Wound Care Nursing

Wound Care Nursing

Wound care nursing plays a crucial role in all healthcare settings, including acute care, home care, and long-term care. Nurses handle wounds of varying complexity levels and need special skills for physical assessments and creating suitable treatment plans. Read this article to understand wound care nursing guidelines, procedures, and ethical considerations.

History of Wound Care Nursing

The roots of wound care nursing trace back to 2000 BCE. Ancient Egyptians used grease, honey, and lint to clean open wounds and promote healing. They utilized vinegar, water, or wine to wash wounds.

In ancient Rome, signs like tumor, rubor, dolour, and color were recognized as inflammation indicators. During the Middle Ages, nursing tasks were performed by nuns. The approach involved allowing wounds to undergo a certain degree of decay. Wound care nursing has evolved from basic dressing techniques to a certified specialty.

With advancements in wound care nursing, we’ve moved from random clinical practices based on traditional opinions to evidence-based practices. This approach combines clinical expertise with external clinical evidence gathered through research.

Basic Principles of Wound Care Nursing

Managing wounds can be complex as tissue damage ranges from deep to superficial. Employing fundamental principles, nurses can formulate effective treatment plans and streamline the process. Explore the following postoperative wound care nursing assessment and management.

Assessment in Wound Care Nursing

Effective wound management begins with a comprehensive assessment. When conducting initial and ongoing wound assessments, consider the following factors:

Type of wound

Wounds are categorized as acute or chronic, such as burns, ulcers, surgical incisions, lacerations, and abrasions.

Pressure injuries

Pressure injuries, also called pressure ulcers, result from prolonged or intense pressure causing damage to the skin or underlying tissue.

Venous ulcers

These ulcers develop when lower extremity valves fail, causing blood to reflux into the venous system.

Arterial wounds

Arterial wounds occur due to severe tissue ischemia caused by atherosclerosis in peripheral arterial vessels.

Diabetic foot wounds

Resulting from reduced pressure perception and pain sensation in the foot, these wounds can be challenging to heal, particularly if there’s bone infection, deep tissue involvement, or reduced blood flow.

Skin tears

Mechanical forces like friction, shear, or blunt impacts cause skin tears. While they vary in depth, they don’t penetrate the subcutaneous layer.

Moisture-associated skin damage (MASD)

MASD arises from skin exposure to different types of moisture, compromising its protective function.

Location and surrounding skin

Inspect the surrounding area of the wound and protect it from further harm. The wound’s location can provide insights into potential causes.

Tissue loss

The extent of tissue damage influences care planning. Tissue loss can be categorized as follows:

Superficial wound: Only the epidermis is affected.
Partial impairment: Both the dermis and epidermis are involved.
Full-thickness wound: The dermis, subcutaneous tissue, and epidermis are affected, and it may reach bones, tendons, and muscles.

Clinical characteristics of the wound bed and healing stage

Granulating

Granulation involves the formation of red or pinkish tissue in the repair process. It contains collagen, a capillary network, and elastin, and it bleeds easily.

Epithelializing

New epithelium covers the wound surface due to granulation tissue. It’s usually pink or almost white and forms over healthy tissue.

Sloughy

Yellow tissue indicates the accumulation of dead cells but isn’t synonymous with pus.

Necrotic

Necrotic wounds feature dead tissues that appear black, complex, and dry, impeding healing. They may appear grey.

Hypergranulating

Hypergranulation results from granulation tissue developing above the wound due to irritants or bacterial imbalance, prolonging healing.

Wound measurement and dimensions

Ongoing evaluation and assessment of wound healing are crucial. Two-dimensional evaluation considers width and length in millimeters, while three-dimensional evaluation gauges cavity depth using a cotton-tip applicator.

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Wound edge

Wound edges are assessed for:

Color

Redness (erythema) indicates inflammation, a dusky edge suggests hypoxia, and a pink edge signals new tissue growth.

Contraction evidence

Contraction signifies healing, raised edges denote hypergranulation, and rolled edges indicate healing progress.

Sensation changes

Absence of sensation or heightened pain requires further investigation.

Exudate

Both acute and chronic wounds produce exudate as part of healing. Exudate helps in healing by cleansing the wound, supplying nutrients, growth factors, energy for cells, white blood cells, maintaining moisture, and promoting epithelialization.

Examining exudate amount, type, odor, and color is crucial. Excessive exudate suggests skin degradation, while minimal exudate indicates a deteriorating wound bed. Infected wounds might exhibit more odor and viscosity.

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Infection presence

Wound infection can damage tissue, disrupt healing, and spread illness. Infection indicators include:

Unpleasant odor
Localized pain
Swelling (edema)
Redness (cellulitis or erythema)
Change in exudate color or consistency
Localized warmth

Pain

Wound pain provides insights into its chronicity and cause. Evaluating pain is essential for selecting appropriate dressings. Assessing pain before, during, and after dressing changes aids in further dressing management.
Wound Management

• Consider psychological implications of wounds.
• Define care goals and expected outcomes.
• Account for the delicate 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 managing principles for acute and chronic wounds.

Wound Care Nursing Procedure

A wound is a break in the skin caused by physical factors, either accidentally or intentionally (like incisions during surgery).

Here’s 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 swelling, redness, or signs of evisceration.
Observe the characteristics of any drainage.
Clean the area around the wound with a cleansing solution.
Wipe from cleaner areas to less clean areas.
Apply medication if needed.
Place a sterile dressing, starting with dry gauze and then cotton pads.
Remove and discard the gloves.
Secure the dressing with adhesive tape or a bandage.

After dressing, remember to:

• Assist the patient in getting dressed.
• Change clothes if they’re soiled.
• Remove the towel and waterproof sheet.
• Change the bed linens.
• Take all tools to the utility room.
• Wash your hands and document the procedure.
• Educate the patient about signs of infection.

Challenges in Wound Care Nursing

Numerous factors can delay wound healing, categorized as local and general:

Local:

Foreign bodies present.
Infection indicators like redness, swelling, warmth, or pain.
Wound pH and high temperature.
Foul odor, pus, or excessive drainage.
Excessive bleeding.
Stitch openings.
Fullness or hardness around the wound.

General:

• Hypoxia and poor blood flow due to smoking, heart conditions, bleeding, and shock.
• Underlying conditions like autoimmune disorders, diabetes, and anemia that hinder healing.
• Malnutrition due to insufficient supply of necessary nutrients.
  Body mass index.
• Radiation therapy.
• Psychological factors like anxiety, stress, and depression.
• Medications including chemotherapy, corticosteroids, NSAIDs, and immunosuppressants.
• Movement or sensation disorders such as cerebral palsy, spina bifida, and peripheral neuropathy.

Legal Aspects of Wound Care Nursing

Nurses, regardless of experience, have a legal and ethical duty to provide optimal care. Legal implications can include unpaid leave, demotion, criminal charges, job loss, jail time, fines, license revocation, and loss of trust by patients, employers, and colleagues, depending on the allegations.

Legal accusations in wound care nursing may involve:

• Failure to communicate with patients, families, or fellow clinicians.
• Failure to provide appropriate treatment and care.
• Errors in medication administration.
• Lack of informed consent.
• Mistakes or omissions in documentation.

In Conclusion

Wound care nursing is a fulfilling career that equips nurses with skills to provide quality patient care. Nurses are crucial in wound management by promoting healing and preventing infection. Additionally, ethical considerations are vital to protect patients and avoid legal consequences. Use the guidelines provided here to understand wound assessment and management for effective patient care.