About this course:
This learning module reviews relevant terminology and explores the current research on best practices related to wound care.
This learning module reviews relevant terminology and explores the current research on best practices related to wound care.
After this activity, learners will be prepared to:
recognize the normal anatomy and physiology of the skin
differentiate between types of acute and chronic wounds
describe factors that impact the normal healing processes
explain the nurse's role in assessing and documenting wounds
identify interventions the nurse uses to prevent acute and chronic wounds
explore treatment options for different categories of wounds and interdisciplinary collaboration
Anatomy and Physiology of the Skin
The skin covers the entire body and is the largest organ, accounting for approximately 20% of total body weight. The skin's primary function is to protect the internal organs and structures from biological invasion, ultraviolet radiation, fluid loss, and physical damage. Additional functions of the skin are thermoregulation through sweating and regulation of blood flow, synthesis of vitamin D, the sensation from nerve endings, excretion of salts and small amounts of waste products, and provision of aesthetics and communication. The skin comprises three layers: the outer layer or epidermis, the deeper layer or dermis, and the subcutaneous layer or hypodermis (see Figure 1 below). The skin’s health influences overall health and has a profound psychological significance since it identifies each individual with unique facial and body characteristics. Self-image may be enhanced or deterred by society's standards for appearance (McCance & Huether, 2019).
The epidermis acts as a defensive barrier that is constantly renewed by shedding the superficial layer (stratum corneum). This layer is very thin, measuring only 0.05 mm on the eyelids and 1.5 mm on the soles of the feet and palms of the hands; however, it can thicken with frequent pressure or friction (e.g., calluses or corns). The epidermis is composed primarily of keratinocytes embedded in a lipid matrix. The epidermis is slightly acidic with a pH of 4.5-6. The epidermis is made up of five layers, including the stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, and stratum basale. Each layer has a function and plays a role in the healing process of wounds (McCance & Huether, 2019).
The stratum corneum is composed of tough superficial sheets of cornified cells. This layer is also waterproof. Forming the outermost layer, it consists of fibrous dead cells that help to regulate pH and temperature and provide protection. This layer is continuously being replaced and helps with the skin's ability to repair itself. The stratum lucidum consists of layers of cells containing eleidin, which becomes keratin as cells move up to the stratum corneum layer. The stratum lucidum is only found in palmoplantar skin to provide extra protection since these areas are exposed to more significant deterioration. In the stratum granulosum, keratinocytes lose their nuclei, flatten, and become cornified or keratinized, a process known as keratinization. Keratinization occurs in this layer and helps reduce water loss from the epidermis. The stratum spinosum is 8-10 cells thick and contains living cells that have spiny processes called desmosomes. This layer also contains Langerhans cells (a type of dendritic cell), which can initiate an immune response. The stratum basale (basal layer) is also known as the basement membrane and forms the lowest layer of the epidermis. The stratum basale constantly makes new keratinocytes that flatten as they move up to the surface, replacing cells that have been shed from the stratum corneum. This process takes between 28 and 35 days. This layer is one cell thick and forms a border between the epidermis and dermis. Cells continuously divide for ongoing rejuvenation of the skin. Melanocytes are also produced in this layer (McCance & Huether, 2019).
The dermis is the next layer below the epidermis. It i
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The third layer of skin is the hypodermis or subcutaneous tissue. This layer connects the dermis to the underlying muscle. It comprises blood vessels, adipose tissue, and connective tissue that support the dermis. Macrophages, fibroblasts, nerves, and hair follicle roots are also found within this layer. The fat stored in this layer provides internal structures with additional protection and insulation against cold temperatures (McCance & Huether, 2019).
Types of Wounds
Wounds are either acute or chronic. Acute wounds often have an identifiable cause that leads to skin integrity loss and usually results from trauma. Acute wounds are present in various depths, sizes, and anatomical locations. Acute wounds can also be created in a controlled surgical environment. Chronic wounds can develop over time from an acute traumatic injury or surgical wound. Chronic wounds often affect individuals with a physiologic process that delays or prevents proper wound healing, such as diabetes, peripheral vascular disease (PVD), immunodeficiency, and malnutrition. At this time, no clearly defined period indicates an acute wound has become a chronic wound; however, some guidelines suggest that an acute wound becomes chronic in the absence of a weekly 15% reduction in wound surface area or a 50% reduction in a month (Armstrong & Meyr, 2020; Ruben, 2014).
There are many different types of wounds (Armstrong & Meyr, 2020; Ruben, 2014):
Abrasions and scrapes occur when a mechanical force, such as friction against a hard surface, scrapes away a partial-thickness area of the skin. These wounds vary in size and depth and can be complicated by dirt or debris embedded in the wound bed (Slachta, 2015).
Bites can originate from animals or humans, but the impact can be equally severe. A dog, cat, or rodent bite can introduce infectious diseases, including rabies, into the wound. Injury to the tissue can occur secondary to the teeth and the force of the bite and movement of the animal as they clamp down onto the tissue. A human bite can introduce bacteria from the mouth, including Staphylococcus aureus, streptococci, syphilis, tuberculosis, or viruses such as hepatitis B (HBV), hepatitis C, and herpes simplex virus. Although not commonly reported, a human bite can transmit the human immunodeficiency virus (HIV) or cause necrotizing fasciitis (Barrett, 2021; Bassett et al., 2019).
Burns can be caused by thermal extremes, electricity, caustic chemicals, or radiation. The extent of damage from burns is dependent on the source, duration of contact or exposure, and anatomical location of the injury. Pre-existing conditions (as listed above) can complicate the healing of burns and may increase morbidity and mortality (Slachta, 2015).
- Lacerations are produced by the tearing of soft tissue. Lacerations are often caused by sharp objects such as glass, metal, wood, or blunt trauma that causes a shearing force on the skin. Lacerations have irregular edges and vary in severity according to the cause, size, depth, and location (Slachta, 2015).
- Punctures such as stab wounds may involve little tissue on the skin surface but have more significant implications or damage below the skin surface, including internal organ damage. Patients with puncture wounds are also at risk for local infection, sepsis, and tetanus and, therefore, may require prophylactic treatment (Slachta, 2015). The Centers for Disease Control and Prevention (CDC, 2020) recommend that for any contaminated wounds, patients should have tetanus immune globulin and a tetanus vaccination if there is no clear history of prior tetanus vaccination or vaccination did not occur within the last five years.
Moisture-associated skin damage (MASD) results from sustained exposure to moisture (versus pressure) caused by incontinence, wound exudate, or perspiration (Slachta, 2015).
Skin tears primarily affect older adults and are caused by a shearing or blunt trauma that separates the layers of the skin. These wounds are classified as partial-thickness wounds if the epidermis separates from the dermis and considered full-thickness wounds if the epidermis and dermis are separated from the hypodermis. These injuries are considered preventable through careful handling of the patient within the healthcare system. Skin tears are further classified using the International Skin Tear Advisory Panel (ISTAP) system (Slachta, 2015):
- Type I is a linear or flap tear that can be repositioned to cover the wound bed.
- Type II is partial tissue loss that cannot be repositioned to cover the wound bed.
- Type III involves total skin flap loss exposing the entire wound bed.
Surgical wounds are intentional breaks in the skin related to surgery. Acute surgical wounds are categorized by the degree of contamination or bacterial load of the wound. These categories include clean, clean-contaminated, contaminated, and dirty. In most cases, clean and clean-contaminated surgical wounds are closed once the surgical procedure is complete. Contaminated and dirty wounds are often left open and require wound care after surgery (Armstrong & Meyr, 2020).
