Fundamentals of Nursing: Wound Care

Skin Functions

• The largest organ system
• Accounts for about 15% of the total body weight.
• Protection, providing a barrier from injury, infection, ultraviolet radiation, and heat
• Plays a crucial role in sensory perceptions from touch, pain, pressure, and vibration
• Regulates temperature and protects the body against temperature changes
• Eliminates waste and supports the underlying structures and synthesis of Vitamin D.

Layers of the Skin

• Epidermis: Outer layer of the skin containing keratinocytes which help protect the skin from water loss, pathogens, and injury.
• Dermis: Largest portion of the skin that sustains and supports the epidermis by providing strength and flexibility.
• Subcutaneous tissue (Adipose fat): insulates the body, absorbs shock, and pads the internal organs and structures

Patients at Risk for Tissue Injury

• Neonates and Children: Immature skin, prolonged duration of pressure, moisture/maceration and poor perfusion leads to diaper rash, skin tear, and pressure injuries.
• Older Adults: Thin skin, decreased elasticity/subcutaneous tissue/blood supply/hydration leads to skin tears, pressure injuries, flaky skin, skin infections, and cellulitis.
• Decreased Mobility: Reduced circulation/incontinence/loss of collagen/muscle atrophy/impaired sensation leads to skin tears, pressure injuries, skin infection, irritant dermatitis.
• Obese Patients: Decreased moisture, dry skin, decreased blood flow, and maceration leads to skin tears, pressure injuries, diabetic ulcers, moisture lesions, and skin fold rashes.
• Cancer Patients: Inflammation, skin surface damage due to radiation, and decreased blood supply leads to pressure injuries, delayed wound healing, skin infections, and cellulitis.
• Chronic Illness: Skin changes due to hepatic/kidney/cardiovascular diseases, malnutrition, stomas, and psychosocial issues leads up skin tears, pressure injuries, infections, and moisture lesions.

Nurses Preparation for Wound Assessment

• Review the facility/unit specific protocol for performing skin assessment.
• Review patients' medical history and allergies.
• Discuss wound assessment plan with patient.
• Assess if patient is experiencing any pain and medicate accordingly.
• Assess need for additional staff to help turn patient.
• Gather supplies like gloves/PPE, light source, and measuring devices.

Skin Assessment Terminology

• Skin color normal in order to evaluate changes, looking for blanchable vs. non-blanchable erythema
• Assess dark-skinned clients for pressure injuries by applying light pressure, observing areas darker than the surrounding skin and comparing with other body parts.
• Look for redness, paleness, flushing, and cyanosis.
• Skin temperature is compared for differences with other body parts.
• Touch the skin to see if it feels cold or hot.
• Edema assesses if it is unilateral or bilateral.
• Measure pitting by applying pressure to area for 5 seconds then releasing pressure.
• For Turgor, pinch skin near the clavicle or forearm then let it go to see if the skin should quickly return to place.
• Check skin Moisture for sweating, urine, or leakage, and if it's accompanied by any odor.
• Assess Skin integrity for intact skin, openings, cuts, bruises, injuries, or cracks.

Key Terms Related to Wounds

• Abscess: Infectious fluid collects in wound
• Debridement: Cleaning out of dead or infectious tissue
• Eschar: Dry, crusted, dead tissue (tan or black)
• Exudate: Collection of drainage (blood, plasma) that can be liquid or dried
• Necrosis/Necrotic: Death of tissue (often appears black)
• Tunneling: Wound extension beneath skin layers (creating a tunnel)
• Irrigation: Cleansing of wound with fluid such as saline

Risk Assessment: Braden Scale

• Six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear
• Scores range for each category: 1 to 4, except friction/shear which ranges from 1 to 3.
• The totals are added to determine risk with lower scores indication high risk

Types of Wounds

• A disruption in the normal composition and performance of the skin and its underlying structures.
• Acute: intentional vs. unintentional
  • Traumatic: lacerations
  • Surgical: intentional during surgery created using sterile technique
  • Moisture Associated Skin Damage caused by excessive sweating, increased body temperature, and deep skin folds.
• Chronic: develop over time because of disruption in the wound healing process associated with acute wounds, or due to conditions that cause alterations in blood flow
  • Venous ulcer, neuropathic (diabetic) ulcer, arterial ulcer, and pressure Injury

