1. Wound Assessment and Dressing Selection
Noreen Campbell RN BScN MA IIWCC Lt CSW
TCS Systems
North Saanich, BC, Canada

2. Maturation/Remodeling
Wound Healing Process
Maturation/Remodeling
Day years
Epithelialisation
Proliferation
Day 4-21
Inflammation
Day 1-4
Kane
Hemostasis
immediate

3. Homeostasis – first 24 hours
‘Meat’
Illustration of wound healing - as building after a disaster and collapse of a house.
This is the sequence in simple terms -- subsequent slides is illustrate more completely the activities associated with subsequent steps.

4. ‘Mess’ Inflammation 1-4 days Hemostasis Platelets
The initial reaction to injury is hemostasis -- the stopping of damage and return to normal.
There is no healing at this point.

5. ‘Full’ Proliferation day 4 - 21 Inflammation
Leakage of plasma and WBCs
Debridement
Macrophages
Phagocytosis
Neutrophils
Inflammation - is the dilatation of the blood vessels and the rush of the white cells and serum products that will begin 'cleaning' the wounds. -- removal of dead tissue and bacteria.
This sets the stage for rebuilding
‘Full’

6. Fibrin, Collagen Bridge to Skin
Yellow, caramel like surface, pain
Granulation peeking, epithelial starting 6

7. ‘Baby skin’ Epithelialization Proliferation
Release of growth factors from macrophages
Granulation
Lymphocytes
Neurocytes
Angiocytes
Contractile proteins
Fibroblasts
At this point - growth factors are released and not only the removal of dead tissue takes place but the building blocks of new tissue is laid down.
This is a primitive stage and the new tissue will transform to the anatomical structures they will replace as healing progresses.
A number of requirements exist at this stage - a moist environment, good nutrition, proper temperature and all of the 'healing' elements.
This is the ideal point of using growth hormones or wound stimulants. The wound is clean and ready to close.

8. Maturation/Remodeling up to 2 years
Normal
Hypertrophic
With incision
Keloid
Extends to normal tissue
Epithelialization
Resurfacing migration of skin cells
Epithelial tissue development
Keratinocytes
Epithialization is the point that the granulation tissue develops a matt finish appearance and is the precursor of skin - as it develops the skin will thicken and become more secure.
New epithial tissue is moist but as it develops there will be less drainage until skin is complete. ]
Growth hormone products are beneficial until the skin is developed. These products may cause callus formation to be rapid and callus care must be monitored to ensure the wound does not prematurely close with bacteria trapped. If this happens - the wound will breakdown, osteomyelitis or if the patient can resist the bacteria the wound will close.
‘stronger’
Well healed scar – always a scar…weaker tensile strength

9. Individual assessment
Potential for Healing
Individual assessment
Wound
Care
Regulation of Wound Healing
Cascade of overlapping events
Growth factors
Cytokines
Matrix metalloproteinases (MMPs)
Tissue inhibitors of MMPs
Hormones
Although the wound healing cycles is the same for all patients to some degree. The efficiency of healing is influenced by many factors.
Diabetics have delayed wound healing due to missing or reduced healing factors. Fortunately, specific elements which are reduced - may be replaced with another factor in the healing cycle.
This is why growth hormones or wound stimulants are used and their exact mechanism is not know.

10. Tissue depth? Probe… 10

11. Culture Infection Heat Redness Swollen Pain Not with neuropathy
Blood Sugars elevated
Culture 11

12. Infection: Assess Clean Wound
Wound Cleansing
Potable tap water
Saline
Boiled cooled water
Mild soap
Dove no dye or perfume
Cochrane Review 2011 water for cleansing

13. Wound Imperatives and Antimicrobials
Product
Function
Cost * CDA
Promogran
Prisma is above with silver
MMP binding
ON the wound “let it dance with the wound”
Promogran 28 sq cm $ sq cm $55.95
Prisma 28 sq cm $26.95
Iodosorb cadexomer iodine
Cochrane level support red. Infection, promote healing, but pain reports may limit
use
Ointment $ Gm
Paste $58.95not recommended
Inadine povidone iodine
Non-adherent sheets
9.5x9.5cm $2.30
Silver dressings
Support of efficacy lacking
Expensive 4x4” $18.95
Honey dressings
Expensive $ gm
Canadian Diabestes Association Store –

