A. Introduction

Welcome to this lesson on wound care and dressing changes for complex wounds. This lesson will cover the essential procedures for managing complex wounds. We’ll discuss how to assess complex wounds, select appropriate dressings, perform dressing changes, and manage potential complications.

• Introduce the topic.
• Review what you will learn in this lesson.
• Explain the importance of proper wound care in the ICU.
• Define complex wounds and discuss the challenges they present.
• Give a quick overview of what we will cover in this lesson.

B. Understanding Complex Wounds

Let’s define complex wounds and discuss the characteristics that make them different from simple wounds.

Define complex wounds.

• Complex wounds are those that fail to heal through the normal healing process within an expected timeframe. They often involve multiple factors that impede healing.

Discuss the characteristics of complex wounds:

• Large surface area: These wounds cover a significant portion of the body, making them more challenging to manage.
• Irregular shape or depth: Complex wounds may have uneven edges, deep pockets, or involve multiple tissue layers.
• Involvement of deeper tissues (muscle, bone): The wound may extend beyond the skin and subcutaneous tissue, affecting underlying structures.
• Presence of necrotic tissue or slough: Dead or devitalized tissue can create a barrier to healing and increase the risk of infection.
• Infection or high risk of infection: Complex wounds are more susceptible to infection due to their size, depth, and the presence of devitalized tissue.
• Exudate (drainage) that is high in volume or abnormal in character: Excessive or foul-smelling drainage can indicate infection or other complications.
• Undermining or tunneling: These are hidden areas of tissue damage that extend under the skin, making it difficult to assess the full extent of the wound.
• Location over bony prominences or areas of pressure: Wounds in these areas are at increased risk of further damage and impaired healing.
• Associated with underlying conditions (e.g., diabetes, vascular disease): Chronic diseases can impair the body’s ability to heal.

Compare complex wounds to simple wounds.

• Simple Wounds: These wounds typically heal through the normal healing process without complications. Examples include small cuts, abrasions, and surgical incisions that heal without infection or complications.
• Complex Wounds: These wounds have one or more factors that impede healing. They require specialized care and may involve a longer healing time.

Discuss the stages of wound healing.

• Hemostasis: The process of stopping bleeding.
• Inflammation: The body’s initial response to injury, characterized by redness, swelling, pain, and warmth.
• Proliferation: The stage where new tissue is built to fill the wound.
• Maturation (Remodeling): The final stage where the tissue is strengthened.

C. Indications and Contraindications

It is important to know when to perform wound care and dressing changes, and when specific techniques or dressings are contraindicated.

Discuss the indications for wound care and dressing changes:

• To promote wound healing: Proper care helps the body’s natural healing processes.
• To prevent infection: Cleansing and dressing protect the wound from microorganisms.
• To manage exudate: Dressings help absorb and contain drainage.
• To protect the wound from further injury: Dressings provide a barrier against physical damage.
• To relieve pain and discomfort: Appropriate care can minimize irritation and promote comfort.

Discuss the contraindications for certain wound care practices:

• Allergy to dressing materials: Using a contraindicated material can cause an adverse reaction.
• Presence of necrotic tissue that requires surgical debridement before dressing: Non-viable tissue must be removed before applying most dressings.
• Active bleeding (requires hemostasis first): Bleeding must be controlled before applying a dressing.
• Specific contraindications to certain dressing types (e.g., occlusive dressings in infected wounds): Some dressings can worsen certain conditions.
• Patient instability that precludes safe dressing changes: In some cases, the patient may not be stable enough for a dressing change.

Discuss when to consult a wound care specialist.

• Wound is not healing after several weeks of appropriate care.
• There are signs of infection that are not resolving.
• The wound is very large or complex.
• The patient has significant pain.
• You are unsure about the best course of action.

D. Assessment of Complex Wounds

A thorough wound assessment is essential for developing an effective wound care plan.

Discuss the components of a comprehensive wound assessment:

• Wound history (etiology, duration, previous treatments): Understanding how the wound occurred and its history informs treatment.
• Wound location and size (length, width, depth): Accurate measurement is crucial for monitoring healing.
• Wound bed characteristics (tissue type, color): The type of tissue (e.g., granulation, slough) indicates the stage of healing.
• Exudate characteristics (amount, color, odor, consistency): Drainage provides clues about the wound status and presence of infection.
• Periwound skin assessment (color, temperature, integrity): The skin around the wound can affect healing.
• Pain assessment: Wound pain can significantly impact the patient’s quality of life.
• Signs of infection (redness, warmth, swelling, pain, purulent drainage): Early detection of infection is critical.
• Presence of undermining or tunneling (use of a cotton-tipped applicator): These hidden areas need to be assessed and addressed.
• Patient’s overall health status and nutritional status: Underlying health conditions and nutrition affect healing.
• Vascular assessment (pulses, capillary refill) if indicated: Adequate blood flow is essential for wound healing.

Explain how to measure wound size accurately.

• Use a sterile, flexible measuring tape.
• Measure length (longest dimension) and width (widest dimension perpendicular to the length).
• Measure depth using a sterile cotton-tipped applicator.
• Document measurements in centimeters.
• Take a photo of the wound, if possible, for comparison over time.

Discuss the use of wound assessment tools (e.g., PUSH tool).

• The PUSH (Pressure Ulcer Scale for Healing) tool is a validated tool for assessing pressure ulcers.
• It assesses wound size, exudate amount, and tissue type.
• A lower PUSH score indicates better healing.

E. Types of Dressings

Many different types of dressings are available for managing complex wounds.

