≥ 92% of participants will know basic wound care.
CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.
≥ 92% of participants will know basic wound care.
After completing this continuing education course, the participant will be able to meet the following objectives:
This course provides specific information to help you approach common wounds from a nursing perspective, which focuses on the basic cleansing and dressing of wounds.
Ideally, care of a wound should begin with a "game plan." There is no strict 'recipe' that will fit all wounds. Still, the following are general measures and evidence-based recommendations that should be considered with all wound care (Goldberg & Diegelmann, 2020; Sibbald et al., 2021).
Common wound care supplies that are needed include (Sibbald et al., 2021; Doughty & McNichol, 2015):
Handwashing is more important than most of us think. Do not take hand washing for granted! You have heard that the most important infection control practice is hand washing. This is true. Proper handwashing prevents infection!
Wash with soap under running water for at least 15 seconds, with no shortcuts. When you perform wound care, wearing gloves is necessary in most cases unless it is a close family member or the patient is doing wound care for themselves. However, gloves are no substitute for handwashing (CDC, 2020).
Wound care has advanced tremendously with modern technology. This advancement is good news for patients but complicates things for healthcare providers. Forty years ago, there was only a small list of wound care products to choose from, and today there are thousands. However, clinicians need not fret about approaching wound care in modern healthcare. Clinicians need only to remember a few basic principles similar to the ABCs of CPR. The following sections include a few different mnemonics to help you remember components of wound care.
Think of this as the "TIME" for wound care. The wound bed preparation concept describes a systematic approach to addressing the wound bed's specific needs in full-thickness open wounds (Sibbald et al., 2021; Doughty & McNichol, 2015). Evidence-based literature describes this mnemonic, such as T-I-M-E or T-I-M-E-S, to help clinicians perform evidence-based wound care (Gupta et al., 2017).
T is for Tissue:
Tissue in the wound bed should be described and documented. This includes the appearance (color, consistency) of wound bed tissue and the presence and amount of any non-viable or necrotic tissue, as well as any hypergranulating tissue, hypertrophic scarring, or foreign bodies in the wound bed. Necrotic or non-viable tissue (including biofilm if detected) should be removed as appropriate or addressed. Hypergranulating tissue should be treated.
I is for Infection:
Signs of infection should be identified and documented. Determine if a critical infection is present. This wound may need systemic treatment versus non-critical chronic bacterial colonization that may require only local management by debridement and topical therapies.
M is for Moisture:
Moisture in the wound bed should be managed. A balance of moisture is important for wound healing. Topical wound care, especially dressings, are used to prevent the wound bed from drying out while eliminating excessive moisture in the wound bed. When excessive moisture in the wound exceeds the dressing's capabilities, it often causes moisture damage to the skin surrounding the open wound (maceration). Dressing selection is most important for addressing this specific need of the wound bed.
E is for the Edge of the wound:
Attention should be given to the wound edges. Rounded, "rolled" wound edges prevent epidermal cell migration, which may impair wound closure. Tracking or tunneling in the wound bed and undermining (a 'lip' or ledge under the wound edge) may impair healing. Undermining is often caused by shearing forces upon the wound area. It is frequently seen in pressure ulcers around the sacral area when the patient repeatedly slips down while sitting up in the bed.
Other mnemonics are changing the T in T-I-M-E to D (for debridement), resulting in D-I-M-E, and adding an S to the anagram to address the skin and tissue surrounding the wound opening. In this case, S reminds us that the surrounding skin and tissue should be examined for the presence of or worsening of erythema (redness), edema (swelling), warmth, and skin lesions (blistering, rash, irritation, callus, or maceration).
Additional publications have described algorithms for wound management or mnemonics to guide clinicians in deciding if local treatment is adequate or if systemic treatment may be advised. The following two mnemonics help to identify just that. Using the NERDS mnemonic, if three or more of the following symptoms are present, treat the wound topically:
Using the STONES mnemonic, if three or more of the following symptoms are present, treat the wound systemically:
Wound dressings are the most common component of wound care, providing a platform for a therapeutic or treatment modality. One aspect of dressings is essential: They should do no harm. That being said, why are we still using wet-to-dry dressings? There are now hundreds of commercially available wound care products in the United States. In clinical trials, numerous dressings or topical wound care applications have reported successful wound healing results. Yet, wet-to-dry dressings are still among frequently ordered wound care modalities in nearly all healthcare settings.
