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Wound Care and Cleaning Year 4 Study Guide

Clinical Skills Teaching & Learning Centre Written by: Clinical Skills Lecturing Team

Reviewed by:

April 2020

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Contents Glossary ....................................................................................................................................... 4

Learning Objectives ..................................................................................................................... 5

Introduction .................................................................................................................................. 6

Surface Anatomy / Relevant Physiology ...................................................................................... 7

Epidermis: ................................................................................................................................. 7

Dermis: ..................................................................................................................................... 7

Hypodermis (subcutaneous tissue): .......................................................................................... 7

Methods of Wound Healing .......................................................................................................... 8

Primary intention ....................................................................................................................... 8

Secondary intention .................................................................................................................. 8

Tertiary intention ....................................................................................................................... 8

Phases of Wound Healing ............................................................................................................ 9

Factors affecting wound healing ................................................................................................ 10

Local Factors .......................................................................................................................... 10

Systemic Factors .................................................................................................................... 11

Types of Wounds ....................................................................................................................... 13

Burns and scalds .................................................................................................................... 19

Diabetic foot ulcers ................................................................................................................. 19

Leg ulcers .............................................................................................................................. 20

Pressure ulcers ....................................................................................................................... 20

Wound Assessment ................................................................................................................... 22

Preparation ................................................................................................................................ 23

Patient safety .......................................................................................................................... 23

Equipment .................................................................................................................................. 24

Principles of Wound Cleansing .................................................................................................. 24

.................................................................................................. Error! Bookmark not defined.

Cleaning a linear wound ......................................................................................................... 25

Cleaning a circular/ puncture wound (figure 32 A&B) ............................................................. 26

Procedure .................................................................................................................................. 27

Documentation ........................................................................................................................... 28

Post Procedure .......................................................................................................................... 29

Appendix A13 ........................................................................................................................... 30

Appendix B14 ........................................................................................................................... 31

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Appendix C ............................................................................................................................. 32

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Glossary

Debridement is the removal of devitalised or contaminated tissue from a wound

until healthy tissue is exposed.

Epithelialisation defined as a process of covering denuded epithelial surface and is

characterised by replication and migration of epithelial cells across

the skin edges in response to growth factors.

Escar is dead crusty tissue that falls from healthy skin as it develops on the

wound. The eschar can be tan, brown or black in colour making it

difficult for the wound to be classified and treated.

Granulation wound granulation is a new connective tissue that forms during the

wound healing.

Hypergranulating this is observed when granulation tissue grows above the wound

margin. This occurs when the proliferative phase of healing is

prolonged usually as a result of bacterial imbalance or irritant forces.

Maceration when tissue that has been moist for a prolonged period and

undergone deterioration. It may occur to the surrounding skin of a

wound if a dressing with a low absorptive capacity is used on a

heavily exuding wound.

Slough is devitalised tissue formed when dead cells and/ or bacteria

accumulate in the wounds. It is yellow/white in colour due to the high

number of leucocytes present in the wound and can be dry or moist

in consistency.

Stratum basale is the deepest layer of the epidermis.

Stratum corneum this is the most superficial layer of skin

Stratum granulosum this is the most superficial layer of the epidermis whose cells still

possess nuclei. It is composed of three to five layers of flattened

keratocytes

Stratum lucidum this is a clear, homogeneous, lightly staining, thin layer of cells

immediately superficial to the stratum granulosum. It is only present

in thick skin i.e. palms of the hands and soles of the feet.

Stratum spinosum this is the thickest layer of the epidermis. It contains several layers of

mitotically active polymorphous cells whose numerous processes

give this layer a prickly appearance

Wound is defined as “break in an epithelial surface that may be surgical or

accidental”1.

Wound contraction is the process in which the surrounding skin is pulled

circumferentially toward an open wound.

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Learning Objectives

Year 4 To understand the basic principles of wound cleaning.

To understand the principles of ANTT (Aseptic non touch technique).

To be able to apply a basic adhesive dressing and within Trust guidelines.

To be able to carry out basic wound closure safely following ANTT principles

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Introduction

The overall aim of this study guide is provide an overview of wound care principles guided by

evidence based practice and ANTT principles.

Prior to addressing any wound it is essential to start with an overall assessment of the patient.

There are a couple of tools that can be identified to assist you with this assessment, for

example HEIDIE1, an acronym used to guide this process. This will be more useful in more

complex and chronic wounds.

Aseptic Non Touch Technique (ANTT) principles must be adhered to when cleaning and

dressing a wound to avoid contamination and minimise infection. This include:

• Key parts and key sites should be protected to prevent contamination of the wound.

