In this section
Note: This guideline is currently under review. Introduction
Physiology of a wound and wound healing
Factors That Inhibit Wound Healing
Documentation within the EMR
The assessment and maintenance of skin integrity in the paediatric patient should be fundamental to the provision of nursing care.
Collaboration between the nursing team and treating medical team is essential to ensure appropriate wound management and facilitate optimal wound healing. Referrals to stomal therapy (via an EMR referral order) may also be necessary to ensure appropriate management and dressing selection for more complex wounds.
Accurate wound assessment and effective wound management requires an understanding of the physiology of wound healing, combined with knowledge of the actions of the dressing products available. It is essential that an ongoing process of assessment, clinical decision making, intervention and documentation occurs to facilitate optimal wound healing.
Acute wound- is any surgical wound that heals by primary intention or any traumatic or surgical wound that heals by secondary intention. An acute wound is expected to progress through the phases of normal healing, resulting in the closure of the wound.
Chronic wound- is a wound that fails to progress healing or respond to treatment over the normal expected healing time frame (4 weeks) and becomes "stuck" in the inflammatory phase. This pathologic inflammation is due to a postponed, incomplete or uncoordinated healing process. Wound healing is delayed by the presence of intrinsic and extrinsic factors including medications, poor nutrition, co-morbidities or inappropriate dressing selection.
Type of Healing-
Primary intention- the wound edges are held together by artificial means such as sutures, staples, tapes or tissue glue. There is minimal tissue loss and wounds heal with minimal scarring. Most clean surgical wounds and recent traumatic injuries are managed by primary closure.
Delayed primary intention- when the wound is infected or requires more thorough intensive cleaning or debridement prior to primary closure usually 3-7 days later. May be used for traumatic wounds or contaminated surgical wounds.
Secondary intention- spontaneous wound healing occurs through a process of granulation, contraction and epithelialisation. Results in scar formation and used as a method of healing for pressure injuries, ulcers or dehisced wounds.
Skin graft- removal of partial or full thickness segment of epidermis and dermis from its blood supply and transplanting it to another site to speed up healing and reduce the risk of infection.
Flap- the surgical relocation of skin and underlying structures to repair a wound. Flaps are named according to their tissue components and may include an anastomosis of blood supply to vessels attached to or at the affected site.
Wound healing is a complex sequence of events that can be broadly divided into two stages:
Haemostasis- is the rapid response to physical injury and is necessary to control bleeding. It involves the following components: 1. Vasoconstriction 2. Platelet response 3. Biochemical response
Tissue Repair & Regeneration- involves 3 phases:
Holistic assessment of the patient is an important part of the wound management process. A number of local and general factors can delay or impair wound healing.
These may include:
When conducting initial and ongoing wound assessments the following considerations should be taken into account to allow for appropriate management in conjunction with the treating team:
Clinical Guideline (Nursing): Nursing Assessment for more detailed nursing assessment information.
There is different terminology used to describe specific types of wounds: such as surgical incision, burn, laceration, ulcer, abrasion. They can be generally classified as either acute or chronic wounds.
The degree of tissue loss may be referred to in broad terms as:
'Assessment and evaluation of wound healing is an ongoing process. All wounds require a two-dimensional assessment of the wound opening and a three-dimensional assessment of any cavity or tracking' (Carville, 2017)
The edges of the wound are assessed for-
Is produced by all acute and chronic wounds (to a greater or lesser extent) as part of the natural healing process. It plays an essential part in the healing process in that it:
It is important to assess and document the type, amount, colour and odour of exudate to identify any changes. Excess exudate leads to maceration and degradation of skin while too little can result in the wound bed drying out. It may become more viscous and odorous in infected wounds.
The surrounding skin should be examined carefully as part of the process of assessment and appropriate action taken to protect it from injury.
Wound infection may be defined as the presence of bacteria or other organisms, which multiply and lead to the overcoming of host resistance. Infection can disrupt healing and damage tissues (local infection) or produce spreading infection or systemic illness. Infection adversely affects wound healing and may be the cause of wound dehiscence.
Local indicators of infection-
Wound healing and clinical infection demonstrate inflammatory responses and it is important to ascertain if increases in pain, heat, oedema and erythema are related to the inflammatory phase of wound healing or infection.
If any of the above clinical indicators are present a medical review should be instigated and a Microscopy & Culture Wound Swab (MCS) should be considered.
Pain can be an important indicator of abnormality. The pain associated with chronic wounds and wounds that require frequent dressing changes can be underestimated.
Accurate assessment of pain is essential with regard to choice of the most appropriate dressing. Assessment of pain before, during and after the dressing change may provide vital information for further wound management and dressing selection.
Guidelines for wound management:
The goal of wound cleansing is to:
Principles of wound cleansing:
A wound 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.
Wound healing progresses most rapidly in an environment that is clean, moist (but not wet), protected from heat loss, trauma and bacterial invasion.
There are a multitude of dressings available to select from. Effective dressing selection requires both accurate wound assessment and current knowledge of available dressings (Ayello, Elizabeth A)
These wounds require little intervention other than protection and observation for complications.
Recommended dressings include:
Occurs when the wound is contaminated or infection is suspected. These traumatic or surgical wounds require intensive cleaning before healing can occur. Debridement using irrigation may be required.
Recommended dressings include:
Absorbent or protective secondary dressings will be required for most wounds- it is important to ensure that the surrounding skin is protected from maceration. A skin barrier wipe can be used.
Acute surgical or traumatic wounds may be allowed to heal by secondary intention- for example a sinus, drained abscess, wound dehiscence, skin tear or superficial laceration.
Dressing selection should be based on specific wound characteristics. Referral to Stomal Therapy should be considered to promote optimal wound healing.
Determine the aetiology for inhibition of wound healing. Address or control the factors identified for example: presence of infection, poor nutritional status, appropriate dressing selection, moist wound environment.
Dressing selection should be based on the specific wound characteristics and referral to Stomal Therapy should be initiated to promote optimal wound healing. Advanced wound therapies may be required to be utilitised e.g surgical debridement, application of a negative pressure dressing, hyperbaric therapy.
Parents and carers should be given a plan for the ongoing management of the wound at home. A range of appropriate dressing products can be obtained from the
RCH Equipment Distribution Centre.
For more complex wound care needs involvement of the inpatient care coordinators may be required to make appropriate referrals to Wallaby or an alternative for ongoing wound management at home.
Medical teams managing patients may request specific wound care and follow up to occur at RCH via Specialist Clinics- this may also include Nurse Led Clinics or patients may be referred to their local GP for wound follow up.
It is an expectation that all aspects of wound care, including assessment, treatment and management plans, implementation and evaluation are documented clearly and comprehensively.
Documentation of wound assessment and management should be completed in the EMR under the ‘flowsheet’ activity, utilising the ‘LDA tab’ (Lines, Drains, Airway Assessment) or by utilising the Avatar acitivity.
Click on the ‘Add New LDA’ button to search for the correct wound type e.g. Burn, Surgical Incision, and Pressure Area. The ‘LDA’ tab or Avatar can be used to monitor and record progress of the wound through its stages of healing. Clinical pictures can be added to the assessment utilising the ‘Rover’ Device.
Wound care and dressing changes can also be ordered/preplanned utilising the ‘Orders’ activity.
EMR Learning Resources and Tip Sheets:
RCH Dressing Selection Resources
Please remember to read the disclaimer
The development of this clinical guideline was coordinated by Kirsten Davidson, EMR Lead Nurse Educator. Approved by the Clinical Effectiveness Committee. Current as of March 2019.