NF 38 Providing Wound Care and Treating Pressure Injuries PDF

ch a p te r Providing Wound Care and Treating Pressure Injuries 38 http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 1. Describe the physiologic process by which wounds heal. 2. Discuss factors that affect wound...

ch a p te r Providing Wound Care and Treating Pressure Injuries 38 http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 1. Describe the physiologic process by which wounds heal. 2. Discuss factors that affect wound healing. 3. Describe four signs and symptoms of wound infection. 4. Discuss correct nursing actions to be taken if wound dehiscence or evisceration occurs. 5. Explain the major purpose of a wound drain. 6. Identify the advantages of negative pressure wound therapy. 7. Compare and contrast the therapeutic effects of heat and cold. Clinical Practice 1. Perform wound care, including emptying a drainage device and applying a sterile dressing. 2. Provide appropriate care for a pressure injury. 3. Perform wound irrigation. 4. Remove sutures or staples from a wound and apply thin adhesive strips (Steri-Strips). 5. Give a heat or cold treatment to a patient. Skills & Steps Skills Steps Skill 38.1 Sterile Dressing Change 775 Skill 38.2 Wound Irrigation 778 Skill 38.3 Applying a Wet-to-Damp or Wet-to-Dry Steps 38.1 Dressing 780 Maintaining a Closed Wound Drainage Unit 768 Steps 38.2 Applying a Hydrocolloid Dressing 777 Steps 38.3 Removing Sutures or Staples 782 Steps 38.4 Irrigating the Eye or Adult Ear 783 Key Terms abscess (ĂB-sĕs, p. 765) adhesions (ăd-HĒ-shŭnz, p. 762) adipose (ĂD-ĭ-pōs, p. 762) approximate (ă-PRŎX-ĭ-māt, p. 762) approximation (ă-prŏx-ĭ-MĀ-shŭn, p. 772) binders (p. 770) cellulitis (sĕl-ū-LĪ-tĭs, p. 765) collagen (KŎL-ă-jĕn, p. 762) débridement (dĕ-BRĒD-măw, p. 767) erythema (ĕr-ĭ-THĒ-mă, p. 761) eschar (ĔS-kăr, p. 767) exudate (ĔKS-ū-dāt, p. 765) fibrin (p. 761) first intention (ĭn-TĔN-shŭn, p. 762) fistula (FĬS-tū-lă, p. 765) granulation tissue (grăn-ū-LĀ-shŭn, p. 774) hemostasis (hē-mō-STĀ-sĭs, p. 761) immunocompromised (ĭm-ū-nō-KŎM-prō-mīzd, p. 765) integument (ĭn-TĔG-ū-mĕnt, p. 760) keloid (KĒ-loyd, p. 762) laceration (lăs-ĕr-Ā-shŭn, p. 762) lysis (LĪ-sĭs, p. 762) maceration (măs-ĕr-Ā-shŭn, p. 781) macrophages (MĂK-rō-fāj-ĕz, p. 762) necrosis (nē-KRŌ-sĭs, p. 761) phagocytosis (făg-ō-sī-TŌ-sĭs, p. 761) platelet aggregation (PLĀT-lĕt ăg-rĕ-GĀ-shŭn, p. 761) purulent (PŪ-rū-lĕnt, p. 765) sanguineous (săng-GWĬN-ē-ŭs, p. 765) second intention (p. 762) serosanguineous (sĕr-ō-săng-GWĬN-ē-ŭs, p. 766) sinus (SĪ-nŭs, p. 766) sloughing (SLŪF-ĭng, p. 767) suppuration (sŭp-ŭ-RĀ-shŭn, p. 785) third intention (p. 762) 759 760 UNIT VIII Care of the Surgical and Immobile Patient Concepts Covered in This Chapter • • • • • • • • Clinical judgment Infection Nutrition Pain Patient education Professionalism Sensory perception Tissue integrity TYPES OF WOUNDS AND THE HEALING PROCESS Wounds occur in a variety of ways. A surgical incision causes a clean and controlled break in skin integrity, whereas trauma may cause an irregular break in the skin. Pressure can cause tissue breakdown and alter skin integrity. Burns can partially or completely destroy skin. The skin and mucous membranes are protective barriers for the body against infection. Thus, Table 38.1 injury to the integument (skin) brings risk of infection and may cause permanent damage. When the integument is injured, a complex healing process is initiated. Nurses act to prevent the invasion of microorganisms into wounds and to support and enhance the body’s ability to affect wound repair. Wounds may be open, occurring through the skin, or closed, without a break in the skin (Table 38.1). Closed wounds are typically caused by blunt trauma, twisting, pulling, straining, or deceleration force against the body. Wounds may be partial thickness (supericial) or full thickness. Partial-thickness wounds heal more quickly because new skin cells are produced by the epithelial cells remaining in the dermal layer of the skin. The ibrin clot that forms after an injury acts as the framework, and regrowth occurs across the open wound area. When a full-thickness wound occurs, the dermal layer is no longer present except at the wound margins. To heal, all dead (necrotic) tissue must be Wound Types and Characteristics TYPE CHARACTERISTICS DOCUMENTATION DESCRIPTION CLOSED Contusion (bruise) Tissue injury without breaking of skin Purple contusion 5 × 7 cm on left thigh Hematoma Tissue injury that damages a blood vessel; pooling of 4 cm diameter hematoma on right forearm blood under the unbroken skin Sprain Wrenching or twisting of a joint with partial rupture of its ligaments; causes swelling Incision OPEN Surgically made separation of tissues with clean, smooth edges Swelling of right foot and around malleolus No bruising noted Approx 7 cm incision on right lower quadrant of abdomen; well approximated; clean and dry with sutures intact Laceration Traumatic separation of tissues with irregular, torn edges 5 cm jagged laceration approx 4 cm deep on lateral aspect of left lower leg Abrasion Traumatic scraping away of surface layers of skin Raw appearing abraded area 6 cm diameter beneath left elbow Puncture Wound made by sharp, pointed object through skin or mucous membranes and underlying tissue Small, circular entry wound on bottom of left foot from stepping on nail Penetrating Variable-size open wound through skin and underlying tissues made by a bullet or metal or wood fragment; may extend deeply into body Jagged deep wound on left chest at third intercostal space, 5 cm lateral to sternum Avulsion Tearing away of a structure or a part, such as a ingertip, accidentally or surgically Avulsion of tip of left little inger from accident with knife Attached only by skin Ulceration Excavation of skin and/or underlying tissue from injury or necrosis Ulceration on lateral aspect of left lower leg 4½ × 5¾ × 2 cm deep; yellow drainage present; wound edges reddened Perforation Internal organ or body cavity tissue opened, usually because of infection or a penetrating wound Abdomen pale, hard to palpation with blue-tinged discoloration noted in right upper quadrant Crush (could cause open or closed wound) Tissue signiicantly disrupted or compressed because of high level of force being applied (e.g., person pinned against a wall by a car hitting him at a moderate speed); may or may not be visible lacerations or maceration of surrounding tissue Both lower extremities with gross deformities; signiicant hematomas present, left greater than right, below the knees, no pulses palpated in popliteal or pedal regions bilaterally Providing Wound Care and Treating Pressure Injuries CHAPTER 38 761 removed so that granulation tissue can gradually ill in the defect (Fig. 38.1). The wound heals by contraction. Wounds may be clean (free of microorganisms) or dirty (containing microorganisms). An infected wound contains a large number of microorganisms that invaded the tissue and released a variety of toxins. When a wound occurs, the two primary methods of healing are replacement of cells and regeneration. Replacement occurs in the form of ibrous connective tissue that does not have the same functional characteristics as the tissue lost when the wound occurred. When cells are not damaged beyond recovery, they restore themselves, with little to no permanent evidence of injury. If the blood supply has been