Clean machine

As you follow these steps, be sure to observe standard precautions and follow
your facility's protocols regarding the use of clean or sterile technique.

* Remove the soiled dressing. Roll or lift an edge of the dressing, then gently
remove it while supporting the surrounding skin. When possible, remove the
dressing in the direction of hair growth.
* Inspect the dressing and wound. Note the color, amount, and odor of drainage
and necrotic debris.

* Clean the wound. Moisten gauze pads either by dipping the pads in wound
cleaning solution and wringing out excess or by using a spray bottle to apply
solution to the gauze. Move from the least contaminated area to the most
contaminated area and use a clean gauze pad for each wipe. To clean a linearshaped wound, such as an incision, gently wipe from top to bottom in one
motion, starting directly over the wound and moving outward. For an open
wound, such as a pressure ulcer, gently wipe in concentric circles, starting
directly over the wound and moving outward (see Wound cleaning techniques).
The type of cleaning agent you'll use depends on the wound type and
characteristics. Sterile 0.9% sodium chloride solution is the most commonly used
cleaning agent. It provides a moist environment, promotes granulation tissue
formation, and causes minimal fluid shifts in healthy adults. Antiseptic solutions,
such as chlorhexidine, povidone-iodine, and hydrogen peroxide, are sometimes
used to clean infected or newly contaminated wounds. Be aware that antiseptic
solutions may damage healthy tissue and delay wound healing.

* Dry the wound. Using the same procedure as for cleaning a wound, dry the
wound using dry gauze pads.
* Reassess the condition of the skin and wound. Note the character of the clean
wound bed and surrounding skin.
* Pack or dress the wound as ordered. See Choosing a dressing for questions you
can ask yourself to find the ideal dressing for your patient's wound.
Got the basics covered
Basic wound care centers on cleaning and dressing the wound. And now you
have a better understanding of the fundamental wound cleaning techniques.

Choosing a dressing

To confirm that you've chosen the proper dressing, answer these questions.

* Does the dressing protect the wound from secondary infection?

* Does it provide a moist wound-healing environment?
* Does it provide thermal insulation?
* Can it be removed without causing trauma to the wound?
* Does it remove drainage and debris?
* Is it free from particles and toxic products?
http://www.nursingcenter.com/static?pageid=819804

Wound care

Note: This guideline is currently under review.

o

Introduction

Aim

Definition of Terms

Assessment

Factors delaying Wound Healing

Types of wounds

Management

Acute management

Ongoing Management

Special considerations

Companion documents

Links

References

Evidence Table

Introduction
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.

Aim
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.

Definition of Terms
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.

comprised of epithelial cells

avascular

0.04mm thick

regenerated every 2-4weeks, subject to an individual's age and friction forces

applied to the skin

receives nutrients from the dermis below

comprised of 4 to 5 layers depending on the body location

Dermis: Is the middle layer of the skin and is approximately 0.5mm thick subject to anatomical site

made up of two layers

is very vascular

contains nerves, connective tissue, collagen, elastin and specialized cells

such as fibroblasts and mast cells

responsible for inflammatory reactions which occur in response to trauma

and infection

receptors for heat, cold, pain, pressure, itch and tickle

Hypodermis: Is the inner most layer of the skin and is referred to as the subcutaneous layer

supports the dermis and epidermis

varies in thickness and depth

comprised of adipose tissue, connective tissue and blood vessels

the function is to store lipids, protect underlying organs, provide insulation

and regulate temperature

Skin Appendages: Includes Sweat glands, hair, nails and sebaceous glands which are all considered
epidermal appendages.
Figure 1 Layers of the Skin

Assessment
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.

Wound Assessment and Management Chart. Please note this form is currently being evaluated in
Butterfly and Platypus Wards. Please use this form in all wards until the evaluation is complete and a
formal MR is available.
See Clinical Guideline (Nursing): Nursing Assessment for more detailed assessment information.

Considerations for assessment

Wound Bed

Granulating: healthy red tissue which is deposited during the repair process,
presents as pinkish/red coloured moist tissue and comprises of newly formed collagen, elastin
and capillary networks. The tissue is well vascularised and bleeds easily

Epithelializing: process by which the wound surface is covered by new

epithelium, this begins when the wound has filled with granulation tissue. The tissue is pink,
almost white, and only occurs on top of healthy granulation tissue

Sloughy: the presence of devitalized yellowish tissue. Is formed by an

accumulation of dead cells. Must not be confused with pus

Necrotic: wound containing dead tissue. It may appear hard dry and black.
Dead connective tissue may appear grey. The presence of dead tissue in a wound prevents
healing

Hypergranulating; granulation tissue grows above the wound margin. This

occurs when the proliferative phase of healing is prolonged usually as a result of bacterial
imbalance or irritant forces

Wound Measurement

'Assessment and evaluation of the healing rate and treatment modalities are
important components of wound care. All wounds require a two-dimensional assessment of
the wound opening and a three- dimensional assessment of any cavity or tracking' (Carville,
K. 2007)

Two-dimensional measures- use a paper tape to measure the length and

width in millimetres. The circumference of the wound is traced if the wound edges are not
even - often required for chronic wounds. (You may also consider photography)

Three -dimensional measures- the wound depth is measured using a

dampened cotton tip applicator

Wound Edges

Healthy wound edges present as advancing pink epithelium growing over

mature granulated tissue.

