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Complex Wound Management

Process - Step by Step

• This process provides the steps and priorities involved in managing complex wounds. It covers preparation, including equipment and ensuring the person is fully informed and has provided consent.
• The essential infection prevention and management considerations include hand washing and using PPE. 
• The process then covers the steps involved in removing the dressing, assessing the wound and cleaning and dressing the wound. 
• Remember, other factors aside from the wound itself are also important as they influence healing, such as adequate nutrition and tissue perfusion. 

• Prepare a clear available workspace, such as a stainless steel trolley. The space must be big enough to put the dressing pack on. Collect together:
  • a sterile dressing/procedure pack
  • Non-sterile gloves to remove the old dressing
  • an apron
  • the appropriate dressings
  • the appropriate solution, e.g. normal saline, for cleaning the wound, if needed.

• Prepare the client:
  • Introduce and explain to the person what you are doing and why
  • gain the person's verbal consent
  • Make necessary arrangements to provide privacy to the person
  • Check the person's relevant care notes to update yourself on any changes in the person’s condition and to make sure the dressing is due to be changed.

• Manage the risk of cross-infection:
  • wash hands thoroughly
  • clean the trolley or work area using soap and water or disinfectant and a cloth
  • Prepare the sterile dressing/procedure pack
  • Open any other sterile items needed without touching them.

• Remove the existing dressing:
  • wash your hands and put on non-sterile gloves (to protect yourself)
  • tease the corners and edges of the dressing away from the skin gently, taking care not to damage the surrounding skin
  • dispose of this dressing in a separate dirty clinical waste bag.

• Assess the wound:
  • Check of the surrounding area, noting the level of erythema and swelling
  • Check of the wound, noting type, colour and level of exudate, any bleeding, the nature and colour of the wound bed, any necrosis or sloughing
  • size
  • odour.
• If concerned about infection in the wound, as indicated by excessive erythema, swelling, exudate, or smell, take a swab and send it for analysis.
• If the wound has not improved as expected or is worsening in any way, contact the treating medical practitioner.
• If the wound has not improved as expected or is worsening in any way, consider re-reviewing the care plan.
• If the wound has necrosed in any area, it may be necessary to apply an autolysing dressing or consider manual debridement—if any doubt, seek advice from a medical professional.

• Make sure the correct dressing type and materials will provide full and appropriate coverage of the wound type, size and location as per the care plan or medical practitioner’s recommendations.
• Wash your hands and put on sterile gloves—if the gloves become desterilised, remove them, re-wash your hands and put on new sterile gloves.
• Start from the dirty area and then move out to the clean area—be very careful when doing this as the tissue or skin may be tender and there may also be sutures in place—clean the area without causing further damage or distress to the person.
• Take care to refrain from re-introducing dirt or ooze by ensuring that cleaning materials are not over-used (change them regularly and use once only if possible) and never re-introduce them to a clean area once they have been contaminated.
• Dress the wound as appropriate, following dressing instructions.

• Clean up:
  • fold up dressing/procedure pack and place all contaminated material in a bag designated for clinical waste and sharps are disposed of in a sharps container
  • Remove gloves and place them in a waste bag
  • wash your hands
  • Clean the trolley with soap and water or disinfectant solution as before
  • Document on the person’s chart your wound assessment, the dressing change and the care you have given
  • Provide the person with some dressing management education and answer any questions
  • Report any changes.

• The holistic assessment of a person with complex wounds is important. This means you must also consider the following:
  • Nutrition – Complex wounds need good nutrition to heal—A full dietary assessment may be appropriate and nutritional supplements, such as protein supplements, may need to be added
  • Hydration – it is important that the patient is adequately hydrated at all times to maximise wound healing—Where there are concerns about someone’s hydration level, consider using a fluid management chart to provide a better overview and to monitor fluid intake
  • Oxygenation – tissues need adequate levels of oxygenation to heal—Ensure oxygen saturation (SaO2) is within normal levels and take appropriate measures if levels are below normal parameters
  • Perfusion – tissues around the wound must be well-perfused—assessing skin colour and tone will indicate the level of local perfusion—consider the need for activity, position and clothing depending on the location of the wound.