This document discusses the management of non-healing wounds, which requires a multidisciplinary approach involving thorough assessment and wound bed preparation. It outlines the key factors in assessment including patient history, wound characteristics, and factors affecting healing. Wound bed preparation principles of debridement, control of inflammation and infection, and maintenance of moisture balance are explained. Various debridement methods and appropriate dressings to promote healing are also described.

1. Dr Yap Gaik Chin
Wound Care Team
Surgical Department

2.  Management of non healing wound is a
complex process and requires a
multidisciplinary approach
 Starts from the first assessment upon
inspection of patient by making a general
assessment and further local assessment of the
wound

3.  Assessment ( General & local )
 TIME – wound bed preparation
 Wound cleansing
 Types of debridement
 Types of dressing

4.  Age
 Psychosocial health
 Complicating conditions
 vascular problem, diabetic, smoking,
immunosuppressive
 Nutritional status
 Pain/Comfort
 Hygiene

5.  Wound etiology
 Pressure, trauma, shearing, friction
 Size
 Wound edges
 Wound Bed
 necrotic, granulation tissue, odour, exudate
 Surrounding skin ( colour, moisture)

6.  In early 1980s, Lars Hellgrens, a Sweeden
dermatologist was the first to claim that
wounds could be categorised according to the
colour of the wound surface
 Red-Granulation
 Yellow-Slough
 Pink-Epithelialization
 Black-Necrotic

7.  Mnemonic for Principles of Wound Bed
Preparation
 What is wound bed preparation?
 Management of wound to accelerate
endogenous healing or facilitate the
effectiveness of other therapeutic measures

8.  T : Tissue Viability
 I : Inflammation, Infection
 M : Moisture Imbalance
 E : Epidermal Margin/ Edge of Wound

9.  Viable ( Granulation, Epithelialising)
 Non viable ( Necrotic, Sloughly, Eschar)
 How does non viable tissue impede healing?
 Prolongs inflammation
 Impedes epitheliazation
 Medium for bacteria growth

10.  Clear away dead or necrotic tissue
 Debridement
 Always ensure adequate tissue oxygenation
for angiogenesis and granulation process

11.  The bacterial continuum
 What is infection?
 End spectrum of bacterial continuum , more
infected than critically colonized wound
 Assessing of wound infection
1. Contamination
2. Colonized
3. Critically colonized
4. Infection ( Local, Systemic)

12.  Classic Presentation of infection of local wound
1. Advancing erythema
2. Fever
3. Warmth
4. Oedema/ Swelling
5. Pain
6. Purulence

13.  Secondary clinical presentation of local wound
1. Delayed healing
2. Change in colour of wound bed
3. Absent/abnormal granulation tissue
4. ↑ or abnormal odour
5. ↑ drainage/exudate
6. ↑ pain @ wound site

14.  Too much moisture –impede wound healing
 Cause Dessication / Maceration of skin
 Need to match exudate volume with product
absorbency for optimal moisture balance

15.  Non advancing wound edge
 Also known as non healing wound
 Undermining of edge is either critically
colonised or infected

16.  Reconsider the principles of wound bed
preparation and the acronym TIME,
1. Has necrotic tissue been debrided?
2. Is there a well vascularised wound bed?
3. Has infection been adequately controlled?
4. What is the status of inflammation or
infection in this patient?
5. How well is moisture balance optimized?
6. What dressings have been applied before?

17.  Removing foreign debris & necrotic tissue
 The process of removing inflammatory
contaminants from the wound surface since
necrotic tissue, excess exudate and foreign
objects impede healing & ↑ the risk of infection
 Routine cleansing ( Fluid irrigation, mild scrub)
 Debridement

18.  Antibiotic should be used to reduce bacterial
level within the wound
 Selection of antibiotic is based upon proven
efficiency against microorganisms obtained
from culture.

19.  Saline
 Octanisept
 Superoxide solution
 Water for irrigation
 PHMB with Betaine

20.  Antiseptics should not be used to clean
wounds
 Topical antiseptics:
1. Betadine
2. Povidone-Iodine
3. Dakin’s Solution ( Eusol)
4. Acetic Acid-> effective against Pseudomonas
A organisms
5. Hydrogen Peroxide

21.  A method of high pressure irrigation which is a
gentle mechanical action to loosen debris and
necrotic tissue

22.  Wound healing is impaired due to prolong
inflammation
 Necrotic tissue –culture medium for bacteria
 Amtibiotics do not reach the wound milieu
 Dressings especially antimicrobial or silver do
not reach wound bed
 For staging of undetermined stage pressure
ulcer

23.  Surgical
 Mechanical
 Autolytic
 Enzymatic
 Biological
 Maggot Debridement Therapy( MDT)

24.  Wound bed utilizes phagocytes and proteolytic
enzymes to remove non viable tissueining a
moist environment
 This process can be promoted and enhanced by
maintaining a moist environment

25.  Recommended for removal of thick, adherent
eschar and devitalized tissue in large wounds
 Not recommended in severely compromised
patients
 Analgesia / anaesthesia may be required

26.  The use of topically applied enzymatic agents
to stimulate the breakdown of non viable tissue
 Faster debridement process compared to
autolytic
 Eg: Honey, Prolase dressing

27.  Used for decades where dressings are allowed
to proceed from moist to dry
 Manually removing the dressing causes a form
of non selective debridement
 Works best on wounds with moderate
amounts of necrotic debris

28.  Small maggots are introduced to a wound to
consume necrotic tissue
 Able to debride a wound within 1-2/7
 The maggots derive nutrients through a
process called ` extracorporeal digestion’

29.  Protect wound from trauma or microbial
contamination
 Absorb drainage and debride wound
 Control & prevent haemorrhage ( pressure
dressing)
 Reduce pain
 Maintain temperature and moisture of wound
 Provide psychological comfort

30.  Traditional
 Conventional
 Leaves, herbs, Honey, Gauze
 Advanced/ environmental dressings
I. more expensive
II. Can be left in situ for several days
III. Films, Alginates, Silver, Hydrogels, Foams,
Hydrocolloids, Charcoals

31.  Safe and easy to use
 Remove excess exudate
 Provide thermal insulation
 Trauma protection
 Provide barrier to pathogens
 Allow gaseous exchange
 Water proof
 Non adherent
 Maintain moist wound healing environment

32.  The Compendium of Wound Care Dressings in
Malaysia, Volume 2 , Harikrishna K.R Nair