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What is the Critical Thinking Behind Choosing the Type of Wound Care for Chronic Wounds?
In Answer to a Question posed by another Hub Author
Reason for This Hub
10 hours ago
"i have a question moist material or damp cloth can harbor bacteria is it ok to include it in the wound dressing? i know its sterile but chances are bacteria can grow since sloughing of dead tissue is inevitable. i got another question (if you dont mind) i thought drying up the wound is the main objective in wound care? i know there a lot of issues regarding wound care (like keep the wound open or close after wound dressing) but i hope you can answer my question..... by the way im a student nurse....tanx"
As you can see, this hub is in answer to this question, a great question, asked by fellow Hubber AND student Nurse! Way to go Dijon! I felt, when I flew through the entire question that I had left WAY too much out and wanted to rectify that matter at once :) 'Sides, it sounds like a cool one to do...so thank you dijon for the great questions as well as my next Hub Page
There are so many resources on the internet about any wound care question you could possibly want to know it can become quickly overwhelming. To top that off, often the information is ambiguous and contradictory.
What do you do?
First, DO NOT PANIC :)
Start with a broad subject, for example wound care. Then narrow it down to, say, pressure ulcers, stasis ulcers, non healing surgical wounds, infected and or self inflicted wounds, reopening of a scarred wound bed and on and on. Now granted, a lot of these sites make you pay but during the course of your career or until you are confident of your own methods these internet sites alone make fantastic resources as well as being easier to use than dozens of heavy books! The trick is to find reputable sites and stick with them.
I have a few online sites that I tend to gravitate to without even thinking, the wound and ostomy association site is my number one favorite but what I really tend to look for and stick with are the sites that say the same things, show the same results, show that research and case studies have been done and most of all, that it is cost effective and easy on both patient and the nurse!
That may sound as if I am penny pinching when and perhaps painful dressing changes, actually I am saving time and money. Long involved wound care with multiple steps, several different products and daily or more dressing changes has potential to harm the patient due to increased time spent in bed (isolation), emotional issues with fear over wound changes itself (anticipated pain), loss of control (can lead t behavior issues such as refusal to participate)and alteration in body image.
The other matter relates to budget and management. The budget is controlled by the management. As much as nurse would love to have any product at her fingertips that has never been the case. The more nurses complain over lack of supplies, the more management will scrutinize all charge slips and make it that much more difficult for nurses to obtain the products necessary to care for their patients. The more nurses adhere to their facilities use of supplies as pertains to their budget the more likely it will be that their supply budget will increase and management will listen more sympathetically to nurses wishes over preferred products.
That is not said as a management nurse. I am not management; my mouth gets me into too much trouble :) rather, it is from watching, participating and listening as a staff nurse for over three decades.
That said, what do I hope to impart to you from this article related to wounds and wound care? As the title states I want to discuss two specific types of wounds, the types of wound care and the critical thinking behind which dressing/treatment/wound care to ask for related to these two different types of wounds
Sounds long and involved but really, it is not. This is just the basics, a template to use in your day to day nursing. Also, at the end of this Hub you will find a few sites pertaining to specific forms of wound care. And as luck would have it that is exactly where I would like to start!
Definition of Pressure Ulcer and Wound Care Options
1. Pressure ulcers. Our skin has three layers; epidermis, dermis and subcutaneous. Whenever pressure is applied over any site for extended length of time, that area will lose blood supply, therefore oxygen and the cells will start to die.
2. Stage One pressure area. This will appear first as a red area that will not blanch (turn white in color then turn back to pink immediately). Hopefully you, as that patients nurse, will have found it by then and removed the cause. Stage one pressure ulcer involves only the epidermis. Remember, the epidermis can be as many as 5 layers thick. These are the layers that are seen as dry skin flaking off every day. The skin renews itself from the outside out; the top layers of skin are constantly renewed as long as they are not damaged in some way. And, from the very start you, as the nurse, need to involve the entire healthcare team in the treatment. They can help by adding information on mattress, ways to improve nutrition, ways to prevent shearing, manage moisture and repositioning. All of these components will continue to be used as treatment options regardless of at what stage the pressure ulcer is at the moment.