Pressure injuries are localized areas of damage to the skin and underlying tissue caused by continuous pressure with or without shearing. These injuries are most common over bony prominences but may occur anywhere that pressure is applied. Bedbound or chairbound patients have a higher risk of developing pressure injuries. Since superficial skin is less susceptible to damage from pressure, the extent of a pressure injury may be more extensive than what is visualized externally. The locations most vulnerable to pressure injuries include the sacrum, calcaneus, and ischium. The National Pressure Injury Advisory Panel (NPIAP) staging system categorizes pressure injuries as shown in Figure 2 (Berlowitz, 2022; National Database of Nursing Quality Indicators [NDNQI], 2021):
- Stage 1 is characterized by localized intact non-blanchable erythema. The presence of blanchable erythema with changes in temperature, firmness, and sensation may indicate a pressure injury before visible changes.
- Stage 2 is characterized by partial-thickness loss with the presence of exposed dermis. In stage 2, the wound bed appears red or pink and moist.
- Stage 3 is characterized by full-thickness loss with the presence of exposed adipose tissue. Granulation tissue and epibole (rolled edges) are often present. Slough or eschar may be visible in the wound bed.
- Stage 4 is characterized by full-thickness skin and tissue loss. Exposed fascia, muscle, tendon, ligament, cartilage, or bone is present. Slough, eschar, epibole, undermining, or tunneling may be present.
- An unstageable pressure injury is characterized by a full-thickness loss that cannot be visualized entirely due to slough and eschar. Removing the slough and eschar would reveal a stage 3 or 4 pressure injury.
- A localized area of persistent non-blanchable deep red, purple, or maroon skin characterizes a deep tissue pressure injury. Pain and localized temperature changes often precede any tissue changes. For more information on pressure injuries, see the Pressure Injuries Nursing CE course.
Arterial or venous insufficiencies may cause ulcers due to impaired blood flow and decreased oxygenation. Venous ulcers result from venous hypertension and occur in the lower legs (see Figure 3 below). Venous ulcers account for 70%-90% of all leg wounds and are commonly found below the knee on the medial surface of the leg above the ankle. These types of wounds usually have irregular borders, are red, and may have drainage. Arterial ulcers result from tissue ischemia caused by arterial insufficiency (see Figure 4 below). They occur at the most distal end of an arterial branch, most commonly in the feet. Arterial ulcers account for 5%-20% of all leg ulcers. Arterial ulcers can vary in color and appear yellow, brown, gray, or black, surrounded by edematous red skin. Arterial ulcers are often very painful for the patient (Slachta, 2015; Vascular Health Clinics, 2018).
- Diabetic ulcers result from poor lower extremity circulation and neuropathies that result in decreased sensation (see Figure 5 below). They are a significant cause of morbidity and account for at least 66% of all non-traumatic surgical amputations in the US. Infected or ischemic diabetic ulcers make up 25% of all hospitalizations of patients with diabetes (Armstrong & de Asla, 2021).
Infants and Children
Often, children are assumed to be more resilient with faster healing times, leading to poor wound management in this population. Infants and children are at an increased risk of sustaining skin injuries due to their fragile skin. Although a full-term infant has anatomically similar skin to an adult, their dermal layer is half the thickness. Even though this thickness increases with age, the skin remains fragile throughout childhood until puberty. Skin injuries in children are more likely to be acute and caused by trauma (e.g., burn, scrape, or laceration); however, pediatric patients can develop chronic wounds from immobility or medical device use (Wound Source, n.d.-b).
During pregnancy, the skin stretches and thins to accommodate the growing uterus. A pregnant individual may require a cesarean section (c-section) or an episiotomy during delivery or experience perineal tearing. An episiotomy is an incision made in the perineum by a healthcare professional (HCP). This is done to make the vaginal opening larger and prevent perineal tearing. Perineal tearing is similar to an episiotomy; however, it occurs naturally without the assistance of an HCP, and therefore the edges are jagged, making suturing more difficult. Once the baby is born, the incision from either an episiotomy or perineal tearing is sutured. A cesarean section is the surgical delivery of a baby. This is accomplished in an operating room and requires the obstetrician to make an incision through the abdominal wall and uterus to deliver the baby. Once the baby is born, the incision is closed with sutures (Lucey, 2020; National Institutes of Health [NIH], 2017).
The aging adult may have skin changes related to atrophy of the skin structures. As aging occurs, the skin loses its elasticity and starts to fold and sag. By the time an individual reaches their 70s or 80s, the skin is thinner, drier, and wrinkled. The epidermis thins and flattens, allowing for increased absorption of chemicals into the body. There is a decrease in collagen in the dermal layer, which increases the possibility of skin tears and shearing injuries. Sweat and sebaceous glands decrease in number and leave the skin drier with an increased risk for heatstroke. There is a decrease in vascularity of the aging skin yet a fragility to the vessels that increases bruising from even minor trauma. If an aging adult smokes tobacco or has sun exposure, there is increased wrinkling, dryness, atrophy, and pigment changes, creating a leathery texture to the skin. The less melanated an individual's skin is, the more damage is visible from sun and smoke exposure. A wound in an older patient can take much longer to heal and carry a much higher associated risk than a similar wound in a younger patient (Jarvis, 2020; Pilgrim & Schub, 2019).
As noted above, age can affect the healing process due to variations in skin structures and make-up. Further risk factors are related to comorbid conditions and disease processes, nutritional status (including obesity and malnutrition), medications, and tobacco or alcohol use. The nurse and the interdisciplinary team must recognize any underlying pathologies that impair wound healing. This includes assessments for underlying vascular impairment, neuropathy, metabolic disease, connective tissue disease, trauma, cancer treatment, iatrogenic disease, hospital-acquired infection, or an adverse effect of a medication that may guide the plan of treatment (Pilgrim & Schub, 2019). Each risk factor will be examined below.
Inadequate tissue perfusion and ischemia can occur when blood glucose is not controlled in patients with diabetes (either type 1 or type 2) and can hinder the wound healing process (WHP). This Ischemia can prolong inflammation leading to further tissue damage instead of healing. Diabetes is also associated with a decreased immune response during wound healing. The patient may also be unaware of an injury to their feet or other body areas and continue to apply pressure to the area due to reduced sensation secondary to neuropathy that can occur because of uncontrolled diabetes. These untreated injuries allow bacterial infiltration. Diabetic wounds may be chronic and take months or years to heal, and others may never completely heal (Armstrong & de Asla, 2021; Chylinska-Wrzos et al., 2017; Wernick et al., 2021).