disrupted to the new wound bed and necrosis (death or injury to cells) has occurred, the affected tissue must heal by regeneration. New cells similar in structure and function to the dead cells are produced if the tissue is a type that will regenerate. Skin, mucous membranes, bone marrow, muscle, bone, liver, kidney, and lung tissue can regenerate with tissue that is structurally similar to that which was lost. Heart muscle and nerve cells are generally unable to regenerate. the margins of the wound toward the base of the scab, and within about 48 hours a thin layer of epithelial tissue forms over the wound. Chemical reactions releasing histamine and prostaglandin occur. Small blood vessels then dilate and become more permeable, causing serous luid to leak into the traumatized area. The collection of plasma and electrolytes leaking into the interstitial spaces causes edema. The wound becomes reddened, swollen, and tender. Reactions that are more chemical bring phagocytic neutrophils to cleanse the wound. The phagocytic cells remove debris and protect against bacterial invasion by phagocytosis (engulfing of microorganisms or foreign particles). The clinical signs of the inlammatory process are as follows: • Swelling or edema of the injured part • Erythema (redness) resulting from the increased blood supply • Heat or increased temperature at the site • Pain stemming from pressure on nerve receptors • A possible loss of function resulting from all these changes PHASES OF WOUND HEALING Concern About Scarring No matter what the cause of the wound, healing occurs in three distinct phases: the inlammatory phase; the proliferation or reconstruction phase; and the maturation, or remodeling, phase. Inlammation is a localized protective response brought on by injury or destruction of tissues. The inlammatory phase begins immediately after injury and lasts approximately 3 or 4 days. It includes constriction of blood vessels, platelet aggregation (clumping), and the formation of fibrin (protein essential to clotting) from the action of thrombin on ibrinogen and epithelial cell migration. This is the process of hemostasis (blood clotting or vessel compression) and clot formation. A scab forms to protect against pathogens. Epithelial cells migrate from Carl Heffner has had open heart surgery and comes to the cardiac rehabilitation center three times a week. The saphenous veins from both legs were used for grafts, so he has three healing incisions from this surgery. He is 64 and divorced. Mr. Heffner: “When it gets warm this summer, I will hate wearing shorts to work out with these leg scars. They are so ugly. I feel like I have little red snakes going up my legs.” Nurse: “You are worried about the appearance of your legs?” Mr. Heffner: “Yes, people must ind these scars repulsive. I’ve always looked away when I’ve seen someone at the gym with all these scars.” Nurse: “Is it dificult to think of yourself looking different than you did before the surgery?” Mr. Heffner: “Yes, I’ve always taken a great deal of pride in my appearance. There was a time when women told me I was handsome. Now I’m just a wreck.” Nurse: “How are you feeling now, compared with before your surgery?” Mr. Heffner: “I feel much better. I am able to do more and am not fatigued all the time. I’m even thinking of playing tennis again.” Nurse: “So before your surgery, you had fairly constant chest pain, were very fatigued, and had to give up playing tennis. Let’s look at what the surgery has meant to your life on the whole.” Mr. Heffner: “Well, sure, I’m much better after the surgery and I’m grateful to be alive. My stamina is improving daily and it looks like I will be able to play tennis again. I am really looking forward to that. But I am very self-conscious about getting out on the court in shorts. My buddies will probably tease me.” Nurse: “Have any of the other players had heart surgery?” Mr. Heffner: “Yes, Charlie has, but he doesn’t have these big red scars on his legs.” Nurse: “Did you know him at the time of his surgery?” FIGURE 38.1 The brown necrotic tissue must be débrided before healing can take place in this pressure injury. (From Potter, P. A., & Perry, G. A. [2009]. Fundamentals of Nursing [7th ed.]. St. Louis: Mosby.) Communication 762 UNIT VIII Care of the Surgical and Immobile Patient Mr. Heffner: “No, I came to the group a couple of years after that.” Nurse: “I think if you look, you will see that Charlie’s leg scar has become white and isn’t nearly as noticeable now. Yours will mature in that way also. It just takes time for the scar to mature and the red color to fade.” Mr. Heffner: “You think they won’t be so prominent later on?” Nurse: “Yes, they will smooth out and fade.” Mr. Heffner: “I could live with that a lot easier. Plus, players are supposed to keep their eyes on the ball, not on their partner’s or opponent’s legs!” Nurse: “That’s the spirit, Mr. H.!” The proliferation stage begins on the third or fourth day after injury and lasts 2 to 3 weeks. In this phase the wound is illed with new connective tissue, and new epithelium will cover the wound. Macrophages (monocytes that are phagocytic) continue to clean the wound of debris, stimulating ibroblasts, which synthesize collagen. Collagen (ibrous structural protein of all connective tissue) is the main ingredient of scar tissue. New capillary networks provide oxygen and nutrients to support the collagen and further synthesis of granulation tissue. This tissue is deep pink in appearance. A full-thickness wound begins to close by contraction as new tissue is grown. Scarring is inluenced by the degree of stress on the wound. In 15 to 20 days the risk of wound separation or rupture is less likely. The inal stage of healing, maturation, begins approximately 3 weeks after injury. Scar maturation, or remodeling, is the process of collagen lysis (breakdown) and collagen synthesis by the macrophages to produce the strongest scar tissue possible. Scar tissue slowly thins and becomes paler in color. At the end of this process, the scar is irm and inelastic. The length of each phase depends on the type of injury and whether the wound heals by irst, second, or third intention. The stages of healing are interwoven rather than linear. Different parts of a wound can be in different stages of healing. The process of wound healing is presented in Concept Map 38.1. To ensure adequate and timely wound healing, the nurse should implement the key steps found in Box 38.1. When a wound occurs around a joint, attention is needed to maintain joint mobility and prevent a contracture (abnormal shortening of muscle tissue) that will restrict joint extension. If collagen overgrowth occurs, which is frequent in dark-pigmented skin, a keloid (permanent raised, enlarged scar) occurs (Fig. 38.2). In the interior of the body, adhesions (ibrous bands that hold together tissues that are normally separated) may grow and interfere with function of the internal organs. A wound with little tissue loss, such as a surgical incision, heals by first intention (closure) (Fig. 38.3). The edges of the wound approximate (close together), and there is only a slight chance of infection. A wound with tissue loss, such as a decubitus (pressure) injury or severe laceration (a torn, ragged, or mangled wound), typically heals by second intention. The edges of the wound do not approximate, and the wound is left open and ills with scar