3. The treatment for a stage one? Simple basic skin care. Clean and dry, pressure relief, barrier ointment if incontinence is an issue and turning and repositioning. No, you do not have to nor should you apply a hydrocolloid. A stage one should make you, as a nurse, become extremely embarrassed! Why? Because you should prevent it before it occurs. If a patient is incapacitated to the point they are unable to shift weight or turn themselves for whatever reason guess what? Someone has to do it for them! Duh. See? Told you my mouth gets me into trouble :) Also do not neglect skin care, basic hygiene, turning, and a low air loss mattress as well as look for any underlying problems that will slow the healing process such as age, mobility orlack of, edema, comorbidity factors..
4. A stage two pressure ulcer picks up where a stage one left off: red area non-blanchable becomes a blister, then the blister opens and becomes a superficial open layer of skin. Just a fluid filled blister is a stage two. Just a superficial open layer of skin caused by pressure is a stage two and a shallow crater in the skin is a stage two.
5. The treatment for a stage two? Again, in addition to treatment for a stage one you now need a healing agent such as hydrocolloids, alginates, or just a simple transparent dressing. The one thing all three products have in common is they form a MOIST wound environment. Pressure ulcers heal best when they are kept CONSISTENTLY clean, moist and free of the offending pressure.
6. A good rule of thumb to follow is: if the area is superficial, without significant depth, scant drainage; then let the hydrocolloid or a transparent dressing do their job. If the area is larger, irregular, has a defined wall or lip, and moderate drainage choose an alginate. Always perform the dressing changes consistently following aseptic technique for at least two weeks then give your patient’s physician an update and go from there.
7. Do NOT forget to involve other healthcare team members. Therapists, aides, family members, dietician, staff nurses all play a part and all are invaluable resources for you to count on!
8. A stage three pressure ulcer is area that now extends into the third layer of skin, the subcutaneous tissue and perhaps but not always into the fascia. It may or may not be undermined and may or may not have slough (dead tissue usually white, stringy ad slick). Slough is non viable tissue that must be debrided before wound will even think of healing.
9. Treatment for a stage three is not much different from the other two: skin care, pressure relief, diet, supplement healing products of hydrocolloid, alginates and transparent dressings, hygiene, mattress and healing agent. Again, stick to the three tried and true moist wound environment!! This is the most important rule of all pressure wounds! Keep the pressure off and keep the wound moist.
10. A stage four pressure wound involves full thickness, past the fascia and into muscle, tendon and bone. Stage four will always remain a stage four. When healed it only has scar tissue over that sore, it will always be a healed stage four ulcer site. If it reopens you must document site of ulcer as the old healed stage four ulcer sites.
11. Treatment for a stage four pressure ulcer involves all the treatments discussed thus far plus it is usually daily, you have to change dressing more often (ususally) due to excessive drainage, you may have to route urine and feces away from the site, you may need to use autolytic, manual, chemical debridemnt methods and you definitely need to look at the surface the patient is sleeping on. Especially in older, debilitated patients and patients in nursing homes where staffing is an issue the use of a bed designed to assist in healng is imperative. The statistics prove the ulcers will heal faster and stay healed longer when all aspects of care are in place and kept in place even after the area is healed.
Second Type of Wound
Non Healing Surgical Wound
Surgical wounds become infected and non healing for any number of reasons. Surgical wounds are not the only kinds of wounds that become non healing wounds; it’s just the one we are discussing today. The best way to treat a non healing surgical wound is.....well, there isn't any best way, just as there are so many different types of surgical non healing wounds. Always follow physician orders and always do your research. Always watch and document the wound itself on a regular basis, just as you do with pressure ulcers.
