HEALING PROTOCOLS

For the beginning of the program, support is planned for 120 interventions/month per team,
with dressings, creams and solutions. During the time in which the treatment is carried out,
they will undergo a medical evaluation and will receive guidance regarding wound care
(cleaning, feeding, rest, etc.) by the nurse. The treatments will be carried out in the place
where the wound carrier is, whether at home or in a hospital institution.

First visit:

 Perform initial clinical evaluation (interview and physical examination) and open
medical history;
 Carry out evaluation of the wound according to established parameters;
 Record pertinent information completely and clearly;
 Inform about the rules of the service, clarify doubts and request informed consent as
well as signing the terms of service document.
 Place the patient in a comfortable position that allows a good view of the injury,
always remembering, and in advance, to guide the patient and their family members
about the procedure to be performed; explain the serum jet technique.

 Recommend blood count, fasting blood glucose and serum albumin when indicated
and as long as there are no results with a period of less than six months.
 Recommend culture and antibiogram of secretions, in case of clinical signs of
infection;
 Prescribe dressings or bandages.
 Make necessary recommendations to the patient (diet, hygiene, clothing, rest, oral
and topical hydration, treatments, care with the secondary bandage);
 Schedule a new visit.
Visits Next:

 Evaluate the appearance of the previous treatment;

 Evaluate the appearance of the injury;
 Record the data (general and wound) in the medical history.
 Record observations in the evolution;
 Measure the wound every 15 days;
 Repeat laboratory tests when:

o there is suspicion of wound infection (culture of secretions with

antibiogram);
o if the blood glucose is greater than or equal to 110 mg/dl (fasting blood
glucose);
o if the hemoglobin is less than or equal to 10 mg/dl (hemogram after 30
days).

 NOTE: Refer to the insurance company when there are laboratory alterations.
 Carry out treatment according to the plan and the evolution of the wound
 Schedule a new visit.

ROLES AND ACTIVITIES OF EACH TEAM MEMBER

NURSE
 Make the nursing consultation, evaluate, classify the wound and propose the
appropriate treatment.
 Fill out the registry of patients treated;
 Refer the patient for medical evaluation (clinical or general) to determine the
etiology of the injury.
 Guide the patient regarding the commitment in relation to their care;
 Measure the injury.
 Prescribe, when indicated, dressings, bandages, solutions and creams for the
treatment of injuries, as well as compression therapy and moisturizing cream,
according to protocol.
 Run the treatment.
 Record the evolution of the wound by filling out the wound evaluation form for
each wound treated.
 Train and supervise the team of nurses and doctors in the treatment process.
 Predict and control the consumption of dressings, bandages, creams and solutions to
carry out the treatments.
 DOCTOR
 Clinically evaluate the patient and define the etiology of the wound.
 Prescribe, when indicated, bandages, solutions and creams to treat injuries, as well
as compression therapy and moisturizing cream, according to protocol.
 Request and interpret tests such as fasting blood glucose, blood count, serum
albumin, cultures and secretion antibiograms, if necessary, and propose the
appropriate treatment for each case on an individual basis;
 Refer the patient to a specialist, when necessary.

 Monitor the evolution of the clinical picture together with the nursing team.

 Schedule the return in an established period, according to evolution or sooner when

necessary;
 Discharge the patient.
 NOTE: In case of suspected local infection, a culture with antibiograms should
always be requested and antibiotics indicated.

CHARACTERIZATION OF WOUNDS

Venous ulcers in lower limbs

This is due to chronic venous insufficiency due to deep vein thrombosis, primary varicose
veins, constitutional venous valve anomalies and other causes that interfere with peripheral
venous return. Ulcers generally form after trauma or infections, although they can develop
without this history.

The prodromal signs are: evening edema in the ankles and ocher angiodermitis,
characterized by red-brown spots, the result of pigmentation due to hemosiderin deposits,
caused by extravasation. Other conditions that may precede, coincide with, or follow the
ulcer are eczema and streptococcal infection.

They are generally located in the lower third, posterior internal peri-malleolar aspect of the
leg, with a single presentation and slow progression, forming an ulcer of variable shapes
and sizes. At the beginning it presents irregular edges, hemorrhagic or purulent
background, however, with evolution the edges become devitalized and adherent to the
underlying tissues. The appearance of erysipelas prolongs it and increases fibrosis, which
predisposes to new sources of infection. The vicious circle is formed that leads to
dermatosclerosis and/or elephantiasis of the leg.