• Working surfaces and areas should be cleaned and disinfected in accordance to local

policies.

• Thorough handwashing using the modified Ayliffe technique

• Use appropriate personal protective equipment (gloves, apron, etc.)

• Select appropriate equipment to maintain asepsis (e.g. sterile dressing pack) and ensure

that all packaging is intact and in date.

• Adhere to non-touch technique throughout the procedure.

• Post procedure, relevant equipment must be decontaminated (e.g. trolley) including hand

hygiene.

H History: the patient's medical, surgical, pharmacological and social

history

E Examination: general and focused (specific to the wound)

I Investigations: relevant blood results, radiological images to inform

your diagnosis and management plan

D Diagnosis: aetiology and pathology

I Implementation of the plan of care.

E Evaluation: monitor, assess progress and adjust management plan,

refer on or seek advice from a specialist practitioner and other senior

colleagues

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Surface Anatomy / Relevant Physiology

Figure 1 – Layers of the Skin

The skin is the largest organ of the body and it has a surface area of more than 2 square meters

and accounts for 6 to 8 lb (2.5 to 3.5 kg) of body weight 2. It has an extensive network of small

blood vessels for perfusion and nutrition.

It consists of three layers:

Epidermis: Outermost layer, which consists of five distinct sublayers (stratum basale, stratum

spinosum, stratum granulosum, stratum lucidum and stratum corneum) and is formed mainly by

keratinocytes (cells that are continuously generated and migrate from the underlying dermis);

serves as protective layer against water loss and physical damage

Dermis: Composed of collagen fibers (provide skin strength), elastin (provides elasticity), and

extracellular matrix (provides strength and pliability)

Hypodermis (subcutaneous tissue): Contains major blood vessels, lymph vessels, and

nerves.

Any break in the skin will result in a wound.

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Wound Classification

• Acute wound – is traumatic or surgical and moves throughgout the stages of healing

process predictable time frame3.

• Chronic wound does not progress through the normal stages of healing and is not

resolved over an expected period regardless of the cause 4.

Methods of Wound Healing5 Wound healing is the process whereby tissue damage is restored to its normal function. This

can occur in primary, secondary and tertiary intention.

Primary intention involves the union of the edges of a wound under aseptic conditions, for

example, a laceration or an incision that is closed with sutures or a skin adhesive.

Secondary intention occurs when a wound’s edges cannot be brought together. The wound

is therefore left open to allow healing to occur by contraction and epithelialisation. Wounds that

require secondary intention include surgical or traumatic wounds where a large amount of tissue

has been lost, heavily infected wounds, chronic wounds, and certain instances where a better

cosmetic or functional result will be achieved.

Tertiary intention, also referred to as delayed primary closure, occurs when a wound is left

open and is then closed primarily after a few days’ delay. This is usually once swelling or an

infection or bleeding has decreased.

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Phases of Wound Healing 5

A normal wound healing process follows a certain predictable pattern that can be divided into overlapping phases as outlined below.

Haemostasis and Inflammatory phase (days 1–6)

• This phase represents the tissue’s attempt to limit any damage

• There is immediate vasoconstriction and coagulation

• Increased vascular permeability mediated by histamine, nitric oxide and serotonin

• Co-ordination of the inflammatory and growth factor response by neutrophils (1–2 days)

• Macrophages are activated by fibrin, foreign body material, and exposure to hypoxic and

acidotic environment (2–4 days). Essential for progression to the proliferative phase

• Lymphocytes are also activated by the inflammatory response within the cells. They are less

numerous than macrophages and peak at 5–7 days post injury

Proliferative phase (days 3–21)

• Fibroblast and endothelial cells are the last cell populations to infiltrate the wound

• Capillary ingrowth (granulation tissue)

• Collagen synthesis with rapid gain in tensile strength

• Wound contraction

Remodelling or maturation phase (weeks 3–52 +)

• Scar formation is the ultimate of wound repair and it could take months to years to form a

mature scar through remodelling

• Gradual gain in tensile strength to 80% of normal

This diagram (figure 2) provides an illustration of the phases of wound healing.

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Figure 2 – Stages of wound healing

Factors affecting wound healing 5,6,7 The process of wound healing is not straightforward and often its rate and success is influenced

by a variety of factors categorised as local and systemic.

Local Factors • Oxygenation

Oxygen is essential as part of the wound healing process. It is involved in the wound

healing stages that are required for restoration of tissue function and integrity. Often in

chronic wounds, tissue hypoxia delays the healing process.