Measurements and description will assist the physician tremendously with surgical wounds because they can change rapidly. What you see on week one may very well be evolved into something entirely different by week two. Most IMPORTANT OF ALL do NOT hesitate to call that surgeon if at any time you suspect a complication of any kind!!
Because with a surgical non healing wound the worst case scenario is septicemia. Also, as all old nurses know Murphy is always there, just waiting :) and Murphy loves to occur when? Of course! Over the weekend!
So, treatments for non healing wounds can vary from the simplest (wet to dry) to more complicated (vac pac) to even a referral to a specialized wound care treatment center The physician may also do a culture and treat with oral as well as topical antibiotics. A few topical antibiotics are employed with the wet to dry dressing system. If the wound cultures show psuedomonas, often the order will be for Acetic Acid; usually one quarter strength wet to dry. If the wound cultures out staphylococcus the physician will likely order Dakins solution with the wet to dry dressing. An older nurse will be able to tell you how we used to make these solutions on the floor of the hospital, in the med room, under a hood using ordinary everyday household vinegar (acetic acid) and bleach (Dakins).
Important Points to Remember About Non Healing Surgical Wounds
1. Observe the wound daily, record your observations a minimum of weekly and do not hesitate to notify the physician for any changes, complications, signs of infection or a gut feeling. Just be ready to give all your assessment information to support that gut feeling!
2. Follow the policy of your facility concerning whether wound care is done sterile or aseptic. In a long term facility or for home health wound care is usually done aseptic. Meaning you use clean (aseptic) technique and sterile supplies.
3. Be consistent with your wound care. Sloppy work is unacceptable, cutting corners or hurrying because you are pressed for time will lead to errors. When you are with that patient, be totally with that patient. That patient deserves it! Golden rule, Karma, what goes around comes around, whatever you want to call it, sooner or later all of us will be a patient for some reason, somewhere. Think on this.
4. Everything you would do for a pressure ulcer can also be applied to a surgical non healing wound. Turning, repositioning, nutrition, hygiene, mattress, healthcare team support all will add to the healing process.
5. Most important of all for a surgical non healing wound is pain relief. Be aware that patients’ body will not heal as well or as quickly without adequate pain relief.
6. The number one factor to keep in mind about surgical non healing wounds is the high risk of infection. As noted earlier, whatever can happen, will happen and it happens at the worst times! So observe, record (document), be consistent and diligent and always keep your surgeon (usually the nurse to the surgeon) on your speed dial!
As to the answer for most wounds do better in a dry environment I must agree to disagree. I haven't seen that work except in a healthy, younger population. Kids with scrapes? They love their band aids. Keep those scrapes clean and dry, soap and water and a band aid ad they'll be fine. Add a greasy kid stuff antibiotic ointment to the scrape, leave that band aid on and next thing you know it’s infected. Ugh. Just soap and water, lots of colorful band aides to changed whenever they want, and nature’s band aide; the scab!
But in a healthcare setting? Dude, healthcare facilities are so full of bacteria is frightening, truly.
Wash your hands. Wash them often and wash them well, always wear gloves during wound care, change your gloves often, wash your hands every time you take your gloves off and never ever let a pressure ulcer or a non healing surgical wound stay open to air.
Now as soon as I've written that, along will come a gastrointestinal surgeon who will look at a patient with a recent evisceration of a laparoscopy and say "Oh, it'll be fine, take a shower every day and leave it open to air. You can put a gauze on it if bothers you but don't tape it. Come see me in a couple of weeks, it should be fine by that time"
It will be too, as soon as you do your nursing responsibility of educating your patient on ways to manage that open wound and prevent infection! Guess what your first sentence should be to that patient?
THE BEST WAY TO PREVENT THE SPEAD OFANY INFECTION IS TO WASH YOUR HANDS!
What is written here does not now nor does it ever take the place of your physician’s advice and services of your physician.
Consult your physician every time for all things medically related and of course, if you feel you have any of the signs or symptoms of what has been written in this hub, please contact your physician for a consultation as soon as possible.