Microangiopathy Ulcers

Leg ulcer can occur due to microangiopathy in cases of chronic arterial hypertension,
diabetic microangiopathy and other vasculitis located in the dermal tissue.

They are ulcers without relief, extremely painful, with a necrotic base, generally occurring
bilaterally and attacking mainly the external surface of the legs, above the ankle.

Ulcers due to arteriosclerosis

Leg or foot ulcer is found in elderly people, frequently diabetic and/or hypertensive, but is
mainly triggered by cutaneous ischemia dependent on truncal arterial lesions, generally
post-traumatic.

They are ulcers with torn, irregular and painful edges, located on the ankles, malleoli or
digital extremities, there is pallor, absence of stasis, delay in recovery of color after
elevating the limb, decreased or absence of pulse in the arteries of the foot and pain of
variable intensity.

Ulcers due to Anemia

Leg ulcer that can occur in various types of hemolytic-spherocytic, non-spherocytic and
particularly sickle-cell anemia, associated with hepatomegaly, splenomegaly, jaundice and
other symptoms. Sickle cell or sickle cell anemia is found in our environment and is
elective for the black or mixed race. The ulcer is quite painful, it is located in the lower
third part of the leg, without specific characteristics.
Neurotrophic Ulcers

Perforating disease is chronic ulceration in the anesthetic area, due to trauma or pressure. It
occurs in Hansen's disease, syringomyelia, injuries or conditions of the peripheral nerves,
such as chronic alcoholism, and in other neurological conditions such as the congenital
absence of pain and Thévenard syndrome. Diabetic peripheral neuropathy frequently causes
perforating disease.

The injury is located in the area of trauma or pressure, such as in the calcaneal or metatarsal
region. Initially there is callus, later fissures and ulceration appear. The typical appearance
is a painless, hyperkeratotic ulcer with edges. Due to secondary infection, there are signs of
inflammation and the bones may be compromised with osteomyelitis and removal of
sequestra.

Pressure Ulcers

Ulcerated lesions that occur in the lumbosacral region, in the ankles, heels and other
regions of bedridden, debilitated or paraplegic patients. They are determined by the
continuous pressure exerted on a certain skin area and depend on vascular and neurotrophic
mechanisms.

Exception : Marjolin ulcer : It is the development of squamous cell carcinoma in chronic

ulceration or scar. It is characterized by the progression of ulceration with a vegetative or
wart appearance, mainly at the edge. The biopsy is essential.

Differential Diagnosis of Ulcers

 Pyoderma Gangrenosum
  Dysglobulinemias
 Skin Neoplasms
 Klinefelter syndrome
 Erythema nodosum (cutaneous TB)
 Lipoid necrosis
 Vasculitis
 Leishimaniasis
 Deep mycoses (Sporotrichosis, Chromomycosis, Paracoccidioidomycosis)
 Tertiary Syphilis
 Acroangiodermatitis (Pseudo Kaposi's Sarcoma)
 Factitious Ulcers

Burns

The burn is an injury caused by the following etiologies: thermal, chemical, electrical and
radiation. There may be partial or total destruction of the skin and its annexes, or of deeper
structures (subcutaneous tissue, muscles, internal organs, tendons, bones). Burns are
classified in three different ways: depth, extension and etiology. . Only small burns can be
treated on an outpatient basis, in non-special areas and without complications, that is:

-1st degree burns;

-2nd degree burns with less than 10% in adults and 6-8% in children.

NOTE: Special areas are considered: the face, the cervical region, the anterior region of the
thorax (burns in this region can cause obstruction of the airways due to edema), axillary
region, fists, hands and feet, cavities, perineum and genitals. Burns in children and the
elderly or accompanied by acute and chronic pathologies (high blood pressure, Diabetes
Mellitus), fractures, external injuries or lacerations in internal organs are very serious.

For the management of the patient with a burn, it must be taken into account.

 In the presence of oily solutions, the skin can be cleaned with liquid hospital soap.
 Burn patients should follow the described care program.
 Protect him from trauma
 Instruct the patient not to break it
 Small Burns
 Presence of Flictenas
  Preserved without infection
 Presence of broken Flictenas.
 Assess the risk of rupture (age, location, occupation)
 Evaluate signs of infection and presence of contamination
 Without risk or with risk
 Maintain Flictena
 Without infection or with infection
 Use devices for debridement (according to medical specifications)
 Thorough cleaning with 0.9% SF jet;
 Wear surgical gloves;
 Remove all devitalized tissue with the help of scissors or tweezers;
 Don't forget to prepare the surgical field (open gauze can be used).

