Wound care nursing is vital and is applied in all healthcare settings, including acute, home care, and long-term care. Nurses treat wounds with different levels of complexity and must have special skills to do physical assessments and develop an appropriate treatment plan. Read this article to learn wound care nursing guidelines, procedures, and ethical implications.
History of wound care nursing
The history of wound care nursing dates back to 2000 BCE. The ancient Egyptians used grease, honey, and lint to remove puss and skin in an open wound to promote healing. They washed wounds with vinegar, water, or wine.
The ancient Romans were the first to explain tumour, rubor, dolour, and colour as signs of inflammation. In the middle age, nuns used to carry out nursing tasks. The practice was to let the wound rot a bit. Wound care nursing has evolved from simple dressing to a certified specialty.
With new developments in wound care nursing, we have advanced from random clinical practice with traditional opinion to evidence-based practice wound care nursing. The practice involves combining clinical expertise with external clinical evidence through research.
Basics of wound care nursing
Managing wounds can be challenging as tissue damage may range from deep to superficial. Using the basic principles, the nurse can devise the necessary treatment plan and simplify the process. Explore the following postoperative wound care nursing assessment and management
Wound care nursing assessment
Wound management starts with an assessment. When conducting ongoing and initial wound assessments, you should consider the following factors;
- Type of wound
There are different types of wounds classified as acute or chronic, such as burns, ulcers, surgical incisions, lacerations, abrasions, etc.
Pressure injuries, also known as pressure ulcers is the skin damage or tissue due to prolonged or intense pressure.
Venous ulcers result from the inability of the lower extremity valves causing blood to reflux into the venous system
The aerial wound result from severe tissue ischemia due to atherosclerosis of peripheral aerial vessels.
Diabetic foot wounds result from pressure perception and pain sensation in the foot. The injury may be difficult to heal, especially when there is a bone infection or deep tissue and a decline in blood flow to the foot.
A skin tear results from mechanical forces like friction, shear, and blunt force. Wound extent may differ by depth but does not reach the subcutaneous layer.
- Moisture-associated skin damage (MASD)
MASD is an inflammation of the skin due to exposure to different types of moisture which disable its protective mechanism.
- Location and surrounding skin
You should examine the surrounding areas of the wound and take caution to safeguard it from injury. The location of the damage can inform the nurse of the possible causes of the wound.
- Tissue lose
The extent of tissue damage will help develop an appropriate care plan. The scope of tissue loss can be defined as follows;
- Superficial wound: it involves the epidermis
- Partial impairment: entails the dermic and epidermis
- Full-thickness wound: involves the dermis, subcutaneous tissue, and epidermis and may reach bones, tendons, and muscles.
- Clinical aspect of the wound bed and stage of healing
Granulation is when red blood tissue is sotted and placed in the repair process. It looks red/pinkish, contains collagen, capillary network, and elastin and it bleeds easily.
Epithelializing is when new epithelium closes the wound surface due to granulation tissue filling the wound. It’s usually pink, almost white, and appears on top of healthy tissue.
Yellow tissue is observed due to the accumulation of dead cells but should not be confused with the presence of pus.
A Necrotic is a wound with dead tissues that seem black, complex, and dry. The dead tissues prevent healing, and they appear grey.
Hyper granulation is when granulation tissues develop above the wound. The wound occurs due to irritant forces or bacterial imbalance, leading to prolonged healing.
- Wound measurement and dimensions
Evaluation and assessment of wound healing is a continuous process. All wounds need a two-dimensional evaluation of the wound opening and a three-dimensional evaluation of any cavity.
- Two-dimensional evaluation
The wound can be measured using paper tape to determine its width and length in millimetres. You can obtain the circumference of the wound if it’s not even for chronic wounds.
- Three-dimensional evaluation
It involves measuring the wound depth using a cotton tip applicator.
- Wound edge
Wound edges are assessed for;
Erythema shows cellulitis or physiological inflammatory response, the dusky edge shows hypoxia, and the pink edge shows the growth of new tissues.
