1. 9.1.05
Basic WoundBasic Wound
Assessment andAssessment and
ManagementManagement
LPCH Pediatric Wound, Ostomy & Continence ServiceLPCH Pediatric Wound, Ostomy & Continence Service
ByBy
Claire Abrajano, RN, MSN, WOCN, PNPClaire Abrajano, RN, MSN, WOCN, PNP

2. 9.1.05
TerminologyTerminology
 Partial-thicknessPartial-thickness
wound:wound: shallow woundsshallow wounds
with tissue loss confined towith tissue loss confined to
skin layers (superficial)skin layers (superficial)
 Painful secondary toPainful secondary to
exposure of nerve endingsexposure of nerve endings
 Loss of epidermis andLoss of epidermis and
possibly part of dermispossibly part of dermis
 Red raw base OR paleRed raw base OR pale
moist base with visiblemoist base with visible
epidermal “islets”epidermal “islets”
 Heal by epithelializationHeal by epithelialization

3. 9.1.05
TerminologyTerminology
 Full-thickness wound:Full-thickness wound:
Involve the total loss ofInvolve the total loss of
all skin layers and maybeall skin layers and maybe
subcutaneous tissuesubcutaneous tissue
 Heal by granulationHeal by granulation

4. 9.1.05
TerminologyTerminology
 Epithelialization:Epithelialization: the regeneration of skin to closethe regeneration of skin to close
a wounda wound
 Granulation:Granulation: The growth of blood vessels andThe growth of blood vessels and
connective tissue in a woundconnective tissue in a wound
 Maceration:Maceration: Excessive moisture in intact skinExcessive moisture in intact skin
causing peeling and loss of integritycausing peeling and loss of integrity
 Excoriation:Excoriation: liner scratch in the skin surfaceliner scratch in the skin surface

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Denuded Skin:Denuded Skin: loss of superficial layerloss of superficial layer

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Ulcer:Ulcer: deeper lesion extending intodeeper lesion extending into
the dermis or belowthe dermis or below

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Eschar:Eschar: Thick, leathery necroticThick, leathery necrotic
tissuetissue

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Slough:Slough: Loose, stringy nonviableLoose, stringy nonviable
tissuetissue

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WOUNDSWOUNDS
 Basic AssessmentBasic Assessment
 LocationLocation
 Dimensions: Measure and record inDimensions: Measure and record in
centimeterscentimeters
 LengthLength
 WidthWidth
 DepthDepth
 Undermining or tunnelingUndermining or tunneling
 Slide sterile swab into opening andSlide sterile swab into opening and
along the fascial plane untilalong the fascial plane until
resistance met. Lay swab against aresistance met. Lay swab against a
measuring guide.measuring guide.
 Relate the location of the tunnelingRelate the location of the tunneling
by referring to the face of a clockby referring to the face of a clock
(i.e. 3 cm of tunneling at 9 o’clock)(i.e. 3 cm of tunneling at 9 o’clock)

10. 9.1.05
Basic Wound Assessment (cont’d)Basic Wound Assessment (cont’d)
 Condition of the wound bedCondition of the wound bed
 Signs of infection (erythema, induration, warmth, tenderness, pain,Signs of infection (erythema, induration, warmth, tenderness, pain,
drainage, foul odor)drainage, foul odor)
 Color of woundColor of wound
 Presence/absence of granulation tissuePresence/absence of granulation tissue
 Presence/absence of necrotic tissuePresence/absence of necrotic tissue
 Color - black, yellow, tan, greenColor - black, yellow, tan, green
 Percent of wound bed covered by necrotic tissuePercent of wound bed covered by necrotic tissue
 ExudateExudate
 Amount: small, moderate, largeAmount: small, moderate, large
 Color: serous, bloody, yellow, green, etc.Color: serous, bloody, yellow, green, etc.
 OdorOdor
 Condition of surrounding skinCondition of surrounding skin
 Signs of infection or maceratonSigns of infection or maceraton
 RashRash

