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Assessment and Dressing Selection
Dressing Education and Research, and Senior Associate,
Department of Pharmacy Practice, Monash University, Melbourne,
An acute wound should first
be cleaned and decontaminated, then if necessary,
the wound edges should be held together by sutures
or tape, and finally an appropriate dressing
The difficulty in the
management of any chronic wound is that there is
always an underlying physiological cause of the
wound that must be treated
Wound assessment includes
wound location, size and depth
A thorough wound assessment
also evaluates the wound bed, the quality and
amount of exudate, the presence or absence of
Wounds are dynamic and as
such the choice of dressing will change as the
Choice of dressing is based
on three simple rules, 'C D E', which indicate the
three major aspects of any wound: colour, depth
Also consider the presence of
infection, the peri-wound tissue, the need to
apply graduated compression, the fragility of the
skin and any medical condition that may impact on
Wound management is no longer simply the application
of a dressing to an acute or chronic wound. It is the
provision of an appropriate environment for healing by both
direct and indirect methods, together with the prevention of
skin breakdown. This article describes the practical aspects
of wound management - use of topical agents, type of wound,
wound assessment and selection of appropriate
Wounds may be either acute or chronic in nature: from
lacerations, grazes, burns and postoperative wounds to leg
ulcers, diabetic wounds and pressure sores. The relative
differences between each of these types of wounds are
Table 1. Relative differences
acute and chronic wounds
by primary intention
of infection due to the inflammatory phase and the
presence of debris contaminating the wound
Have a lower
risk of infection
Will vary in
appearance from granulating to sloughy or covered with
General Principles of
The basic principles of
wound manage are as follows:
major objective is to facilitate optimal healing. That is,
with as little scar tissue as possible, with a good cosmetic
appearance. Therefore, to treat an acute wound, it should
first be cleaned and decontaminated, then if necessary, the
wound edges should be held together by sutures or tape, and
finally an appropriate dressing applied. Tetanus vaccination
should be considered if foreign bodies may be trapped in the
All traumatic wounds have some form of
contamination, so it is very important to remove any dirt,
foreign material or potential bacterial contamination from the
wound before closure and dressing.[1,2]
The choice of cleansing solution
will depend on the severity of the wound and the level of
contamination. If the wound is basically clean, then water or
saline is most suitable. If there is any level of
contamination, a surfactant solution such as chlorhexidine/
cetrimide is the most satisfactory, due to the ability of the
product to remove material by a soap-like action.
The use of topical antiseptics and antibiotics in
acute wounds is entirely different to that used in chronic
wounds. In a traumatic wound the risk of infection from
contamination at the time of wounding is very high. This is
also the case in major burns, since the presence of necrotic
tissue is a focus for infection. Therefore it is mandatory to
use topical therapy in the treatment of acute wounds. The aim
is to use antiseptics and antibiotics prophylactically in
order to reduce the level of bacteria in the wound, and then
to allow the body's own mechanisms to destroy the rest.[3-5] Chronic Wounds
proportions of wounds seen in clinical practice are chronic in
nature. Chronic wounds may be classified into the following
Chronic infected wounds.
The difficulty in the management of any chronic
wound is that there is always an underlying physiological
cause of the wound that must be treated. Many patients have
multifactorial shortages; for best results the basic cause of
the problem must be attacked, and the negative factors
It must be understood that some patients
may never heal due to the basic pathophysiology of the disease
process, and the inability to alter some or all of the major
factors influencing the non-healing of the wound. However,
even in the most extreme cases, good wound care can be a great
help in minimising the worst effects of such chronic
Of all of the
chronic wounds seen in practice, surely the most preventable
are the pressure wounds. The essential part of prevention is
patient assessment and active intervention in the case of
high-risk patients. Pressure wounds may be as simple as the
blister most of us may have experienced over the years from
footwear or the extensive pressure sores experienced by
bedridden patients suffering from afflictions like stroke,
spinal injury, multiple sclerosis, dementia.[6,7]
A pressure wound develops when the capillary blood flow to the
skin and tissue over a bony prominence is decreased for a
sufficient period of time. The main causes of pressure wounds
are pressure, friction and shearing forces.
