Wound Care Nursing

Wound Care Nursing

Wound care nursing is a crucial aspect of healthcare across acute, home care, and long-term care settings. Nurses in this specialty must possess specialized skills to conduct physical assessments and develop appropriate treatment plans for wounds with varying levels of complexity. In this article, we will explore the history of wound care nursing, the basics of wound care nursing, wound care nursing assessment, wound management, wound care nursing procedures, and the legal implications and ethical considerations associated with this essential field of nursing.

History of Wound Care Nursing

The roots of wound care nursing can be traced back to 2000 BCE, with the ancient Egyptians using grease, honey, and lint to promote wound healing by removing pus and dead skin. They also utilized vinegar, water, or wine to cleanse wounds. In ancient Roman times, signs of inflammation, such as tumour, rubor, dolour, and colour, were first identified. During the Middle Ages, nuns were involved in nursing tasks, and a practice emerged where wounds were left to decompose slightly before treatment. Over time, wound care nursing has evolved from simple dressing methods to becoming a certified specialty. Advancements have led to the adoption of evidence-based practices, combining clinical expertise with external clinical evidence derived from research.

Basics of Wound Care Nursing

Managing wounds can be challenging as they vary in tissue damage, ranging from superficial to deep. By adhering to basic principles, nurses can develop effective treatment plans and simplify the wound care process. Understanding postoperative wound care nursing assessment and management is essential.

Wound Care Nursing Assessment

The wound management process begins with a comprehensive assessment of the wound. Key factors to consider during both ongoing and initial wound assessments include:

– Type of wound:

Wounds can be classified as acute or chronic, such as burns, ulcers, surgical incisions, lacerations, and abrasions.

– Pressure injuries:

Also known as pressure ulcers, these result from prolonged or intense pressure on the skin.

– Venous ulcers:

Caused by the inability of lower extremity valves to prevent blood reflux into the venous system.

– Arterial wounds:

Result from severe tissue ischemia due to atherosclerosis of peripheral arterial vessels.

– Diabetic foot wounds:

Associated with impaired pressure perception and pain sensation in the foot, often challenging to heal, particularly if there is bone infection or compromised blood flow.

– Skin tear:

Occurs due to mechanical forces like friction, shear, or blunt force, with varying depths that do not reach the subcutaneous layer.

– Moisture-associated skin damage (MASD):

Inflammation of the skin resulting from exposure to different types of moisture, disrupting its protective mechanism.

– Location and surrounding skin:

Examination of the surrounding area provides insights into the possible causes of the wound.

– Tissue loss:

The extent of tissue damage helps formulate an appropriate care plan, categorized as superficial wound, partial impairment, or full-thickness wound.

– Clinical aspect of the wound bed and stage of healing:

Different aspects, such as granulating, epithelializing, sloughy, necrotic, and hypergranulating wounds, provide valuable information on healing progress.

– Wound measurement and dimensions:

Evaluating wound healing involves a two-dimensional assessment of wound opening and a three-dimensional evaluation of any cavity.

– Wound edge:

Assessing wound edges for color, evidence of contraction, and sensation changes offers essential information for proper care.

– Exudate:

Acute and chronic wounds produce exudate as part of the healing process, and examining its amount, type, odor, and color is crucial for wound management.

– Presence of infection:

Indicators of wound infection include malodor, localized pain, edema, redness (cellulitis or erythema), change in purulent fluid, and localized heat.
– Pain: Evaluating wound pain provides insights into wound chronicity and etiology, guiding dressing selection and management.

Wound Management

Proper wound management is vital for successful healing. Some key considerations include:

– Understanding the psychological implications of wounds on patients.
– Defining the goal of care and anticipated outcomes.
– Taking into account the fragile wound environment.
– Maintaining bacterial balance, wound moisture, stable pH, and temperature.
– Allowing draining wounds to drain naturally.
– Selecting suitable dressings and techniques for wound care.
– Implementing appropriate wound therapies.
– Following managing principles for both acute and chronic wounds.

Wound Care Nursing Procedure

Wound dressing is a critical aspect of wound care nursing, and nurses must follow specific procedures during the dressing process. The procedure involves:

– Explaining the process to the patient using sensory preparation techniques.
– Washing hands and wearing gloves for infection control.
– Examining the wound for signs of inflammation, swelling, or evisceration.
– Assessing the characteristics of any wound drainage.
– Cleaning the surrounding area with a cleansing solution.
– Applying any prescribed medication if necessary.
– Applying sterile dressings, starting with dry gauze pieces and cotton pads.
– Removing gloves and discarding them safely.
– Covering the dressing with adhesive tapes or bandages.

Aftercare dressing, nurses should help patients dress up, change garments if dirty, remove the towel and mackintosh, change bed linen, take all tools to the utility room, wash hands, and document the procedure. Educating the patient about signs of infection is also crucial.

Drawbacks to Wound Care Nursing

Several factors can delay wound healing, categorized as local and general factors:

– Local factors include the presence of foreign bodies, signs of infection, wound pH and temperature, excessive exudate, excessive bleeding, wound edge characteristics, and changes in sensation.
– General factors encompass hypoxia and impaired perfusion, underlying diseases like diabetes, autoimmune disorders, and anaemia, malnutrition, body mass index, radiation therapy, anxiety, stress, and depression, and medications that can affect wound healing.

Legal Implications of Wound Care Nursing

Wound care nursing involves significant legal and ethical responsibilities for nurses. Failing to uphold optimum care can lead to serious consequences, including unpaid leave, demotion, criminal charges, job termination, jail time, penalties, cancellation of licensure, and loss of trust from patients, employers, and colleagues. Common legal accusations in wound care nursing may involve failure to communicate with patients or colleagues, inadequate treatment and care, administration of incorrect medication, lack of informed consent, and errors or omissions in documentation.

Final Word

Wound care nursing is a rewarding and essential aspect of nursing that requires skilled care and compassion. Nurses play a vital role in wound management, promoting healing, and preventing infection. Moreover, adherence to ethical principles ensures patients receive the best possible care while avoiding legal implications. These guidelines provide valuable insights into wound assessment and management that nurses can apply in their daily patient care.