Jeanne Lowe PhD, RN, CWCN
VA HSR&D Center of Excellence
Objectives:
•Describe skin function and structure
•Discuss normal phases of healing
•Identify factors that can interfere with normal healing
•Describe basics of wound assessment
•Discuss different categories of wound dressings
2
Functions of the Skin
 Protection
 Thermoregulation
 Sensation
 Metabolism
 Communication
3
Skin Structure
Epidermis
Dermis
Subcutaneous Fat
Muscle
Bone
4
Factors Contributing to Impaired
Skin Integrity
 Circulation
 Systemic Diseases
 Nutrition
 Trauma
 Condition of the
 Excessive Exposure
Epidermis
 Allergies
 Infections
 Mechanical Forces
 Friction
 Shearing
 Pressure
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Phases of Wound Healing
Hemostasis and Inflammation
 Platelets release
 vasoactive substance
causing  permeability
 enzymes that attract
leukocytes
 growth hormones that
influence fibroblasts
 Wound develops
erythema and edema
Phases of Wound Healing
Wound “clean up”
 Neutrophils arrive
 Phagocytosis
 Macrophages appear
within 3-4 days
 Phagocytosis
 Release of enzymes
that trigger fibroblast
response
 Stimulate
angiogenesis
Wound Repair
 Regeneration of injured cells by cells of same type
(i.e. Epidermis, bone)
 Replacement by fibrous tissue (fibroplasia, scar
formation)
Epithelialization
Fibroplasia (Proliferation)
 Occurs within the granulation tissue
framework (new blood vessels and loose
collagen)
 Proliferation of fibroblasts at site of injury
 Growth factors
 Cytokines
Wound Healing
Granulation = Collagen and Capillaries
Surgical Wound
 Intentional injury that disrupts blood vessels and
causes clotting and cascade of events that leads to
wound closure within 2 to 4 weeks
 History of Surgery
 18th Century surgeons were
apprentices of barbers and
butchers
Primary Closure
Patient Risk Factors for Post-Surgical Wound
Complications
 Obesity
 Diabetes
 Immunosuppression
 Cardiovascular disease
 Smoking
 Cancer
 Previous surgery
 Malnutrition
Surgical Wounds: Complications
 Hemorrhage
 Hematomas
 Infection
 Dehiscence
 Evisceration
 Fistula
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Incision Healing Time
 Epithelial resurfacing complete at 2-3 days
 No tensile strength, but impenetrable to bacteria
 “Healing ridge” 5-9 days
 Lack of ridge = interventions to reduce incisional strain
 Most dehiscences occur 5-8 days post-op, and
about half are associated with infection
Incision Care
 Cover with dry sterile dressing 24 to 48
hours, then open to air
 Gently wash between sutures/staples to
remove crusts
 Report persistent pain, bleeding, erythema,
wound edge separation or cloudy drainage
Wound Closure Aids
 Steri-strip
 Montgomery straps
 Medical Staples
 Sutures
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Steri-Strips
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Montgomery Straps
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Medical Staples
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Suture/Staple Removal
 Usually removed 7-10 days post-op
 Incisions over areas with tension up to two
weeks
 If concerned about incision dehiscence:
 Remove every other one
 Steri-strip
Wound Dehiscence
 Fascial or Cutaneous
disruption
 Heavy bacterial load
 Long time-lapse since
wounding
 Crushed or ischemic
tissue – severe
contused avulsion
injury
 Sustained high-level
steroid therapy
Secondary Intention
(includes chronic wounds)




Large tissue defect
More inflammation
More granulation tissue
Wound contraction - myofibroblasts
Factors Inhibiting Wound Healing
 Medication
 Cortisone, and epinephrine
 Malnutrition
 Protein & calories
 Vitamin & mineral deficits
 Zinc, Vitamin A, Vitamin C, Vitamin E
 Dehydration
 Edema
 Perfusion
 Chronic illness & other conditions
 i.e. diabetes, CHF, immobility
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Principles of Wound Care
 Keep wound moist
 Manage drainage
 Fill deep wounds
 Control bacterial load
 Protect wound from trauma
 Assess healing
Keep Wounds Moist

Select dressings that
maintain moisture.