TOPICAL TREATMENT:
 Hydrocolloid: in wounds with little to moderate secretion and size equal to or less
than 250 cm 2 ;
 Calcium alginate: in wounds with a lot of secretion and a size equal to or less than
250 cm 2

 Silver sulfadiazine wound with more than 250 cm 2 and when:

- Little secretion change 1 time a day;

- Moderate to intense secretion change from 2 to 3 times a day.

 Use devices for debridement;

 Thorough cleaning with SF 0.9% jet (no need to use antiseptic);
 Wear surgical gloves;
 Remove all devitalized tissue with the help of scissors or tweezers;
 Don't forget to use a surgical field (open gauze can be used).
 Aspirate the flictena at the base with an insulin syringe and 25x8 mm needle;
 Preserve burned skin.

GENERAL GUIDELINES
WOUND CLEANING TECHNIQUE
According to the Spanish language dictionary, cleaning is the act of removing dirt. Then,
wound cleaning is the removal of necrotic tissue, exogenous matter, excess secretion,
residues of topical agents and microorganisms existing in the lesions, promoting and
preserving granulation tissue.

The ideal wound cleaning technique is one that spares granulation tissue, preserves
recovery potential, and minimizes the risk of trauma and/or infection. The best technique
for cleaning the lesion bed is irrigation with warm 0.9% saline jets.

NECESSARY MATERIALS:
 procedural gloves;
 surgical gloves;
 Physiological serum 0.9% - 250 ml or 500 ml;
 Needle 25x8 mm.

 Plastic garbage bag (Red, green or gray; depending on waste classification);

 Garbage bin (red, black, green and guardian bags);
 Mask;
 Safety glasses;
 Dressings, bandages, cream or ointment indicated;
 10x10 gauze, tetras gauze or both;
 Alcohol at 70%;
 Liquid soap.
 Adhesive tapes.
 Instruments (tweezers, scissors, scalpel)

PROCEDURE DESCRIPTION:
 Hand washing;
 Gather and organize all the material that will be necessary to carry out the
treatment;
 Place the patient in a comfortable position and explain what will be done;
 Do the treatment in a space with good lighting that preserves the patient's privacy;
 Use protective equipment (goggles, mask, gloves and white coat) and follow
international biosafety measures. NOTE : Do not perform the procedure wearing
shorts, skirts and sandals, to avoid work accidents.
 Use a 0.9% saline bag, or failing that, a bottle, taking into account disinfecting the
upper part of the bottle with 70% alcohol and piercing before the upper curvature
with a 25x8 mm needle (only one hole). ;

(NOTE: The gauge of the needle is inversely proportional to the pressure obtained
by the serum jet, discard the needle after each procedure .)

 Use the procedure glove only on the most dexterous hand, leaving the other free;
 Remove the tie and wound dressing using the procedurally gloved hand;

 If, when removing the bandage and/or binding of the wound, they are very adherent
to the injury, take the bottle of physiological saline with your ungloved hand and
apply the jets, stirring very delicately, avoiding trauma. and thus setbacks in the
healing process.

 Discard used bandages and gloves in the RED trash bag.

 Putting on a new procedural glove:

 Thoroughly irrigate the wound bed with a stream of saline solution from a distance
of around 15 cm until all dirt is removed.

 Manually clean the skin around the lesion with gauze moistened with 0.9% SF. In
case of contamination, hospital liquid soap can be added;

Note: When necessary, use a wooden spatula and sterilized scissors (depending on the
procedure). Do not dry the wound bed with gauze.

 Apply the chosen dressing as prescribed by the nurse or doctor (use surgical gloves
when necessary);

 Apply moisturizer to the skin around the wound, when necessary, always after
applying the dressing or bandage.

 Bind the limbs distally proximally, from left to right, with the roll of binding facing
up. In the case of an open abdomen, use adhesive tape to approximate the edges and
perform the wrapping technique with a sheet.

 Make the compression bandage in case of venous ulcer.

  Record the evolution in the medical history and in the patient registry.

 Discard the bottle with serum residue at the end of the day;

 Clean the instruments used according to the Sterilization Manual.

 Clean and organize at the end of the procedure.