tissue. Because of the longer healing period, the chance of infection is higher. Third intention healing, also known as delayed or secondary closure, occurs when there is delayed suturing of a wound. Such wounds are sutured after the granulation tissue has begun to form. An abdominal wound left open for drainage and then later closed is an example of healing by third intention. Think Critically If a patient asks why swelling occurs after an injury, what would you say? FACTORS AFFECTING WOUND HEALING AGE Healthy children and adults heal more quickly than those with chronic health conditions and older adults. Metabolism and regeneration in the chronically ill and older adult are slower. Peripheral vascular disease impairs blood low, which can impede healing. Atherosclerosis and atrophy reduce skin capillaries and impair blood low to the wound. A decline in immune function reduces the formation of antibodies and monocytes necessary for wound healing. Reduced liver function impairs the synthesis of blood factors. Decreases in lung function reduce available oxygen needed for synthesis of collagen and the formation of new epithelial cells. Older skin is much thinner, more fragile, and more easily damaged than the skin of younger people; thus, older patients’ skin should be handled carefully when performing wound care to avoid further wound formation. NUTRITION Added protein and adequate luid are of great importance when a patient has a chronic wound. A diet that is rich in carbohydrates, lipids, vitamins A and C, thiamine, pyridoxine, and ribolavin, plus the minerals zinc, iron, and copper, is needed for wound healing. Malnourished patients and patients with diabetes are at risk for delayed wound healing. Adipose (fatty) tissue has less blood supply and predisposes the obese patient to wound infection and slower healing. (See Chapter 26 for more information on nutrition.) LIFESTYLE Regular exercise enhances blood circulation and thus promotes healing because blood brings oxygen and nutrients to the wound. Smoking reduces the functional hemoglobin of the blood, which limits oxygencarrying capacity. The person who does not smoke and who exercises regularly typically heals more quickly. Providing Wound Care and Treating Pressure Injuries CHAPTER 38 763 Wound Inflammatory phase Vascular constriction Proliferation phase Platelet aggression Fibrin formation Phagocytosis continues Fibroblasts synthesize collagen Hemostasis and clot formation Chemical release Collagen lysis and production Scar remodeling New capillary networks Small vessels dilate Fluid accumulates, causing edema Granulation tissue forms Contraction Redness, tenderness, and swelling Maturation (remodeling) phase Possible contracture Epithelialization Phagocytes enter phagocytosis CONCEPT MAP 38.1 Process of wound healing. Box 38.1 Key Steps to Ensure Appropriate Wound Healing • Keep surrounding skin and tissue clean and dry. • Ensure adequate oxygen and nutrient supply to the wound by maintaining appropriate body positioning to prevent undue or prolonged pressure. • Ensure dressings, compression stockings, NPWT and wound VAC units, and drains are applied and positioned correctly so that circulation is not impaired and the risk of developing lymphedema is minimized. • Report any signs or symptoms of infection immediately to ensure appropriate therapies are quickly initiated. • Provide appropriate nutrition and optimize blood glucose levels to aid in the healing process. NPWT, Negative pressure wound therapy; VAC, vacuum-assisted closure. FIGURE 38.2 Keloid along a sutured wound. (From Habif, T. P. [1991]. Clinical Dermatology: A Color Guide to Diagnosis and Therapy [2nd ed.]. St. Louis: Mosby.) 764 UNIT VIII Care of the Surgical and Immobile Patient Healing by first intention Clean incision Early suture “Hairline” scar An aseptically made wound with minimal tissue destruction and minimal tissue reaction begins to heal as the edges are approximated by close sutures or staples. No open areas or dead spaces are left to serve as potential sites of infection. Healing by second intention (granulation) and contraction Gaping, irregular wound Granulation and contraction Growth of epithelium over scar An infected or chronic wound or one with tissue damage so extensive that the edges cannot be smoothly approximated is usually left open and allowed to heal from the inside out. The nurse periodically cleans and assesses the wound for healthy tissue production. Scar tissue is extensive, and healing is prolonged. Healing by third intention (delayed closure) Infected wound Granulation Closure with wide scar A potentially infected surgical wound may be left open for several days. If no clinical signs of infection occur, the wound is then closed surgically. FIGURE 38.3 The process of wound healing. (From Ignatavicius, D. D., & Workman, M. L. [2002]. Medical-Surgical Nursing: Critical Thinking for Collaborative Care [4th ed.]. Philadelphia: Saunders.) Providing Wound Care and Treating Pressure Injuries CHAPTER 38 MEDICATIONS Use of steroids, immunosuppressants and other antiinlammatory drugs, anticoagulants such as heparin, and antineoplastic agents interfere with various aspects of the healing process. Steroids may mask the signs of wound infection because they inhibit the inlammatory response. Inlammation is generally a signal of infection, but it may not occur when steroids are present. INFECTION A wound infection slows the healing process. The acute phase of an infection is characterized by a sudden onset of symptoms and by the vascular changes of inlammation, especially swelling caused by luid collecting in tissue. The acute phase is followed by an increase in white blood cells (WBCs), which overwhelm the invading microorganisms and clear away the damaged tissues so that healing can occur. A bacterial infection of the skin or mucous membranes frequently causes luid drainage from the wound or damaged tissue. Clinical Cues Assess drainage for color, consistency, odor, and amount, and document the findings. The color may range from creamy yellow to dark green. Purulent (containing purulent exudate) drainage contains dead phagocytes, bacteria, and tissue and is thick in consistency. As the infection disappears, the drainage lessens, has minimal to no odor, is more serous or watery, and lightens in color. All signs of inlammation subside as healing occurs. CHRONIC ILLNESS Patients who have a chronic illness, such as diabetes, cardiovascular disease, or a disorder of the immune system, may take longer to heal. Slowed wound healing occurs from decreased oxygen and nutrients at the cellular level, disruptions in the normal metabolism of substances in the body that aid in the healing process, or inability of the body to ight infection. Patients who are immunocompromised (with poorly functioning immune systems) have delayed wound healing because ibroblast function, collagen synthesis, and phagocytosis are affected. These patients are at high risk for health care–associated infection (HAI). This type of infection is one that someone acquires while receiving treatment for another condition in a health care setting. COMPLICATIONS OF WOUND HEALING HEMORRHAGE Some bleeding from a wound is normal, but hemorrhage is abnormal. Internal hemorrhage is evidenced by swelling or distention in the area of the wound and, perhaps, sanguineous (bloody) drainage from a surgical drain. 