WOUND CARE – NURSING PROCEDURE

WOUND CARE – Definition, Types, Wound Healing, Wound Dressing, Equipment and Procedure

A wound is a break in the continuity of an external or internal surface caused by physical means. Wounds can be accidental or intentional (as when the physician makes an incision during a surgical operation). There are two basic types of wounds: closed and open.

DEFINITION

Wound care: wound care is defined as cleaning, monitoring and promoting healing in a wound that is closed with sutures, clips or staples.

Wound: an injury to living tissue caused by a cut, blow, or other impact, typically one in which the skin is cut or broken

Surgical or wound dressing: sterile dressing covering applied to a wound or incision using aseptic technique with or without medication.

WOUND TYPES

A closed wound involves an injury to the underlying tissues of the body without a break in the skin surface or mucous membrane; an example is a contusion, or bruise.

A contusion results when the tissues under the skin are injured and is often caused by a blunt object. Blood vessels rupture, allowing blood to seep into the tissues, which results in a bluish discoloration of the skin. After several days, the color of the contusion turns greenish yellow as a result of oxidation of blood pigments

Bruising commonly occurs with injuries such as fractures, sprains, strains and black eyes. Open wounds involve a break in the skin surface or mucous membrane that exposes the underlying tissues; examples include incisions, lacerations, punctures, and abrasions.

An incision is a clean, smooth cut caused by a sharp instrument, such as a knife, razor, or piece of glass. Deep incisions are accompanied by profuse bleeding; in addition, damage to muscles, tendons, and nerves may occur.

A laceration is a wound in which the tissues are torn apart, rather than cut, leaving ragged and irregular edges. Lacerations are caused by dull knives, large objects that have been driven into the skin, and heavy machinery. Deep lacerations result in profuse bleeding and a scar often results from the jagged tearing of the tissues.

A puncture is a wound made by a sharp-pointed object piercing the skin layers, for example, a nail, splinter, needle, wire, knife, bullet, or animal bite. A puncture wound has a very small external skin opening, and for this reason bleeding is usually minor. A tetanus booster may be administered with this type of wound because the tetanus bacteria growth best in a warm anaerobic environment, such as the one in a puncture.

An abrasion or scrape is a wound in which the outer layers of the skin are scraped or rubbed off, resulting in oozing of blood from ruptured capillaries. Abrasions are often caused by falling on gravel and floors (floor burn). These falls can result in skinned knees and elbows.

WOUND HEALING

The skin is a protective barrier for the body and is considered its first line of defense. When the surface of the skin has been broken, it is easy for microorganisms to enter and cause infection. The body has a natural healing process that works to destroy invading microorganisms and to restore the structure and function of damaged tissues.

Phases of Wound Healing

Phase 1: Phase 1, is also called the inflammatory phase, begins as soon as the body is injured. This phase lasts approximately 3 to 4 days. During this phase, a fibrin network forms, resulting in a blood clot that “plugs” up the opening of the wound and stops the flow of blood.

The blood clot eventually becomes the scab. The inflammatory process also occurs during this phase. Inflammation is the protective response of the body to trauma, such as cuts and abrasions, and to the entrance of foreign matter, such as microorganisms. During inflammation, the blood supply to the wound increases, which brings white blood cells and nutrients to the site to assist in the healing process.

The four local signs of inflammation are redness, swelling, pain and warmth. The purpose of inflammation is to destroy invading microorganisms and to remove damaged tissue debris from the area so that proper healing can occur.

Phase 2: Phase 2 is also called the granulation phase and typically last 4 to 20 days. During this phase, fibroblasts migrate to the wound and begin to synthesize collagen. Collagen is a white protein that provides strength to the wound. As the amount of collagen increases, the wound becomes stronger, and the chance that the wound will open decreases. There also is a growth of new capillaries during this phase to provide the damaged tissue with an abundant supply of blood. As the capillary network develops, the tissue becomes a translucent red color. This tissue is known as granulation tissue. Granulation tissue consists primarily of collagen and is fragile and shiny and bleeds easily.

Phase 3: Phase 3, is also known as the maturation phase, begins as soon as granulation tissue forms and can last for 2 years. During this phase, collagen continues to be synthesized, and the granulation tissue eventually hardens to white scar tissue. Scar tissue is not true skin and does not contain nerves or have a blood supply. The medical assistant should always inspect the wound when providing wound care. The wound should be observed for signs of inflammation and the amount of healing that has occurred. This information should be charted in the patient’s record.

