1. Wound FieldWound Field
ConceptConcept
Dr Clare FenwickDr Clare Fenwick
Fatima College Health SciencesFatima College Health Sciences
Griffith UniversityGriffith University
20102010
3. Dr Clare Fenwick 2010
Existence of bacteria with no obvious host reactionExistence of bacteria with no obvious host reaction
All wounds are colonisedAll wounds are colonised
WOUND COLONISATIONWOUND COLONISATION
4. Dr Clare Fenwick 2010
Introduction of micro-organisms into the wound or the presence ofIntroduction of micro-organisms into the wound or the presence of
non-replicating micro-organisms on the wound surfacenon-replicating micro-organisms on the wound surface
Re-introduction of the patient’s own microbes back into the woundRe-introduction of the patient’s own microbes back into the wound
is NOT contaminationis NOT contamination
WOUND CONTAMINATIONWOUND CONTAMINATION
5. Dr Clare Fenwick 2010
Invasion and multiplication of micro-organismsInvasion and multiplication of micro-organisms
causing local and systemic effectscausing local and systemic effects
WOUND INFECTIONWOUND INFECTION
6. Dr Clare Fenwick 2010
ContaminationContamination
Host resistanceHost resistance
Patients immune system, limited controlPatients immune system, limited control
Environmental virulenceEnvironmental virulence
What we carry on our bodies, innate objects, limited controlWhat we carry on our bodies, innate objects, limited control
EndogenousEndogenous
Patient’s own flora and bacteriaPatient’s own flora and bacteria
ExogenousExogenous (most common cause)(most common cause)
Foreign matter – hair, wool fibresForeign matter – hair, wool fibres
Nurses hands are the worst offenderNurses hands are the worst offender
If it is wet and not yours, protect yourselfIf it is wet and not yours, protect yourself
Watch what you discard and whereWatch what you discard and where
7. Dr Clare Fenwick 2010
Things to considerThings to consider
Acknowledge colonisation asAcknowledge colonisation as normalnormal
Prevent/minimise contaminationPrevent/minimise contamination
Identify and treat infectionIdentify and treat infection
8. Dr Clare Fenwick 2010
Wound Bed PreparationWound Bed Preparation
Cleansing techniquesCleansing techniques
DebridementDebridement
SharpSharp
AutolyticAutolytic
EnzymaticEnzymatic
MechanicalMechanical
SurgicalSurgical
Biodebridement (maggots)Biodebridement (maggots)
9. Dr Clare Fenwick 2010
Cleansing TechniqueCleansing Technique
Clean versus sterile techniqueClean versus sterile technique
Normal saline and tap water (safeNormal saline and tap water (safe
enough to drink)enough to drink)
Hand washing is essential to reduceHand washing is essential to reduce
infectioninfection
Dirty hand & clean handDirty hand & clean hand
Wound field conceptWound field concept
10. Dr Clare Fenwick 2010
Clean and dirty handClean and dirty hand
Dressing
Equipment
clean
dirty
14. Dr Clare Fenwick 2010
Reading SourcesReading Sources
Ellis, T.,Beckmann, A. (1997) Wound Field Concept Primary
Intention 5, (2)
Ellis, T. (2004). CPD: Understanding the act of contamination in
wound dressing procedure. Collegian, 11(3), 39-42.
Fenwick, C. (2006) Wound fields and the undergraduate nurse.
Australian Nursing Journal 13, (11) pp 41
Gillespie, B. & Fenwick, C. (2009) Comparison of the two leading
approaches to attending wound care dressings. Wound Practice
and Research 17 (2) pp 62-67
Editor's Notes
CONTAMINATION
Host resistance – Patients immune system you have little control over
Environmental virulence - What each person carries on them or on innate objects you also have little control over
Endogenous – patients own flora or bacteria
Exogenous – is the most common cause of contamination. Anything foreign to the wound such as your microbes, your hair or clothes fibre can contribute to the deterioration of the wound. Cotton wool fibres left behind in the wound when cleaning can set up an inflammatory process. Nowadays gentle cleaning with warmed sterile water or normal saline using a 19 gauge needle with a 35ml syringe or tap water is sufficient to clean the wound bed of exudate.
Always wear protective equipment (gloves, goggles, gown) if there is a contamination risk of body product. If it is wet and not yours you need to protect yourself
Be aware of what you are discarding and where you are placing it. If the dressing is contaminated with body fluid such as blood or pus it should be disposed in a contaminant bin. If it is wet from dressing product discard in a plastic lined bin. If it is a dry dressing, discard in a normal bin. Always familiarise yourself with the hospital protocol regarding infection control. Sharps MUST always be discarded in the sharps container.
CLEANSING TECHNIQUE
Clean procedures and dressings are for areas that are already loaded with bacteria such as nasogastric insertion, the gut is full of bacteria or wound dressings, wounds have a bacterial load
Sterile procedures and dressings are reserved for areas that have no bacterial load such as insertion of a urinary catheter or accessing a central venous catheter. Consider, is it safe to transfer bacteria from one area such as the skin to another area such as the urinary bladder. What would happen; sepsis.
Research suggests that there is no significant increase in wound infection or wound colonisation when normal saline or tap water is used during wound cleansing. Antiseptics are no longer favoured as a wound cleansing agent as some will destroy epithelising tissue and can be deactivated by the presence of pus. However some antiseptics are still used for specific wound care such as MRSA and pseudomonas colonisation
Hand washing is the single most effective intervention to prevent the spread of infection (Hollinworth & Kingston 1998)
Showering postoperative wounds does not increase infection. Research suggests allow 48 to pass then shower. Chronic wounds can be showered with no increase in bacterial load
Wound Field concept, this is concept where we acknowledge that the wound is contaminated with microbes, and anything not of the wound such as yourself or foreign matter should not be introduced.
Dirty hand & clean hand is still used actively within a sterile environment however it is loosing favourability in the ward and community environment. This technique has been based on historical significance rather than research based.
CLEAN AND DIRTY HAND
The clean/dirty hand technique is when the dressing area is considered to be separate of the wound. The clean hand can only operate over the area of the dressing field. The dirty hand is allowed only over the wound area. Neither hand should cross the imaginary fence line. At this fence line cleaning product is passed to the dirty hand which cleans the wound. The product is discarded and the dirty hand returns to the fence line for more cleaning product from the clean hand
Considering that wound care is now requiring wound irrigation the clean/dirty hand concept is becoming impractical and outdated.
WOUND FIELD CONCEPT
Infection occurs when an imbalance of normal flora numbers occurs and the body’s normal defences cannot confine or control them.
A wound is considered infected if there is 100 000 (105) organisms per gram of tissue (Carville, 2001), a wound is contaminated if levels are lower than this
The wound field concept is based upon the theory that the contaminants of the person and their wound will not further infect the wound. Only items introduced will cause further infection such as a sneeze across the wound bed or your clothing touching the wound. The wound field concept is an alternative to the clean/dirty hand theory.