11. 9.1.05
Stages of Wound HealingStages of Wound Healing
 Inflammatory Stage (1Inflammatory Stage (1stst
few days)few days)
 Inflammation – WBC clean wound of debris & bacteriaInflammation – WBC clean wound of debris & bacteria
 Homeostasis – vasoconstrictionHomeostasis – vasoconstriction
 Platelets & thromboplastin form clotsPlatelets & thromboplastin form clots
 Proliferative Stage (~ 3 weeks or longer)Proliferative Stage (~ 3 weeks or longer)
 Granulation occurs – fibroblasts make collagenGranulation occurs – fibroblasts make collagen
 New blood vessels, wound contracts, epithelializationNew blood vessels, wound contracts, epithelialization
 Maturation/Remodeling Stage (up to 2 yrs)Maturation/Remodeling Stage (up to 2 yrs)
 New collagen forms, change shape of wound, increasingNew collagen forms, change shape of wound, increasing
tissue strength (80% of original)tissue strength (80% of original)

12. 9.1.05
Factors that Affect Wound HealingFactors that Affect Wound Healing
 Perfusion/oxygenationPerfusion/oxygenation
 Nutritional StatusNutritional Status
 InfectionInfection
 CorticosteroidsCorticosteroids
 DiabetesDiabetes

13. 9.1.05
Wound Care Objectives:Wound Care Objectives:
DIPAMOPIDIPAMOPI
 D=D= DebrideDebride
 I= Identify and treatI= Identify and treat infectioninfection
 P=P= PackPack dead space—dead space— lightly!lightly!
 A=A=AbsorbAbsorb excess exudateexcess exudate
 M= MaintainM= Maintain moistmoist wound surfacewound surface
 O=O= OpenOpen or excise closed wound edgesor excise closed wound edges
 P=P= ProtectProtect healing wound/surrounding skin fromhealing wound/surrounding skin from
infection /traumainfection /trauma
 I=I= InsulateInsulate

14. 9.1.05
Types of DebridementTypes of Debridement
 AutolyticAutolytic
 ChemicalChemical
 Enzymatic (i.e. Accuzyme)Enzymatic (i.e. Accuzyme)
 Dakin’s solutionDakin’s solution
 MechanicalMechanical
 Wet-to-dry dressings: works when dressing is removedWet-to-dry dressings: works when dressing is removed
 Irrigation: 35ml syringe with 19 angiocath or whirlpoolIrrigation: 35ml syringe with 19 angiocath or whirlpool
 SharpSharp
 SurgicalSurgical
 ConservativeConservative

15. 9.1.05
Cleanse WoundCleanse Wound
 Acute Traumatic Wound (lacerations orAcute Traumatic Wound (lacerations or
abrasions)abrasions)
 Remove all foreign bodies/debrisRemove all foreign bodies/debris
 Clean while minimizing traumaClean while minimizing trauma
 Clean WoundClean Wound
 Flush gentlyFlush gently
 Necrotic or Dirty WoundNecrotic or Dirty Wound
 Remove while minimizing trauma of underlyingRemove while minimizing trauma of underlying
tissuetissue

16. 9.1.05
Irrigation SolutionsIrrigation Solutions
 The only acceptable wound-The only acceptable wound-
cleansing solution is normalcleansing solution is normal
saline solution (0.9% sodiumsaline solution (0.9% sodium
chloride, or salt, in water)chloride, or salt, in water)
 Effectively removesEffectively removes
contaminants and has the samecontaminants and has the same
salt concentration as the fluidsalt concentration as the fluid
in cells, so it does not damagein cells, so it does not damage
cells by pulling water out ofcells by pulling water out of
them.them.
 InexpensiveInexpensive
 Readily availableReadily available
 Alternative solution: LactatedAlternative solution: Lactated
Ringer’sRinger’s

17. 9.1.05
Irrigation Solutions?Irrigation Solutions?
 Many previously accepted wound-cleansingMany previously accepted wound-cleansing
solutions have been found to be toxic tosolutions have been found to be toxic to
fibroblasts and lymphocytes, the cellsfibroblasts and lymphocytes, the cells
required to heal wounds.required to heal wounds.
 These solutions include:These solutions include:
 Providone-iodineProvidone-iodine
 Acetic acid (vinegar)Acetic acid (vinegar)
 Concentraton of 0.25% notConcentraton of 0.25% not
cytotoxiccytotoxic
 IodophorIodophor
 Hydrogen peroxideHydrogen peroxide
 Dakin's solution (sodium hypochlorite)Dakin's solution (sodium hypochlorite)
 Concentration of 0.025% notConcentration of 0.025% not
cytotoxic.cytotoxic.
NOTE: Commercially prepared solutions areNOTE: Commercially prepared solutions are
not regulated by the FDA, and many havenot regulated by the FDA, and many have
been found to be cytotoxic.been found to be cytotoxic.