Colour - pink edges indicate growth of new tissue; dusky edges indicate
hypoxia; and erythema indicates physiological inflammatory response or cellulitis

Raised - wound edges (where the wound margin is elevated above the
surrounding tissue) may indicate pressure, trauma or malignant changes

Rolled -wound edges (rolled down towards the wound bed) may indicate
wound stagnation or wound chronicity

Contraction -

wound edges are coming together, signs of healing

Sensation - increased pain or the absence of sensation should be noted

Exudate

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:

Contains nutrients, energy and growth factors for metabolising cells

Contains high quantities of white blood cells

Cleanses the wound

Maintains a moist environment

Promotes epithelialisation

It is important to asses and document the type, amount and odour of exudate
to identify any changes.

Too much 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 exudate may be:

Colour

Consistency

Significance

us

Clear, straw coloured

Thin, watery

Normal. An increase may be indicative of infection

moserous

Clear, pink

Thin, watery

Normal

guinous

Red

Thin, watery

Trauma to blood vessels

Yellow, grey, green

Thick

Infection. Contains pyogenic organisms and other inflammatory

lent

Infection

Wound infection may be defined as the presence of bacteria or other

organisms, which lead to a host reaction. A host reaction can present with one or a
combination of the following local and systemic clinical indicators:

Local indicators

Redness (erythema or cellulitis) around the wound

Increased amounts of exudate

Change in exudates colour

Malodour

Localised pain

Localised heat

Delayed or abnormal healing

Wound breakdown

Systemic indicators

Increased systemic temperature

General malaise

Increased leucocyte count

Lymphangitis

If any of the above clinical indicators are present medical review should be
instigated and an Microscopy & Culture Wound Swab (MCS) should be considered

Surrounding Skin

Surrounding tissue may present as

Healthy

Macerated

Dry/flaky

Eczematous

Black/blue discoloration

Fragile

Oedema

Erythema

Induration (hardening)

Cellulitis

The surrounding skin should be examined carefully as part of the process of

assessment and appropriate action taken

Pain

The pain associated with chronic wounds can be underestimated. It is

important that pain scores are captured accurately and regularly to ensure

patients have a more active role in dealing with their pain

effective pain relief can be provided

documented evidence of pain patterns are captured

Numerous pain assessment tools are used throughout the RCH:

Wong Baker faces - used in most inpatient areas

FLACC Scale - either used in isolation or in conjunction with Wong Baker

faces

Neonatal Pain Assessment tool

Comfort B - used only in PICU

Pain scores should be clearly documented on observation charts.

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

(Exceptions: patients with peripheral neuropathy who may have reduced

sensation.)

Factors Delaying Wound Healing

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:

Malnutrition- inadequate supply of protein, carbohydrates, fatty acids, and

trace elements essential for all phases of wound healing

Reduced Blood supply - Cardiovascular disorders and Ischaemia

Medication - Non-steroidal anti inflammatory drugs and Corticosteroids.

Chemotherapy - suppresses the immune system and inflammatory response

Radiotherapy - increases production of free radical which damage cells

Psychological stress and lack of sleep- increase risk of infection and delayed
healing

Obesity - decreases tissue perfusion

Infection -prolong inflammatory phase, use vital nutrients, impair

epithelialisation and release toxins

Reduced wound temperature - prolonged dressing changes or use of cold

cleansing products.

Underlying Disease - Diabetes Mellitis and Autoimmune disorders

Maceration - excess wound exudates or contact with bodily fluids reduces
wound tensile strength

Inappropriate wound management

Patient compliance

Unrelieved pressure

Immobility

Substance abuse including alcohol and cigarette smoke

Types of Wounds throughout RCH

Acute Surgical Wounds
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.

Trauma Wounds
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.

Burns
Injuries to tissues caused by heat, friction, electricity, radiation, or chemicals. Burns may be caused by
even a brief encounter with heat greater than 120F (49C). 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).

Chronic Wounds
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:

Non viable wound tissue (slough and/or necrosis)

Lack of healthy granulation tissue (wound tissue may bepale, greyish and
avascular)

No reduction in wound size over time

Recurrent wound breakdown

Pressure Injuries
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.