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• Infection

This is one of the most common causes delaying wound healing. The presence of

excess bacteria within the wound bed leads to prolonged inflammatory phase thus

interfering with epithelialisation, contraction and collagen deposition.

• Contamination

Poor aseptic technique when accessing and cleaning the wound could lead to

contamination and infection resulting in delayed wound healing.

• Foreign bodies such as fragments of clothing or unsuitable dressings, splinters, a piece

of glass could later cause wound infection. Adequate history will help identify possible

presence of foreign bodies depending on the nature of injury. Glass can be identified on

an x-ray but not wood.

• Venous insufficiency occurs when valves in leg veins fail and are not effectively returning

blood back towards the heart resulting in venous hypertension. This will often cause pain,

swelling. Oedema, skin changes and ulcerations. Affected tissues become poorly

nourished and fragile leading to very slow healing to existing wounds.

• Unsuitable dressings

If used, dressings that are not suitable for a particular wound could create unfavourable

conditions for wound healing. For instance if the wound has a lot of exudate, but the

dressing does not control this, there is a risk to the surrounding skin to be too wet

increasing the risk of developing maceration and infection.

• Interference by patient

If possible adequate education is needed for the patient to ensure that they do not

unnecessarily expose the wound or dressing which could lead to wound contamination

and infection.

Systemic Factors • Age

Age affects how the entire body functions and responds to internal processes; including

the structure and function of the skin, thus leading to delay in wound healing. As the body

cellular functioning and metabolism slows down with aging, so do the inflammatory

responses essential for wound healing. There is also an increased incidence of chronic

disease with aging such as, cardiovascular and metabolic diseases, malnutrition, and

vitamin deficiencies all contributing to delay in wound healing.

• Malnutrition – hypoproteinaemia, deficiencies especially vitamin C and zinc.

Lack of adequate nutrition to the body causes delay in wound healing due to lacking in

necessary nutrients to facilitate cell repair and growth.

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• Immunosuppression due to:

o Diseases (e.g. AIDS)

o Drugs (e.g. chemotherapy, corticosteroids, NSAIDs)

• Social factors

o Alcohol

o Smoking

o IV drug abuse

o General neglect

• Stress

Stress causes generalised physiologic responses that could delay wound healing.

• Chronic disorders such as:

o Metabolic disease – renal failure, hepatic failure

o Endocrine disease – uncontrolled diabetes mellitus can lead to reduced

inflammation, angiogenesis and collagen synthesis. It also results in large and

small vessel disease contributing to local hypoxaemia.

o Autoimmune disorders – rheumatoid arthritis, systemic lupus erythematosus

(SLE),

o Collagen disorders – e.g. Marfan, Ehlers Danlos, Osteoporosis

o Carcinomatosis / cachexia

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Types of Wounds 3,8 Management of wounds will vary according to Trust policy and local guidelines however in this

section, standard wound management approaches are discussed.

Necrotic Wound

Description: Black/brown tissue; hard eschar (Figure

3)

Management: Encourage a clean wound bed by

debriding the escar. Rehydrate

Primary dressing: Hydrogel e.g. Aquaform or

Intrasite gel; Honey-based dressing (figure 4)

Secondary dressing: Non adherent; padding or

bandage (figure 4).

Debridement - is the removal of devitalised or contaminated tissue from a wound until healthy

tissue is exposed. It therefore promotes wound healing.

Figure 4 - Primary and secondary dressings for a necrotic wound

Figure 3 - Necrotic wound

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Sloughy wound

Description: Green/ yellow pus dying tissue +/-

infection.

Management: Debride, treat and prevent local wound

infection. Reduce malodour and absorb excess

exudate.

Primary dressing: Alginate or Bordered Hydrofibre

dressing e.g. Sorbsan, Aquacel, Allevyn (figure 6)

Secondary dressing: Bordered Hydrofibre, highly

absorbent wound dressing, padding or bandaging

(figure 7)

Figure 5 - Sloughy wound

Figure 6 - Primary dressings for a sloughy wound

Figure 7- Secondary dressings for a sloughy wound

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Granulating Wound

Description: Wound is moist, red or dark pink in

appearance

Management: The aim is to – protect the wound, absorb

excess exudate, prevent trauma to granulation tissue and

maintain a moist environment.