18. 9.1.05
Manage ExudateManage Exudate
 Wounds heal faster if kept moistWounds heal faster if kept moist
 Excessive exudate will macerate peri-wound skinExcessive exudate will macerate peri-wound skin
 May promote fungal growthMay promote fungal growth
 Wet dressing attract bacteriaWet dressing attract bacteria
 Product selection is importantProduct selection is important

19. 9.1.05
Pack Dead Space—Lightly!Pack Dead Space—Lightly!
 Observe for cavities, sinuses and tracts in woundObserve for cavities, sinuses and tracts in wound
 Design a treatment protocol to ensure dressingDesign a treatment protocol to ensure dressing
fills these areasfills these areas
 Wound may close prematurelyWound may close prematurely
 Predispose to later abscess and woundPredispose to later abscess and wound
breakdownbreakdown

20. 9.1.05
Protect Wound and SurroundingProtect Wound and Surrounding
SkinSkin
 Surrounding skin needs to be able to regenerateSurrounding skin needs to be able to regenerate
epithelial cells to close woundepithelial cells to close wound
 May be macerated, dry, infected (fungal)May be macerated, dry, infected (fungal)
 Work to restore “normal” skin integrityWork to restore “normal” skin integrity
 Protect wound from additional traumaProtect wound from additional trauma
 Insulation: normal body temperature at woundInsulation: normal body temperature at wound
surface reduces vasoconstriction and enhancessurface reduces vasoconstriction and enhances
cellular activitycellular activity

21. 9.1.05
Which Dressing?Which Dressing?

22. 9.1.05
Selecting a DressingSelecting a Dressing
 Examine the woundExamine the wound
 Decide which characteristics of the wound needsDecide which characteristics of the wound needs
immediate treatmentimmediate treatment

23. 9.1.05
Factors to ConsiderFactors to Consider
 Cover vs FillerCover vs Filler
 Amount of absorption requiredAmount of absorption required
 Impact of occlusionImpact of occlusion
 Impact of adhesionImpact of adhesion
 Cost/availability/usageCost/availability/usage

24. 9.1.05
Selecting a DressingSelecting a Dressing
Deep & ExudativeDeep & Exudative
Goal:Goal: Fill dead space; absorb exudate;Fill dead space; absorb exudate;
maintain moisture; support autolysis ifmaintain moisture; support autolysis if
necrotic; protectnecrotic; protect
Need:Need: Absorptive Filler + coverAbsorptive Filler + cover
dressingdressing
Deep & DryDeep & Dry
Goal:Goal: Fill dead space; maintain moisture;Fill dead space; maintain moisture;
protectprotect
Need:Need: Hydrating filler + cover dressingHydrating filler + cover dressing
Shallow & ExudativeShallow & Exudative
Goal:Goal: Absorb exudate; maintainAbsorb exudate; maintain
moisture; support autolysis if necrotic,moisture; support autolysis if necrotic,
insulate and protectinsulate and protect
Need:Need: Absorptive cover dressing (MayAbsorptive cover dressing (May
add small amount of filler)add small amount of filler)
Shallow & DryShallow & Dry
Goal:Goal: Maintain (or create) moisture;Maintain (or create) moisture;
protect, insulateprotect, insulate
Need:Need: Hydrating or moisture retentiveHydrating or moisture retentive
cover dressingcover dressing