765 Clinical Cues Monitor all patients with fresh surgical wounds for signs of hemorrhage. Be certain to check underneath the patient who had abdominal surgery to be certain blood is not seeping from the side of the dressing under the patient. If internal hemorrhage is extensive, hypovolemic shock may occur with a fall in blood pressure, rapid and thready pulse, increased respiratory rate, restlessness, diaphoresis, and cold clammy skin. Intervene promptly to prevent a potentially life-threatening situation. In other cases a hematoma may occur. A hematoma may appear as a swelling that is bluish red. If a hematoma is large, it may place pressure on blood vessels and obstruct blood low to the surrounding tissue. A hematoma may also cause the patient to exhibit a slight elevation in temperature. The risk of hemorrhage is greatest during the irst 48 hours after surgery; when it occurs, it requires emergency intervention. If external hemorrhage occurs, apply extra pressure using sterile dressings to the site; closely monitor the patient’s vital signs. Notify the surgeon because the patient may need to be immediately returned to the operating room for further intervention. INFECTION A wound may be infected with microorganisms at the time of injury, during surgery, or postoperatively. Local signs that a wound is infected include increased pain, redness, warmth in the surrounding tissues, and purulent exudate (luid accumulation containing cellular debris). Traumatic wounds are more likely to become infected than surgical wounds. A localized infection called an abscess is an accumulation of purulent exudate made up of debris from phagocytosis when microorganisms have been present. The luid may be white, yellow, pink, or green, depending on the infecting microorganisms. Surgical wound infection is often an HAI, but can be from microorganisms that are present in the wound bed or on the surface of the skin. The microorganism most frequently present in wound infections is Staphylococcus aureus. Other microorganisms commonly responsible for wound infections include Escherichia coli, Streptococcus pyogenes, methicillin-resistant Staphylococcus aureus (MRSA), and Pseudomonas aeruginosa. When wound infection is suspected, a specimen of wound exudate is obtained and tested. A Culturette tube is used to obtain a specimen for the culture (see Chapter 24), and a sensitivity test is performed to determine which antimicrobial agent is most effective against the offending organism (Fig. 38.4). Cellulitis is an inlammation of the tissue surrounding the initial wound, with redness and induration (skin hardening). A fistula is an abnormal passage or 766 UNIT VIII Care of the Surgical and Immobile Patient the fourth or ifth postoperative day, before extensive collagen has built up. A sign of impending dehiscence may be an increase in the low of serosanguineous (serum and blood mixture) drainage into the wound dressing. When dehiscence occurs, the patient may state that “something has given way.” If dehiscence or evisceration occurs, quickly place the patient supine and place large sterile dressings, or towels soaked in normal saline, over the incision and viscera. Notify the surgeon immediately and prepare the patient for return to surgery. Life Span Considerations Older Adults Complications of wound healing, such as dehiscence and evisceration, may occur more frequently in older adults because of the prolonged healing process. Think Critically FIGURE 38.4 Take a specimen from the interior of the wound for a culture. communication usually formed between two internal organs or leading from an internal organ to the surface of the body. A istula may result from an infection, or it may be present congenitally. Common postoperative istulas are designated according to the organs or parts with which they communicate, such as a rectovaginal, anal, or biliary istula. A sinus is a istula leading from a purulent exudate-illed cavity to the outside of the body. The best way to prevent wound infection is to maintain strict asepsis when performing wound care. Use sterile equipment, meticulous hand hygiene, sterile gloves, and sterile dressings. To prevent shedding of microorganisms into the wound, contain long hair so that it is not swinging over the wound and remove the stethoscope from around the neck. Refrain from talking while dressing a wound to prevent microorganisms in the mouth or saliva from possibly landing in the wound. Think Critically What discharge instructions would you give a patient about assessing for signs of wound infection? DEHISCENCE AND EVISCERATION Dehiscence is the spontaneous opening of an incision. Dehiscence of an abdominal wound often involves separation of the layers beneath the skin as well. Evisceration is the protrusion of an internal organ through the incision. Risk factors for dehiscence are obesity, poor nutrition, multiple traumas, excessive coughing, vomiting, strong sneezing, suture failure, and dehydration. The greatest risk for wound dehiscence is on What would you do if you were ambulating in the hall with a patient who has an abdominal incision and he bends forward suddenly and says “something gave way”? TREATMENT OF WOUNDS WOUND CLOSURE Sutures and staples are typically used to hold the edges of a surgical wound together until the wound can heal. Traumatic wounds are usually cleaned, trimmed, and sutured closed. Sutures used to attach tissues beneath the skin are made of absorbable material, are not removed, and are reabsorbed or dissolve within a few days. Skin sutures are made of silk, cotton, linen, wire, nylon, or Dacron. Silver wire clips are also sometimes used. Large retention sutures may be used on a wound when the surgeon believes there is a danger of dehiscence (Fig. 38.5). These are usually wire, and the portion of the suture outside the skin is covered with rubber. Sometimes the wound is small, and Steri-Strips can be used. These are small, reinforced adhesive strips placed over the break in the skin that effectively hold the wound edges together while healing takes place. Dermabond is synthetic, noninvasive glue that decreases the trauma from removing a dressing, while providing a seal that protects underlying tissue without the need for bandages. This may sometimes be used in place of sutures in small areas. It loosens and comes off in 7 to 10 days. It is not used on mucous membranes. The recommended method of open wound classiication is based on the wound’s color rather than its cause or dimensions. There are three basic wound types: red, yellow, and black. The type of wound indicates the type of dressing needed. Red wounds are clean and ready to heal. Protection is the best method of treatment. A yellow wound has a layer of yellow Providing Wound Care and Treating Pressure Injuries CHAPTER 38 767 FIGURE 38.6 Penrose drain in a “stab wound” close to an abdominal incision. (Redrawn from Potter, P. A., & Perry, G.A. [2005]. Fundamentals of Nursing [6th ed.]