The care of neonates with medical and surgical problems frequently involves the healing of wounds.  Surgical patients must recover from surgical incisions, and medical patients occasionally suffer from wounds despite the very best nursing care.  These wounds most frequently include iv infiltrates and abrasions from tape removal.

Partial thickness wounds may result from tape removal or topical antiseptic burns.

            They present as abrasions or blisters.

Full thickness wounds include iv infiltrations, pressure ulcers, and skin donor sites.

            The injury involves subcutaneous tissues and even muscle, tendon, or bone.

Factors essential for wound healing

1. Tissue perfusion and oxygenation
2. Proper nutrition- Adequate protein, calories, vitamin A, vitamin C, zinc, and copper are necessary for tissue regeneration.
3. A normothermic environment
4. Cleanliness-Saline irrigation is the preferred cleansing method.  Antiseptic agents such as betadine and hydrogen peroxide are cytotoxic as well as bactericidal and can inhibit healing by preventing reepithelialization.
5. Moisture- A moist wound surface prevents dessication and cell death, enhances the migration of epithelial cells across the wound surface, and promotes angiogenesis and connective tissue synthesis.
6. Autolytic debridement-Any necrotic tissue present in a wound promotes inflammation, supports the growth of pathologic organisms, and retards wound healing.  Autolytic debridement refers to the digestion of dead tissue and the eschar by enzymes normally present in wound fluid.

Wound healing products

Transparent adhesives are semi-permeable dressings: they are impermeable to bacteria and environmental contaminants, but allow oxygen to enter and water vapor to escape.

These products conform to body contours and stretch with movement.  Transparent adhesives are excellent for superficial or shallow wounds where friction is a contributing factor.  They both protect the skin surface and decrease pain and discomfort.  Once applied, transparent adhesives should be left on for several days at a time. Daily removal of adhesive can injure intact skin.

Hydrogels, when mixed with water, form a viscous solution or gel.  Gel sheet dressings include ClearSite and Vigilon.  These products require dressing changes every 6-12 hours to preserve moisture at the wound surface.  Vigilon may dry out quicker than ClearSite.  Carrasyn gel is an amorphous gel product which contains acemannen derived from aloe, which is soothing to the patient’s skin.  Carrasyn gel dries out quickly necessitating dressing changes q4-6 hours.

MultiDex gel or powder facilitates autolytic debridement.  MultiDex consists of a hypertonic mixture of glycerin and complex carbohydrates which draw fluid and cells (macrophages and fibroblasts) into the wound area.  MultiDex also contains ascorbic acid to decrease bacterial colonization counts.  MultiDex gel is typically applied to neonatal wounds.

Topical antibiotics (Silvadene, Bactroban, etc.) are only needed when wounds are infected.

Wound care protocol

Clean the area by flushing with normal saline. (May use NS bristojets.)

For a full thickness wound, apply a small amount of MultiDex gel using Q-tips.

Apply ClearSite dressing to the wound area only.

Wrap soft gauze around the dressing to secure it.

Use elastic netting to hold the dressing in place. (Make sure the dressing is not too tight!)

Change the dressing q12 hours or more often if it dries out or is disrupted.

Evaluation of a healing wound

Epidermal cells in a wound bed begin to migrate across a wound surface within 24 hours of injury.  In a dry wound, the epidermal cells must tunnel down to a moist level and secrete collagenase to lift the scab away from the wound surface to migrate.  If a wound is kept moist, epithelial migration may begin as early as 8 hours after injury.  The new epidermis resurfaces the wound from the margins.  This process is usually complete within 6-7 days if the wound is left open to air and within 4 days if the wound is kept moist.

While a healthy wound is healing, it develops increasing vascularity.  Formerly pale areas will become beefy red as granulation tissue forms.  The surrounding skin may be erythematous and edematous.  A serous or milky exudate composed of leukocytes may be present. 

Infected tissue appears more yellow or green.  A yellow wound may or may not be healthy.  The goal of therapy is to gently remove the yellow surface and expose the healthy red tissue underneath.

A black wound surface signifies necrosis and is worrisome.

Nurses should evaluate the wound site at least twice daily documenting the wound’s appearance and size and assessing for evidence of infection.

A consistent method of wound measurement should be used.  One approach is to measure the longest part of the wound from a head-to-toe orientation, and then measure the width perpendicular to the length.

Wound infections

All wounds are colonized with bacteria.  Wound colonization ≠ wound infection.  Colonization can be minimized but not prevented with effective wound cleansing and debridement.  If purulence of a foul odor develops, more frequent cleansing and possibly more aggressive debridement are required. These measures may prevent heavy colonization from becoming clinical infection.

If infection is suspected, cultures may be indicated.  Swab cultures should not be used as they only detect surface colonization and have no diagnostic value.  If a culture is required, a needle aspiration or biopsy should be obtained.

            If an apparently clean wound is not healing after 2 – 4 weeks, consider a 2 week trial of a topical antibiotic.  If such a wound does not respond to topical antibiotics, obtain quantitative bacterial cultures and evaluate the underlying bone for osteomyelitis.  Systemic, rather than topical, antibiotics should be used.  Wound dressing treatment should be continued.

CONSULTATION

Any questions should be directed to the Clinical Nurse Specialist, Derenda Hodge, or the wound management nursing team (Debra Gray is an inpatient wound/ostomy care nurse; beeper 835-0491.)  Plans are being made to train the NICU charge nurses as resource nurses in wound care management. 

Currently, consult Derenda Hodge for all full thickness wounds in the NICU.  She will follow these patients on a regular basis and ensure consistency of care. She will also assist with consultation of the wound management team.  The wound management team will make recommendations to consult Plastic Surgery or Physical Therapy if needed.

Discussed at the Collaborative Pathways Committee meeting 11/28/01; approved at the Clinical Division Meeting 1/21/02.

References:

Young T. Wound healing in neonates. The Journal of Wound Care 1995; 4: 285-8.

Stickland ME. Evaluation of bacterial growth with occlusive dressing use on excoriated skin in the premature infant. Neonatal Network 1997; 16: 29-34.

David JA. Wound Management: A Comprehensive Guide to Dressing & Healing. 1986.

Beaumont E, Anderson-Dam M. Wound care science at the crossroads: A guide for selecting from the latest wound care products. American Journal of Nursing 1998; 98: 16-21.