In this section
Note: This guideline is currently under review.
The skin is the largest organ of the body, making up 16% of body weight. It has several vital functions, which include; immune function, temperature regulation, sensation and vitamin production. Skin is a dynamic organ in a constant state of change; cells of the outer layers continuously shed and are replaced by inner cells moving to the surface. These guidelines have been developed by a range of clinicians who treat children with skin disorders, breakdowns and wounds; they reflect current research and evidence based expert opinion.
These guidelines are intended for use as a resource for wound management and should be available to all members of the healthcare team involved in the assessment, treatment and ongoing management of wounds throughout the Royal Children's Hospital. The guidelines are not a substitute for professional judgement but should support clinical decision making in relation to the assessment and management of wounds, in line with individual professional competence.
Acute Wound:is the result of tissue damaged by trauma. This may be deliberate, as in surgical wounds of procedures, or be due to accidents caused by blunt force, projectiles, heat, electricity, chemicals or friction. An acute wound is by definition expected to progress through the phases of normal healing, resulting in the closure of the wound.
A Chronic Woundfails to progress or respond to treatment over the normal expected healing time frame (4 weeks) and becomes "stuck" in the inflammatory phase. Wound chronicity is attributed to the presence of intrinsic and extrinsic factors including medications, poor nutrition, co-morbidities or inappropriate dressing selection
Epidermis: Is the outer layer of the skin.
Dermis: Is the middle layer of the skin and is approximately 0.5mm thick subject to anatomical site
Hypodermis: Is the inner most layer of the skin and is referred to as the subcutaneous layer
Skin Appendages: Includes Sweat glands, hair, nails and sebaceous glands which are all considered epidermal appendages.
Figure 1 – Layers of the Skin
All patients with wounds will have their wounds appropriately assessed by nursing staff within 24hours of recognition with timely referrals to stomal therapy where appropriate.
Documentation of wound assessment and management should be completed under the ‘Flowsheet’ activity, utilising the ‘LDA tab’ (Lines, Drains, Airway and Wound tab). Click on the ‘Add New LDA’ button to search for the correct wound type e.g. Burn, Surgical Incision, Flap/Digit Reimplant.
See Clinical Guideline (Nursing): Nursing Assessment for more detailed assessment information.
Yellow, grey, green
Infection. Contains pyogenic organisms and other inflammatory cells
Holistic assessment of the patient is an important part of the wound care process. A number of local and systemic factors can delay or impair wound healing. These may include:
A clean cut with a sharp instrument which cuts or punctures the skin deliberately during a surgical procedure. Acute surgical wounds normally proceed through an orderly and timely reparative process resulting in sustained restoration of anatomic and functional integrity. If an acute wound fails to heal within six weeks, it can become a chronic wound.
A stressful event caused by either a mechanical or a chemical injury resulting in tissue damage. Depending on its level, trauma can have serious short-term and long-term consequences.
Injuries to tissues caused by heat, friction, electricity, radiation, or chemicals. Burns may be caused by even a brief encounter with heat greater than 120°F (49°C). The source of this heat may be the sun , hot liquids, steam, fire, electricity, friction (causing rug burns and rope burns), and chemicals (causing a caustic burn upon contact).
Fail to heal in an orderly and timely manner. The chronic wound environment is different to the acute wound environment. The clinical signs of chronic wounds may include:
A localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, shear and/or friction, or a combination of these factors.
Invasion of wound tissue by and multiplication of pathogenic microorganisms, which may produce subsequent tissue injury and progress to overt disease through a variety of cellular or toxic mechanisms
No impairment to healingNo obvious clinical signs of infection
Phases of Wound Healing to consider
Mechanisms of wound healing to consider
It is an expectation that all aspects of care, including assessment, treatment and management plans, implementation and evaluation are documented clearly and comprehensively.
All wounds should be assessed regularly and outcomes of the assessment docuemented. Documentation of wound assessment and management should be completed under the ‘flowsheet’ activity, utilising the ‘LDA tab’ (Lines, Drains, Airway and Wound tab). Click on the ‘Add New LDA’ button to search for the correct wound type e.g. Burn, Surgical Incision, Flap/Digit Reimplant. The ‘LDA’ tab can be used to monitor and record progress of the wound through its stages of healing. Wound care and dressing changes can also be ordered/preplanned utilising the ‘Orders’ activity.
Requires the application of fluid to clean the wound and optimise the healing environment.
The goal of wound cleansing is to:
Awound 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. Considerations when choosing dressing products -
Wound Dressings - Quick Reference Guide
Refer to the Dressing Choices Table for a more comprehensive guide to assist you in your decision making
Dressings can be catagorized into four types:
Inappropriate management of wounds can lead to delayed healing, deterioration of wounds and wound breakdown. Wounds should be carefully reassessed with every dressing change to ensure the most appropriate products are used. If unsure refer to a more experienced member of your team or refer to the stomal therapist. Stomal therapy referrals can be made by paging the Stomal therapy team on 5338; Stomal therapists are available during business hours Monday to Friday.
Provide parents/carers with appropriate discharge information. Please click here for the fact sheet on wound care.
Parents and carers should be given a plan for the ongoing management of the wound at home with the appropriate dressing products prescribed. Dressings can be obtained from the Equipment Distribution Centre : EDC Home or a preferred pharmacy.
If required, a patient can be referred to the Nurse Led Outpatient Clinic which is available to provide nursing services to patients post admission or as ongoing outpatients and can include wound care as requested by medical or nursing staff. Patients are firstly reviewed in clinic times and if additional dressings are required this is coordinated with nursing staff. Please complete a referral form for suitable patients, Nurse led Outpatient Clinic Referral Form.
Referrals to RCH @ Home should be considered when the wound requires ongoing assessment and management. RCH @ Home can source outside providers for patients who live in rural settings. To make a referral complete the RCH HIP Services Referral and contact the intake liaison officer on extension 5674.
For those patients requiring a one off check or review, follow up with their regular General Practitioner (GP) should be encouraged.
For complex wounds follow up appointments with Stomal Therapy should also be organized for one week following discharge. Stomal Therapy should already be involved with these patients.
For patients with impaired nutritional status a dietitian referral should be considered.
Please remember to read the disclaimer
The development of this clinical guideline was coordinated by Kylie Moon, Nursing Services. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published April 2012, current as of July 2013.