WOUND MANAGEMENT

 

WOUND MANAGEMENT

1. Definition of Wound

A wound is a break in the continuity of the skin, mucous membranes, or tissue resulting from physical, chemical, thermal, or microbial damage. It may range from minor injuries to major trauma.

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2. Types of Wound

Based on Cause:

• Incised wound: Clean cut from a sharp object (e.g., knife).
• Lacerated wound: Torn, jagged injury due to blunt force.
• Abrasion: Surface scrape or rubbing off the skin.
• Contusion: Bruise caused by blunt trauma.
• Puncture: Deep wound caused by pointed object (e.g., nail).
• Penetrating wound: Object enters and lodges in body (e.g., stab).
• Gunshot wound: Caused by bullet/projectile.

Based on Skin Integrity:

• Open wound: Skin is broken, exposing tissue (e.g., cut, ulcer).
• Closed wound: Skin remains intact; underlying tissues damaged (e.g., contusion).

Based on Healing Time:

• Acute wound: Heals within expected time (e.g., surgical incision).
• Chronic wound: Prolonged healing (e.g., pressure ulcer, diabetic foot).

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3. Complications of Wounds

• Infection
• Delayed healing
• Wound dehiscence (wound reopening)
• Hemorrhage
• Scarring and keloids
• Necrosis
• Tetanus (in contaminated wounds)
• Sepsis

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4. Factors Affecting Wound Healing

Local Factors:

• Infection
• Oxygenation
• Moisture balance
• Presence of foreign bodies
• Pressure/friction on the wound site

Systemic Factors:

• Age
• Nutrition (protein, vitamins like C, zinc)
• Chronic illnesses (e.g., diabetes, cancer)
• Medications (e.g., steroids, chemotherapy)
• Smoking and alcohol
• Obesity
• Immune status

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5. List of various Wound Framework:

🔹i). T.I.M.E Framework

A foundational and globally recognized model for wound bed preparation.

• T – Tissue (viable vs. non-viable)
• I – Inflammation/Infection
• M – Moisture balance
• E – Edge of wound (non-advancing or undermined)

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🔹 ii). MEASURE Framework

Focuses on quantitative and qualitative wound characteristics.

• M – Measure (length, width, depth)
• E – Exudate (amount, type)
• A – Appearance (tissue type)
• S – Suffering (pain)
• U – Undermining
• R – Re-evaluate
• E – Edge (condition)

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🔹 iii). HEIDIE Framework

Used for structured clinical documentation and wound photography.

• H – History
• E – Examination
• I – Inspection
• D – Description
• I – Intervention
• E – Evaluation

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🔹 iv). NERDS and STONES (for Infection and Biofilm)

Used to distinguish superficial critical colonization and deep/surrounding infection:

• NERDS (superficial/local infection):
  • N – Non-healing
  • E – Exudative wound
  • R – Red and bleeding granulation tissue
  • D – Debris (yellow/black necrotic tissue)
  • S – Smell
• STONES (deep infection):
  • S – Size increasing
  • T – Temperature elevated
  • O – Os (bone exposed or probe to bone)
  • N – New or satellite wounds
  • E – Erythema, edema
  • S – Smell

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🔹 v). Wound ABCDE Framework

A general patient and wound safety checklist.

• A – Assess the patient
• B – Barriers to healing
• C – Clinical signs of infection
• D – Dressing selection
• E – Evaluate outcomes

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🔹 vi). DIMES Framework

An enhancement of the TIME model, adding Supportive products.

• D – Debridement
• I – Infection/Inflammation
• M – Moisture balance
• E – Edge advancement
• S – Support products and services

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🔹 vii). PQRST Pain Assessment (for wound-related pain)

• P – Provokes (what causes or relieves the pain)
• Q – Quality (sharp, dull, burning, etc.)
• R – Radiates (location and spread)
• S – Severity (0–10 scale)    
• T – Time (when it occurs and duration)

 

6. Wound Assessment Frameworks Comparison Chart:

Framework	Focus Area	Best Used For	Strengths	Clinical Setting
T.I.M.E	Wound bed preparation	Most chronic wounds, especially pressure ulcers	Easy to remember, focuses on wound bed	Hospital, wound care clinics
MEASURE	Detailed wound assessment	Ongoing documentation, tracking healing progress	Quantitative + qualitative; good for comparison	Long-term care, research studies
HEIDIE	Full wound documentation	Comprehensive assessment with photos	Good for digital records & audit trail	Outpatient clinics, telehealth
NERDS/STONES	Infection & biofilm identification	Differentiating superficial vs. deep infection	Simple criteria for clinical decision-making	Acute care, diabetic foot ulcers
ABCDE	Holistic wound & patient care	Initial wound care planning	Integrates patient safety & wound factors	ER, primary assessment
DIMES	Advanced wound bed prep	Wounds requiring support products or adjuvants	Expands on TIME with extra care options	Complex wounds, surgical wounds
PQRST	Wound-related pain	Pain assessment for dressing change or chronic pain	Excellent for patient-reported outcomes	Any setting, especially pain-sensitive wounds

 

7. WHEN TO USE THE FRAMEWORK:

Scenario	Recommended Framework(s)	Why?
Initial wound assessment	ABCDE, HEIDIE	Broad coverage of wound and patient
Infection suspected	NERDS/STONES	Helps guide antimicrobial decisions
Daily/weekly wound monitoring	MEASURE, T.I.M.E	Tracks healing consistently
Complex or non-healing wounds	DIMES	Adds advanced product/intervention layer
Pain evaluation	PQRST	Focused pain assessment
Clinical photography/documentation	HEIDIE	Structured record and image pairing

 

8. Wound Debridement and Its Types

Wound debridement is the removal of dead (necrotic), infected, or damaged tissue to promote healing.