Bacteria are present on all skin surfaces, and when the skin integrity is breached, bacteria present on the surface can enter the wound. When the bacterial presence increases and wound damage occurs, an infection is present. Infection contributes to wound chronicity, morbidity, and mortality. Most wound infections occur from bacterial colonization. This can be from outside bacteria or an increase in the normal skin flora. The most common wound infections are caused by Staphylococcus aureus and other types of staphylococci. Healthy individuals can usually avoid developing an infection due to their immune system defense response, yet an immunocompromised patient will have a decreased ability to fight the bacteria. "The number of bacteria and their effect on the patient are categorized as: contamination, colonization, local infection, spreading infection, and systematic infection" (NPIAP, 2019, p. 251). Microorganisms may multiply, invade, or damage tissues in or around the wound bed, delay healing, and cause systemic responses. Infection is present if a pressure injury is not healing due to the bacteria in the wound bed. Chronic wounds may also have biofilm-associated infections, characterized as complex colonies of microbes encased in a protective extracellular polymer attached to the surface and embedded into the wound bed. Pseudomonas aeruginosa and S. aureus are the most common microbes in wound biofilms. Bacteria composing the biofilm are traditionally more challenging to treat. When a biofilm is present in the wound, the healing process stalls at the inflammatory phase and fails to progress to the proliferative and epithelialization stages. The biofilms must be removed by debridement and prevented from reforming by using antiseptics and antimicrobial dressings (Gajula et al., 2020; NPIAP, 2019; Wound Source n.d.-a). Other signs or symptoms of infection are:
erythema that extends past the wound edges
induration of the tissue
increasing or change in pain
change in temperature
increasing wound size
systemic reactions including fever, malaise, lymph node enlargement, confusion, or anorexia (particularly in the older adult; NPIAP, 2019)
The healing process may be impaired in those who are immunocompromised secondary to HIV infection, cancer, burns, or immunosuppressive therapies such as corticosteroids and chemotherapeutic drugs (see the section on medications below). Other factors leading to immunodeficiency are age, malnutrition, recent surgery, significant trauma, alcoholic liver cirrhosis, chronic renal disease, diabetes mellitus, and systemic lupus erythematosus. Stress can increase cortisol levels, decreasing the immune response by blocking the production of cytokines. Impairing or reducing the immune response negatively impacts wound healing (Schub & March, 2018; Wernick et al., 2021).
Patients with PVD often have non-healing wounds on the extremities. These wounds are chronic with delayed healing due to decreased blood flow depriving the area of sufficient oxygenation and the nutrients needed for adequate wound healing (Vascular Health Clinics, 2018).
Dry Wound Bed
A dry wound bed can inhibit wound healing. Landmark evidence that moist wounds heal quicker was found in 1962. In a moist wound bed, the exudate (the moisture that seeps out of the wound site) transports enzymes, growth factors, and hormones into the wound bed. These mediators promote cellular communication and movement of the wound through the healing stages. A dry wound bed can also lead to dressing adherence, requiring interventions to remove the dressing or risking further damage to the wound bed. Too much exudate can impair wound healing; however, a moist wound bed is preferred over a dry one (Fletcher & Probst, 2020).
With an estimated 40% of adults experiencing obesity in the United States, this clinical population has a high prevalence of wounds. Skin irritation and breakdown may occur in the presence of obesity. Pressure injuries can also affect the obese population. Obesity limits activity, body movement, and optimal blood flow. These limitations can lead to pressure injuries even when mobility is assisted. Patients that are morbidly obese often require two or more individuals to reposition or assist them with activities of daily living (ADLs) in the home and clinical settings. If an individual with obesity is also incontinent, the risk of skin breakdown increases further. Microorganisms grow in the moist skin folds and increase the risk of rashes and lesions. Poorly vascularized adipose tissue and greater skin surface area increase the risk of skin injury. Due to the decreased vascularization, obesity is also a significant factor in wound healing (Schub & Schub, 2018; Wernick et al., 2021).
The nutritional needs required for proper wound healing are complex due to the increased demand for micronutrients and macronutrients. Since proteins are the building blocks of tissues, sufficient protein and amino-acid-rich foods are needed to ensure proper wound healing. Individuals who are malnourished do not have adequate nutritional intake to promote proper wound healing. These individuals are also at an increased risk for developing pressure injuries due to decreased subcutaneous fat and more pronounced bony prominences (Wernick et al., 2021).
Certain medications can inhibit or interfere with the WHP, often by affecting a specific step in the process. Common medications that affect the WHP include the following (Beitz, 2017; Deptula et al., 2019; Levine, 2018):
Corticosteroids affect wound healing through multiple mechanisms, including contraction, matrix deposition, epithelialization, and decreased wound tensile strength. Steroids also suppress wound healing by inhibiting the inflammatory response. They thin the epidermis and significantly impact wound healing when given over a prolonged time.
Anticoagulants such as warfarin (Coumadin), apixaban (Eliquis), rivaroxaban (Xarelto), and dabigatran (Pradaxa) inhibit coagulation factor production and disrupt the hemostasis phase of the WHP.
Antiplatelet medications such as acetylsalicylic acid (Aspirin), clopidogrel (Plavix), and dipyridamole (Persantine) can inhibit platelet aggregation, hindering the hemostasis stage of the WHP.
Non-steroidal anti-inflammatory drugs (NSAIDs) have an antiproliferative effect on blood vessels while decreasing the granulocytic inflammatory response, hindering wound healing.
Chemotherapeutics agents such as cyclophosphamide (Cytoxan) and cisplatin (Platinol) block the cell cycle by alkylating DNA nucleotides and complicate wound healing. Chemotherapeutic agents inhibit cellular metabolism, cellular division, or angiogenesis to stop the growth of cancer cells. Unfortunately, this action also influences wound healing by decreasing the ability of tissues to regenerate.
Tobacco and Alcohol Use
Tobacco use has a profound effect on the WHP. Multiple healing pathways are affected by tobacco use; however, ischemia is the major contributing factor to wound healing. The nicotine in cigarettes, vape pens, and smokeless tobacco (e.g., chew or dip) acts as a vasoconstrictor and stimulates the release of epinephrine. The release of epinephrine further reduces blood flow and increases hypoxia. Nicotine also reduces fibrinolysis, which causes the blood to become more viscous, leading to decreased blood flow. Tobacco use contributes to the development of chronic obstructive pulmonary disease (COPD), which chronically lowers the oxygen level in the blood. Cigarettes and vape pens also contain carbon monoxide, which has a 200-times higher affinity to hemoglobin than oxygen. Due to this increased affinity, even a small amount of carbon monoxide in the blood can profoundly impact the oxygen-carrying capability of hemoglobin, leading to less oxygen reaching the tissues. Patients who successfully cease smoking, vaping, or using smokeless tobacco show improved wound healing (Wernick et al., 2021).
Alcohol use impacts all body systems, and the skin is equally affected. Alcohol disrupts the immune system and the WHP. Slowed wound healing is more pronounced in individuals who binge drink or consume alcohol regularly. Not only does alcohol consumption slow wound healing, but it also increases the risk of acquiring a wound infection and delays the closure of both surgical and non-surgical wounds. Alcohol also impairs the function of dermal fibroblasts, which play a role in wound healing. In a study on the chronic administration of alcohol in mice, there were 30%–50% fewer epidermal immune cells after four weeks of regular alcohol consumption, which likely accounts for the decreased immune response when a pathogenic organism enters a wound. Excessive alcohol use may lead to chronic malnutrition, further impairing wound healing. Adequate nutrition is vital for wound healing, and alcohol use inhibits fat absorption, leading to deficiencies in the fat-soluble vitamins A, D, E, and K. Deficiencies in these vitamins or proteins can impair wound healing (Curtis et al., 2014; Szelinski, 2021; Trevejo-Nunez et al., 2015).
Wound Healing and Closure
There are four stages in the WHP. The phases of wound healing include hemostasis, inflammation, proliferation, and remodeling. The clotting cascade is initiated when a wound forms, whether due to trauma or a medical procedure. Platelets are the first to arrive in the area and release cytokines and growth factors, leading to hemostasis. This release of cytokines and growth factors promotes the migration of inflammatory cells to the wound. Within 24-48 hours after initial wound development, vasodilation occurs, allowing inflammatory cells, including neutrophils, monocytes, macrophages, and lymphocytes, to perform specialized functions within the injured tissue. Neutrophils arrive at the wound first to phagocytize bacteria and clear microbial and cellular debris. Then, the accumulation of macrophages occurs 48-72 hours after wound development. The arrival of macrophages initiates the proliferation phase of the WHP. Macrophages further promote the inflammatory healing process by releasing additional cytokines, clearing cellular debris, and attracting blast cells to the wound. As the proliferation phase transitions to the remodeling phase of the WHP, fibroblasts begin to form the extracellular matrix (ECM) and allow for re-epithelialization of the wound. Endothelial cells promote angiogenesis and the formation of a new capillary bed to continue the remodeling process. Then, myofibroblasts promote wound contracture. As healing occurs over time, the area of the wound will regain 70%-80% of its original tensile strength (Wernick et al., 2021).
