› Wound Care

Wound Care Management Basics

Wound care is performed by nurses under physician’s orders for many reasons.  There are a variety of wounds based on their etiology (the origin of the disease): 

  • Surgical
  • Pressure or decubitus ulcer
  • Venous stasis ulcer
  • Arterial ulcer
  • Diabetic ulcer
  • Traumatic

All these require wound care management in order to allow the body to heal.

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In general, the broad idea of wound care management is to give the body the optimal environment to heal itself. There is nothing magical in the products used so much as they each do some basic function:

Moisture

Contain moisture at the wound bed. Eons ago the idea was to dry out the wound. How many patients do you hear say they wanted the air to get to the wound? We have since learned that “a dry cell is a dead cell”. Keeping the wound bed moist (not sopping wet) allows the cells to multiply and fill in a wound as well as allow islands of epithelial cells to eventually cover it over. 

Remove moisture from the surrounding skin (peri-wound area). Too much moisture on the surrounding skin will make is soft and macerated (that white looking appearance from absorbing fluid) which will allow the skin to slough off, leaving the patient with a larger wound than with what they started.

Bacterial Load

Reduce or eliminate local bacterial load on the surface of the skin (contamination). Any wound that has been open for more than 24-48 hours is bound to have some bacteria on it, no matter how carefully clean technique is used. When the bacterial load becomes more than the body can cope with, healing is retarded.

Debridement

Debride the wound of necrotic tissue. Yellow slough or black eschar prevents healing. Removing that by a variety of means gets the wound down to good healthy tissue that can multiply and fill in the wound. (I tell patients I want the wound to look like a good beef steak.)

Temperature

Keep the wound as close to body temperature as possible.

Again, eons ago, we changed dressings at least daily if not more frequently. If for no other reason than to monitor the progress. After all, we are nurses. We are paranoid about complications arising unnoticed. Feeling responsible for everything that happens to the patient does that to you.

However, studies have shown that every time a dressing is taken off, the temperature of the wound drops, halts cell regeneration until the new dressing is applied and the temperature can rise again.This then makes the healing process take longer.

If a wound can safely be covered for a few days at a time before changing the dressing it allows the body to heal faster. Sometimes you have to explain to patients that you aren’t being lazy you are doing what works best.

Margins

Prevent the margins of the wound to from rolling under. Easier said than done. Sometimes the physician has to do sharp dissection to remove some of the margin.

Sometimes just scrubbing the margins vigorously can shear the rolled edges enough to make them raw again.

Why don’t you want rolled margins? Because the body, for whatever reason, reads that as the wound is closed and stops any further generation of granulation tissue or epithelium.

Technique

There are two basic methods to do wound care

  • Sterile technique
  • Clean technique

Obviously, any wound care management in the Operating Room is sterile. Usually, the first dressing change after surgery is done by the surgeon with the nurse changing the dressing based on physician orders using clean technique thereafter. On occasion the physician will specify he wants sterile technique followed.

Wound Care Management Specialties

Nurses can become certified in wound care management and become a WOCN (Wound and Ostomy Care Nurse). That specialty allows them to perform additional procedures that isn’t usually covered under the Registered Nurse practice act.

Playing Detective. Finding Out What Works

Generally speaking, what works for one patient doesn’t necessarily work for another. While etiology, location, size and availability of supplies will direct the wound care management, the nurse and physician must be flexible enough to change the protocol if no improvement is noticed. Usually, after two or three weeks maximum, a re-evaluation of the wound care management and supplies needs to be performed. 

The basic supplies for wound care used to be gauze in a variety of forms, saline and tape. Over the decades manufacturers have come up with a boatload of products for more efficient absorption of fluid and retention on the body.

If not for the benefit of the patient, if you expect the insurance company to pay for services and supplies, what you as the nurse are doing, needs to be effective. Lack of efficacy will terminate payment quickly. 

Related Pages

Wound Care Management

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