PRINCIPLES OF WOUND MANAGEMENT

WOUND ASSESSMENT
Baseline assessments are essential in order to determine the rate of deterioration or healing. Consistency in the data collection process will provide valuable information in the overall plan of care.
ASSESS FOR:	RATIONALE
1. Causative, contributory factors	Underlying cause, eg. pressure, shear, venous insufficiency, diabetes
2. Location	Diagram, photo (if possible) for accuracy
3. Stage of wound injury	Classification system a) red, yellow, black b) pressure ulcer staging
4. Size, depth	Measure length, width, depth, undermining by using Q-tip in a clock-wise manner Count and measure sinus tracts
5. Wound Bed	Colour: pink, yellow, black. Texture: granulation, slough fibre, necrotics as effectively as more expensive barrier creams and is less irritating to most patients.
6. Exudate	Amount, colour, odour, gaseous bubbles
7. Wound Edges	Graded, smooth, punched out
8. Periwound area.	Smooth, dry, macerated, erythematous, edematous, induration, temperature, sensation, crepitus
STAGING OF PRESSURE ULCERS - STAGE I
	non-blanchable erythema intact skin discolouration warmth redness painful "reversible"
Treatment Goals	Treatment Options
A. Remove cause/pressure, shear, friction, moisture B. Protect area from further injury	A. Duoderm CGF extra thin B. Transparent film C. Turn patient q2h
STAGING OF PRESSURE ULCERS - STAGE II
	partial thickness loss epidermis and/or dermis superficial abrasion, blister, shallow crater painful
Treatment Goals	Treatment Options
A. No exudate protect against further injury maintain moist environment	Duoderm C6F extra thin
B. Exudate present absorb exudate prevent maceration autolytic debridement	(for moderate exudate) Duoderm CGF border (for high exudate) Combiderm ACD Aquacel and cover with occlusive dressing: Duoderm CGF border or Combiderm ACD Conventional dosage if leakage within 24 hours Duoderm hydroactive gel and cover with: Duoderm CGS border or Conventional dressing if leakage occurs within 25 hours
STAGING OF PRESSURE ULCERS - STAGE III

Treatment Goals	Treatment Options
Maintain moist environment Fill dead space	Duoderm CGS border Duoderm hydroactive gel - cover with Duoderm CGF border or conventional dressing Aquacel ribbon for exudative cavity
Absorb exudate	Aquacel sheet/ribbon (depending on depth) - cover with Duoderm CGS border, Combiderm ACD or conventional dressing Combiderm ACD may be used along or in conjunction with Aquacel
Observe for signs of infection - erythema, warmth, swelling, odour, purulent exudate and fever	consult MD
STAGING OF PRESSURE ULCERS - STAGE IV
	damage to muscle, bone, tendon not painful infection and osteomyelitis undermining +/- sinus tracts +/-
Treatment Goal	Treatment Options
Maintain moist environment Fill dead space Remove necrotic tissue	Duoderm CGF border Duoderm hydroactive gel - cover with Duoderm CGS border, Combiderm ACD or conventional dressing Combiderm ACD: may be used alone or in conjunction with Aquacel
Observe for signs of infection, erythema, warmth, swelling, odour, purulent exudate and fever	consult MD systemic antibiotics are usually required
STAGING OF PRESSURE ULCERS - STAGE V
	unable to assess due to eschar
Treatment Goal	Treatment Options
Debridement Enzymatic Surgical Autolytic When debridement is complete, begin wound assessment	Consult MD according to MD order Consult MD or appropriate clinician Duoderm Hydroactive Gel - cover with Duoderm CGS border (may be left on for a maximum of 3 days for necrotic or sloughy wounds)
RED, YELLOW, BLACK CODE
Wound Category	Care Goals
Red	Protect
Yellow	Cleanse
Black	Debride

date typed :December 5, 2000

Revised : 
Reviewed : 
LR/pk : wound_mgmt.htm

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PRINCIPLES OF WOUND MANAGEMENT

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Last Updated March 24, 2009 | © 2007, LHSC, London Ontario Canada