Wound Care Guidelines: A Comprehensive Guide for Clinicians

Wound care is a critical aspect of healthcare performed by nurses, physical therapists, physicians, and surgeons across various settings. However, evidence-based practices often elude many healthcare providers. This article aims to provide a comprehensive overview of wound care guidelines, incorporating recent advances and addressing critical issues to help clinicians achieve optimal patient outcomes.

Significance of Wound Care Guidelines

The Wound Healing Foundation (WHF) recognized the need for consensus-based, unbiased recommendations for wound treatment due to the increasing financial and medical burden of chronic wounds, exacerbated by the growing elderly population. The WHF aimed to develop standards based on evidence for wound healing, encompassing diagnosis and treatment of chronic wounds, with specific guidelines for pressure ulcers, diabetic foot ulcers, venous ulcers, and ischemic ulcers. As a first step, a consensus on the treatment of chronic wounds was developed and published in 2022. The current publication on acute wounds represents the second step in this process.

Acute wounds, resulting from burns, military operations, or trauma, necessitate timely and evidence-driven intervention. This article provides a structured guide for clinicians and learners in all patient care settings, focusing on the causes, diagnosis, and therapeutic management of acute wounds.

Recent Advances in Wound Care

Recent advancements in acute wound management emphasize stabilization and treatment in military and combat environments. Key improvements include advancements in hemostasis, resuscitation, and infection mitigation through timely antibiotic administration and avoidance of high-pressure irrigation in contaminated soft tissue injuries.

Critical Issues in Wound Care

Several critical issues influence wound management, including:

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Infection Control: Preventing and managing wound infections is paramount to promote healing.
Pain Management: Addressing patient comfort is crucial for adherence to treatment plans and overall well-being.
Pediatric Considerations: Managing acute wounds in pediatric patients requires special attention due to their unique physiological characteristics.

Future Directions in Wound Care

Future research focuses on preventing burn progression using specific gel formulations. Additionally, ongoing efforts aim to develop new strategies for various wound types and improve overall wound care practices.

Key Considerations in Wound Care

Five key considerations-clean vs. sterile technique, hydrofiber vs. alginate dressing, negative pressure therapy and fistula management, co-morbidity management, and pressure injury risk assessment tools-can help all clinicians who provide wound care no matter the practice setting.

1. Clean vs. Sterile Technique

The debate between clean and sterile techniques in wound care persists, although limited clinical data supports sterile technique over clean technique. Providers often specify "sterile" for routine dressing changes, causing confusion among clinicians.

According to the Centers for Disease Control and Prevention, only post-surgical wounds require a sterile dressing applied in the operating room. These dressings remain in place for 24 to 48 hours, after which they are considered contaminated, negating the need for a sterile environment. The WOCN fact sheet states that clean technique is the most cost-effective approach to wound care and requires less time and fewer resources. In 2018, Kent and colleagues also found no difference in wound infection rates when using clean or sterile techniques.

2. Hydrofiber vs. Alginate Dressings

Hydrofiber and alginate dressings, while similar in appearance, possess significant differences. Alginates, derived from algae or brown seaweed, can absorb up to 20 times their weight. Hydrofiber dressings, made from lab-created carboxymethylcellulose, can hold 30 times their weight and present less risk of maceration than alginates, making them the preferred choice when managing wounds with copious amounts of drainage. Compound dressings that offer a mix of hydrofiber and alginate also are available. No evidence exists that compound dressing provides more efficacy than pure alginate or pure hydrofiber.

When selecting a dressing, consider the patient’s condition, wound drainage, and costs. Hydrofiber dressings cost slightly more than alginates but they last longer, which results in fewer dressing changes. They also can handle more drainage than alginates, making them a good option for heavily draining wounds. It is important to always read the manufacturer’s guidelines before using advanced wound care products.

3. Negative Pressure Therapy and Fistula Management

The WOCN Core Curriculum includes evidence-based guidelines for using negative pressure wound therapy (NPWT) to manage fistula output. NPWT is recommended for fistulas in open wounds with closure potential and no exposed bowel. If wound healing is not the goal, NPWT is not indicated.