 Exceptions: If tweezers or scissors are used, the instruments must be placed in a

container with water and enzymatic soap. If containers and plates are used, they
must be cleaned and disinfected after the procedure.

MEASUREMENT TECHNIQUE OF THE INJURED AREA

 Clean the wound with the serum jet technique;

 Measure the depth of the wound by inserting a sterile applicator and after removing
it, measure the centimeters on a ruler or meter.

 Measure the length and width of the wound regardless of the patient's cephalo-
caudal position.

 Write down the measurements of the lines in cm, in the medical history, for later
comparisons, multiply one measurement by the other to obtain the area in cm 2 .

 Exceptions:

-In the presence of two or more wounds, separated by intact skin of up to 2 cm, it should be
considered a single injury. Take measurements of the wounds, calculate the injured area
and add it up;

-During the healing process, with the formation of the epithelialization island, which
divides the wound into several, the measurement of the largest wound must be considered
horizontally and, vertically, the measurement of all the wounds must be added.
 TECHNIQUE FOR MEASURING THE DEPTH OF THE
INJURY

 Clean the wound;

 Introduce an applicator into the deepest point of the lesion using the clockwise
technique to record.

 Mark the closest point of the edge on the instrument;

 Measure the marked segment with a ruler and write down the results in cm for later
comparison.

TECHNIQUE FOR MEASURING THE FALSE CLOSING

OF THE INJURY

 Insert a number 10 urethral catheter into the wound;

 Do a cleaning (thoroughly clockwise);

 Identify the point of greatest tissue clearance (direction in hours);

 Mark the point closest to the edge on the probe;

 Measure the marked segment on the ruler;

 Record in history the size (cm) and direction (H) of the measurement for later
comparison. Example: 5cm towards 10 o'clock.

S ECRETION
  Describe volume (absent, scarce, moderate, abundant), color, smell .

S KIN AROUND THE WOUND

 Describe color, warmth, hydration

Evaluation Scales
PAIN

The patient reports the scale of his pain, according to his own evaluation, assigning a value
like this:

0 – Absence of pain;

1 – Mild: pain without demand for analgesics;

2 – Moderate: pain with relative analgesic demand;

3 – Intense: pain with demand for analgesic at specific times.

P RESSURE U LCER C LASSIFICATION

This staging describes the degree of depth and tissue involvement:

Stage I: involvement of the epidermis;

Stage II: involvement to the dermis;

Stage III: involvement up to the subcutaneous level;

Stage IV: involvement of the muscle and adjacent tissue.

T YPES OF FABRICS

Evaluation of the amount of viable and non-viable tissue through the attribution of
percentage values of what is being observed. Example: 20% necrotic tissue and 80% viable
tissue.

 Viable tissues: granulation tissue, epithelialization.

 Non-viable tissues: Devitalized, dry necrotic, moist necrotic, macerated, callused,

fibrinous.

P ULSE

This evaluation must be done by comparing the homologous segments to establish the
measurement:

4 Normal pulse

3 Discretely decreased

2 Moderate decrease

1 Significant decrease

0 Absence of pulse

Dermatitis

1+/4+: Presence of hyperemia or peeling in the peri-wound area;

2+/4+: Presence of hyperemia or peeling that exceeds the peri-wound area;

3+/4+: Hyperemia associated with peeling;

4+/4+: Presence of hyperemia associated with points of secretion in the area beyond the
periwound, which may or may not be associated with peeling.

BANDAGE TECHNIQUE

It is the placement of a sash with the objective of:

1. Wrap, pin and protect injured parts;

2. Maintain treatments.

3. Facilitate venous circulation through slight compression;

4. Immobilize limbs.

COMPLEMENTARY EXAMS

These exams must be performed according to the patient's conditions, their evolution;
according to observation of the medical and nursing team.

NUTRITIONAL ASSESSMENT
The patient's nutritional status is reflected in the healing process. The Body Mass Index
(BMI) should always be evaluated to characterize low weight or obesity and, thus,
intervene efficiently.

Follow the description of some foods rich in vitamins (A and C) and minerals (iron and
zinc). This knowledge is essential to guide patients with wounds.

MC= Current weight / height m 2 .

<0= 16 (caloric malnutrition G III.

1.

(grade GII caloric malnutrition)

2.

17-18.5 (Grade I caloric malnutrition)

3.
18.5 – 20 (normal underweight)
4.
20-25 (normal).
5.
25 – 30 (grade I obesity).
6.
30-40 (degree II obesity)
7.
>40 (grade III obesity).
8.