Types:

1. Surgical (sharp) debridement: Using scalpel or scissors; quick and effective.
2. Mechanical debridement: Using wet-to-dry dressings or irrigation.
3. Autolytic debridement: Body’s own enzymes break down tissue; supported by moisture-retentive dressings.
4. Enzymatic debridement: Application of chemical enzymes.
5. Biological debridement: Use of sterile maggots to consume necrotic tissue.

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9. Types of Dressings

• Gauze: Basic dressing; used for cleaning and packing wounds.
• Hydrocolloid: Gel-forming; used in low-exudate wounds.
• Hydrogel: Moisture-donating; used for dry wounds.
• Alginate: Derived from seaweed; used in heavily exuding wounds.
• Foam: Absorbent and cushioning.
• Transparent film: Semipermeable; used for superficial wounds.
• Antimicrobial dressings: Contain silver or iodine; used for infected wounds.
• Collagen dressings: Promote healing in chronic wounds.

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10. Dressing for Types of Wound

Wound Type	Recommended Dressing
Surgical wound	Sterile gauze, hydrocolloid
Pressure ulcer (stage 1-2)	Transparent film, foam
Pressure ulcer (stage 3-4)	Alginate, hydrogel, antimicrobial
Diabetic foot ulcer	Collagen, foam, antimicrobial
Burn wound (superficial)	Hydrogel, non-adherent dressing
Infected wound	Antimicrobial dressing, alginate
Dry necrotic wound	Hydrogel (for autolytic debridement)
Exudative wound	Foam, alginate

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11. Nursing Management of Wounds:

Assessment:

• Monitor size, depth, drainage, odor, signs of infection
• Assess surrounding skin
• Evaluate patient’s pain and overall condition

Intervention:

• Maintain aseptic technique
• Regularly clean and dress wound
• Manage drainage with appropriate dressings
• Provide nutritional support
• Administer prescribed antibiotics if infected
• Educate patient on wound care and hygiene
• Positioning to reduce pressure (in pressure ulcers)
• Monitor healing progress and document

Patient Education:

• Importance of hygiene
• Signs of infection
• Wound care at home
• Nutrition and hydration
• When to seek medical help

 

 

 

 

 

 

 

 

 

 

 

COMMON WOUND ASSESSMENT SCALES:

 

Scale	Purpose	Components Assessed	Scoring System	Best Used For
PUSH Tool (Pressure Ulcer Scale for Healing)	Tracks healing of pressure ulcers	Wound size, exudate amount, tissue type	0–17 (lower score = better healing)	Pressure ulcers (Stage II and above)
BWAT (Bates-Jensen Wound Assessment Tool)	Comprehensive wound status	13–15 parameters (size, edges, exudate, skin color, etc.)	13–65 (lower = better healing)	All wound types, especially in research/clinical audits
DESIGN-R	Monitors chronic wound healing	Depth, Exudate, Size, Inflammation, Granulation, Necrotic tissue, Pocket, Re-epithelialization	Score 0–66 (lower = better)	Japan, widely used in long-term care
TIME Framework	Clinical guide for wound management	Tissue, Infection/inflammation, Moisture, Edge of wound	Not scored; descriptive	Universal assessment and treatment planning
Wagner Ulcer Classification	Grading foot ulcers in diabetics	Depth of wound, presence of gangrene/infection	Grade 0–5	Diabetic foot ulcers
NPUAP/EPUAP Staging	Pressure injury classification	Depth and tissue involvement	Stage 1–4, Unstageable, Deep Tissue Injury	Pressure ulcers

 

COMPARISION SUMMARY:

 

Criteria	PUSH	BWAT	DESIGN-R	TIME	Wagner	NPUAP/EPUAP
Score-based	✔️	✔️	✔️	❌	✔️	❌
Quantifies healing	✔️	✔️	✔️	Partial	❌	❌
Clinical use ease	High	Moderate	Moderate	High	Moderate	High
Used for all wounds	❌ (PU only)	✔️	✔️	✔️	❌ (Diabetic only)	❌ (PU only)
Best for planning	❌	✔️	✔️	✔️	❌	❌
Visual-based	❌	✔️	❌	✔️	❌	✔️

 

 

Notes:

• PUSH is ideal for quick, routine pressure ulcer monitoring.
• BWAT is more detailed and suited for clinical documentation and research.
• TIME is not scored but highly useful in making treatment decisions.
• Wagner and NPUAP are classification systems, not healing trackers.

 

 

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