WOUND DRESSING

Purpose of Dressing

  • Provide physical, psychological and aesthetic comfort
  • Remove necrotic tissue
  • Prevent, eliminate or control infection
  • Absorb drainage
  • Maintain a moist wound environment
  • Protect the wound from further injury
  • Protect the skin surrounding the wound
  • Promote homeostasis as in a pressure dressing
  • Prevent contamination from feces, urine, vomitus, etc
  • For splinting or immobilization of wound

Major Principles for Wound Dressing

  • Uses standard precautions at all times
  • When using a swab or gauze to cleanse a wound, work from the clean area out toward the dirtier area. (Example: when cleaning a surgical incision, start over the incision line, and swab downward from top to bottom). Change the swab and proceed again on either side of the incision, using a new swab each time.
  • When irrigating a wound, warm the solution to room temperature, preferably to body temperature, to prevent lowering of the tissue temperature. Be sure to allow the irrigant to flow from the cleanest area to the contaminated area to avoid spreading pathogens.

TYPES OF DRESSING

  • Dry dressing: clean wounds are dressed by the application of 4 to 8 layers of gauze folded into suitable size and shape. The surrounding of the wound is cleansed by some antiseptic and dried and dry dressing is applied after the application of medicine to the wound.
  • Wet dressings: it is used if wounds are infected and if there is pus. The wet dressing compresses the hot, it stimulated the supportive process. The dressing is made of many layers of gauze or cotton pad covered with gauze.
  • Pressure dressing: it is done when there is bleeding or oozing from the wound. The dressing consists thick pad of sterile gauze applied over the wound with a firm bandage and binder

General Instructions

  • Maintain aseptic technique to prevent cross infection to the wound and to the ward
  • All the material touching the wound should be sterile
  • Wash hands before and after each dressing top avoid cross infection
  • All articles should be disinfected thoroughly, so that they will be free from pathogens
  • Use masks, sterile gloves and gown for large dressing to minimize the wound contamination
  • Dressing is changed at least 15 minutes after the room has been cleaned and avoid meal timings
  • Clean wound should be dressed before infected or discharging wounds
  • Wounds that are draining freely should be dressed frequently, according to the doctor’s order
  • Avoid coughing, sneezing and talking when the wound is opened
  • While dressing avoid contamination with patients skin. Clothing and bed linen with soiled instruments and dressings
  • Clean the wound from cleanest area to the less clean area, e.g. clean the wound from its center to the periphery
  • If the dressings are adherent to the wound due to drying of the secretions or blood, wet it with normal saline before it is removed from the wound
  • While dressing, keep the wound edges as near as possible to promote healing
  • Measure the amount of discharge from the wound. Note the color, amount and consistency of the drainage
  • Before doing the dressing, inspect the wound for any complication and if it is present, report immediately to avoid further complications

PRELIMINARY ASSESSMENT

  • Check the doctor’s order for specific instructions
  • Identify the correct patient, bed number and general condition
  • Check the nurse’s record to note the condition of the wound in previous dressing
  • Check the abilities of the patient for self-help understanding and limitation
  • Check the availabilities of the articles

EQUIPMENT

A sterile tray containing:

  • Artery forceps: 1
  • Dissecting forceps: 2
  • Scissors: 1
  • Sinus forceps: 1
  • Probe: 1
  • Small bowl: 1
  • Safety pin: 1

Gloves, masks and gowns, cotton balls, gauze pieces, cotton pads, and site or dressing towels.

A trolley containing: cleaning solutions as necessary, ointments and powders as ordered, Vaseline gauze in sterile containers, roller gauze in sterile container, chittle forceps in a solution, sterile gauze, cotton and pad drum, bandages, adhesive plaster, pins and scissors, mackintosh and draw sheet, kidney tray and covered bucket to put soiled dressing.

PROCEDURE

  • Explain the procedure to the patient, using sensory preparation
  • Inspect the wound for redness, swelling or signs of dehiscence or evisceration
  • Observe the characteristics of any drainage
  • Clean the area around the wound with an appropriate cleansing solution
  • Swab from clean area towards the less clean area (clean the wound from the center to periphery)
  • Apply medications if ordered
  • Apply sterile dressing – apply gauze pieces first and then the cotton pads
  • Remove the gloves and discard it into the bowel with lotion
  • Secure the dressing with bandage or adhesive tapes

DRESSING TECHNIQUES

The following dressing techniques are easy to do and require on sophisticated equipment. Clean technique is usually sufficient. Pain medication may be required as dressing changes can be painful. Gently cleanse the wound at the time of dressing change

Wet-to-Dry

Indication: to clean a dirty or infected wound

Technique: moisten a piece of gauze with solution and squeeze out the excess fluid. The gauze should be damp, not soaking wet. Open the gauze and place it over top of the wound to cover. You do not need many layers of wet gauze. Place a dry dressing over top. The dressing is allowed to dry out and when it is removed it pulls off the debris. It’s ok to moisten the dressing if it is too stuck.

