Wound Care Nursing

Wound Care Nursing

Wound care nursing is crucial and applicable across various healthcare settings, including acute, home care, and long-term care. Nurses encounter wounds of varying complexity and require specialized skills for physical assessments and the development of suitable treatment plans. This article presents wound care nursing guidelines, procedures, and ethical considerations.

History of Wound Care Nursing

The roots of wound care nursing trace back to 2000 BCE when ancient Egyptians used grease, honey, and lint to address open wounds, promoting healing. They employed vinegar, water, or wine for wound cleansing.

In ancient Rome, the signs of inflammation, such as tumour, rubor, dolour, and colour, were first explained. During the Middle Ages, nuns undertook nursing tasks, often allowing wounds to decompose slightly. Over time, wound care nursing has evolved from basic dressing to becoming a certified specialty.

Wound Care Nursing

Modern wound care nursing has transitioned from empirical clinical practices based on traditional opinions to evidence-based practice, combining clinical expertise with external clinical evidence derived from research.

Evidence-based Practice Nursing Papers

Fundamentals of Wound Care Nursing

Wound management presents challenges as tissue damage can vary from superficial to deep. By adhering to fundamental principles, nurses can create effective treatment plans and simplify the process. Below, we explore postoperative wound care nursing assessment and management.

Wound Care Nursing Assessment

Wound management initiates with a thorough assessment. During both initial and ongoing wound assessments, nurses must consider the following factors:

– Type of Wound:

Wounds vary, categorized as acute or chronic, including burns, ulcers, surgical incisions, lacerations, abrasions, among others.

– Pressure Injuries:

Also known as pressure ulcers, these result from prolonged or intense pressure causing skin or tissue damage.

– Venous Ulcers:

These occur due to lower extremity valve dysfunction, leading to blood reflux into the venous system.

– Arterial Wounds:

Arterial wounds result from severe tissue ischemia due to peripheral arterial vessel atherosclerosis.

– Diabetic Foot Wounds:

These wounds stem from diminished pressure perception and pain sensation in the foot. Healing can be challenging, particularly in cases of bone infection, deep tissue involvement, and reduced blood flow.

– Skin Tears:

Caused by mechanical forces like friction, shear, or blunt force, skin tears may differ in depth but typically do not reach the subcutaneous layer.

– Moisture-Associated Skin Damage (MASD):

MASD results from skin inflammation due to exposure to various moisture sources, impairing its protective function.

– Location and Surrounding Skin:

Examining the wound’s surroundings and protecting it from further injury is essential. The wound’s location can provide insights into its potential causes.

– Extent of Tissue Loss:

Determining the extent of tissue damage helps formulate an appropriate care plan, with three categories: superficial wounds (involving the epidermis), partial thickness wounds (involving the dermis and epidermis), and full-thickness wounds (involving the dermis, subcutaneous tissue, epidermis, and possibly reaching bones, tendons, and muscles).

– Clinical Characteristics of the Wound Bed and Stage of Healing:

Understanding the wound’s healing stage is crucial. These stages include granulating (characterized by red/pink tissue with collagen, capillary networks, and elastin), epithelializing (new epithelium closure on healthy tissue), sloughy (yellow tissue due to dead cell accumulation, distinct from pus), necrotic (black, dry, dead tissue inhibiting healing), and hyper granulating (excessive granulation tissue development above the wound due to irritants or bacterial imbalances).

– Wound Measurement and Dimensions:

Evaluation and assessment of wound healing is an ongoing process. All wounds require both two-dimensional evaluation (measuring width and length in millimeters) and three-dimensional evaluation (measuring wound depth with a cotton tip applicator).

– Wound Edge:

Assessing wound edges involves observing their color (erythema indicates cellulitis, dusky edges suggest hypoxia, and pink edges indicate new tissue growth), evidence of contraction (healing, hyper granulation, or rolled edges), and any sensation changes (lack of sensation or increased pain).