Foods rich in Vitamins and Mineral Salts : Broccoli (raw flowers) Broccoli Oats (raw
fringes) liver.

Foods Rich in Vitamin A : Carrot Beet (raw) eggs, Manga Walnuts Raw liver.

Foods Rich in Vitamin C: Green lemon (juice) Raw soy, Orange paprika (juice) Raw
dried lentils.
Foods Rich in Iron: Meat, Red guava Broccoli (raw leaves) Beans Spinach Broccoli (raw
flowers) Milk, Raw beef liver Raw beet Raw spinach Legumes.

Foods Rich in Zinc: Spinach, Guava, Coffee, whole grains, Strawberries, Nuts, Orange.
Indications and Contra-indications of bandages,
Solutions and Creams Standardized by the FDA
SILVER SULFATE + CERIUM NITRATE CREAM

 Antiseptic

 Composition: micronized silver sulfate and cerium nitrate hexahydrate.

 Actions: effective against a wide variety of microorganisms, such as: gram negative
bacteria, fungi, protozoa and some viruses; re-epitalizing; promotes better grafting
bed and immunomodulatory action;

 Indication: treatment of burns, and wounds that do not evolve with occlusive
bandages and extensive wounds (with an area greater than 350 cm²);

 Contra-indications: presence of hypersensitivity to the components;

 Adverse reactions: renal or hepatic dysfunction, transient leukopenia, very rare

cases of hypo-osmolarity, very rare episodes of increased sensitivity to sunlight;

 Change with a maximum period of 24 hours.

HYDROCOLID DRESSINGS

 Composition: they have two phases: an external one, composed of polyurethane

film or foam, flexible and impermeable to water, bacteria and other external agents;
and an internal one, composed of hydroactive particles, based on
carboxymethylcellulose, gelatin and pectin or both (some do not have these last two
elements) – which interact with the wound secretion, forming a yellowish, viscous
gel with a strong odor;
  Actions: stimulate angiogenesis (due to hypoxia in the wound bed), absorb excess
secretion, maintain humidity, provide pain relief, maintain temperature around
37ºC, ideal for cell growth, promote debridement self lytic;

 It should be applied directly to the wound, leaving a margin of 2 to 4 cm around it,

for better adhesion;

 It can be cut, it does not need sterilized scissors because the edges of the plate will
not come into contact with the wound bed;

 Selective permeability, allows gas diffusion and water evaporation;

 Impervious to liquids and microorganisms (reduces the risk of infection);

 Indication: wounds with low to moderate secretion, without necrotic tissue,

superficial burns.

 Contraindication: infected wounds with a large degree of secretion, full thickness

wounds

 Change: for up to seven (7) days.

CALCIUM ALGINATE

 Composition: alginic acid fibers (guluronic acid and mannuronic acid) extracted
from brown seaweed ( Laminaria ). They also contain calcium and sodium ions;

 It comes in the form of a sterile plate or cord, and must be used with open gauze or
double gauze (Secondary dressing);

 Actions: through ionic change promotes hemostasis; absorbs secretion, forms a gel
that maintains moisture, promotes granulation, helps aotolytic debridement;

 Use with gloves or sterile tweezers;

 It can be cut, but sterilized scissors should be used and the leftovers should not be
reused;

 Calcium alginate place of horizontal absorption, must be cut to the exact size of the
lesion, avoiding maceration of the surrounding skin;

 Indication: infected wounds with intense secretion with or without necrotic tissue
and bleeding (not bactericidal).
  Contraindication: wounds with little or no drainage of secretion;

 Change: primary coverage up to 7 days; Secondary dressing changes should be

made as needed.

ACTIVATED CARBON AND SILVER:

 Composition: activated carbon fabric, impregnated with silver (o.25%) externally

wrapped by a nylon film (sealed);

 Primary and sterile coverage; requires secondary coverage (open or double gauze);

 Use with sterile gloves;

 Actions: absorption of secretion, microbicide, elimination of unpleasant odors,

autolytic debridement and maintenance of temperature around 37ºC;

 Indications: fetid, infected wounds with a lot of secretion or colonized wounds.

 It cannot be cut due to the release of silver into the wound bed, which can cause
tissue burns from silver or form granuloma due to carbon residue;

 Change: primary coverage for up to 7 days or until saturation and change of

secondary dressing as needed.