Discuss the categories of wound dressings:

• Gauze dressings
• Transparent film dressings
• Hydrocolloid dressings
• Hydrogel dressings
• Foam dressings
• Alginate dressings
• Collagen dressings
• Antimicrobial dressings
• Skin sealants

Explain the properties, advantages, and disadvantages of each type of dressing.

• Gauze dressings:
  • Properties: Made of woven or non-woven cotton or synthetic materials.
  • Advantages: Inexpensive, absorbent, can be used for cleansing, packing, or covering.
  • Disadvantages: Can stick to the wound, may require frequent changes, does not maintain a moist environment.
• Transparent film dressings:
  • Properties: Thin, see-through, adhesive dressings.
  • Advantages: Allow wound visualization, protect from friction, waterproof, promote autolytic debridement.
  • Disadvantages: Not very absorbent, can cause skin maceration if exudate is not managed, can be difficult to apply.
• Hydrocolloid dressings:
  • Properties: Contain gel-forming agents.
  • Advantages: Maintain a moist environment, promote autolytic debridement, provide some absorption.
  • Disadvantages: Can have an odor, may leave a residue, not suitable for heavily exudating wounds.
• Hydrogel dressings:
  • Properties: High water content gels.
  • Advantages: Provide moisture to dry wounds, promote autolytic debridement, conform to wound shape.
  • Disadvantages: Limited absorption, may require a secondary dressing.
• Foam dressings:
  • Properties: Soft, absorbent, and conformable.
  • Advantages: Provide cushioning, absorb exudate, maintain a moist environment.
  • Disadvantages: May require a secondary dressing, can be bulky.
• Alginate dressings:
  • Properties: Made from seaweed, highly absorbent.
  • Advantages: Absorb large amounts of exudate, promote hemostasis, fill dead space.
  • Disadvantages: Require a secondary dressing, can dry out the wound bed if not used properly.
• Collagen dressings:
  • Properties: Contain collagen.
  • Advantages: Promote cell growth and wound healing.
  • Disadvantages: May require a secondary dressing, can be expensive.
• Antimicrobial dressings:
  • Properties: Contain agents like silver, iodine, or chlorhexidine.
  • Advantages: Reduce or prevent infection.
  • Disadvantages: Can be expensive, some agents can be toxic to healthy tissue with prolonged use.
• Skin sealants:
  • Properties: Liquid that dries to form a protective layer on the skin.
  • Advantages: Protect periwound skin from moisture and adhesive damage.
  • Disadvantages: Can be irritating if applied to broken skin.

Discuss how to select the appropriate dressing based on wound characteristics.

• Wound bed condition: Is the wound dry, moist, or necrotic?
• Exudate level: How much drainage is present?
• Infection status: Is the wound infected?
• Wound location: Is the wound on a bony prominence or in a difficult-to-dress area?
• Periwound skin condition: Is the skin intact or irritated?
• Patient factors: Does the patient have any allergies or sensitivities?

Discuss the concept of moist wound healing.

• Moist wound healing involves maintaining a balanced moisture level at the wound bed.
• It promotes cell growth, migration, and proliferation.
• It is the foundation of modern wound care.

F. Preparing for a Dressing Change

Proper preparation is crucial for a safe and effective dressing change.

Explain how to prepare the patient and the environment:

• Gather all necessary supplies: This includes the new dressing, cleansing solution, gloves, waste bag, measuring tools, etc.
• Perform hand hygiene: Wash hands thoroughly to prevent infection.
• Don appropriate personal protective equipment (PPE): Gloves are required; gown and mask may be needed depending on the wound.
• Explain the procedure to the patient: Reduce anxiety and promote cooperation.
• Position the patient comfortably: Ensure the patient is in a position that allows easy access to the wound.
• Provide privacy: Dressing changes can be exposing; ensure the patient’s privacy.
• Ensure adequate lighting: Good visibility is essential for accurate assessment and dressing application.
• Prepare a clean work area: Organize supplies on a clean surface.

Discuss how to manage patient pain during dressing changes.

• Administer pain medication as prescribed, before the procedure.
• Use gentle techniques when removing and applying dressings.
• Consider using dressings that minimize trauma to the wound bed.
• Provide emotional support and reassurance.
• Document the patient’s pain level before, during, and after the procedure.

G. Procedure for Dressing Change

Here are the steps involved in performing a dressing change for a complex wound.

Explain the procedure for changing a dressing:

• Step 1: Remove the old dressing
  • Gently remove the old dressing, noting the amount, color, and odor of any drainage
  • If the dressing is stuck, moisten it with sterile saline to loosen it
  • Dispose of the old dressing properly
• Step 2: Assess the wound
  • Assess the wound bed, periwound skin, and any drainage
  • Measure the wound size if indicated
  • Document your findings
• Step 3: Cleanse the wound
  • Cleanse the wound with an appropriate cleansing solution (e.g., sterile saline, wound cleanser)
  • Use gentle irrigation or wiping motions
  • Cleanse from the least contaminated to the most contaminated area
  • Dry the wound gently with sterile gauze
• Step 4: Apply the new dressing
  • Apply the selected dressing according to the manufacturer’s instructions
  • Ensure good contact between the dressing and the wound bed
  • Secure the dressing appropriately (e.g., with tape, bandage)
  • Avoid applying the dressing too tightly
• Step 5: Document
  • Document the procedure

Discuss how to handle heavily draining wounds.

• Use highly absorbent dressings (e.g., alginates, superabsorbent polymers).
• Change dressings more frequently.
• Consider using negative pressure wound therapy (NPWT).
• Monitor the periwound skin for maceration.

Discuss how to pack a wound.