Primary dressing: Hydrocolloid foam e.g. Duoderm,

Hydrofibre or bordered hydrofibre, highly absorbent

dressings, and alginates (figure 9)

Secondary dressing: same as above, but including padding

and bandages (figure 10)

Figure 8 - Granulating wound

Figure 9 - Primary dressings for a granulating wound

Figure 10 - Secondary dressings for a granulating wound

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Epithelialising wound

Description: Cells are migrating and wound is getting

smaller and is healing

Management: the aim is to - protect newly formed

tissue; maintain wound temperature with infrequent

dressing changes; maintain a moist environment and

prevent pain

Primary dressing: Thin hydrocolloid semi-permeable

film e.g. Duoderm

Secondary dressing: not necessary unless if non

bordered dressing has been used. Foam, padding and

bandaging

These type of dressings are recommended to remain

in situ up to 7 days dependent on exudate levels. The

dressings should only be changed when clinically indicated, usually when exudate reaches 1 to

2 cms from the edge of the pad, which is clearly visible on the outer layer.

Figure 11 - Epithelialising wound

Figure 12 - Primary dressings for an epithelialising wound

Figure 13 - Secondary dressings for an epithelialising wound

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Hypergranulating wound (Hypergranulation)

Description: also referred to as overgranulation,

this is an excess of granulation tissue beyond the

amount required to replace the tissue deficit

incurred as a result of skin injury or wounding

(Tortora & Grabowski, 2000)

Management: the aim is to – encourage

subsistence of hypergranulation tissue; if possible

the cause should be eliminated; allow

epithelialisation

Primary and Secondary dressings are outlined in

figures 16 & 17 below.

Figure 14 - Hypergranulation

Figure 15 - Primary dressings for a hypergranulating wound

Figure 16 - Secondary dressings for a hypergranulation wound

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Infected wound

Description: Wound has odour, pus and

exudate, inflammation and pain.

Management: the aim to treat local infection

and make sure extra exudate is managed

Primary dressing: Antimicrobial dressings

such as Iodine/ silver/ alginate/ honey-based

dressing e.g. Aquacel AG

Secondary dressing: Foam sheet, bordered

dressing, bordered hydrofibre. Padding and

bandaging as required

Figure 17 - Infected wound

Figure 18 - Primary dressing for an infected wound

Figure 19 - Secondary dressings for an infected wound

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Other types of wounds that are likely to have delayed healing due to large amounts of tissue

loss and underlying chronic diseases. These include:

Burns and scalds

Effective and timely first aid and initial management are key in ensuring that long-term effects are minimised when managing burns9. When assessing a burn wound a Lund and Browder's assessment chart (figure 21) is used to assess the position, depth and area affected. The wound should be dressed with non-adherent dressing. NICE guidelines10, the National Standards for Provision and Outcomes in Adult and Paediatric Burn Care11, and local protocols must be adhered to when managing and treating burns.

Diabetic foot ulcers

The cause of the ulceration should be assessed such as diabetic

neuropathy, ischaemia or neuroischaemia12. The main aim here it to ensure

good control of blood sugars, relieve pressure from ulcerated areas and

dress wounds with absorbent non-adherent dressings such as foams or

alginate dressings. Local guidelines and protocols must be followed in the

management of diabetic foot ulcer.

Figure 20 - Burns

Figure 21 - The rule of nines and Lund-Bowder charts

Figure 22 - Diabetic foot ulcer

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Leg ulcers13 Assessment of leg ulcers includes using a Doppler ultrasound to establish the cause of the ulceration (venous or arterial) and the calculation of the ankle brachial pressure index (ABPI) by a trained and proficient practitioner. Venous ulcers often benefit from multilayer compression bandaging, with a non-adherent dressing as a primary layer.

Pressure ulcers A pressure ulcer is “localised damage to the skin and/or underlying tissue, usually over a bony prominence (or related to a medical or other device), resulting from sustained pressure (including pressure associated with shear). The damage can be present as intact skin or an open ulcer and may be painful”14. The NHS Improvement (NHSI) and the European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance (EPUAP/ NPIAP/PPPIA) 15 have set out comprehensive guidance on management on prevention and management of pressure ulcers. Pressure ulcers (PU) are classifies as follows:

Classification Definition Image

Stage I pressure ulcer

Non-blanchable erythema

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Difficult to detect in people with dark skin tones.

Figure 24 - Stage 1 pressure ulcer

Stage II pressure ulcer Partial thickness skin loss

Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister.

Figure 25 - Stage 2 pressure ulcer

Figure 23 – Venous leg ulcer

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Classification Definition Image

Stage III pressure ulcer Full thickness skin loss

Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss.

Figure 26 - Stage 3 pressure ulcer

Stage IV pressure ulcer Full thickness tissue loss

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.