Direct pressure on tissue over a bony
prominence in excess of 30 mmHg will cause ischaemia in the
surrounding tissue. This can occur with a patient in bed, on a
trolley or sitting in a chair (Fig.
1). The extent of tissue damage will depend on the
intensity of the pressure and the length of time the pressure
remains unrelieved. The tissue can tolerate pressure for short
periods of time, however, even low pressure over a long period
of time will have some detrimental effect (Fig.
Friction occurs when the
top layers of skin are worn away by continued rubbing against
an external surface. This can manifest itself in a simple
blister, tissue oedema or an open pressure wound. Friction can
be caused by ill fitting footwear, or even bed
when the skin remains in place, usually unable to move against
the surface it is in contact with, while the underlying bone
and tissue are forced to move. Shearing forces will contribute
to the destruction of deep tissue and the obstruction of blood
vessels in a manner similar to direct pressure. This type of
pressure injury is seen in patients left sitting up in bed or
on a chair, while gravity causes the patient to slide down
with the skin adhering to the bed linen or the surface of the
1. Grade 2 pressure wound in the sacral
Fig 2. Escharotic heel due to
pressure and friction - requires autolytic or sharp
debridement before healing can
Venous ulcers are most
often found in the gaiter area of the leg and where there is a
history of varicose veins. They are usually irregular in
shape, not painful and oedema is often present. The skin is
often stained around the ulcer area (Fig. 3) with past fractures or trauma with a possible silent
deep vein thrombosis, skin changes, eczema, atrophie blanche
(white stippled scars on the skin), ankle flare or distended
small veins on the medial aspect of the foot.
Fig 3. Pseudomas spp.
infection in venous ulcers in 75-year-old
The main feature is a lack of venous
return caused by a malfunction of the valve system, either in
the deep or the peripheral system (Figs
Figures 4-9. 88-year-old female with bilateral venous ulcers on the
medial malleoli - infected on first presentation. Progressive
pictures of each leg (left leg, Figs 4-6; right leg, Figs
7-9). Treated initially with cadexomer iodine to clear surface
infection, then zinc and compression for venous
are very painful, especially at night. The pain is as marked
in small ulcers as in larger ulcers. Their edges are sharply
defined and the ulcer is 'punched out'. The base is often
covered with slough and this may deepen to bare the tendons.
The skin is often shiny and friable (Figs
10, 11). Uncontrolled diabetes and smoking are significant
factors causing arterial insufficiency. Healing is often slow
and may depend on control of the underlying cause. There is
usually a history of intermittent claudication, dependant foot
(dusky foot) white on elevation or peripheral vascular
It is important to note that between 10
and 15% of leg ulcers are of mixed aetiology
(Figs 12, 13). Infections may lead to ulceration, which
are often hard to heal due to associated oedema, cellulitis,
thrombophlebitis, diabetes or underlying vascular disease,
rheumatoid diseases (especially in bedridden patients) and
skin conditions associated with malnourishment.[8,9]
diabetic ulcer is associated with peripheral neuropathy and
reduced arterial blood flow. There is also abnormal plantar
pressure. Surgical wounds may become chronic due to dehiscence
of the suture line and subsequent infection of the wound base.
These wounds are often slow to heal, and close by contraction
and secondary intention.
A small number of chronic
ulcers may be as a result of neoplasia and some may develop
into non-healing ulcers. The most common of these are squamous
cell and basal cell carcinomas (Fig.
Figures 10, 11.