Wet-to-dry dressings are no longer evidence-based practice for wound care (Sibbald et al., 2021). As the name implies, a wet-to-dry dressing ultimately results in a dry wound bed (even if for limited amounts of time). Research demonstrates these dressings disrupt granulating tissue, impair epithelial cell migration, leave behind foreign bodies in the wound bed, increase the risk of infection, aerosolize bacteria, and cause severe pain upon removal (Sibbald et al., 2021).
Nevertheless, wet-to-dry dressings have been a standard, traditional, or 'default' dressing for decades. Modern wet-to-dry dressings are accomplished by moistening sterile cotton gauze with a solution (usually 0.9% normal saline) and placing it in the wound, allowing it to dry, then removing it dry from the wound bed (along with tissue that adheres to it), thus performing mechanical debridement (Goldberg & Diegelmann, 2020; Sibbald et al., 2021).
There are several reasons why this form of debridement may be detrimental to the wound bed and unnecessary, with so many other forms of wound debridement available today. Cost, compliance, pain, increased risk of infection, and re-injury to healthy granulating tissue are several reasons (Sibbald et al., 2021). Most healthcare providers have continued with wet-to-dry dressings more from misunderstood tradition than evidence-based wound care practices. Furthermore, the use of wet-to-dry dressings as a wound care modality (in most cases) is outdated and used with inappropriate frequency in today's health care arena (Goldberg & Diegelmann, 2020; Sibbald et al., 2021).
If not wet-to-dry, then what? How do you select a moist wound dressing? There are so many from which to choose. What dressing has the most evidence supporting it? How often should you change the dressing?
Unfortunately, several systematic reviews have failed to produce strong evidence favoring one specific dressing type for all wounds to simplify the decision-making. Most clinicians who are not familiar with modern wound products just want to know, "if not wet-to-dry, then what one product can safely be used in its place?" The answer to this question should be, "it depends."
Wound experts now realize the "one size fits all" approach is not ideal for wound care or dressing product selection. Multiple wound treatment algorithms and guidelines exist to assist the clinician in selecting wound treatment approaches (Wounds Canada, 2017; Gupta et al., 2017; Sibbald et al., 2021).
Any dressing selection approach should agree with the principles of evidence-based practice (EBP). The principles of EBP affirm that health care should be delivered based on (Melnyk & Fineout-Overholt, 2019):
The strongest and most current research evidence
The patient's (and family's) preferences and values
Assessing the wound is only one small part of a whole person. Do not forget to assess and talk to the person attached to the wound in assessing the wound. Assess the person (physically as well as psychosocially). What are the preferences, personal needs, likes, dislikes of the patient (and their caregiver)? What are their feelings about wound/wound care? (Bates-Jensen, 2016; Melnyk & Fineout-Overholt, 2019). For a caregiver who gets sick and faints at the sight of blood, asking them to empty bloody drainage from a drainage tube may not be a good choice. As you assess the wound itself, identify its etiology and comorbid conditions affecting wound healing. Determine the goal of wound care for this person.
Is the goal of wound care temporary "maintenance" or to prevent further deterioration until the patient can tolerate more aggressive treatment?
This scenario may apply if a patient has a gangrenous toe or nonhealing/necrotic arterial foot ulcer. This patient is also in the ICU following a massive stroke and cannot tolerate any surgery until they are hemodynamically stable. In other words, the patient's condition needs to stabilize before aggressive approaches to wound healing can be safely deployed.
This may be the case if you know the wound is not likely to heal (as at the end of life with multiple organ failure). Different products and approaches may be employed for wound care if the purpose of wound care is not to heal or close the wound but to provide pain relief, moisture management, or odor control and prevent or reduce the risk of spreading infection. This may frequently occur with malignant lesions in hospice patients, and these patients may present challenging situations. Still, rewarding outcomes may be possible to ease a person's suffering or improve quality at the end of life. (Gupta et al., 2017).
Typically, the process of wound dressing changes will look something like this:
It is necessary to educate the patient, their families, and/or involved caregivers about (Doughty & McNichol, 2015):
It is also helpful to demonstrate the wound dressing change for both patient and involved caregivers. You can use a simulation model while providing instruction. Written instructions are beneficial as well. As in learning any new skill, have the patient or caregiver repeat the demonstration of the dressing change to ensure complete understanding has taken place.
You volunteer at a summer camp. Mike is a 23-year-old young man working at the camp as a counselor. He is 6ft tall and weighs 155 lbs. He was skateboarding with some of the teens at camp. He fell on a wooden ramp resulting in several superficial abrasions to the right forearm below the elbow and his right upper shin below the right knee.