Figure 27 - Stage 4 pressure ulcer

The best management for pressure ulcers is always prevention by identifying patients that are most at risk using a recognised scale (Waterlow or Braden Scale). For treatment, a systematic assessment should be completed and categorise the PU according to the table above. Referral to tissue viability services early is also key to help identify and prescribe appropriate dressing.

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Wound Assessment 16, 17 Accurate wound assessment is essential in ensuring appropriate patient and wound management. It is imperative to consider the following key factors as part of the assessment.

• Type of wound – is the wound acute or chronic?

• Aetiology – surgical, laceration, ulcer, burn, abrasion, traumatic, pressure ulcer, or neoplastic

• Location – this should be accurately documented on a body map (appendix C) using correct anatomical terms. A body map provides accurate visualisation of the exact location of the wound especially if a patient has multiple wounds in different locations. It is also useful to use anatomical terms when identifying the location for example using ‘right greater trochanter’ rather than right hip; and using standard clinical terms such as distal and proximal enhances clarity.

• Surrounding skin – this should be carefully examined to ensure that it is protected from deterioration and further injury.

• Tissue loss can be classified as: o Superficial wound – involving the dermis o Partial wound – involving the dermis and the epidermis o Full thickness wound – involving the epidermis, dermis, subcutaneous tissue

and may extend to muscle, bones and tendons.

• Wound bed appearance and stage of healing o Is the wound granulating, epithelialising, sloughy, necrotic, or hyper granulating? It

is also important to note the wound healing phase.

• Measurement and dimensions – ‘wounds require a two dimensional assessment of the wound opening and a three dimensional assessment of a cavity of tracking’16.

• Wound edge should be assessed for: o Colour: pink shows healthy new tissue; dusky indicate tissue hypoxia; and

erythema is evidence of cellulitis o Evidence of contraction: when wound edge start coming together, it indicates that

healing process has commenced. Raised edges are a sign of hyper granulation and rolled edges towards the wound bed can inhibit the healing process

o Altered sensation: if there is increased pain or reduced/absent sensation will require further investigation.

• Exudate – plays an important part in the wound healing process. It helps maintain a moist environment and provides the wound with essential nutrients, energy and growth factors. The wound exudate should be assessed for type, amount, colour, and odour to identify any changes. Excess exudate could cause maceration and degradation of skin and too little lead to the wound bed drying out. It is often viscous and offensive in infected wounds.

• Presence of infection – it can delay the process of wound healing and damage tissues and if left untreated could also lead to systemic infection. The following are a sign of

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infection; localised pain, redness, heat around the wound, oedema, and purulent exudate. A swab for culture and sensitivity may be required for appropriate treatment.

• Pain – healing wounds should not be painful therefore the presence of pain usually indicates inflammation or infection. Accurate assessment of pain is crucial to ensure that appropriate dressing is used. Appropriate analgesia should be prescribed to ensure patient comfort whether they experience pain constantly or during dressing change.

• Previous wound management methods need to be explored to inform current

assessment and management plan.

Preparation

Patient safety Introduce yourself

Check the patient’s identity and allergies

Explain what you want to do

Gain informed consent

Consider an appropriate chaperone

Adequate exposure maintaining dignity

Position the patient appropriately – consider moving and handling

Wear Personal Protective Equipment as you are coming into contact with bodily fluids

Wash your hands before and after you touch the patient (as per WHO guidelines)

Additional checks include:

Assess patient for pain and ensure that analgesia has been administered as required

Allow the patient to ask any questions that they may have and discuss any past problems (e.g.

fainting/ bleeding/ medication history)

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Equipment

Prior to collecting any equipment, it is good practice to see the patient first in order to assess

the wound, to ensure that the relevant dressings are used. Some of the specialised dressings

need a prescription. Tissue viability specialist nurses should be involved when dealing with

complex wounds for advice on the most suitable wound dressing products.

• Dressing trolley

• Dressing pack

• Sterile gloves (if not included in the dressing pack)

• Relevant dressing

• Sodium Chloride 0.9% solution for irrigating the wound

• Documentation (local policy to be followed)

• Hand gel

• Apron

• Non sterile gloves

• Disinfectant wipes

Principles of Wound Cleansing18 The main aim of wound cleansing is provide optimum conditions locally to promote the wound

healing processes. It is important to assess the wound prior to cleansing in order to make an

informed decision. If the wound is clean, with minimal exudate, and showing sign of

granulation, unnecessary repeated cleaning might adversely affect wound healing as new tissue

might be damaged.

The temperature of the wound should not be allowed to fall due to prolonged wound exposure

during the procedure. This might lead to reduced cellular activity and resulting in delay in wound

healing.