14. Eschar: risk infection and delay healing
Stable
Wet
Black
Dry
Hard
Drainage
Marbling
Breakdown
Autoamputation?
Debride
Iodosorb
+ cast padding
Inadine PHD

15. Debride Unstable Eschar
Drainage
Fluctuance
Iodine produce will become paler with release of iodine

16. Surgery, expensive, pain, non-selective Conservative Sharp
Debridement
Advantage
Disadvantage
Surgical
Fast
Surgery, expensive, pain, non-selective
Conservative Sharp
Bedside, pain,
Scope of practice
Skill
Maggot
Selective, disinfect wound, stimulate healing
Ordering process, $120 treatment, dressing change 48 hours
Enzyme (Santyl)
Selective
$ tube, weeks
Mechanical
Wet to dry
Saline Compresses
Irrigation
Shower
Non-selective
Pain (wet to dry)
Labour - compresses
Autolytic (natural)
Moisture (gel)
Natural, selective
Slow 16

17. MDT 4 days 17

18. What type of debridement?
92yo anesthetic risk
Trauma scooter accident
Inner thigh 18

19. Differentiation: drainage or allergy?
Contact Dermatitis
pattern
Sensitivity
Localized to wound and product
Drainage
Direction of pooling

20. Blister: drain if risk expansion20

21. Edge: Undermined, rolled edge
Packing – think ‘wicking’.

22. Dressing: think ‘Band Aid’ ‘protect, absorb, hold layers’
Function
Product
Cost
Protection
Surface protection
Silicon (7 days) severe pain or fragile
Mepitel $ ”x7”
Inadine (antimicrobial+)
Inadine $2.30 4”x4”
Jelonet (petrolatum mesh)
10cmx40cm $3.50
Tin 10 cm x 7M $36.00
Adaptic non-adherent
$3.75 3”x8” 3pkg
Absorb
Alginates – lowest absorb., sticks if insufficient exudate
Hydrocolloid
Minimal exudate containment and hold
Do not recommend
There are no standards for stating performance of dressings (i.e. absorption). Standard for approval ONLY safety not efficacy.

23. Function
Product
Cost
Foam
Rated high exudate but generally <5ml 4”x4”
protection layer
built into dressing
Fragile skin
Adhesive border strength varies and can damage skin, change when drainage at border
Mepilex 3”x3” $3.75
Allevyn Gentle 3x3 $3.95
Tegaderm 3.5”x3.5” $4.59
**do not recommend unless dressing one week
Acrylic
poor expensive
Do not recommend
Absorbent Dressing
Classic Pads- incontinent pad 17x20cm can hold 750ml (stay dry)
10x20cm 3 $1.95
Ultra 17x40cm 2 $3.00
Classic super 50 $33.00
Gauze – chronic wound or > 48 hours Clean not Sterile
poor absorption
Adequate cover dry gangrene
2x2” 200 $1.95
4x4” 200 $6.50
Non-sterile clean package
Cast padding
Holds dressings padding
Protouch 17 rolls $17.59
Single roll $1.50

24. Function
Product
Cost
Tape – peal factor is tension to remove, adhesive is ability to hold
Fragile skin may strip or tear.
*consider skin strength
**how many dressings
***how frequent
Order of peal factor
Transpore (3M) +++
Kind Removal (3M) ++
Mepitac silicon +
Transpore $1.65 roll
Kind Removal silicon roll $6.95
Mepitac silicon $11.50
Stockinet - TubiFast
Roll or meter*
Blue normal limb adult
Yellow larger
Blue 10M $16.95*
Yellow 10M $10M $23.75
Tubigrip elastic
Size determines pressure – straight may constrict limb
Skin barriers
If you need these the products are not appropriate
Steroids
Good for immediate skin reactions i.e venous excema