Accurate and effective wound care is vital for ensuring a wound heals in a healthy and timely manner. Wounds that are not properly managed may become chronic wounds which do not heal properly and may cause prolonged pain for the patient. Understanding how to correctly assess, clean and dress a wound can help improve outcomes for the patient.
The wound care checklist below covers the 4 main stages of wound management:
- Assessing the wound
- Cleaning the wound
- Dressing the wound
- Preparing for patient discharge
Assessing the wound
A wound assessment is important for determining what type of wound it is and what the best treatment is to ensure a safe and timely recovery.
During a wound assessment, you should identify:
- Wound type
Wounds are usually classified as acute or chronic. An acute wound is a wound that is expected to heal according to the normal stages of healing.
A chronic wound is a wound that does not heal in the normal pattern or doesn’t respond to treatment. Chronic wounds become stuck in the inflammatory phase. This may be due to a wide range of reasons such as infection, persistent bleeding, ulcers, smoking, poor nutrition or existing medical conditions.
- Cause of the wound
Wounds should be classified according to the specific cause. For example, a wound may be classified as surgical, ulcer, burn, pressure injury or laceration.
- Amount of tissue loss
In superficial wounds, only the top layer of skin (epidermis) is affected. For partial wounds, both the epidermis and the underlying dermis is affected. Full thickness wounds affect the epidermis, dermis and underlying tissue. They may even affect muscles, tendons and bone.
- Size of the wound
Three dimensions of the wound should be measured. If the wound is not even in shape, the circumference can be measured instead of the length and width. The depth of the wound should be measured also.
- Stage of healing and state of wound bed and wound edges
The colour of the wound edges should be examined to see if new tissue is forming. Also check if the wound edges are curled up or under as this may inhibit the healing process.
When checking the condition of the wound bed, look for pink/red tissue to indicate healthy blood supply to the wound. Slight yellowing of the wound bed may indicate the gathering of dead cells. If the wound is hard, dry and black, it may be the collection of dead connective tissue.
- Presence of pus or other fluids
All wounds produce fluids as part of the healing process. When assessing a wound, you should look at the amount, colour and consistency of the fluid.
- Presence of infection
The wound should be inspected for signs of infection including redness, excess fluid, odours, pain and heat. Infection in a wound will need to be managed effectively.
- Pain levels of patient
The patient’s pain levels should be monitored throughout the wound management process. The amount and the way pain levels change can help you monitor the progression of healing and spot abnormalities in the healing process.
Cleaning the wound
Cleaning the wound is crucial for removing any contaminants that may affect the healing process. Any debris in the wound should be removed, as well as any materials from old dressings.
During the cleansing process:
- Do not touch the wound unless necessary
- Use sterile gloves (such as Nitrile gloves) if the wound must be touched
- Have minimal impact on the wound as new tissue can be fragile
- Use sterile isotonic saline or water to clean wounds
- A syringe may help loosen debris inside the wound
Dressing the wound
Dressing a wound appropriately is essential to promote healing. The correct dressing for the wound should be chosen based on the assessment carried out. The most appropriate type of dressing for a wound may change throughout the healing process and so the wound should be reassessed frequently.
Wound dressings should help provide an environment that is clean and moist, but not wet. The dressing should protect the wound from heat loss and bacterial growth.
Below we look at some of the common wound dressings and which types of wounds they are appropriate for. These types of dressings can be purchased from a retailer who sells wholesale medical supplies or first aid kit refills.
Film dressings are usually made from a transparent material such as polyurethane which is flexible and waterproof. Film dressings are suitable for superficial acute wounds. They should not be used on infected wounds or wounds that need to stay more moist.
Non-adherent dressings are designed to not stick to the wound and cause minimal pain when removed. They are often used for cuts, grazes and minor burns.
Foam dressings are absorbent dressings that absorb wound fluids and help prevent heat loss. Foam dressings may be used in conjunction with other types of dressings if higher absorbency is required. They are ideal for wounds such as pressure injuries, leg ulcers, burns and skin tears. They should not be used on dry wounds.
Island dressings are made of an absorbent pad and an adhesive backing. They are most commonly used to dress surgical incisions after an operation.
Made of a woven or non-woven material, gauze dressings are low cost and have a wide range of applications. They can be used on infected wounds, wounds that are draining and wounds that need packing. Gauze dressings must be changed often and so are suitable for wounds which require frequent redressing.
Planning for patient discharge
Before patients are sent home, they should be well educated and prepared to care for their wound. They should be equipped with the right types of dressings for the type of wound and stage of healing. For complex cases, patients may need to come in for scheduled assessments to ensure the wound continues to heal properly.