Sodium Chloride 0.9% is an ideal solution for wound cleansing as it has similar osmotic

pressure to that already in the cells. It is non-toxic but effective in diluting bacteria. There is now

an increased use of tap water for irrigating chronic wounds as research has showed no

difference in the healing and infection rates between tap water and 0.9% sodium chloride.

However local organisational policies must be followed.

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Irrigation of the wound rather than wiping is seen as less harmful particularly to new tissue.

Especially aggressive cleaning using a gauze swab could potentially damage granulation tissue.

It is also worth knowing that wound cleansing is not recommended at all for certain wounds e.g.

gangrenous wounds. Such wound are recommended to be left dry to promote autolytic

debridement 19, 20. In chronic wounds however cleansing using a gauze is essential as it helps

remove residue i.e. creams/ emollients from previous dressings thus allowing clinicians a good

view of the wound for adequate assessment 18.

Always seek advice from your supervisor when deciding cleansing by wiping or irrigation.

Cleaning a linear wound (fig. 30)

Please note that only wipe the wound directly if required i.e. if

there is slough that requires removing.

Stroke 1 – wipe the area directly over the wound with a single

stroke moving from top to bottom, and then discard the wipe.

Discard the used gauze into the clinical waste bag.

Stroke 2 – on the patient's right side (or left), wipe the area next

to the wound with a single stroke, and then discard the wipe.

Stroke 3 – on the patient's left side (or right), wipe the area next

to the wound with a single stroke and then discard the wipe.

Stroke 4 & 5 – continue according to the diagram following However if the wound is clearly infected

and has purulent discharge the strokes will usually move in the opposite direction (starting from

outside inwards).Starting away from the area of infection and working towards it.

Figure 30 - Linear wound cleaning

Figure 28 - Wound cleaning by wiping Figure 29 - Wound cleaning by irrigation

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Cleaning a circular/ puncture

wound (figure 31 & 32)

Stroke 1 - Starting at the centre of the

wound, swab the area in an outward

circular spiral. Then discard the swab.

Stroke 2 - From the spot where the

first stroke ended, continue swabbing

(wiping) in an outward circular pattern

for about one and one-half revolutions.

Then discard the swab.

Stroke 3 - From the spot where the second stroke ended, continue swabbing (wiping) in an

outward circular pattern for about one and one-half revolutions. Then discard the swab.

Continue cleaning the area, if needed, until the area around the wound has been cleansed.

However if the wound is clearly infected and has purulent discharge the concentric circles will

usually move in the opposite direction (starting from outside inwards).Starting away from the

area of infection and working towards it – so as not to spread the discharge over healthy tissue

(figure 32).

Figure 31 - Circular wound cleaning

Figure 32 - Circular wound cleaning

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Procedure

Figure 33 - Step by step procedure for wound cleaning and dressing

Step by step procedure for wound cleaning and dressing 1. Wash hands 2. Clean the trolley 3. Thoroughly wash

your hands with soap and water

4. Don apron

5. Select and check equipment for expiry and packaging integrity. Place on bottom shelf of clean trolley

6. Open the sterile pack and all relevant equipment without contaminating key parts

7. Use yellow waste bag (or non-sterile gloves) to remove loosened dressing

8. Wash hands

9. Apply sterile gloves

10. Clean wound using non-touch technique

11. Apply relevant dressing

Thank the patient and ensure they are left comfortable

12. Dispose of equipment, waste & then gloves

13. Clean trolley 14. Wash hands

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Documentation Once the procedure has been completed, it is essential to document accurately and clearly,

figure 34 shows an example of paperwork that can be used, this may vary from Trust to Trust.

Figure 34 - Wound care document

Documentation type varies between organisations and it may on paper or electronic, however the following details are essential:

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• Patient details – name, date of birth, hospital number, ward or department

• Date and time of the procedure

• Using a body map appendices 3 will ensure that the position of the wound is accurately

recorded

• Wound dimensions (length X width X depth)

• Wound bed appearance (necrotic, slough, macerated, granulating (red), or epithelializing

(pink))

• Skin around the wound (e.g. intact, dry, oedema)

• Exudate level (none, low, moderate or high). Also comment if ir is increasing or decreasing

in amount.

• Odour

• Factors affecting wound healing

• Bleeding (none, slight, moderate, or heavy). State if this is due to dressing change.

• Pain (using the scoring system)

• If infection suspected, state if swab taken and if treatment has been prescribed.

• Once completed the recording should be signed by both the student and their supervisor.

