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Wound Care

Introduction

A wound refers to any breakage on the skin. If it is not treated properly, wound infection may result. Skin aging and some chronic diseases may also affect wound healing. Adequate knowledge of wound management is therefore very important.

Skin structure and function

Skin consists of epidermis, dermis and subcutaneous tissue. It has numerous functions include protection, sensation, regulation of body temperature, secretion, excretion, immunity and production of vitamin D.

Wound healing process

The wound healing process can be divided into inflammatory phase, proliferative phase and remodeling phase. The time taken for healing can be affected by both external and internal factors.

External factors include persistent pressure on the wound (which impairs circulation), repeated injuries, wound infection or improper wound care (e.g. misuse of antiseptics or dressing).

Internal factors include aging, chronic diseases like diabetes, long-term drug therapy, smoking and alcoholism (which impairs nutrient absorption).

All these factors may impair the immune system, making the wound more susceptible to infection which delays wound healing.

Classification and management of wounds

Acute wound: Acute wound refers to accidental skin injury, such as abrasion, cut, burn or scald. When the accident occurs, stay calm. Make a quick assessment to decide on the treatment according to the wound site and severity. For bleeding wound without foreign body, apply direct pressure on the wound for about 5-15 minutes to stop bleeding. Clean and dress the wound properly to prevent wound infection. If bleeding persists or if a foreign body is deeply seated in the wound (do not try to remove it as the bleeding may worsen), seek medical treatment immediately. For dirty wounds, especially if contaminated by mud or rust, anti-tetanus toxoid (ATT) injection should be given if none has been given before, or if given more than a decade ago. A full course of ATT comprises 3 injections and offers 10 years protection.
For burns and scald wound, cooling is the most important principle in management. The aim is to prevent the heat from spreading to the deeper layers of skin. Rinse the wound under cold running water for at least 10 minutes. Dress the wound with sterile and non-adhesive dressing. Seek hospital care if the condition is serious.
Chronic wound: Chronic wound refers to any wound which has remained unhealed for longer than 4 weeks, such as pressure sore or venous ulcer. The basic principle in chronic wound care is to keep the wound clean to prevent infection and promote healing. Regular aseptic wound dressing is crucial. The choice of dressing materials varies according to the wound's condition and it is better to follow the nurse instruction. To promote healing, other factors are also important, e.g. balanced diet for nutrition and appropriate exercise to promote circulation for wound healing.
Prevention and care of pressure sore Pressure sore, also known as bedsore, is common among the bedridden. It is caused by persistent pressure, friction and moisture. Prominent bony areas of the body are prone to bed-sore, such as sacrum, ankles, etc. In order to prevent bed sore, patients should increase activity and avoid prolonged staying in the same posture. Relatives can carry out passive exercise for the bedridden and assist in changing position regularly. It is crucial to avoid frictional injury to skin during position change, and pay attention to skin hygiene and wound cleansing. Apart from daily bathing and regular dressing, it is necessary to promptly change dirty and wet dressing, napkin, clothing and bedding. Adequate nutrition intake is also important to maintain healthy skin.

Principles of Wound Management

(1) Prevent infection - Apply strict aseptic technique in wound dressing. - Ensure sterile materials are being used.
(2) Promote wound healing - Avoid putting pressure on wound (such as too tight strapping, bandages or heavy blanket), as it may impair blood supply. - Assist the immobile or bed-ridden to change position regularly. - Maintain balanced diet.
(3) Minimize further damage - Avoid persistent pressure and friction on the wound. - Use hypoallergenic dressings if necessary.

Proper techniques in Wound Management

Information for home carers

Relatives can accompany the elder to nearby out-patient clinics for dressing as instructed by the doctor. For frail or immobile clients, they can apply for Community Nursing Service during follow-up consultations. Family member or carers should look out for signs and symptoms of wound infection (see below) and seek for early medical advice accordingly.

Proper techniques in Wound Management

Information for carers at home

Carers should follow advice from doctor and bring the elder to a nearby clinic for regular wound dressing. Frail elders or elders with mobility problem could apply for the Community Nursing Services through doctor's referral during follow up. Observe for signs and symptoms of infection (please refer to details on next page) and consult doctor if necessary.

Signs and Symptoms of Wound Infection

- Local signs of infection: pain, swelling, warmth, redness, smelly blood stained or cloudy secretion.
- General signs of infection: fever, chills and rigor, rapid respiration, rapid pulse, headache, nausea, anorexia and malaise. Seek medical attention if there is suspected wound infection and delayed wound healing.

Information for carers working in elderly home

Wound assessment, evaluation and documentation

The aim is prevent pressure sore, skin infection and monitor the wound condition. Health workers should regularly inspect the skin condition for high-risk residents (frail, immobile, incontinent and/or bed-ridden). Observation can be done during bathing, diaper changing, position turning and wound care by Community Nursing Service. Special attention should be paid to the prominent bony areas. If the skin is red or a blister is seen, do more frequent turning and give appropriate wound care. For wound assessment, the aspects to pay attention include the cause of the injury, medical history, wound location, wound condition (color, size, depth, secretion and infection), pain intensity and the patient's nutritional status. It is recommended to assess, evaluate and document weekly or every 2 weeks. If wound infection is observed, medical treatment should be sought as soon as possible.

Commonly used cleansing fluid and dressing

Normal Saline (0.9% NaCl) is a commonly used cleansing fluid. As it is similar to human body fluid, it does not irritate wound tissues and causes less pain when applied. Antiseptics may irritate the wound or cause allergic reaction.

Generally, non-infected wound could be cleansed by Normal Saline and antiseptics is not required. Infected wound must be managed according to doctor's instructions.

General dressings include:
- Gauze: can absorb secretion.
- Film dressings: transparent, permeable to gas and water vapour but not germs.
- Hydrocolloid dressings: help to remove slough and dead tissue; absorb secretion but does not cause over-drying, non-adhesive during removal; reduce the frequency of dressing.
- Antimicrobial dressings: kills germs and requires doctor's prescription.

Health workers must follow strict aseptic technique in wound cleansing

Preparation of environment, equipments, resident and carer

- Avoid dusting 2 hours before and during procedure.
- Adequate lighting.
- A clean dressing trolley (clean with detergent and water, then swab with 70% alcohol).
- Dressing materials (a disposable dressing set, additional swabs and gauzes, cleansing fluid, mask, gloves, surgical tape, bandage, scissors and a bag for rubbish).
- Position the resident and expose the wound; ensure privacy of resident.
- Wash hands thoroughly with soap.

Procedure of wound cleansing

- Open the sterile package and line up the plastic forceps.
- Pour adequate amount of cleansing solution into the container.
- Use a pair of forceps to remove the old dressing (if there are only two plastic forceps, remove the old dressing with a gloved hand).
- If the old dressing sticks tightly to the wound, soak the inner dressing with saline before removal.
- Discard the used forceps or glove.
- Use another 2 clean forceps for cleansing and dressing.
- Dip the swab into the solution and remove excessive solution by forceps or press it against the edge of container. Start wiping the wound from inside outwards, the swab should be used only once, repeat this step until the wound is clean.
- Pad the wound dry with gauze gently and cover it with suitable dressing.
- Secure the dressing with surgical tape or bandages.
- Never touch the wound or sterile gauze with hands to avoid contamination.

After care

- Discard everything in a plastic bag and tie it up securely before disposal.
- Wash hands thoroughly with soap.
- Document the wound condition in the resident's personal health record.

Please click here to watch the video on “Home Safety: Wound Care” (Cantonese voice-over with English Subtitles).

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