Classic arterial ulcers located on foot; very regular punched
out appearance, weak pulses, low Ankle Brachial Index (ABI),
Figures 12, 13. Two
views (lateral, Fig. 12; posterior, Fig. 13) of the same
patient with mixed venous and arterial components to the
ulcer. The ulceration is almost circumferential and is highly
Fig 14. Basal cell carcinoma - may
be mistaken for a non-healing wound and is diagnosed on
Controlling Intrinsic and
Control of intrinsic and extrinsic factors is essential
to assist in the healing of any wound, either acute or
chronic. Factors such as nutrition, smoking, circulation,
immune function, medications and infection should be
addressed. See earlier article 'Wound Management and the
Physiology of Healing'.Wound Assessment
After patient assessment, the next step is to
carefully assess the wound. Wound assessment includes wound
location, size and depth. A thorough wound assessment also
evaluates the wound bed in terms of type of tissue present,
the quality and amount of exudate and the presence or absence
of infection. It also involves assessment of the condition of
the peri-wound area and evaluation of any past and current
Location of the wound can indicate the
need for special attention. For example, sites that are
exposed to urine and faeces need special protection.
Peripheral wounds tend to heal more slowly and blood flow
improvement is important. Location of wounds can be documented
by using body outline drawings.
Wound size and depth are helpful in predicting
the speed and quality of healing. Measurement of the wound
area provides an objective guide to the healing progress.
Measurements of wound areas generally apply only to wounds
healed by secondary intention - open wounds that must fill
with granulation tissue and re-epithelise from the wound
edges. Wounds that heal by primary intention (eg surgical
wounds closed with sutures or staples) do not have a
It should be noted that while a
decrease in wound area indicates healing, an increase in the
area does not always signal deterioration. For example, when
necrotic debris is removed the wound area is often larger, but
this is a positive sign as it allows healing to progress.
The patient should be in the same position for each
measurement; this position should be noted in the
documentation so that continuity is maintained and the
measurements are meaningful.
Undermining is an area where
skin covers an open area or 'dead space'. There may be sinus
tracts that run under the wound. The skin appears grey or
purplish in colour and should be probed carefully to determine
the extent of undermining.
type of tissue at the wound bed reveals important information
such as the phase and progress of wound healing.
Partial-thickness wounds heal
mainly by epithelisation. Whereas deeper, full-thickness
wounds heal mainly by contraction, filling with granulation
tissue and epithelial migration from the wound edges.
Epithelial tissue is 'pearly pink' in
The presence of the
classical 'shiny, beefy, red' granulation tissue denotes
healing progress and is a healthy sign. Danger signs to look
for in the granulating wound bed are grey or purple colouring,
indicating an inadequate blood supply.
Necrotic tissue in a wound bed delays healing and must
be removed. Yellow necrotic tissue is referred to as slough.
The thick, hard, black necrotic material seen covering wounds
is called eschar. Both slough and eschar interfere with
healing - their removal is essential. The area and depth of a
wound cannot be properly assessed until this debris is cleaned
Wound exudate or drainage is an
indication of the inflammatory processes taking place in the
wound. Drainage is not necessarily a negative phenomenon.
Wound fluid is rich in white blood cells and growth factors
that will facilitate healing. Difficulties arise, however,
when drainage increases dramatically or has a foul odour and
purulent appearance. This can increase the chances of
bacterial infection and possibly prolong the inflammatory
process, which delays the progression of
The amount of drainage can be described as
small, moderate or large. The type of drainage can be
described as purulent, serous, clear or bloody.
Assessment of peri-wound skin,
or wound margins, can give indications of problems. Erythema
of the wound margin can signal infection. A blue-grey or
blanched margin can indicate an undermined area. White margins
can result from maceration. These areas should be noted and
Current and Prior Treatment
It is helpful to know
what treatments have been used and what result was obtained.
Hopefully, one modality will have been used long enough to
evaluate its effectiveness. If no improvement is seen in 2-4
weeks after a treatment is initiated, a re-evaluation of the
aetiology, systemic factors and treatment regimen is needed.
Selection of the Appropriate
Wounds are dynamic and as
such the choice of dressing will change as the wound changes.
The choice should be based on three simple rules, 'C D E',
which indicate the three major aspects of any wound: colour,
depth and exudate.[12,13]
aspects that will need to be considered are the presence of
infection, the peri-wound tissue, the need to apply graduated
compression, the fragility of the skin and any medical
condition that may impact on the dressing choice.