 In wounds with little secretion, use Vaseline primary dressing (petrolate emulsion).

AMORPHOUS HYDROGEL :

 Composed of a large amount of glycerinated water; currently some contain sodium

alginate.
 It should always be used in conjunction with semi-occlusive coverage or Vaseline
gauze.

 Actions: maintains humidity and helps autolytic debridement

 Does not adhere to the wound bed

 Indication: maintain moisture in the wound bed allowing autolytic debridement,

change every 3 days.
  Contraindication: wounds with excessive secretion, cannot be packed.

COLLAGEN DRESSINGS:

 Offers structural support to new tissues.

 It maintains a physiologically moist microenvironment on the wound surface that

contributes to the formation of granulation tissues and epithelialization.

 It is absorbent, leaves no residue in the wound, can be cut, heals every 4 days

 Contraindication: infected, necrotic wounds, some patients may present allergic

reactions.

HYDROPOLYMER DRESSINGS:

 They are special foams that capture excess exudate from wounds and are
impermeable to liquids.

 They are semi-occlusive (they allow vapor exchange). They are a viral barrier.

 Indications: clean wounds with moderate to abundant exudate, change for up to 7

days.

 Contraindication: wounds with no or very low exudate, deep wounds (if there is no
primary dressing), infected wounds.

TRANSPARENT DRESSINGS:

 They are semi-occlusive transparent polyurethane films indicated mainly in wounds

with zero to low exudate, especially in burns and lacerations of 1 and 2 degrees or
prevention of pressure ulcers.

 It is also used in the fixation of central and peripheral catheters.

 They are a viral barrier and waterproof.

 Change for up to 7 days.

 Contraindications: wounds with moderate or abundant exudate, infected wounds.

VASELINED DRESSINGS:

 They are cellulose acetate gauze impregnated with petrolatum emulsion. Their main
indications are: Burns, donor areas, lacerations, wounds with low exudate.

 Changes every 7 days; must have secondary dressing for support and absorption.

COLLAGENASES:

 They are enzymes derived from clostidium histolicum that have the ability to break
the native collagen cords; Its main action is wounds with necrotic tissues.

 Contraindications: infected wounds.

 Change every 48 hours.

MOISTURIZER:

 Composition: 8% urea, 5% glycerin, 3% sweet almond oil and stearic acid. Neutral
PH

 Action: the urea present in the cream facilitates the penetration of water molecules
to deeper layers of the skin;

 Indication: topical hydration;

 Contraindications: friable skin, report of allergy to any component of the product.

TERMS OF THE COMMITMENT

TREATMENT GOALS

In the treatment of wounds, THE SERVICE PROTOCOL aims to:

1. Evaluate and accompany the patient with an injury;

2. Refer to other professionals when necessary;

3. Promote conditions that facilitate wound healing;

4. Guide and encourage self-care.

PATIENT UNDERSTANDING

The right and opportunity to ask questions related to the service, treatment, its objectives
and its rules is made clear to the patient, and health professionals are always able to answer
them.

It is your responsibility:

 Avoid failing to comply with the visit for 2 consecutive times or 3 alternate times
without prior communication;

 Respect and follow all guidelines given by health professionals;

 Do not withdraw or change treatments without the permission of the professional;

 Do not cut the dressings without informing the treating professional;

 Attend your health service outside of scheduled visits in case of emergencies or

complications;

 Assume activities related to cleaning and personal hygiene;

 Facilitate the team's activities by preparing for the visit, taking into account that the
time allocated per patient is 20 minutes on average, and any delay may interfere
with scheduled activities.

Explanatory note: The treatment of various injuries should be prescribed by the nurse,
preferably by the person with the most training in the area. The prescription of medications
and the request for laboratory and X-ray tests, when performed, is done respecting the
protocol of each institution or insurer.
Using my mental faculties, I sign this document which I have read and understood in its
entirety, assuming the responsibilities as a patient stated here and recognizing my rights as
a user.

TECHNICAL INFORMATION FOR INTERVENTION ON

THE WOUND CARRIER

This document contains technical information regarding the evaluation of the carrier of a
skin lesion, the evaluation, classification and treatment of the lesion, including methods of
debridement of necrotic tissue. Its objective is to establish the performance of nursing
professionals in the prevention and treatment of skin lesions.