Post Procedure Clear post procedure care should be documented in the patient’s notes. Instructions of ongoing

care of the wound should be recorded to ensure that the wound is cleaned and dressed

appropriately. Patient education is also key to ensure compliance.

Patients should be informed to:

Keep dressing clean and intact as required (dependent on type of wound and dressing).

Seek medical advice if there are any signs of infection (redness, exudate or heat etc.)

Take analgesia as needed.

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Appendices

Appendix A13

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Appendix B14

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Appendix C Body map

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Bibliography & Further Reading Gartner L. Textbook of Histology. Chapter 14, Integument 5th Edition. Pages 333-354 [Retrieved from: https://www-clinicalkey-com.liverpool.idm.oclc.org/student/content/toc/3-s2.0-C20140021375 Jul 2020] Kirk, R. M. Basic Surgical Techniques E-Book. [ClinicalKey Student]. Retrieved from https://clinicalkeymeded.elsevier.com/#/books/9780702049101/ Grey JE, Enoch s, Harding KG ABC of wound healing - Wound assessment. British Medical Journal Vol 332. 4th February 2006 pp. 285-288 World Health Organisation. WHO guidelines on hand hygiene in health care. 2009 https://www.who.int/infection-prevention/tools/hand-hygiene/en/ https://www.clinicalskills.net Adult Procedures https://www.bing.com/videos/search?q=how+to+clean+a+wound&&view=detail&mid=31E39C5BC2FBA225734B31E39C5BC2FBA225734B&rvsmid=25DF5038C80042D6803B25DF5038C80042D6803B&FORM=VDQVAP

References 1. Hampton S. Wound management 4: Accurate documentation and wound measurement.

Nursing Times; 111: 48, p16-19. 2015. Available from https://www.nursingtimes.net/clinical-archive/tissue-viability/wound-management-4-accurate-documentation-and-wound-measurement-23-11-2015/

2. Gallo R Human skin is the largest epithelial surface for the interaction of microbes. Journal of Investigative Dermatology. Issue 137, p1213-1214. 2017. Available from https://pubmed.ncbi.nlm.nih.gov/28395897/ DOI:10.1016/j.jid.2016.11.045

3. Dougherty, Lisa, et al., editors. The Royal Marsden Manual of Clinical Nursing Procedures. John Wiley & Sons, 2015.

4. Harries RL, Bosanquet DC, and Harding KG. Wound Preparation: TIME for an update. International Wound Journal. 2016. 13 (suppl. S3):8–14. Available from https://pubmed.ncbi.nlm.nih.gov/27547958/ doi: 10.1111/iwj.12662.

5. Kordestani SS. Atlas of wound healing : a tissue regeneration approach [Online]. Elsevier; [cited 2020 Aug 18]. Available from https://search-ebscohost-com.liverpool.idm.oclc.org/login.aspx?direct=true&db=cat00003a&AN=lvp.b5582505&site=eds-live&scope=site

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6048&site=eds-live&scope=site

7. Bishop A. Role of oxygen in wound healing. Journal of Wound Care; 17: 9, 399-402. 2008. DOI: 10.12968/jowc.2008.17.9.30937

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8. Jones J. Choice of dressings directed by wound appearance. 2015. https://www.clinicalskills.net/node/223 [accessed 01.07.2020]

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10. National Institute for Health and Care Excellence (NICE) Burns and Scalds. 2019 Available from https://cks.nice.org.uk/topics/burns-scalds/#!organizationalbarriers

11. British Burn Association: Burn Care Standards and Outcomes. 1st Edition. 2018. Available from https://www.britishburnassociation.org/wp-content/uploads/2018/11/BCSO-2018-FINAL-v28.pdf

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13. Joseph E. Grey, Stuart Enoch, Keith G. Harding. Abc Of Wound Healing: Venous And Arterial Leg Ulcers. BMJ: British Medical Journal [Internet]. 2006 [cited 2020 Aug 18];332(7537):347. Available from: https://search-ebscohost-com.liverpool.idm.oclc.org/login.aspx?direct=true&db=edsjsr&AN=edsjsr.25456108&site=eds-live&scope=site

14. Revised Pressure Ulcer (PU) Definition and Measurement Framework in June 2018 (NHS Improvement, 2018) Available from https://improvement.nhs.uk/resources/pressure-ulcers-revised-definition-and-measurement-framework/

15. European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance (EPUAP/ NPIAP/PPPIA). Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide 2019

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17. Mahoney K. Clinical skills part 1: wound assessment. Journal Community Nursing.34(2): 28–32. 2020 Available from https://www.jcn.co.uk/key-topics/wound-care/