Fistula management should start with the simplest approach, modifying as needed. The gold standard is a pouching system, which is cost-effective and enhances patient mobility. If this fails, advanced modalities like NPWT and suction may be considered, but only if closure is possible.

4. Managing Co-morbidities

Selecting a dressing alone is insufficient for wound healing. Patient condition and co-morbidities (such as diabetes, obesity, immune system dysfunction, malnutrition, cardiovascular disease, and cancer treatment) can prevent wound closure. A dressing provides an environment to help optimize wound healing, but if nutrition and co-morbidities aren’t managed appropriately, wounds will become chronic.

A thorough assessment should include medical history, medications, nutrition, and recent lab results. Standardized tools like the Bates-Jensen Wound Assessment Tool can be used. Medications like glucocorticoids can interfere with wound healing, and abnormal lab markers (e.g., glucose, glycated hemoglobin, and prealbumin) may indicate nutritional deficiencies. Consider the whole patient when selecting a plan.

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5. Pressure Injury Risk Assessment Tools

Pressure injury (PI) risk assessment tools, such as the Braden Scale, Norton Scale, and Waterlow Scale, are often misunderstood and misused. Developed over 30 years ago, these tools do not reflect current research. Factors like skin temperature, oxygenation, perfusion status, co-morbidities, age, blood tests, and medications impact PI risk.

The National Pressure Injury Advisory Panel notes that while structured PI risk assessment tools provide critical information, clinicians should not rely solely on the score. Nurses and caregivers should use professional judgment with an assessment tool to determine an accurate risk level for each patient.

Types of Chronic Wounds and Their Management

Chronic wounds are those that do not progress through a normal, orderly, and timely sequence of repair. Common lower extremity wounds include arterial, diabetic, pressure, and venous ulcers. The mainstay of treatment is the TIME principle: tissue debridement, infection control, moisture balance, and edges of the wound.

Venous Ulcers

Venous ulcers are the most common type of chronic wound, typically shallow and located on the medial supramalleolar aspect of the lower extremity. They are caused by venous hypertension due to incompetent veins or venous obstruction, leading to wall damage, fluid exudation into the interstitial space, and edema.

Management: If a venous pathology is confirmed, apply graduated compression bandages or stockings to the ulcers. Treatment of venous ulcers involves compression and elevation of the lower extremities, plus exercise if tolerated.

Arterial Ulcers

Arterial ulcers are typically located on the distal extremities and may be deep, with tendon or bone exposed. They result from reduced arterial blood flow.

Management: The first step in the management of arterial ulcers is treating the underlying cause, which may include vascular bypass, stents, or dilation by a vascular surgeon. The acute management of arterial ulcers usually involves improving blood flow through angioplasty, stenting or bypass grafting and, if necessary, the amputation of a digit or limb. The goals of wound care before adequate perfusion is obtained are to prevent infection and minimize debridement. Patients with arterial ulcers should be immediately referred to a vascular surgeon for appropriate intervention.

Diabetic Ulcers

Diabetic ulcers are the most common cause of lower extremity amputation. Early intervention and management are essential given the high mortality rate after amputation. Diabetic foot ulcers are caused by a combination of underlying neuropathy, peripheral arterial disease, and structural deformities that cause increased pressure on affected areas of the foot. Diabetic ulcers are typically located on the toes or the plantar aspect of the metatarsal heads.

Management: Treatment of diabetic ulcers begins with optimal control of blood glucose levels. The preferred treatment approach for diabetic foot ulcers is offloading the foot to remove pressure from the affected area. Most patients with diabetic foot ulcers also have underlying peripheral arterial disease, which requires evaluation. Optimising glycaemic control is critical for management. The main management issues are ensuring that the circulation is adequate, that any infection is controlled and that pressure is removed. It is essential to involve a multidisciplinary team including an orthotics specialist and podiatrist in the management of diabetic foot ulcers. Treatment will often involve antimicrobial dressings and pressure off-loading.

Pressure Ulcers

A pressure ulcer is a localized injury to the skin or underlying tissue-usually over a bony prominence such as the sacrum, coccyx, hip, or heel-that results from pressure in combination with shear force.