. St. Louis: Mosby.) FIGURE 38.5 Retention sutures. ibrous debris or exudate. Wounds can be yellow if there are a large amount of leukocytes present (Grady, 2014). Sloughing (natural shedding of dead tissue) may cause drainage. A yellow wound needs to be frequently cleansed and should have a dressing that will absorb the drainage and débride the surface mechanically. A yellow wound often becomes infected. Black wounds need débridement (removal of all foreign or unhealthy tissue from a wound) of the eschar (sloughing dead tissue, usually caused by a thermal injury or gangrene) to heal. Eschar can be mechanically débrided by a surgeon, softened by soaks or enzyme substances, and gradually removed as it separates. Licensed practical/ vocational nurses (LPN/LVNs) can become certiied in wound care; they can also perform débridement of wounds if allowed by their state boards of nursing and allowed by the agency’s policies and procedures. DRAINS AND DRAINAGE DEVICES At surgery, one or more drains may be placed to provide an exit for blood, purulent exudate, luids, or air that accumulates and could increase the risk of infection. The drain may be active or passive. An active drain is attached to a wound suction device to remove any accumulated exudate or other material. A passive drain has no suction device attachment; it works by the increased pressure inside the wound and depends on gravity and capillary action to pull out any luid buildup. The drain is placed within the surgical area and exits through a “stab” wound (a puncture or slit made by the surgeon) at a location different from the incision. A Penrose drain is a lat rubber tube. Often a safety pin is placed at the external end of the drain to prevent it from slipping into the wound (Fig. 38.6). Whenever this drain is ordered to be shortened, place a new safety pin proximal to where you will cut the drain tubing to the desired length before cutting the tubing. Catheters of various sizes can also be used as drains. FIGURE 38.7 Compress the Hemovac-type drainage system to activate it. FIGURE 38.8 After emptying drainage, compress the bulb of the Jackson-Pratt–type drainage device to activate it. Plastic drainage tubes can be connected to a drainage system that is compressed and closed, applying slight suction to the drainage tube to help to evacuate wound luids (Fig. 38.7). The Hemovac evacuators and JacksonPratt drains are examples of this (Fig. 38.8). The luid in a drainage device is measured and then emptied at the end of each shift, and the amount drained is entered on the intake and output record (Steps 38.1). Draining excess luid from a wound area helps to prevent the formation of an abscess or a istula. Drains are sometimes used when traumatic wounds are sutured closed. The skin around the drain is cleansed during each dressing change. 768 UNIT VIII Care of the Surgical and Immobile Patient Steps 38.1 Maintaining a Closed Wound Drainage Unit A wound drainage unit pulls luid from a wound to prevent swelling. It promotes healing and helps to prevent the formation of an abscess or a istula. Standard Precautions are followed and may require the use of a cover gown, mask, protective eyewear, and gloves. Jackson-Pratt drainage system bulbs should be drained and recompressed at least once every 4 hours and when they are at least two-thirds full. This ensures that the negative pressure is maintained while the drain is in place. Review and carry out the Standard Steps in Appendix A. ACTION (RATIONALE) 1. Place a waterproof underpad on the bed under the drainage device. Perform hand hygiene, and don personal protective equipment (PPE). (Protects the bedding if spill occurs. Protects from transfer of microorganisms in splashed luids.) 2. Hold the device with the spout pointing away from you and release the vacuum by gently removing plug from the pouring spout. (Avoids contaminating yourself if luid spurts out of the spout.) 3. Do not touch the drainage spout or plug. (Touching these areas contaminates these surfaces, increasing risk of infection.) 4. Empty the contents into a measuring container. Note the amount and appearance of drainage. (Allows accurate output measurement. Provides data for documentation and evaluation.) DÉBRIDEMENT Necrotic tissue must be removed from the wound before healing can occur. Sharp débridement is performed at the bedside or in the operating room, using sterile scissors, forceps, and a scalpel blade. Sharp débridement is performed when there are signs of cellulitis or sepsis. It is a painful procedure, and the wound bleeds afterward. The surgeon or nurse practitioner usually performs this function, although nurses can perform it under certain conditions (described earlier). Nurses often are directed to perform enzymatic débridement, which uses topical substances that break down and liquefy the dead tissue. These substances are placed in the wound, and another dressing is placed over it to hold them in place. This is useful for uninfected wounds. Chemical débridement using Dakin solution or sterile maggots is occasionally used on a wound with necrotic tissue that is not responding to other treatments. Autolytic débridement is a longer process that uses the body’s enzymes to break down nonviable tissue in the wound. It is best used on small, uninfected 5. Clean the pouring spout and plug using a separate alcohol sponge for each. (Prepares for reinitiation of vacuum and suction.) 6. Reactivate the unit by fully compressing it. For a Hemovac, place the unit on a irm surface and compress it equally. For a Jackson-Pratt balloonshaped device, tightly compress it in one hand and replace the plug in the drainage spout with the other hand. (Compression creates a vacuum and causes negative pressure, which acts to suction drainage into the reservoir.) 7. Check to see that the unit remains compressed when you release the manual pressure. Be certain that drainage tubes are not kinked or loose. (Reinstitutes suction of the wound and ensures the drain[s] can safely collect luid as it drains.) 8. Secure device to patient’s gown below the level of the wound. (Prevents pulling on the drains and wound if device is caught on something and aids in draining luid from wound.) 9. Remove and dispose of PPE, and wash your hands. Note the amount of drainage on the shift intake and output record. (Prevents transfer of microorganisms and tracks the amount of drainage.) 10. Document amount, color, and odor of drainage and that system is recharged/compressed and drainage tubes are unkinked. (Provides a record of your actions and indings.) wounds because the type of dressing used provides a warm, moist environment that could encourage growth of bacteria if they are present. Closely monitor the wound for signs of infection during the autolytic process. Mechanical débridement is the physical removal of wound debris by irrigation or hydrotherapy with a whirlpool bath or ultrasound mist. The physical therapist performs the whirlpool procedure. With ultrasound mist therapy, microscopic saline bubbles and sound waves clean and débride the wound bed and remove bacteria while stimulating cell growth. Treatments are usually ordered three times a week. The procedure is usually painless but may be followed by tingling and redness of the site. The mist is delivered in a grid pattern, perpendicular to the wound. Wet-to-dry dressings are an older form of dressing changes that mechanically débride because tissue sticks to the dressing material, and a layer of cells is pulled off when the dressings are removed. They are no longer recommended because they disrupt newly regenerated tissue. Providing Wound Care and Treating Pressure Injuries CHAPTER 38 FIGURE 38.9 Various types of dressings. Clinical Cues The only necrotic wound for which débridement is not recommended is a pressure injury on a heel. According to Agency