Infected Wounds
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
Level of bacterial
impairment

Bacterial activity

Contaminiation

Bacteria are on the wound surface. No No impairment to healing

division is occurring
No obvious clinical signs of infection

Colonisation

Bacteria are dividing

Clinical signs

No impairment to healing
No obvious clinical signs of infection

Topical infection
Bacteria are dividing and have invaded Impairment to healing
(Critical colonisation) the wound surface
Clinical signs of infection may not be obvious or are subtle
There may be an increasing variety of absence of vibrant granulation tissue, slough, hypergranu

bacteria present
Biofilm may be present

wound edges

Bacteria and / or their products have

invaded the local tissue

Impairment to healing
Usually obvious signs of infection localised to the wound e
breakdown, increase in size, erythema, increased pain, pu
exudate, malodour and increased temperature at wound s

Regional / Spreading Bacteria and / or their products have

infection / Cellulitis
invaded the surrounding tissue

Impairment to healing
Usually obvious signs of infection. May have systemic sig
(more than 2cm from wound edge), induration of regional
regional tissue, malaise and/or general feeling of unwellne

Local infection

Impairment to healing
Bacteria and / or their products have Usually obvoius systemic clinical signs; patient acutely un
entered the blood stream and may
may occur, high fever, lymphangitis and regional lymphad
have spread to distant sites or organs compromise or failure and possibly circulatory shock (incl
tachypnoea, tachcardia)

Sepsis

Management
Phases of Wound Healing to consider

Phase 1 - INFLAMMATORY PHASE (0-3 Days) the body's normal response

to injury. This phase activates vasodilatation leading to increased blood flow causing HEAT,
REDNESS, PAIN, SWELLING, LOSS OF FUNCTION (e.g. arm swells and cannot bend).
Wound ooze may be present and this is also a normal body response.

Phase 2 - PROLIFERATIVE PHASE (3-24 Days) the time when the wound is
healing. The body makes new blood vessels, which cover the surface of the wound. This
phase includes reconstruction and epithelialisation. The wound will become smaller as it
heals.

Phase 3 - MATURATION PHASE (24-365 Days) the final phase of healing,

when scar tissue is formed. The wound at this stage is still at risk and should be protected
where possible.

Mechanisms of wound healing to consider

Primary Intention; most clean surgical wounds and recent traumatic injuries
are managed by primary closure. The edges of the wounds are approximated with steri strips,
glue, sutures and/or staples. Minimal loss of tissue and scarring results.

Delayed Primary Intention; is defined as the surgical closure of a wound 3

-5 days after the thorough cleansing or debridement of the wound bed. Used for 1. Traumatic
wounds, 2. Contaminated surgical wounds.

Secondary intention; occurs slowly by granulation, contraction and reepithelialisation and results in scar formation. Commonly used for 1. Pressure Injuries 2. Leg
ulcers 3. 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; is a surgical relocation of skin and underlying structures to repair a

wound

Acute Management
Documentation
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 documented. A Wound
Assessment and Treatment Chart can be used to monitor and record the progress of the wound
through its stages of healing. Simple wound documentation can be captured in progress notes and
treatment plans.

Wound cleansing
Requires the application of fluid to clean the wound and optimise the healing environment.
The goal of wound cleansing is to:

Remove visible debris and devitalised tissue

Remove dressing residue

Remove excessive or dry crusting exudates

Principles:

Use Aseptic Technique procedure

Wound cleansing should not be undertaken to remove 'normal' exudate

Cleansing should be performed in a way that minimises trauma to the wound

Wounds are best cleansed with sterile isotonic saline or water

The less we disturb a wound during dressing changes the lower the
interference to healing
Fluids should be warmed to 37C to support cellular activity

Skin and wound cleansers should have a neutral pH and be non-toxic

Avoid alkaline soap on intact skin as the skin pH is altered, resistance to
bacteria decreases

Avoid delipidising agents as alcohol or acetone as tissue is degraded

Antisepticsare not routinely recommended for cleansing and should only be
used sparingly for infected wounds

Method:

Irrigation is the preferred method for cleansing open wounds. This may be
carried out utilising a syringe in order to produce gentle pressure - in order to loosen debris.
Gauze swabs and cotton wool should be used with caution as can cause mechanical damage
to new tissue and the shedding of fibres from gauze swabs/cotton wool delays healing.