The Pink wound is in the final stages of healing. With
new epithelium covering the wound, the major aim is to protect
this very delicate tissue, prevent the wound from drying out
(to maintain a moist environment) and to insulate.
The Red wound is a granulating wound with new tissue
filling the deficit and with some islets of epithelium
present. The aim is to absorb any excess exudate, maintain a
moist environment and protect the wound. Yellow
Yellow wound contains a level of slough. This is non-viable
tissue that must be removed or healing will not take place.
The aims are slough removal by rehydration with dressings such
as hydrogels or hydrocolloids, and absorption of exudate.
Surgical removal of slough may be necessary.
The Black wound has an outer layer of thick hard
eschar - this must be removed to commence the healing process.
The fastest and most effective method is surgical removal. The
use of dressings such as hydrogels to aid autolytic
debridement will at best be slow.
wound may be superficial, partial-thickness or a deep cavity.
The product choice will depend on the shape, position and type
of wound. Exudate
wounds will contain some exudate; this will vary from very
little to copious levels. The choice of both primary and
secondary dressing will depend on this level and the depth of
dressing chosen will depend on the amount of exudate from the
wound, the need for a waterproof cover, the location of the
wound (ie if it is on a flexor), along with the need for a
dressing that will be elastic in its properties. Some examples
of suitable dressings are listed in the Guide Chart 'Treatment
Options Based on Wound Type', facing page 40 of the May issue
of Current Therapeutics.
In addition to the dressing
used to cover the wound, some wounds will require extra
protection in the form of a bandage around the wound and limb.
For simple extra support a lightweight cohesive bandage (eg
Handy gauze cohesive or Easy fix cohesive) is suitable. When
support is also required, a heavyweight crepe bandage or a
heavyweight cohesive bandage may be used.
Only after a thorough wound assessment can
appropriate treatment be planned. Reassessment is just as
important; as the wound changes, so should the treatment plan.
Web Site Wound Education and Research Group, Monash
Wijetunge DB. Management of acute and traumatic wounds: main
aspects of care in adults and children. Am J Surg 1994; 167
Suppl. 1a: 50S-56S
2. Ilulten L. Dressings for surgical
wounds. Am J Surg 1994; 167 Suppl. 1a: 42S-45S
C. Antibacterial prophylaxis in burns and other surface
wounds. Wound Management 1992; 2: 13-15
4. Dire JD. A
comparison of wound irrigation solutions used in the emergency
department. Ann Emerg Med 1990 Jun: 704-7
5. Sleigh JW.
Hazards of hydrogen peroxide. Br Med J 1985;
6. Young JB.
Pressure sores: epidemiology and current management concepts.
Drugs Aging 1992; 2: 42-57
7. Leigh IH, Bennett G. Pressure
ulcers: prevalence, aetiology and treatment modalities: a
review. Am J Surg 1994; 167 Suppl. 1a: 25S-30S
8. Group TA.
Consensus paper on venous leg ulcers. Phlebology 1992; 7:
9. Harper D, Hajivassiliou C. The aetiology of leg
ulcers. Wound Management 1991; 1 (3): 10-11
10. Morgan DA.
Wound management: which dressing. The Pharmaceutical Journal
1993 May 29: 738-43
11. Thomas S. Handbook of wound
dressings. London: MacMillan, 1994
12. Sussman G. Wound
Management. In: Sansom L, editor. 2000, Pharmaceutical Society
of Australia. Canberra: Pharmaceutical Society of Australia,
13. Thomas S. Functions of a wound dressing.
In: Wound management and dressings. London: The Pharmaceutical
Press, 1990: 9-19
14. Thomas S. Bandages and bandaging. The
Pharmaceutical Journal 1993 May 29: 744-5
Geoff Sussman, PhC (Vic), AFAIPM, is the
Director of Wound Dressing Education and Research, and a
Senior Associate at the Department of Pharmacy Practice,
Monash University. His research interests include tissue
repair and wound healing, wound dressings and the role of
drugs in wound healing.
Dressing Education and Research Department of Pharmacy
Practice, Victorian College of Pharmacy, Monash University,
381 Royal Parade, Parkville, VIC 3052
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