The “ABCs” of wound management: a quick guide for veterinary nurses

There are many dressings, creams and bandages on the market, all claiming to speed up wound healing. In some cases, they make fairly big claims about how they can help you heal a patient’s wound. But the truth is that most wounds will heal with time. What veterinary nurses need to do, however, is ensure this is done as quickly, effectively and safely as possible, with as little discomfort and disruption to our patients as possible.

So, it is important to remember a couple of crucial things:

1. The moist wound healing principle, which speeds up the healing of a wound
2. Your care of the wound can work in one of two ways – either to increase and improve the wound healing, or to slow the progression of wound healing

For these reasons, I feel it is essential to follow the subsequent steps for the treatment and management of a wound.

Wound preparation

This step is broken down into three further steps: wound clip and cleanse, wound lavage, and debridement or decontamination.

Wound clip and cleanse

When clipping and cleansing a wound, there are five aspects you should consider:

1. You should always wear gloves when handling or treating a wound
2. Pack the wound with a water-based gel. Traditionally, people use hydrogel or KY Jelly – just make sure that if you are using KY Jelly, it has not been used for thermometers!
3. Use clean size 40 clipper blades to clip the fur from the periphery of the wound. First clip in the direction of the hair, then repeat against the direction of the hair. You should ensure that the clip margins are wide to prevent contamination from the patient’s hair – this will also stop any exudate or wound cream from getting stuck and clogged up in the hair
4. Vacuum up excess hair and clean the vacuum – how often does the end and suction tube of your surgical hoover get cleaned?
5. The skin around the wound should be prepped as if the patient is going into surgery. While doing this, you should cover the wound with a water-based gel or saline-soaked swab to prevent contamination of the wound with potentially irritant cleaning solutions

Wound lavage

Delayed wound healing and/or a prolonged phase of inflammation is commonly linked to poor wound lavage and wound bed preparation.

The ideal pressure to lavage a wound is 8 to 15psi, which is easily achieved using a 19 to 20g needle with a 20ml syringe. At this psi, there is enough pressure to dislodge forming biofilms, but it is not strong enough to push contaminants deeper into the wound.

Delayed wound healing and/or a prolonged phase of inflammation is commonly linked to poor wound lavage and wound bed preparation

The old saying “dilution is the solution to pollution” is definitely true, and it is where things often go wrong. Things go wrong when not enough lavage solution is used, either due to the time constraints of wanting to get the patient into theatre or because after a certain amount of lavage, people feel that “that’s enough”. I personally find it easier to make a lavage system instead of a 20ml syringe and 19g needle on their own, as you have to keep returning to the fluid bag to fill the syringe. I attach a cheap giving set to the fluid bag, with a three-way tap on the end; I then place the 19g needle on one side and the 20ml syringe on the other and hang the bag above the patient. This makes it much quicker to refill your syringe: just twist the three-way tap, fill the syringe, turn the tap again and fire away!

There is a six-hour golden period before the wound becomes stationary, therefore early irrigation is important. For every hour a wound is flushed before this time, the potential bacterial load will be halved.

Debridement/decontamination

Debridement and/or decontamination is the removal of bioburdens such as bacteria, foreign material and necrotic tissue. It is crucial that this is done effectively as any bioburden remaining in the wound will lead to an elongation of healing times and, potentially, the length of the inflammatory phase of healing.

There are different types of debridement, and the choice of which to use is dependent on the type of wound you are dealing with:

• Surgical or wet to dry for physical wounds
• Larvae or protease for chemical/enzymatic wounds
• Hydrogel or osmotic factors for autolytic wounds

Enhancing wound healing

This section on enhanced wound healing looks at how we promote/encourage the wound to heal as efficiently as possible.

A moist but not macerated wound environment is required for enhanced wound healing. This means you need to choose the correct dressing to manage exudate

A moist but not macerated wound environment is required for enhanced wound healing. This means you need to choose the correct dressing to manage exudate from the wound while maintaining a moist environment.

During this stage you must:

• Ensure the wound is free of contamination and excess debris
• Ensure the wound is free of toxic chemicals, particles and fibres – this may seem straightforward, but it also refers to substances like chlorhexidine coming in contact with the wound bed. This is because chlorhexidine and some other compounds are toxic to fibroblasts, which are crucial to wound healing! At this point, you also need to think about the use of lint-free swabs over cotton wool when cleaning in or around the wound due to the amount of fibres left behind by cotton wool
• Minimise the need for tissue disturbance – this involves choosing the correct wound dressings to minimise disturbance upon removal. Don’t change the dressings too often as once the patient is out of the inflammatory phase, you don’t want to disturb the wound bed too frequently

Any dressings used should be painless to apply and remove, minimise contamination to and from the wound and promote ideal healing. Don’t forget that “dressing” refers to pads and potions. It is important to ensure the correct dressing is selected for the wound depending on the properties of the wound dressing – but that is a whole different subject!

Wound protection

This section breaks down how veterinary nurses can protect the wound during its repair and healing, by contemplating four aspects that can interfere with wound management.

Patient interference

Traditionally, patient interference would be “busted” with a buster or Elizabethan collar; however, these can be quite traumatic for the patient (and owner). Furthermore, they can actually cause more trauma to a wound as they tend to have rough/hard edges which can traumatise the skin if the patient turns round to look at the wound or clean a nearby area.

There will always be that one patient who will need a buster collar, but for many patients, there are lots of alternatives now available to prevent patient interference. These include soft collars, inflatable neck collars and my own personal favourites: body suits! Body suits come in various patterns and sizes, but you can also buy ones specifically for a forelimb or a hindlimb; you can even get ones with little pockets on them to hold the grenade part of a suction drain or wound catheter!

Environmental contamination

Environmental contamination can include those items mentioned to prevent patient interference, but can also include items such as dog boots and socks.

When considering environmental factors, it is important to remember that they may be needed for some time after a wound has healed. This is because, once healed, a wound only has 80 percent of its original tensile strength, meaning wounds in areas that are under high environmental impact – such as toes – or wounds on areas with little protection under the skin – bony prominences such as elbows – may need protection from environmental factors for a period of time after apparent healing.

Owner education

Owner education is something I feel passionately about. If I had a wish in veterinary practice, it would be to ensure that every patient leaving the surgery on day one of bandage application should receive a bandage care form for the owners to take home and read through. The bandage care form should detail what owners should do with the bandage and their pet, what they should be looking out for that may signify a problem and when they should seek help/return to the clinic. This is important because if you are doing a great job with wound care and management but don’t educate the owner to come back if the bandage gets wet, slips or shows strikethrough, it will delay wound healing.

If you are doing a great job with wound care and management but don’t educate the owner to come back if the bandage gets wet, slips or shows strikethrough, it will delay wound healing

Bandage application

Bandaging is not an easy task, and it is something which is not focused on in the grand scheme of veterinary nurse training and education.

There are lots of potential complications involved with bandaging: pressure sores, friction injuries and constriction injuries, whether the bandage is too tight, too loose or if it’s lumpy, and whether you have dissipated the pressure from bony prominences. All of these things can result in delayed healing of the wound but can also cause further injuries from the bandage. So it is important to ensure you practise best-practice bandage care and application and provide the whole team with bandage training so they understand the science behind bandage application.

Conclusion

So, as you can see, there is much more to wound healing than just choosing the new super-duper dressing and hoping for the best.