Choiceof dressing
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

Maintain a moist environment at the wound/dressing interface

Be able to control (remove) excess exudates. A moist wound environment is

good, a wet environment is not beneficial

Not stick to the wound, shed fibres or cause trauma to the wound or
surrounding tissue on removal

Protect the wound from the outside environment - bacterial barrier

Good adhesion to skin

Sterile

Aid debridement if there is necrotic or sloughy tissue in the wound (caution

with ischaemic lesions)

Keep the wound close to normal body temperature

Conformable to body parts and doesn't interfere with body function

Be cost-effective

Diabetes - choose dressings which allow frequent inspection

Non-flammable and non-toxic

Dry wound

Minimal exudate

Moderate exudate

Heavy

Non adherent island dressing

Hydrogel

Calcium alginate

Hydrofib

Hydrocolloid

Hydrocolloid

Hydrofibre

Foam

Films semi permeable

Silicone absorbent

Foams

Absorbe

Negative Pressure

Negativ

Hydrocolloid: paste/powder

Ostomy

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:

Primary dressing: is one that comes directly in contact with the wound bed

Secondary dressing:is used to cover a primary dressing when the primary

dressing does not protect the wound from contamination

Occlusive dressing: covers a wound from the outside environment and keep
nearly all wound vapors at the wound site

Semi-occlusive dressing: allows some oxygen and moisture vapour to

evaporate

Management recommendations for specific wound types - throughout RCH

Acute Surgical Wounds

Trauma Wounds

Burns

Chronic Wounds

Pressure Injuries

Ongoing management
Management of complications and troubleshooting
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.

Discharge planning and community-based management

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 Form 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.

Special Considerations
For patients with impaired nutritional status a dietitian referral should be considered.

Companion Documents

Aseptic Technique

Wound dressings - acute traumatic wounds; Clinical Practice guideline

Burns unit - Clinical information

Burns - Clinical practice Guideline

Vulval Ulcers - Clinical Practice Guideline

Cellulites and Skin Infections - Clinical practice Guideline

Eczema Management - Clinical guideline

Lacerations - Clinical practice Guideline

Links

Australian Wound Management Association

AWMA 2011 standards for wound management

WoundsWest

References

Australian Wound Management Association Inc. (August 2011). Bacterial

impact on wound healing: From contamination to infection. Position Paper, Version 2.

Ashton J, Morton N, Beswick S, Barker V, Blackburn F, Wright C, Turner L,

Morton K, Jennings A. BoltonNHS - Primary Care Trust. (March 2008) "Wound care
Guidelines"

Butler. C. T. (2006) Paediatric Skin care: Guidelines for Assessment,

prevention and Treatment. Paediatric Nursing, 32(5), 443-450.

Carville K, Keaton J, Rayner R, Prentice JL & Santamaria N. 'Wounds West

education: taking the evidence on wounds to the clinician". (August 2009) Wound Practice
and Research. Volume 17 Number 3 Pages 114 - 120

Cooper, C. L., & Nolt, J. D. (2007). Development of an evidence-based

paediatric fall prevention program. Journal of Nursing Care Quality, 22(2), 107-112

Dunk AM & Taylor J."A survey of clinicians' perceptions of, and product
choices for, the infected wound" (February 2009) Wound practice and Research. Volume 17
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Derbyshire A."Innovative solutions to daily challenges". (September 2010)

British Journal of Community Nursing, Volume 15, Issue. 9 Pages S38 - S45

Dumville JC, Walter CJ, Sharp CA, Page T."Dressings for the prevention of
surgical site infection" The Cochrane Library Issue 7 (2011)

Enoch S & Harding K. (2003) Wound bed preparation: the science behind the
removal of barriers to healing. WOUNDS 2003; 15, 213-229.

Ken J Farion, Kelly F Russell, Martin Hamond, Lisa Hartling, Terry P Klassen,
Tamara Durec, Ben Vandermeer"Tissue adhesives for traumatic lacerations in children and
adults" (January 2009) Cochrane wounds Group

Marja N Storm-Versloot, Cronelis G Vos, Dirk T Ubbink, Hester Vermeulen.

(2010) "Topical silver for preventing wound infection". The Cochrane Wounds Group. Issue 3

Moore K. (2003) Wound physiology: from healing to chronicity. J Wound Care

(Suppl):2-7.

Owens, p.L., Zodet, M.W., Berdahl, T., Dougherty, D., McCormick, M. C., &
Simpson, L. A (2008) Annual report on health for children and youth in the United states:
focus on injury-related emergency department utilisation and expenditures. Ambulatory
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Templeton S. (2005) Management of chronic wounds: the role of silvercontaining dressings. Primary Intention. 13(4), 170-179.

Vancouver Island health Authority (2007) Wound and Skin Care clinical
Guideline

Vermeulen H, Ubbink D, Goossens A, De Vos R, Legemate D, Westerbos S

J."Dressings and topic agents for surgical wounds healing by secondary intention" (2009) The
Cochrane Wounds Group