HCPs can implement different wound closure mechanisms to assist with the WHP. Various treatments are implemented based on the wound closure type. The following are wound closure options (see Figure 6 below; Azmat & Council, 2021):
Primary-intention healing or primary closure occurs when wound edges are brought together and closed using sutures or staples. Surgical wounds or those with minimal tissue loss allow for primary closure and result in minimal scarring.
Secondary-intention healing or secondary closure occurs when wounds are left open to allow granulation tissue to form, contracting the wound edges and leading to epithelization. This type of closure is often used for burns or wounds too extensive for primary intention. Healing by secondary intention increases the risk of wound infection due to the lack of an epidermal barrier.
Tertiary-intention healing or delayed primary closure involves postponing the closure of a wound for a time. This period varies depending on the wound and HCP preference. These types of wounds are often grossly contaminated and can be closed once the wound is explored for foreign objects, irrigated, debrided, and observed for complications for 3-7 days.
Every patient who enters an acute care, home health, or long-term care setting must have a skin assessment within 24 hours of admission. This assessment should occur as soon as possible to ensure that all pre-existing wounds are carefully identified and documented and appropriate treatment is initiated. An approved skin assessment risk tool should be utilized to identify pre-existing injuries and determine the risk for pressure wound development during the inpatient or outpatient admission. It is recommended that a full head-to-toe skin assessment be completed upon admission, upon transfer from a different unit or facility, and with any condition change that may increase the patient's risk. This assessment should be repeated daily to identify skin changes early (NDNQI, 2021).
The Joint Commission (2021) included the prevention of hospital-acquired pressure injuries in their 2022 Patient Safety Goals for acute and long-term care settings. They require using a skin assessment tool such as the Braden Skin Assessment Scale. The Braden Scale has been in use since 1988 and is the most commonly used tool for predicting pressure injuries and skin breakdown during hospitalizations or in long-term care facilities (The Joint Commission, 2021). The Braden Scale estimates a patient's risk of pressure injuries by assessing the following:
sensory perception and the patient's ability to respond to pressure-related pain or discomfort and whether the patient's sensory perception is completely limited, very limited, slightly limited, or no impairment present
moisture and the degree to which the patient's skin is exposed to moisture and whether the skin is constantly moist, often moist, occasionally moist, or rarely moist
activity and whether the patient is bedfast, chairfast, walks occasionally, or walks frequently
mobility (i.e., the patient's ability to move when changing body position) establishes whether they are completely immobile, have very limited mobility, have slightly limited mobility, or have no mobility limitations
nutrition measures the patient's nutritional intake (including parenteral and enteral nutrition) and whether the patient's intake is very poor, probably adequate, adequate, or excellent
- a patient who is NPO or has been restricted to clear liquids or parenteral therapy for greater than five days is considered to have very poor nutrition; a patient receiving less than optimal amounts of liquid diet or enteral nutrition is considered to have a nutritional status of probably inadequate
- once enteral feeding is maintained at optimal levels, the patient is considered to have an adequate nutrition assessment
friction and shear measure the patient's ability to move in the bed or chair and whether their risk of experiencing friction and shear is a problem, potential problem, or no apparent problem (Bergstrom et al., 1987)
Each category is given a score of 1-4 (except the friction and shear category, which is scored 1-3). These are then added to determine the individual's risk for skin-related issues during admission. A higher score is associated with a lower risk of pressure injuries. After the patient's risk has been determined, interventions are instituted accordingly to prevent the development of skin breakdown (Bergstrom et al., 1987).
After completing the risk assessment tool and identifying any pre-existing wounds, the nurse must perform a focused wound assessment to determine the plan of action. The initial step is taking a thorough history, including any risk factors that may impede the healing process. Considerations for the initial history include systemic diseases such as diabetes and PVD, smoking history, alcohol use, medications (e.g., NSAIDs, corticosteroids, anticoagulants, chemotherapeutics, and antiplatelets), nutrition, and any other risk factors that may impact healing. Additionally, the nurse will assess the origin of the wound, onset of injury or awareness of the wound, and any mitigating factors related to the wound, including increasing pain, drainage, or severity (Dowsett & Hall, 2019).
Determining the origin of a wound is an essential part of the assessment to predict further complications that may occur. Other factors that should be considered are the location, depth, size, age of the injury, and pain level. Wound healing complications may increase based on any of these factors. A careful assessment of the wound and documentation to share with the healthcare team will offer insight into the healing process and allow for early intervention if a change in treatment is needed (Driver et al., 2017).
The wound bed and surrounding tissue must be assessed for size and depth. The measuring device is most often a disposable tool to avoid contamination. The width is measured at the longest distance across the wound and the length at a 90-degree angle to the width. Most HCPs use the clock method to determine the reference points such as "12 and 6, 3 and 9" for length and width. To measure the depth of a wound, use a cotton-tipped swab that can be inserted into the deepest part of the wound and mark the distance where it meets the skin edges. Then, measure the distance from the end of the swab to this mark to determine the wound depth. Avoid pushing into the wound bed as organs or vessels could be injured. A picture of the wound is often needed for insurance reimbursement and can be used to track healing progress. Before taking photos of wounds, obtain consent for photography to avoid Health Information Portability and Accountability Act (HIPAA) or Health Information Technology for Economic and Clinical Health (HITECH) violations. Follow the facility's policy regarding wound care photography acquisition (Jarvis, 2020).
In addition to measurements of the wound, it is vital to give a clear description of its appearance. The wound bed tissue should be described in relation to color, tissue type, surrounding tissue condition, edge appearance, and the presence or absence of moisture or notation of a dry wound bed. The color and odor of drainage should be described if present. In the absence of moisture, the cells involved in healing cannot move across the wound bed, the wound edges dry out, and epithelial cells fail to grow over the wound. Consequently, healing will stop, and necrotic tissue will form. In contrast, too much moisture can be an equally detrimental issue and damage the intact cells at the wound's edge. Nurses must monitor the wound edges to ensure the skin is smooth without rolled or dry edges. The color of the wound bed and the surrounding skin can indicate concerns. White skin surrounding the wound indicates too much moisture and may worsen tissue damage. Erythema or inflammation can indicate infection, injury, tape burn, or irritation from wound care products. Typically, erythema over 2-3 cm from the wound edge indicates an infection (Brown, 2018; Ward et al., 2019).
Palpate the tissue around the wound to determine whether it is hard or soft, as hardened tissue can indicate infection or inflammation. Measure any areas of hardness or induration and document these findings. A wound bed tissue assessment should include appropriate terminology for the wound bed condition. Granulation tissue, fibrin slough, or eschar should be managed appropriately to support wound healing (Driver et al., 2017). Appropriate treatments will be discussed later.
Specific tools should be considered for pressure injuries, including the PUSH (Pressure Ulcer Scale for Healing), which the NPIAP developed. This tool considers a wound's length and width, exudate, and tissue type, assigning numbers that yield a total risk score. These scores are plotted on a pressure injury healing record and graph to determine the progress toward healing (Brown, 2018; NPUAP, n.d.).