Contraction of wound edges shows healing, raised edges show hyper granulation, and rolled edges show healing.
The absence of sensation or increased pain would require further investigation.
Acute and chronic wounds create exudate as part of healing. It helps in the healing process because;
- It cleanses the wound
- It includes nutrients, growth factors, and energy for assimilating cells.
- It has high numbers of white blood cells
- It preserves a moist environment
- It promotes epithelialization
Examining the amount, type, odour, and colour of exudate is vital. A lot of exudate shows the degradation of the skin, while too little shows the wound bed is dying. For infected wounds, it may have more odour and viscosity.
- Presence of infection
Wound infection can damage tissue, disturb healing, or spread disease and illness. Indicators of infection include;
- Localized pain
- Redness (cellulitis or erythema)
- Exudate: change of purulent fluid
- Localized heat
The pain of the wound can provide information about wound chronicity and aetiology. Evaluation of pain is essential to determine the best dressing. Assessment of pain before, during, and after dressing may help in further dressing selection and management.
- Think about the psychological indications of a wound
- Find out the goal of care and anticipated outcome
- Consider the fragile wound environment
- Maintain bacterial balance
- Maintain wound moisture
- Maintain a stable ph. and temperature
- Let a draining wound drain candidly
- Choose a suitable dressing and techniques
- Perform appropriate wound therapies
- Follow managing principles for acute and chronic wounds
Wound care nursing procedure
A wound is a fracture of the skin’s internal or external surface due to physical causes. They can be accidental or intentional (incisions during surgical operation).
The following is the procedure for wound or surgical dressing;
- Expound the process to the patient by use of sensory preparation
- Wash your hands and wear gloves
- Examine the wound for swelling, redness, or signs of evisceration
- Check the features of any drainage
- Clean the surrounding area with a cleansing solution
- Wipe from the clean place to the less clean
- Apply medication if requested
- Apply sterile dressing. Start with dry gauze pieces, then cotton pads
- Remove the gloves and discard them
- Cover the dressing with adhesive tapes or bandage
Aftercare dressing, you should;
- Help the patient to dress up
- Change the garments if dirty
- Remove the towel and mackintosh. Change the bed linen
- Take all 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 delay wound healing which can be categorized as local and general as follows;
- Presence of eternal bodies
- Redness, swelling, warmth, or pain due to infection
- Wound Ph. and high temperature
- Bad smell, pus, or excessive drainage
- Excessive bleeding
- Any opening of stitches
- Fullness or hardness around the wound
- Hypoxia and impaired perfusion: smoking, cardiac conditions, bleeding, and shock
- Underlying diseases, e.g., autoimmune disorders, diabetes, and anaemia which impair healing
- Malnutrition: inadequate supply of carbohydrates, protein, lipids, and vitamins, which are vital for the healing process.
- Body mass index
- Radiation therapy
- Anxiety, stress, and depression
- Medications such as chemotherapy, corticosteroids, NSAIDs, immunosuppressive drugs
- Disorders of movement or sensation, e.g., movement disorder, cerebral palsy, spina bifida, peripheral neuropathy
Legal implications of wound care nursing
Nurses, whether experienced or new nurse, has a legal and ethical obligation to enhance optimum care regardless of their pride. Legal implications include unpaid leave, demotion, criminal charges, job termination, jail time, penalty, cancellation of licensure, and loss of trust by patients, employers and colleagues, which may depend on accusations.
Some of the legal accusations in wound care nursing may include the following;
- Failure to communicate with the patient, family, or with fellow clinicians
- Failure to offer the appropriate treatment and care
- Failure to administer the correct medication
- Lack of informed consent
- Errors and omissions while documenting
Wound care nursing is a rewarding career that provides nurses with skills to support patients with quality care. Nurses play an essential role in the management of wounds by promoting healing and preventing infection. In addition, nurses should implement ethical concepts to protect patients and avoid legal implications.
Use the guidelines in this blog to understand wound assessment and management that you may apply while providing patient care.