Wound Assessment Parameters

• Color of Wound Bed and Odor
• Measurement of depth, tunneling, and undermining
• Exudate (drainage)
• Serous: Thin, watery plasma
  • Sanguineous: bloody wound drainage
  • Serosanguineous: watery drainage mixed with blood
  • Purulent: Thick with WBCs, yellow/green with foul odor

Pressure Injury Details

• A localized damage to the skin and/or underlying tissue because of a pressure or pressure in combination with shearing.
• Most often occur over bony prominences, such as urinary catheters, oxygen tubing, endotracheal tubing, or drains.
• The most susceptible areas are over bony prominences, such as the heels, toes, sacrum, hips, elbows, shoulders and back of the head.

Pressure Injury Staging

• Injuries are classified according to how much tissue loss is observed in the wound. Nurses assess and stage or classify the wounds using a scale of 1-4 based on the level of tissue loss.

Stage Classifications

• Stage I: Non-blanchable erythema of intact skin and can be swollen or different texture.
• Stage II: Partial thickness skin loss with exposed dermis and a viable wound bed with no slough, eschar, granulation tissue, or adipose tissue.
• Stage III: Full thickness skin loss with visible adipose tissue and possible granulation tissue and some slough or eschar but NO MUSCLE TENDONS LIGAMENTS CARTILAGE AND BONES
• Stage IV: Full thickness skin and tissue loss with cartilage, bone, fascia, muscle, tendons ligaments exposed in wound.
• Unstageable: obscured full-thickness skin and tissue loss
• Deep tissue pressure injury: persistent non-blanchable deep red, maroon, or purple discoloration

Unstageable Wounds

• No determination of stage because eschar and slough obscures wound bed and actual depth is unknown.

Deep Tissue Pressure Injury (DTPI)

• Discoloration of non-intact or intact skin
• Intact skin is non-blanchable with deep red, maroon, or purple discoloration
• Non-intact skin or open wounds have a dark wound bed or blood blister

TIME Mnemonic

• Should be used as a good reminder for how pressure injury should be described in the nurse notes
• T= Tissue Integrity describes how the tissue looks, the wound color, and if there is dead necrotized tissue present.
• I= Inflammation or infection notes if there are signs of infection: redness, warmth, swelling, discharge, and swelling.
• M= Moisture should document if the wound is dry or moist and if the wound is macerated.
• E= Edge of wound and should describe the wound edges.

Types of Wound Care

• Surgical debridement: process of surgical removing dead tissue and other debris that can cause infection
• Irrigation: removes surface materials and decreases bacterial levels in the wound
• Biological Debridement: Ex: papaya extract, larvae
• Wound Dressings: Clean vs sterile dressings, dry vs wet dressings, open dressings, semi-occlusive dressings, negative pressure therapy, staples and sutures
• Advanced dressing matrix:
  • Hydrocolloids used for light to moderately exudative wounds
  • Maintains the wound moist and avoids infection.
  • Hydrogel used for little to no excess exudates helps autolytic debridement and cools and soothes.
  • Alginates are used for moderate to high exudates, is low cost, convenient, suitable for shallow or cavity wounds, and is non-toxic and biocompatible material.
  • Polyurethane foam is used for exudating venous ulcers and is permeable and adsorbent.

Negative Pressure Wound Therapy (NPWT)

• NPWT systems are FDA class II devices consisting of a vacuum pump, drainage tubing, and wound dressing set requiring electricity to maintain its use.
• Indicated for the application of suction (negative pressure) to promote wound healing and for the removal of fluids such as wound exudate, irrigation fluids, bodily fluids or infectious materials.
• May be indicated for use on chronic, acute, traumatic, subacute and dehisced wounds, diabetic ulcers, pressure ulcers, skin flaps and grafts.