An interdisciplinary team must diagnose the patient's wound and initiate appropriate evidence-based care. Upon discovery, nurses should thoroughly investigate a wound to help determine if the cause is pressure, friction, or traumatic injury. In addition, diagnostic testing may be done to determine the optimum treatment plan. Testing could include lab work to evaluate the patient's nutritional status (albumin, pre-albumin, and total protein) or potential infection, imaging studies (e.g., ultrasound, doppler, x-ray) to assess any underlying injuries, or biopsy as appropriate (Seppanen, 2019).
Treatment depends on the nature of the injury and individual patient risk factors. For example, an elderly patient with diabetes who has a pressure injury on their foot may be managed differently than a younger, otherwise-healthy patient with the same wound. Treatment options vary in cost, availability, and accessibility for each patient, so careful consideration should be taken to determine the best treatment modality in collaboration with the interdisciplinary team. Both topical and systemic antimicrobial agents may be used with dressings. (Bergstrom et al., 2018; CDC, 2021).
Wound cleansing will vary across wound types but can be a vital part of the WHP by removing foreign materials, necrotic tissue, excess medication, and bacteria or contamination. Unless contraindicated, wound cleansing should occur with each dressing change. Typical wound cleansing is completed with normal saline, sterile water, or a commercial cleaner with varying ingredients. Cleansers should be hypoallergenic, non-toxic for the healthy tissue, and appropriate to use with subsequent dressings. It is essential to follow the manufacturer guidelines for any dressing product (Brown, 2018).
If antibiotics/antimicrobials are to be used, a wound culture should be obtained first to determine the type of organism, promote the treatment's effectiveness, and reduce the risk of antibiotic-resistant organisms. The CDC (2021) reported over 2.8 million infections and 35,000 deaths in the US due to antibiotic-resistant organisms created by the overuse of antibiotic therapies. Therefore, antibiotic treatment should be limited to two weeks, and if there is no progress in that time, further testing should be completed to rule out underlying disease processes. Antimicrobial therapies should be discontinued once the wound infection clears and inflammation has improved. If a biofilm is recognized, a tissue biopsy may be necessary. Other healthcare team members should be notified of signs and symptoms of infection, including dieticians, nurses, and providers, such as vascular and wound care specialists. Poor nutritional status, lack of glycemic control, certain medications, and inadequate circulation are possible causes of an infection. Any deficits in these areas should be further explored and managed by the healthcare team (CDC, 2021; NPIAP, 2019).
Treatment of infected wounds can include systemic antibiotics, topical antiseptics, silver Silvadene, medical-grade honey, or topical antibiotics. (NPIAP, 2019). Wound dressings should be selected based on the following:
• ability to keep the wound bed moist
• need to address the bacterial burden
• type and amount of wound exudate
• condition of the tissue in the wound bed
• status of the surrounding skin
• injury stage and location
• presence of tunneling or undermining
• goals of the patient and the healthcare team (NPIAP, 2019)
Antibiotic therapy for treating a wound infection commonly includes intravenous (IV) and oral antibiotics to elicit systemic effects. Topical antibiotic use should be limited except when the benefits outweigh the risk of side effects and bacterial resistance. The most common oral antibiotics prescribed for wound infections include amoxicillin-clavulanate (Augmentin), cephalexin (Keflex), clindamycin (Cleocin), doxycycline (Vibramycin), or trimethoprim-sulfamethoxazole (Bactrim). Common IV antibiotics used to treat wound infections include erythromycin (Erythrocin), cefazolin (Ancef), cefoxitin (Mefoxin), and cefotetan (Cefotan). Specific side effects of antibiotics are greatly dependent on their administration route and classification. General side effects of IV antibiotics include swelling, redness, and pain at the injection site. Common side effects of oral antibiotics include diarrhea, nausea, bloating, and abdominal pain (Nelson, 2021; NPIAP, 2019; Singhal, 2021).
Wound debridement is the process of removing all material from the wound considered to be impeding wound healing. This includes necrotic tissue, cellular debris, exudate, bacteria, and foreign materials. The goal of debridement is to promote re-epithelialization. Debridement is used for various wounds, including pressure injuries and burns (Avital & Schub, 2018; Manna et al., 2021). There are a variety of debridement types, including autolytic, enzymatic, mechanical, surgical, and biological debridement:
Autolytic debridement uses the body's enzymes and healing processes to rehydrate, soften and liquefy, and then expel the necrotic tissue from the wound. Occlusive dressings are often used to keep the body's fluids in the wound bed and maintain a moist healing environment. Dressings used for autolytic debridement include foam dressings, hydrogel sheets, honey dressings, hydrocolloid dressings, and amorphous hydrogel. This type of treatment should not be used in infected wounds or those that need to be urgently debrided for best outcomes. Wounds with large amounts of necrotic tissue, undermining, or tunneling, and immunocompromised patients should not undergo autolytic debridement (Caple & DeVesty, 2019).
Enzymatic debridement or chemical debridement is the process of dissolving necrotic tissue, cellular debris, wound exudate, and foreign materials. One commonly used medication in this category in the US is collagenase SANTYL ointment. The active ingredient is from the bacterium Clostridium histolyticum, which breaks down collagen in necrotic tissue. This debridement can also be used on burns to remove eschar. Patients receiving this treatment are at an increased risk for systemic infection related to bacteria from the wound bed. Silver and iodine can inactivate collagenase, so dressings with these ingredients should be avoided after applying the collagenase ointment (Caple, 2019).
Surgical debridement is performed by the physician or primary healthcare provider. Surgical debridement physically removes necrotic tissue, cellular debris, wound exudate, or eschar from the wound bed to facilitate healing. This invasive procedure uses sharp and sterile instruments to excise nonviable materials from the wound bed. For wounds requiring this intervention, the interdisciplinary team must support the procedure and perform subsequent wound care and assessments. Non-healing or inadequately perfused wounds should not be surgically debrided as this may lead to further complications, including necrosis or enlargement of the wound bed. This procedure can be quite painful, as with any surgery, and appropriate pain management should be part of the treatment plan (Pilgrim & Heering, 2017).
Mechanical debridement has been completed for all wound types using wet-to-dry dressings over the last few decades. With this type of mechanical debridement, the wound is cleansed, and a moist dressing is applied to the wound bed. After the dressing has dried, it is removed. The goal is to pull away the top layer of tissue within the wound with the dried dressing. This removes exudate, necrotic or infected material, and foreign bodies. The disadvantage of a wet-to-dry dressing is that it is non-selective. The entire top layer of the wound is removed without discerning between viable and nonviable tissue. This type of debridement can be excruciating for the patient, so pre-medication with analgesics might be indicated to increase patient comfort. A patient on anticoagulant medication or with underlying coagulopathy may have significant bleeding with mechanical debridement, so these individuals require extra care. Although mechanical debridement with wet-to-dry dressings is cost-effective, dressing changes must be completed frequently, increasing overall supply cost. New forms of mechanical debridement include hydrotherapy (also known as hydrosurgery or whirlpool), pulsatile lavage, and ultrasonic mist. Hydrotherapy debridement is well tolerated by patients and has shown to be faster and more cost-effective than traditional debridement methods. Pulsative lavage combines intermittent lavage with suction to loosen and remove nonviable tissue from the wound. With this method, caution must be taken not to damage underlying structures such as blood vessels, bones, and tendons. Ultrasonic mist debridement uses acoustic energy to remove unviable tissue from the wound. This type of debridement is commonly used for patients with periodontal disease (Avital & Schub, 2018).