25. 9.1.05
Selecting a DressingSelecting a Dressing
Deep & ExudativeDeep & Exudative
Filler:Filler: Ca Alginates, gauze, cavity dressingCa Alginates, gauze, cavity dressing
Cover:Cover: Gauze pad, ABD, etc., transparentGauze pad, ABD, etc., transparent
thin film, Polyurethane foamthin film, Polyurethane foam
Deep & DryDeep & Dry
Filler:Filler: Amorphous gel, damp gauze packingAmorphous gel, damp gauze packing
Cover:Cover: Gauze pad, ABD, etc., transparentGauze pad, ABD, etc., transparent
thin filmthin film
Shallow & ExudativeShallow & Exudative
Hydrocolloid, polyurethane foam, CaHydrocolloid, polyurethane foam, Ca
Alginates, gauzeAlginates, gauze
Shallow & DryShallow & Dry
Amorphous or solid gel, thin hydrocolloid,Amorphous or solid gel, thin hydrocolloid,
polyurethane foam, transparent thin film,polyurethane foam, transparent thin film,
non-adherent gauze, impregnated gauzenon-adherent gauze, impregnated gauze
dressings (vaseline gauze or Xeroform)dressings (vaseline gauze or Xeroform)

26. 9.1.05
Pediatric Pressure PrinciplesPediatric Pressure Principles
 < 1 meter square< 1 meter square
 OcciputOcciput
 School ageSchool age
 Sacrum and CoccyxSacrum and Coccyx
 Heels in supineHeels in supine
 Toddler and upToddler and up
 Ischial ulcersIschial ulcers
 For wheelchair bound schoolFor wheelchair bound school
age and upage and up

27. 9.1.05
Decreasing Pressure RiskDecreasing Pressure Risk
 Gel E donuts or water bagsGel E donuts or water bags
 SheepskinSheepskin
 Egg crateEgg crate
 Specialty beds with airSpecialty beds with air
mattressmattress

28. 9.1.05
Treating PressureTreating Pressure
SoresSores
No matter the location, remove theNo matter the location, remove the
source of pressuresource of pressure

29. 9.1.05
Treatment: Heel SoresTreatment: Heel Sores
 Skin prep, double coats,Skin prep, double coats,
elevate heel – pressureelevate heel – pressure
reliefrelief
 No adhesive productsNo adhesive products
 If scabbed, use antibioticIf scabbed, use antibiotic
ointment to edges ofointment to edges of
scab onlyscab only

30. 9.1.05
Treatment: OccipitalTreatment: Occipital
 Shave first no matter which dressing usedShave first no matter which dressing used
 No scabNo scab
 Skin prep and tegadermSkin prep and tegaderm
 ScabScab
 Skin prep and tegaderm orSkin prep and tegaderm or
 Antibiotic ointment or silvadene and telfaAntibiotic ointment or silvadene and telfa
(dependent on(dependent on erythema and risk)erythema and risk)

31. 9.1.05
Treatment: OccipitalTreatment: Occipital
 Calcium alginateCalcium alginate
 For deeper debridementFor deeper debridement
 Hydrocolloid once wound cleanHydrocolloid once wound clean

32. 9.1.05
Treatment: Sacral and CoccygealTreatment: Sacral and Coccygeal
 Intact skin only.Intact skin only. No blister, scab or open skinNo blister, scab or open skin
 Skin prepSkin prep
 Open skin, no escharOpen skin, no eschar
 Skin prep and hydrocolloid or tegadermSkin prep and hydrocolloid or tegaderm
 EscharEschar
 Debride with silvadene and gauze or wet to dryDebride with silvadene and gauze or wet to dry
dressingdressing

33. 9.1.05
Preventive Care for Perineal RashPreventive Care for Perineal Rash
 AquaphorAquaphor
 VaselineVaseline
 Diaper aid creamDiaper aid cream
 DesitinDesitin
 Vitamin A&D creamVitamin A&D cream

34. 9.1.05
Thicker Barrier Creams for ModerateThicker Barrier Creams for Moderate
to Severe Perineal Rashto Severe Perineal Rash
 Points to considerPoints to consider
 May use Vaseline over Desitin or other skin barrierMay use Vaseline over Desitin or other skin barrier
creams that are thicker in consistency (i.e. Sensicarecreams that are thicker in consistency (i.e. Sensicare
cream)cream)
 Warm soaks and remove 2 times/day.Warm soaks and remove 2 times/day.
 Do not remove barrier creams with every diaperDo not remove barrier creams with every diaper
change. Cleanse area of stool and reapply throughoutchange. Cleanse area of stool and reapply throughout
day.day.

35. 9.1.05
Case Example 1: How would youCase Example 1: How would you
manage this wound?manage this wound?

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Case Example 2Case Example 2

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Case Example 3Case Example 3

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Case Example 4Case Example 4