Types of Drains

• Penrose Drain: flat, pliable passive drain that uses gravity to drain accumulated fluids.
• Portable wound bulb suction device: active, closed system drain that uses negative suction to drain fluid from the wound
• Large Bottle Drainage: higher-pressure, large bottle
• Circular Portable Wound Suction Device: designed to continuously suction drainage from a wound by providing a low vacuum pressure.
• Nursing Interventions: Avoid kinking of the tubing and empty it regularly
• Drains are generally removed when drainage is less than 30 to 100ml per day.

Wound Management - Nursing Considerations

• Prevention is key in Wound Management
• Nursing Considerations:
  • Relieve Pressure using pressure relieving devices and avoiding donut-type devices and synthetic sheepskins
  • Proper Nutrition by increasing protein intake, adequate hydration, and considering possible enteral nutrition
  • Skin Hygiene by cleaning skin with mild soap, cleaning incontinent patients, avoiding scrubbing bony prominences, using barriers for incontinence, moisturizing for hydration, and preventing moisture build-up
  • Reposition the patient every 2 hours while in the bed by lifting/not pulling to avoid shearing/friction from force and encouraging early mobilization
  • Monitor the size & color of the wound using the Braden Scale to anticipate the risk of pressure ulcers

Healing Process

• Primary healing or first intention occurs in clean lacerations and surgical incisions, which are closed with skin adhesives or sutures.
• Secondary healing or second intention is wound healing that happens when the wound is left open to heal
• Delayed primary closure or tertiary intention a combination of primary and secondary healing, when the wound is left open for 5-10 days before it is closed with sutures

Three Phases in the Wound Healing Process

• Hemostatic or Inflammatory lasts 3-6 days, where damaged tissue releases cytokines triggering hemostasis so that the wound starts to heal with blood coagulating and plasma leaking into surrounding tissue causing swelling with blood coagulates.
• Proliferative occurs in the next 3-24 days as new collagen fibers are formed, a new wound bed is created, and capillaries start growing as the wound edges begin pulling closer and new granulation tissue grows.
• Remodeling occurs from after 21 days and up to a year as stronger collagen replaces the soft gelatinous collagen with this tissue being much weaker than the original tissue and susceptible to re-injury.

Factors Influencing Wound Healing

• Can be remembered easily by the mnemonic DIDN'T HEAL.
  • D= Diabetes, I= Infection, D= Drugs, N= Nutritional problems, L= Low temperatures, A= Another wound, E= Extensive tension, T= Tissue necrosis, H= Hypoxia

Complications of Wounds

• Infection: tested with culture wounds
• Dehiscence: a complete or partial separation of the suture line and underlying tissues that occurs when a wound fails to heal properly due to poor surgical technique, infection, or presence of foreign particles in the wound (rupture)
• Evisceration: Protrusion of internal organs through a surgical wound which has dehisced or opened.
• Bleeding/Hemorrhage: hematoma

Basic Nutrient Requirements

• Calories – energy that is stored in food
• Macronutrients – building blocks eaten in large amounts
  • Carbohydrates: body's primary quick fuel source (grain breads, baked potatoes, brown rice)
  • Fats: absorb vitamins while providing energy (olive oil, salmon, avocado, omega 3 Fatty Acids)
  • Proteins: provides amino acids to body for build and repair of muscle and tissue (beans, soy, nuts, meats, eggs, fish)
• Micronutrients – small amounts needed for growth, development and body functions
  • Vitamins promote health and support immune system (fat soluble: A, D, E, & K water soluble: C & B complex
  • Minerals help body develop and function normally (iron, zinc, calcium)
• Water –half the body weight, needed for cell function and replaced fluid body loses

Fat Soluble Vitamins

• Vitamin A for bone formation, vision, tooth formation, immune function, cellular function, with food sources that come from fish liver oil, beef liver, dairy products, green leafy vegetables, and sweet potatoes.
• Vitamin D for bone and teeth development, absorption and metabolism of calcium and phosphorus from fish oil, milk, eggs, dairy products, and sunlight
• Vitamin E fights infection and provides healthy red blood cells from almonds, wheat germ, and sunflower seeds.
• Vitamin K is used for blood clotting and bone health from spinach, liver, butter, kale, and parsley