Biologic debridement, otherwise known as maggot debridement therapy, uses sterile, medical-grade larvae of the Lucilia sericata species of the green bottle fly to remove necrotic tissue from the wound bed. This type of debridement is used for chronic wounds, including diabetic foot ulcers, venous stasis ulcers, pressure injuries, and burns. It is beneficial for large wounds needing painless removal of necrotic tissue. Biologic debridement works through the release of proteolytic enzymes from the larvae that can dissolve necrotic tissue. The wound bed is cleaned, and sterile larvae are applied to the wound bed and then covered with a mesh-like, air-permeable dressing for 1-3 days, after which the dressing and larvae are removed. If further debridement is needed, the process can be repeated. Wounds should never be allowed to close over the maggot larvae, and the larvae should not be left in the wound bed if they die, as this increases the risk of allergic reaction or further infection. Larvae used for this treatment are considered contaminated and should be disposed of properly by sealing them in a plastic bag and placing the bag in a biohazard container for incineration (Manna et al., 2021; Schub & Walsh, 2018; Wernick et al., 2021).
Skin grafts promote the healing of extensive burns, wounds, and venous or pressure injuries (see Figure 7 below). They may also be performed to restore skin that has been removed during surgery or after a severe skin infection. The graft may be taken from the patient's body, known as an autograft. This type of graft has the fewest complications related to rejection. Grafts may also be taken from a cadaver or animal or created using synthetic tissue. Grafts should be placed on tissue that will support growth and adherence. Grafts placed on bone, tendons, or nerves will likely be unsuccessful as there is a limited blood supply to support the growth of the graft. Wounds with necrotic tissue, eschar, or high bacterial counts also do not support graft success. Factors that increase graft complications include patient age (pediatric and geriatric patients), smoking, diabetes, poor overall health, or certain medications. There are three types of graft techniques: split-thickness grafts, full-thickness grafts, and composite grafts. Depending on the method, the graft may take longer to heal. Skin graft procedures can be excruciating, so anesthesia should be utilized to prevent pain during the surgery. Pain control after the procedure can be managed with oral, intramuscular (IM), or intravenous (IV) pain medication. Skin tissue engineering is a newer procedure that uses stem cells to produce skin products that can replace the damaged tissue (Kaur et al., 2019).
Hyperbaric Oxygen Therapy
Hyperbaric oxygen therapy (HBOT) may be used on chronic wounds to promote wound healing. Wounds that are not healing are typically hypoxic, and increasing oxygen tension and pressure by various methods can stimulate healing. HBOT promotes muscle and nerve regeneration by stimulating angiogenesis or developing new blood vessels. The treatments can be done on limbs placed in a limb-encasing device or a full-body chamber. HBOT has been in use for over 40 years and should be part of an interdisciplinary team approach with a comprehensive plan of care for wound healing that includes strategies for extensive vessel disease, glycemic abnormalities, nutritional deficiencies, infection, and the presence of necrotic tissue. Contraindications for full-body HBOT are asthma, claustrophobia, COPD, eustachian tube dysfunction, pacemaker, high fever, epidural pain pump, pregnancy, seizures, and upper respiratory infections. Absolute contraindications would include a pneumothorax, severe respiratory disease, recent chemotherapy, and other drugs, including disulfiram (Antabuse) or mafenide (Sulfamylon; Kaur et al., 2019; Mechem & Manaker, 2020; Wernick et al., 2021).
Negative-Pressure Wound Therapy
Negative-pressure wound therapy (NPWT), also called vacuum-assisted closure, applies suction or negative pressure to the wound bed. This promotes wound healing by removing excess drainage, stimulating vascularization, and supporting the closure of wound edges or margins. Negative pressure creates mechanical stress that promotes growth factor expressions, angiogenesis, and granulation tissue growth. The negative pressure helps open the capillary beds and draw blood to the wound area. In addition, the negative pressure aids in healing by reducing edema and bacterial colonization and providing a moist wound bed. This treatment is most often used on deep or full-thickness and chronic wounds such as pressure injuries and diabetic foot ulcers. It may also be used to prepare a wound bed for skin grafts. Pain is commonly reported as an adverse reaction and should be proactively managed during treatment. This treatment should not be used for individuals at increased risk of bleeding as life-threatening hemorrhage could result (Gestring, 2022; Kaur et al., 2019; Wernick et al., 2021).
Nurses must possess a keen awareness and understanding of the various wound types and the appropriate dressings for each. A proper dressing will support wound healing and accelerate the healing time. Dressing types will likely change throughout the healing stages, and the nurse will need to assess and update the dressing throughout the trajectory of care. Unfortunately, the cost is essential in determining wound care products when planning treatment. Comfort and usability are important factors to consider, as the patient or their family members may be performing the wound care once the patient is discharged from the healthcare facility. The frequency of dressing changes should be considered for staff workload and patient compliance. Newer treatment modalities require less frequent changes and can stay in place for extended periods with optimal results.
Gauze and non-woven dressings have been used for wound care for decades, but with the advancement of new materials devised to accelerate healing, they are rarely used in modern-day wound care. Daily dressing changes are required with these materials to manage drainage effectively. Gauze may be helpful in the first 24 hours after surgery to manage drainage; however, most surgical wounds are left open to air after the first 12 hours unless there is significant drainage. Examples of gauze and non-woven dressings are Kerlix and Curad (Brown, 2018).
Absorptive or superabsorbent dressings are made up of materials that will allow for optimal absorbency and may be used alone or in combination with other dressings. These dressings are typically cotton, cellulose, or rayon and absorb the wound drainage to avoid tissue maceration. They are designed to be nonadherent to the wound and therefore do not damage the wound bed or cause pain upon removal. These dressings are not appropriate for dry wound beds, as they can cause further damage. Examples of absorption dressings are Optilock, Xtrasorb, ConvaMax, Drawtex, and DynaSorb (Wound Source, n.d.-c).
Alginates are used for highly exudative wounds and contain alginic acid from seaweed covered in calcium/sodium salts. These dressings are highly absorbent (i.e., up to 20 times their weight). Alginate dressings may also contain controlled-release ionic silver. These dressings interact with sodium ions to form a hydrophilic gel in the wound bed. They support a moist wound environment, absorb well, and may prevent microbial contamination. These dressings are used for pressure injuries, diabetic wounds, venous wounds, tunneling or cavity wounds, and wounds with minor bleeding. Examples of alginate dressings are Maxsorb and Megisorb (Walsh & Schub, 2018).
Skin substitutes are made to mimic human skin and are helpful for hard-to-heal wounds and burns. Skin substitutes protect the wound from further trauma and water loss and provide a physical barrier to bacteria while promoting new tissue growth and wound healing. Skin substitutes can be temporary or permanent. They also improve the functional and cosmetic results of the wound healing process, enhancing the quality of life for patients with wounds on exposed skin. Examples of skin substitutes are Alloderm and Dermagraft (Pilgrim, 2018).
Bioactive dressings improve wound healing and are derived from natural sources, proteins, or tissues. These products are beneficial for burns and hard-to-heal wounds. Examples are collagen dressings and medical-grade honey (Wood, 2021).
Hydrocolloid dressings are moisture-retentive dressings used to protect wounds with a small to moderate amount of drainage. These are often used to treat non-infected Stage I through Stage IV pressure injuries, partial- to full-thickness wounds, abrasions, and necrotic wounds. Examples of hydrocolloid dressings are DuoDerm and Nu-Derm (Smith & Caple, 2019).
