficacy lacking
Expensive $24.95
50gm
Canadian Diabestes Association Store – dodi.forbes@diabetes.ca
Eschar: risk infection and delay
Stable
Wet
healing
• Black
• Dry
• Hard
• Drainage
• Marbling
• Breakdown
Debride Unstable Eschar
• Drainage
• Fluctuance
• Iodine produce
will become
paler with
release of iodine
Debridement
Advantage
Disadvantage
Surgical
Fast
Surgery, expensive,
pain, non-selective
Conservative Sharp
Bedside, pain,
Scope of practice
Skill
Maggot
Selective, disinfect
wound, stimulate
healing
Ordering process, $120
treatment, dressing
change 48 hours
Enzyme (Santyl)
Selective
$90-120 tube, weeks
Mechanical
Wet to dry
Saline Compresses
Irrigation
Shower
Non-selective
Pain (wet to dry)
Labour - compresses
Autolytic (natural)
Moisture (gel)
Natural, selective
Slow
16
MDT 4 days
17
What type of debridement?
92yo anesthetic risk
Trauma scooter accident
Inner thigh
18
Differentiation: drainage or
allergy?
• Contact
Dermatitis
– pattern
• Sensitivity
– Localized to
wound and
product
• Drainage
– Direction of
pooling
Blister: drain if risk expansion
20
Edge: Undermined, rolled
edge
Packing – think ‘wicking’.
Dressing: think ‘Band Aid’
‘protect, absorb, hold layers’
Function
Product
Protection
Surface protection
Cost
Silicon (7 days) severe pain or
fragile
Mepitel $11.50 4”x7”
Inadine (antimicrobial+)
Inadine $2.30 4”x4”
Jelonet (petrolatum mesh)
10cmx40cm $3.50
Tin 10 cm x 7M $36.00
Adaptic non-adherent
$3.75 3”x8” 3pkg
Absorb
Alginates – lowest absorb., sticks
if insufficient exudate
Hydrocolloid
Minimal exudate containment and
hold
Do not recommend
There are no standards for stating performance of dressings (i.e.
absorption). Standard for approval ONLY safety not efficacy.
Function
Product
Foam
Rated high exudate but
generally <5ml 4”x4”
protection layer
Fragile skin
built into dressing Adhesive border strength
varies and can damage
skin, change when
drainage at border
Cost
Mepilex 3”x3” $3.75
Allevyn Gentle 3x3 $3.95
Tegaderm 3.5”x3.5” $4.59
**do not recommend
unless dressing one week
Acrylic
poor expensive
Do not recommend
Absorbent
Dressing
Classic Pads10x20cm 3 $1.95
incontinent pad 17x20cm Ultra 17x40cm 2 $3.00
can hold 750ml (stay
Classic super 50 $33.00
dry)
Gauze – chronic
wound or > 48
hours Clean not
Sterile
poor absorption
Adequate cover dry
gangrene
2x2” 200 $1.95
4x4” 200 $6.50
Non-sterile clean package
Cast padding
Holds dressings padding
Protouch 17 rolls $17.59
Single roll $1.50
Function
Product
Cost
Tape – peal factor is
tension to remove,
adhesive is ability to
hold
Transpore $1.65 roll
Fragile skin may strip
or tear.
*consider skin strength
**how many dressings
***how frequent
Order of peal factor
Transpore (3M) +++
Kind Removal (3M) ++
Mepitac silicon +
Stockinet - TubiFast
Roll or meter*
Blue normal limb adult
Yellow larger
Blue 10M $16.95*
Yellow 10M $10M
$23.75
Tubigrip elastic
Size determines
pressure – straight may
constrict limb
Skin barriers
If you need these the
products are not
appropriate
Steroids
Good for immediate
skin reactions i.e
venous excema
Kind Removal silicon
roll $6.95
Mepitac silicon $11.50