Minimize time that
wounds are open to air.

Add moisture to wound
bed?
Manage Drainage
 Maceration makes skin
more fragile.
 Excessive drainage
requires nursing time.
Fill Dead Space
 Fill wound with
dressing
 Be careful not to
over-fill (no rocks)
Control Bacterial Load
 Take time to wash or
irrigate wounds to
decrease bacterial load.
 No need to scrub!
Protect From Trauma
 Be gentle to skin
 Use non-stick
dressings
 Minimize tape
But . . .
 Remember to protect yourself from splash
Assess
 Know what is under
the dressing
 Know typical healing
pattern
 Size matters
 Document
Document findings
 Location
 Size (length / width / depth)
 Wound base
 Drainage
 Surrounding skin
 Systemic infection
 What we’re doing
Wound Documentation:
Wound Base Descriptors
 Granulation tissue
 Red, cobblestone/beefy.
 Only in full thickness
wounds
 Epithelial tissue
 Regrowth of epidermis
 Pink or pearly
 Smooth, shiny
Wound Documentation:
Wound Base Descriptors
 Slough
 Necrotic/avascular tissue.
 Moist.
 Can be white, yellow, tan, or
green.
 Eschar
 Necrotic/avascular.
 Black or brown
 Hard or soft.
 Often leathery adherent tissue.
Wound Healing Basics
 Wounds do best in moist environment
 not too wet, not too dry
 Loosely pack when needed
 tight packing → injury to wound bed.
 Protect peri-wound skin
 No Sting Barrier
 Cleanse/irrigate before assessment
 Pre-medicate for pain prior to dressing changes
 If culture is needed
 cleanse wound thoroughly prior to swabbing
 swab in area of granulation/viable tissue if present.
 Never culture dressing!
Product Selection
 Frequency of change
 Ease of procedure
 Caregiver ability
 Availability of products
 Cost/reimbursement factors
Dressing Purposes:
 To absorb drainage
 To prevent contamination
 To prevent mechanical injury to the wound
 To help maintain pressure to prevent
excessive bleeding
 To provide a moist wound environment
 To provide comfort
Topical Wound Care Products
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Alginates/Fiber Gelling Dressings
Antimicrobials
Collagen
Contact Layers
Foams
Gauze & Impregnated Gauze
Hydrocolloid
Hydrogels (Amorphous)
Skin Sealants
Topical Debriders
Negative Pressure Therapy
Compression Therapy
Gauze Packing
(Kerlix, Nu-gauze, 4 x 4s)
 description - inexpensive,
user dependent
 indications - to fill deep
defects to maintain moisture
and absorb exudate, may
be soaked with antibiotic
solution
 considerations - pack lightly,
may cause surrounding
wound maceration, may
traumatize wound if allowed
to dry
Contact Layer Dressings
(Greasy gauzes, N-terface, Adaptic, Xeroform, Mepitel)
 description - nonadherent,
prevents trauma and
permits exudate to “pass
through” pores of dressing
for absorption by a
secondary dressing,
inexpensive
 indications - superficial
wounds with minimal to
moderate exudate
 contraindications - if goal is
to “clean up” wound
Hydrocolloids
(Duoderm, Comfeel)
 description - absorbs
exudate, maintains
moisture, insulates, protects
from secondary infection,
non-permeable
 indications - or superficial
wounds with minimal to
moderate drainage
 contraindications - infected
wounds
Typically changed every
3 - 5 days
Polyurethane Foam
(Mepilex,Biatain, LyoFoam)
 description - nonadherent
foam, absorbs exudate,
insulates, variable protection
from environmental
contaminants (outer layer water
proof or water-repellent)
 indications - superficial
weeping wounds, cover for
deep (packed) wounds
leave on for 3 - 5 days or change
when cover-layer is at least
50% saturated
Hydrogels
(solid gel sheets or amorphous gel)
 description - nonadhesive,
maintains moisture, protects wound
and allows visualization, nonabsorptive
 indications - superficial wounds with
minimal drainage; amorphous gel
may be buttered on semi-dry red
wound before applying moist
dressing; good dressing for arterial
ulcers
 contraindications - heavily
exudating wounds
Alginates / Fiber Gel
(Kaltostat, Sorbsan, Medifil, Aquacel)
 description - applied to
wound dry but forms gel
with absorption of exudate
 indications - heavily
exudating wounds to allow
daily or QOD dressing
changes
 contraindications - minimally
exudating wounds (it will
stick to wound and
dehydrate)
Moisture Barriers
 Barriers are products
that wick away
moisture from skin
 Contain
 Zinc oxide
 Dimethicone
 Petrolatum
 Polymer
(i.e. SensiCare,
Proshield, Perineal
wipes, No Sting)
Compression Therapy
(Profore, SurePress, Jobst, Isotoner)
description – Single or multilayer compression bandage or
stocking usually applied over
primary dressing
indications – management and
treatment of venous leg ulcers.
Can be left on for up to one
week.
contraindications – do not use
on patients with ABI <0.8 or on
diabetic patients with advanced
small vessel disease
Tapes and Adhesives
 Consider
gentleness to skin
 Consider cost
 Consider job to be
done
Clinical Interventions
 Monitor skin at every visit
 Evaluate type of skin care practices
 Assess patient and/or caregiver ability
 Minimize exposure of skin to moisture from
incontinence, perspiration, or drainage
 Evaluate need for specialty mattresses or
seating cushions
 Assess nutritional status
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Nutritional Deficits
 Determine barriers to the patient
eating sufficient quantities of quality
food
 Nutritionist consult?
 Diabetes education?
Moisture and incontinence
 Minimize exposure to moisture and soiling
 Use briefs and underpads to wick away
moisture from skin
 Teach patients & caregivers to cleanse skin
at the time of soiling