I) EVALUATION OF THE INJURY CARRIER

1. Clinical examination

1.1. Interview

1.2. Physical exam

II) EVALUATION OF THE INJURY

1. Fabric characteristic

1.1. granulation tissue

1.2. epithalization tissue

1.3. Necrotic tissue

2. Appearance of the secretion

2.1. Serous

2.2. Sero-bloody

2.3. Bloody

2.4. Pio-sanguinolenta

2.5. Purulent

3. Exhibition of anatomical structures

3.1. Muscle

3.2. Tendon

3.3. Blood vessels

3.4. Bone

3.5. Cavity/ organs

III) CLASSIFICATION OF THE INJURY

1. Extension - area = cm2

1.1. Small: less than 50 cm2

1.2. Medium: greater than 50 cm2 and less than 150 cm2

1.3. Large: greater than 150 cm2 and less than 250 cm2

1.4. Extensive: greater than 250 cm2

Observation: Recommended measurement: the measurement of the greatest vertical and

horizontal extensions of the wound to be classified is used. It is highlighted that the two
layouts must be perpendicular, constituting an angle of 90º.

In the case of more than one wound on the same limb or in the same body area, with a
minimum distance between them of 2 cm, the sum of their largest extensions (vertical and
horizontal) is made.

2. Depth - structural compromise

2.1. Superficial: up to the dermis

2.2. Deep superficial: up to subcutaneous

2.3. Total depth: muscle and adjacent structures.

Note: In the case of necrotic tissue, this classification will be used after debridement.

3. Tissue compromise (this classification applies only to pressure ulcer)

Stage 1 – epidermis involvement.

Stage 2 - involvement of epidermis and dermis.

Stage 3 - involvement of epidermis, dermis and subcutaneous tissue.

Stage 4 - involvement of epidermis, dermis, subcutaneous and adjacent tissues.

Observations: In case of necrotic tissue, the states must be reevaluated.

4. Presence of microorganisms

4.1.Clean

4.2. contaminated

4.3. Infected

5. Evolution time

5.1. Acute

5.2. Chronicle

IV) TREATMENT

1. Cleaning

1.1. acute wound

Exhaustive cleaning that aims to remove dirt and microorganisms existing in the lesion bed.
In this case, the use of antiseptic solutions is permitted.

1.2. chronic wound

Cleaning that debrides the removal of tissue, excess secretion, residues of topical agents
and microorganisms existing in the lesion bed, in addition to preserving granulation tissue.
For this purpose, only warm 0.9% physiological saline is used in a jet (hydraulic force),
regardless of whether there is an infection or not.
2. Debridement

Removal of foreign or devitalized material from traumatic injury tissue, whether infected or
not, or adjacent to it, until the surrounding healthy tissue is exposed.

2.1. Mechanical - by physical action

2.1.1. Friction

Rub the gauze or sponge soaked with saline solution on the lesion bed in one direction.

Indication: acute injuries with dirt;

Contraindication: chronic injury.

2.1.2. With sharp instruments

Remove necrotic tissue using cutting instruments (blades and/or scissors).

Indication: lesions that involve even the subcutaneous tissue – deep, superficial or ulcers

stage 3 pressure

Contraindication: ischemic ulcers and those without the possibility of healing, ulcers

fungal and neoplastic, coagulation disorders, with tendon exposure or with patients

in anti-coagulant therapy.

Necessary material:
- package containing reta hemostatic forceps, anatomical and dissection, reta delicate
scissors, with tip (Iris)

- scalpel blade and corresponding cape

- sterilized compress packs

- surgical gloves

- individual protective equipment (goggles, gown, hat and mask)

- 0.9% physiological saline and antiseptic (for peri-wound use)

Locations indicated for carrying out the technique:

 outpatient clinics and hospitalization floors.

The environment must be private, clean, with adequate lighting, quiet and comfortable,
both for the patient and the professional.

Coagulative necrosis technique (ex.: eschar)

- Clamp the necrotic tissue at the edge, with the dissecting forceps;

- Dissect the necrotic tissue in thin slices, in one direction, using the scalpel blade;

- In the case of intensely adherent tissue or professionals with little skill, it is recommended
to delimit the necrotic tissue in small squares (escharotomy), using the scalpel blade and
proceeding to debridement;
- Interrupt the procedure before the appearance of viable tissue, in case of bleeding,
complaints of pain, fatigue (of the client/patient or the professional), prolonged time and
insecurity of the professional.