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19. Brown A. When is wound cleansing necessary and what solution should be used? Nursing Times 114(9): 42–5. 2018 Available from https://insights.ovid.com/nursing-times/nrtm/2018/09/000/when-wound-cleansing-necessary-solution-used/55/00006203

20. Lloyd Jones M Wound cleansing: has it become a ritual or is it a necessity? British Journal of Community Nursing. Wound Care Supplement. S22–26. 2012. Available from https://lohmann-rauscher.co.uk/downloads/clinical-evidence/Wound_cleansing_is.pdf

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Picture Credits

Figure 1 The layers of the skin. Talley, Nicholas J, MBBS (Hons)(NSW), MD (NSW), PhD (Syd), MMedSci (Clin Epi)(Newc.), FRACP, FAFPHM, FAHMS, FRCP (Lond. & Edin.), FACP, FACG, AGAF, FAMS, FRCPI (Hon), Talley & O'Connor's Clinical Examination, Chapter 43, 799-825 Copyright © 2018

Figure 2 Stages of wound healing. Adobe photo library. Reproduced with permission

in June 2020 Figure 3 to 19 Various wound types and suggested dressings. Reproduced with

permission from clinicalskills.net https://www.clinicalskills.net/node/ Figure 20 Burn Hand https://i1.wp.com/www.edokita.com/wp-

content/uploads/2018/06/burns-1.png?resize=500%2C400 burn hand Figure 21 The rule of nines and Lund-Bowder charts

http://image1.slideserve.com/2952400/the-rule-of-nines-and-lund-browder-charts-n.jpg

Figure 22 Diabetic foot ulcer. Grey JE, Enoch S, Harding KG ABC of wound healing - Wound assessment. British Medical Journal Vol 332. 4th February page 287

Figure 24-27 Scottish Adaptation of the European Pressure Ulcer Advisory Panel (EPUAP) Pressure Ulcer Classification Tool

Figure 28-32 CSTLC team Figure 33 Images from CSTLC, clinicalskills.net and ANTT©

List of Figures Figure 1 – Layers of the Skin ....................................................................................................... 7

Figure 2 – Stages of wound healing ........................................................................................... 10

Figure 3 - Necrotic wound .......................................................................................................... 13

Figure 4 - Primary and secondary dressings for a necrotic wound ............................................ 13

Figure 5 - Sloughy wound .......................................................................................................... 14

Figure 6 - Primary dressings for a sloughy wound ..................................................................... 14

Figure 7- Secondary dressings for a sloughy wound ................................................................. 14

Figure 8 - Granulating wound ..................................................................................................... 15

Figure 9 - Primary dressings for a granulating wound ................................................................ 15

Figure 10 - Secondary dressings for a granulating wound ......................................................... 15

Figure 11 - Epithelialising wound ............................................................................................... 16

Figure 12 - Primary dressings for an epithelialising wound ........................................................ 16

Figure 13 - Secondary dressings for an epithelialising wound ................................................... 16

Figure 14 - Hypergranulation ..................................................................................................... 17

Figure 15 - Primary dressings for a hypergranulating wound ..................................................... 17

Figure 16 - Secondary dressings for a hypergranulation wound ................................................ 17

Figure 17 - Infected wound ........................................................................................................ 18

Figure 18 - Primary dressing for an infected wound ................................................................... 18

Figure 19 - Secondary dressings for an infected wound ............................................................ 18

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Figure 20 - Burns ....................................................................................................................... 19

Figure 21 - The rule of nines and Lund-Bowder charts .............................................................. 19

Figure 22 - Diabetic foot ulcer .................................................................................................... 19

Figure 23 – Venous leg ulcer ..................................................................................................... 20

Figure 24 - Stage 1 pressure ulcer ............................................................................................. 20

Figure 25 - Stage 2 pressure ulcer ............................................................................................. 20

Figure 26 - Stage 3 pressure ulcer ............................................................................................. 21

Figure 27 - Stage 4 pressure ulcer ............................................................................................. 21

Figure 28 - Wound cleaning by irrigation...................................... Error! Bookmark not defined.

Figure 29 - Wound cleaning by wiping ......................................... Error! Bookmark not defined.

Figure 30 - Linear wound cleaning ............................................................................................. 25

Figure 31 - Circular wound cleaning .......................................................................................... 26

Figure 32 - Circular wound cleaning .......................................................................................... 26

Figure 33 - Step by step procedure for wound cleaning and dressing ....................................... 27

Figure 34 - Wound care document ............................................................................................. 28