Wound care nursing is a critical aspect of healthcare across various settings, including acute care, home care, and long-term care. Nurses with specialized skills in wound care are responsible for performing physical assessments, developing appropriate treatment plans, and managing wounds of varying complexity. This article delves into the history, basics, assessment, management, and ethical implications of wound care nursing.
A Brief History of Wound Care Nursing
The roots of wound care nursing can be traced back to 2000 BCE when ancient Egyptians employed grease, honey, and lint to promote wound healing. They also used vinegar, water, or wine to cleanse wounds. In ancient Rome, the signs of inflammation, such as tumour, rubor, dolour, and colour, were first recognized. During the Middle Ages, nuns were responsible for nursing tasks, and the practice involved allowing wounds to partially heal. Over time, wound care nursing has evolved into a certified specialty, transitioning from traditional opinions to evidence-based practices supported by research.
The Basics of Wound Care Nursing
Managing wounds can be complex due to the range of tissue damage that can occur, from superficial to deep wounds. By understanding the fundamental principles of wound care, nurses can develop effective treatment plans and simplify the overall process. The following section explores the assessment and management of wound care nursing, with a focus on postoperative wound care.
Wound Care Nursing Assessment
A comprehensive wound assessment is the foundation of effective wound management. During initial and ongoing assessments, nurses should consider various factors, including:
– Type of wound:
Categorizing wounds as acute or chronic, such as burns, ulcers, surgical incisions, lacerations, and abrasions.
– Pressure injuries:
Damage to the skin or tissue resulting from prolonged or intense pressure, also known as pressure ulcers.
– Venous ulcers:
Ulcers caused by impaired lower extremity valves, leading to blood reflux in the venous system.
– Arterial wounds:
Wounds resulting from severe tissue ischemia caused by atherosclerosis of peripheral arterial vessels.
– Diabetic foot wounds:
Wounds in diabetic patients due to compromised pressure perception, pain sensation, and reduced blood flow to the foot.
– Skin tears:
Wounds caused by mechanical forces such as friction, shear, or blunt force, which may vary in depth but typically do not reach the subcutaneous layer.
– Moisture-associated skin damage (MASD):
Inflammation of the skin caused by exposure to different types of moisture that impairs its protective mechanism.
– Location and surrounding skin:
Examination of the wound’s surrounding area to ensure its protection from further injury, with the location providing insights into potential causes.
– Tissue loss:
Determining the extent of tissue damage, including superficial wounds (involving the epidermis), partial-thickness wounds (involving the dermis and epidermis), and full-thickness wounds (involving the dermis, subcutaneous tissue, and potentially reaching bones, tendons, and muscles).
– Clinical aspect of the wound bed and stage of healing:
Observing characteristics such as granulating (red/pinkish with collagen, capillary network, and elastin), epithelializing (pink/white with new epithelium closing the wound surface), sloughy (yellow due to dead cell accumulation, not to be confused with pus), necrotic (black, complex, and dry due to dead tissues impeding healing), and hyper granulating (granulation tissues developing above the wound due to irritant forces or bacterial imbalance, leading to delayed healing).
– Wound measurement and dimensions:
Continuously evaluating wound healing progress through two-dimensional measurements of width and length (in millimeters) and three-dimensional measurements of depth using a cotton tip applicator.
– Wound edge assessment:
Assessing wound edges for color (erythema indicating cellulitis or inflammation, dusky or pink indicating new tissue growth), evidence of contraction (indicating healing), and sensation changes (absence or increased pain requiring further investigation).
– Exudate examination:
Evaluating the amount, type, odor, and color of exudate, which plays a role in cleansing the wound, providing nutrients and growth factors, preserving a moist environment, and promoting epithelialization.
– Presence of infection:
Identifying indicators such as malodor, localized pain, edema, redness, change in exudate characteristics, and localized heat, which may signify wound infection.
– Pain assessment:
Understanding the pain associated with the wound to guide appropriate dressing selection and management, including evaluation before, during, and after dressing changes.
Effective wound management requires consideration of various factors, including psychological indications, goal of care, fragile wound environment, bacterial balance, wound moisture, pH and temperature stability, appropriate drainage management, suitable dressing selection and techniques, and the application of appropriate wound therapies. Additionally, the principles for managing both acute and chronic wounds should be followed.
Wound Care Nursing Procedure
Proper wound care procedures are crucial for promoting healing and preventing infection. The procedure for wound or surgical dressing involves the following steps:
1. Explaining the process to the patient, ensuring sensory preparation.
2. Washing hands and wearing gloves.
3. Examining the wound for signs of swelling, redness, or evisceration.
4. Assessing drainage characteristics.
5. Cleaning the surrounding area with a cleansing solution, wiping from the cleanest to the least clean area.
6. Applying requested medication.
7. Applying a sterile dressing, starting with dry gauze pieces followed by cotton pads.
8. Removing gloves and discarding them.
9. Covering the dressing with adhesive tapes or bandages.
Aftercare dressing includes assisting the patient in dressing, changing soiled garments if necessary, removing the towel and mackintosh, changing bed linen, taking tools to the utility room, washing hands, documenting the procedure, and educating the patient about signs of infection.
Drawbacks to Wound Care Nursing
Several factors can impede wound healing, including local factors such as infection, wound pH and temperature, excessive drainage, bleeding, and compromised stitches, as well as general factors such as hypoxia, underlying diseases, malnutrition, radiation therapy, anxiety, stress, medication side effects, and movement or sensation disorders.
Legal Implications of Wound Care Nursing
Nurses have a legal and ethical obligation to provide optimum care, and failure to do so can lead to legal consequences. Legal implications may include unpaid leave, demotion, criminal charges, job termination, jail time, penalties, cancellation of licensure, and loss of trust from patients, employers, and colleagues. Accusations in wound care nursing can range from failure to communicate, failure to provide appropriate treatment, medication errors, lack of informed consent, to errors and omissions in documentation.
In conclusion, wound care nursing is a rewarding career that requires nurses to have specialized skills in assessing and managing wounds. Nurses play a crucial role in promoting healing and preventing complications. It is important for nurses to adhere to ethical principles and legal standards to protect patients and maintain professional integrity in wound care nursing.