Water Soluble Vitamins

• Vitamin B1 or thiamine converts nutrients to energy and comes from whole grains, pork, seeds, and trout.
• Vitamin B2 or riboflavin aids energy production and fat metabolism from yogurt, milk, organ meats, and almonds.
• Vitamin B3 or niacin helps produce energy from food and comes from meat, fish nuts, grains, and legumes.
• Vitamin B5 or pantothenic is used for fatty acid synthesis from mushrooms, tuna, avocado, and chicken.
• Vitamin B6 or pyridoxine helps the body release sugar for energy and immune function from organ meats, salmon, tuna, and potatoes
• Vitamin B7 or biotin breaks down carbohydrates, fats, and protein with sources of organ meats, eggs, salmon, and sunflower seeds.
• Vitamin B9 or folate is necessary for proper cell division and comes from leafy green vegetables, orange juice, eggs, beans, and avocado.
• Vitamin B12 or cobalamin uses aids red blood cell formation, as well as proper nervous system and brain function that comes from clams, beef, salmon, milk, and yogurt
• Vitamin C or ascorbic acid promotes iron absorption, wound healing, bone formation, and immune function with sources of Brussels sprouts, citrus fruits, spinach, berries, tomatoes, and potatoes.

Nutritional Status

• Adequate Nutrition is measured by someone's physical appearance measuring weight, vital signs, cholesterol levels etc., and eating a balanced meal with adequate calories and nutrients allows a client to concentrate and have energy throughout the day.
• Inadequate Nutrition results from Fluctuation in weight, brittle hair, irritated gums, cavities, poor skin condition, and irregular bowel patterns

BMI Formulas

Weight (in pounds)

• BMI = 703 X Height 2 (in inches)
• Weight (in kilograms) BMI = Height² (in meters)

Nutritional Assessment Elements

• Intake and Output a.k.a. I&O's: measuring patient's fluid intake and output
• Intake refers to patient's fluid intake by mouth, feeding tubes, or intravenous catheters.
• Output refers to fluid output from kidneys, gastrointestinal tract, drainage tubes, and wounds
• Physical Assessment: measuring height/weight to determine BMI, inspecting teeth/skin/hair for breakdown, vital signs, and cholesterol levels
• Daily Weights: taking at the same time, after voiding using bed scales and reporting a 1 lb gain in one day
• Concern for Aspiration: noticing Dysphagia symptoms like coughing, choking, gagging, and drooling and telling patients to tuck their chin when swallowing to help propel food by avoid straws & looking for "pocketing" in cheeks/mouth sitting up at 90 degrees while eating food and keeping Semi-Fowler's (45 degrees) for at least 1hr after meals, and allowing extra time for patient to chew and swallow each bit of food

Therapeutic Diets

• Clear liquid: Fruit juices without pulp, gelatin, broth, tea (no milk), ice chips
• Full liquid: Milkshakes, ice cream, pudding, Jell-O
• Pureed: Pudding, mashed potatoes, yogurt, baby food, ice cream
• Mechanical soft: Diced, ground food, cottage cheese, pancakes, banana
• Soft/low residue: Low in fiber, easy to digest, pasta, tender meats
• Regular: No restrictions
• NPO: Nothing by mouth
• Heart healthy: Whole grain bread, lean meat, skim milk, fish, no-salt added
• Renal diet: No salt added, avoid processed meats, no prune juice
• Low sodium: No added salt, 1 to 2g sodium
• Low cholesterol: 300mg/day of cholesterol

Gastrostomy & Nasogastric Intubation

• Purpose is for decompression, feeding/medications, gastric lavage and compression
• Nasogastric tube has been Placed is from the nostril, down the esophagus and ending in the stomach
• used short term for patients who are unable to eat on their own to remove stomach contents (pumping the stomach).
• RNs can place the tube at patient's bedside
• Gastrostomy or G-Tube is used for nutrition and medication, directly administered through the stomach
  • intended for long term use with patients who cannot eat on their own
  • Tube has to be surgically placed by surgeon
• Nursing Considerations for use:
  • Verify placement of tube before initial use with x-ray or check gastric sections for ph level (less than 4)
  • No longer standard practice to inject air into tube to hear a whoosh to verify placement
  • Record all drainage, measurements, and patient position
  • Assess patient for complications, excoriation, discomfort, and occlusion