Foam dressings can be constructed from either foam that draws in fluid and physically expands as it retains the drainage or pseudo-foam that contains absorbent materials such as viscose and acrylate fibers designed to hold extra fluid. These options are best for wounds with moderate to heavy drainage. Both can be used as a primary or secondary dressing on wounds and remain in place for up to seven days. Most are non-adhesive and can easily be used on those with allergies to adhesives. There are antimicrobial foam dressings that can be used on infected wounds. Examples of foam dressings are Aquacell Foam and Optifoam (Mennella & Schub, 2017).
Hydrogel dressings contain a high water/glycerin content within a gel base and are used to provide moisture to the wound bed. A moist environment facilitates the debridement of necrotic tissue and tissue granulation. The amorphous hydrogel can be applied in a layer over the wound surface, or a hydrogel-impregnated gauze can be used to fill dead spaces in deep wounds such as stage 3 or 4 pressure injuries. These dressings should not be used with moderate to heavy wound exudate or when the goal of care is to maintain dry eschar. Hydrogel dressings can contain allergens such as iodine, silver, or sodium carboxymethyl cellulose and should not be used for patients with known sensitivities or allergies to these products. These dressings should not be combined with collagenase (Santyl) ointment since the iodine and silver may decrease the enzymatic action of the collagenase (Santyl). Examples of hydrogel dressings are Aquasite gel/sheets and Derma-gel (Caple & Walsh, 2018).
Hydrofiber and sodium carboxymethyl cellulose dressings are used for wounds that may require packing since they are available in sheets or ribbons. These products combine with the wound exudate and produce a hydrophilic gel that maintains a moist wound environment. These dressings should not be used on dry wounds. Examples of hydrofiber dressings are Biosorb and Aqua-cell (Caple & Schub, 2018).
Contact layers are non-adhesive layers placed on a wound bed to allow drainage to flow through but keep the secondary dressing from contacting the wound bed. They may be used on burns, grafts, or other wounds to prevent damage to the underlying tissue with dressing changes. They may be used in tandem with topical medications or wound fillers. Examples of contact layers are Dermanet, Telfa, and Adaptic (Smith & Caple, 2019).
Antimicrobial dressings are essential for routine care for an infected wound, particularly diabetic ulcers. These dressings decrease the number of bacteria in the wound bed and reduce the need for systemic antibiotics. The antimicrobial materials may be impregnated into other dressing types such as hydrogels or foams to reduce the bacterial count in the wound. Care must be used to choose the appropriate antimicrobial dressing that will support wound healing. Their use should be limited to two weeks to avoid resistant organisms. These dressings should not be combined with collagenase (Santyl) ointment since some antimicrobial formulations decrease the enzymatic action of the collagenase (Santyl). Examples of antimicrobial dressings include Optifoam Ag, Aquacell Ag, Acticoat, Iodoflex, and Iodasorb (Bishop, 2018).
Transparent films may be used to secure other wound care products or alone for clean, dry wounds with minimal drainage. These dressings allow for visualization of the wound and work well on areas that need to be waterproofed. They also use the body's fluids to support debridement. Transparent dressings should not be used on wounds with moderate to large amounts of drainage. Examples of transparent dressings are Op-Site and Tegaderm (Schub, 2019).
While this is a long list of dressing types and examples, it is by no means exhaustive of the vast resources for wound care. The nurse and interdisciplinary team must consider all aspects of each patient's needs and resources and determine the best plan of action in collaboration with the patient.
Nutrition is a fundamental requirement of the human body for typical day-to-day functioning. Patients with wounds have higher nutritional needs than they do when healthy. Wound healing is complex and relies on the coordination and internal regulation of various metabolic processes to promote epithelialization within the injured tissue (Bishop et al., 2018). Nutritional factors should be considered for all diseases, and optimal nutrition should be considered promptly with wound healing to promote the best outcomes. An optimal diet for those with a wound is high in protein and amino acids with sufficient amounts of vitamin A, vitamin B complex, vitamin C, and vitamin E; iron, zinc, and copper; fats; and carbohydrates. An early referral to a dietician can facilitate an appropriate dietary intake to support wound healing. A dietician consult should be considered for any high-risk patient for nutritional imbalances or deficiencies and for those who have high-risk comorbidities such as diabetes, renal disease, obesity, liver disease, or any condition that affects the body's ability to process or eliminate nutrients (Bishop et al., 2018).
All patients with wounds should consume a diet of 20% protein, 40% vegetables and fruits, and 40% carbohydrates. This diet provides the body with the nutrients required for timely wound healing in most patients. Supplements may be needed to support the nutritional needs of some patients during the WHP, and dieticians and primary HCPs may collaborate to develop an ideal treatment plan that ensures adequate dietary intake (Bishop et al., 2018).
Pain is an expected side effect of most wounds, and many patients report the pain they endure during wound care is as painful as the initial injury. Depending on the severity and location of the wound, the pain may or may not be a significant problem. Burns are particularly painful and require ongoing pain relief. Factors that increase pain include the depth of the wound, structures involved, infection, and other injuries or conditions that co-exist with the wound. The nurse should complete a pain assessment to determine all aspects of the patient's pain, including its location, exacerbating and relieving factors, quality, and severity. Pain medication administration is essential, along with other nonpharmacological interventions that may decrease the intensity and duration of pain. Some examples of pain-relieving techniques are as follows (Chester et al., 2016):
Distraction may help decrease pain, including watching television, playing games, or reading.
Space patient care activities to give the patient uninterrupted rest in a quiet environment.
Music therapy or other guided imagery techniques may reduce anxiety levels.
Position the patient for comfort during any procedures or dressing changes.
Limit the number of dressing changes, leaving the dressings in place for extended periods whenever possible.
Avoid dressings that adhere to the wound bed and adhesives that pull at the wound.
Allow the patient to choose times for treatments or dressing changes to create a feeling of independence and decrease anxiety.
Consider alternative therapies such as hypnosis to reduce pain.
IV, IM, and PO medications can manage pain before wound care and dressing changes. The patient should be pre-medicated at an appropriate time interval before scheduled debridement or other painful dressing changes. While pain medications, including opioids, may be used during dressing changes and wound debridement, careful consideration of the adverse risk for addiction should be openly discussed with the patient and healthcare team to determine the best options for positive outcomes (Chester et al., 2016).
Sutures, Staples, and Surgical Glue
Sutures are the gold-standard method for closing minor surgical wounds or accidental injury closure. In either situation, the nurse must monitor the suture line for approximation of the skin, signs of infection, and appropriate healing. Suture materials have changed substantially in the past decade, and wound closures may have many appearances. Suturing and staples are painful for the patient and require local or another form of anesthesia before the procedure. Most suture materials are synthetic and may be absorbable or non-absorbable. Types must be differentiated so that proper instructions are given to the patient for follow-up care. Deep wounds may require sutures to minimize skin tension and reduce the risk of hematoma formation. Superficial sutures enable functional closure with minimal scarring for cosmetic purposes on areas like the face (Azmat & Council, 2021; Bonham, 2016).
Staples are typically used for superficial wounds. They are a reasonable alternative to sutures on the scalp and extremities. They are quick to insert, which is helpful in cases of brisk bleeding or mass casualty incidents. Staples are not suitable for areas such as the face due to scarring. There is less risk of infection associated with staples since they do not form a tract between the wound edges. Most staples are stainless steel or titanium and should not interfere with an MRI. Still, if other injuries are suspected, a radiologist should be consulted to ensure there will be no interference from the staples or to assess whether another closure option would be best (Azmat & Council, 2021; Bonham, 2016).
Surgical glues are highly effective in closing wounds in pediatric settings, where fear of needles is more prevalent. Surgical glue is quick to apply and provides excellent cosmetic outcomes. Some wounds are not appropriate for glue, as wound margins must be apposable and dry; this may not be the case with traumatic injuries. Glues work well for scalp wounds, and fewer cosmetic complications occur with adhesives (Azmat & Council, 2021; Bonham, 2016).