Wet Necrosis (soft)

- Clamp the necrotic tissue with dissecting forceps and cut with scissors;

- Interrupt the procedure before the appearance of viable tissue in case of bleeding,
complaints of pain, fatigue (client/patient or professional), prolonged time and insecurity of
the professional.

2.2. Self lytic

By autolysis, bone, auto degradation of necrotic tissue under the action of lysosome
enzymes, released by macrophages.

Indication: Wounds with necrotic tissue, highlighting that, in cases of bedsores, this process
can be prolonged. An eschar is understood as the necrotic tissue adhered to the bed of the
lesion with a hard, dry and petrified consistency, generally dark in color.

Contraindication: ischemic and fungal ulcers.

Necessary material:

- physiological saline 0.9%

Coverage that guarantees an environment conducive to autolysis, in other words, an

environment with physiological humidity, temperature around 37ºC, maintaining the
impermeability or occlusion of the wound, promoting hypoxia in the wound bed.
Technique

- Cleaning the wound bed with warm 0.9% physiological saline, in a stream.

- Dry the entire skin, through the wound, and apply the indicated coverage.

Chemical

By the action of proteolytic enzymes, which remove devitalized tissue through the
degradation of collagen.

Indication: Wounds with necrotic tissue, regardless of their characteristics.

Contraindication:

- Ischemic, fungal and neoplastic ulcers;

- Patients with coagulation disorders.

Necessary material:

 physiological saline 0.9%

 Topical medications based on proteolytic enzymes such as collagenase

Technique

- Cleaning the wound bed with warm, 0.9% physiological saline, in a stream;

- Dry the entire skin around the wound, apply a thin layer of the indicated product on the
lesion bed, and occlude the lesion.

3. Coverage
The coverage to be indicated must guarantee the principles of maintaining the temperature
in the lesion bed at around 37ºC, maintaining physiological humidity and promoting
hypoxia in the lesion bed. In addition to that, the coverage must have the following
characteristics:

- fill dead space;

- be impermeable to microorganisms and other fluids;

- promote hemostasis;

- be easy to apply and remove, avoiding trauma to the injury bed;

- be comfortable and aesthetically acceptable;

- absorb excess secretion;

- reduce pain and odor.

MANAGEMENT OF WOUNDS WITH SPECIALIZED

DRESSINGS
 WOUNDS WITH NECROSIS:

DRESSINGS: Amorphous Hydrogel, Collagenase.

ACTION: Debrides membranes and dead tissue from wounds. Promotes the formation of
granulation tissue; creates a moist environment for wound healing that assists with natural
autogenous debridement for longer than other types of saline-impregnated dressings or
gauze.
Observation: Healing every three days; must be fixed with secondary dressing: No exudate
with Transparent Semi-occlusive Dressing; With exudate with Hydropolymer; or with
Vaseline Dressing as appropriate.

 WOUNDS WITH NO EXUDATION

DRESSINGS: Amorphous hydrogels, Transparent films, Vaselined.

ACTION: Amorphous hydrogels provide moisture longer than moist gauze for up to 72
days.

 WOUNDS WITH LOW EXUDATION.

DRESSINGS: Hydrocolloids.

ACTION: This type of material, upon contact with the little exudate, forms a gel which
keeps the tissue hydrated, thus providing optimal conditions for healing, promoting
autolytic debridement.

Observation: Change for up to 7 days.

 WOUNDS WITH MODERATE TO ABUNDANT EXUDATE.

DRESSINGS: hydropolymers, Alginates.

ACTION: They absorb excess moisture to prevent tissue maceration, creating optimal
conditions for the healing process.

Observation: Changes for up to 7 days.

 DEVITALIZED WOUNDS:

DRESSINGS: Collagen.
ACTION: Contributes to the formation of granulation and epitalization tissue, giving
structural support to these tissues.

Observation: Healing every 4 days, must have secondary dressing.

 INFECTED OR COLONIZED WOUNDS.

DRESSINGS: Activated Carbon and Silver.

ACTION: This dressing is bactericidal, acting only with the microorganism causing the
infection, and also helps eliminate bad odor from the wound.

Observations: Healing for up to 7 days, must have secondary dressing.

 WOUNDS WITH GRANULATION AND/OR EPITALIZATION

TISSUE:

DRESSINGS: Transparent, Vaselined, Extra-thin Hydrocolloids.

ACTION: Create optimal humidity conditions so that the fabrics do not lose moisture or
temperature.

Observation: Healing for up to 7 days, only Vaseline needs secondary dressing for support.