As the camp health care provider, you would approach Mike like any other first-aid patient and determine if he needs more than simple first aid.
What should you know about Mike before you try to provide first aid to his wounds?
Right shin wound measures and description:
Right inferior forearm wound measures and description:
After a quick triage assessment, you determine that even though Mike wore knee and elbow protectors and the abrasion wounds are superficial, the nature of his fall to knee and elbow could entail a potential deeper injury (consider sending to the emergency room (ER) for x-rays to rule out fractures).
You are also aware that the forearm and shin wounds present potential complications. Why? The location (close to the joint) and thickness of the skin over these parts of the body make these superficial abrasions full-thickness wounds.
How will you perform first aid to Mike to send him to the ER for x-rays? Using universal precautions and clean or aseptic technique, gently cleanse the wounds with saline pat with gauze (Kent et al., 2018; Pickering & Marsden, 2015). Apply a wound hydrogel, or petrolatum impregnated gauze, cover with sterile gauze, secure in place with tubular gauze, cotton stockinette, or self-adherent wrap. This will be simple for ER providers to remove to inspect wounds and not interfere with x-rays. You note that you do not have any at camp. Still, if you had had a silicone interface self-adherent border dressing, this would have worked nicely too and would have been easily removed and reapplied (this could potentially be left in place for 3 days if only scant wound drainage).
Mike comes back to your station the next day for a dressing change. His x-rays of the knee and elbow were all within normal limits. The ER staff told him to rest and elevate the elbow and knee and ice them (10 min on and 30 min off) for 24 hours and continue daily wound care with you. They also told him to take 600mg of ibuprofen as needed every 6 to 8 hours.
Today, his right elbow/forearm self-reported pain level is 6-8, and his right knee/shin is 4-5. Using universal precautions and clean technique, you change the dressing, continuing to use a hydrogel wound gel or petrolatum impregnated gauze over the entire wound, secured in place by a secondary dressing and tubular netting. You also protected the wound edges using a skin protectant wipe applied to the skin immediately around the open wound. This approach maintains a moist wound bed, prevents the dressing from sticking to the wound, allows for continued extremity motion, and protects the surrounding skin.
You change this dressing daily for the next 5 days. You note the shin wound is healing as expected, and the knee joint edema is resolved, with some bruising now evident. However, the elbow area and forearm wound remain edematous, painful to touch, and movement. There is still a moderate amount of serosanguineous to yellow exudate (no unusual odor) as well as dark red erythema extending 0.7 cm from the proximal wound edges. This wound is not following the expected pathway to healing.
What are some possible reasons?
While any of these may interfere with wound healing, we should also consider other potential complications. The two biggest ones to consider in Mike's case are:
A missed wood splinter or organic foreign body may not have been detected by x-ray. Close examination of the wound and gentle probing with the wood end of a sterile cotton-tipped applicator reveals a hard embedded splinter that you can remove with forceps. It is a thin 0.7 cm long wood splinter at the proximal end of the forearm wound pointing deep into the wound towards the elbow. You note that it did not measure long enough to potentially invade the joint space, even fully embedded.
After it was removed, Mike states he felt some immediate pain relief. You decide to use an antimicrobial wound dressing for this wound while continuing the same petrolatum impregnated gauze dressing for the shin wound (though now you can change it 3 x per week along with the new dressing orders for his forearm). You also just happen to have a sample tube of Cadexomer Iodine gel you brought with you in your first aid kit.
Mike's new forearm wound dressing includes:
You follow Mike's wounds for wound care 3 x a week for the next 2 weeks, and the wounds close within 3 weeks.
Mike's wounds should have both healed as expected. However, one did not. We have discussed that we should look to local factors within the wound itself for the impaired healing of the forearm wound (his other wound was healing as expected even though it was the most distal wound); this may (although not always) point to something more local within the forearm wound itself. When looking at wounds, remember to look at the whole person, not just the wound. It is also important to consider all the initial factors which led to the wound if things start to take a turn away from the anticipated pathway to healing.
This course covered an essentials list of necessary wound care supplies, a thorough review of several wound care mnemonics, an explanation of wet-to-dry dressing changes and what is currently most evidence-based in the literature, the full typical step-by-step process of wound dressing changes, as well as the important teaching points that patients and their families should be provided in reference to their wound care. For more information regarding wound bed cleansing and wound dressings, please continue forth within the wound care series to Wound Series Part 2c: Wound Bed Cleansing.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.