– Exudate:

Both acute and chronic wounds produce exudate as part of the healing process. Exudate contributes to wound cleansing, provides nutrients, growth factors, energy for cell assimilation, high white blood cell counts, maintains a moist environment, and promotes epithelialization. Assessing the amount, type, odor, and color of exudate is vital, as excessive exudate may indicate skin breakdown, while minimal exudate suggests a deteriorating wound bed. In cases of infection, exudate may exhibit increased odor and viscosity.

– Presence of Infection:

Wound infections can harm tissue, disrupt healing, and spread disease. Signs of infection include malodour, localized pain, edema, redness (cellulitis or erythema), changes in exudate (purulent fluid), and localized heat.

– Pain:

Evaluating wound pain provides insights into its chronicity and cause. Pain assessment is essential for selecting the most appropriate dressing. Assessing pain before, during, and after dressing changes aids in selecting the optimal dressing and management approach.

Wound Management

– Consider psychological indications related to the wound.
– Establish the care goal and expected outcomes.
– Account for the fragile wound environment.
– Maintain bacterial balance.
– Preserve wound moisture.
– Ensure stable pH and temperature.
– Allow draining wounds to drain freely.
– Select appropriate dressing and techniques.
– Implement suitable wound therapies.
– Adhere to management principles for both acute and chronic wounds.

Wound Care Nursing Procedure

A wound refers to a disruption in the skin’s internal or external surface, resulting from physical causes. Wounds can be accidental or intentional, such as incisions made during surgical operations. The following outlines the procedure for wound or surgical dressing:

– Explain the process to the patient using sensory preparation.
– Wash your hands and put on gloves.
– Inspect the wound for signs of swelling, redness, or evisceration.
– Examine the characteristics of any drainage.
– Cleanse the surrounding area with a cleansing solution.
– Wipe from the clean area toward the less clean area.
– Apply medication if required.
– Apply a sterile dressing, beginning with dry gauze pieces and then cotton pads.
– Remove the gloves and dispose of them.
– Secure the dressing with adhesive tape or a bandage.

After dressing, follow these steps:

– Assist the patient in dressing.
– Change garments if they are soiled.
– Replace the towel and mackintosh. Change the bed linens.
– Take all used tools to the utility room.
– Wash your hands and document the procedure.
– Educate the patient about signs of infection.

Drawbacks to Wound Care Nursing

Several factors can impede wound healing, categorized as local and general:

Local Factors Include:

– Presence of foreign bodies.
– Redness, swelling, warmth, or pain due to infection.
– Wound pH and elevated temperature.
– Foul odor, pus, or excessive drainage.
– Excessive bleeding.
– Suture dehiscence.
– Fullness or hardness around the wound.

General Factors Include:

– Hypoxia and impaired perfusion, often associated with smoking, cardiac conditions, bleeding, and shock.
– Underlying diseases like autoimmune disorders, diabetes

, and anemia that hinder healing.
– Malnutrition, resulting from inadequate carbohydrate, protein, lipid, and vitamin intake essential for the healing process.
– Body mass index.
– Radiation therapy.
– Psychological factors such as anxiety, stress, and depression.
– Medications like chemotherapy, corticosteroids, NSAIDs, and immunosuppressive drugs.
– Disorders affecting movement or sensation, such as movement disorders, cerebral palsy, spina bifida, and peripheral neuropathy.

Legal Implications of Wound Care Nursing

Nurses, regardless of their experience level, bear a legal and ethical responsibility to provide optimal care, setting aside personal pride. Legal implications encompass various consequences, including unpaid leave, demotion, criminal charges, job termination, incarceration, fines, licensure revocation, and eroded trust among patients, employers, and colleagues. The severity of consequences often hinges on the nature of the allegations.

Legal allegations in wound care nursing may include:

– Failure to communicate adequately with patients, families, or fellow clinicians.
– Failure to provide appropriate treatment and care.
– Administration of incorrect medications.
– Lack of informed consent.
– Errors and omissions in documentation.

Final Thoughts

Wound care nursing represents a gratifying profession, equipping nurses with the skills needed to offer quality care to patients. Nurses play a pivotal role in wound management, promoting healing and infection prevention. Ethical principles should guide nurses in their practice to safeguard patients and avert legal implications.

Refer to the guidelines in this article to enhance your understanding of wound assessment and management for effective patient care.