Contaminated wounds or those that are not sterile—including bites, puncture wounds, skin tears, abrasions, or lacerations—may have exposure to the bacteria Clostridium tetani, which causes a tetanus infection. Tetanus, or "lockjaw," as it is often called, is caused by the exotoxin produced by this bacterium. This leads to serious nervous system effects, including tightening of the jaw muscles, making it hard to breathe, open the mouth, or swallow. The disease is not contagious but is contracted via deep puncture wounds or cuts. Patients with burns or dead skin are also at risk (CDC, 2022).
The CDC (2022) has recommended that babies and children receive the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine at 2, 4, and 6 months and boosters at 15-18 months and 4-6 years of age. Preteens and teens should get one dose of the tetanus, diphtheria, and pertussis (Tdap) vaccine between 11 and 12 years. Pregnant women should have a Tdap during their third trimester of pregnancy, and adults should have a tetanus booster (Td) every ten years. For patients injured with one of the wound types discussed in this section who are not current with their tetanus vaccination or who have never been vaccinated against tetanus, a Td booster is essential for immediate protection (CDC, 2022).
Hepatitis B vaccines should be administered to patients who have been bitten by known carriers of HBV or if the bite status is unknown. The vaccine is administered in three doses over six months. Patients should also be given hepatitis B immune globulin (IG) immediately after injury for protection from disease (USDHHS, 2019).
Although not common, HIV may be transmitted through bites. Prophylaxis with antiviral treatments should be administered to decrease the chance of active infection. This regimen includes multiple drugs used in combination to prevent replication, production, and the virus's ability to use host tissues (CDC, 2022).
Rabies can be transmitted via animal bites. If the animal's infection status cannot be confirmed, rabies immune globulin and rabies vaccine should be administered as soon as possible after the initial injury. If a rabies infection is identified, the local and national health departments should be notified of a risk to the general animal and human population (CDC, 2020).
Animal bites are a significant cause of morbidity and mortality worldwide. Dog bites account for millions of injuries annually worldwide, with the highest risk being to children. Children and adults should be taught safe practices around animals to avoid bites, which include the following (World Health Organization [WHO], 2018):
Avoid animals displaying aggressive behaviors or those unknown to the child or adult.
Never make quick movements toward animals or provoke them.
Avoid leaving children unattended with animals, even family pets.
Vaccinate all household animals for rabies and other infectious diseases per state guidelines.
Avoid tall grassy areas and wear protective footwear.
Seek treatment immediately if an animal bites a child or adult or if any signs of infection occur.
Burns may be prevented by educating the public to do the following (American Burn Association, n.d.):
Turn off electrical currents before attempting home repairs.
Stand at least 3 feet away from hot outdoor objects (e.g., a grill or fire).
Keep outlets covered with protective childproof coverings if small children are in the home.
Repair or discard frayed electrical wires immediately.
Keep water heater temperatures set below 120 degrees.
Avoid wearing loose-fitting clothing while cooking.
Turn pot handles away from the front of the stove and keep children away from the burners of a hot stove.
Keep hot drinks away from the edge of tables and counters.
Do not allow appliance cords to dangle over the counter edge.
Do not use heated blankets or pads while sleeping.
Pressure injuries are entirely preventable with good nursing care and an interdisciplinary team focused on nutrition, activity, and proper hygiene (NPIAP, 2019). Nursing care for patients who are immobile or physically impaired due to an acute or chronic illness should include the following:
turning patients every two hours unless contraindicated
keeping patients clean and dry at all times
keeping bed linens free of wrinkles and dry at all times
performing daily skin assessments or more frequently if the patient is incontinent
utilizing appropriate pressure relief devices, including mattress toppers, specialty mattresses, pillows, and wedges
integrating wound care experts into the interdisciplinary team if any areas of breakdown occur
consulting dietary/nutrition services to ensure proper nutrition
utilizing incontinence products if indicated (e.g., barrier creams for prophylaxis in the inpatient setting at any sign of erythema; NPIAP, 2019)
Nursing staff should focus on preventing skin tears, especially in the geriatric population. The following strategies can be implemented to prevent skin tears (Baranoski et al., 2016):
Identify and remove potential sources of injury, including medical equipment.
Ensure adequate lighting, especially in unfamiliar environments such as a hospital.
Apply padding to beside rails, wheelchair armrests, and leg supports.
Encourage patients to wear long sleeves and pants when the weather allows.
Keep caregiver and patient fingernails smooth and short.
Use lukewarm water and no-rinse pH-balanced cleansers for bathing.
Apply moisturizing creams frequently to prevent dry skin.
Avoid placing products with adhesive directly onto the skin; if necessary, use paper tape and non-adhesive dressings.
Use skin guards for individuals who repeatedly experience skin tears.
Patients with diabetes should be educated on preventative measures to decrease the risk of developing a diabetic ulcer. Nurses should teach all clients the following (Engelke & Schub, 2018; Wernick et al., 2021):
Encourage patients to control their blood glucose level by eating a healthy diet, monitoring their blood glucose regularly, maintaining an exercise regimen, and taking all medications as prescribed.
Patients should see their primary healthcare provider annually and as needed.
Patients should see their podiatrist for inspections and regular care of their feet. This may vary from every three months to annually. Patients at high risk may need to have their toenails cut by a podiatrist to prevent complications.
Patients or caregivers should perform daily foot inspections.
Patients should wear shoes that fit well.
Patients should be instructed to keep the area between their toes dry and avoid applying lotion to this area.
Encourage patients to wear cotton socks and footwear when walking.
Both venous and arterial disorders can lead to ulcers (Criqui et al., 2021). The following strategies should be taught to all patients with PVD:
glycemic control with diabetes
daily inspection of feet, especially in between toes and soles of feet
moderate exercise (after consulting with an HCP)
routine health check-ups
medication compliance (anticoagulants, antihypertensives, and statins) as prescribed (Criqui et al., 2021)
Wound Care Specialty Certifications and Organizations
Nurses often seek certification in their area of expertise, and wound care is no different. While all nurses are expected to deliver safe and effective care to patients with wounds, there are higher-level certifications for those wishing to demonstrate expertise in this area. Nurses certified in wound care offer their patients a higher level of care and add credibility to their organization. The following organizations certify and support nurses who work in wound care:
The Wound, Ostomy, and Continence Nursing Society (WOCN, 2022) offers the Wound, Ostomy, and Continence (WOC) certification.
The National Alliance of Wound Care and Ostomy (NAWCO, 2020) offers the Wound Care Certification (WCC).
The American Board of Wound Management (ABWM, 2020) offers the Certified Wound Specialist (CWS) and Certified Wound Care Associate (CWCA) certifications.
As discussed in this lesson, nurses play multifaceted roles on the interdisciplinary team when caring for patients at risk for wounds or those who have wounds upon entry to the healthcare system. Nurses function as coordinators of care, educators, advocates, and protectors of patients under their care. While nurses do not control the risk factors that patients experience—such as smoking, obesity, diabetes, or other lifestyle choices or conditions—they can control aspects of the environment in which the care is delivered, striving to prevent skin tears, pressure injuries, and MASD or hospital-acquired infections. Nurses must remain knowledgeable of evidence-based treatment options and serve as leaders in the field by acquiring specialty certifications. As the world's most respected profession, nurses are looked to by patients and their families for advice and guidance on their care, often at critical points when their health has declined. Thus, nurses' advice should be current and based on the best available evidence.
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