How often: ideally, 3-4 times per day, more often on a wound in need of debridement, less often on a cleaner wound. When the wound is clean, change to a wet-to-wet dressing or an antibiotic ointment

Wet-to-Wet

Indication: to keep a wound clean and prevent buildup of exudates

Technique: moisten a piece of gauze with solution and just barely squeeze out the excess fluid so it is not soaking wet. Open the gauze and place it over top of the wound to cover it. Place a dry dressing over top. The gauze should not be allowed to dry or stick to the wound

How often: ideally, 2-3 times a day. If the dressing gets too dry, pour saline over the gauze to keep it moist

Antibiotic ointment: antibiotic ointment is used to keep a wound clean and promote healing

Technique: apply ointment to the wound – not a thick layer; just a thin layer is enough. Cover with dry gauze

How often: 1-2 times per day

PROCEDURE OF WOUND/SURGICAL DRESSING

  • Position the patient comfortably
  • Expose the dressing site
  • Instruct not to touch wound, equipment or dressing
  • Wash hands
  • Open dressing pack
  • Transfer extra cotton balls and gauze pieces into the dressing pack if the wound is large
  • Pour cleaning solution into the dressing cup
  • Cover the pack without contaminating the inner layer
  • Place dressing mackintosh and towel under the part and place clean K-basin over mackintosh
  • Remove outer dressing
  • Use ether to remove adherent adhesive
  • Leave the inner dressing if it does not come out with outer dressing
  • If wound drain is present, remove one layer at a time
  • Do surgical hand washing
  • Wear gloves if the wound is contaminated
  • Flip open the dressing pack cover by inserting fingers in the inner layer of the wrapper
  • Using thumb forceps, pick up cotton ball and wet it in saline
  • Using artery clamp and thumb forceps, soak adherent gauze squeezing the cotton ball over the gauze
  • Using the same artery clamp, remove the gauze and dispose in the plastic bag
  • Discard the artery clamp
  • Observe the character and amount of drain and assess the condition of the wound
  • Use only thumb forceps to pick up cotton balls
  • Pick up cotton balls every time using only the thumb forceps and soak in cleaning solution
  • Squeeze out excess solution from the cotton balls into the kidney basin (sterile)
  • Clean the wound (clean to dirty) with firm stroke using the artery clamp
  • Discard used cotton balls into the clean K-basin
  • Use only one cotton ball for each stroke
  • Ensure wound is thoroughly cleaned
  • Finally, clean the skin is proximity to the wound edge, with strokes away from the wound
  • Soak gauze piece in the dressing solution, squeeze out excess solution, spread it keeping it over the sterile field
  • Apply over the wound, fully covering the wound with medicated gauze pieces
  • Apply dry gauze pieces over the medicated gauze pieces
  • Apply pad if the wound is large or lot of exudates is present in the wound
  • Discard gloves if used
  • Discard the used artery clamp and thumb forceps into the clean K-basin
  • Secure dressing with adhesive/bandage

After Care

  • Assist the patient to dress up and to take a comfortable position
  • Change the garments if soiled with drainage
  • Remove the mackintosh and towel. Replace the bed linen
  • Take all articles to the utility room. Discard the soiled dressing into a covered container and send for incineration
  • Wash hands and record the procedure on the nurse’s record with date and time
  • Teach the patient/family about wound care and signs and symptoms of infection

PATIENT EDUCATION

Explain the following to the patient regarding wounds:

  • The type of wound that the patient has: incision, laceration, puncture, or abrasion
  • The purpose of suturing the wound: to close the skin and protect against further contamination, to facilitate healing, and to leave a smaller scar
  • If a tetanus toxoid has been administered, explain the purpose of this immunization: to protect against tetanus (lockjaw)
  • Teach the patient how to care for the wound, as follows:

Keep the dressing clean and dry. If it becomes wet, contact the medical office to schedule a sterile dressing change

Apply an ice bag for swelling (if prescribed by the physician)

Report immediately any signs that the wound is infected. These signs include the following:

Fever

Persistent or increased pain, swelling or drainage

Red streaks radiating away from the wound

Increased redness or warmth

  • Notify the doctor’s office if the sutures become loose or break
  • Return as instructed by the physician for the removal of sutures
  • Teach the patient how to apply an ice bag (if prescribed by the physician)
WOUND CARE – Definition, Types, Wound Healing, Wound Dressing, Equipment and Procedure

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