Urine & feces very caustic
 Use barrier cream as necessary
Pressure Ulcer Prevention
 Assess for risk factors: immobility, moisture
& incontinence, inadequate nutrition,
impaired sensation or perception,
decreased activity, exposure to friction &
shear
 Incorporate risk assessment into plan of
care
 Monitor patient’s skin at each visit
Document Evaluation
 Is the skin intact?
 Is the wound healing? Did the interventions work
or not?
 If no progress at two-week assessment, time to
change interventions
 If yes, do you want to continue?
 If no, how do you want to revise?
 Does patient understand risk factors and wound
care plan?
Case Studies
 89-year-old male with hx of COPD with chronic
steroid use. Uses 2 L O2 at home and smokes 1/2
pack cigarettes a day. Hx. Includes DM, depression,
and prostate cancer.
 Presents to your clinic with right forearm wound after
scraping arm against wheelchair.
How do we optimize healing?
Case Studies
 49-year-old male with hx of IV heroin use. Smokes 2
packs cigarettes a day. Hx also includes Hep C,
depression, and hypertension.
 Presents to your clinic with fever, chills, and right
lower limb wound that he has had for months.
Case Studies
 46 year-old female admitted to hospital for elective
surgery to remove renal growth. Morbidly obese,
uses 2 L O2 at home, smokes 2 packs a day. Hx
includes DM, depression, sleep apnea. Rarely gets
out of bed at home (able to walk w/ assistance to
bathroom).
 Suspected deep tissue injury to sacrum present on
admission. Wound surgically debrided.
 Warning . . .
What do you see?
Make sure there are no hidden surprises
Questions?