Enteral Feedings

• Purpose is to provide nutrients to clients who can't consume diet orally and have functioning GI tract
• Formula Types- Route/Prescription/expiration/storage
• Access Tubes- Nasogastric, Gastrostomy, Jejunostomy:
• Ongoing Care involves verifying the placement before each use, aspirating for residuals and flushing the tube before/after each use, using 30mL of water flush tubing, continuous vs. bolus feeding, and keeping I&O's
• Complications to look for are if the Residual exceeds 250ml in two consecutive times, Diarrhea happens 3 times in 24hr, N/V, Aspiration holds feeding and turns to the side to check Xray and auscultate, and prevent Skin Irritation by using skin barrier and proper skin assessment

Insulin Administration for Diabetic Patients

• Therapeutic Use: Treats Diabetes Mellitus
• Adverse Drug Reactions:
  • Hypoglycemia
  • Injection site reactions- lipohypertophy
  • Allergic response
• Nursing Interventions:
  • Monitor for signs of hypoglycemia
  • Check blood glucose levels w/administration
  • Administer SubQ -Storage: Check expiration date of opened vials, check if refrigeration needed.
• Patient Education Tips: Wear A Medical Alert Bracelet
• Watch for symptoms of hypoglycemia and test blood glucose as needed
• Always carry carb snack
• Rotate injection sites

Mixing insulin

• To Prevent Contaminating A Short-Acting Insulin such as "Reg", draw up the clear insulin. Before the Cloudy, draw up the cloudy insulin such as NPH

Surgical Client

• Includes three Perioperative Phases
  • Preoperative: Initial phase of care before surgery where both physical and psychological preparations are made for clients based on their individual needs.
  • Intraoperative: The time period from which clients are moved onto bed in the OR to transfer to recovery or post anesthesia care unit. -Postoperative: Final phase immediately after surgery that can be brief lasting only a few hours, or include rehabilitation and recuperation.

Preoperative Assessment

• Confirm name of client, medical record, client's age, date, time, medical diagnosis, the chief complaint, and the source giving the information with two identifiers.
• Obtain a complete client history and consent and do client teaching.
• Also involves the promotion of safety through identification of clients having a high risk of complications from surgery.

Allergies

• During the perioperative phase, allergies should be noted and verified and then entered into the electronic medical record (EMR).
• Note the client's allergies to medications, foods, and environmental elements.
• Document the nature and the seriousness of prior reactions and any intolerances to medications.

Smoking

• Provide counsel to clients who are smokers undergoing surgery to stop as soon as possible before a procedure, especially for surgeries involving the chest or abdomen.

Pregnancy

• Administer a pregnancy test if there’s a chance of pregnancy, if the last menstrual period is more than 3-4 weeks, or upon the client's request.
  • This right can be refused to the clinet, but this must be documented

Informed Consent

• Requires a client's full understanding and choice to have a treatment or procedure, including the risks involved, benefits, and other alternatives available, and knowing who will perform the treatment as well as it’s purpose

Preoperative Education

• Intended to prepare and inform clients of what to expect before and after surgery to have a better understanding, feel empowered lessen anxiety as an effect to decrease hospital stay and recovery period.

Anesthesia types

• Local Anesthesia prevents pain impulses affecting motor and sensory nerves at the surgical site.
• Regional Anesthesia causes a temporary loss of feeling in an area of the body.
• General Anesthesia for use of drugs or inhalants to depress the central nervous system.
• Moderate or Conscious Sedation permits the client to remain relaxed and calm so they can follow commands without pain or anxiety.

Indications of Postoperative Complications

• Nausea
• Vomiting
• Postoperative Cognitive Dysfunction (POCD)
• Venous Thromboembolism/ Pulmonary Embolism
• Hypotension/Hypovolemia
• Atelectasis
• Wound Infection
• Wound Dehiscence
• Ileus
• Oliguria or Acute Kidney Injury