for Healthcare Research and Quality guidelines (National Pressure Ulcer Advisory Panel, 2015), this type of pressure injury is not débrided if the eschar is dry and if edema, erythema, or drainage is not present. DRESSINGS Dressings, which are protective coverings placed over wounds, serve a number of purposes. They prevent microorganisms from freely entering or escaping the wound, and they absorb drainage. Dressings can be used for applying pressure to control bleeding and for improving the adherence of a skin graft to the grafted site. In addition, dressings help to support and stabilize tissues and reduce discomfort from a wound. A wide variety of dressing materials are available for dressing a wound (Fig. 38.9). Choices are based on the location, size, and type of wound; whether infection is present or débridement is needed; and the frequency with which the dressing will be changed. Several standard sizes of dry sterile gauze are available: 2 × 2 inch (5 × 5 cm), 4 × 4 inch (10 × 10 cm), and 4 × 8 inch (10 × 20 cm). The size and number of gauze pads needed depend on the size of the wound and the amount of exudate. Dressings may be folded or cut with sterile scissors to it around drains. Telfa and other nonadherent dressings have a shiny, nonadherent surface on one side that is applied to the wound. Exudate seeps through this surface and collects in the absorbent material on the other side. This dressing causes less wound trauma when it is removed. Surgi-Pads or abdominal pads (ABDs) are used to cover small gauze dressings. They hold the dressings in place and absorb and collect excess drainage. The more absorbent surface of the Surgi-Pad is placed facing the wound; the less absorbent outward side helps 769 to protect from external contamination. The outer side is usually indicated by a blue stripe or a seam. Whichever dressings are used, the purpose is to fully cover the wound and supply suficient absorbent material to contain any exudate produced. The outermost dressing should completely cover the inner dressings. It has been known for some time that supericial wounds heal faster when kept moist than when kept dry. A variety of air or luid occlusive and semi-occlusive wound dressings have been developed, including thin ilms, hydrocolloids, and foams. These dressings keep the wound moist while insulating and protecting it from external contamination. Foam dressings absorb drainage. These dressings are used more frequently than gauze for chronic or hard-to-heal wounds. Two commonly used dressings are transparent ilm and hydrocolloid dressings. Many combination varieties and other wound dressings are also available. It is important to determine the desired action for treatment of the wound before choosing the appropriate dressing. Other types of dressings include hydrogels, calcium alginate, composites, collagens, and enzymatic débriders. Transparent Film Dressings Clear ilm dressings, such as OpSite or Tegaderm, allow you to assess the wound without removing the dressing. The transparent dressing does not require the use of tape and is less bulky than a gauze dressing. These dressings are often used to cover intravenous catheter sites and to protect a stage 1 or 2 pressure injury. They are useful for supericial, partial-thickness wounds. They do not absorb drainage. A transparent ilm dressing should be changed when it no longer adheres to the skin properly. They may remain in place from 3 to 7 days. Do not use a transparent ilm dressing over an infected wound. Assignment Considerations Pressure Injury and Wound Observation Remind unlicensed assistive personnel (UAPs) to report any changes, such as drainage, increased reddening, or a loose dressing, to you. Perform your own assessments of wounds and pressure injuries. Assessment is not the UAP’s job. Hydrocolloid Dressing Hydrocolloid dressings, such as DuoDERM, keep a wound moist and have been shown to reduce wound size (Kirman, 2015). They are water and air occlusive and self-adhesive. You cannot see through a hydrocolloid dressing. This dressing facilitates autolytic débridement and provides thermal insulation, keeping the wound warm. Once applied, this dressing may stay in place for 3 to 5 days, as long as it stays intact with good skin contact on all edges. Hydrocolloids are not recommended for heavily draining wounds. 770 UNIT VIII Care of the Surgical and Immobile Patient FIGURE 38.10 Montgomery straps may be used to hold a dressing in Incorrect shoulder Correct shoulder Incorrect knee Correct knee place. Box 38.2 Principles for the Application of Tape on a Dressing • Place the tape so that the wound will stay covered by the dressing and the tape will adhere to intact skin. Place strips of tape at the ends of the dressing, and space tape strips evenly across the middle. • The tape should be long and wide enough to adhere irmly to intact skin on each side of the dressing but not so long that activity will loosen it. • Place the tape opposite to body action in the wound location. Tape should go across a joint or crease, not lengthwise along it (see Fig. 38.11). • Turning under the end of the tape leaves a tab, making removal easier. Securing Dressings The dressing is secured to the wound using tape, stretch roller gauze (Conform, Kerlix, Kling), mesh netting, an elastic bandage, or Montgomery straps (tie tapes). The correct product must be selected for the purpose. Elastic tape or bandages provide pressure; stretch gauze and mesh netting allow some movement without dislodging the dressing; and Montgomery straps allow changing of the dressing without removing and reapplying tape, which can cause repeated skin irritation (Fig. 38.10). Tincture of benzoin may be applied to protect sensitive skin before the dressing is taped (Box 38.2). Strips of hydrocolloid dressing can be placed on either side of the wound edges, the dressing applied, and then tape applied to the hydrocolloid strips for wounds that need frequent dressing changes. Non-allergenic tapes are available for the patient who has an allergy to other types of tape. Ensure that tape adheres to the skin for several inches on both sides of the dressing, and if it is a large dressing, place a length of tape across the middle of the dressing (Fig. 38.11). Do not apply tape over irritated or broken skin. To remove tape, gently loosen the tape ends and gently pull each parallel to the skin surface toward the wound while applying FIGURE 38.11 Tape across a joint or a crease. light traction to the skin away from the wound as the tape is loosened. If the tape will not loosen, adhesive remover may be used. Clinical Cues In the home setting, self-adherent plastic wrap can be used to secure dressings on patients who have problems with tape. Use the plastic wrap only for securing dressings over uninfected wounds. BINDERS Binders (wide elasticized fabric bands) are used to decrease tension around a wound or suture line, increase patient comfort, decrease lactation after childbirth, or hold dressings in place. An abdominal binder provides support and comfort for an abdominal incision when the patient must perform deep breathing and coughing exercises and when getting in and out of bed (Fig. 38.12). An elastic athletic supporter is used to hold dressings in place on the male scrotum and perineum. Elastic mesh panties can be used to hold dressings in place for the female perineum. Think Critically Why should