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.

---

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).

---

3. Complications of Wounds

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

---

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

---

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)

---

🔹 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)

---

🔹 iii). HEIDIE Framework

Used for structured clinical documentation and wound photography.

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

---

🔹 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

---

🔹 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

---

🔹 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

---

🔹 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.

---

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.

---

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

---

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.

 

 

Converted to HTML with WordToHTML.net

INFLAMMATION

 

Inflammation

Inflammation is a nonspecific cellular response to tissue injury. The body has physiological responses that are designed to eliminate invading organisms and protect against infection.

Inflammation is always present with infection, but infection is not always present with inflammation

The inflammatory response is a physiological process that attacks, confines, and kills invading organisms.

It also allows for tissue repair after damage from an invading organism or from tissue injury and death.

It is the local response of living tissues injury due to injury due to any agencies and that attempts to self-protection to remove harmful stimuli including damage cells, pathogens and being the healing process.

  

Etiology / Causes for inflammation

1.     Infective Agents: Viruses, Bacteria, Fungi etc

2.     Physical Agents: heat cold radiation trauma

3.     Chemical agents: Acid, base, organic solvents, poison

4.     Immunological Agents: Cell mediated and antigen antibody reaction

5.     Inert materials: foreign body.

.

The inflammatory process involves a vascular phase and a cellular phase.

            1. The vascular phase consists of the following processes, which occur almost  simultaneously:

§  Temporary vasoconstriction to avoid blood loss after injury

§  Vasodilation to increase blood supply to the area, leading to redness and increased warmth of the area

§  Increased hydrostatic pressure related to the increase in blood flow

§  Increased permeability of blood vessel walls caused by chemical mediators

§  Leakage of fluid and cells out of capillaries into interstitial spaces so that toxins are diluted. This leakage of fluid and eventually protein leads to increased osmotic pressure in the interstitial spaces and edema.

 

2.   The cellular phase involves the response of white blood cells (WBCs) to the cellular  injury. It begins as chemotactic substances are released from the tissues by cellular injury and complement is activated. Neutrophils are the first WBCs to arrive at the site and are the main phagocytic cell.

The processes involved in the cellular phase are as follows:

§  An increased number of WBCs are attracted to the site of injury by chemotactic factors.

§  WBCs adhere to the vessel wall during a process called margination.

§  WBCs migrate through the vessel wall into the interstitial tissue during a process called diapedesis or emigration.

§  WBCs are attracted to the inflamed site by chemotactic factors.

§  Neutrophils ingest the bacteria and dead cells through a process of coating microorganisms called opsonization.

§  This coating allows the bacteria and dead cells to be easily engulfed and killed by WBCs.

§  Neutrophils then die, releasing proteolytic enzymes that liquefy the dead cells and bacteria, resulting in the formation of pus.

§  Fibrin is secreted by fibroblasts and serves to wall off the area to prevent the spread of bacteria and lay the groundwork for tissue rebuilding

Inflammotory  Mediators:

Clinical Manifestations:

The signs and symptoms related to inflammation can be local and/or systemic depending on the location and severity of the inflammatory response.

There are five cardinal local symptoms of inflammation:

·       Redness (rubor) – hyperaemia from vasodilation,

·       Heat (calor) due to increased metabolism at inflammatory site,

·       Swelling (tumor) due to the fluid exudates that form in the interstitial tissue,

·       Pain (dolor) caused by the pressure of the exudates and release of chemicals that irritate nerve endings, and

·       Loss of function (functio laesa) related to the pain and swelling.

Systemic manifestations of inflammation include an increased WBC count (Leukocytosis) with a shift to the left, malaise, nausea and anorexia, increased pulse and respiratory rate, and fever

Types of Inflammation

The basic types of inflammation are acute, subacute, and chronic.

v  In acute inflammation, the healing occurs in 2 to 3 weeks and usually leaves no residual damage. Neutrophils are the predominant cell type at the site of inflammation.

v  A subacute inflammation has the features of the acute process but lasts longer. For example, infective endocarditis is a acute inflammation, but it persists for weeks or months.

v  Chronic inflammation lasts for weeks, months, or even years. The injurious agent persists or repeatedly injures tissue. The predominant cell types present at the site of inflammation are lymphocytes and macrophages. Examples of chronic inflammation include rheumatoid arthritis and osteomyelitis.

Management:

The best management of inflammation is the prevention of infection, trauma, surgery, and contact with potentially harmful agents.

v  Vital signs are important to note with any inflammation, especially when an infectious process is present.

v  Adequate nutrition is essential so that the body has the necessary factors to promote healing when injury occurs.

v  Sponge baths increase evaporative heat loss, they may not decrease the body temperature.

v  Antipyretics should be given to reduce temperature.

v  Acetaminophen acts on the heat-regulating center in the hypothalamus.

v  Antihistamine drugs may also be used to inhibit the action of histamine.

Drug Therapy:

Drug	Mechanism of Action
Antipyretic Drug:     §  Salicylates(asprin)     §  Acetomenophen     §  NSAID	Inhibit synthesis of PGs
Anti inflammatory  Drug:     §  Salicylates(asprin)     §  Corticosteroids     §  NSAID	Inhibit synthesis of PGs Interfere with tissue granulation   Inhibit synthesis of PGs

RICE. Rest, ice, compression, and elevation (RICE) is a key concept in treating soft tissue injuries and related inflammation.

Rest: Rest helps the body use its nutrients and 0 2 for the healing process.

Cold: Cold application is usually appropriate at the time of the initial trauma to promote vasoconstriction and decrease swelling, pain, and congestion from increased metabolism in the area of inflammation.

Compression and immobilization. Compression counters the vasodilation effects and development of edema. Compression by direct pressure over a laceration occludes blood vessels and stops bleeding.

Immobilization of the inflamed or injured area promotes healing by decreasing the tissues' metabolic needs.

Elevation. Elevating the injured extremity above the level of the heart reduces the edema at the inflammatory site by increasing venous and lymphatic return. Elevation also helps reduce pain associated with blood engorgement at the injury site. Elevation may be contraindicated in patients with significantly reduced arterial circulation.