Management: Localized treatment for pressure ulcers follows the same TIME principle used for all chronic wounds, but has a greater emphasis on pressure redistribution, offloading, and microclimate control. Pressure ulcers are managed by offloading the affected area. A common mistake is the recommendation of donut-style cushions for offloading.

Wound Assessment

Assessment of wounds should begin with a thorough physical examination. A more focused examination of the wound itself can then help guide treatment. The wound location, size, and depth; presence of drainage; and tissue type should be documented. All patients with a nonhealing lower extremity ulcer should have a vascular assessment, including documentation of wound location, size, depth, drainage, and tissue type; palpation of pedal pulses; and measurement of the ankle-brachial index. Atypical nonhealing wounds should be biopsied.

Assessing for Infection

When assessing a chronic wound for infection, physicians should be aware that chronic infected wounds have different signs and symptoms than acute infected wounds. Typical signs of infection such as erythema, edema, pain, and fever are not always present.

NERDS (for wounds with biofilm or critical colonization): nonhealing, exudative, red and bleeds easily, debris, and smell.
STONEES (for infection): size increasing, temperature increased, os (probes to or exposed bone), new areas of breakdown, exudative, erythema/edema, and smell.

Biopsy with quantitative processing is the best method of wound culture; a result of more than 100,000 colony-forming units is considered positive. Other options include the Levine and Z techniques.

Atypical Wounds

A chronic wound that does not respond to appropriate care may be an atypical wound. Atypical wounds are located in abnormal locations, have an abnormal appearance, and do not heal after three to six months of standard wound care. Atypical wounds have inflammatory, infectious, vasculopathic, metabolic, genetic, malignant, or external etiologies (e.g., calciphylaxis, pyoderma gangrenosum, vasculitis, autoimmune disease).

Debridement

Debridement is the removal of dead cells and is an essential part of wound care. It is the first-line treatment for chronic wounds. In addition to removing dead cells and tissue, debridement of biofilm-multicellular communities held together by a self-produced extracellular matrix that can halt the healing process-is a key factor in wound healing. There are several different types of debridement: surgical, autolytic, enzymatic, and biologic. Surgical debridement is used most often, but other methods may be appropriate depending on the type of wound.

Infection Control

Infection is usually controlled with topical agents, including dressings with silver, polyhexamethylene biguanide, and cadexomer iodine. Antimicrobial washes may also be beneficial if biofilm is suspected. For localized wound infections, use topical antimicrobials (e.g. polyhexamethylene biguanide (PHMB), octenidine dihydrochloride, chlorhexidine, povidone-iodine). Tissue biopsy is the most accurate method of identifying an infection. Do not swab chronic wounds routinely, as this often leads to unnecessary antibiotic use and does not address the underlying problem. However, if a swab is to be used, the Levine method is preferred.

Moisture Balance

Moisture balance is an essential part of wound care. Chronic wounds should never be exposed to air to “dry out,” as is often recommended. Moist wounds heal more quickly and have less risk of infection. If a wound appears dry, moisture needs to be added; this is accomplished by choosing an appropriate dressing. Conversely, if a wound is draining, the drainage needs to be controlled and kept off of the periwound.

Types of Dressings

Dressings and bandages provide the optimal environment for the healing of all wound types. It is important for healthcare practitioners to understand the key differences in their properties, uses and precautions. Dressings provide the best environment for wound healing in combination with the management of the cause of the wound and factors impacting healing. Table 1 lists the different dressings that are available. Dressings and bandages provide the optimal environment for the healing of all wound types. It is important for healthcare practitioners to understand the key differences in their properties, uses and precautions.

The Role of Bandages

There are three main roles for a bandage: keeping a dressing in place, supporting an injured joint and assisting venous return by compression. Compression is the major management strategy for venous disease, and this can be provided with the use of bandages, stockings and wraps. Crepe bandages are not appropriate for the management of venous leg ulcers and have little use for dressing retention.

Staying Current and Open-Minded

Staying current with wound care best practices requires continuous effort. Take the time to read about new research and evidence to ensure you implement the most recent best practices. Stay open-minded and willing to change care approaches beneficial to patients.

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