you assess the number and type of dressings needed for a particular dressing change before taking dressings to the patient’s bedside? Providing Wound Care and Treating Pressure Injuries CHAPTER 38 Box 38.3 FIGURE 38.12 An abdominal binder provides support. VAC unit Absorbent foam dressing Connective tubing FIGURE 38.13 Wound VAC unit. (Courtesy Kinetic Concepts, Inc., San Antonio, TX.) 771 Guidelines for Care of the NegativePressure Wound Therapy Dressing • Observe the dressing area when assessing vital signs. • Film covering dressing must remain attached to skin in all areas for negative pressure to be maintained. • Check the setting on the NPWT unit and assess whether it is working properly. Ensure tubing is not pressing against the skin. • Assess for proper collapse of the dressing, indicating negative pressure is present. A whistling sound may indicate a leak. • If a leak is present, press down gently around the drape and/or edges of the foam to better seal the drape. Use excess drape to patch over leaks. • If the dressing needs to be replaced, follow agency protocol and instructions. When changing the dressing, document the wound appearance, wound size, and the presence of erythema or purulent drainage. • Assess the patient for any complaints or problems in the wound area. If wound has a large amount of exudate, monitor the patient for deicient luid volume. • If the NPWT is interrupted for more than 2 hours, remove the old dressing and irrigate the wound prior to resuming therapy. • Document your indings and that the unit is in place and functioning properly. NPWT, Negative pressure wound therapy. NEGATIVE PRESSURE WOUND THERAPY Wounds that are dificult to heal may respond to negative pressure wound therapy (NPWT). This treatment can increase development of granulation tissue, speed healing rate, and reduce hospitalizations when used to treat open wounds (Huang et al., 2014), while minimizing the need for dressing changes. The therapy, also known as vacuumassisted closure (VAC), involves applying a suction device to a special wound dressing to institute negative pressure at the wound site, drawing the edges together (Fig. 38.13). Mechanical stretch of cells occurs, which increases cellular proliferation and tissue growth. The negative pressure and suction remove luid from the wound, allowing increased blood low, and thereby oxygen and nutrients, to be delivered to the wound (Box 38.3). After a few days of therapy, bacterial counts in the wound bed drop. NPWT keeps the wound moist (Fig. 38.14). The system may be used on a wound before a skin graft is performed to close the wound completely. Dressing changes for the system depend on the type of wound being treated. If the wound is infected, the dressing may be changed every 12 to 24 hours. For a clean wound, the dressing is changed three times a week. Contraindications to the use of a NPWT include bleeding, exposed organs, exposed blood vessels or nerves, and malignant (cancerous) tissue. FIGURE 38.14 VAC unit working on a chronic leg wound. (Courtesy Kinetic Concepts, Inc., San Antonio, TX.) 772 UNIT VIII Care of the Surgical and Immobile Patient Safety Alert Serious complications can occur with NPWT, most often related to bleeding and infection; even deaths have occurred, so proper use and patient assessment are crucial. TREATMENT OF PRESSURE INJURIES OR VASCULAR ULCERS Causes, staging, and prevention of pressure injuries, along with illustrations, are presented in Chapter 19. Treatment is discussed here along with care for most wounds. Life Span Considerations wound to help to débride eschar in Stage 4 Pressure Injuries. Sometimes a wet-to-dry dressing may also be applied to help the sloughing of necrotic tissue by mechanical débridement. Occasionally hyperbaric oxygen chamber treatment is used to treat nonhealing wounds. Electrical stimulation may also be used to accelerate wound healing. Growth factors and NPWT have also demonstrated success in healing stage 3 and stage 4 pressure injuries. An unstageable pressure injury needs eschar débridement chemically or mechanically before healing can begin. For a deep tissue pressure injury, aggressive pressure ofloading needs to be accomplished. Various techniques are being studied to determine effective methods of pressure reduction, including air luidized therapy and low frequency ultrasound. Older Adults Transparent dressings placed over a reddened area can often prevent skin breakdown in older adults. Clean ulcers or pressure injuries at each dressing change. Use a syringe and plastic cannula with water, saline, or a nontoxic cleanser to perform pressure irrigation at 4 to 15 psi to prevent damage to new granulation tissue. Use 250 to 500 mL of solution and irrigate using a syringe with a small catheter to reach undermined areas and tunnels (Fig. 38.15). Observe and document the wound characteristics at every dressing change. Cover the wound with a dressing selected according to the wound characteristics. For Stage 1 Pressure Injuries, use protective dressings such as thin ilm, to protect the pressure injuries from shearing forces and to keep them moist. For Stage 2 Pressure Injuries that are uninfected, use a hydrocolloid, foam, or hydrogel dressing, which will protect against bacterial contamination. For a Stage 3 Pressure Injury that is draining, use a dressing that will absorb exudate and maintain a moist environment. For infected pressure injuries or ulcers, a nonocclusive dressing is always used. Chemical enzyme formulas may be used in the FIGURE 38.15 Wound irrigation using a 35-mL syringe and a 19-gauge plastic intravenous cannula. (From Potter, P. A, & Perry, G. A. [2009]. Fundamentals of Nursing [7th ed.]. St. Louis: Mosby.) APPLICATION OF THE NURSING PROCESS ASSESSMENT (DATA COLLECTION) Assessment includes complete inspection of all skin areas. Every abrasion, laceration, contusion, reddened area, ecchymosis (small hemorrhagic spot in the skin or mucous membranes), and incision should be noted. Be alert for signs of inlammation: redness, swelling, pain, heat, and loss of function. The location and appearance of wounds should be documented daily in speciic terms because changes can occur rapidly. During the wound care process, note the number and type of dressings saturated or the diameter of the drainage on the dressing. Assess the wounds by visual inspection, palpation, and smell, noting the wound’s appearance and any drainage, swelling, odor, separation, and complaints of pain. Note the color of the wound and surrounding tissue, as well as the approximation (degree of closure) of the wound edges. Use the back of a gloved hand to detect increased warmth, tautness of tissue, or edema around the wound. Carefully assess the site for surrounding edema. Gently palpate the periphery of the wound for signs of pain. Assess for drain placement and security, the amount and character of the drainage, and the effectiveness of any suction device. Assess whether signs or symptoms of local or systemic inlammation or infection are present by reviewing temperature trends, WBC count, and patient report of discomfort. A temperature greater than 101°F (38.3°C), a WBC count greater than 10,000/dL, and a feeling of malaise may indicate wound infection. Assess acute wounds at least once every 8 hours and chronic wounds daily. Measure chronic wounds and pressure injuries every 2 to 4 weeks to determine whether they are healing (Cowan, 2015). It is important to note that in a dark-skinned person, you must rely on localized skin color changes at and around the wound site. The affected skin may be darker or shinier than surrounding skin. Assess the progress of healing by checking decreases in wound size. The size of a nonsurgical wound should be measured and the length, width, and depth recorded as ordered or per facility protocol. Providing Wound Care and Treating Pressure Injuries CHAPTER 38 Moderate postoperative pain is normal for 3 to 5 days, but persistent severe pain or sudden onset of new pain may indicate infection or internal hemorrhage. If the initial dressing is in place, do not touch it until the primary care provider changes it or leaves orders for the nurse to do so. Assess the dressing; its appearance provides some indirect information about the wound underneath it. The dressing may be dry and intact, or it might be soaked with serous or serosanguineous drainage. It is also important to assess the patient’s reaction to the wound and readiness to learn to perform wound care. Document your indings after the dressing change. Clinical Cues Assess for allergy to iodine, medications, cleaning solutions, and tape because many patients are allergic to substances used in wound care. NURSING DIAGNOSIS Common nursing diagnoses used for patients with wounds are as follows: • Impaired skin integrity related to surgical incision (or trauma) • Risk for infection related to nonintact skin or impaired skin integrity • Acute pain related to infected wound • Activity intolerance related to pain and malaise from wound infection • Disturbed body image related to wound appearance • Deicient knowledge related to care of wound • Anxiety related to need to perform wound care PLANNING Include time for wound assessment and care in planning the work load. Consideration of whether dressings may become damp from bathing dictates whether wound care is provided before or after a shower or bath. Check orders for directives regarding wound care. Dressing changes require a medical order, and wound irrigations may be performed only with an order. Check the medical record for the date of wound occurrence or the surgical procedure to understand how old the wound is. This information is essential to assess the progress of wound healing. Determine what supplies will be necessary for a dressing change or irrigation. Sample goals and expected outcome statements related to the nursing diagnoses listed above are as follows: • Incision will be well approximated without disruption. • Wound will be clean and dry without redness or swelling. • Pain will resolve when infection is cleared. • Activity tolerance will improve when infection resolves. • Patient will verbalize acceptance of wound appearance. 773 • Patient will learn to properly perform wound care before discharge. • Practice of wound care before discharge will alleviate anxiety. A speciic time frame for the outcome to be met is individualized to each patient. IMPLEMENTATION When implementing wound care, the nurse must use the principles of asepsis presented in Chapters 16 and 17. Careful technique is essential to prevent contamination of the wound and spread of infection, if it is present. Use Standard Precautions for all patient care, particularly during wound care, when one comes into direct contact with body luids. Use sterile gloves or sterile forceps whenever you touch an open or fresh surgical wound. After the wound is closed or sealed, you may use nonsterile disposable gloves. If a dressing becomes wet, it must be changed (Nursing Care Plan 38.1). Wound Cleansing and Dressing Change Clean wounds with water, normal saline, or a noncytotoxic wound cleanser. Sometimes antimicrobial solutions are ordered for wound irrigation. Many of these solutions must be kept refrigerated; allow the necessary amount of solution to come to room temperature before performing the irrigation. Using cold solution lowers the wound temperature, which slows healing. If an antimicrobial solution is used, dilute it properly. Clean grossly contaminated or infected wounds at each dressing change. Cleaning a healthy wound incorrectly can cause mechanical trauma and delay healing. Use gauze pads rather than cotton balls for cleansing because the cotton ibers can become embedded in the wound and delay healing. For supericial, uninfected wounds, rinse lightly with normal saline rather than using gauze to reduce mechanical trauma. Avoid drying a wound after cleaning because it heals better if it remains moist. Clean surgical wounds from the center outward to avoid pulling microorganisms from the skin into the wound. Change surgical and open wound dressings using sterile technique (Skill 38.1). Safety Alert Solutions That Damage Granulation Tissue Certain solutions are toxic to growing and normal cells and should not be used to cleanse granulating wounds. Never use Dakin solution (sodium hypochlorite), acetic acid, povidoneiodine, or hydrogen peroxide to clean an uninfected, granulating wound. Think Critically What interventions would you place on the care plan for a patient with a surgical wound? What interventions might be needed for a patient with an open traumatic wound? 774 UNIT VIII Care of the Surgical and Immobile Patient Nursing Care Plan 38.1 Care of the Patient with a Vascular Ulcer SCENARIO Frank Walters, age 72, who smokes one pack of cigarettes a day, has a vascular ulcer on his left lower leg. He had originally bruised the spot when working in the garden. Now he has a stage 4 pressure injury that is not improving. His primary care provider has admitted him for débridement and whirlpool treatments because he lives 175 miles from the hospital. PROBLEM/NURSING DIAGNOSIS Open wound/Impaired skin integrity related to injury and decreased peripheral blood supply. Supporting Assessment Data Subjective: “It’s been there for 2 months. It will not heal.” Objective: 5- × 4½-cm open wound on lower lateral aspect of left leg with area of black eschar on upper aspect, yellow tissue, and purulent drainage. Goals/Expected Outcomes Nursing Interventions Selected Rationale Evaluation Wound will be without infection within 10 days. Obtain wound culture as ordered. Administer antimicrobials as ordered. Culture will determine infecting organism. Antimicrobials will help ight infection. Is infection present? Culture results pending. Monitor signs of infection. Tracking signs of infection will tell whether wound condition is improving. Use whirlpool bath on lower leg daily. Whirlpool low will help débride and cleanse wound. Débride mechanically with Travase. Travase enzymatically breaks down necrotic tissue. Maintain sterile wet-to-damp dressing on wound. Damp wound environment helps break down eschar. Medicate for pain as needed 30 min before whirlpool treatment and dressing change. Whirlpool and dressing change on a stage 4 pressure injury may be painful. Measure wound twice a week. Measurements tell whether wound size is decreasing or increasing. Encourage cessation of smoking Smoking contributes to vessel damage to help promote wound healing that causes vascular disease. and prevent further progression of vascular disease. Turn q 2 h. Smoking fewer cigarettes. Turning prevents formation of new pressure injuries. Wound will close within 1 month. Has wound closed? Progressing toward expected outcomes Continue plan. hr, h